Edith Lane Of Cincinnati
Inspection history, citations, penalties and survey trends for this long-term care facility in Cincinnati, Ohio.
- Location
- 2586 Lafeuille Avenue, Cincinnati, Ohio 45211
- CMS Provider Number
- 365005
- Inspections on file
- 47
- Latest survey
- March 19, 2026
- Citations (last 12 mo.)
- 4
Citation history
Health deficiencies cited at Edith Lane Of Cincinnati during CMS and state inspections, most recent first.
The facility failed to maintain a functional phone system on its secured behavioral units. On the women’s secured behavioral unit, the nurse’s station phone was not working and a second unit phone was unplugged, leaving staff without a working line for incoming calls from families. On the men’s secured behavioral unit, the unit phone was also unplugged and not operational, and staff reported frequent problems with phones not working. The receptionist stated that after her work hours, calls are routed to nurse’s stations, but acknowledged there had been recent periods when phones were not working. The administrator did not view families’ inability to call in as a problem, noted that staff sometimes shared personal phone numbers with families, and confirmed there was no specific phone policy.
The facility failed to maintain a sanitary, clean, and safe environment, including multiple resident rooms and common areas on a secured women’s behavioral unit and the main entrance. Several residents with impaired cognition and complex medical/psychiatric conditions were found in rooms with heavily soiled toilets, floors blackened with dirt and debris, dried blood and stool on bathroom floors, missing tiles, exposed drywall, and pest activity such as fruit flies and mouse droppings. A shared shower room used by all women on the unit was heavily soiled, with suspected mold, a broken drain, and a ceiling fan hanging from the ceiling, while the unit’s dining/activity room had a broken interior window with a sharp edge, a large hole in the wall, and non-functioning ceiling lights. One resident’s heating unit blew cold air despite reports it had been repaired, and her bathroom remained soiled and in disrepair. Another resident’s room contained evidence of mice, which she described as pets, without documented targeted pest treatment. At the main entrance, residents repeatedly smoked in a posted non-smoking area, and the entrance and surrounding landscaping were littered with cigarette butts, with no proper receptacle provided, despite a designated smoking area being located across the parking lot.
The facility failed to maintain safe and controlled smoking areas, as evidenced by heavily littered smoking and entrance areas and residents smoking in a designated non‑smoking zone. Surveyors observed numerous discarded cigarette butts around the secured behavioral unit’s smoking exit and the main entrance, where no cigarette disposal container was present. A resident with multiple psychiatric and medical diagnoses, assessed as an independent smoker, reported routinely smoking at the main entrance, while two other cognitively intact residents, including one with hemiplegia assessed as an unsafe smoker requiring supervision, were also seen smoking there. Staff, including a CNA and an LPN, confirmed that residents smoked at the main entrance despite it being a non‑smoking area and acknowledged the extensive cigarette litter.
Multiple deficiencies were identified, including missing window coverings, mold on window sills, broken window panes, ripped mattresses, and unusable shower facilities with exposed drywall and standing water. Residents and staff confirmed these issues, which affected privacy, cleanliness, and access to functional bathing areas.
A deficiency was identified when multiple residents, including those with significant medical and mobility needs, did not have individual or accessible call systems in their rooms. Observations showed that in double occupancy rooms, only a single pull cord was available and was out of reach for residents in bed, and in one case, a call system was entirely absent. Staff and administration confirmed these issues, which were not in accordance with facility policy.
Two residents, both cognitively intact and with complex medical histories, were found in rooms with significant environmental deficiencies, including an improperly installed AC unit leaving a large gap to the outside, missing window coverings, unattached drywall, and the absence of a functioning call system. These issues were confirmed by facility staff and administration.
Surveyors found that kitchen staff failed to properly label and date opened food items, including lunch meat, cheese, tomatoes, and sandwiches, in the refrigerator. Additionally, staff were observed not using appropriate hair and beard restraints while working in the kitchen, as required by facility policy.
The facility did not conduct care conferences or update care plans in a timely manner for several residents with complex medical needs. Missed or unscheduled care conferences, delayed documentation of interventions after falls, and lack of communication with families were confirmed by staff and resident interviews, as well as medical record reviews.
A RN discarded gabapentin and memantine tablets into an open trash receptacle on a medication cart and left the cart unattended in a common area with several residents present. The DON confirmed that medications should not be left where residents could access them.
Several residents experienced environmental deficiencies, including an improperly installed air conditioning unit that left gaps allowing air and light into a room, and multiple rooms with non-functioning electrical outlets that prevented use of devices such as televisions. These issues were confirmed by resident and staff interviews, observations, and service reports, indicating the facility did not provide a safe, comfortable, and homelike environment as required.
Two residents with significant cognitive and physical impairments did not have working call lights or alternative signaling devices in their rooms, preventing them from summoning staff for assistance. Staff and management confirmed the deficiency, and facility policy requiring functional and accessible call systems was not followed.
A resident with severe cognitive impairment and multiple comorbidities experienced significant, undocumented weight loss over several months. Facility staff failed to consistently obtain and accurately document weights, resulting in the physician not being notified of the resident's decline. No nutritional interventions were implemented due to missing or inaccurate data.
A resident with a history of impacted cerumen and multiple psychiatric and medical conditions did not receive recommended follow-up audiology care after an initial visit identified complete ear canal occlusion. Despite a care plan intervention and recommendations for follow-up, there was no documentation of further audiology appointments, and staff confirmed no additional services were scheduled or refused.
A resident with severe cognitive impairment and multiple comorbidities experienced significant weight loss due to the facility's failure to consistently monitor and document weights. Despite variable oral intake and a physician order for a no added salt diet, no nutritional interventions were implemented, and staff were unaware of the extent of the weight loss due to missing or inaccurate weight records. The facility did not follow its own policy for regular weight monitoring and intervention.
The facility did not obtain or complete laboratory tests as ordered by physicians for three residents with complex medical conditions. Required tests, including CBC, renal panels, medication levels, and a toxicology screen, were either missed or not performed at the specified intervals. The DON confirmed that the missing laboratory results were not available in the residents' medical records.
A resident with dysphagia and multiple comorbidities was served food that did not meet the ordered mechanical soft texture, including whole-leaf brussel sprouts, large pieces of meat, and bow tie pasta. An LPN identified the issue and removed the plate before the resident could eat the food, and the resident declined a replacement meal.
A CNA did not wear an isolation gown while providing care to a resident with an indwelling urinary catheter who was on enhanced barrier precautions. The CNA was unaware of the need for these precautions, despite facility policy and signage, and reported not having been educated on enhanced barrier precautions.
The facility failed to prevent accident hazards by allowing a resident with cognitive impairment to leave for an unsupervised community appointment without verifying the appointment or transportation, resulting in the resident not returning. Additionally, another resident with recent stroke symptoms and left-sided weakness was transferred using a sit-to-stand lift without proper assessment, despite being unable to safely grip the device. These incidents reflect lapses in supervision and assessment of residents' needs.
A resident with significant cognitive and physical impairments, dependent on staff for incontinence care, was left without timely assistance after the assigned CNA was moved to another floor. The resident was last changed before lunch and was later found to be moderately saturated with urine, contrary to facility policy requiring regular checks and care.
The facility failed to maintain comfortable air temperatures, resulting in residents being moved to a dining room due to non-functioning heating units in their rooms. Observations showed temperatures as low as 57.6°F, and residents expressed dissatisfaction with the cold conditions. The facility's policy to provide a homelike environment with comfortable temperatures was not upheld.
Due to heating issues, several residents were moved to a dining room without privacy curtains or barriers, affecting their visual privacy. The move was prompted by a break in the sprinkler pipe that impacted the heating system, and the dining room was used as it had a separate heating system. Residents and staff confirmed the lack of privacy and cold conditions, with beds remaining in the dining room even after heat was restored to most rooms.
A resident with a full code status was found unresponsive, and the facility staff failed to administer CPR according to AHA guidelines. Although chest compressions were initiated, rescue breaths were not provided until a registered nursing supervisor arrived, as the initial responders did not know how to use the Ambu bag. This failure to follow the facility's CPR policy and professional standards of care resulted in a deficiency.
A resident with a trauma wound on the left lower leg did not receive timely wound care as prescribed upon readmission to the facility. Despite hospital instructions to change the wound dressing every three days, the facility did not implement the treatment orders until several days later. Interviews with the DON and an LPN confirmed the delay in care, which was contrary to the facility's wound care policy.
A resident with multiple health issues, including moderate cognitive impairment, was readmitted with an unstageable pressure ulcer. Despite orders for daily dressing changes, the facility failed to provide the prescribed treatment for over a week. Interviews with the DON and an LPN confirmed the delay, highlighting noncompliance with the facility's wound care policy.
A facility failed to maintain a medication error rate below five percent, with an observed error rate of eight percent. An LPN administered an incorrect dose of vitamin D3 and failed to administer Entresto to a resident due to its unavailability. The resident had a history of acute hepatitis C, hypertension, and chronic respiratory failure. The errors were confirmed by the LPN, who did not adhere to the facility's medication administration policy.
Two residents suffered actual harm due to the facility's failure to conduct timely skin assessments and implement interventions for pressure ulcers. One resident developed an unstageable ulcer on the buttocks after a lack of weekly assessments, while another developed a heel ulcer due to an unmonitored splint. The facility's non-compliance with its pressure ulcer risk assessment policy led to these deficiencies.
A resident with dementia and behavioral disturbances was abused by a staff member after becoming combative during personal care. The staff member struck the resident multiple times on the head, violating the facility's abuse prevention policy. The incident was witnessed by other staff and reported, highlighting a failure to protect the resident from abuse.
A resident with multiple diagnoses, including paraplegia and sepsis, did not receive adequate catheter care in an LTC facility. Despite physician orders for catheterization, there were no specific orders for Foley catheter care, and the resident reported not receiving catheter care for seven days. An LPN confirmed the lack of catheter care documentation, and the facility's policy for routine hygiene was not followed.
A resident with multiple diagnoses, including a recent thoracic spine surgery, did not receive necessary therapy services due to a lost back brace and delayed evaluation. Despite attempts to clarify the use of a thoracic-lumbar-sacral orthosis (TLSO) brace with the hospital, the facility failed to provide therapy services for 16 days.
A resident with multiple medical conditions and minimal cognitive impairment was found to have a non-operational call light system, leaving them unable to summon staff assistance. The issue had persisted since the previous evening, and the facility's administrator was unaware of how long the call light had been non-functional.
A resident with a history of aggressive behavior intentionally ran over another resident with his wheelchair, causing a fracture. Despite being on a secured unit, the aggressive resident was able to harm others, including another resident involved in a physical altercation. The facility's investigation was unsubstantiated, despite evidence of intentional harm.
A resident was not provided with the ordered occupational and physical therapy services, receiving only initial and discharge sessions despite being evaluated for five sessions over 30 days. The resident expressed frustration over the lack of therapy, and the facility failed to provide additional sessions due to pending insurance approval. The administrator confirmed the lack of therapy and could not provide billing information.
Nonfunctional Phone System on Secured Behavioral Units
Penalty
Summary
The facility failed to maintain a properly operating phone system, resulting in nonfunctional phones on both the Secured Women’s Behavioral Unit and the Secured Men’s Behavioral Unit. On the Secured Women’s Behavioral Unit, surveyor observation with a CNA showed the nurse’s station phone did not work and a second phone on the unit was unplugged and not operational; the CNA confirmed there was no working phone on the unit and stated that if a resident’s family member tried calling in, there was no way to reach staff. On the Secured Men’s Behavioral Unit, observation with another CNA revealed the phone was not plugged in and therefore not operational; this CNA reported the facility had many issues with phones often not working, and the RN assigned to that unit also verified the phone was not operational. The receptionist reported that when she is not on duty, incoming calls roll to the nurse’s station depending on the prompt selected, and acknowledged there had been times recently when the phones were not working. The Administrator stated he did not think it was an issue when families were unable to call into the facility, explained that staff often gave families their personal phone numbers, and confirmed there was no specific policy regarding phones. The deficiency involved all residents on the secured behavioral units, as the lack of functioning phones at the nurse’s stations and within the units meant staff could not be reliably reached through the facility’s phone system, particularly when the receptionist was not present and calls were supposed to roll over to the units.
Failure to Maintain Sanitary, Safe Environment and Proper Smoking Controls
Penalty
Summary
The deficiency involves the facility’s failure to maintain a sanitary, clean, and safe environment for residents on the secured women’s behavioral unit and for residents using the main entrance. Multiple resident rooms and common areas were observed to be heavily soiled and in disrepair. One resident with schizophrenia, COPD, hypertension, hypothyroidism, schizoaffective disorder, and osteoarthritis, who had impaired cognition and required staff assistance with ADLs and medications, was found to have a bathroom with brown splatter on the walls behind and opposite the toilet, a heavily soiled toilet, and a floor blackened with dirt and debris. Her bedroom walls were soiled, scuffed, and had exposed drywall, with unknown splatter and dried substances around the receptacle and under the light. A CNA confirmed these conditions. Another resident with essential hypertension, antisocial personality disorder, inhalant abuse, DM, schizoaffective disorder, bipolar disorder, dementia, and anxiety disorder, who had severely impaired cognition and required supervision or set-up for ADLs and was dependent on staff for medications, was observed without sheets on her bed. Her bed contained a wadded-up blanket heavily soiled with yellow and brown substances and swarmed with fruit flies. The floor in front of the bed was blackened with dirt and debris, and a soiled incontinent brief with apparent blood and stool was on the bedroom floor, surrounded by reddish-brown droplets and brown dried splatter on the wall near the toilet. The bathroom floor was missing tiles. The CNA stated the blanket was soiled with urine and verified the room conditions. A housekeeper confirmed the presence of stool and blood on the bathroom floor and stated she does not clean up blood. Later observation showed the bathroom sink filled with brown water and cigarette butts, with no running hot or cold water, and dried blood on the floor. The maintenance supervisor acknowledged awareness of the non-functioning sink and standing brown water and stated no pest treatment had been provided to the room. On the women’s secured unit, the shared shower room used by all twelve residents had a floor blackened with dirt and heavily soiled, with unknown brown spots and splatter in the shower corners and up the walls. The toilet in the shower room was heavily soiled, the shower drain was partially broken, and the ceiling fan was hanging down with the ceiling spotted by an unknown black substance that a CNA stated appeared to be mold. The large dining/activity room on the unit had a half-broken window opening into the nurse’s station, leaving a sharp edge, and a large hole in the wall with exposed drywall beneath it. Five large ceiling lights in this room had no light bulbs. The maintenance supervisor verified the non-functioning lights and the hole in the wall and stated he was not aware of the broken window. Another resident with DM, hypertension, asthma, atherosclerotic heart disease, schizoaffective disorder, anxiety disorder, and GERD, who had impaired cognition and required supervision, moderate, or set-up assistance for ADLs and was dependent on staff for medications, reported that her room was very cold. She indicated her heating unit, covered with a blanket and with another blanket at the base of the window, was blowing cold air despite being told it had been fixed. Observation confirmed the unit was running but blowing cold air, and her bathroom was soiled, missing floor tiles, and had a heavily soiled toilet with a black ring. A CNA confirmed the room had been cold for some time and verified the bathroom conditions. The maintenance supervisor later confirmed the heater was blowing cold air and noted holes in the wall beside the bed and shredded privacy curtain pieces hanging from the ceiling. A further resident with impaired cognition and diagnoses including hypertension, DM, atherosclerotic heart disease, schizoaffective disorder, anxiety disorder, and cystitis was observed to have a dish of water under her sink and a large pile of what appeared to be mouse droppings under the sink. The sink did not drain correctly when water was running. The resident stated the dish of water was for mice living in a large hole in the corner under the sink and referred to the mouse as her pet. The maintenance supervisor stated he was aware of the mouse droppings and the mouse issue in the room and that the facility had been treated for mice. However, review of pest control work orders showed no specific treatments for fruit flies in the room with the soiled blanket and flies, or for mice in this resident’s room. At the main entrance, residents and staff used a double set of doors with a small concrete pad and awning. One resident was observed smoking directly outside the front doors in a posted non-smoking area. Numerous discarded cigarette butts were scattered across the ground near the front door, in the landscaping rocks on both sides of the doors, and around a trash can with a plastic liner, with no container provided for cigarette disposal. A CNA confirmed the resident was smoking in the non-smoking area and identified a designated smoking area across the parking lot, also verifying the scattered cigarette butts. The resident stated he often smoked by the main entrance doors. On a subsequent observation, two other residents were seen smoking directly outside the main entrance in the same non-smoking area, with the area still littered with cigarette butts on the ground and in the landscaping. An LPN confirmed the residents were smoking in the non-smoking area and verified the large amount of discarded cigarette butts. Facility policy stated that the maintenance department was responsible for maintaining the building, grounds, and equipment in a safe and operable manner at all times, including heating/cooling systems, plumbing fixtures, and ensuring lights were in good working condition, with the maintenance director responsible for inspection of the building.
Failure to Maintain Safe and Controlled Smoking Areas
Penalty
Summary
The facility failed to maintain a safe smoking environment in both the secured women's behavioral unit and the main entrance area. On the secured women's behavioral unit, surveyors observed numerous discarded cigarette butts lying all over the ground near the exit door to the smoking area and along the sidewalk leading away from the building; a CNA confirmed the presence of these cigarette butts. At the main entrance, which was identified as a non‑smoking area, surveyors observed a concrete pad and awning where residents, visitors, and staff entered the building, and noted numerous discarded cigarette butts scattered across the ground near the front door, throughout the landscaping rocks on both sides of the doors, and around a trash can with a plastic liner. There was no container for discarded cigarettes at this entrance. Multiple residents with documented smoking evaluations and intact cognition were observed smoking in the non‑smoking main entrance area. One resident, with diagnoses including essential primary HTN, antisocial personality, inhalant abuse, schizoaffective disorder, bipolar disorder, anxiety disorder, and psychosis, had been assessed as an independent smoker with no history of smoking safety concerns and reported that he smoked by the main entrance doors often. Another resident, with diagnoses including paranoid schizophrenia, bipolar disorder, essential primary HTN, anxiety disorder, and psychotic disorder with delusions, was also assessed as an independent smoker. A third resident, with cerebrovascular disease, hemiplegia and hemiparesis, hyperlipidemia, depression, anxiety disorder, and epilepsy, had been assessed as an unsafe smoker requiring staff supervision due to left‑sided paralysis. Despite these assessments, surveyors observed these residents smoking directly outside the main entrance in the non‑smoking area, and staff (a CNA and an LPN) verified both the residents’ smoking in this location and the large amount of discarded cigarette butts scattered on the ground and in the landscaping.
Environmental Deficiencies Impacting Resident Comfort and Safety
Penalty
Summary
The facility failed to provide a clean, safe, and comfortable environment for residents, staff, and the public, as evidenced by multiple deficiencies observed in Building #2 and the 2 west unit of Building #1. In Building #2, numerous resident rooms lacked curtains or blinds on ground-level windows, compromising privacy for 19 residents. Mold was observed on the window sills in several rooms, affecting eight residents, and one room had a broken inside window pane. Additionally, some rooms contained ripped mattresses. The shower room in Building #2 was found with drywall off the walls and lying on the floor, lacked a shower curtain for privacy, and was missing a shower head, rendering it unusable for all residents who relied on it for bathing. In Building #1, the unit shower on the 2 west unit was not operational, with approximately one inch of standing water in both the shower and dressing areas, dirty floors, and a dark substance resembling mold on the walls. Residents expressed dissatisfaction with having to use a distant shower in another unit due to the non-functioning shower on their own unit. Staff interviews confirmed the observations, and a review of the facility's maintenance policy indicated that maintenance personnel are responsible for keeping the building in good repair and free from hazards. These findings were substantiated through direct observation, staff, and resident interviews.
Failure to Provide Accessible Call Systems for Residents
Penalty
Summary
The facility failed to ensure that a functioning call system was available and accessible for residents in the secured men's behavioral unit. Observations revealed that in one resident's room, the call system cord was lying on the floor and there was no call system box present on the wall, making it impossible for the cord to be plugged in. Interviews with staff confirmed the absence of a call system in this room and were unable to determine how long it had been inactive. Medical record review for this resident showed significant medical needs, including traumatic brain injury, kidney cancer, morbid obesity, and left-sided hemiplegia, with dependence on staff for all activities of daily living. Further observations across the unit found that in double occupancy rooms, only a single pull cord was available between the two beds, positioned in the middle of the wall and out of reach for residents while in bed. This arrangement did not provide each resident with individual access to the call system. The facility's policy required that call lights be plugged in at all times and within easy reach of residents, but this was not followed for 14 residents on the unit. The deficiency was confirmed by the administrator, who acknowledged the lack of individual call system access for these residents.
Failure to Maintain Safe and Homelike Resident Environment
Penalty
Summary
The facility failed to provide a safe, clean, comfortable, and homelike environment for two residents. For one resident with chronic obstructive pulmonary disease, chronic congestive heart disease, and acute kidney failure, an air conditioning unit was observed to be improperly installed in the room's outer wall, leaving a large gap through which the sky and surrounding buildings were visible. This issue was confirmed by the Maintenance Director during the observation. Another resident, who had a history of traumatic brain injury, kidney cancer, anemia, morbid obesity, hypertension, cerebrovascular accident with left hemiplegia/hemiparesis, bipolar disorder, depression, and anxiety, was found in a room with no pictures on the walls, no window coverings, and drywall at the top of the inner window frame hanging unattached. Additionally, the call system cord was on the floor and out of reach, and there was no call system box present in the room for the cord to be plugged into. These conditions were verified by both nursing and maintenance staff, as well as the facility administrator.
Improper Food Storage and Inadequate Use of Hair Restraints in Kitchen
Penalty
Summary
Surveyors observed multiple instances of improper food storage in the facility's kitchen. Specifically, there were opened and undated packages of ham lunch meat and yellow cheese, as well as undated halved tomatoes wrapped in plastic. Additionally, several sandwiches (ham, bologna, and peanut butter) were individually packaged in plastic bags without any labels or dates. The Food Service Director confirmed that these items were not labeled or dated as required by facility policy, which mandates that all foods stored in the refrigerator or freezer be covered, labeled, and dated with a use-by date. Further observations revealed that kitchen staff did not consistently use appropriate hair restraints. One dietary assistant was seen wearing a hat, but her long braided ponytail was not contained within the hat. Another staff member entered the kitchen without a hair net and was also observed with a short beard but no beard protector. Both staff members confirmed during interviews that they were not using the required hair or beard restraints while in the kitchen.
Failure to Conduct Timely Care Conferences and Update Care Plans
Penalty
Summary
The facility failed to ensure that care conferences were conducted and care plans were updated in a timely manner for multiple residents, as required by policy and regulation. Medical record reviews, interviews, and incident reports revealed that several residents did not have care conferences scheduled or rescheduled within the required timeframes, particularly when residents were unavailable or out of the facility. In some cases, care conferences were missed for entire quarters, and documentation confirmed that these were not rescheduled at the earliest convenience, as verified by staff interviews. Additionally, the facility did not consistently update care plans when new interventions were implemented following incidents such as falls. For example, after a resident experienced multiple falls, immediate interventions like non-skid socks and pharmacy reviews were initiated but not promptly or accurately reflected in the resident's care plan. In some instances, interventions were back-dated in documentation to appear as though they were implemented earlier than they actually were. Interviews with the DON confirmed that certain interventions were not added to the care plan until much later, despite being put in place following incidents. Residents affected by these deficiencies had a range of complex medical conditions, including cognitive impairments, neurological disorders, and chronic diseases. Family members and residents reported a lack of communication regarding care conferences, with some stating they had not participated in or been informed about care planning meetings for extended periods. Staff interviews corroborated that care conferences and care plan updates were not completed as required, impacting the facility's ability to provide coordinated and individualized care.
Unsecured Discarded Medications Left Accessible During Medication Pass
Penalty
Summary
During medication administration, a registered nurse was observed discarding two 300 mg gabapentin capsules and one 5 mg memantine tablet into an open trash receptacle attached to the medication cart. The medication cart, containing the unsecured discarded medications, was left locked but unattended on four separate occasions in a common area between the facility's front entrance and the rehabilitation room. At the time, five residents were present in the hallway where the cart and the open trash receptacle with the medications were accessible. The registered nurse confirmed that the medications should not have been discarded in an unsecured trash receptacle and acknowledged that any resident passing by could have accessed them. The Director of Nursing also confirmed that medications should not be left unattended where residents could access them.
Failure to Maintain Homelike Environment Due to Improper AC Installation and Electrical Outlet Issues
Penalty
Summary
The facility failed to provide a safe, clean, comfortable, and homelike environment for several residents, as evidenced by multiple environmental deficiencies observed and reported. One resident's room had an improperly installed air conditioning unit that did not fit the wall opening, leaving visible gaps around the unit. A thin plastic covering, secured with painter's tape, was used in an attempt to seal the gaps, but holes were present and both light and air could pass through. The resident confirmed that the replacement unit had never fit properly and that the plastic did not keep cold air out. The Maintenance Director acknowledged the issue, stating the new unit was smaller than the original opening and that makeshift measures had been used to address the gaps, but these were ineffective as air and light continued to enter the room. Additionally, several residents reported and were observed to have non-functioning electrical outlets in their rooms. These issues prevented residents from using electrical devices such as televisions, as the outlets on the relevant walls did not provide power. Interviews with residents confirmed their awareness of the problem and that the facility had not corrected it. Observations corroborated that multiple rooms had outlets without electricity, affecting the residents' ability to use their rooms comfortably and safely. The Director of Nursing verified that the electrical issues were present in several rooms, and a review of a service report from an electrical contractor indicated a short in a wall affecting power in two rooms. The facility's policy requires providing a homelike environment, including safe and functional living spaces, but the observed conditions did not meet these standards. The deficiencies were identified through observations, interviews, and record reviews, and were associated with multiple complaint investigations.
Nonfunctional Call Systems in Resident Rooms
Penalty
Summary
The facility failed to ensure that resident call systems were functioning properly in the rooms of two residents who required assistance with activities of daily living. Both residents had significant cognitive and physical impairments, including dementia, schizoaffective disorder, and a history of falls, and were care planned to have call lights within reach to request help. Observations revealed that the call lights in their rooms were not working, and both residents expressed an inability to summon staff when needed. A CNA confirmed that the call lights for both residents were nonfunctional, and the unit manager verified that neither resident had a working call light or an alternative signaling device, such as a bell, in their room. Review of facility policy indicated that staff are required to ensure call lights are plugged in and within easy reach, and to promptly report any defective call lights to the nurse supervisor. Despite these policies, the deficiency was identified through direct observation, resident and staff interviews, and review of medical records and care plans, which all indicated that the required call systems were not available or operational for the affected residents.
Failure to Notify Physician of Significant Weight Loss
Penalty
Summary
The facility failed to notify the physician of a significant weight loss experienced by a resident with multiple diagnoses, including chronic obstructive pulmonary disease, frontotemporal neurocognitive disorder, generalized anxiety disorder, major depressive disorder, and vascular dementia. The resident was severely cognitively impaired and required varying levels of assistance with activities of daily living. Medical record review showed a substantial decrease in the resident's weight over several months, with weights dropping from 135.6 pounds to 87.8 pounds. There were also several months where the resident was not weighed, and some recorded weights were identified as inaccurate or missing. The registered dietician noted the need for reweighing and recognized the significant weight loss but was unable to implement nutritional interventions due to the lack of accurate data. Interviews with facility staff, including the DON and the RD, confirmed that they were unaware of the extent of the resident's weight loss and that there were gaps in weight documentation. The physician stated she was not notified of the resident's weight loss or the inconsistent weight monitoring. There was no documented evidence in the medical record that the physician had been informed of the resident's significant weight loss, and no nutritional interventions were put in place to address the issue.
Failure to Provide Follow-Up Audiology Services
Penalty
Summary
A deficiency was identified when a resident with multiple psychiatric and medical diagnoses, including schizoaffective disorder, anxiety disorder, impulse disorder, pseudobulbar affect, and type II diabetes, did not receive appropriate follow-up care for audiology services. The resident was cognitively intact and had a care plan intervention to refer for audiology evaluation as needed. An audiologist visit documented that the resident had impacted cerumen in both ears, which completely occluded the ear canals. Although ear wax removal drops were administered, the resident declined further cerumen removal attempts. The audiologist recommended a follow-up cerumen evaluation in four to six months. Subsequent review of the medical record revealed no documentation of follow-up appointments or further audiology services for the resident after the initial visit. The resident was not included on the facility's list of those seen for audiology services at a later date. Interviews with the resident and facility staff confirmed that no additional audiology appointments were scheduled or refused since the initial visit, and the resident reported ongoing issues with ear clogging and no recollection of seeing an audiologist at the facility.
Failure to Monitor and Address Significant Weight Loss
Penalty
Summary
The facility failed to consistently monitor and document the weights of a resident with multiple diagnoses, including chronic obstructive pulmonary disease, frontotemporal neurocognitive disorder, generalized anxiety disorder, major depressive disorder, and vascular dementia. The resident was severely cognitively impaired and required varying levels of assistance with activities of daily living. Despite having a physician order for a no added salt diet and regular monitoring, the resident's weights were not consistently recorded for several months, including October, November, January, and March. This lack of consistent weight monitoring led to gaps in the resident's nutritional assessments. During the period in question, the resident experienced significant weight loss, dropping from 126.6 pounds to 87.8 pounds over several months. Nutrition notes indicated that the resident's oral intake varied, but no additional nutritional interventions, such as supplements or drinks, were implemented to address the weight loss. The registered dietician noted the need for reweighing due to suspected inaccuracies in the recorded weights and acknowledged that incomplete or missing weight data prevented the implementation of appropriate interventions. Interviews with facility staff, including the DON, RD, and physician, revealed a lack of awareness regarding the resident's significant weight loss and the inconsistent documentation of weights. The RD confirmed that inaccurate or missing weights were a recurring issue, and the physician stated she was not notified of the resident's weight loss or the failure to obtain weights consistently. The facility's policy required regular weight monitoring and intervention, but these procedures were not followed, resulting in the failure to address the resident's nutritional needs.
Failure to Obtain and Complete Ordered Laboratory Tests
Penalty
Summary
The facility failed to obtain and complete laboratory tests as ordered by physicians for three residents. For one resident with multiple complex diagnoses, including cerebral palsy, epilepsy, and dementia, physician orders required regular laboratory monitoring such as CBC, renal panel, Dilantin and Phenytoin levels, lipid panel, liver function tests, hemoglobin A1C, and PSA at specified intervals. Review of the medical record and laboratory results revealed that not all ordered laboratory values were completed as scheduled, and the DON confirmed the missing results. Another resident with chronic obstructive pulmonary disease, neurocognitive disorder, and other conditions had physician orders for periodic lipid panels, hepatic function, CBC, and renal panels. The available laboratory results did not meet the frequency specified in the orders, and the DON verified that no additional results were present. A third resident with extradural and subdural abscess, osteomyelitis, and Arnold Chiari Syndrome had an order for a toxicology drug screen, which was not performed. The DON confirmed the absence of this test result.
Failure to Serve Diet in Prescribed Texture for Resident with Dysphagia
Penalty
Summary
A deficiency occurred when a resident with a history of dysphagia oropharyngeal phase, cognitive communication deficit, carotid artery stenosis, chronic diastolic heart failure, type 2 diabetes, atrial fibrillation, anxiety disorder, and dementia was not served food in the prescribed form. The resident was ordered a regular diet with mechanical soft texture and thin liquids, and the care plan required monitoring and serving the diet as ordered. During observation, the resident was served brussel sprouts with whole leaves, large pieces of chopped meat, and bow tie pasta, which did not meet the mechanical soft texture requirement. An LPN confirmed that the resident was not supposed to have the food as served and removed the plate to prevent consumption. The resident stated he was full and did not want another plate of food.
Failure to Use PPE During Enhanced Barrier Precautions
Penalty
Summary
Staff failed to wear appropriate personal protective equipment (PPE) when providing direct care to a resident on enhanced barrier precautions. Specifically, a Certified Nurse Aide (CNA) did not wear an isolation gown while emptying the urinary catheter bag of a resident who had an indwelling urinary catheter and was on enhanced barrier precautions per the care plan. The CNA confirmed during an interview that he did not use an isolation gown and was unaware of the need for enhanced barrier precautions for this resident, despite signage and the presence of isolation gowns outside the resident's room. The resident involved had multiple diagnoses, including chronic viral hepatitis C, type II diabetes, morbid obesity, substance dependence, anxiety and mood disorders, paraplegia, and chronic obstructive pulmonary disease. The care plan for this resident specifically required enhanced barrier precautions and the use of an isolation gown and gloves during high-contact care activities, such as device care for the indwelling urinary catheter. Facility policy also required these precautions, but the CNA reported not having received education on enhanced barrier precautions.
Failure to Prevent Accident Hazards and Ensure Proper Resident Assessment
Penalty
Summary
The facility failed to recognize and address potential hazards related to residents attending community appointments unsupervised and did not ensure a resident was properly assessed for the use of a sit-to-stand lift for transfers. In one instance, a resident with diagnoses including dementia, COPD, malnutrition, anxiety, psychosis, and alcohol dependence, who resided on a secured unit due to impaired cognitive function and risk for elopement, was allowed to leave the facility for a supposed health clinic appointment without verification. The nurse on duty did not check the resident's appointment documentation or confirm with the clinic before permitting the resident to leave in an unmarked car. Later, it was discovered that the clinic had not scheduled an appointment and had not sent transportation. The resident did not return to the facility and later communicated that he would not be coming back, resulting in the facility contacting the family, adult protective services, and the police. The facility's policy required investigation and reporting of all missing residents, but the incident was not initially reported as an elopement. In another case, a resident with a history of cognitive communication deficit, heart failure, COPD, atrial fibrillation, depression, anxiety, and dementia was assessed as requiring a two-person transfer with a mechanical lift. After a recent hospital stay for stroke-like symptoms, the resident exhibited increased weakness and left-sided deficits. During observation, two CNAs assisted the resident with a transfer using a sit-to-stand lift, but the resident was not able to properly grip the lift with his left hand due to weakness and was observed leaning to the left side in his wheelchair. The therapy director confirmed that the resident had not been assessed for the use of a sit-to-stand lift and should have been transferred with a gait belt and two-person assist. The facility's policy required ongoing assessment of residents' transfer needs by nursing and rehabilitation staff, but this was not followed in this case. Both deficiencies demonstrate failures in supervision and assessment, specifically in verifying the safety of residents leaving the facility for appointments and in ensuring proper evaluation for transfer equipment. The lack of adherence to established policies and procedures contributed to unsafe situations for the residents involved.
Failure to Provide Timely Incontinence Care for Dependent Resident
Penalty
Summary
A deficiency occurred when a resident who was dependent on staff for incontinence care did not receive timely assistance. The resident, who had multiple diagnoses including spastic diplegic cerebral palsy, dementia, and intellectual disabilities, was documented as requiring total dependence for toileting and personal hygiene. The care plan specified the use of incontinence briefs, cleaning the peri-area with each episode, and regular checks during rounds. However, on the day in question, the assigned CNA was pulled to another floor at 3:00 P.M., leaving the resident without appropriate care. The resident was last changed before lunch at 12:20 P.M., and was observed sitting in the main lobby from 1:39 P.M. to 4:31 P.M. At 4:31 P.M., an LPN verified that the resident was moderately saturated with urine and was wet, and also noted an old scar area on the right upper buttocks. Staff interviews confirmed the absence of the CNA and the lapse in incontinence care. Facility policy on perineal care emphasized cleanliness, comfort, infection prevention, and regular observation of skin condition, but these standards were not met during the period when the resident was left unattended.
Failure to Maintain Comfortable Air Temperatures
Penalty
Summary
The facility failed to maintain comfortable air temperatures and provide a homelike environment for its residents. Observations and interviews revealed that several resident rooms and a common shower room had air temperatures significantly below comfortable levels, with some rooms as low as 57.6 degrees Fahrenheit. The packaged terminal air conditioner (PTAC) units in certain rooms were not functioning, and the common shower room lacked a heater. As a result, residents had to be moved from their rooms to the dining room on the women's secured unit, which had a different heating system unaffected by a sprinkler pipe break that occurred earlier. Interviews with residents and staff confirmed the discomfort caused by the cold temperatures, with residents expressing dissatisfaction with having to sleep in the dining room. The facility's maintenance director acknowledged the issue with the PTAC units and the lack of documentation for their inspection in the past year. The facility's policy emphasizes providing a homelike environment with comfortable temperatures, which was not upheld in this instance. This deficiency was investigated under Complaint Number OH00161091.
Lack of Privacy for Residents Due to Heating Issues
Penalty
Summary
The facility failed to ensure full visual privacy for residents, affecting nine out of 123 residents. These residents had their beds moved to the dining room on the women's secured unit due to heating issues in their rooms. The dining room lacked privacy curtains or barriers, allowing the beds to be visible to the entire room. This situation arose after a break in the sprinkler pipe affected the heating system, prompting the relocation of residents to the dining room, which had a separate heating system. Interviews with residents and staff confirmed the lack of privacy and the cold conditions in the rooms. Residents expressed discomfort with sleeping in the dining room, and staff verified that the beds remained there even after heat was restored to most rooms. The facility's maintenance director and administrator acknowledged the issue with the PTAC units and the decision to move residents to the dining room. The Director of Nursing confirmed the absence of privacy measures in the dining room, leading to the deficiency cited in the report.
Failure to Administer CPR According to AHA Guidelines
Penalty
Summary
The facility failed to administer cardiopulmonary resuscitation (CPR) according to its policy and professional standards of care, as outlined by the American Heart Association (AHA). This deficiency was identified during the review of an incident involving a resident with multiple medical conditions, including multiple sclerosis and dementia, who was found unresponsive and not breathing. The resident's care plan and physician's orders indicated a full code status, meaning CPR should have been administered. However, during the emergency response, the staff did not provide rescue breaths as required by the AHA guidelines. The incident involved a certified nursing assistant (CNA) who discovered the resident unresponsive and notified a registered nurse (RN). The RN initiated chest compressions but did not provide rescue breaths, as neither the RN nor the CNA knew how to use the Ambu bag for rescue breathing. It was not until a registered nursing supervisor (RNS) arrived that rescue breaths were administered. The facility's policy on CPR, which aligns with AHA guidelines, requires the provision of rescue breaths, which were not given until several minutes into the CPR process. This lapse in following the established procedure contributed to the deficiency noted in the report.
Failure to Implement Timely Wound Care
Penalty
Summary
The facility failed to provide timely care and treatment for a trauma wound for Resident #64, who was one of three residents reviewed for skin impairment. Resident #64 was readmitted to the facility from the hospital on 09/09/24 with a trauma wound on the left lower leg. The hospital's continuity of care form included an order to cover the wound with Mepilex border and change it every three days, with a follow-up at the wound care clinic scheduled for 09/13/24. However, the Treatment Administration Record (TAR) indicated that the resident did not receive the prescribed wound treatments from 09/09/24 through 09/17/24. Interviews with the Director of Nursing (DON) and a Licensed Practical Nurse (LPN) confirmed that the treatment orders for the trauma wound were not implemented until 09/18/24, despite the hospital's instructions. The facility's policy on wound care, dated December 2011, required staff to verify a physician's order and document the wound care provided, including any changes in the resident's condition or refusal of treatment. This deficiency was investigated under Complaint Numbers OH00158909 and OH00158323.
Failure to Implement Timely Pressure Ulcer Care
Penalty
Summary
The facility failed to implement timely care and treatment for pressure ulcers for a resident, identified as Resident #64, who was readmitted from the hospital with an unstageable pressure ulcer on the left lower leg. The resident had multiple diagnoses, including multiple myeloma, chronic respiratory failure, malignant neoplasm of the brain, and hypertension, and was noted to have moderate cognitive impairment, requiring staff assistance with activities of daily living. Despite a wound clinic progress note dated 09/13/24 indicating the need for daily dressing changes, and a physician's order dated 09/17/24 specifying the treatment regimen, the Treatment Administration Record (TAR) showed that the resident did not receive the prescribed treatment from 09/09/24 through 09/16/24. Interviews with the Director of Nursing (DON) and a Licensed Practical Nurse (LPN) confirmed that the treatment order for the pressure ulcer was not implemented in a timely manner. The facility's wound care policy, dated December 2011, outlined the procedure for wound care, including verifying physician orders and documenting the care provided. However, the failure to adhere to these guidelines resulted in the deficiency. This issue was investigated under Complaint Numbers OH00158909 and OH00158323 and was a recite to a complaint survey completed on 09/03/24.
Medication Error Rate Exceeds Acceptable Threshold
Penalty
Summary
The facility failed to maintain a medication error rate below five percent, as evidenced by an eight percent error rate during the survey. This was determined through a review of medical records, observations, staff interviews, and facility policy. Specifically, two medication errors were identified out of 25 opportunities observed, affecting one resident. The errors involved the administration of an incorrect dose of vitamin D3 and the failure to administer Entresto due to its unavailability. The resident involved had a medical history that included acute hepatitis C, hypertension, and chronic respiratory failure, and required partial assistance with activities of daily living. The resident's physician had ordered vitamin D3 25 mcg and Entresto 24-26 mg, but the LPN administered vitamin D3 50 mcg and did not administer Entresto. The LPN confirmed these errors during an interview, acknowledging the discrepancies between the physician's orders and the medications administered. The facility's policy on administering oral medications, which outlines steps for verifying and confirming medication orders, was not followed in this instance.
Failure to Prevent and Manage Pressure Ulcers
Penalty
Summary
The facility failed to adequately assess and provide timely interventions for pressure ulcers, resulting in actual harm to two residents. Resident #135, who was at risk for pressure ulcers due to conditions such as muscle weakness and diabetes, was not given weekly skin assessments from mid-June to early July. Despite being identified with stage one sacral decubitus ulcers during a hospital visit, no skin assessment was conducted upon their return to the facility. It wasn't until early July that a nurse identified an unstageable pressure ulcer with eschar on the resident's right buttocks, which had advanced significantly by that time. Resident #01, with a history of schizoaffective disorder and a recent surgical procedure on the right ankle, was also at risk for pressure ulcers. The resident returned from the hospital with a splint on the right leg, but there was no documentation of this device in the facility's records. The splint was not removed until mid-August, at which point a pressure ulcer was discovered on the resident's right heel. This ulcer was related to the prolonged use of the splint, which had not been monitored or adjusted by the facility staff. The facility's policy on pressure ulcer risk assessment, revised in 2005, emphasizes the importance of regular skin assessments and immediate reporting of any signs of pressure ulcers. However, the facility staff failed to adhere to these guidelines, leading to the development and worsening of pressure ulcers in both residents. The lack of timely assessments and interventions contributed to the severity of the ulcers, highlighting a significant deficiency in the facility's care practices.
Failure to Protect Resident from Abuse
Penalty
Summary
The facility failed to ensure that residents were free from abuse, as evidenced by an incident involving Resident #25. This resident, who had diagnoses including dementia with behavioral disturbances, Alzheimer's disease, and anxiety disorder, was involved in an altercation with a staff member. During personal care, Resident #25 became combative and head-butted a staff member, who then retaliated by striking the resident multiple times on the head with an open hand. This incident was witnessed by other staff members. The medical record for Resident #25 indicated severely impaired cognition and behaviors that posed a significant risk for injury. The care plan for the resident included interventions such as administering medications, providing one-on-one care, and explaining procedures before starting. Despite these measures, the resident's combative behavior during care led to the abusive response from the staff member. The facility's policy on abuse prevention was not effectively implemented in this case, as the staff member's actions violated the resident's right to be free from abuse. The incident was reported, and the staff member was immediately separated from the resident and sent home. The facility's failure to protect the resident from abuse was identified as a deficiency during the survey.
Inadequate Catheter Care for Resident
Penalty
Summary
The facility failed to provide adequate catheter care for a resident with an indwelling urinary catheter. The resident, who had been admitted with multiple diagnoses including paraplegia and sepsis, was dependent on staff for all care. Physician's orders indicated that the resident should be straight catheterized as needed every eight hours, with reinsertion of an indwelling catheter if the resident had not voided. However, there were no specific orders for Foley catheter care. A nurse's progress note indicated that the resident's indwelling catheter was changed, and urine was observed in the catheter bag. The resident reported not receiving catheter care for seven days, with staff only emptying the catheter bag when full. An LPN confirmed the placement of the indwelling catheter and acknowledged the absence of an order for catheter care, as well as the lack of documentation for daily catheter care in the resident's medical record. The facility's policy required emptying the urinary collection bag every eight hours and providing routine daily hygiene, which was not followed. This deficiency was investigated under multiple complaint numbers.
Failure to Provide Timely Therapy Services
Penalty
Summary
The facility failed to provide necessary and timely therapy services to a resident, identified as Resident #57, who was admitted with multiple diagnoses including extradural and subdural abscess, paraplegia, and a recent thoracic spine surgery. Upon admission, the resident was required to wear a thoracic-lumbar-sacral orthosis (TLSO) brace as per hospital therapy notes. However, the resident's back brace was lost during transit from the hospital to the facility, and the resident did not receive any therapy services since admission. The initial therapy assessment was conducted ten days after admission, and the resident confirmed the lack of therapy services during an interview. The facility's physical therapist, PT #451, acknowledged the need for therapy services but delayed the evaluation due to uncertainty about the mandatory use of the back brace. Despite multiple attempts to contact the hospital for clarification, including calls to the hospital and the hospital social worker, no response was received. The facility's Director of Nursing and PT #451 confirmed that the resident had been in the facility for 16 days without receiving therapy services, highlighting a significant lapse in care. This deficiency was investigated under multiple complaint numbers.
Non-Operational Call Light System for Resident
Penalty
Summary
The facility failed to provide an operational call light system for a resident, which is essential for alerting staff to the resident's needs. This deficiency was identified during a review of the medical record, observation, and interviews with both the resident and staff. The affected resident, admitted with multiple diagnoses including extradural and subdural abscess, hepatitis C, paraplegia, and other conditions, was found to have minimal cognitive impairment and was dependent on staff for all care. On the day of observation, the resident's call light was non-operational, and there was no alternative device available for the resident to summon assistance. The resident confirmed that the call light had been non-operational since the previous evening, and the facility's administrator was unaware of the duration of the issue.
Failure to Prevent Resident-to-Resident Abuse
Penalty
Summary
The facility failed to protect residents from abuse, resulting in actual harm when a resident with a known history of aggressive behavior intentionally ran over another resident with his wheelchair. This incident led to the victim being diagnosed with a closed fracture of the right tibial plateau. The aggressive resident had a history of verbal and physical aggression, and despite being on a secured unit, he was able to cause harm to other residents. The facility's investigation into the incident was unsubstantiated, despite witness statements and medical records indicating intentional harm. Resident #14, who was cognitively intact and had multiple medical conditions including vascular dementia and schizoaffective disorder, was the victim of the wheelchair incident. She was ambulating without an assistive device at the time of the incident and sustained a fracture that required hospitalization and resulted in her being unable to walk post-incident. The facility's records and staff interviews confirmed that the aggressive resident intentionally ran over Resident #14, causing significant injury. Another resident, Resident #60, was also involved in a physical altercation with the aggressive resident. This altercation was initiated by the aggressive resident rolling into Resident #60 with his wheelchair, leading to a physical fight. Although no injuries were reported from this incident, it highlighted the ongoing risk posed by the aggressive resident. The facility's failure to adequately address and manage the aggressive behaviors of Resident #52, despite previous incidents and warnings, contributed to the harm experienced by the other residents.
Failure to Provide Ordered Therapy Services
Penalty
Summary
The facility failed to provide necessary therapy services to a resident as evaluated and ordered by the physician. Resident #900, who was admitted with diagnoses including muscle weakness and other conditions, was evaluated for occupational therapy (OT) and physical therapy (PT) on 04/16/24. The orders specified that the resident should receive therapy services five times over a 30-day period. However, the resident only received therapy on the initial evaluation date and on the discharge date, 05/17/24, without any additional documented sessions in between. The resident expressed frustration over the lack of therapy, and it was explained that insurance approval was pending, which did not materialize. Despite being eager to participate in therapy to regain independence, the resident was discharged with minimal progress due to the absence of treatment sessions. The facility's administrator confirmed the lack of additional therapy sessions and was unable to provide billing information for the therapy services, despite multiple requests from the state surveying agency. This deficiency was investigated under Complaint Number OH00154204.
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A resident with intact cognition receiving Medicare Part A skilled services for metabolic encephalopathy had services discontinued while benefit days remained, but the facility did not issue the required Skilled Nursing Facility Advance Beneficiary Notice (SNF ABN). The Social Services Director later confirmed that no SNF ABN was provided and reported she believed only a Notice of Medicare Non-Coverage (NOMNC) was needed when all skilled services were stopped. This practice conflicted with the facility’s written policy, which required SNF ABNs to be issued when extended care items or services were initiated, reduced, or terminated due to expected non-coverage by Medicare.
Surveyors identified that the facility exceeded the acceptable medication error rate when two residents with type 2 DM received insulin doses that were not administered according to orders or manufacturer instructions. In two separate observations, an LPN administered Novolog and another LPN administered insulin glargine and insulin lispro without priming the insulin pens, and the insulin lispro and Novolog were given after the residents had already consumed a significant portion of their breakfast meals, despite orders for administration before meals. Manufacturer information for both insulin products required priming before each injection to ensure accurate dosing, and facility policy required medications, including insulin, to be administered safely, timely, and in accordance with prescriber orders and specified time frames.
Surveyors found that the facility failed to document tray line food temperatures for multiple meals served from two dining room kitchenettes, despite having a “Trayline Taste & Temperature Log” and a policy requiring food to be stored, prepared, distributed, and served according to professional food safety standards. Review of logs showed repeated missing entries for breakfast, lunch, and dinner services in both the Harrison and McClellan dining areas, and the Senior Director of Culinary Services confirmed that temperatures had not been recorded for those meals, potentially affecting all residents receiving meals from those kitchenettes.
The facility failed to conduct and document required periodic care conferences for two residents, despite multiple comprehensive, quarterly, and significant change MDS assessments and a policy requiring periodic care conferences with resident and/or family participation. One resident with Parkinson’s disease, post-stroke hemiplegia, TIA, DMII, and depression had only two documented care conferences over a year, while another resident with aphasia, cerebrovascular disease, DMII, gait difficulty, coagulation defect, depression, and muscle weakness had no documented care conferences in the past year, aside from a declined invitation to the representative. The UCC confirmed that care conferences were expected to occur quarterly and that no additional documentation existed for either resident.
A resident with Alzheimer's disease and type II DM, who required extensive assistance with ADLs and was receiving scheduled Lantus and sliding-scale Humalog, experienced a severely elevated blood glucose level. The on-call provider was notified and ordered an additional dose of lispro insulin with a directive to recheck the blood glucose after administration. Nursing staff administered the extra insulin but did not document any follow-up blood glucose check, and the DON confirmed that this reevaluation was required by the facility's abnormal blood glucose policy and was not completed or documented.
A resident with Parkinson’s disease, dementia, and hypothyroidism was prescribed levothyroxine once daily along with other medications. A consultant pharmacist’s monthly drug regimen review recommended that levothyroxine be given in the morning on an empty stomach, 30–60 minutes before food, per manufacturer instructions. The medical record contained no documented physician response to this recommendation, and the MAR showed the drug scheduled for morning administration while the resident was observed eating breakfast and receiving the medication at the same time. An LPN confirmed administering levothyroxine during the meal, and the DON verified there was no documentation explaining whether or why the pharmacist’s recommendation was or was not followed, resulting in a failure to act on and document the identified irregularity.
A resident with severe cognitive impairment, multiple comorbidities, documented gait and balance abnormalities, and a high fall risk was care planned and assessed by therapy to require contact guard assistance and use of a gait belt for transfers and ambulation. While being assisted by a CNA from a recliner to the bathroom with a walker, the CNA did not apply a gait belt, even though the resident had a known tendency to lean backward when standing. As the CNA reached to open the bathroom door, the resident lost balance and fell backward, striking the back of the head, and was later found by an LPN without a gait belt in place, contrary to the facility’s gait belt policy and the resident’s assessed needs.
A resident with CKD stage five requiring peritoneal dialysis (PD) was admitted with pre-admission physician orders for three daily PD exchanges and monitoring for peritonitis (fever, abdominal pain, cloudy effluent), but these monitoring orders were not entered into the facility’s physician orders. The care plan referenced PD and general monitoring but did not specifically address peritonitis monitoring. Paper PD flowsheets showed incomplete and inconsistent documentation of exchanges and resident condition, including missing condition/comments for individual treatments and no record of one ordered PD exchange. The PD cycler flowsheet lacked effluent descriptions on multiple days. The PD nurse reported facility staff were expected to monitor effluent and symptoms, and the DON confirmed the absence of specific peritonitis monitoring orders, lack of an order for the PD cycler, and documentation gaps, despite a facility policy requiring ongoing assessment and monitoring for complications before, during, and after dialysis treatments.
A nurse was observed preparing multiple oral medications for a resident with depression, traumatic brain injury, anxiety, and impaired cognition by pushing tablets and capsules from unit-dose cards directly into her ungloved hand and then using her fingers to place them into a medication cup. In a follow-up interview, the RN confirmed this practice and acknowledged that the correct procedure is to dispense medications directly from the card into the cup, contrary to the facility’s medication administration policy requiring adherence to good nursing principles and practices.
A resident with Alzheimer’s disease, diabetes, anxiety, significant ADL dependence, and behavioral symptoms was observed seated in a chair positioned against the nursing station with a locked wheelchair placed directly in front, also against the nursing station, effectively restricting movement. An LPN confirmed both wheelchair wheels were locked and that it should not have been placed there, while a CNA stated she had positioned the wheelchair to prepare for lunch, was unable to complete the transfer, and left it in place, acknowledging this was wrong. This arrangement conflicted with the facility’s restraint policy, which prohibits physical restraints except when alternatives are ineffective for treating a medical symptom and defines restraints as devices adjacent to the body that cannot be easily removed and that restrict freedom of movement or access to the body.
Failure to Issue Required SNF ABN When Discontinuing Medicare Part A Services
Penalty
Summary
The deficiency involves the facility’s failure to issue a Skilled Nursing Facility Advance Beneficiary Notice (SNF ABN) when Medicare Part A services were discontinued for a resident who still had available benefit days. The resident was admitted with a diagnosis of metabolic encephalopathy and had intact cognition per the Minimum Data Set assessment. The facility’s own SNF Beneficiary Notification Review documented that Medicare Part A skilled services began on 02/11/26 and the last covered day was 03/11/26, and that the facility initiated discharge from Medicare Part A services before the resident’s benefit days were exhausted. Despite this, no SNF ABN was provided to the resident or the resident’s representative. During interviews, the Social Services Director stated that the SNF ABN was issued hours prior to the last covered day but, upon reviewing her files, confirmed that no SNF ABN had actually been issued for this resident. She further explained that she believed an SNF ABN was only required if one skilled service remained and that if all skilled services were being discontinued, only the Notice of Medicare Non-Coverage (NOMNC) needed to be issued. The Administrator, however, stated that a resident should always receive both a SNF ABN and a NOMNC when Medicare Part A services are discontinued and benefit days remain. Review of the facility’s written policy dated 03/28/23 showed that the facility was required to issue SNF ABNs for initiation, reduction, or termination of extended care items or services when Medicare payment was not expected, which did not occur in this case.
Plan Of Correction
This Plan of Correction is submitted as required under State and Federal law. This Plan of Correction does not constitute an admission on the part of the Facility that the findings cited are accurate, that the findings constitute a deficiency or that the scope and severity regarding the deficiency cited are correctly applied. Any changes to the Facility's policies and procedures should be inadmissible in any proceeding on that basis. Without admitting or denying the validity or the existence of the alleged noncompliance, the Facility submits this Plan of Correction with the intention that it be inadmissible by any third party in any civil or other action against the facility or any employee, agent, officer, director or shareholder of the Facility. The Facility is utilizing this Plan of Correction as its allegation of substantial compliance as of 05/29/2026 F-0582 Corrective action for resident/s: On 5/14/26 Resident #34 was informed of rights and responsibilities related to Advanced Beneficiary Notice and voiced understanding of information for future reference by administrator. Identification of other residents who may be affected: Any resident receiving skilled services from nursing or therapy services. The Administrator audited all residents who were discharged from skilled services in the past 30 days to ensure they were issued a Notice of Non-Coverage and Advanced Beneficiary Notice on 5/29/26. No non-compliance was noted. Measures for systemic change: On 5/14/2026 Business Office Manager, Director of Rehab, Minimum Data Set nurse, Director of Nursing and Social Services Director were educated on proper procedure of issuing of Notice Of Medicare Non Coverage and Advanced Beneficiary Notice by administrator. All upcoming discharges from skilled services will be reviewed weekly at Utilization Review meeting to ensure notices will be delivered timely. How Corrective Action will be monitored: Administrator or designee to complete audits of all residents being discharged from skilled services to ensure they were issued a Notice of Non-Coverage and Advanced Beneficiary. This audit will be completed weekly x 4 weeks, then monthly x 2 months. Corrective action will be initiated for any noted non-compliance. Audit findings will be reviewed as part of the monthly quality assurance process to determine the need for further monitoring. Date of Compliance 5/29/26
Insulin Administration Errors and Failure to Prime Insulin Pens
Penalty
Summary
The deficiency involves the facility’s failure to maintain a medication error rate below 5%, with surveyors identifying 3 errors out of 28 medication administration opportunities, resulting in a 10.71% error rate. For one resident with type 2 diabetes mellitus and moderate cognitive impairment, the physician’s order directed Novolog insulin 10 units via subcutaneous pen-injector to be given before meals. During an observed medication pass, the LPN administered 10 units of Novolog insulin without priming the pen and did so after the resident had already consumed approximately 50% of the breakfast meal. The LPN later confirmed she did not prime the pen and acknowledged that the insulin was ordered to be administered prior to meals. Manufacturer instructions for the Novolog FlexPen specified that an air shot (priming) must be performed before each injection to ensure proper dosing. Another resident, also diagnosed with type 2 diabetes mellitus and with intact cognition, had orders for insulin glargine 35 units subcutaneously twice daily and insulin lispro 20 units subcutaneously before meals, plus 12 units subcutaneously if blood glucose was between 251 mg/dL and 300 mg/dL. During an observed medication administration, an LPN administered 35 units of insulin glargine and 32 units of insulin lispro without priming the insulin pens and after the resident had consumed approximately 90% of the breakfast meal, despite orders for insulin lispro to be given before meals. The LPN later stated she could not remember if she had primed the pen and acknowledged that the insulin was ordered to be administered prior to meals. Manufacturer information for insulin lispro stated that the pen must be primed before each injection to confirm insulin delivery and remove air, and that failure to prime could result in too much or too little insulin. The DON confirmed the expectation that insulin be administered as ordered, including priming each pen with two units before dialing the prescribed dose, and facility policy required medications, including insulin, to be administered safely, timely, and in accordance with prescriber orders and required time frames.
Plan Of Correction
This Plan of Correction is submitted as required under State and Federal law. This Plan of Correction does not constitute an admission on the part of the Facility that the findings cited are accurate, that the findings constitute a deficiency or that the scope and severity regarding the deficiency cited are correctly applied. Any changes to the Facility's policies and procedures should be inadmissible in any proceeding on that basis. Without admitting or denying the validity or the existence of the alleged noncompliance, the Facility submits this Plan of Correction with the intention that it be inadmissible by any third party in any civil or other action against the facility or any employee, agent, officer, director or shareholder of the Facility. The Facility is utilizing this Plan of Correction as an allegation of substantial compliance as of 5/29/2026. F-0759 Corrective action for resident/s: Residents #21 and #22 were assessed and evaluated by nurse and Director of Nursing 5/14/26. Resident #21 and #22 both denied any adverse effects and none were noted upon assessment by the Director of Nursing on 5/14/2026. Notification made to physician on 5/14/2026. LPN # 2 competency Eval on insulin administration with the Director of Nursing completed 5/14/2026. Identification of other residents who may be affected: Diabetic residents on assignment of LPN #2/station 2 have the potential to be affected and were assessed by the DON/Designee on 5/14/26 and found to be within normal limits. Measures for systemic change: All Nurses were educated by the Director of Nursing on the steps for Insulin administration per competency, diabetes clinical protocol policy, Medication and treatment orders policy, administering medications policy, and Obtaining fingerstick Glucose Level policy On 5/14/2026. How Corrective Action will be monitored: Director of Nursing and Assistant Director of Nursing will complete insulin administration audits on 5 nurses. This audit will be completed weekly x 4 weeks, then monthly x 2 months. Corrective action will be initiated for any noted non-compliance. Audit findings will be reviewed as part of the monthly quality assurance process to determine the need for further monitoring. Date of Compliance: 5/29/2026
Failure to Document Tray Line Food Temperatures in Dining Room Kitchenettes
Penalty
Summary
The deficiency involves the facility’s failure to document tray line food temperatures for meals served from the Harrison and McClellan Dining Room kitchenettes, as required by professional standards for food service safety and the facility’s own policy. Review of the “Trayline Taste & Temperature Log” (revised September 2018) showed missing temperature documentation for multiple meals from the Harrison Dining Room kitchenette, including dinner on 03/30/26 and 03/31/26, lunch and dinner on 04/01/26 and 04/02/26, dinner on 04/07/26, and lunch and dinner on 04/08/26 and 04/10/26. The Senior Director of Culinary Services confirmed during interview that tray line food temperatures were not documented on the log for these meals. Similarly, review of the same log for the McClellan Dining Room kitchenette revealed that tray line food temperatures were not documented for dinner on 04/01/26, breakfast and lunch on 04/02/26, and lunch and dinner on 04/07/26. The Senior Director of Culinary Services also verified these omissions during interview. The facility census at the time was 27 residents, and the governing “Food and Nutrition” policy, approved on 09/07/21, stated that the facility must store, prepare, distribute, and serve food in accordance with professional standards for food service safety.
Plan Of Correction
F812 The facility will continue to ensure food temperatures are completed before meals are served for all residents. To ensure compliance with this standard the following measures have been taken: 1. Immediately 4/15/26 culinary supervisor #224 was re-educated by Dietary Manager to this standard and policy "Food and Nutrition" which includes documentation of food temperatures. 2. All dietary staff have been re-educated to the standard and policy "Food and Nutrition" during the month of April 2026. 3. Audits of food temperature documentation to be completed by Dietary Manager 4 x per week for 4 weeks then weekly for 4 weeks. 4. Administrator to validate audits/compliance and provide additional training as needed. Administrator will present to QAPI committee for ongoing monitoring and further direction.
Failure to Conduct and Document Required Care Conferences
Penalty
Summary
The deficiency involves the facility’s failure to complete and document comprehensive care conferences at required intervals in accordance with care plan regulations and facility policy. For one resident with Parkinson’s disease with dyskinesia, cognitive communication deficit, hemiplegia and hemiparesis following cerebral infarction, transient cerebral ischemic attack, type II diabetes mellitus, and major depressive disorder, the record showed multiple MDS assessments over a one-year period, including annual, quarterly, and significant change assessments. However, only two care conferences were documented during the last 12 months, despite the expectation that care conferences be conducted quarterly with the resident and family when possible. The Unit Care Coordinator confirmed that no additional care conference documentation existed for this resident beyond the notes dated 04/21/25 and 01/02/26. A second resident, with diagnoses including aphasia following cerebrovascular disease, cerebral infarction, type II diabetes mellitus, unsteadiness on feet, difficulty in walking, coagulation defect, depression, and muscle weakness, also had multiple MDS assessments completed over the review period, including quarterly and annual assessments. The record contained a note that a care conference was offered to the resident’s representative, who declined to attend, but there was no documentation of any care conferences for the most recent 12 months. The Unit Care Coordinator confirmed that no other care conference documentation was available for this resident. Facility policy stated that periodic care conferences involving the resident, family, and the interdisciplinary team are part of the care planning process, but the required periodic care conferences and corresponding documentation were not completed for these two residents.
Plan Of Correction
THIS PLAN OF CORRECTION SERVES AS BERKELEY SQUARE'S CREDIBLE ALLEGATION OF SUBSTANTIAL COMPLIANCE AS OF June 1, 2026. Without admitting or denying the validity or existence of the alleged deficiencies, Berkeley Square provides the following Plan of Correction: F657 The facility will continue to document completion of care conferences at the required intervals for all residents, including residents #04 & #15. To ensure compliance with this standard the following measures have be taken: 1. The social service designee and the inter- disciplinary team were re-educated by the administrator to the facility policy "Care Conference" on 4/29/26 and verbalized understanding. 2. Care conferences for resident #04 and resident #15 were conducted on or before 4/29/2026 by the interdisciplinary team. 3. Review of all other residents was conducted by the social service designee to validate and ensure that care conference schedule is up to date with timely care conferences scheduled for them on 4/15/2026. Audits of care conferences to be completed weekly for four weeks and then monthly after that by the social service designee. Documentation of the care conference including any identified concerns in the medical record. Administrator to validate audits/compliance and provide additional training as needed. Administrator will present results of these audits to QAPI committee for ongoing monitoring and further direction.
Failure to Reevaluate Blood Glucose After Treatment for Hyperglycemia
Penalty
Summary
The facility failed to ensure that a resident with diabetes received treatment in accordance with professional standards of practice when nursing staff did not reevaluate the resident's blood glucose after treatment for severe hyperglycemia. The resident, admitted with diagnoses including Alzheimer's disease, type II diabetes mellitus, and depression, had physician orders for Humalog insulin on a sliding scale before meals, Lantus insulin 25 units daily, and lisinopril 5 mg daily. The resident required extensive assistance with activities of daily living, including transfers, toileting hygiene, eating, and bathing. On the evening in question, the resident's blood glucose was documented as 532 mg/dL, and the on-call provider was notified. The provider gave a new order to administer an additional 8 units of lispro (Humalog) and to recheck the blood glucose in 30 minutes. The electronic medication administration record showed that the blood glucose of 532 mg/dL was obtained at 9:00 p.m. and that the additional 8 units of lispro were administered at 9:21 p.m. However, there was no documentation in the resident's chart that the blood glucose was rechecked after the additional insulin was given. In an interview, the DON confirmed there was no evidence of reevaluation and verified that, according to the facility's "Abnormal Blood Glucose Procedure" policy, the resident should have been reevaluated and that the evaluation step should have been included in the progress note documentation.
Plan Of Correction
F684 The facility will continue to ensure all residents, including #03, receive treatment in accordance with professional standards of practice and reevaluated for hyperglycemia. To ensure compliance with this standard the following measures have been taken: 1. The director of nursing assessed resident #03, reviewed documentation and orders and found no ill effects immediately 4/16/26. 2. All licensed nurses were re-educated to facility policy "Blood Glucose Monitoring" by the Director of Nursing/designee in April 2026. 3. Audits of like-residents that require blood sugar checks to be completed by the director of nursing/designee two times a week for 4 weeks and then monthly after that to validate correct follow through when there is abnormally high blood glucose result. The Administrator will bring results of these audits to the QAPI committee for ongoing monitoring and further direction.
Failure to Act on Pharmacist Drug Regimen Recommendation for Thyroid Medication
Penalty
Summary
The deficiency involves the facility’s failure to ensure that pharmacy recommendations from the monthly drug regimen review were acted upon and documented for a resident. The resident was admitted with diagnoses including Parkinson’s disease, dementia, and hypothyroidism, and had current physician orders for levothyroxine 150 mcg once daily, buspirone 50 mg twice daily, and losartan 100 mg once daily. A medication regimen review dated 11/25/2025 included a consultant pharmacist recommendation that levothyroxine be administered consistently in the morning on an empty stomach, at least 30–60 minutes before food, per manufacturer instructions. There was no specific physician response in the medical record to this recommendation, and the facility’s policy stated that consulting pharmacist reviews are sent to nursing and addressed with the primary care provider or consulting specialist for review and follow-up. Review of the resident’s medication administration record for April 2026 showed levothyroxine scheduled for 9:00 a.m. On observation, the resident was seen eating breakfast in the dining area at 8:03 a.m., and an LPN reported administering the levothyroxine 150 mcg to the resident while the resident was in the dining area eating breakfast. The DON confirmed there was no evidence in the resident’s medical record explaining why the consultant pharmacist’s recommendation from 11/25/2025 was or was not acted upon. This lack of documented physician review and action on the pharmacist’s identified irregularity constituted noncompliance with the drug regimen review requirements.
Plan Of Correction
F756 The facility will continue to ensure the pharmacy recommendations from the monthly drug regimen review by a licensed pharmacist are acted upon for all residents, including #08. To ensure compliance with this standard the following measures have been taken: 1. Resident #08 was assessed by the registered nurse and med review completed by 4/28/26. After review of resident's drug regime's, it was discovered that resident #8 had 2 separate medication recommendations on the same form, to be reviewed by two separate practitioners, pharmacy has been instructed and agreed to separate meds on individual forms. 2. Licensed nurses re-educated to facility policy "Drug Regimen Review" by Director of nursing/designee in April 2026 and no later than 5/8/26. Licensed nurses are responsible for ensuring the reviews and recommendations are given to the physician for timely review. 3. Review of all other current residents Drug Regimen orders completed by Director of nursing/designee on 4/16/26 to ensure recommendations were followed up on/reviewed by the physician and address concerns if needed. 4. Audit of drug regime recommendations, pharmacy recommendations, and physician follow up to be completed weekly for four weeks by the Director of nursing/designee. Administrator will present results of these audits to the QAPI committee for ongoing monitoring and further direction.
Failure to Use Required Gait Belt During Ambulation Resulting in Resident Fall
Penalty
Summary
The deficiency involves the facility’s failure to ensure that a required gait belt was used while assisting a high fall‑risk resident with ambulation, resulting in a fall with head injury. The resident had multiple diagnoses including metabolic encephalopathy, hypertension, osteoarthritis, muscle weakness, gait and mobility abnormalities, major depressive disorder, anxiety, and visual hallucinations. Admission and subsequent MDS and fall risk assessments documented that the resident was severely cognitively impaired, required moderate to maximal assistance with transfers and ambulation, could not independently come to a standing position, exhibited loss of balance while standing, used an assistive device, and had decreased muscle coordination. The resident had a history of falls prior to admission and was assessed as being at high, later moderate, risk for falls. The resident’s fall care plan identified her as at risk for falls and included interventions such as providing maximum to moderate assistance with transfers and walking short distances, use of a walker and wheelchair, and following the facility’s fall protocol. Therapy notes and care conference documentation indicated that the resident leaned backwards when standing, required contact guard to minimal assistance for bed mobility and transfers, and needed constant verbal cueing for safe sequencing during toilet transfers. The physical therapist confirmed that the resident was to use a gait belt with staff when ambulating, and the DON verified that therapy had assessed the resident as requiring contact guard assistance and a gait belt for ambulation and transfers. On the day of the incident, a CNA was assisting the resident from her recliner to the bathroom using a walker. The CNA walked beside the resident, providing guidance and support, and reported having a hand on the resident while assisting her. As they approached the bathroom door, the CNA reached for the doorknob to open it, and at that moment the resident began to lose her balance and fell backwards to the floor, striking the back of her head. The nurse who responded found the resident on her back at the foot of the bed with her feet near the bathroom, noted a red raised area on the back of the head, and documented that the resident was not wearing a gait belt and that the gait belt was on the dresser. In the facility’s investigative summary and in interviews, the CNA acknowledged that she did not have a gait belt on the resident while ambulating her, despite the resident’s assessed need for hands‑on assistance and gait belt use per facility policy and the resident’s care and therapy plans.
Failure to Implement PD Orders and Monitor Resident Receiving Peritoneal Dialysis
Penalty
Summary
The deficiency involves the facility’s failure to implement pre-admission physician orders for peritoneal dialysis (PD) and to provide ongoing monitoring for a resident with chronic kidney disease (CKD) stage five who required PD. Pre-admission orders dated 11/14/25 specified three daily PD exchanges at 6:00 A.M., 2:00 P.M., and 10:00 P.M., and directed staff to monitor for signs and symptoms of peritonitis, including fever, abdominal pain, and cloudy effluent. These monitoring orders were not entered into the facility’s physician orders. The resident’s care plan noted the need for PD and included general monitoring interventions (labs, signs of bleeding, bacteremia, septic shock, and significant vital sign changes), but did not specifically address the ordered monitoring for peritonitis. Review of PD documentation showed incomplete and inconsistent charting of treatments and resident condition. The paper peritoneal flowsheet had columns for time of PD and condition/comments, including instructions to call the nurse immediately for cloudy fluid, abdominal pain, or fever. However, the first entry on 11/15/26 at 2:00 P.M. only noted that the PD nurse completed the exchange, and the 10:00 P.M. entry that day had no condition/comment documentation. Subsequent days (11/16/25, 11/17/25, and 11/18/25) contained only one condition/comment entry per day rather than for each exchange, and there was no documentation that the 6:00 A.M. PD on 11/18/25 was completed. The PD cycler flowsheet starting 11/19/25 lacked any description of the effluent on multiple days. The PD nurse from the dialysis company stated facility staff were expected to monitor effluent for cloudiness and assess for abdominal pain and fever, and the DON confirmed there was no electronic physician order for peritonitis monitoring or for use of the PD cycler, that the paper charting did not allow for effluent description or symptom documentation for each treatment, and that PD was not documented at one ordered time. The facility’s dialysis policy required ongoing assessment and monitoring for complications before, during, and after treatments, which was not reflected in the documentation for this resident.
Improper Infection Control During Medication Administration
Penalty
Summary
Surveyors identified a deficiency in infection prevention and control related to medication administration for Resident #29. The resident was admitted on 02/28/14 with diagnoses including depression, traumatic brain injury, and anxiety, and had impaired cognition per a quarterly MDS assessment. During an observation on 03/25/26 at 6:58 A.M., RN #281 prepared the resident’s medications by removing an Amoxicillin-Pot Clavulanate tablet from the medication card and pushing it directly into her ungloved hand, then using her fingers to place the pill into a medication cup. The same process was observed for multiple other medications, including Escitalopram Oxalate, Furosemide, Sennosides, Lyrica, and Vitamin D, each being pushed from the card into the RN’s ungloved hand and then transferred by her fingers into the medication cup before administration to Resident #29. In a subsequent interview at 7:27 A.M. the same day, RN #281 confirmed she had placed each medication into her ungloved hands prior to administration and acknowledged that the proper procedure was to push the pills directly from the card into the medication cup. Review of the facility’s “Medication Administration – General guidelines” policy, revised 10/08/25, stated that medications are to be administered in accordance with good nursing principles and practices. This practice failure was cited as a deficiency under Complaint Number 2681777.
Improper Use of Wheelchair as a Physical Restraint
Penalty
Summary
Surveyors identified a deficiency related to the facility’s failure to ensure a resident was free from physical restraints. Resident #7, admitted with diagnoses including Alzheimer’s disease, diabetes mellitus, and anxiety disorder, was documented on a recent MDS as rarely understood and dependent for ADLs except eating. The resident ambulated independently on the unit without an assistive device and had documented verbal and other behaviors occurring one to three days during the look-back period. The care plan noted the resident had potential to be physically aggressive, chase staff, throw objects, and be combative with care, with interventions such as offering choices, administering medications as ordered, and intervening early when agitation occurred. During an observation and interview, Resident #7 was found sitting in a chair with the right arm of the chair positioned against the nursing station and a wheelchair placed directly in front of him. The left arm of the wheelchair was also against the nursing station, and both wheelchair wheels were locked, creating a barrier that appeared to restrain the resident, who was sleeping with his knees touching the locked wheelchair. An LPN confirmed both wheelchair wheels were locked and that the wheelchair should not have been placed in front of the resident. A CNA reported she had placed the wheelchair there in preparation to get the resident up for lunch, was unable to transfer him, and left the wheelchair in that position, acknowledging it was wrong to keep it there. The facility’s physical restraint policy stated that physical restraints are not used except when alternatives are not appropriate or effective for treating a medical symptom and defined physical restraints as any device attached or adjacent to the body that the individual cannot easily remove and that restricts freedom of movement or access to the body.
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