East Park Care Center
Inspection history, citations, penalties and survey trends for this long-term care facility in Brook Park, Ohio.
- Location
- 8 East Park Circle, Brook Park, Ohio 44142
- CMS Provider Number
- 365731
- Inspections on file
- 25
- Latest survey
- October 28, 2025
- Citations (last 12 mo.)
- 7
Citation history
Health deficiencies cited at East Park Care Center during CMS and state inspections, most recent first.
A resident with a chronic right heel wound did not receive appropriate wound care after returning from a hospital stay, as wound care orders were not transcribed and no dressing changes were documented for nearly a month. The wound deteriorated, leading to infection, hospitalization, and the discovery of maggots in the wound. Staff interviews and record reviews confirmed lapses in wound care, documentation, and implementation of recommended interventions, resulting in actual harm to the resident.
Three residents, each with significant medical conditions, were moved to different rooms without receiving the required written notification. Staff confirmed that only verbal discussions occurred and that no policy existed for written room move notifications, resulting in non-compliance.
A shower area was found with missing tiles, a large hole in the wall, a broken toilet, and feces present, with these issues persisting for an extended period. Staff and a family member confirmed the ongoing nature of the problem, affecting multiple residents who used the area.
A resident with multiple medical conditions reported feeling mistreated, but the facility did not conduct a thorough investigation as required by policy. No staff or resident interviews or skin assessments were completed, and no documentation of an investigation was found.
A resident with a history of recurrent yeast infections reported vaginal discomfort and itching, but did not receive timely notification to a provider or administration of prescribed antifungal medication due to unavailability. Despite repeated complaints and documentation, the medication was not delivered or given as ordered, and staff could not account for the delay, resulting in a failure to provide prompt and adequate care.
A resident with multiple complex medical conditions had an air mattress set at 610 pounds despite weighing only 165 pounds, contrary to the manufacturer's instructions and without documented care plan justification. Staff interviews revealed the setting was based on an undocumented preference, and the DON confirmed no care plan supported this deviation.
A resident with multiple medical conditions and a PEG tube developed mold within the feeding tube due to the facility's failure to provide proper routine care and monitoring as ordered. Staff did not recognize or report the discoloration in the tube, and the issue was only addressed after the resident was sent to the hospital for evaluation and tube replacement.
A resident reported that a housekeeper took $40.00 to purchase vape supplies but did not return with the items or money. The incident was reported to the Activity Director and then to the Administrator, but the facility failed to report the misappropriation to the State Survey Agency within the required timeframe, resulting in non-compliance.
A resident with a history of dementia and other conditions experienced a fall resulting in a left elbow fracture. Despite receiving STAT x-ray results indicating the fracture, the facility delayed notifying the NP and seeking medical intervention until the following day. This delay led to increased pain and a delay in identifying additional injuries. Interviews revealed communication breakdowns and procedural failures in addressing the resident's condition promptly.
The facility failed to maintain a clean kitchen, with food splatters and debris observed on various surfaces, including the steamer table, prep table, stove, and dish machine. Additionally, two male dietary staff members were seen with uncovered beards during meal service, contrary to facility policy. The Dietary Manager confirmed these findings.
The facility failed to maintain a clean and safe environment, affecting all residents. Observations revealed a nonfunctional spa tub with exposed pipes, unclean ceiling fans, dirty dining room furniture, damaged doors, and water-stained ceiling tiles. Additional issues included exposed and dusty air conditioning units, peeling paint, dirty hoyer lifts, stained carpeting, and mold-like substances in the shower room. Residents expressed concerns about the facility's cleanliness and maintenance.
The facility failed to address grievances regarding the distribution of evening snacks, affecting several residents. Despite complaints raised in resident council meetings, the issue persisted, with reports of staff consuming the snacks. The Dietary Manager informed the DON and Staff Coordinator, but no documented follow-up occurred. Some residents received individual snack bags, but the overall grievance remained unresolved.
The facility failed to develop and implement adequate care plans for several residents, leading to deficiencies in care. A resident's hospice care plan lacked specific visit frequencies, while another resident's care plan did not address an indwelling urinary catheter and wounds due to delays. A third resident's care plan failed to document refusals of showers, and a fourth resident did not have a smoking safety plan. Additionally, a resident with pressure ulcers lacked a care plan for wound care, as confirmed by the MDS Coordinator.
A facility failed to timely convey a resident's funds upon their death. The resident, with end-stage renal disease and heart failure, passed away, and their account was closed with $160.21 disbursed to their estate. The Business Manager confirmed the funds were not disbursed within the required 30-day period.
The facility failed to conduct comprehensive assessments for two residents. One resident did not have a current bedrail assessment despite mobility deficits, and another resident did not have a care plan for pain management despite physician orders and reported pain. The MDS Coordinator confirmed delays in care plan development due to a power outage.
A facility failed to complete a required MDS 3.0 discharge assessment for a resident with multiple diagnoses, including Hepatitis C and kidney failure. The resident was discharged without the necessary assessment, despite facility policy requiring adherence to federal and state submission timeframes. This oversight was confirmed by an MDS nurse.
A facility failed to obtain an accurate admission weight for a resident at risk for significant weight loss, delaying the monitoring of their nutritional status. The resident, with multiple health issues and a history of weight loss, was admitted without a documented weight, and the first recorded weight showed a significant loss compared to hospital records. Interviews confirmed the absence of an admission weight, which was essential for assessing the resident's nutritional needs.
A resident with polyneuropathy and spinal issues experienced inadequate pain management due to the facility's failure to document pain levels accurately and conduct a pain risk assessment. Despite reporting significant pain to nursing staff, the resident's pain was consistently recorded as 0 out of 10, and no changes were made to the pain management regimen until the issue was identified by surveyors.
A facility failed to address pharmacy recommendations in a timely manner for a resident with multiple diagnoses, including dementia and schizoaffective disorder. The resident had active orders for medications like Breo Ellipta, Tiotropium Bromide, Seroquel, and Ativan. Recommendations to prevent thrush and address PRN psychotropic medication orders were delayed, with some not acted upon for months. The DON confirmed the delay, and the facility's policy requiring review within 30 days was not followed.
A facility failed to ensure PRN psychotropic medication orders for a resident had end dates, as required by policy. The resident had active PRN orders for Seroquel and Ativan without end dates, despite the facility's policy limiting such orders to 14 days unless extended with documented rationale. The resident, with multiple psychiatric diagnoses, received Ativan several times but not Seroquel. The DON confirmed the oversight, and the physician discontinued the orders.
A resident with diabetes received insulin without the pen being primed, as observed during a survey. The LPN administering the insulin was unaware of the need to prime the pen, which is necessary to ensure correct dosing. The facility's policy and manufacturer's instructions require priming, but this step was missed, leading to a significant medication error.
A resident with a history of a tooth abscess did not receive timely dental care due to a lack of follow-up and coordination between the facility and hospice. Despite completing antibiotics, the resident's dental issues persisted, and conflicting responsibilities between the facility and hospice led to delays. A change in the dental provider further postponed the resident's dental evaluation, leaving the resident in discomfort.
A resident with a history of stroke and dementia was diagnosed with Legionnaires disease in the hospital, but the attending physician failed to communicate this to the LTC facility upon the resident's return. The facility only learned of the diagnosis from the local health department, indicating a breakdown in communication and coordination of care.
The facility failed to notify emergency contacts of changes in condition for two residents. One resident experienced falls and fractures without timely notification to their daughter, while another resident's guardian was not informed of their return from the hospital. This non-compliance with notification policies was confirmed by facility staff.
Two residents requiring assistance with bathing did not receive scheduled showers, as documented in their care plans. One resident, with impaired cognition and mobility issues, reported not having a shower in two weeks, while another, needing substantial assistance, had not been offered a shower since admission. Staff interviews revealed a lack of awareness and documentation regarding scheduled shower days, leading to noncompliance with facility policies.
The facility's assessment was incomplete, lacking input from direct care staff and failing to consider specific staffing needs for each shift and resident unit. This deficiency was confirmed by the Administrator.
A resident with ALS, dependent on staff for ADLs, developed maggots in her mouth and nose due to inadequate oral care, leading to hospitalization. Documentation showed gaps in care provision, and staff confirmed oral care was not completed as required. Flies were observed in the resident's room, contributing to the issue.
A resident with recurrent UTIs did not receive timely and comprehensive care, leading to multiple infections. Delays in obtaining urine specimens and a missed urology appointment due to lack of a staff escort contributed to the deficiency. The facility failed to implement a care plan for recurrent UTIs in a timely manner.
Failure to Provide Comprehensive Pressure Ulcer Care Resulting in Harm
Penalty
Summary
The facility failed to develop and implement a comprehensive and effective pressure ulcer program, resulting in a lack of appropriate wound care for a resident with a chronic right heel wound. After returning from a hospitalization, the resident's wound care orders were not transcribed into the facility's electronic health record, and no wound care orders or documented dressing changes were in place for nearly a month. During this period, the resident's wound was not assessed or treated as required, and there was no evidence of interventions such as offloading or the use of heel boots, despite the resident's high risk for pressure ulcers and a history of complex wounds. The resident's wound deteriorated significantly, as noted by the wound nurse practitioner, with increased exudate and eventual infection. The resident required hospitalization for debridement due to gas gangrene and osteomyelitis of the right heel, resulting in significant exposure of the heel bone and a prolonged hospital stay with intravenous antibiotics. Upon return to the facility, there continued to be lapses in wound care, including the absence of proper dressing changes and failure to implement recommended interventions such as Prafo heel boots and a low air loss mattress. Documentation and communication failures persisted, with staff unable to locate wound care orders and no evidence of consistent wound care being provided. The situation escalated when staff discovered maggots in the resident's right heel wound, indicating severe neglect of wound management and hygiene. Multiple staff interviews confirmed that wound care was not performed as ordered, dressings were not changed as scheduled, and the resident was dependent on staff for all care needs. The facility's own wound care policy required verification of physician orders and documentation of wound care procedures, but these were not followed. The resident experienced actual harm, including repeated hospitalizations, wound deterioration, and infection, as a direct result of the facility's failure to provide appropriate pressure ulcer care and prevent further decline.
Failure to Provide Written Notice for Room Changes
Penalty
Summary
The facility failed to provide written notification to residents prior to room changes, as required. Three residents were affected by this deficiency. One resident with dementia, CHF, and hypertension requested a room move, but there was no evidence of written notification in the medical record. Another resident with Parkinson's disease, COPD, and dementia agreed to a room move after a discussion with social services, but again, no written notice was documented. A third resident with CKD, osteoporosis, and atrial fibrillation was moved to accommodate another resident requiring isolation, with agreement from the emergency contact, but no written notification was found in the record. Interviews with facility staff confirmed that room moves were discussed verbally with residents or their representatives, but written notifications were not provided. Additionally, the facility did not have a policy in place regarding room moves. This lack of written notification and policy resulted in non-compliance with regulations regarding residents' rights to receive written notice before a room change.
Failure to Maintain Safe and Sanitary Shower Area
Penalty
Summary
The facility failed to maintain the shower area on the [NAME] hallway in good working condition, as evidenced by multiple direct observations and staff interviews. The shower room was found to have several tiles missing from the wall, with a large hole exposed, and a pile of broken tiles in the corner. The toilet in the same area was broken off its seal and had feces smeared on the outside. Staff confirmed that the tiles had been broken for an extended period, and a family member reported that the issue had persisted for about a year. Facility policy requires the environment to be safe, functional, sanitary, and comfortable for residents, staff, and the public, but these conditions were not met for the 11 residents who used this shower area.
Failure to Investigate Alleged Abuse
Penalty
Summary
The facility failed to thoroughly investigate an allegation of abuse involving a resident with multiple complex medical conditions, including chronic obstructive pulmonary disease, severe protein-calorie malnutrition, atrial fibrillation, and cognitive communication deficit. The resident reported feeling mistreated while at the facility, which was communicated to the social worker at the hospital. Upon the resident's return, the administrator interviewed the resident, who then stated he felt safe and did not feel mistreated. However, there was no documentation of a comprehensive investigation into the allegation. Review of facility records and the Self-Reported Incident (SRI) revealed that no further investigative actions were taken. There were no interviews conducted with staff or other residents, and no skin assessments were completed. The facility's policy requires all allegations of abuse, neglect, or mistreatment to be investigated, but in this case, no investigation could be found, and the Regional Director of Clinical Services confirmed the absence of any investigative documentation related to the incident.
Delayed Treatment and Medication Unavailability for Yeast Infection
Penalty
Summary
A deficiency occurred when a resident with multiple medical conditions, including skin infection, cognitive communication deficit, and Parkinson's disease, reported pain and burning in the vaginal area. Despite these complaints being documented in the medical record, there was no evidence that the physician was notified until nearly two weeks later, when the resident herself brought the issue to the attention of the facility's nurse practitioner. The nurse practitioner subsequently ordered miconazole cream for the resident's symptoms, but the medication was not administered on several documented dates because it was not available in the facility. Pharmacy delivery records showed no evidence that the medication was delivered during the relevant period. Further review and staff interviews confirmed that the resident continued to complain of vaginal discomfort and did not receive the prescribed treatment in a timely manner. The resident reported informing nurses multiple times about her symptoms and the recurring nature of her yeast infections following antibiotic use, but stated that no action was taken until she contacted her own doctor. Facility staff were unable to explain why the medication was not delivered or administered as ordered, and documentation confirmed the lack of timely treatment. Facility policy required medications to be administered safely, timely, and as prescribed, which was not followed in this case.
Failure to Set Air Mattress to Resident's Weight as Ordered
Penalty
Summary
A deficiency was identified when staff failed to ensure that an air mattress for a resident was set at the appropriate weight according to the manufacturer's instructions. The resident, who had multiple complex medical conditions including cerebral infarction, SIRS, diabetes, hemiplegia, anoxic brain damage, and was dependent on staff for all ADLs, had a physician's order for an air mattress with bolsters and specific wound care instructions. Despite the resident weighing only 165 pounds, observations on two consecutive days revealed the air mattress was set at 610 pounds. The operation manual for the mattress specified that the pressure range should be adjusted according to the resident's weight, with settings adjustable between 90 and 650 pounds. Staff interviews revealed that the LPN believed the mattress was set at 610 pounds based on a care plan to allow the resident to be elevated higher for television viewing, but the DON confirmed there was no documentation in the care plan supporting this preference. The discrepancy between the resident's actual weight and the mattress setting, as well as the lack of documentation for the deviation from standard practice, led to the deficiency in providing appropriate pressure ulcer care and prevention.
Failure to Prevent Mold Formation in Feeding Tube
Penalty
Summary
The facility failed to provide proper care for a resident's feeding tube, resulting in mold formation within the tube. The resident, who had multiple complex medical diagnoses including cerebral infarction, diabetes, hemiplegia, anoxic brain damage, and dysphagia, was dependent on staff for all activities of daily living and had a PEG tube for nutrition and hydration. Physician orders required regular hydration flushes every four hours, daily cleansing of the PEG tube site, and routine tube feedings. Despite these orders, the internal tubing developed brownish discoloration and mold, which was not identified or reported by staff in a timely manner. Staff interviews revealed that certified nursing assistants had noticed the discoloration but did not recognize it as mold, and licensed nurses did not observe or report the issue during routine care. The facility's policy required licensed nurses to provide routine care to maintain tube patency and skin integrity, but this was not followed, as evidenced by the presence of mold in the tube. The resident was eventually sent to the hospital for evaluation and replacement of the PEG tube after the mold was discovered.
Failure to Timely Report Misappropriation Allegation
Penalty
Summary
The facility failed to timely investigate and report an allegation of misappropriation involving a resident. The incident involved a resident with intact cognition, who reported that a housekeeper took $40.00 to purchase vape supplies but did not return with the items or the money. The resident reported this to the Activity Director, who then informed the Administrator. However, the Administrator did not report the incident to the State Survey Agency within the required timeframe. The facility's policy mandates that any misappropriation of resident property be reported to the Ohio Department of Health immediately, or within 24 hours of the incident being known to staff. Despite this policy, the report was not submitted until several days later, resulting in non-compliance. Interviews with the Administrator and the Regional Director of Clinical Operations confirmed the delay in reporting the incident, which was not submitted until a week after the initial report by the resident.
Delayed Medical Intervention After Resident Fall
Penalty
Summary
The facility failed to ensure timely evaluation, physician notification, and treatment following a fall with a fracture for a resident. On the evening of 10/21/24, the facility received results of a STAT x-ray indicating the resident had a left elbow fracture but did not seek immediate medical intervention. The nurse practitioner was not notified of the results until the following morning, at which point an order was obtained to transfer the resident to the hospital. This delay in treatment resulted in the resident experiencing increased pain and a delay in identifying additional injuries, including a left acetabulum fracture, left iliac fossa fracture, and left retroperitoneal hemorrhage. The resident, who had a history of vascular dementia, atrial fibrillation, and other conditions, was found on the floor after a fall. Initial assessments noted elbow pain, and a STAT x-ray was ordered. However, despite the x-ray results being available the same evening, there was no immediate action taken to address the fracture. The resident's pain levels increased following the fall, and observations the next morning showed swelling and discoloration of the elbow, yet the resident remained untreated until the nurse practitioner was contacted. Interviews with facility staff revealed a breakdown in communication and procedure, as the x-ray results were not acted upon promptly. The LPN on duty the following morning discovered the x-ray results and attempted to contact the nurse practitioner, eventually receiving an order to send the resident to the emergency room. The Director of Nursing confirmed that the nurse practitioner should have been notified immediately upon receiving the x-ray results, and acknowledged that the resident's injuries went untreated for an extended period.
Sanitation and Hair Restraint Deficiencies in Kitchen
Penalty
Summary
The facility failed to maintain a clean and sanitary kitchen environment, as observed during a kitchen tour. Various food splatters and stains were found on the outside of the steamer table and the shelf underneath. The preparation table had open bags of dried pasta stored with clean pots and pans, and both shelves were dirty with dried food and debris. The stove and flat grill were covered in black, dried, burnt-on grease, and dust-covered grease was observed under the flat grill area. The back wall and floor between the steamer and stove had dried food splatters and debris, and the pipe affixed to this wall had dried food crumbs and debris. Additionally, a dark-colored dried substance and a tan-colored dried substance were found on the floor underneath the dish machine, with a build-up of a tan-colored substance on the dish machine itself. The reach-in cooler near the dish machine, which stored milk and juice, had a dried white splatter along the inside walls and the bottom. Furthermore, during meal service, two male dietary staff members were observed with uncovered and unrestrained beards, which was verified by the Dietary Manager. The facility's policy on sanitation, revised in October 2008, requires the food service area to be maintained in a clean and sanitary manner, which was not adhered to in this instance. The Dietary Manager acknowledged the oversight, stating that she intended to have the staff put on hair restraints when they started their shift.
Facility Fails to Maintain Clean and Safe Environment
Penalty
Summary
The facility failed to maintain a clean, sanitary, and safe environment, affecting all 50 residents. Observations revealed multiple deficiencies, including a nonfunctional spa tub with exposed pipes and wires in the west hall shower room, which had been broken for about a month. During an environmental tour, it was noted that ceiling fans in the dining area were unclean, with one fan missing a chain, preventing it from being turned off. Dining room tables and chairs were significantly dirty, with chipped paint and debris. Wooden doors to resident rooms and bathrooms showed significant damage, and numerous water-stained ceiling tiles were observed throughout the facility. Additional findings included exposed and dusty air conditioning unit coils in residents' rooms, a metal baseboard on the floor, and walls with peeling paint. Tube feed poles were coated in residual formula, and hoyer lifts were cracked and dirty. Carpeting in several rooms was significantly stained, and some rooms had water-stained ceiling tiles. The west unit shower room had an unknown red substance and a mold-like substance around the drain. Interviews with residents confirmed concerns about the facility's cleanliness and maintenance, indicating these issues had persisted for a significant period.
Failure to Address Grievances on Snack Distribution
Penalty
Summary
The facility failed to ensure that grievances related to the distribution of evening snacks were addressed in a timely and appropriate manner. This deficiency affected eight residents who attended the resident council meetings and one resident specifically reviewed for food. During interviews, residents expressed concerns that evening snacks were not being distributed as expected, and some staff members were reportedly consuming the snacks meant for residents. The issue was raised in multiple resident council meetings, but the concerns were not adequately addressed by the facility. The Dietary Manager acknowledged the complaints and informed the Director of Nursing and the Staff Coordinator about the issue. Despite these communications, there was no documented follow-up or resolution to ensure that snacks were distributed as required. The Staff Coordinator spoke with the aides and nurses but did not document these interactions. The Dietary Manager took some individual actions by preparing snack bags for specific residents, but the overall grievance regarding snack distribution remained unresolved.
Deficiencies in Resident Care Plans
Penalty
Summary
The facility failed to develop and implement resident-centered care plans for five residents, leading to deficiencies in care. Resident #4, who was admitted with dementia and other conditions, had a care plan for hospice care that lacked specific frequency information for hospice visits, contrary to the facility's policy and hospice contract requirements. The Director of Nursing confirmed the care plan's inadequacy in reflecting the necessary details for hospice services. Resident #19, admitted with multiple diagnoses including an indwelling urinary catheter and wounds, did not have a care plan addressing these specific needs. The MDS Coordinator LPN acknowledged that the care plans for the catheter and wounds were delayed due to a weather-related power outage and were overdue. Similarly, Resident #20, who required assistance with daily activities due to a stroke and other conditions, had a care plan that did not document the resident's refusal of showers, despite multiple refusals being recorded in the facility's documentation. Resident #40, a smoker with intact cognition, did not have a care plan addressing smoking safety, as confirmed by the MDS Coordinator. Lastly, Resident #51, who had multiple diagnoses including pressure ulcers, did not have a care plan addressing wound care or skin impairments. The MDS Coordinator verified the absence of a care plan for these issues, despite the resident being educated on the importance of hygiene and mobility to prevent skin breakdown.
Delayed Disbursement of Resident Funds
Penalty
Summary
The facility failed to ensure timely conveyance of resident funds upon discharge or death, affecting one resident. The resident, who had been admitted with diagnoses including end-stage renal disease, heart failure, and anxiety disorder, passed away at the facility. A review of the account records showed that the resident's account was closed, and $160.21 was disbursed to the resident's estate. However, an interview with the Business Manager revealed that the personal funds were not disbursed within the required 30-day timeframe following the resident's death.
Failure to Conduct Comprehensive Assessments for Residents
Penalty
Summary
The facility failed to ensure comprehensive assessments were implemented and completed for two residents. For Resident #7, the facility did not conduct a current bedrail assessment despite the resident having a mobility deficit related to multiple health conditions, including seizures and spinal stenosis. The last documented bedrail assessment was completed over three years ago, and the Director of Nursing confirmed the absence of a current assessment. The facility's policy required such assessments to be conducted upon initiation, quarterly, and as needed, but this was not adhered to. For Resident #204, the facility did not initiate a care plan for the resident's risk of pain due to polyneuropathy and spinal issues. Despite physician orders to monitor pain every shift and administer pain relief medications, no pain risk evaluation was conducted upon admission. The resident reported constant pain, which was not adequately addressed, and the MDS Coordinator confirmed that care plans had not been initiated due to a prolonged power outage. This resulted in a delay in developing appropriate care plans for residents.
Failure to Complete Discharge MDS Assessment
Penalty
Summary
The facility failed to complete a required Minimum Data Set (MDS) 3.0 assessment for a resident upon discharge. This deficiency was identified during a review of records, staff interviews, and facility policy. Specifically, a resident with diagnoses including Hepatitis C, cocaine abuse, chest pain, and kidney failure was admitted to the facility and later discharged without the completion of a required discharge MDS assessment. The initial MDS assessment was completed, but no subsequent assessments, including the discharge assessment, were conducted during the resident's stay. This oversight was confirmed by an MDS nurse during an interview, and it was noted that the facility's policy mandates adherence to federal and state submission timeframes for resident assessments.
Failure to Obtain Accurate Admission Weight for Nutritional Monitoring
Penalty
Summary
The facility failed to ensure an accurate weight was obtained to monitor the nutritional status of a resident at risk for significant weight loss. The resident, who had multiple diagnoses including dementia, hypertension, and severe major depressive disorder, was admitted with a history of weight loss and a BMI indicating severe underweight status. The care plan required weekly weights upon admission, but the facility did not obtain an admission weight until nine days after the resident's admission, which was also two days after the nutritional assessment was completed. This delay resulted in the absence of a current weight to compare against the resident's nutritional status and needs. The hospital records indicated the resident had a weight of 95.7 lbs. and a BMI of 14.2, classifying them as severely underweight. However, the facility did not document an admission weight, and the first recorded weight was 83.6 lbs., indicating a significant weight loss of 12.1 lbs. since the hospital's estimated weight. Interviews with the Nutrition Consultant Diet Tech and the Director of Nursing confirmed the lack of an admission weight, which was crucial for monitoring the resident's nutritional status due to their severe underweight condition.
Inadequate Pain Management Documentation and Response
Penalty
Summary
The facility failed to accurately document and effectively manage the pain of a resident with multiple diagnoses, including polyneuropathy and spinal issues. The resident, who was cognitively intact and required minimal assistance for activities of daily living, had physician's orders to monitor pain every shift and was prescribed acetaminophen and pregabalin for pain management. However, the resident's pain levels were consistently recorded as 0 out of 10 on the Medication Administration Record, and no pain risk assessment was completed upon admission. Interviews with the resident revealed that he experienced constant pain in his hands and arms, which he reported to the nursing staff multiple times without any changes to his pain management regimen. The Director of Nursing and Assistant Director of Nursing were unaware of the resident's ineffective pain management until the surveyor's investigation. The facility's policy required contacting the physician if the current pain management regimen was ineffective, but this was not done until after the surveyor's findings.
Failure to Address Pharmacy Recommendations Timely
Penalty
Summary
The facility failed to ensure that pharmacy recommendations were addressed in a timely manner for a resident with multiple diagnoses, including dementia, schizoaffective disorder, suicidal ideation, and major depressive disorder. The resident had active physician orders for medications such as Breo Ellipta, Tiotropium Bromide, Seroquel, and Ativan. The pharmacist made several recommendations regarding these medications, including advising the resident to rinse their mouth after using inhaled corticosteroids to prevent thrush and addressing the PRN orders for psychotropic medications, which are limited to 14 days per CMS regulations. However, these recommendations were not addressed promptly, with some not being acted upon until months later. The Director of Nursing (DON) confirmed that the recommendations from January and February were not addressed until October. Although the physician addressed the March recommendation, the order was not updated with an end date. The physician disagreed with adding a stop date for the PRN Seroquel and Ativan, and these orders were only discontinued on the day of the interview. The facility's policy required the DON or Assistant Director of Nursing (ADON) to review recommendations with the physician and Medical Director within 30 days, but this was not adhered to, leading to the deficiency.
Failure to Ensure PRN Psychotropic Medication Orders Had End Dates
Penalty
Summary
The facility failed to ensure that as-needed (PRN) psychotropic medication orders for a resident had an end date, as required by their policy. The medical record review for a resident revealed active PRN orders for Seroquel and Ativan, both lacking an end date. The Seroquel order was initiated in August 2024, and the Ativan order in March 2024. The facility's policy mandates that PRN orders for psychotropic drugs are limited to 14 days unless the physician documents a rationale for extending the order and specifies the duration. However, this was not adhered to in the case of the resident. The resident, who was admitted with diagnoses including dementia, schizoaffective disorder, suicidal ideation, and major depressive disorder, received the PRN Ativan multiple times in April, May, and June, but not in the subsequent months. The PRN Seroquel was not administered at all. During an interview, the Director of Nursing confirmed the absence of end dates for these medications and stated that the physician had decided to discontinue both orders on the day of the interview. This oversight affected one of the five residents reviewed for unnecessary medications, with the facility census being 50.
Failure to Prime Insulin Pen Leads to Medication Error
Penalty
Summary
The facility failed to ensure that residents were free from significant medication errors during insulin administration. This deficiency was identified during an observation of insulin administration for a resident with a history of type II diabetes, aphasia, traumatic brain injury, cerebral infarction, and anxiety. The resident had a physician's order for Lispro insulin to be administered subcutaneously using a pen prior to meals and at bedtime, with a sliding scale based on glucose levels. During the observation, an LPN prepared and administered four units of insulin for a glucose level of 163 but did not prime the insulin pen before injection. The LPN admitted to being unaware of the need to prime the pen, which is a crucial step to ensure the pen is functioning correctly and to avoid administering incorrect insulin doses. The manufacturer's instructions clearly state that priming the pen is necessary to remove air from the needle and cartridge, which can accumulate during normal use. The facility's policy on insulin administration, revised in September 2014, also requires nursing staff to follow the manufacturer's instructions for all insulin delivery systems. This oversight in following proper insulin administration procedures led to the deficiency noted in the report.
Failure to Provide Timely Dental Care for Resident
Penalty
Summary
The facility failed to provide timely and adequate dental care for Resident #30, who had a history of a tooth abscess treated with antibiotics. Despite the completion of the antibiotic course, there was no follow-up evaluation by a physician, nurse practitioner, or dentist, and no monitoring of the resident's dental status was documented. The resident's care plan did not include any follow-up for the tooth infection, and the facility did not ensure that the resident was seen by a dentist in a timely manner. Resident #30, who was receiving hospice care, had severe cognitive impairment and was dependent on assistance for daily activities. The resident's husband reported ongoing issues with the tooth abscess, including bleeding and soreness, and expressed frustration with the lack of action from both the facility and hospice. The facility and hospice staff had conflicting views on who was responsible for addressing the dental issue, leading to a delay in care. Interviews with facility staff revealed that the dental provider had changed, causing a delay in scheduling a dental appointment for the resident. The new dental provider was not available until December, leaving the resident without necessary dental care for an extended period. The facility's failure to coordinate care and ensure timely dental services resulted in the resident's continued discomfort and unresolved dental issues.
Failure in Communication of Legionella Diagnosis
Penalty
Summary
The facility failed to ensure effective communication between attending physicians and administration, which resulted in inadequate coordination of care for a resident diagnosed with Legionnaires disease. The resident, who had a history of stroke, dementia, and other medical conditions, was admitted to the hospital with sepsis, Legionella pneumonia, and acute renal failure. Upon returning to the facility, the discharge summary did not include the Legionella diagnosis, and the attending physician, who treated the resident both in the hospital and at the facility, did not communicate this crucial information to the facility's administration or nursing staff. Interviews with the facility's Administrator, Director of Nursing (DON), Medical Director (MD), and a Registered Nurse (RN) revealed that the attending physician failed to relay the Legionella diagnosis, which was only discovered by the facility after notification from the local health department. The MD confirmed that it was the responsibility of the admitting physician to communicate such critical information to the administration. The lack of communication led to a delay in the facility's awareness and response to the resident's condition, highlighting a breakdown in the coordination of care.
Failure to Notify Emergency Contacts of Change in Condition
Penalty
Summary
The facility failed to timely notify emergency contacts or guardians of a change in condition for two residents, resulting in a deficiency. Resident #205, who had a history of vascular dementia, atrial fibrillation, and other conditions, experienced two falls on 10/18/24 and 10/21/24. Despite the care plan's directive to notify family and the physician of incidents, the resident's daughter was not informed of these falls until 10/22/24, after the resident was sent to the emergency room for a fractured elbow and hip discovered during an ER visit. The facility's policy required notification of changes in the resident's condition, which was not adhered to in this case. Resident #20, who had diagnoses including cerebral infarction and dementia, was sent to the hospital on 08/23/24 and returned to the facility on 08/31/24. However, there was no documented evidence that the resident's guardian was notified of the resident's return from the hospital. The guardian confirmed during an interview that they were unaware of the resident's return, indicating a failure to communicate significant changes in the resident's status as required by the facility's policy. The deficiency was identified during a complaint investigation, revealing non-compliance with the facility's policy to notify residents' representatives of changes in their medical or mental condition. The Director of Nursing and Assistant Director of Nursing confirmed the lack of documentation supporting timely notification for Resident #205, and the Administrator verified the same issue for Resident #20. This deficiency was investigated under Complaint Number OH00158492.
Failure to Provide Scheduled Bathing Assistance
Penalty
Summary
The facility failed to ensure that residents requiring assistance with activities of daily living, specifically bathing and showering, received the necessary care. This deficiency affected two residents. Resident #22, who has a history of impaired cognition, left femur fracture, and other medical conditions, reported not having received a shower or bath in the last two weeks. Despite being scheduled for showers twice a week, there was no documentation of showers for September and October 2024. Interviews with the resident and staff revealed inconsistencies in care, with excuses made for missed showers and a lack of documentation to support the provision of care. Similarly, Resident #51, who requires substantial assistance due to conditions such as sepsis and morbid obesity, had not received a shower since admission. The resident expressed a desire for a shower, but there was no evidence of showers being offered or provided. Observations confirmed the resident wore the same clothing over several days, and the room was noted to be odorous. Staff interviews indicated a lack of awareness of the resident's scheduled shower days, further highlighting the facility's failure to adhere to its policy on supporting activities of daily living.
Incomplete Facility Assessment
Penalty
Summary
The facility failed to ensure that its facility-wide assessment contained all the required information necessary for competent care of its 50 residents during both day-to-day operations and emergencies. The assessment lacked evidence of direct input from direct care staff, including RNs, LPNs, CNAs, and other representatives. Additionally, it did not consider specific staffing needs for each shift or plans to adjust based on changes in the resident population. Furthermore, the assessment did not address specific staffing needs for each resident unit or plans to adjust as necessary. This deficiency was confirmed during an interview with the Administrator.
Failure to Provide Adequate ADL Assistance Leads to Resident Harm
Penalty
Summary
The facility failed to provide adequate assistance with activities of daily living (ADLs) for a resident who was totally dependent on staff for personal and oral hygiene. This deficiency resulted in actual harm when the resident developed maggots in her mouth and nose, necessitating hospitalization. The resident, who had amyotrophic lateral sclerosis (ALS) and was nonverbal, was admitted to the facility with a gastrostomy tube and required complete assistance for ADLs. The resident's medical records indicated that she was dependent on staff for all efforts related to personal hygiene and oral care. However, documentation revealed significant gaps in the provision of oral care, with no evidence of care being provided on several shifts leading up to the incident. On the day of the incident, a hospice nurse discovered fly larvae on the resident's gown, and further examination revealed maggots in her mouth and nose. The resident was then transferred to the hospital for further assessment and care. Interviews with facility staff confirmed that the resident's oral care was not completed as required, and flies were observed in the resident's room. The facility's policy stated that residents should receive appropriate care to maintain or improve their ability to carry out ADLs, but this was not adhered to in the case of the affected resident. The lack of consistent oral care and the presence of flies in the resident's environment contributed to the development of maggots, leading to the resident's hospitalization.
Failure to Manage Recurrent UTIs and Coordinate Care
Penalty
Summary
The facility failed to ensure that a resident's frequent urinary tract infections (UTIs) were comprehensively assessed, care planned, and treated in a timely manner to prevent recurring infections. The resident, who had mixed bladder incontinence related to impaired mobility, experienced multiple UTIs over several months. Despite having a care plan that included monitoring for signs and symptoms of UTIs and encouraging fluid intake, the care plan for recurrent UTIs was not initiated until several months after the resident's admission. The resident's medical records indicated multiple instances where antibiotics were prescribed for UTIs, yet there was a delay in obtaining and processing urine specimens for urinalysis and culture. For example, a urine specimen ordered on one date was not collected and sent until six days later, which was acknowledged as inappropriate by the Nurse Practitioner. Additionally, there was a lack of guidelines related to managing the resident's UTIs, and no orders were given to increase fluid intake, which could have potentially mitigated the risk of infection. Furthermore, the resident missed a critical urology appointment due to a lack of a staff escort, which was required as per the physician's orders. The Director of Nursing confirmed that the request for a staff escort was not transcribed onto the transportation form, resulting in the resident not being seen by the urologist. This oversight was attributed to a miscommunication between the facility staff and the resident's family member, who was unable to attend the appointment. The facility's failure to provide appropriate care and coordination for the resident's UTIs and medical appointments represents a significant deficiency in their care practices.
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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