Dublin Post Acute
Inspection history, citations, penalties and survey trends for this long-term care facility in Dublin, Ohio.
- Location
- 4075 West Dublin-granville Road, Dublin, Ohio 43017
- CMS Provider Number
- 366418
- Inspections on file
- 31
- Latest survey
- March 4, 2026
- Citations (last 12 mo.)
- 15
Citation history
Health deficiencies cited at Dublin Post Acute during CMS and state inspections, most recent first.
The facility failed to consistently provide scheduled bathing and personal hygiene care to two dependent residents who required maximal or total assistance with ADLs. One resident with cognitive impairment and mobility limitations had multiple scheduled showers missed over several weeks, with documentation either absent or marked as "No" without any recorded refusals, follow-up, or family communication, while the spouse reported very few showers since admission. Another resident with cerebral palsy, asthma, malnutrition, and schizoaffective disorder, cognitively intact but dependent for showering and toilet hygiene, had only one bed bath documented over an extended period, despite a twice-weekly shower schedule and no recorded refusals. An LPN confirmed that refusals should be documented as such, and the facility’s ADL policy required provision and monitoring of hygiene services in line with residents’ assessed needs.
A resident with multiple complex conditions returned from a hospital stay with AVS orders for Ciprofloxacin and vancomycin, discontinuation of enoxaparin, and holding Metformin for several days. Review of the MARs showed the ordered antibiotics were never administered, enoxaparin continued to be given on multiple days, and Metformin was administered while it was ordered to be held. An RN confirmed the resident was not receiving the prescribed antibiotics, and the DON acknowledged that the hospital discharge orders were not transcribed or implemented upon the resident’s readmission.
A resident with dehydration concerns and multiple medical conditions had an IV line placed by a contracted provider after the POA requested PRN IV fluids. Documentation from the contractor showed IV placement was completed, but there was no immediate nursing assessment recorded to confirm tourniquet removal or evaluate the IV site. Later nursing notes and the self‑reported incident indicated that a tourniquet was left on the resident’s arm after IV placement, with swelling noted and at least one nurse and the resident’s daughter identifying the problem before the tourniquet(s) were removed and local measures applied. The facility’s investigation lacked clear times for IV placement and discovery of swelling, contained conflicting accounts of how long the tourniquet remained in place, and interviews showed there was no defined expectation for immediate post‑procedure assessment of IV sites placed by outside companies, nor timely documentation of monitoring after the procedure.
A resident with multiple fractures, thrombocytopenia, and hypertension had physician orders for a CBC and BMP that were not completed as ordered, as confirmed by medical record review and provider notes. A later set of CBC and BMP orders was carried out. The resident also had an order for a wound culture and sensitivity; the initial specimen was rejected by the lab due to use of an expired swab, and there was no documentation of an immediate recollection despite instructions to obtain a new specimen. The DON confirmed that the earlier labs were not completed and that the wound culture was collected with an expired swab and not recollected until a later date.
The facility failed to provide comprehensive, individualized pressure ulcer prevention and treatment, resulting in actual harm to a resident and placing two others at risk. A resident with multiple fractures, edema, and high dependence for mobility was admitted with existing skin issues but had no skin integrity concerns on the baseline care plan, no timely treatment order for a newly identified back wound, and no wound-specific interventions added to the care plan. Ordered daily wound treatments were documented on only a fraction of days, turning and repositioning were missed on multiple shifts, Braden scores understated the resident’s risk, and an air mattress was not in place despite high risk. Conflicting documentation between the wound nurse and an NP regarding whether back wounds were pressure or surgical, whether they were present on admission, and whether the resident was on hospice or noncompliant with repositioning further contributed to poor wound management. Two additional residents on low air loss mattresses had mattress settings that did not correspond to their weights, with staff unable to state correct settings and one resident subsequently developing an in‑house acquired Stage II pressure ulcer to the buttock, while another had the mattress dial set far above their weight without care plan guidance on proper settings.
Surveyors found that meals were not consistently palatable or served at appropriate temperatures. Test tray checks by the Dietary Manager showed a beef macaroni casserole and mixed vegetables at suboptimal temperatures, with the casserole described as lukewarm and the issue attributed to food carts sitting too long before service. Multiple residents reported that their food was served cold, tasted terrible, or was otherwise unappealing, and one resident also reported improper portion sizes.
The facility failed to maintain an adequate supply of clean linens, including towels, washcloths, bed pads, and fitted sheets, for residents on one floor. A resident reported insufficient towels and washcloths for scheduled showers, and observation confirmed that the primary linen room on that floor lacked key items, with only a small quantity of linens available in the laundry room. The housekeeping supervisor acknowledged staff complaints about linen shortages and noted that CNAs often took large amounts of linens to rooms and left unused items there. During a resident council meeting, two residents reported missed showers and inability to change bed linens due to lack of towels and fitted sheets, and one resident stated she was given a "clean" fitted sheet that was actually soiled and smelled of urine. Review of CNA standards and the homelike environment policy showed that required practices for providing clean, adequate linens were not followed.
The facility failed to conduct and document required initial and quarterly care plan conferences with multiple residents and/or their representatives, despite facility policy requiring conferences within seven days of admission and quarterly thereafter. Several residents with complex conditions such as ALS, COPD, diabetes, severe malnutrition, vascular dementia, and chronic respiratory failure had intact cognition and completed MDS assessments, yet had either no care conferences or large gaps between conferences. Some residents reported never being invited to or aware of care plan meetings, and one resident with severe cognitive impairment had no documented initial conference with the responsible party. The Social Service Director and Social Work Director confirmed that conferences were not held or documented, sometimes citing behavioral issues, difficulty reaching family, or undocumented verbal discussions, without the required documentation of attempts, refusals, or explanations in the medical record.
Surveyors found that staff repeatedly failed to implement and document ordered treatments for multiple residents, including topical medications for skin folds and MASD, wound care for diabetic and post-amputation foot wounds, and daily care for a surgical incision. Several residents did not receive ordered compression therapy such as TED hose and ace wraps, and there were numerous missed or undocumented wound treatments on the MAR/TAR. After visit summaries from outside providers often did not match in-house orders, some AVS documents were missing, and wound measurements and status updates were not recorded. Preventative and therapeutic orders, such as betadine treatment for a toe injury and timely initiation of a new diabetic foot ulcer treatment, were delayed or not started, and staff interviews confirmed gaps in assessment, order transcription, and completion of prescribed care.
Surveyors found that multiple residents were exposed to unsafe conditions, including unsecured medications, inadequate fall prevention measures, and an unrepaired entrance door. One cognitively intact resident who relied on staff for medication administration had numerous medications, including some without active orders, stored openly in his room despite only one drug being ordered for supervised self‑administration. Another resident who could not self‑administer medications had a cup of scheduled pills left at the bedside. A cognitively intact resident’s fall from bed with a forehead skin tear was not documented until days later, and bed rail interventions were delayed, while a severely cognitively impaired, high‑fall‑risk resident with prior unwitnessed falls was observed with his bed raised and a fall mat pushed under the bed, limiting protection. In addition, a cognitively intact resident reported a toe wound caused by a broken front door that slammed on his toe; the door had been reported broken for weeks before repair, and the incident was not documented in the incident log or medical record, contrary to facility policies on safety and fall risk management.
The facility failed to provide scheduled ADL care, including bathing and nail care, for multiple dependent residents. One cognitively intact resident with complex medical and psychiatric conditions went extended periods without documented showers despite needing only setup assistance. Another resident with dementia and multiple comorbidities, who was dependent on staff for personal hygiene, did not consistently receive twice‑weekly showers as expected. A third cognitively intact, bedbound resident with severe respiratory disease and morbid obesity, care‑planned for dependent assistance with bathing and nail care, had repeated documentation of nail care as not attempted and missed bathing on several scheduled days; he reported his nails had not been cared for in months, and staff confirmed his nails were long and visibly soiled, contrary to facility ADL policy.
A resident with multiple medical conditions, bowel incontinence, an indwelling catheter, and total dependence for toileting went four consecutive days without a documented bowel movement, and no bowel interventions were initiated. The resident’s care plan called for staff to check and change the resident and provide toileting assistance, and the facility’s Bowel Management Protocol defined normal bowel patterns and required nursing assessment, tracking, and treatment for constipation. The DON confirmed that the resident had no bowel movement during this period and that the bowel protocol, including obtaining or providing ordered bowel medications and documenting and following up on results, was not followed.
Two residents with severe cognitive impairment and multiple comorbidities experienced significant weight loss that was not properly addressed. One resident had a large recent weight decline, after which a dietitian ordered frozen nutritional treats twice daily and weekly weights; however, dietary staff were never notified, the meal ticket was not updated, the supplement was not placed on trays, weekly weights were not done, and an RN documented 100% supplement intake without verifying it was served. Another resident had repeated significant weight losses despite orders for weekly weights, Boost supplementation, and full assistance with meals; staff did not re-weigh as required for large percentage changes, did not notify the dietitian or physician of the losses, and did not follow the facility’s weight monitoring policy.
Surveyors identified a 12% medication error rate when observing medication passes, including three errors involving insulin and pantoprazole administration. A resident ordered pantoprazole granules mixed in apple juice instead received the medication mixed in water, contrary to FDA instructions requiring administration only in apple juice or applesauce. Another resident ordered 18 units of Lantus insulin twice daily initially had 20 units drawn up in an insulin syringe by an RN, who misread the syringe markings before correcting the dose when questioned. A third resident ordered Humalog insulin via KwikPen had the dose dialed and prepared for injection by a CMA who did not understand or perform required priming of the pen before administration. These errors occurred despite facility policies and job descriptions requiring staff to follow medication labels, verify orders, and administer medications safely and accurately.
Two residents experienced deficiencies in accurate medical record documentation. One resident with significant recent weight loss had an order for frozen nutritional treats twice daily, and the MAR showed 100% intake, but observation revealed the supplement was not placed on the meal tray, the meal ticket did not list it, and dietary staff confirmed it had not been sent, while an RN had documented full consumption. Another resident with multiple sclerosis, an indwelling catheter, and total dependence for ADLs had a positive urine dipstick and two contaminated urine cultures, yet there was no documented follow-up, evaluation, or inclusion of related lab results in the chart, and an LPN confirmed that no further assessment or documentation was completed.
A resident with a history of spinal issues experienced severe pain after an unwitnessed fall, resulting in a T12 spinal fracture. Despite reporting a pain level of 10 out of 10, the resident did not receive additional pain medication or non-pharmacological interventions before being transported to the hospital. The facility staff failed to monitor the resident's pain adequately, and the transport to the hospital was delayed by nearly four hours.
The facility did not ensure timely delivery of mail to residents on weekends. Interviews with residents and staff revealed that mail received on Saturdays is not distributed until Monday because the activity staff responsible for mail distribution do not work on weekends. This practice contradicts the facility's policy that residents should receive personal mail, including Saturday deliveries, unopened.
The facility failed to ensure the Activity Director met the minimum qualifications, affecting all 99 residents. The AD, hired in July 2024, had minimal training and no prior LTC experience. She was enrolled in a certification course but could not provide evidence of progress. HR acknowledged the AD should not have been hired without meeting the criteria.
The facility failed to implement a comprehensive water management plan for Legionella prevention, lacked proper infection control during wound care, and did not complete required tuberculosis testing for staff. Additionally, Enhanced Barrier Precautions were not used for a resident with a gastric tube, contrary to CDC guidelines.
The facility failed to include a daily room rate on bed hold notices for four residents transferred to the hospital. Despite being provided with a Notice of Transfer and Bed Hold, the notices lacked the necessary information regarding the daily room rate, which is required for residents or their representatives to make informed decisions about holding their beds during hospital stays. Interviews with staff confirmed the omission, and the facility's policy mandates that non-Medicaid residents be provided with this information.
The facility failed to follow physician orders and ensure medication availability for several residents, leading to deficiencies in care. A resident was not weighed daily due to a malfunctioning machine, and physicians were not notified of significant weight changes. Another resident had blood pressure and heart rate readings outside prescribed parameters without physician notification. A third resident did not receive medications due to pharmacy delays. Additionally, a resident with a malfunctioning PEG tube was not promptly treated, resulting in hospital transfer.
The facility failed to enforce its non-smoking policy, affecting three residents who were observed smoking near the entrance without safety measures. Additionally, a resident with a history of falls did not have a required bedside commode, and another resident did not receive scheduled neurological checks after a fall. The facility's policies were not adhered to, leading to these deficiencies.
The facility failed to provide adequate nutritional and hydration support to residents at risk, affecting six residents. A resident dependent on staff for eating experienced significant weight loss without proper documentation of meal and fluid intake. Another resident on TPN had unmonitored weight loss, and other residents faced issues with inadequate monitoring of weights and fluid intake, highlighting systemic failures in care.
The facility failed to provide evening snacks to residents, as revealed by interviews and observations. Residents reported not receiving snacks, and staff indicated that it was the responsibility of nurses and STNAs to retrieve snacks upon request. However, nutrition rooms lacked available snacks, and there was no routine practice of offering snacks, contrary to the facility's policy.
The facility failed to maintain sanitary conditions in the kitchen and nutrition rooms, affecting 96 residents. Observations revealed gnats, dirty ice machines, and improperly stored food. A refrigerator freezer was not functioning, and dirty trays were found in the nutrition rooms. Facility policies on food preparation and storage were not followed.
A facility failed to return a resident's personal funds upon discharge, despite having a policy requiring funds to be returned within 30 days. The resident, with multiple diagnoses including dementia and diabetes, had $1,331.19 in their account, which was closed in January. The Business Office Manager confirmed no check was provided, and the dispersal of funds was still awaiting administrator approval months later.
The facility failed to provide required spenddown notifications to two residents whose personal fund balances exceeded Medicaid resource limits. One resident had balances exceeding the limit from January to April, while another had balances exceeding the limit from April to July. The Business Office Manager confirmed the facility's policy to notify residents but could not provide evidence of notifications being given.
A resident experienced significant weight loss over 19 days without the physician or dietician being notified, despite facility policy requiring such notification. The resident, receiving TPN and on a clear liquids diet, lost 9.4 pounds, equating to 4.37% of her body weight. Interviews confirmed the lack of communication, raising concerns about the resident's health and discharge plans.
A resident's personal fund account was improperly accessed, resulting in an unauthorized withdrawal of $1,136, leaving the account with a zero balance. The Business Office Manager withdrew the funds without informing the resident or obtaining written authorization, contrary to facility policies. The misappropriation was discovered during a surveyor intervention.
A resident with multiple health issues, including multiple sclerosis and diabetes, did not have a care plan for dental care despite needing several teeth extractions. Although a dentist recommended extractions and dentures, and the resident expressed a desire for the procedure, there was no evidence of follow-up or a care plan in place. Interviews with staff confirmed the absence of a dental care plan and lack of follow-up on the resident's dental needs.
A resident with multiple health conditions requested a transfer closer to Ohio, but the facility failed to provide timely assistance with referrals. Initial referrals were made, but there was no follow-up or ongoing discharge planning for several months. The Social Services Director confirmed the lack of assistance and failure to provide a list of in-network facilities, contrary to the facility's discharge planning policy.
A resident with cognitive impairment and multiple health issues required maximum assistance for personal hygiene, including shaving. Despite being scheduled for regular showers, there was no documentation of facial hair removal, and observations showed significant facial hair. The resident expressed a desire for proactive assistance, but staff only acted upon request, contrary to the facility's ADL policy.
The facility failed to provide daily activities that met the interests and needs of two residents. One resident, with cognitive impairments, was observed lying in bed without music or television, and his activity preferences were not assessed. Another resident, with severe cognitive impairment, was found yelling for help and without stimulating activities. The care plans for both residents included interventions for engaging in activities, but these were not implemented. Staff confirmed the lack of activities for residents requiring one-on-one assistance, and there were no documented recreation visits.
The facility failed to ensure proper orders and routine care for indwelling urinary catheters for two residents. One resident, with multiple health conditions, had no current orders for catheter care, while another, who is severely cognitively impaired, lacked documented routine care for their catheter. The facility's policy to prevent infection through regular catheter care was not followed.
A facility failed to identify and care plan for a resident with PTSD, lacking non-pharmacological interventions to prevent re-traumatization. The resident, with multiple diagnoses and total dependence on staff, had no trauma assessment or care plan addressing PTSD, as confirmed by a Regional RN.
The facility failed to ensure pharmacy recommendations were addressed by physicians, affecting two residents. A pharmacist's recommendations for medication management, including clarifying oxycodone use and evaluating psychotropic drugs, were not properly documented or rationalized by the physician. Additionally, a resident's allergy profile was not updated, and a lipid panel for another resident was overdue. An LPN confirmed the lack of parameters and incomplete documentation.
The facility failed to establish parameters for administering as-needed pain medications for two residents, leading to inconsistent pain management. One resident, with multiple diagnoses, received Oxycodone and acetaminophen without clear guidelines, while another resident with chronic conditions was given Norco and acetaminophen without documented pain scores. Interviews confirmed the absence of parameters, contrary to the facility's pain management policy.
A resident with multiple health issues, including diabetes and multiple sclerosis, did not receive timely dental services for recommended teeth extractions and dentures. Despite expressing a desire for the procedure, the facility failed to coordinate and follow up on dental appointments, resulting in missed care. The resident, who was cognitively intact, demonstrated loose teeth and expressed concerns about his dental condition. The facility's policy required social services to arrange dental care, but there was no evidence of rescheduling or follow-up after a missed appointment.
Two residents were inappropriately prescribed antibiotics due to the facility's failure to follow its antibiotic stewardship program. One resident received Macrobid for a suspected UTI without clinical evidence, while another was given Macrobid prophylactically despite a history of resistance. The facility did not adhere to its policy, which requires using McGeer's criteria for infection diagnosis.
A resident with multiple health conditions was not treated with dignity and respect when a social services aide blamed them for missing a dental appointment due to transportation issues. The aide yelled at the resident and threatened to arrange for a guardian, despite the resident being cognitively intact. The Social Services Director confirmed the incident, which violated the facility's policy on resident rights.
A resident with multiple diagnoses, including quadriplegia, was unable to reach her call light due to improper placement, despite being totally dependent on staff for mobility and care. Observations confirmed the call light was not within reach, violating the facility's policy.
A resident reported that their over-the-bed light had been out for several weeks, but the facility failed to address the issue promptly. Despite informing the Maintenance Director, the problem persisted due to delays in ordering and receiving the correct bulbs. The maintenance log lacked documentation of the issue, and the Maintenance Director was unsure about the timeline for resolving the problem, resulting in a deficiency in maintaining a safe and comfortable environment.
A resident with a language barrier experienced multiple falls due to ineffective communication in an LTC facility. Despite a care plan indicating the need for a translator, staff were unaware of how to access translation services, and no instructions were available in the resident's room. The DON confirmed the existence of translation services but acknowledged a lack of staff training, leading to a deficiency in care.
The facility failed to provide timely and appropriate pressure ulcer care for three residents. One resident experienced a delay in treatment for an arterial ulcer, while another had a malfunctioning mattress that was not promptly replaced. A third resident was admitted with pressure injuries but did not receive timely wound care. These deficiencies highlight the facility's failure to implement a comprehensive skin integrity program.
Two residents in an LTC facility experienced non-functional call light systems, impacting their ability to call for assistance. One resident, who was cognitively impaired and dependent on staff, had a non-functioning call light for over a month, with no repair requests made. Another resident's call light failed to alert staff, leaving their call for assistance unanswered. Staff interviews confirmed the malfunctions and lack of timely repair requests.
A resident with a history of diabetes and skin conditions developed three non-pressure ulcers, but the facility delayed implementing treatment for four days. Despite initial assessments and the presence of fungal infections, necessary physician orders for treatment were not promptly made, leading to a lapse in care.
A facility failed to maintain a sanitary and comfortable environment, affecting a resident and potentially impacting others on the second floor. Observations revealed a foul odor, a brown substance on the wall, and dirty shower curtains in the community shower room. Interviews with staff confirmed these conditions, and the facility's policies indicated that residents have the right to a clean environment.
The facility failed to maintain sanitary conditions in two nourishment room refrigerators, affecting all 104 residents. Observations revealed outdated and undated food items, including mashed potatoes, beans, and drinks, as well as an expired milk carton and a brown substance spill. These findings were verified by a Housekeeping Supervisor and an LPN, indicating non-compliance with the facility's policy on food storage and labeling.
The facility failed to maintain safe flooring in the second-floor nourishment room, affecting one of two nourishment rooms and potentially impacting 58 residents. An observation revealed multiple floor tiles with missing pieces and raised edges, posing a trip hazard. An LPN confirmed the hazard during the observation.
A facility failed to include the discharge location in a 30-day notice for a resident with moderate cognitive impairment, leading to a successful appeal. The resident was being discharged for non-compliance with the smoking policy, but the notice lacked the required address, resulting in a deficiency finding.
Failure to Provide Scheduled Personal Hygiene Care for Dependent Residents
Penalty
Summary
The deficiency involves the facility’s failure to consistently provide scheduled personal hygiene care, specifically bathing, to dependent residents as required by their care needs and facility policy. One resident with metabolic encephalopathy, asthma, post–joint replacement aftercare, and difficulty walking was admitted in late January with an MDS indicating moderate cognitive impairment and a need for maximal assistance with showering and extensive assistance with other ADLs. Nursing documentation showed no showers during the first week after admission and only four documented showers over the following month, with multiple scheduled shower dates marked as “No” without any notation of refusal. There was no documentation of follow-up interventions, attempts to reschedule missed showers, or communication with the resident’s family regarding missed hygiene care. The resident’s spouse reported that, to his knowledge, the resident had only received two showers since admission and noted in writing that a scheduled wash had not occurred. A second resident, admitted with cerebral palsy, moderate persistent asthma, moderate protein-calorie malnutrition, and schizoaffective disorder, had an MDS showing no cognitive impairment but dependence for showering and toilet hygiene and maximal assistance for other ADLs. Review of shower task documentation, excluding a hospitalization period, revealed that the only recorded bathing from admission through early March was a single bed bath, with no refusals documented in the progress notes. The resident reported not having been bathed since admission except for that bed bath and stated that showers were scheduled twice weekly on night shift. An LPN confirmed that refusals should be documented as refusals rather than “No” and verified that the only documented bathing for this resident was the one bed bath. The facility’s ADL policy required provision of necessary services to maintain grooming and personal hygiene, including bathing, in accordance with the plan of care and based on MDS findings, but the documented care did not reflect consistent provision of scheduled hygiene services for these dependent residents.
Failure to Implement Hospital Discharge Medication Orders After Readmission
Penalty
Summary
Facility staff failed to transcribe and implement hospital discharge orders for one resident following readmission from the hospital. The resident, who had diagnoses including necrotizing fasciitis, acute and chronic respiratory failure, type 2 diabetes, and obstructive and reflux uropathy, was discharged from the hospital with an after visit summary (AVS) dated 02/27/26. The AVS contained new orders for Ciprofloxacin 500 mg every 12 hours for 13 doses and vancomycin 125 mg four times a day for nine days. Review of the Medication Administration Records (MARs) for February and March 2026 showed that neither Ciprofloxacin nor vancomycin was administered during those periods. An RN confirmed that the resident was not taking the prescribed antibiotics. The AVS also included orders dated 02/27/26 to discontinue enoxaparin 40 mg/0.4 ml and to hold Metformin 500 mg until 03/02/26. However, review of the March 2026 MAR revealed that enoxaparin was administered once on 03/01/26, 03/02/26, and 03/03/26, and Metformin was administered twice on 03/01/26, contrary to the hospital discharge instructions. In an interview, the DON verified that the resident’s orders were not transcribed upon readmission and acknowledged that the discharge orders should have been implemented when the resident returned. This deficiency was identified during an investigation of a complaint and affected one of three residents reviewed, with a facility census of 69.
Failure to Monitor IV Placement and Tourniquet Removal by Contracted Provider
Penalty
Summary
The deficiency involves the facility’s failure to ensure adequate supervision and monitoring following IV insertion by a contracted provider for one resident. The resident was admitted with diagnoses including syncope, generalized muscle weakness, cognitive communication deficit, and expressive language disorder, and was assessed as cognitively intact but requiring maximal assistance with most ADLs. A hospital discharge summary indicated IV fluids were to be discontinued and oral intake encouraged. On admission, nursing obtained orders for lab work due to dehydration concerns, and later, at the request of the resident’s POA, the DON obtained an order for PRN IV fluids and contacted a contracted IV company to place an IV line. Documentation from the contracted company showed IV line placement was completed and signed off at a specific time, but the medical record contained no immediate post‑procedure nursing assessment to verify removal of the tourniquet or evaluate the IV site. A late entry nursing note documented that the POA was concerned about hydration and that an IV team placed an IV line; the note stated the tourniquet was not removed prior to administering IV fluids and that another nurse later observed the tourniquet still in place and removed it. A subsequent nursing note documented that an IV was placed in the left arm, IV fluids were started, and that the resident’s daughter requested assessment of the arm, which was found to be swollen with a tourniquet still on the upper arm. The tourniquet was removed, the arm was elevated, and a cold compress was applied. The facility’s self‑reported incident and investigation did not specify the exact time of IV placement, the time swelling was identified, or the duration the tourniquet remained in place, and contained conflicting statements about how long the tourniquet was left on. Interviews revealed there was an expectation that staff assess IV sites after outside companies place lines, but no defined requirement for immediate post‑placement assessment. The Administrator acknowledged that the facility could not determine the timeframe the tourniquet remained on, had no documentation of when post‑placement assessment occurred until surveyor intervention, and had not provided education or information to the contracted company related to this event. An RN reported that after the contracted company completed the IV placement, he received verbal handoff, entered the room, and removed a tourniquet he observed, and then, after the resident’s daughter raised further concern, he reentered the room and removed a second tourniquet from the upper arm, noting slight swelling and applying a cold compress. He also stated that management was not notified of the arm’s condition until his next scheduled shift, and there was no documented evidence of timely monitoring by facility staff following the IV placement.
Failure to Complete Ordered Labs and Wound Culture Timely
Penalty
Summary
The deficiency involves the facility’s failure to ensure ordered laboratory tests and wound cultures were completed in a timely manner for one resident. The resident was admitted with multiple serious diagnoses, including a right humerus fracture, wedge compression fracture of the second lumbar vertebra, multiple rib fractures, thrombocytopenia, and hypertension, and was later discharged. Physician orders dated on one occasion directed that a complete blood count (CBC) and basic metabolic panel (BMP) be obtained, but review of the medical record showed no evidence these blood tests were ever completed. A provider progress note confirmed that the labs ordered on that date were not done. A subsequent physician order for a CBC and BMP was carried out, and those labs were completed as ordered. The facility also failed to complete a wound culture and sensitivity as ordered in a timely manner. A physician ordered a wound culture and sensitivity, and a specimen was collected and reported by the laboratory. However, the lab report indicated the test was not performed due to specimen integrity issues, specifically that the facility had submitted an expired swab and was instructed to recollect a new specimen. The medical record contained no documentation that a repeat wound culture was obtained following this notification. A later physician order for a wound culture and sensitivity was eventually carried out, with the culture collected on a later date. In an interview, the DON verified that the ordered labs from the earlier date were not completed and confirmed that the wound culture specimen had been collected with an expired swab and was not recollected until a later date.
Failure to Provide Comprehensive Pressure Ulcer Prevention, Treatment, and Appropriate Support Surfaces
Penalty
Summary
The deficiency involves the facility’s failure to implement and carry out a comprehensive, individualized pressure ulcer prevention and treatment program, resulting in actual harm to one resident and placing two additional residents at risk. One resident with multiple fractures, edema, and limited mobility was admitted with a Stage II pressure ulcer on the right upper thigh and a recent lumbar kyphoplasty incision closed with Dermabond. On admission, the baseline care plan did not identify any skin integrity concerns, despite the resident’s high assistance needs for bed mobility and a Braden score indicating risk for pressure ulcer development. A pressure ulcer care plan with specific interventions based on the Braden assessment was not developed, and the resident’s back wound was not identified until two days after admission, with no treatment order in place until another two days had passed. When an outside wound company first evaluated the resident’s upper back on 12/10, it identified a Stage II pressure ulcer with daily treatment orders including cleansing, medical grade honey, and calcium alginate. Facility wound documentation inconsistently described the wound location (mid back, lower back) and did not add wound-specific interventions to the care plan. The Treatment Administration Record showed that the ordered daily treatment was completed on only 8 of 35 days across December and January, with no documentation of as‑needed treatments. Turning and repositioning documentation showed 11 shifts in which the resident was not turned. Braden assessments were repeatedly documented as if the resident were only at risk for developing pressure ulcers, even after the back pressure ulcer was present, and the DON later verified these assessments were incorrect and that the resident was actually at high risk. The resident did not have an air mattress in place during observation, and the wound nurse confirmed that although one had been ordered, it was not yet in use. Over time, the resident’s back wound progressed from a Stage II pressure ulcer to an unstageable ulcer with 100% slough and then to a larger unstageable wound with odor after cleansing. The outside wound provider’s documentation and the facility wound nurse’s documentation conflicted regarding whether the back wounds were pressure ulcers or surgical wounds, whether they were present on admission, and whether the resident was on hospice or noncompliant with repositioning. The NP acknowledged miscommunication with the wound nurse and verified that the areas were on a bony prominence and not from dehiscence, while also stating there was no documentation of copious drainage or abscess despite suggesting that possibility. The facility wound nurse later verified that two separate areas on the resident’s back had been treated as one, that the care plan was not updated to address the back pressure ulcer, and that daily treatments were not completed as ordered. The deficiency also includes failures related to pressure-relieving surfaces for two other residents. One resident with severe cognitive impairment, dependence for mobility and ADLs, and significant weight loss had an order for a pressure reduction mattress documented on the TAR, but there were no orders for an air mattress, and staff could not state how long an air mattress had been in place. Observations showed the air mattress set at 170 pounds, while staff, including the wound nurse, were unaware of the resident’s current weight or the correct setting. This resident subsequently developed an in‑house acquired Stage II pressure ulcer to the right gluteus/buttock, first identified during bathing and later confirmed by the outside wound company. Another resident with multiple sclerosis, generalized muscle weakness, and dependence on staff for repositioning had an active order for a low air loss mattress with instructions to check function every shift, but there was no order specifying the appropriate weight dial setting and no care plan interventions to ensure correct mattress settings. Observation revealed the air mattress dial set to 325 pounds while the resident weighed approximately 173 pounds. An LPN confirmed the setting was too high and reported that the DON had instructed staff to raise the dial to make the bed firmer. The facility’s wound care policy required detailed documentation of wound care, including assessment data and resident tolerance, and required supervisor notification if wound care was refused, but the report documents missed treatments and lack of documentation of refusals or noncompliance, contributing to the identified deficiency in pressure ulcer prevention and care.
Failure to Provide Palatable Meals at Safe and Appetizing Temperatures
Penalty
Summary
Surveyors identified a deficiency in the facility’s failure to ensure food was palatable and served at appropriate temperatures for all residents receiving meals from the kitchen. During observation on 01/14/26 at 12:08 P.M., after all resident room trays had been delivered, the Dietary Manager (DM #216) obtained test tray temperatures and found the beef macaroni casserole at 131°F and the mixed capri vegetables at 120°F. At 12:10 P.M., review of the test tray with DM #216 showed the beef macaroni casserole was lukewarm, and DM #216 acknowledged the casserole should have had a much higher temperature and expressed surprise that the vegetables did not taste colder given the low temperature reading. DM #216 attributed the improper temperatures to the length of time the food cart sat on the unit before service. Resident interviews further supported concerns about food temperature and palatability. On 01/12/26 at 11:13 A.M., Resident #34 reported that the food was served cold. At 11:40 A.M. the same day, Resident #01 stated he disliked the food, did not like what was served or how it was cooked, and reported the food was served cold. At 12:49 P.M., Resident #10 stated the food tasted terrible and was always served cold. On 01/13/26 at 9:12 A.M., Resident #37 reported that the food was served cold and that serving sizes were improper. This deficiency was investigated under Complaint Number 2590724.
Inadequate Clean Linen Supply Affecting Resident Care and Comfort
Penalty
Summary
The facility failed to provide adequate clean linens, including towels, washcloths, bed pads, and fitted sheets, for residents on the first floor. A resident reported there were not enough towels and washcloths for residents to receive scheduled showers. Observation of the first-floor linen room showed only 14 bath towels and no washcloths, bed pads, or fitted sheets available, and a CNA confirmed this was the only clean linen storage area on that floor, stating staff would have to go to the laundry room to look for more. Observation of the laundry room revealed no dirty linens waiting to be washed, only one washer in use, and a limited supply of clean linens consisting of eight fitted sheets, eight bed pads, 12 towels, and 17 washcloths. The Housekeeping Supervisor stated he had recently put out 300 towels and many washcloths and verified that staff had reported there were not enough linens to provide resident care. He explained that some linens might be thrown away and that extra linens were often found left in resident rooms because CNAs took large amounts of linens to rooms and left unused items there. During a resident council meeting, two residents residing on the first floor reported that showers could not be completed at times due to a lack of towels and that there had been occasions when clean linens could not be placed on beds because there were no fitted sheets. One resident also reported receiving a fitted sheet that was supposed to be clean but was soiled and smelled of urine. Review of CNA Standards of Care and the Homelike Environment Policy showed expectations for showers, nail care, and linen changes, and for clean bed and bath linens in good condition, which were not met.
Failure to Conduct and Document Required Initial and Quarterly Care Plan Conferences
Penalty
Summary
The deficiency involves the facility’s failure to conduct and document initial and quarterly care plan conferences with residents and/or their representatives as required by regulation and facility policy. The facility policy states that patient care conferences are to be held within seven days of admission, upon significant change, and quarterly thereafter, with the interdisciplinary team developing a comprehensive, person-centered care plan in conjunction with the resident and family or legal representative. For multiple residents, surveyors found missing or significantly delayed care conferences despite completed MDS assessments and intact cognition, and the Social Service Director confirmed that required conferences were not held. For one resident with diagnoses including moderate protein malnutrition, cystic fibrosis, ALS, anxiety, gastrostomy, chronic pain syndrome, major depression, and functional quadriplegia, records showed care conferences only on 02/10/25 and 10/15/25, with no evidence of quarterly conferences in between. Another resident with diabetes, morbid obesity, adult failure to thrive, COPD, chronic respiratory failure, asthma, schizoaffective disorder, anxiety, depression, personality disorder, and PTSD had intact cognition and required varying levels of ADL assistance, yet there was no documented evidence of any plan of care conferences. The Social Service Director verified that quarterly care conferences were not held for these residents. Additional residents were similarly affected. One resident with protein calorie malnutrition, COPD, peripheral vascular disease, and atherosclerosis with leg ulceration had care conferences documented only on 02/05/25 and 04/11/25, with no further quarterly meetings. Another resident with type 2 diabetes, a right below-knee amputation, moderate protein-calorie malnutrition, and chronic kidney disease had intact cognition, but there was no evidence of any care conferences; the resident reported never attending a care conference, and the Social Service Director stated conferences were not done due to the resident’s inappropriate sexual behaviors and inability to reach family, without documentation of attempts or explanations as required by policy. One resident admitted with acute on chronic diastolic heart failure, ulcer of anus and rectum, and type 2 diabetes had an admission care conference, during which the resident requested that the wife not be notified; however, no quarterly care conferences were completed afterward, despite an MDS showing intact cognition. The resident stated they were not aware of any care conferences being held. Another resident with malignant carcinoid tumor of the stomach, severe protein-calorie malnutrition, type 2 diabetes, and vascular dementia, with severe cognitive impairment and a son listed as emergency contact, had no evidence of an initial care conference with either the resident or responsible party. The Social Service Director confirmed there was no initial care conference and could not explain why. A further resident with acute and chronic respiratory failure with hypoxia and hypercapnia, obstructive sleep apnea, and morbid obesity with alveolar hypoventilation had intact cognition and required assistance with ADLs, with documentation that the resident rejected care on some days. The medical record contained no indication that a care conference had been conducted or attempted. The resident reported not being asked to participate in care plan meetings, expressed a desire to go home, and stated dislike of social work interactions, indicating no opportunity to engage in the care planning process. The Social Work Director confirmed there was no documentation of a care conference, acknowledged only a verbal discussion about a potential conference months earlier, and no subsequent attempts or documentation, contrary to the facility’s comprehensive person-centered care plan policy requiring conferences and documentation of refusals or impracticability.
Failure to Implement and Document Ordered Wound, Skin, and Compression Treatments
Penalty
Summary
The deficiency involves multiple failures by facility staff to provide and document treatments and care as ordered for several residents. One resident with acute and chronic respiratory failure and morbid obesity had an order for Nystatin powder to the right neck fold twice daily and as needed, along with barrier cream after incontinence. The treatment administration records showed that, aside from a brief period in September, the Nystatin was not documented as given from September through mid-January, and bathing documentation was inconsistent, with several dates showing no bed bath or topical application. Observation revealed raw, red, painful skin under the neck fold, and both an LPN and a CNA acknowledged noticing redness for weeks without consistent treatment or reporting, while the DON confirmed the resident had not received proper topical treatment. Another resident with osteomyelitis, DM with foot ulcer, toe amputation, cellulitis, lymphedema, and edema had multiple wound and compression orders for a right great toe amputation site and lower extremity compression. The MAR/TAR showed numerous missed daily wound treatments, and there were no wound measurements or status updates to indicate improvement or decline, despite an earlier note stating the wound was closed while orders remained active. After visit summaries (AVS) from wound clinic and hospital visits contained detailed instructions for daily dressing changes and specific compression techniques that frequently did not match the facility’s physician orders, and several AVS documents were missing entirely. The wound nurse and other staff could not verify that treatments were completed, could not confirm certain absences from the facility, and acknowledged that AVS instructions were not consistently transcribed into orders or reflected on the TAR, while observations showed the resident without ordered ace wraps on multiple occasions. A resident with multiple sclerosis, chronic pain, and generalized weakness had active orders for three topical agents (zinc oxide, triamcinolone, terbinafine) to treat bilateral buttocks MASD three times daily, with cleansing prior to application. The MAR/TAR documented repeated missed administrations across many days in December and January for all three medications, despite progress notes confirming ongoing MASD and care planning for moisture control and incontinence management. The resident reported that staff were supposed to apply cream when she was changed but that treatments were not being completed as ordered, and the DON confirmed there was no documentation explaining the missed treatments and no interventions to ensure compliance with the orders. Another resident with COPD, DM, and peripheral vascular disease developed a new diabetic ulcer on the left foot, documented in a progress note with detailed measurements and cleansing and dressing instructions. However, the corresponding physician order was not entered until several days later, and the treatment was not documented as completed until the day after the order was written, resulting in a delay between identification of the wound and initiation of ordered care. A separate resident with acute kidney failure, malnutrition, COPD, AFib, and weight loss had an order for bilateral knee-high TED hose once daily for swelling, to be applied on day shift, but repeated observations over several days showed the resident without TED hose, and an LPN confirmed they were not in place as ordered. A resident with diabetes, morbid obesity, COPD, chronic respiratory failure, and psychiatric diagnoses had orders for wound care to the right groin and left genital region, including cleansing, mupirocin application, packing, and ABD pad coverage twice daily. Review of the TAR for December and January showed numerous dates and times where these treatments were not documented as completed, and an RN verified the missing treatment documentation for the groin wound. Another hospice resident with multiple comorbidities, including obesity, GERD, HTN, OSA, hyperlipidemia, gout, DM, and malignancy of the neck, had a left great toe area first identified by hospice as a DTI. The hospice nurse practitioner recommended preventative betadine treatment and leaving the area open to air starting on the date of assessment, but the facility did not initiate this order at that time. Progress notes were confusing regarding whether the toe had been assessed, no treatments were in place for the toe until a later order, and skin assessments for multiple weeks were created and locked on a single later date, rather than contemporaneously. A further resident admitted with lumbago with sciatica, COVID-19, acute respiratory failure, bradycardia, hyperlipidemia, and emphysema had a hospital discharge order for an incision to be left open to air with the surrounding skin washed daily with mild soap and water and patted dry. The admission assessment documented a mid-back incision measuring 16 cm by 1 cm, but the MAR/TAR contained no evidence that the daily washing and drying of the skin around the incision was performed. The DON confirmed that this order should have been on the treatment administration record and completed as ordered. Across these residents, surveyors identified failures to complete ordered treatments, failures to transcribe and implement AVS and physician orders in a timely manner, inconsistent or missing documentation of wound and skin care, and lack of alignment between external provider instructions and in-house orders and records.
Unsecured Medications, Inadequate Fall Prevention, and Unrepaired Door Hazard
Penalty
Summary
The deficiency involves the facility’s failure to maintain a safe, hazard‑free, and homelike environment, including improper medication security and supervision, delayed and incomplete fall prevention interventions, and failure to address a known door hazard. For one cognitively intact resident who was dependent on staff for medication administration but had an order to self‑administer only Promethazine under nurse supervision, surveyors observed multiple medications in his room. These included ordered medications such as Promethazine, allergy sprays, asthma inhalers, topical creams, and ammonium lactate, as well as additional inhalers (Symbicort and Breo Ellipta) for which there were no active physician orders. Some medications were on the bedside table and others were in a hospital return bag and backpack. The resident confirmed he kept medications in his room, including medications without current orders, and the Administrator acknowledged that only Promethazine was ordered for supervised self‑administration. In a separate instance, another cognitively intact resident who was dependent on staff for medication administration was found with a cup containing six morning medications on his bedside table. The RN confirmed these were his scheduled medications and that he was unable to self‑administer, despite facility policies requiring medications to be administered only by licensed staff and stored in locked compartments. The facility also failed to implement timely and adequate fall prevention interventions for residents at risk for falls. One cognitively intact resident, dependent on staff for medication administration and requiring supervision for several ADLs, experienced a fall from bed while reaching for an item on her bedside table, resulting in a skin tear to her right forehead. The fall occurred on a specific date but was not documented until a late entry note several days later, and the intervention to utilize arm rails was not initiated until the date of the late entry. The DON confirmed the facility did not identify or document the fall until that late entry and that the intervention was not put in place until that time. Another resident with severe cognitive impairment, high fall risk, extensive assistance needs, and a history of falls had multiple fall‑related interventions care planned, including bilateral fall mats and 1/2 side rails for maneuverability. This resident had two prior unwitnessed falls from bed, one with the resident partially on the floor with his arm trapped between the bed rail and frame and another with the resident found on his knees on the floor mat holding the bed rail, with pain and a skin tear documented. During observation, his bed was found raised and one fall mat was pushed almost completely under the bed, limiting its protective function. The RN confirmed the bed was not in the lowest position and that the mat’s placement would allow the resident to fall directly onto the floor, despite facility protocol to keep beds in the lowest position for safety. Additionally, the facility did not adequately address an environmental hazard related to the main entrance door, which resulted in injury to a resident. A cognitively intact resident with COPD, diabetes, peripheral vascular disease, and absence of the right great toe reported that a wound to his left big toe occurred when the broken front door slammed on his toe. Progress notes documented a skin issue to the left big toe with treatment started, but there was no documentation in the incident/accident log or medical record describing the door‑related incident. An RN stated she had received communication that the resident’s toe was crushed in the front door when it was broken, and confirmed the lack of incident documentation. The Maintenance Director reported the front door was first reported broken on a specific date and was not repaired until several weeks later by an outside vendor, indicating the door remained in disrepair during the period when the resident’s toe was injured. These combined failures—unsecured and unauthorized medications in resident rooms, leaving medications at bedside for a resident unable to self‑administer, delayed and improperly implemented fall interventions, and prolonged failure to correct a known door hazard—demonstrate the facility’s noncompliance with its own policies on medication storage, homelike environment, and fall risk management. This deficiency was investigated under Complaint Numbers 2669834 and 1350536 and affected five residents in a facility with a census of 65. The residents involved had varying levels of cognitive function and physical dependence, including severe dementia, high fall risk, and multiple chronic conditions such as heart failure, COPD, diabetes, and osteoarthritis. Facility policies reviewed by surveyors, including Medication Administration, Medication Labeling and Storage, Homelike Environment, and Falls and Fall Risk, Managing, required that medications be stored securely and administered only by licensed staff, that residents be provided a safe homelike environment, and that resident‑centered fall prevention interventions be implemented and adjusted based on risk factors and environmental hazards. The observations, interviews, and record reviews showed that these policies were not consistently followed in practice for the residents cited.
Failure to Provide Scheduled Bathing and Nail Care for Dependent Residents
Penalty
Summary
The deficiency involves the facility’s failure to ensure that dependent residents received activities of daily living (ADL) care, specifically bathing and nail care, as assessed and care-planned. One resident with intact cognition and multiple diagnoses, including diabetes, morbid obesity, COPD, chronic respiratory failure, and psychiatric conditions, had a quarterly MDS showing she required only setup or cleanup assistance for eating and was otherwise independent with oral hygiene, toileting, dressing, and personal hygiene. Review of her shower documentation showed no shower or bath recorded for two separate multi‑day periods, and the DON confirmed there was no evidence she received showers twice weekly as expected. Another resident with dementia, bipolar disorder, depression, anxiety, peripheral vascular disease, diabetes, and chronic kidney disease had an MDS indicating cognition was not intact and that she was dependent on staff for personal hygiene. Review of her shower records showed that showers or baths were not consistently provided twice weekly across multiple months. The DON verified that showers were not completed twice a week for this dependent resident, indicating that scheduled bathing needs were not met according to her assessed level of dependence. A third resident, cognitively intact with significant respiratory diagnoses and morbid obesity, was care‑planned as at risk for ADL decline and required dependent assistance for transfers, bed mobility, toileting, and showering, with maximum assistance for personal hygiene and nail care to be done on shower days or as needed. Documentation from mid‑November through mid‑January showed nail care consistently marked as N/A, with no indication that staff attempted nail care when the resident refused, and multiple scheduled shower/bed bath days lacked any record of bathing or nail care. The resident reported he had not left bed since July and that his nails had not been cared for during that time; observations showed long, soiled fingernails with brown debris and yellowing. The DON confirmed that N/A meant staff did not attempt nail care and that nail care had not been provided, and an LPN acknowledged the resident’s nails were long and visibly soiled and could not identify when nail care was last completed. The facility’s ADL policy required provision of bathing and grooming care unless decline was unavoidable or care was refused with appropriate documentation, which was not reflected in the records reviewed.
Failure to Follow Bowel Management Protocol for Constipated Resident
Penalty
Summary
Surveyors identified a deficiency related to failure to follow the facility’s Bowel Management Protocol for a resident with bowel incontinence. The resident was admitted with diagnoses including necrotizing fasciitis, acute and chronic respiratory failure, type 2 diabetes, and obstructive and reflux uropathy. The admission MDS documented that the resident was cognitively intact, had an indwelling catheter, and was always incontinent of bowel. The care plan dated 11/13/25 indicated the resident had bowel incontinence, with interventions to check and change the resident and encourage use of the call light for toileting assistance. A separate care plan dated 11/13/25 documented an ADL self-care performance deficit, stating the resident was totally dependent on one staff member for toileting. Review of bowel movement documentation showed that the resident did not have a bowel movement for four consecutive days on 12/23/25, 12/24/25, 12/25/25, and 12/26/25. During an interview on 01/14/26 at 2:31 P.M., the DON confirmed that the resident had no bowel movement for four days and that no bowel interventions were implemented during that period. The DON verified that the facility’s Bowel Management Protocol should have been followed. The protocol, dated 02/15/15, stated that residents were to be kept free from complications secondary to constipation through adequate assessment, tracking, and treatment, with normal bowel patterns defined as once every day up to once every three days. It further required nurses to provide or obtain ordered bowel medications for residents on the bowel care list, document medications on the MAR and bowel care list, and follow up for results. These steps were not carried out for this resident during the four-day period without a bowel movement.
Failure to Address Significant Weight Loss and Provide Ordered Nutritional Supplements
Penalty
Summary
The deficiency involves the facility’s failure to adequately address and monitor significant weight loss for two residents, including failure to provide ordered nutritional supplements and to complete required weekly weights. One resident with severe cognitive impairment and multiple diagnoses, including dysphagia, CHF, acute kidney failure, and anxiety disorder, experienced a documented 15.7% weight loss in 30 days and 10% in 90 days. The care plan identified risk for altered nutrition and ordered house supplements, snacks, and diet per physician orders. A dietitian recommended adding frozen nutritional treats twice daily and weekly weights after the significant weight loss was identified. Although an order for frozen nutritional treats with lunch and dinner was entered, the dietary department was not notified, and the meal ticket was never updated to include the supplement. On observation, the resident’s lunch tray did not include the frozen nutritional treat, and the CNA confirmed the meal ticket did not list it. Despite this, the MAR showed 100% consumption of the frozen nutritional treat, and the RN acknowledged documenting 100% intake without verifying that the supplement had been served or consumed. The Dietary Director confirmed that frozen nutritional treats had not been sent for the resident during the month and that half portions were being provided at the resident’s request, which the dietitian was not aware of. The dietitian stated she relied on medical record documentation to determine if supplements were being consumed and confirmed that inaccurate documentation could affect additional interventions. The DON verified that weekly weights ordered for the resident were not completed as recommended, and that the resident should have been weighed on specific weekly dates but was not. For the second resident, who had severe cognitive impairment, dementia with behavioral and mood disturbances, anorexia, and other comorbidities, the facility failed to follow its own policy for weight monitoring and notification after significant weight losses. The resident’s care plan and orders included weekly weights, Boost supplementation, total assistance with meals, offering alternatives if less than 50% of a meal was consumed, and notifying the nurse manager if meals or supplements were refused. Despite this, documented weights showed a 10.7% loss over six days and a 5.71% loss over three days, with no documentation that the dietitian or physician was notified. Subsequent dietary notes recorded weight warnings and acknowledged fluctuations and loss but did not show follow-up interventions or timely notifications after these significant losses. The dietitian later reported she was not notified of the significant weight loss episodes and instead identified one of the losses herself and requested a re-weigh order days later. She stated that staff were supposed to notify her of any weight change of 5 pounds or more, which did not occur during the July/August or November losses. Review of the facility’s Weight Monitoring and Nutritional Intervention policy showed that any weight change of 5% or more required a re-weigh the next day and notification of the dietitian, but this policy was not followed for this resident. Across both residents, the survey findings document failures to provide ordered nutritional supplements, failures in communication between nursing and dietary, inaccurate intake documentation, and failures to complete required weight monitoring and notifications in accordance with facility policy.
Medication Administration Errors with Insulin and Pantoprazole
Penalty
Summary
The deficiency involves a failure to maintain a medication error rate below 5%, with surveyors identifying 3 errors out of 25 observed medication administration opportunities, resulting in a 12% error rate. One resident with chronic kidney disease and aftercare for joint replacement had a physician order for pantoprazole 40 mg packet to be dissolved in 5 milliliters of apple juice and given once daily. During observation, a Certified Medication Aide (CMA) poured the pantoprazole packet into a cup of water and administered it, rather than using apple juice as ordered and as required by FDA instructions for pantoprazole delayed-release oral suspension. The Executive Director confirmed that the electronic MAR did not specify administration in apple juice or applesauce, and FDA guidance indicated pantoprazole granules must be given only in apple juice or applesauce due to pH requirements and specific preparation instructions. Another resident, admitted and readmitted with diagnoses including metabolic encephalopathy and type 2 diabetes, had a care plan addressing potential for unmanaged blood sugar and an order for Lantus insulin 18 units twice daily. During observation, an RN drew up Lantus in an insulin syringe, and when asked to verify the dose, the syringe’s black stopper was at the 20-unit mark. The RN initially asserted that the surveyor was looking at the wrong side of the syringe and claimed that one side showed 1-unit increments and the other 2-unit increments, stating she had drawn up 18 units. Upon further questioning, the RN rechecked the syringe and adjusted the plunger to the 18-unit mark. The DON later verified that the insulin syringe was marked in 1-unit increments on both sides, confirming that the RN had initially prepared an incorrect dose. A third resident with a fracture of the left femur and type 2 diabetes had a care plan for altered endocrine function and an order for Humalog insulin 19 units before every meal. During observation, the CMA removed a new Humalog KwikPen from the medication cart, dialed it directly to 19 units, and prepared to administer it. When the surveyor asked whether the pen needed to be primed, the CMA stated she did not understand the question and again indicated she did not know what priming was before entering the resident’s room to administer the insulin. Manufacturer instructions for the Humalog KwikPen specified that the pen must be primed before each injection by selecting 2 units, holding the pen needle-up, tapping to collect air bubbles, and pushing the dose knob until zero appears, to ensure proper function and accurate dosing. These events occurred despite facility policies and the medication aide job description requiring staff to follow medication labels, verify orders, and administer medications in accordance with established nursing standards, facility policies, and state requirements.
Incomplete and Inaccurate Medical Records for Nutrition and UTI Evaluation
Penalty
Summary
The deficiency involves failures to maintain complete and accurate medical records for two residents. For one resident with neuropathy, sick sinus syndrome, dysphagia, congestive heart failure, urogenital implants, acute kidney failure, and anxiety disorder, the care plan identified potential for altered nutrition and ordered house supplements and diet per physician orders. A weight change note documented that this resident’s weight had decreased to 121 pounds, reflecting a 15.7% loss in 30 days and 10% in 90 days, and a frozen nutritional treat supplement twice daily with weekly weights was recommended and ordered. The MAR showed the frozen nutritional treats as started and consistently documented as 100% consumed twice daily. However, direct observation of a lunch meal showed that no frozen nutritional treat was on the resident’s tray, the meal ticket did not list the supplement, and the CNA confirmed it had not been provided. The RN who documented 100% intake of the frozen nutritional treat acknowledged making that entry, and the Dietary Director confirmed that frozen nutritional treats had not been sent to the resident during the month, demonstrating inaccurate documentation of supplement administration. For another resident with multiple sclerosis, refractory anemia, centrilobular emphysema, and mild persistent asthma, the medical record showed the resident was cognitively intact but totally dependent on staff for ADLs, had an indwelling catheter, and was occasionally incontinent of urine and always incontinent of bowel. The record documented a positive urine dipstick for leukocytes and/or nitrate, followed by two urine cultures that were reported as contaminated with more than three organisms and included lab instructions to follow up if clinically indicated. There was no documentation in the medical record of any follow-up, evaluation, or intervention related to the positive dipstick results, the contaminated cultures, or the resident’s reported abdominal pain, and no laboratory results for the positive dipstick were present in the chart. An LPN confirmed that no follow-up was completed and that there was no documentation addressing these findings, indicating incomplete and inaccurate medical records regarding possible infection.
Failure to Manage Resident's Pain After Fall
Penalty
Summary
The facility failed to effectively manage the pain of a resident following an unwitnessed fall that resulted in a T12 spinal fracture. The resident, who had a history of spinal stenosis, dementia, and osteoporosis, reported severe pain after the fall. Despite being assessed by a Certified Nurse Practitioner (CNP) and reporting a pain level of 10 out of 10, the resident did not receive any additional pain medication or non-pharmacological interventions before being transported to the hospital. The resident was initially given scheduled pain medications, including Tylenol, Oxycodone, and Gabapentin, but no PRN medications were administered despite the resident's severe pain. The facility's staff, including a Unit Manager and a Licensed Practical Nurse, failed to monitor the resident's pain levels adequately or provide any additional pain relief measures. The resident was transported to the hospital nearly four hours after the initial assessment, where a CT scan confirmed an acute T12 vertebral fracture. Interviews with facility staff revealed a lack of communication and timely action in managing the resident's pain. The CNP was unaware of the delayed transport and stated that additional pain management would have been provided if the delay had been known. The facility's policy on pain management, which includes conducting comprehensive pain assessments and attempting non-pharmacological interventions, was not followed, leading to the resident experiencing prolonged and severe pain.
Failure to Deliver Resident Mail Timely on Weekends
Penalty
Summary
The facility failed to ensure timely delivery of mail to residents, particularly on weekends. Interviews with several residents revealed that they do not receive mail on Saturdays because the activity staff, responsible for distributing mail, do not work on weekends. The receptionist confirmed that mail is received from Monday through Saturday, but any mail delivered on Saturday is kept at the front desk or in the copy room until Monday. The Activities Director corroborated that there is no activity department staff available on weekends, resulting in Saturday mail being distributed on Monday morning. A review of the facility's notice on mail delivery, dated November 30, 2023, stated that residents should receive personal mail unopened, including Saturday deliveries, which was not being adhered to.
Activity Director Lacks Required Qualifications
Penalty
Summary
The facility failed to ensure that the Activity Director met the minimum qualifications for the position, which had the potential to affect all 99 residents. The Activity Director, who started in July 2024, had only received about a day and a half of training and had no prior experience in long-term care or with activities or recreation. During an interview, the Activity Director mentioned that she was working on a certification course for activities, funded by the facility, which was expected to take about six months to complete. However, she was unable to provide evidence of any completed modules or a certificate of completion. The Human Resources representative acknowledged that the Activity Director should not have been hired without meeting the minimum criteria for the position. A review of the employee record confirmed enrollment in the course but did not specify when the enrollment occurred or the status of the coursework.
Deficiencies in Infection Control and Water Management
Penalty
Summary
The facility failed to implement a comprehensive water management plan to prevent Legionella, as evidenced by the absence of a water management team and lack of documentation regarding the water flow system. The Maintenance Director admitted to not having regular meetings with a water management team and was unable to provide documentation about the water system's intake points and distribution. Additionally, the Maintenance Director lacked adequate training in infection control and Legionella management, which is crucial for identifying and managing hazardous conditions that support the growth and spread of Legionella. In another instance, the facility did not adhere to proper infection control techniques during wound dressing changes for a resident with multiple pressure injuries. The Wound Clinic Nurse used the same gauze to clean three different wounds on the resident, which is against standard infection control practices. The nurse admitted to using the same gauze and only turning it over between cleaning different areas, which could lead to cross-contamination and infection. Furthermore, the facility failed to complete tuberculosis testing as per its own assessment requirements. Two State Tested Nurse Aides were found to have incomplete or missing tuberculin tests upon hire. Additionally, the facility did not utilize Enhanced Barrier Precautions for a resident with a gastric tube, despite CDC guidelines recommending such precautions for residents with indwelling medical devices. The Director of Nursing confirmed that the resident was not under enhanced barrier precautions, as the gastric tube was only used for flushing and not for nutrition.
Failure to Include Daily Room Rate on Bed Hold Notices
Penalty
Summary
The facility failed to include a daily room rate on bed hold notices for four residents who were transferred to the hospital. This deficiency was identified through a review of medical records, bed hold notices, staff interviews, and facility policy. The residents affected included those with various medical conditions such as chronic respiratory failure, spinal stenosis, and diabetes, among others. Each resident was transferred to the hospital for different medical reasons, such as a fall, uncontrolled pain, or issues with a PEG tube site. Despite being provided with a Notice of Transfer and Bed Hold, the notices lacked the necessary information regarding the daily room rate, which is required for residents or their representatives to make informed decisions about holding their beds during hospital stays. Interviews with the Director of Nursing and other staff confirmed the omission of the daily room rate on the bed hold notices. The facility's policy on resident transfer and discharge, which was reviewed, mandates that non-Medicaid residents be provided with written notice of the facility's bed-hold policy, including the amount of the bed-hold. However, this policy was not adhered to, as evidenced by the missing information on the notices provided to the residents. This oversight affected the residents' ability to make informed decisions regarding their bed holds during their hospital transfers.
Deficiencies in Following Physician Orders and Medication Administration
Penalty
Summary
The facility failed to follow physician orders for several residents, leading to deficiencies in care. Resident #37, who had chronic respiratory failure and other conditions, was not weighed daily as ordered due to a malfunctioning weight machine, and the physician was not notified of significant weight fluctuations. Similarly, Resident #43, with a history of hypertension and other medical issues, had blood pressure and heart rate readings outside the prescribed parameters, yet the physician was not informed as required by the orders. Resident #51, diagnosed with dementia and other conditions, also experienced a lack of communication with the physician regarding blood pressure and heart rate readings that were outside the specified parameters. Additionally, there was no evidence that the resident's heart rate was monitored before administering Carvedilol, as ordered. Resident #62 did not receive several medications as prescribed due to delays in pharmacy delivery, affecting their treatment for conditions such as HIV and diabetes. Resident #68, who had undergone a complex surgical procedure, experienced issues with a malfunctioning PEG tube that was not promptly addressed. The resident was confined to bed due to the leaking tube, which was not properly managed or repaired, and there was a lack of communication with a GI specialist to resolve the issue. This situation led to the resident's transfer to a hospital after surveyor intervention, as the facility could not meet the resident's needs.
Non-Compliance with Smoking Policy and Fall Prevention Measures
Penalty
Summary
The facility failed to enforce its non-smoking policy, affecting three residents who were observed smoking near the facility's main entrance. Resident #92, with mild cognitive deficits, was deemed safe to smoke independently if he followed the facility's rules, but was observed smoking on the premises. Resident #94, with mild cognitive deficits and a history of non-compliance with the smoking policy, was also observed smoking near the entrance. Resident #213, with severe cognitive deficits and deemed unsafe to smoke independently, was similarly observed smoking near the facility. The facility's policy requires residents to smoke off the premises, but this was not enforced, and safety measures such as ashtrays and fire extinguishers were not present. The facility also failed to implement fall prevention measures for Resident #37, who had a history of falls and required a bedside commode as an intervention. Despite multiple unwitnessed falls in the bathroom, the care plan did not include the necessary intervention, and observations confirmed the absence of a bedside commode in the resident's room. The Director of Nursing confirmed the oversight, acknowledging that the resident should have had a bedside commode due to the risk of falls. Additionally, the facility did not conduct neurological checks as scheduled for Resident #43 after an unwitnessed fall. The resident, with impaired cognition and a history of falls, reported new onset head and back pain following the fall. Although neurological assessments were initiated, they did not adhere to the facility's policy of checks every 15 minutes for the first hour. The Director of Nursing confirmed the deficiency in completing the required neurological assessments, which were crucial given the resident's condition and reported pain.
Inadequate Nutritional and Hydration Support in LTC Facility
Penalty
Summary
The facility failed to provide adequate nutritional and hydration support to residents at risk, as evidenced by the cases of six residents. Resident #15, who was totally dependent on staff for eating, experienced significant weight loss without proper documentation of meal and fluid intake. Observations revealed that Resident #15 was left without necessary feeding assistance, and there were multiple instances where meal and fluid intakes were not recorded. Additionally, nutritional supplements were not consistently provided or documented, leading to further nutritional decline. Resident #68, who was receiving Total Parenteral Nutrition (TPN), experienced weight loss without adequate monitoring or follow-up on her nutritional status. Despite being on TPN and a clear liquid diet, her weight was only recorded twice during her stay, and there was no documentation of her nutritional status after the initial assessment. This lack of monitoring and communication with the physician and dietitian contributed to her unaddressed weight loss. Other residents, such as Resident #4, Resident #100, Resident #58, and Resident #55, also faced issues with inadequate monitoring of weights and fluid intake. Resident #4, who was on tube feeding, did not have weights recorded as per facility policy. Resident #100 and Resident #55 had fluids placed out of reach, leading to dehydration risks. Resident #58 did not have weights recorded for two months, and meal intakes were consistently low, indicating potential nutritional deficits. These deficiencies highlight a systemic failure in ensuring proper nutritional and hydration care for residents at risk.
Failure to Provide Evening Snacks to Residents
Penalty
Summary
The facility failed to ensure that residents were offered snacks in the evening, affecting specific residents and potentially impacting a large portion of the facility's population. Interviews with residents during a Resident Council meeting revealed that they were not receiving snacks as expected. The Director of Dietary Services and the Regional Dietary Manager indicated that it was the responsibility of nurses and state-tested nursing aides (STNAs) to retrieve snacks for residents upon request. However, observations showed that the nutrition rooms on different floors lacked available snacks, and there was no routine practice of offering snacks to residents. The facility's policy on snacks, dated October 2022, stated that snacks and beverages should be provided as identified in individual care plans, with bedtime snacks available for all residents. Despite this policy, observations and interviews with staff revealed inconsistencies in the availability and distribution of snacks. The nutrition rooms were found to be inadequately stocked, and there was no clear process for routinely offering snacks to residents, leading to the deficiency noted in the report.
Sanitation Deficiencies in Kitchen and Nutrition Rooms
Penalty
Summary
The facility failed to maintain the kitchen and nutrition rooms in a sanitary manner, potentially affecting 96 residents who received food from the kitchen. During observations, surveyors noted the presence of gnats in the kitchen entryway and dry storage area. The ice machine in the kitchen had a black speckled substance on the chute, and the dry storage area had dirt-like substances around the baseboards. Additionally, two large bins containing open bags of sugar and cornmeal were not dated when opened, and the bin lids had dry particles on them. Further observations revealed that a refrigerator freezer in Unit One's nutrition room was not functioning, with a temperature of 58 degrees Fahrenheit and thawed ice packs inside. The ice machine chute in this room also contained a black speckled substance. On the second floor, dirty trays with food containers were found stacked on counters, and the ice machine chute was similarly dirty. The facility's policies on food preparation, storage, and environmental cleanliness were reviewed, highlighting the requirement for food contact surfaces to be cleaned and sanitized after each use, and for cold foods to be stored properly to prevent contamination.
Failure to Return Resident Funds Upon Discharge
Penalty
Summary
The facility failed to properly manage and return a resident's personal funds upon discharge, affecting one resident. The resident, who had been diagnosed with unspecified dementia, diabetes, malnutrition, bipolar disorder, and delirium, was admitted on an unspecified date and had $1,331.19 in their resident fund account as of January 2024. The account was closed, but the funds were not returned to the resident upon discharge. The Business Office Manager, who started in July 2024, confirmed that there was no evidence of a check being provided to the resident. The facility's policy requires that funds be returned within 30 days of discharge, but the dispersal of funds was still pending administrator approval as of October 2024.
Failure to Provide Spenddown Notifications to Residents
Penalty
Summary
The facility failed to provide required spenddown notifications to residents, affecting two residents out of six reviewed for resident funds. Resident #6, who was admitted with diagnoses including dementia, schizophrenia, nutritional anemia, and diabetes, had personal fund balances exceeding the Medicaid resource limit from January to April 2024. Despite these balances, there was no evidence that the resident received the necessary notifications to spend down their resources to remain under Medicaid limits. Similarly, Resident #74, admitted with conditions such as hypertensive heart disease, heart failure, atrial fibrillation, pulmonary hypertension, bipolar disorder, and mood disorder, had a personal fund balance that exceeded the Medicaid resource limit from April to July 2024. The Business Office Manager confirmed that the facility provided quarterly spenddown notifications but could not provide evidence of any notifications given to residents. The facility's policy required notifying residents when their account balance approached $2000.00 of the Medicaid resource limit, but this was not adhered to.
Failure to Notify Physician of Resident's Weight Loss
Penalty
Summary
The facility failed to notify the physician of a change in condition for a resident, which was identified during a review of the medical records and staff interviews. The resident, who had no cognitive deficits, was admitted with diagnoses including diabetes, hypertension, and post-surgical complications. She was receiving Total Parenteral Nutrition (TPN) and was on a clear liquids diet. Over a period of 19 days, the resident experienced a weight loss of 9.4 pounds, equating to 4.37% of her body weight. Despite this significant weight loss, there was no documentation indicating that the physician or dietician had been informed. Interviews with the resident and her sister revealed concerns about the resident's weight loss and lack of communication regarding her condition and discharge plans. The facility's policy on notifying changes in a resident's condition was not followed, as confirmed by interviews with a registered nurse and a dietician. They acknowledged that neither the physician nor the dietician had been notified of the resident's weight loss, and no additional weight measurements were available. This oversight had the potential to affect the resident's nutritional status and overall health.
Unauthorized Withdrawal from Resident's Fund Account
Penalty
Summary
The facility failed to protect a resident's personal funds from misappropriation, affecting one resident out of six reviewed for resident funds. The resident, who had multiple sclerosis, failure to thrive, muscle weakness, and diabetes, had their account improperly accessed. The resident's funds statement showed regular deposits from pensions and social security, with withdrawals leaving only $50 each month. However, an additional unauthorized withdrawal of $1,136 was made, leaving the account with a zero balance. This withdrawal was acknowledged in email communication between the Regional Business Office Manager and the Business Office Manager, who confirmed the unauthorized transaction. The Business Office Manager admitted to withdrawing the funds under the instruction of another Regional Business Office Manager, mistakenly believing it was for an outstanding care balance. The resident was not informed, nor was there written authorization for this transaction. The facility's policy required authorization and signatures for withdrawals, and accounts were to be audited quarterly. Despite these policies, the facility could not account for the funds until surveyor intervention revealed the misappropriation. The facility's policies on resident personal funds and abuse prevention emphasized safeguarding funds and investigating misappropriations, which were not adhered to in this instance.
Lack of Dental Care Plan for Resident
Penalty
Summary
The facility failed to ensure that a resident had a care plan for dental care, which affected one resident out of a sample of 27. The resident, who was cognitively intact, had multiple diagnoses including multiple sclerosis, failure to thrive, weakness, chronic pain, and diabetes. A progress note from February 2022 indicated that the resident had seen a dentist who recommended the extraction of several teeth and the creation of dentures. However, despite a care conference in April 2022 where the resident expressed a desire to proceed with the extractions, there was no evidence in the progress notes that the extractions were performed. Further review of the resident's medical records revealed a physician order for a dentist referral for two teeth extractions in April 2024, but the plan of care dated October 2024 did not include any mention of dental needs. Interviews with the resident, Social Services Director, Regional Administrator, and Clinical Regional RN confirmed the absence of a dental care plan and lack of follow-up on the dental services needed. The facility acknowledged the deficiency but had not implemented a care plan to address the resident's dental needs.
Failure to Assist Resident with Timely Transfer Referrals
Penalty
Summary
The facility failed to assist a resident, identified as Resident #22, in a timely manner with referrals for transfer, which was a deficiency found during the survey. Resident #22, who was admitted with diagnoses including multiple sclerosis, failure to thrive, weakness, chronic pain, and diabetes, expressed a desire to move closer to Ohio. Initial referrals were made, but there was a significant gap in follow-up and further assistance. The resident was cognitively intact, as indicated by a BIMS score of 15, and had been waiting for assistance with the transfer for several months. Interviews with the resident and the Social Services Director confirmed that while initial referrals were made, there was no evidence of ongoing discharge planning or assistance from January 26, 2024, to October 20, 2024. The Social Services Director acknowledged the lack of follow-up and confirmed that the resident had not been provided with a list of in-network nursing facilities from their insurance. This inaction was contrary to the facility's discharge planning notice, which stated that residents should be assisted in selecting a post-acute care provider in line with their goals and treatment preferences.
Failure to Meet Personal Care Needs for Shaving
Penalty
Summary
The facility failed to adequately meet the personal care needs of a resident, specifically in relation to shaving. The resident, who was admitted with multiple diagnoses including diabetes mellitus with diabetic chronic kidney disease, obesity, dislocation of lumbar vertebra, bilateral osteoarthritis, and a history of transient ischemic attack, was cognitively impaired and required maximum assistance for personal hygiene. Despite being scheduled for showers twice a week, there was no documentation of facial hair removal during these times, and observations revealed the resident had significant facial hair on multiple occasions. Interviews with the resident indicated a desire for staff to proactively assist with facial hair removal, as the staff only performed this task upon request. The Director of Nursing confirmed that staff should be asking residents if they would like their facial hair trimmed. However, observations during the survey period showed that the resident continued to have unkempt facial hair, indicating a failure to adhere to the facility's ADL policy, which emphasizes preserving function, promoting independence, and maintaining dignity through grooming interventions.
Failure to Provide Resident-Centered Activities
Penalty
Summary
The facility failed to provide daily activities that met the interests and needs of residents, specifically affecting two residents. Resident #55, who has multiple diagnoses including cerebrovascular disease and cognitive communication deficit, was observed multiple times lying in bed in a dark room without any music, television, or interaction with others. Despite having preferences for listening to music and going outside, these were not assessed in recent MDS assessments, and the care plan did not align with his preferences. The Activity Director confirmed that Resident #55's activity preferences were not assessed during significant change and quarterly MDS assessments, and there was no documented attendance for activities. Resident #100, with severe cognitive impairment and multiple health issues, was also not provided with activities that matched his preferences. Observations revealed that he was often found yelling for help, lying in bed without personal belongings or stimulating activities, and the television was positioned out of his view. The care plan included interventions for engaging in simple activities and encouraging social interaction, but these were not implemented. The Leisure Services staff confirmed the lack of activities for residents who do not leave their rooms or require one-on-one assistance, and there were no documented recreation visits for Resident #100. The facility's recreation programs are designed to meet individual needs and are scheduled daily, but these were not effectively implemented for the two residents. The Activity Director and Leisure Services staff acknowledged the deficiencies in assessing and providing activities according to the residents' preferences and care plans. The lack of documented activity participation and the failure to assess preferences during MDS assessments contributed to the deficiency in meeting the residents' needs.
Failure to Ensure Proper Catheter Care and Orders
Penalty
Summary
The facility failed to ensure proper orders and routine care for indwelling urinary catheters for two residents. Resident #88, who has multiple health conditions including diabetes, pressure ulcers, and sepsis, was found to have an indwelling urinary catheter without any current orders for its care, treatment, or placement. The resident, who is cognitively intact, reported that the catheter had not been changed since admission. This was confirmed by a Clinical Regional Registered Nurse, who verified that there were no orders for catheter care until a later date. Similarly, Resident #100, who is severely cognitively impaired and dependent on staff for all activities of daily living, had an indwelling catheter with no documented routine care from the time of admission until a later date. The resident's care plan lacked interventions for catheter care, and the treatment administration record showed that routine catheter care was not implemented until much later. The Director of Nursing confirmed that routine catheter care was not started until the specified date, despite the facility's policy to prevent infection and reduce irritation through regular catheter care.
Failure to Address PTSD in Resident Care Plan
Penalty
Summary
The facility failed to identify and care plan for a resident with Post Traumatic Stress Disorder (PTSD), which included the lack of non-pharmacological interventions to eliminate or mitigate triggers that may cause re-traumatization. The resident, who was admitted with multiple diagnoses including PTSD, was assessed to have mildly impaired cognition and was totally dependent on staff for daily activities. Despite these conditions, the social service admission assessment indicated that the resident did not wish to speak with a mental health professional, and no further trauma assessment or care planning was initiated. Additionally, the nursing admission assessment did not include a trauma assessment, and the resident's care plan did not address the PTSD diagnosis. This oversight was confirmed by a Regional Registered Nurse during an interview.
Failure to Address Pharmacy Recommendations and Incomplete Documentation
Penalty
Summary
The facility failed to ensure that pharmacy recommendations were addressed by the physician, including providing a rationale for not following these recommendations. This deficiency affected two residents. For Resident #11, the pharmacist made several recommendations regarding medication management, including clarifying oxycodone administration instructions, evaluating psychotropic drug therapy, and addressing a potential insulin allergy. The physician disagreed with the pharmacist's recommendations without providing the required rationale or completing the necessary documentation. Additionally, the resident's allergy profile was not updated despite a note indicating the insulin allergy was not true. For Resident #15, the pharmacist recommended a lipid panel for monitoring due to the resident's antipsychotic medication use, which was overdue. The physician disagreed with this recommendation but did not provide an explanation or complete the necessary documentation. Interviews with an LPN confirmed the lack of parameters for medication administration and the incomplete documentation by the physician, contributing to the deficiency.
Lack of Parameters for As-Needed Pain Medications
Penalty
Summary
The facility failed to ensure that residents receiving multiple as-needed pain medications had appropriate parameters in place for their administration. This deficiency was identified during a review of medical records, facility policy, and staff interviews, affecting two residents. Resident #11, who was cognitively intact, had diagnoses including chronic obstructive pulmonary disease, pyogenic arthritis, chronic kidney disease, and migraines. The resident's medication orders included Oxycodone and acetaminophen, both prescribed as needed for pain, but lacked specific parameters for their administration. The medication administration records showed frequent use of Oxycodone with varying pain scores, and acetaminophen was administered without clear guidelines. Similarly, Resident #15, with diagnoses of chronic obstructive pulmonary disease, quadriplegia, and constipation, also had multiple as-needed pain medications prescribed without parameters. The resident's medication orders included Norco and acetaminophen, both administered as needed for pain. The medication administration records indicated that Norco was given on multiple days with pain scores ranging from three to eight, and acetaminophen was administered without documented pain scores. Interviews with nursing staff confirmed the absence of parameters for administering these medications, and the facility's policy emphasized the need for pain assessment and management based on verbal and non-verbal cues.
Failure to Provide Timely Dental Services
Penalty
Summary
The facility failed to provide timely dental services and follow-up for a resident, affecting their dental health. The resident, who was admitted with multiple sclerosis, failure to thrive, weakness, chronic pain, and diabetes mellitus, was recommended for multiple teeth extractions and dentures by a dentist. Despite the resident expressing a desire for the extractions during a care conference, the facility experienced delays in scheduling and coordinating the necessary dental services. Initial attempts to arrange the extractions with 360 dental were unsuccessful, leading to a referral to other dental clinics. However, the resident missed an appointment due to transportation issues and lack of information, and there was no documentation of rescheduling or follow-up for the extractions until 2024. The resident, who was cognitively intact, expressed concerns about his dental condition, demonstrating loose teeth during an interview. The facility's social services director confirmed that there was no evidence of the resident being rescheduled for dental services after the missed appointment in 2022, and there was no knowledge of a physician order placed in 2024 for dental care. The facility's policy stated that residents should receive dental services according to their assessment and care plan, with social services responsible for arranging appointments and transportation. However, the lack of follow-up and coordination resulted in the resident not receiving the necessary dental care.
Inappropriate Antibiotic Prescriptions Due to Non-Adherence to Stewardship Program
Penalty
Summary
The facility failed to adhere to its antibiotic stewardship program, which aims to ensure antibiotics are used only when necessary and appropriately prescribed. This deficiency was identified through a review of medical records, staff interviews, and facility policy. Two residents were affected by this failure. Resident #10 was prescribed Macrobid for a suspected urinary tract infection (UTI) without any supporting evidence of infection, such as abnormal lab results or symptoms that met McGeer's criteria. The prescription was initiated at the family's insistence despite the absence of clinical indicators for a UTI. Similarly, Resident #163 was inappropriately prescribed Macrobid as a prophylactic measure following hospital discharge, despite having a history of resistance to this antibiotic. The resident did not exhibit symptoms that met the Loeb minimum criteria for antibiotic use. The initial prescription was not supported by the facility's infection control log, which later indicated a switch to ampicillin after a urine culture identified an infection caused by Escherichia coli. The facility's failure to follow its antibiotic stewardship policy resulted in the inappropriate use of antibiotics for both residents. The policy, which incorporates McGeer's definitions of infection, was not adhered to, leading to unnecessary antibiotic prescriptions. This oversight was confirmed by Registered Nurse #384, who acknowledged the lack of evidence supporting the antibiotic orders for both residents.
Failure to Treat Resident with Dignity and Respect
Penalty
Summary
The facility failed to treat a resident with dignity and respect, as observed in the case of a resident diagnosed with multiple sclerosis, failure to thrive, weakness, chronic pain, and diabetes. The resident was cognitively intact with a BIMS score of 15. The issue arose when the resident missed a dental appointment due to transportation issues, and the social services staff blamed the resident for the missed appointment. The social services aide was reported to have yelled at the resident and threatened to arrange for a guardian, despite the resident being alert and oriented. Interviews confirmed that the social services aide had been disrespectful towards the resident, and the Social Services Director acknowledged overhearing the incident and intervening. The facility's policy on resident rights emphasizes treating residents with dignity, courtesy, and respect, which was not adhered to in this case. This deficiency was noted under Complaint Numbers OH00158801 and OH00158752.
Failure to Ensure Call Light Accessibility for Resident
Penalty
Summary
The facility failed to ensure that call lights were within reach of a resident, leading to a deficiency. Resident #15, who was admitted with diagnoses including chronic obstructive pulmonary disease, quadriplegia, schizophrenia, anxiety disorder, and major depressive disorder, was affected by this oversight. The resident had mildly impaired cognition and was totally dependent on staff for bed mobility, transfers, toileting, and eating. According to the care plan, the resident was supposed to have a disc call button on the left side of her head within reach to activate it by turning her head. However, observations on two separate occasions revealed that the call light pad was not within reach, as it was either hanging off the side of the bed or clipped to the pillow but not accessible to the resident's chin. Staff confirmed that the resident could not reach the call light, which was against the facility's policy requiring call lights to be within reach at all times.
Failure to Address Lighting Issues Timely
Penalty
Summary
The facility failed to address lighting issues in a timely manner for a resident, leading to a deficiency in maintaining a safe, clean, comfortable, and homelike environment. The resident, who was cognitively intact, reported that the over-the-bed light had been out for several weeks. Despite informing the Maintenance Director, the issue remained unresolved due to delays in ordering and receiving the correct light bulbs. The maintenance log did not contain any entries regarding the light being out, indicating a lack of documentation and follow-up on the reported issue. Interviews with the resident and the Maintenance Director revealed that the resident had been informed about the high cost of the order and was waiting for corporate approval. The Maintenance Director admitted to being unsure about when the request was sent for approval and could not provide any records to establish a timeline for the resolution of the issue. This lack of documentation and timely action resulted in the resident waiting an extended period for the light to be replaced, highlighting a deficiency in the facility's maintenance and response procedures.
Communication Barrier Leads to Deficiency in Resident Care
Penalty
Summary
The facility failed to consistently engage in effective communication with a resident whose primary language was Spanish, leading to a deficiency in care. The resident, who had a history of chronic respiratory failure, repeated falls, anxiety disorder, and other conditions, required assistance with personal care and had a communication problem due to a language barrier and unspecified hearing loss. Despite the care plan indicating the need for a translator, there was no evidence that a translator was utilized during multiple incidents where the resident experienced falls. The lack of communication tools or translator services hindered the staff's ability to understand the resident's needs and circumstances surrounding the falls. Observations and interviews revealed that the resident had difficulty understanding English and was not provided with adequate resources to communicate effectively. Staff, including an LPN, were unaware of how to access translation services, and there were no instructions available in the resident's room. The Director of Nursing confirmed the existence of a phone number for translation services but acknowledged that staff had not been educated or trained on its use. The facility's policy on translation services was not effectively implemented, contributing to the communication barrier and subsequent deficiency.
Deficiencies in Pressure Ulcer Care and Mattress Replacement
Penalty
Summary
The facility failed to develop and implement a comprehensive and individualized skin integrity program, affecting three residents. Resident #40 was identified with an arterial ulcer on the left heel, but there was a delay in initiating treatment. The wound was identified on 04/17/24, but treatment orders were not placed until 04/23/24. Despite interventions like offloading heels and using an air mattress, the facility did not document the completion of dressing changes for seven days. The wound nurse practitioner was informed of the wound in a timely manner but was unaware of the delay in treatment orders. Resident #5 experienced issues with a malfunctioning mattress, which was not addressed promptly. The mattress was reported to be flat and beeping on 10/15/24, but no action was taken until 10/23/24, when a replacement was ordered and then canceled due to the resident's refusal. The resident had multiple pressure ulcers and was noncompliant with treatment, which was documented in the care plan. Despite the resident's refusal to change the mattress, there was no documentation of attempts to address the issue or the resident's refusals. Resident #4 was admitted with pre-existing pressure injuries, but there were no physician orders for wound dressing changes until four days after admission. The resident's wounds were not assessed or treated until 10/07/24, despite being admitted on 10/03/24. The facility's policy required that residents with identified skin breakdown receive treatments as ordered, but this was not followed. The lack of timely wound care and documentation contributed to the deficiency in providing appropriate pressure ulcer care.
Non-Functional Call Light Systems in LTC Facility
Penalty
Summary
The facility failed to ensure a functional call light system for residents, affecting two residents reviewed for call light systems. Resident #31, who was cognitively impaired and dependent on staff for all activities of daily living, had a non-functioning call light system for over a month. Despite the resident's care plan indicating a need for assistance due to fall risk, no work orders were placed for the repair of the call light system. Observations confirmed that the call light did not alert staff at the nurses' station or illuminate above the door, and the resident was provided with a bell as an alternative. Interviews with staff confirmed the malfunction and the lack of a repair request. Similarly, Resident #55, who was cognitively impaired and required substantial assistance for bed mobility, had a call light system that failed to alert staff. Observations showed that the call light did not activate in the hallway or at the nurses' station, and the resident's call for assistance went unanswered for an extended period. Interviews with staff confirmed the malfunction and revealed that the maintenance director was only informed of the issue on the day of the survey. The facility's policy required a functioning call light system, but the equipment failed to meet these standards, leading to non-compliance.
Delayed Treatment for Non-Pressure Ulcers
Penalty
Summary
The facility failed to implement timely treatments for a resident who developed three non-pressure related ulcers. The resident, who was cognitively intact, was admitted with a history of cystitis, type II diabetes mellitus, chronic pain, and erythema intertrigo. Upon admission, the resident had a blister on the right great toe and fungal infections under the breasts and abdominal folds, but no physician order for nystatin was in place despite its mention in the records. The resident was receiving Fluconazole for fungal infections, but there was no evidence of nystatin being ordered or administered. On a subsequent assessment, the resident was found to have developed three non-pressure wounds: a skin tear on the right lateral groin, a wound on the right distal groin, and another on the center midline abdomen. Despite these findings, there were no physician orders for treatment of these wounds until four days later. Interviews with facility staff confirmed the delay in treatment orders. The Director of Nursing verified that the wounds were identified on a specific date, but treatments were not ordered or implemented until four days later. Additionally, there was no documentation of nystatin being ordered or administered to the resident, highlighting a lapse in the facility's care protocol.
Failure to Maintain Sanitary and Comfortable Environment
Penalty
Summary
The facility failed to maintain a sanitary, orderly, and comfortable environment for its residents, specifically affecting one resident and potentially impacting 36 others residing on the second floor. The deficiency was identified through a combination of record reviews, interviews, and observations. Resident #75, who was cognitively intact and required maximum assistance with bathing, reported that the community restroom/shower room was not cleaned routinely, resulting in a terrible smell. Observations confirmed the presence of a foul odor emanating from a drain, a brown smeared substance on the wall, and black dots on one of the shower curtains. Interviews with staff, including a State Tested Nursing Assistant (STNA) and the Clinical Service Manager, corroborated the observations. The STNA acknowledged the foul odor and the dirty conditions, stating that housekeeping was responsible for cleaning the restroom and changing the shower curtain. The Clinical Service Manager confirmed that the shower room should be cleaned when soiled and that water should be run down the drains to prevent gas buildup. The facility's policies on resident rights and routine cleaning were reviewed, revealing that residents have the right to a safe and clean living environment, and that cleaning should occur according to a schedule or when dust or soil is visible.
Failure to Maintain Sanitary Conditions in Nourishment Rooms
Penalty
Summary
The facility failed to maintain the nourishment room's refrigerators in a clean and sanitary manner, affecting two nourishment rooms and potentially impacting all 104 residents. During an observation of the first-floor nourishment room, a refrigerator was found to contain a bag with various foods dated, several small white bowls with undated food resembling mashed potatoes, several opened undated drink containers, and a black bowl containing undated beans and brown meat. The outdated food was verified by the Housekeeping Supervisor. In the second-floor nourishment room, a refrigerator was observed to have a brown substance spilled at the bottom, along with multiple containers of undated and outdated food and an expired carton of milk. These findings were verified by an LPN. The facility's policy requires that food brought by visitors be sealed, labeled with the resident's name and date, and discarded after 72 hours, which was not adhered to in these instances.
Flooring Hazard in Second-Floor Nourishment Room
Penalty
Summary
The facility failed to maintain the flooring in good repair and ensure safety in the second-floor nourishment room, affecting one of two nourishment rooms. This deficiency had the potential to impact 58 residents residing on the second floor, with the facility census totaling 104. During an observation on July 12, 2024, at 11:21 A.M., multiple floor tiles in the nourishment room were found to have missing pieces, resulting in raised edges. This condition was verified by an LPN present during the observation, who confirmed that the raised edges posed a trip hazard to residents using the nourishment room.
Deficiency in 30-Day Discharge Notice Documentation
Penalty
Summary
The facility failed to ensure that the 30-day discharge notice for a resident included the location of discharge, which is a requirement for proper notification. This deficiency affected one resident who was reviewed for the 30-day discharge notice. The resident, who had a range of medical conditions including moderate cognitive impairment, was issued a discharge notice due to endangering the safety of other residents by persistently engaging in illegal smoking. The notice stated that the facility was smoke-free, but it did not provide an address for the discharge location. Interviews conducted during the investigation revealed that the facility had one active 30-day discharge for non-compliance with the smoking policy. The resident appealed the discharge notice, and the appeal was successful because the notice was not completed correctly, specifically lacking the discharge location address. The Licensed Social Worker confirmed that the facility lost the hearing due to this omission, which was also noted by the Ombudsman.
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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