Edgewood Manor Rehabilitation & Healthcare Center
Inspection history, citations, penalties and survey trends for this long-term care facility in Port Clinton, Ohio.
- Location
- 1330 S Fulton St, Port Clinton, Ohio 43452
- CMS Provider Number
- 365489
- Inspections on file
- 28
- Latest survey
- August 13, 2025
- Citations (last 12 mo.)
- 2
Citation history
Health deficiencies cited at Edgewood Manor Rehabilitation & Healthcare Center during CMS and state inspections, most recent first.
A resident with a history of chronic illness and a recent hospital-treated toe wound infected with S. aureus was readmitted without timely wound care or dressing change orders in place for two days, despite hospital discharge instructions and facility policy. This lapse was confirmed by the Administrator and DON.
A resident admitted with a wound infection positive for S. aureus was not placed on appropriate isolation precautions until two days after admission, despite having positive lab results and ongoing antibiotic treatment. Staff failed to provide a waste receptacle for used PPE outside the resident's room, and an LPN entered the room without PPE, stating she was unaware of the isolation status. These actions were not in accordance with the facility's infection prevention and control policy.
A facility failed to provide timely incontinence care for a resident with multiple health issues, leading to a deficiency. Despite a care plan requiring checks every two hours, the resident was found heavily soiled, indicating a lapse in care. The resident had a history of UTIs, and staff interviews confirmed the failure to adhere to the care plan.
A resident was found with unattended medications at their bedside, which they forgot to take before breakfast. An LPN had administered the medications but did not verify their consumption, yet marked them as administered in the electronic record. The facility's policy requires medications to be administered safely and timely, with proper documentation.
A resident with cognitive impairment and multiple health issues fell and fractured her femur due to inadequate staff assistance during bed mobility. Despite requiring two-person assistance as per her care plan, only one staff member was present, leading to the fall. The facility's policy on fall prevention was not adhered to, resulting in the deficiency.
Two residents reported abuse by STNA #198, including verbal abuse, neglect, and rough handling. Despite consistent reports from the residents, the facility failed to substantiate the claims and did not conduct a thorough investigation, highlighting a deficiency in implementing abuse prevention policies.
A resident with a complex medical history and high fall risk fell out of bed while receiving care from a single STNA, despite requiring two-person assistance. The fall resulted in a left femur fracture, but the facility failed to report the incident as potential neglect to the state agency, contrary to its policies.
A facility failed to maintain proper infection control practices for a resident under Enhanced Barrier Precautions (EBP) due to a coccyx wound. Despite a sign indicating EBP, two STNAs provided incontinence care without the required PPE, believing the order had expired. Interviews confirmed the EBP order was active, and the facility's policy on EBP was not followed, resulting in a deficiency.
The facility did not maintain the required RN coverage for a minimum of eight hours a day on several occasions, potentially affecting all 65 residents. This was confirmed by the Administrator and was contrary to the facility's staffing policy, which mandates adequate staffing to meet residents' needs.
The facility's kitchen was found to be unsanitary, with excessive buildup and grime observed in various areas, including between and behind the fryer and stove, on a metal food cart, and under tables and appliances. The Regional Dietary Manager confirmed these observations, and pest control logs recommended cleaning the kitchen.
The facility failed to maintain cleanliness in the memory care unit, affecting 28 residents. Observations showed thick layers of dust and grime on the flooring in hallways and resident rooms. Housekeeping staff confirmed the issue and had just started deep cleaning. The facility's policy required cleaning schedules to ensure a clean environment, which was not followed.
A facility failed to report a resident's elopement and allegations of unlicensed staff administering unprescribed melatonin to residents. The resident, at high risk for elopement, left the facility through a window and visited local bars. Additionally, several residents were allegedly given melatonin without prescriptions. Despite these incidents, no Self-Reported Incidents were filed, violating the facility's policy on abuse investigation and reporting.
The facility failed to investigate an allegation of unlicensed staff administering unprescribed melatonin to four cognitively impaired residents, only one of whom had a prescription for the medication. Despite being notified, the DON and Administrator did not conduct a thorough investigation or file a self-reported incident, contrary to the facility's policy on abuse investigation and reporting.
A resident with chronic obstructive pulmonary disease was observed receiving three liters of oxygen per minute instead of the prescribed two liters. The resident, who was cognitively intact, confirmed the correct prescription. A nurse acknowledged the error, suggesting the concentrator control might have been accidentally adjusted.
The facility failed to discard expired insulin, affecting three residents with diabetes. During an observation, an LPN confirmed that expired insulin pens and a multi-dose vial were still stored in the medication cart. The facility's policies require that expired medications be discarded and expiration dates checked before administration, which was not followed in this instance.
A facility failed to complete a resident's HbA1c test as ordered by the physician, despite a recommendation to monitor it every three months for diabetes management. The resident, with a history of diabetes and other conditions, had not had the test since the previous year. The DON confirmed the oversight, which was against the facility's policy to follow physician orders for diagnostic services.
A resident in an LTC facility experienced verbal abuse from an STNA, who made derogatory remarks about the resident's incontinence. Despite witness statements and the resident's report, the facility did not substantiate the abuse but did suspend the STNA for one day. The resident was cognitively intact and required assistance with daily activities due to various health conditions.
A facility failed to prevent a resident's elopement and did not implement fall interventions for another resident. One resident, with cognitive impairment and identified as a flight risk, left the facility unsupervised and visited local bars. The staff was unaware of his absence until he returned. Another resident, at risk for falls, did not have a required safety mat in place next to the bed, as confirmed by staff observations and interviews.
Failure to Provide Timely Wound Care Orders After Hospital Discharge
Penalty
Summary
A deficiency occurred when a resident with multiple medical diagnoses, including chronic kidney disease, osteoarthritis, and a recent hospital admission for a wound on the left great toe, was readmitted to the facility. Hospital records indicated the wound was positive for Staphylococcus aureus and included a physician's order for an antibiotic regimen, with eight doses remaining at discharge. The hospital discharge paperwork also contained laboratory results confirming the infection. Upon review of the facility's medical record, it was found that there were no orders for wound care or dressing changes for the resident's left great toe from the date of readmission through two days later. This lack of timely wound care was confirmed in an interview with the Administrator and the DON, who verified that no wound care or dressing change orders were in place during this period. The facility's own wound care policy, which aims to promote healing, was not followed in this instance.
Failure to Implement Timely and Adequate Infection Control Precautions
Penalty
Summary
The facility failed to implement adequate infection prevention and control practices for a resident who was admitted with a wound infection positive for Staphylococcus aureus. Upon admission, the resident's hospital discharge paperwork included laboratory results indicating the presence of S. aureus, and the resident was receiving antibiotic treatment for the infection. Despite this, there were no physician orders for isolation precautions until two days after admission, and the resident was not placed into appropriate isolation precautions until that time. Facility leadership confirmed that it is the responsibility of the admitting nurse to review laboratory results and ensure proper isolation measures are implemented as needed. Further observations revealed additional lapses in infection control practices. There was no waste receptacle available for discarding used PPE outside the resident's room, as verified by the DON and a registered nurse. Additionally, an LPN entered the resident's room without donning PPE and stated she was unaware that the resident was on isolation precautions. The facility's infection prevention and control policy requires the implementation of appropriate isolation precautions when necessary, but these procedures were not followed in this instance.
Failure to Provide Timely Incontinence Care
Penalty
Summary
The facility failed to provide timely interventions for a resident's incontinence patterns, which led to a deficiency in care. The resident, who was admitted with multiple diagnoses including cognitive communication deficit, hemiplegia, and polyneuropathy, was assessed as incontinent of bowel and bladder and at risk for pressure ulcers. Despite having a care plan that required incontinence care as needed and regular checks every two hours, the resident was found heavily soiled during an observation, indicating a lapse in the care plan's implementation. The resident had a history of urinary tract infections, with recent treatments for E.coli infections. The deficiency was confirmed through staff interviews, where it was acknowledged that the resident should have been checked every two hours. The Director of Nursing verified the resident's recent urinary tract infection and the requirement for regular incontinence checks, highlighting the facility's failure to adhere to the care plan and prevent further complications.
Medication Administration Deficiency
Penalty
Summary
The facility failed to ensure medications were maintained and administered securely, affecting a resident who was observed with medications unattended at the bedside. The resident, who had intact cognition and required partial to moderate assistance with activities of daily living, was found with a medication cup containing five different pills on the overbed table. The resident admitted to forgetting to take the medication before breakfast, which was approximately one hour prior to the observation, and was unable to identify the medications. An interview with the LPN responsible for administering the medication revealed that she had handed the medications to the resident before breakfast but was unaware that the resident did not take them. The LPN did not observe the consumption of the medications and had already initialed the electronic medication administration record as if the medications had been administered. The facility's policy on administering medications requires that medications be administered safely, timely, and as prescribed, with the individual administering the medication initialing the record only after giving the medication.
Failure to Follow Care Plan Results in Resident Fall and Injury
Penalty
Summary
The facility failed to ensure that a resident requiring two staff members for bed mobility was properly assisted, resulting in a fall and injury. Resident #65, who was moderately cognitively impaired and had a history of multiple health issues including dementia, chronic kidney disease, and generalized weakness, required two-person assistance for bed mobility as per her care plan. However, on the day of the incident, only one staff member, STNA #159, was providing care, which led to the resident falling from the bed and sustaining a supracondylar fracture of the left femur. The incident occurred when STNA #159 was changing Resident #65 by himself, contrary to the care plan that required two staff members for such tasks. During the care, the resident was rolled away from the STNA, and she inadvertently placed her legs off the side of the bed, causing her to slide off and fall to the floor. The fall resulted in the resident experiencing left leg pain, and she was subsequently diagnosed with a fracture that required a cast and pain management. The facility's policy on falls, dated September 2021, emphasized the need for staff to identify interventions related to specific risks to prevent falls and minimize complications. Despite this policy, the care plan for Resident #65 was not followed, leading to the fall and injury. The deficiency was identified during an investigation under Complaint Numbers OH00159072 and OH00159507.
Failure to Protect Residents from Abuse by Staff
Penalty
Summary
The facility failed to protect residents from abuse by staff, specifically involving two residents. Resident #14, who was admitted with multiple medical conditions including pneumonia, COPD, and PTSD, reported verbal abuse and neglect by STNA #198. The resident stated that the aide would ignore call lights, respond rudely, and once threw a pillow that damaged the resident's orchid. Despite these allegations, the facility unsubstantiated the verbal abuse claim. Resident #60, with a history of cerebral infarction and other medical issues, also reported rough treatment by a caregiver with a ponytail, later identified as STNA #198. The resident described being thrown against the bed railing and taunted from the hallway. Initially unable to identify the perpetrator, the resident later confirmed it was STNA #198. The facility's investigation into these incidents was inadequate, as the abuse was unsubstantiated despite the residents' consistent reports. The facility's policies on abuse prevention and investigation were not effectively implemented, as evidenced by the lack of thorough investigation and reporting of the incidents. The facility's response to the allegations was insufficient, with only minimal corrective action taken against the staff member involved. This deficiency was identified under Complaint Number OH00159507.
Failure to Report Potential Neglect Incident
Penalty
Summary
The facility failed to timely report an incident of potential neglect involving Resident #65 to the appropriate state agency. Resident #65, who had a complex medical history including dementia, chronic kidney disease, and a high risk for falls, was care planned to require two-person assistance for bed mobility and transfers. However, on the morning of 09/28/24, State tested Nursing Assistant (STNA) #159 provided care independently, without the required assistance of another staff member, leading to Resident #65 falling out of bed and sustaining a left femur fracture. The incident occurred when STNA #159 was rolling Resident #65 away from himself during incontinence care, and she placed her legs off the side of the bed, subsequently sliding off and falling to the floor. Despite the care plan specifying the need for two-person assistance, STNA #159 was unaware of this requirement at the time of the incident. The fall resulted in Resident #65 being sent to the emergency room, where she was diagnosed with a left femur fracture and returned to the facility with a cast. The facility's failure to report this incident as a potential neglect case was confirmed during interviews with the Administrator and the Director of Nursing (DON). The facility's policy on abuse prevention and reporting mandates that all incidents of potential abuse or neglect be promptly reported to the appropriate authorities, but no self-reported incident (SRI) was filed in this case. This oversight highlights a significant deficiency in the facility's adherence to its own policies and regulatory requirements.
Failure to Maintain Infection Control Practices for Resident in Isolation
Penalty
Summary
The facility failed to maintain proper infection control practices for a resident in isolation, specifically for Resident #54, who was under Enhanced Barrier Precautions (EBP) due to a wound on the coccyx. The resident had a complex medical history, including cellulitis, sepsis, heart failure, chronic ulcers, and chronic kidney disease, and was dependent on staff for all functional abilities. Despite the presence of a sign indicating EBP at the resident's room, two State Tested Nursing Aides (STNAs) entered the room to provide incontinence care without wearing the required personal protective equipment (PPE), which includes a gown and gloves. Interviews with the STNAs revealed that they were unaware that the EBP order was still active, mistakenly believing it had expired. Further interviews with the Licensed Practical Nurses (LPNs) and the Director of Nursing (DON) confirmed that the EBP order was indeed active and had been placed for the resident's coccyx wound. The facility's policy on Enhanced Barrier Precautions, which mandates the use of gloves and gowns during high-contact care activities for residents with certain conditions, was not adhered to in this instance, leading to the deficiency.
Failure to Ensure Required RN Coverage
Penalty
Summary
The facility failed to ensure the required Registered Nurse (RN) coverage, which had the potential to affect all 65 residents. A review of staff timesheets revealed that on several specific dates, the facility did not have an RN working a minimum of eight hours a day. This was confirmed during an interview with the Administrator, who verified the lack of RN coverage on those dates. The facility's policy, dated September 2021, states that adequate staffing must be maintained on each shift to ensure residents' needs and services are met, with licensed registered nursing and licensed nursing staff available to provide and monitor the delivery of resident care services.
Kitchen Sanitation Deficiency
Penalty
Summary
The facility failed to maintain the kitchen in a clean and sanitary manner, which had the potential to affect all 65 residents receiving meals from the kitchen. During an initial tour of the kitchen, excessive buildup and grime were observed between and behind the fryer and stove, as well as on the lower part of a metal food cart used for resident meal trays. Additionally, there was buildup and debris on the floor and along the edges of the walls surrounding the interior side of an exit door in the dry storage room, and excessive black-colored buildup under tables and appliances throughout the kitchen. The Regional Dietary Manager confirmed the presence of debris and buildup on the floors and meal cart. A review of the facility's pest control service logs from May and June indicated that the kitchen had been inspected and spot treated, with recommendations for cleaning. The Maintenance Director verified that the pest control logs noted the need for kitchen cleaning.
Failure to Maintain Cleanliness in Memory Care Unit
Penalty
Summary
The facility failed to maintain a clean and sanitary environment in the memory care unit, affecting 28 residents. Observations over several days revealed that the flooring along the edges of the hallways and in specific resident rooms had a thick layer of dust and grime. This was noted in the memory care unit and in the rooms of specific residents, where the flooring, particularly around the corners and edges, was unclean with a noticeable build-up of substances. Interviews with housekeeping staff confirmed the presence of dirt and debris in these areas. Housekeeping staff acknowledged the issue and mentioned that they had just begun deep cleaning, planning to clean two rooms per day. The facility's housekeeping policy, which lacked a date, indicated that cleaning schedules should be developed and implemented to maintain a safe, clean, and comfortable environment, but this was not adhered to, leading to the observed deficiencies.
Failure to Report Elopement and Unprescribed Medication Administration
Penalty
Summary
The facility failed to report an incident of elopement involving a resident who was at high risk for elopement. The resident, who had a history of cognitive impairment and was deemed appropriate for the memory care unit, managed to leave the facility through a window. The resident was found outside the facility after visiting local bars, consuming alcohol, and returning to the premises. Despite the severity of the incident, no Self-Reported Incident (SRI) was filed by the facility. Additionally, the facility did not report allegations of an unlicensed staff member administering unprescribed melatonin to several residents. This involved four residents who were either not prescribed melatonin or were cognitively impaired. The Director of Nursing was aware of the allegations but did not conduct further reporting, and the Administrator confirmed that no SRI was filed regarding this issue. The facility's policy on abuse investigation and reporting mandates that all reports of resident abuse, neglect, and other related issues be promptly reported to appropriate authorities. However, the facility did not adhere to this policy in the cases of the resident's elopement and the administration of unprescribed medication, leading to non-compliance with regulatory requirements.
Failure to Investigate Allegation of Unlicensed Staff Administering Unprescribed Medication
Penalty
Summary
The facility failed to investigate an allegation of unlicensed staff administering unprescribed melatonin to residents. This issue affected four residents, all of whom were cognitively impaired and included individuals with diagnoses such as dementia and Alzheimer's disease. The medical records revealed that only one of the four residents had a prescription for melatonin, while the others did not. Despite being notified of the allegation, the Director of Nursing (DON) only spoke with the nurse involved and reported the incident to the Administrator, without conducting a thorough investigation. The Administrator also failed to file a self-reported incident or investigate the allegation of abuse involving the administration of unprescribed medication by unlicensed staff. The facility's policy on Abuse Investigation and Reporting, dated September 2021, mandates that all reports of abuse, neglect, exploitation, and other related issues be reported and thoroughly investigated by facility management. This includes interviewing the resident and staff members involved in the alleged incident. The deficiency was investigated under Complaint Number OH00154857.
Oxygen Administration Error for Resident
Penalty
Summary
The facility failed to ensure that a resident received oxygen at the correct rate as prescribed by the physician. The resident, who was cognitively intact and had a history of chronic obstructive pulmonary disease among other diagnoses, was supposed to receive two liters of oxygen per minute via nasal cannula. However, during an observation, it was noted that the oxygen concentrator was set to deliver three liters per minute. The resident confirmed that they were supposed to receive two liters per minute. A registered nurse acknowledged the discrepancy and suggested that the control for the oxygen concentrator might have been accidentally adjusted.
Expired Insulin Not Discarded
Penalty
Summary
The facility failed to properly manage the storage and disposal of expired insulin, affecting three residents diagnosed with diabetes mellitus type II. During an observation, it was found that insulin pens and a multi-dose vial were opened and expired, yet still stored in the medication cart. Specifically, a multi-dose vial of aspart insulin for one resident, a fiasp insulin pen for another, and a novolog insulin pen for a third resident were identified as expired. This was confirmed by an LPN during the observation. The facility's policy on medication storage mandates that all drugs and biologicals be stored safely and securely, and that discontinued, outdated, or deteriorated drugs should not be used. Additionally, the policy on administering medications requires checking the expiration or beyond-use date on medication labels before administration. The failure to adhere to these policies resulted in the presence of expired insulin in the medication cart, which was not discarded as required.
Failure to Complete Ordered Laboratory Tests
Penalty
Summary
The facility failed to ensure that laboratory tests were completed according to the pharmacist's recommendation and physician's order for a resident. The resident, who was admitted with diagnoses including type II diabetes mellitus with diabetic polyneuropathy, obesity, muscle weakness, anxiety, and depression, was identified as cognitively intact. The plan of care for the resident included monitoring labs and diagnostic testing per physician order. However, the last Hemoglobin A1C (HbA1c) test was completed on 12/28/23, despite a pharmaceutical recommendation made on 05/24/24 to monitor HbA1c every three months for diabetes therapy. This recommendation was reviewed and an order was placed on 06/11/24 to monitor HbA1c every three months starting on the 12th. Despite the physician's order, the laboratory work completed on 06/12/24 did not include the HbA1c test. An interview with the Director of Nursing on 07/08/24 confirmed that the HbA1c test was not completed as ordered on 06/12/24, and the most recent HbA1c test for the resident was on 12/28/23. The facility's policy on requests for diagnostic services stated that orders for diagnostic services would be carried out as instructed by the physician's order, indicating a failure to adhere to this policy.
Failure to Protect Resident from Verbal Abuse
Penalty
Summary
The facility failed to protect a resident from verbal abuse by a staff member, specifically a State Tested Nurse Aide (STNA). The incident involved a resident who was cognitively intact and required assistance with activities of daily living due to conditions such as chronic obstructive pulmonary disease, muscle weakness, and incontinence. The resident reported that an STNA was verbally abusive, which was corroborated by witness statements from other staff members who observed the STNA cursing and belittling the resident about their incontinence. The incident was reported on the same day it occurred, and the STNA involved was immediately removed from the facility pending investigation. Despite the resident expressing shock and discomfort at the STNA's behavior, the facility's investigation concluded that verbal abuse was not substantiated. However, the STNA was disciplined with a one-day suspension for verbal abuse, indicating some acknowledgment of inappropriate behavior. Interviews with other staff members and the resident's daughter confirmed the STNA's inappropriate comments and actions, which included cursing and making derogatory remarks about the resident's urinary habits. The facility's administrator acknowledged the disciplinary action taken against the STNA but did not report the incident to the nurse aide registry. The resident expressed that the STNA had never behaved in such a manner before, and the STNA was not allowed to provide care for the resident following the incident.
Failure to Prevent Elopement and Implement Fall Interventions
Penalty
Summary
The facility failed to provide adequate supervision to prevent the elopement of a resident identified as Resident #54. This resident, who had a history of cognitive impairment and was deemed a flight risk, managed to leave the facility unsupervised. Despite being on a secure memory care unit, the resident was able to unscrew his window screen and exit the building. He then visited two local bars, consuming alcohol before returning to the facility. The staff was unaware of his absence until he was found outside the facility early in the morning. The resident's care plan had identified him as an elopement risk, but the necessary supervision and checks were not in place to prevent this incident. Additionally, the facility failed to implement fall prevention interventions for Resident #58, who was at risk for falls due to cognitive impairment and physical weakness. The care plan for this resident included the use of a mat on the floor next to the bed to prevent injury from falls. However, observations revealed that the mat was not in place on multiple occasions, and staff interviews confirmed that the mat had not been used as required. This oversight left the resident vulnerable to potential falls, as the necessary safety measures were not adhered to. These deficiencies highlight lapses in the facility's adherence to care plans and supervision protocols, which are critical for ensuring resident safety. The lack of proper monitoring and implementation of safety interventions contributed to the incidents involving both residents, indicating a need for improved compliance with established care procedures.
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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