Embassy Of Lyndhurst
Inspection history, citations, penalties and survey trends for this long-term care facility in Lyndhurst, Ohio.
- Location
- 1575 Brainard Rd, Lyndhurst, Ohio 44124
- CMS Provider Number
- 366114
- Inspections on file
- 47
- Latest survey
- April 7, 2025
- Citations (last 12 mo.)
- 0
Citation history
Health deficiencies cited at Embassy Of Lyndhurst during CMS and state inspections, most recent first.
A resident with ALS receiving hospice care was left alone, unable to call for help, and denied hydration and adequate pain management due to staff miscommunication and failure to follow care plans. The resident, fully dependent for care, was observed in severe pain and thirst, with staff incorrectly believing she was NPO despite no such order, and her physician was not notified of her decline or the withholding of fluids.
Surveyors found improper storage of food items, including boxes of frozen food and containers of ingredients placed directly on the floor, as well as unsanitary conditions in the kitchen and nursing unit refrigerators. Food preparation areas and equipment were soiled with food debris and spills, and refrigerators contained unlabelled, undated food and were heavily soiled. Staff confirmed the issues and noted confusion over cleaning responsibilities.
Multiple staff failed to follow infection prevention protocols, including not wearing required PPE during high-contact care for residents with indwelling devices, neglecting hand hygiene before and after resident care and medication administration, and mishandling incontinence and respiratory equipment. These lapses included staff contaminating clean linen carts with soiled gloves, not cleaning or labeling shared wash basins, and leaving respiratory equipment on the floor, all contrary to facility policy and physician orders.
The facility did not provide a complete and accurate facility-wide assessment, omitting key details such as involved personnel, accurate census data, admission and discharge rates, common diagnoses, services offered, and staffing levels for each shift. The Administrator confirmed these omissions, potentially affecting all residents.
Several residents, including those with conditions such as quadriplegia, paraplegia, and dementia, were not offered or documented as having received or refused influenza or pneumococcal vaccines, despite facility policy requiring these immunizations. The DON and cognitively intact residents confirmed that the vaccines were not offered, and medical records lacked documentation of administration, refusal, or contraindication.
Three residents dependent on staff for ADLs did not receive scheduled or as-needed hygiene and grooming care, including missed showers, lack of nail care, and failure to provide timely incontinence care. Observations and interviews revealed that staff, including agency personnel, did not consistently offer or document required care, and residents were left with unmet hygiene needs.
A resident with multiple chronic conditions was served a meal containing a disliked food item, despite documented preferences and care plan interventions. Dietary staff confirmed that the facility lost access to a system tracking food likes and dislikes, resulting in the inability to provide alternate menu items for residents' dislikes. This issue had the potential to affect most residents receiving meals.
A resident dependent on staff for transfers and toileting was left in a wheelchair overnight without timely assistance to bed or incontinence care, despite repeated requests for help. Staff interviews confirmed the resident was found soiled and upset in the morning, and the incident was not documented in the medical record. The resident's right to dignity and self-determination was not honored due to staff inaction and inadequate response.
A resident with multiple complex medical conditions and no support system was left without access to her personal clothing and electric wheelchair for an extended period after admission, as staff did not arrange timely retrieval of her belongings from a previous facility despite her requests.
Two residents who were dependent on staff for ADLs were found unable to access their call lights, with one call light observed on the floor and another wrapped around a bed rail. Both residents confirmed they could not reach their call lights, and staff verified the inaccessibility, contrary to facility policy requiring accessible call systems.
Two residents were not provided with the opportunity to exercise self-determination regarding important aspects of their care. One resident, who was cognitively intact and wheelchair-dependent, was denied timely information about ancillary service schedules despite repeated requests, while another was assigned shower times during the night shift without being consulted about her preferences. The facility did not assess or document resident preferences as required by its own policy.
A resident with multiple serious medical conditions had a physician order for DNRCC-A, but the required code status form was not completed and present in the medical record at the time of review. The deficiency was confirmed by the Administrator during the survey.
The facility did not ensure timely notification to the physician and resident representative regarding significant weight loss for two residents with complex medical conditions, despite facility policy requiring such communication. Documentation was lacking for both physician and family notification, and staff interviews confirmed uncertainty or absence of these notifications.
The facility did not provide accurate NOMNC letters or maintain proper documentation regarding the last covered day for Medicare services and subsequent payor sources for several residents. In multiple cases, medical records lacked evidence of payor transitions or reasons for discharge, and a social worker confirmed these discrepancies.
A resident with significant medical needs was not offered or provided quarterly care plan meetings as required. Documentation showed no evidence of meetings or refusals over a year, and interviews revealed that scheduling conflicts and lack of follow-up led to missed care conferences, despite facility policy supporting flexible scheduling and participation by phone.
The facility failed to obtain ordered lab tests for a UTI and did not provide proper catheter care for a resident with a history of recurrent UTIs, including repeated improper placement of the urinary drainage bag. Additionally, there was a delay in starting prescribed antibiotic therapy for a UTI in another resident due to medication availability issues and lapses in administration. These deficiencies were confirmed through record review, staff interviews, and observation.
Pharmacy recommendations for medication dose reductions and laboratory testing were not timely or properly addressed for two residents, with missing or inadequate documentation of clinical rationale. Additionally, an antibiotic was administered to a resident at a dose outside recommended guidelines without physician review or adjustment, despite facility policy requiring such actions.
Two residents experienced deficiencies in their living environment, including an unaddressed, uncomfortable mattress with a large dip for a resident with quadriplegia, and a soiled floor mat and carpet in another resident's room that had not been cleaned. Staff were aware of the issues, but there was no documentation or timely resolution.
A resident with a history of severe respiratory conditions did not receive their ordered auto-PAP therapy overnight due to an LPN forgetting to apply the device. The missed treatment was not communicated to the day staff, and the resident was later found in respiratory distress, prompting emergency intervention.
Two residents experienced failures in accurate medical record documentation. One resident did not receive a prescribed auto-pap treatment, though an LPN signed off as if it was administered. Another resident's antibiotic was not documented as given, with missing signatures and times for medication pulled from the starter kit. Interviews with the DON and a unit manager confirmed the lack of required documentation.
A resident with dementia smoked in his room, causing a fire hazard, despite the facility's non-smoking policy. The resident, who had a history of smoking and was deemed unfit to live alone, refused to allow staff to inspect his belongings upon admission. This oversight led to the resident retaining smoking materials, which resulted in a smoldering jacket and smoke in the facility.
A resident with chronic pain syndrome and ALS did not receive timely pain medication, leading to severe pain. Despite requests for Morphine Sulfate Concentrate starting at 8:00 P.M., the medication was not administered until after midnight. The LPN on duty did not provide the medication as needed and refused to communicate with the hospice nurse, resulting in a deficiency in pain management.
A resident with severe cognitive impairment fell out of bed during incontinence care due to inadequate assistance from two CNAs, resulting in a head injury and multiple contusions. The resident, who required two staff for bed mobility, was over-rolled and slid to the floor. The facility's procedure for turning patients was not followed, contributing to the fall.
The facility failed to provide dignified feeding assistance to two residents, leaving meal trays out of reach and delaying assistance. Additionally, a resident was transferred using a mechanical lift without proper privacy measures. These incidents highlight a lack of coordination and respect for resident dignity.
The facility did not notify the responsible parties and medical practitioners of two residents involved in a potential sexual abuse incident. Despite facility policy requiring immediate reporting, the family of a resident learned of the incident through informal means, and the Director of Nursing confirmed the lack of formal notification.
A resident with cognitive impairment was allegedly touched inappropriately by another resident, leading to a police investigation. Despite the facility's conclusion of consensual interaction, the resident's mother alleged sexual assault. The incident highlighted a failure to protect the resident from abuse, as per the facility's policy.
A facility failed to report a potential sexual abuse incident involving a cognitively impaired resident who was allegedly touched inappropriately by another resident. Despite the incident being witnessed by a staff member, the facility did not report it to authorities until the resident's mother made a formal allegation. The facility viewed the incident as consensual, overlooking the resident's cognitive impairments and communication deficits.
The facility failed to document an incident involving inappropriate touching between two residents in their medical records. Despite the incident being reported by a staff member, there was no documentation regarding the event or its outcomes in the residents' records, as confirmed by the DON.
The facility failed to maintain a clean and sanitary kitchen environment, including proper labeling and dating of food, discarding expired food, and monitoring the low-temperature dish machine. Observations revealed unlabeled and expired food items, debris in the walk-in freezer, and insufficient sanitizer concentration in the dish machine. The District Dietary Manager confirmed these findings.
The facility failed to properly collect and store trash, including biohazardous waste, potentially affecting all 57 residents. Observations revealed multiple dumpsters with surrounding debris, an overflowing biohazard room, and improperly stored biohazard barrels. Staff confirmed the issues and the need for waste pickup.
The facility failed to ensure washing machines reached the minimum required temperatures for hot water processing, potentially affecting all 57 residents. Observations and interviews revealed uncertainty about the exact temperatures reached during wash cycles, and the facility lacked documentation to confirm compliance with the required 160 degrees Fahrenheit.
The facility failed to serve the appropriate quantities of food as specified in the menu, affecting 49 residents. Cook #141 served only four ounces of macaroni and cheese instead of the required eight ounces, and this discrepancy was confirmed by the Dietary District Manager and Dietetic Technician Registered. Additionally, the facility did not adhere to specific dietary requirements for residents on NPO and NAS diets.
A resident reported that her lockbox containing money, a checkbook, and a bank card went missing from her room. Despite the issue being raised with the facility's management and the Long Term Care Ombudsman, the incident was not reported to the State agency as required by the facility's policy. The resident had mild or no cognitive impairment and diagnoses including major depressive disorder, epilepsy, and hemiplegia.
Failure to Provide Comfort, Hydration, and Pain Management for Dependent Hospice Resident
Penalty
Summary
A resident with amyotrophic lateral sclerosis (ALS), chronic pain syndrome, and total dependence for care was admitted to hospice for end-of-life care. The resident's care plan included interventions for comfort, pain management, and hydration, with specific mention of the need for total assistance with meals, snacks, and fluids, as well as monitoring for dehydration. Despite these documented needs and preferences, the resident was left alone behind a closed door, unable to summon help due to physical limitations and the lack of an accessible call light. The resident was observed to be in severe pain, thirsty, and unable to communicate effectively with staff, repeatedly mouthing requests for help and water. Staff actions and inactions contributed to the deficiency. Certified Nursing Assistant (CNA) staff believed the resident was on nothing by mouth (NPO) status, despite there being no physician or hospice order for NPO, and therefore withheld fluids. The resident reported not having received anything to drink since the previous day and was denied hydration measures, even though she was alert and able to tolerate sips of fluid. Pain management was also inadequate, as all routine pain medications were discontinued, and only one as-needed dose of morphine was administered over a two-day period, with no documentation of its effectiveness. The resident reported pain at the highest level and did not receive timely pain relief due to staff prioritizing other tasks. Communication failures were evident, as staff did not notify the resident's physician of her decline or the withholding of fluids, instead only communicating with the hospice provider. The hospice nurse confirmed there was never an order for NPO status and that the resident required a blow call light, which had not been provided. Facility policies required physician notification for changes in condition and supportive measures for hydration and pain, but these were not followed. The resident remained unable to call for help, was left in discomfort, and her preferences and care needs were not met.
Deficient Food Storage and Unsanitary Kitchen and Refrigerator Conditions
Penalty
Summary
Surveyors observed multiple deficiencies in food storage and kitchen sanitation during their inspection. In the kitchen, several boxes of frozen food were stored directly on the floor of the walk-in freezer, and the dairy walk-in cooler contained an opened and undated bag of hard-boiled eggs, as well as a container of cooked fish with the lid left open. The prep table and surrounding areas were found with dried food splatters, crumbs, and food debris, including on and around equipment such as the Robocoup, steamer, tilt skillet, fryer, grill, and juice machine. The dry storage area also had several boxes and containers of food on the floor, some opened, and a scoop stored inside a container of sugar. The floor under the racks was littered with various debris. The Dietary Manager confirmed these findings and attributed some of the issues to a recent delivery and transition to a new company. Further inspection of nursing unit refrigerators revealed heavy soiling, with dried spills, food containers lacking labels or dates, and the presence of hair on shelves. One refrigerator was filled with unlabelled and undated food items, including lunch bags, pizza, and a grocery bag, with a large spill and utensils left inside. The freezer section contained empty cups, dried food splatter, and a sticky substance. The Diet Technician confirmed that both staff and resident foods were stored together and that there was confusion between nursing and housekeeping regarding responsibility for cleaning the refrigerators. The facility's policy required the food service area to be maintained in a clean and sanitary manner, which was not followed.
Infection Control Lapses in PPE Use, Hand Hygiene, and Equipment Handling
Penalty
Summary
The facility failed to implement an effective infection prevention and control program, as evidenced by multiple observed lapses in the use of personal protective equipment (PPE), hand hygiene, handling of incontinence care supplies, and storage of respiratory equipment. Staff did not consistently don gowns and gloves when providing high-contact care to residents on enhanced barrier precautions (EBP), including those with feeding tubes and other indwelling devices. For example, a certified nursing assistant (CNA) provided hands-on care to a resident with a feeding tube without wearing any PPE, despite clear care plan and physician orders requiring EBP. The CNA was unaware the resident was on EBP, and this was later confirmed by the Director of Nursing (DON). Additional deficiencies were observed in the handling of incontinence care and hand hygiene. One CNA left a resident's room wearing soiled gloves and gown, touched clean linen carts, and returned to the resident's room with soiled gloves in hand, confirming she had contaminated clean supplies. Another CNA failed to wash hands before, during, or after providing incontinence care to two residents, did not properly use PPE, and handled clean and soiled items with contaminated gloves. Shared wash basins were left uncovered and unmarked on the floor, and were not cleaned or labeled as required, creating a risk of cross-contamination between residents. The DON confirmed that staff were required to don PPE for EBP and perform hand hygiene, and that wash basins should be cleaned, labeled, and not shared or stored on the floor. Medication administration practices also failed to meet infection control standards. A registered nurse (RN) did not perform hand hygiene before preparing or administering medications to two residents, and there was no hand sanitizer available on the medication cart. Additionally, a resident's BIPAP mask was found on the floor after being knocked off the nightstand, and a nurse confirmed it was not stored in a sanitary manner. Facility policies reviewed required hand hygiene before and after resident contact, proper use of PPE, and adherence to infection control procedures during medication administration, all of which were not followed in these instances.
Incomplete Facility Assessment Documentation
Penalty
Summary
The facility failed to provide a complete and detailed facility-wide assessment as required. Review of the Enhanced Facility Assessment, last updated by the Administrator, showed that it did not identify all personnel involved in the writing and approval process, did not provide an accurate average census, and did not accurately report the average number of residents admitted and discharged daily. Additionally, the assessment lacked information on common diagnoses admitted to the facility, the types of services or care offered, and details regarding staffing levels for each shift. During an interview, the Administrator acknowledged and agreed with these discrepancies. This deficiency had the potential to affect all 81 residents residing in the facility.
Failure to Offer and Document Flu and Pneumonia Vaccinations
Penalty
Summary
The facility failed to offer influenza and/or pneumococcal vaccines to all residents as required by its own policies. Record reviews and interviews revealed that four out of five residents reviewed for immunizations were neither offered nor refused the flu or pneumonia vaccines for the years 2024 or 2025. For these residents, there was no documentation of vaccine administration, refusal, or contraindication in their medical records. The Director of Nursing (DON) confirmed during interviews that the vaccines were not offered or refused for these residents, and the residents themselves, when cognitively able, also confirmed they had not been offered the vaccines. The affected residents had various diagnoses, including functional quadriplegia, hemiplegia, paraplegia, cerebral infarction, muscle wasting, dysphagia, and vascular dementia. Most were cognitively intact and able to confirm their immunization status. The facility's policies, last revised in 2019 and 2022, require that all residents be offered pneumococcal and influenza vaccines unless medically contraindicated. Despite these policies, the required offers and documentation were not completed for the residents reviewed.
Failure to Provide Scheduled and As-Needed Hygiene and Grooming Care
Penalty
Summary
The facility failed to provide scheduled and as-needed hygiene and grooming care for three residents who were dependent on staff for activities of daily living (ADLs). For one resident with cerebral infarction and muscle weakness, observations over several days revealed long, uneven fingernails embedded with a thick dark substance, and the resident reported not receiving routine showers as scheduled. Certified Nursing Assistants (CNAs) observed the condition of the resident's nails but did not offer assistance. Review of shower and bath records showed multiple missed or undocumented bathing opportunities, and the administrator confirmed the absence of documentation for these dates. Another resident with rhabdomyolysis, osteoarthritis, and upper extremity impairment was scheduled for showers during the night shift. The resident reported that staff would attempt to provide showers in the middle of the night, which she declined due to the timing, but stated she was not refusing showers altogether. Review of shower records indicated several dates with no documentation of showers being offered or completed, and both the administrator and unit manager confirmed that lack of documentation meant the care was not provided. Staff interviews revealed issues with time management, use of agency staff unfamiliar with facility routines, and inconsistent completion of scheduled showers. A third resident, dependent on staff for transfers and toileting due to morbid obesity, lymphedema, and amputation, reported being left in a wheelchair all night without incontinence care due to short staffing and reliance on agency aides. The resident described being left soiled and unattended despite repeated requests for assistance, and this was corroborated by staff interviews. There was no documentation in the medical record regarding the incident, and staff confirmed the resident was found soiled and upset in the morning. The facility's policy required provision of necessary services to maintain hygiene and grooming for residents unable to perform ADLs independently, but this was not followed in these cases.
Failure to Accommodate Resident Food Preferences Due to Loss of Dietary Tracking System
Penalty
Summary
The facility failed to provide meals that accommodated resident food preferences, as evidenced by a cognitively intact resident with chronic kidney disease, gout, and type 2 diabetes mellitus receiving a meal containing corn, which he had repeatedly stated he disliked. The resident's care plan included interventions to provide meals based on his food preferences and physician orders, and his diet order specified a two gram low sodium diet with double protein/meat portions. Despite these documented preferences and orders, the resident was served corn and did not eat it, stating he had informed staff multiple times of his dislike for corn. Interviews with dietary staff revealed that the facility recently lost access to a software system that tracked residents' food likes and dislikes, resulting in the inability to provide alternate food items for residents' documented dislikes. The dietary manager confirmed that since the removal of the previous system, there was no way to retrieve or reference residents' food preferences, and no likes or dislikes were available for any residents in the new system. This failure had the potential to affect the majority of residents receiving food from the kitchen.
Resident Left Without Timely Bed Transfer and Incontinence Care
Penalty
Summary
A resident with morbid obesity, lymphedema, major depressive disorder, generalized anxiety disorder, muscle weakness, and an acquired absence of the right leg below the knee, who was cognitively intact but dependent on staff for transfers and toileting, was not assisted to bed or provided timely incontinence care during a night shift. The resident reported using the call light multiple times and was told by an aide that assistance was delayed due to the need for a second aide for a mechanical lift transfer. The aide later informed the resident that the other aide was on break and he would have to wait. After having a bowel movement, the resident was again told he would have to wait, but no one returned to assist him, and he remained in his wheelchair until the morning shift arrived. Upon arrival of the day shift, staff found the resident still in his wheelchair, soiled, and with a full urinal and cups of urine. The resident expressed that the experience was demeaning and that his requests for care and to go to bed were not honored. Staff interviews confirmed that the resident had been left up all night and that the night shift was short-staffed, with one aide unaccounted for during much of the shift. The incident was not documented in the resident's progress notes, and there was no record of the resident being left in his wheelchair or not receiving incontinence care throughout the night. Further interviews with staff and management revealed inconsistent accounts regarding whether the resident was put to bed as requested. Some staff stated the resident was left in his chair all night, while others claimed he was put to bed. The agency aide assigned to the resident was reported to have left her duties and was subsequently placed on a do-not-return list. The facility's policy states that residents have the right to choose their daily routines, including sleeping and waking times, and to receive care consistent with their needs and preferences. However, in this instance, the resident's autonomy and dignity were not respected, and his care needs were not met in a timely or respectful manner.
Failure to Provide Timely Access to Personal Property
Penalty
Summary
A deficiency occurred when the facility failed to ensure that a resident had timely access to her personal property, including clothing and an electric wheelchair, after admission. The resident, who had diagnoses including ALS, chronic respiratory failure, COPD, pulmonary hypertension, malnutrition, major depressive disorder, and anxiety disorder, was cognitively intact and dependent on staff for all activities of daily living. Upon admission, the resident had no family or friends to assist with the transfer of her belongings from her previous facility. Documentation from a care conference indicated the resident expressed a need for her personal items, and interviews confirmed she had repeatedly requested them. Despite these requests, the resident remained without her personal items for an extended period, as staff had not arranged for their retrieval. Observations showed the resident lying in bed in a hospital gown with no personal clothing or wheelchair present in her room. Staff interviews revealed that while arrangements were discussed, the items were not picked up due to time constraints and lack of clear responsibility among staff. The facility did not have a specific timeframe for obtaining personal property for residents without family support, resulting in the resident's prolonged lack of access to her belongings.
Failure to Ensure Call Lights Within Reach for Dependent Residents
Penalty
Summary
Surveyors identified that the facility failed to ensure call lights were within reach for two residents who required staff assistance for activities of daily living. For one resident with functional quadriplegia, hemiplegia, and a feeding tube, the call light was observed on the floor, out of reach, while the resident was in bed and requested assistance for repositioning due to discomfort. The resident confirmed inability to access the call light, and a CNA verified its placement on the floor. For another resident with cerebrovascular disease, dementia, and moderate cognitive impairment, the call light was found wrapped around the right-side bed rail, making it inaccessible while the resident was lying in bed with a constricted left arm. The resident stated he could not reach the call light, and a housekeeper confirmed its inaccessibility. Facility policy requires that each resident be provided with a means to call staff directly for assistance from their bed, toileting, bathing facilities, and from the floor.
Failure to Honor Resident Self-Determination and Preferences
Penalty
Summary
The facility failed to respect and promote resident self-determination for two residents reviewed for the ability to choose important aspects of their lives. One resident, who was cognitively intact and used a wheelchair due to paraplegia and other conditions, repeatedly requested to be informed in advance about the schedule of ancillary services such as optometry, podiatry, and dental visits. Despite his requests to the social worker to have this information posted in his room, the social worker refused, stating the information was posted elsewhere. However, observation revealed that the only posted schedules were outdated and located in a secured memory care unit, with no current schedules posted elsewhere in the facility. Another resident, also cognitively intact and dependent on staff for activities and personal care, was scheduled to receive showers during the night shift without being consulted about her preferences. The resident reported that she was never asked when she preferred to have her showers and was simply told they would occur during the 11:00 P.M. to 7:00 A.M. shift. When staff attempted to provide showers during these hours, the resident declined due to the late timing, but this was recorded as a refusal rather than a lack of preference accommodation. Review of the resident's care plan and admission documentation confirmed that her preferences for shower times were not assessed or documented. The facility's policy states that residents have the right to exercise autonomy regarding important facets of their lives, including scheduling healthcare and daily routines such as bathing. However, the facility did not follow its own policy in these cases, as residents' requests and preferences regarding ancillary service schedules and shower times were not honored or accommodated.
Failure to Complete Code Status Form for Resident with DNR Order
Penalty
Summary
The facility failed to ensure that a completed code status form was present for a resident with multiple complex medical diagnoses, including ALS, chronic respiratory failure with hypoxia, COPD, pulmonary hypertension, malnutrition, major depressive disorder, and anxiety disorder. Although a physician order for Do Not Resuscitate Comfort Care Arrest (DNRCC-A) was written and present in the resident's medical record, the required code status form documenting this directive was not completed at the time of review. The resident was noted to have intact cognition, no behaviors, and was dependent on staff for all activities of daily living. This deficiency was confirmed during an interview with the Administrator, who acknowledged that the form had not been completed prior to the surveyor's inquiry.
Failure to Notify Physician and Representative of Significant Weight Loss
Penalty
Summary
The facility failed to ensure timely notification of significant weight loss to the physician and/or resident representative for two residents. For one resident with diagnoses including dementia, failure to thrive, dysphagia, Alzheimer's disease, and moderate protein-calorie malnutrition, weight records showed fluctuations and a notable decrease. Although the nutrition note acknowledged the weight loss and indicated ongoing monitoring, there was no documentation that the physician, nurse practitioner, or resident representative had been notified. The diet technician was unsure if the family had been informed and confirmed that no documentation of such notification existed. The nurse practitioner also stated she was unaware of the weight loss and would have assessed the resident if notified. For another resident with a history of cerebrovascular infarction, traumatic subdural hemorrhage, multiple fractures, gastrostomy, dysphagia, and moderate protein-calorie malnutrition, weight records indicated a significant decrease over several months. Progress notes mentioned a discussion with the resident's mother about the weight loss and plans for weekly monitoring, but there was no documentation of notification to the physician or nurse practitioner. The facility's policy requires prompt notification of the resident, attending physician, and representative regarding changes in condition or status, but this was not followed in these cases.
Failure to Provide Accurate Medicare Coverage Notices and Documentation
Penalty
Summary
The facility failed to provide accurate Notice of Medicare Non-Coverage (NOMNC) letters to residents, specifically regarding the correct last covered day (LCD) for skilled services. In five cases reviewed, the NOMNC letters indicated the end date for Medicare coverage, but the residents' medical records did not contain documentation of the next payor source beginning immediately after the LCD. Additionally, for residents who were discharged, there was no documentation in the medical record explaining the reason for discharge on or before the LCD. Staff interview with a Licensed Social Worker confirmed discrepancies in the documentation of LCDs and the absence of progress notes explaining changes in coverage or payor concerns. This deficiency affected five out of eleven residents reviewed for liability notices, with the facility census at 81. The lack of proper documentation and communication regarding coverage and payor source transitions was directly observed in the medical records and confirmed by staff.
Failure to Offer or Complete Quarterly Care Plan Meetings
Penalty
Summary
The facility failed to ensure that quarterly care plan meetings were offered or completed for a resident with multiple complex medical conditions, including cerebral infarction, neuromuscular dysfunction of the bladder, obstructive and reflux uropathy, and muscle weakness. Record review showed that the resident was cognitively intact but required significant assistance with daily activities and had an indwelling catheter. There was no documentation of care plan meetings or refusals for the resident over a period of twelve months, despite facility policy requiring such meetings and encouraging participation by residents and their representatives. Interviews with the resident, her responsible party, and facility staff revealed that care plan meetings were not scheduled or documented as required. The social worker confirmed that no care plan meeting had been held in the past seven months, citing scheduling conflicts with the resident's daughter and a lack of documentation of attempts to schedule meetings. The responsible party reported only two care plan meetings in five years and described instances where meetings were canceled or not rescheduled due to facility requirements or scheduling difficulties. The administrator confirmed that care conferences could be held by phone or without the resident present if preferred, but there was no evidence that these options were offered or documented for the resident in question.
Failure to Provide Proper Catheter Care and Timely UTI Treatment
Penalty
Summary
The facility failed to obtain ordered laboratory testing to identify a urinary tract infection (UTI) and did not provide proper care and treatment for an indwelling urinary catheter for one resident. This resident had a history of recurrent UTIs, neurogenic bladder, and required an indwelling catheter. Despite orders from the certified nurse practitioner (CNP) on two occasions to obtain a urinalysis with culture and sensitivity, nursing staff did not collect the required urine samples. The resident subsequently developed urinary pain and was sent to the emergency department, where a malpositioned catheter was identified and the resident was treated for cystitis and UTI. Observations revealed repeated improper placement of the urinary drainage bag above the bladder level, both in bed and in a wheelchair, which was confirmed by nursing staff and acknowledged as a recurring issue. Additionally, the facility failed to timely initiate treatment for a UTI for another resident. Laboratory results identified a specific organism and indicated the appropriate antibiotic, but there was a delay between the urine culture result and the administration of the first dose of the prescribed antibiotic. Documentation showed that the medication was not available on the day it was ordered, and the first dose was not given until two days after the culture result. The delay in starting antibiotic therapy was confirmed by the Director of Nursing (DON). Both deficiencies were identified through record review, staff interviews, and direct observation. The failures included not following physician orders for laboratory testing, not maintaining proper catheter care and positioning, and not ensuring timely administration of prescribed medications for UTIs. These actions and inactions directly affected the care and treatment of the residents involved.
Failure to Address Pharmacy Recommendations and Medication Orders in a Timely Manner
Penalty
Summary
The facility failed to ensure that pharmacy recommendations were addressed in a timely and appropriate manner for multiple residents. For one resident with vascular dementia and schizoaffective disorder, pharmacy progress notes indicated recommendations for a gradual dose reduction (GDR) of Cymbalta, as required by federal regulation. The documentation for declining the GDR lacked a patient-specific rationale, and the form was reprinted and signed with inconsistent dates. Additionally, the facility was unable to locate a subsequent pharmacy recommendation for this resident. Another resident with multiple diagnoses, including major depressive disorder and generalized anxiety disorder, also had a pharmacy recommendation for a GDR of Cymbalta. The rationale for declining the GDR was not documented in the medical record, and the form was similarly reprinted and signed with earlier dates. Furthermore, repeated pharmacy recommendations for laboratory testing were not acted upon until several months later, despite being agreed to and signed by the provider. A third resident with sepsis, osteomyelitis, heart failure, and dementia received an antibiotic order for Macrobid that was outside the recommended dose or frequency and required dose adjustment based on renal function. There was no evidence in the progress notes that the dose was reviewed or clarified with the physician, and the medication was administered as ordered. The DON confirmed that the order was not addressed for proper dosing. Facility policies required timely review and documentation of pharmacy recommendations and medication orders, which was not consistently followed.
Failure to Maintain Cleanliness and Provide Comfortable Bedding
Penalty
Summary
The facility failed to provide a clean, sanitary, and comfortable environment for two residents. One resident with quadriplegia, anxiety disorder, contractures, and reduced mobility reported that her mattress was uncomfortable and had a large dip in the middle, which had persisted for about a month. Certified Nurse Aides confirmed the resident's complaints and stated they had informed either the Director of Maintenance or a nurse, but there was no documentation of the concern in the maintenance logs. The mattress issue was only addressed after surveyor observation and staff interviews confirmed the problem. Another resident with cerebrovascular disease, dementia, psychotic and mood disturbances, and dysphagia was observed lying in bed with a floor mat and carpet nearby that were soiled with a dried white substance. The housekeeper verified the dirty condition and stated that the room had not been cleaned that day. These findings demonstrate a failure to maintain a clean, sanitary, and homelike environment for the residents involved.
Failure to Apply Ordered Auto-PAP for Resident with Respiratory Conditions
Penalty
Summary
The facility failed to apply an Automatic Positive Airway Pressure (auto-PAP) machine as ordered for a resident with significant respiratory conditions, including respiratory failure, COPD, obesity, and emphysema. The physician's order required the auto-PAP to be applied every night and as needed for naps. Documentation showed the treatment was not administered on a specific night, and the responsible LPN admitted to forgetting to apply the device, without providing a specific reason. The resident's medical record indicated a history of severe respiratory issues and multiple recent hospitalizations for respiratory failure. On the morning following the missed treatment, the resident was initially alert and eating breakfast but was later found to be in respiratory distress after a call from her daughter. The assigned RN assessed the resident, applied the auto-PAP, and arranged for emergency transfer to the hospital. The night nurse did not communicate the missed treatment to the day staff. The incident was self-reported by the facility, and staff interviews confirmed the lapse in following the treatment order for the auto-PAP application.
Failure to Accurately Document Medical Treatments and Medication Administration
Penalty
Summary
The facility failed to ensure accurate documentation in the medical records for two residents. For one resident with respiratory failure, COPD, obesity, and emphysema, a physician's order required the use of an auto-pap device as needed for naps and every night. The treatment record indicated the device was administered on two specific evenings; however, a self-reported incident and subsequent interviews revealed that the auto-pap was not actually applied on one of those nights. The nurse responsible could not provide a reason for not administering the treatment and had signed off as if it had been completed. For another resident with sepsis, osteomyelitis, heart failure, dementia, and peripheral vascular disease, there was a physician's order for an antibiotic to be administered twice daily. Documentation showed the medication was not available at the time it was needed, and although it was later pulled from the starter kit, there was no record of the time or signature of the nurse who retrieved it. The medication administration record noted the antibiotic was not given and referred to a nurse's note, but there was no documentation confirming administration. Interviews with the DON and a unit manager confirmed the lack of required documentation.
Resident Smokes in Room Despite Non-Smoking Policy
Penalty
Summary
The facility failed to ensure an environment free of accident hazards when smoking materials were not secured, allowing a resident with dementia to smoke in his room. This resident, who had a history of smoking and was deemed unfit to live alone by Adult Protective Services, was admitted to the facility with several medical conditions, including dementia. Upon admission, the resident refused to allow staff to inspect his belongings, and there was no documentation of an inventory of his personal effects. An incident occurred when an alarm sounded in the resident's room, and staff found the room filled with smoke. The smoke was traced to a smoldering jacket in the resident's wardrobe, which was extinguished by a CNA. The resident admitted to having smoked a cigarette butt and placing it in his jacket pocket, which led to the smoldering. Despite the facility's non-smoking policy and the resident's awareness of it, he had an uncontrollable urge to smoke and managed to keep smoking materials in his possession. Interviews with staff revealed inconsistencies in the resident's account of the incident, likely due to his cognitive impairment. The facility's smoking policy required that smoking materials be kept in a designated area and that residents without independent smoking privileges could not have smoking items. However, the resident's refusal to allow an inspection of his belongings upon admission and the lack of a documented inventory contributed to the oversight that led to the incident.
Failure in Pain Management for Resident with Chronic Pain
Penalty
Summary
The facility failed to provide effective pain management for a resident with chronic pain syndrome, ALS, and other conditions, who was admitted to hospice care. The resident was prescribed multiple medications, including Morphine Sulfate Concentrate for breakthrough pain, which was to be administered as needed. On a specific day, the resident's pain levels were documented as high, yet she did not receive her requested breakthrough pain medication in a timely manner, leading to extreme pain. The resident requested her Morphine Sulfate Concentrate starting at 8:00 P.M., but it was not administered until after midnight. The resident was dependent on staff for all personal care and was unable to reposition herself in bed. Despite her requests, the LPN on duty did not provide the medication as needed and refused to communicate with the hospice nurse who was contacted by the resident. The hospice nurse attempted to reach the facility but received no response, and the resident's pain was not addressed until hours later. The facility's failure to administer the medication as ordered and the lack of communication between the LPN and hospice staff contributed to the deficiency. The resident's pain management plan was not followed, and the facility's policy on medication administration was not adhered to, resulting in the resident experiencing severe pain unnecessarily.
Inadequate Assistance During Incontinence Care Leads to Resident Fall
Penalty
Summary
The facility failed to provide adequate assistance to a severely cognitively impaired resident during incontinence care, resulting in a fall with injury. The resident, who required two staff members for bed mobility and was incontinent, fell out of bed while being changed by two CNAs. The incident occurred when the resident was over-rolled and slid to the floor, causing pain and swelling to the left side of the head, cheek, and eye, as well as pain in the left elbow. The resident was transferred to the hospital and diagnosed with a head injury and multiple contusions. The medical record review revealed that the resident had a high risk for falls due to a history of falls, impaired cognition, and dependence on continence care. The care plan indicated the need for total staff assistance with toileting and bed mobility. Despite these requirements, the CNAs involved in the incident did not maintain the resident's safety, leading to the fall. The facility's fall investigation confirmed that the resident was being changed by two CNAs when the fall occurred, and witness statements corroborated the sequence of events leading to the fall. Interviews with the DON and other staff members verified the findings, although there was a discrepancy regarding which CNAs were present during the incident. The facility's procedure for turning patients over in bed was not followed, as the resident was not positioned correctly, increasing the risk of falling. This deficiency was investigated under a specific complaint number, highlighting the failure to provide adequate supervision and assistance during incontinence care.
Failure to Provide Dignified Care and Assistance
Penalty
Summary
The facility failed to provide feeding assistance to two residents, both of whom required help with meals due to their medical conditions. One resident, diagnosed with quadriplegia and anxiety disorder, was observed to have their meal tray placed out of reach, and the staff left without setting up the meal. The resident expressed frustration about the staff's tendency to rush through feeding. Similarly, another resident with amyotrophic lateral sclerosis and anxiety disorder had their meal tray left untouched for an extended period, as no staff member provided the necessary assistance. Despite the presence of staff, the resident was left waiting, and the meal remained untouched. In another incident, the facility failed to maintain the dignity and privacy of a resident during a mechanical lift transfer. The resident, who had severe cognitive impairment and required a mechanical lift for transfers, was being moved without the door closed or privacy curtains drawn. This lack of privacy was only addressed when a staff member noticed the surveyor's presence and closed the door. The staff involved initially provided conflicting accounts of the situation, with one CNA stating that privacy was not necessary, while another later acknowledged that the door should have been closed. These deficiencies highlight the facility's failure to adhere to its policy of providing assistance with meals and maintaining resident dignity during personal care. The observations and interviews conducted during the survey revealed a lack of coordination and communication among staff, resulting in residents not receiving the care and respect they are entitled to.
Failure to Notify Responsible Parties of Potential Abuse Incident
Penalty
Summary
The facility failed to notify the responsible parties and medical practitioners of two residents involved in a potential sexual abuse incident. Resident #100, who was moderately cognitively impaired and required extensive assistance for activities of daily living, was allegedly touched inappropriately by Resident #101, who was cognitively intact and required supervision for daily activities. The incident was reported by a State tested Nursing Assistant to the Registered Nurse Shift Supervisor, who then informed the Director of Nursing. However, there was no evidence that the families or doctors of the involved residents were notified about the incident. The facility's policy mandates immediate reporting of such incidents to various parties, including the resident's representative and attending physician. Despite this, the mother of Resident #100 was not informed by the facility but learned of the incident through a personal phone call from a friend who worked at the facility. The Director of Nursing confirmed the lack of notification to the residents' families and medical practitioners. This deficiency was identified during an investigation under specific complaint numbers.
Failure to Protect Resident from Sexual Abuse
Penalty
Summary
The facility failed to protect a resident from sexual abuse, as evidenced by an incident involving inappropriate touching. Resident #100, who was moderately cognitively impaired and required extensive assistance for activities of daily living, was allegedly touched inappropriately by Resident #101. The incident was reported by a State Tested Nursing Assistant (STNA) who witnessed Resident #101 rubbing Resident #100's breast. Despite the facility's conclusion that the interaction was consensual, the resident's mother alleged sexual assault, prompting an investigation. Resident #100 had a history of communication deficits and cognitive impairment, with a mental capacity likened to that of an eight-year-old child due to past brain aneurysms. During interviews, Resident #100 confirmed the touching incident with a childish demeanor, indicating a lack of full comprehension of the situation. The facility's investigation involved interviews with staff and residents, and a police report was filed by Resident #100's mother, leading to further investigation by law enforcement. The facility's policy on abuse prevention was reviewed, highlighting the residents' right to be free from abuse and neglect. Despite the policy, the facility's interpretation of the incident as consensual was challenged by the resident's mother and the police report, which considered the possibility of gross sexual imposition. The deficiency was noted under a master complaint number, indicating non-compliance with regulations designed to protect residents from abuse.
Failure to Report Potential Sexual Abuse Incident
Penalty
Summary
The facility failed to implement its abuse policy in response to an incident involving potential sexual abuse of a resident. Resident #100, who was moderately cognitively impaired and required extensive assistance for daily activities, was allegedly touched inappropriately by another resident, Resident #101. The incident was initially reported by a State tested Nursing Assistant (STNA) who witnessed the event. However, the facility did not take immediate protective actions or report the incident to local law enforcement or the state agency until the resident's mother made a formal allegation of sexual abuse. The facility viewed the incident as consensual due to both residents being their own responsible parties. Resident #100's medical history included epilepsy, major depressive disorder, anxiety disorder, and communication deficits, with a mental capacity likened to that of an eight-year-old child. Despite these factors, the facility did not follow its policy, which required immediate reporting of such incidents to various authorities, including law enforcement and the state agency. The deficiency was identified during an investigation under Master Complaint Number OH00156168 and Complaint Number OH00156099.
Failure to Document Incident in Medical Records
Penalty
Summary
The facility failed to maintain complete and accurate medical records for two residents, which is a deficiency in safeguarding resident-identifiable information and maintaining medical records according to accepted professional standards. Resident #100, who was moderately cognitively impaired and required extensive assistance for activities of daily living, was involved in an incident where Resident #101, who was cognitively intact and required supervision for activities of daily living, allegedly engaged in inappropriate touching. This incident was reported by a State tested Nursing Assistant to the Registered Nurse Shift Supervisor, who then notified the Director of Nursing. Despite the incident being reported, a review of the medical records for both residents revealed no documentation regarding the incident or its outcomes. An interview with the Director of Nursing confirmed the absence of documentation in the medical records concerning the alleged sexual abuse incident. This lack of documentation indicates a failure to ensure a complete and accurate medical record for the residents involved.
Failure to Maintain Sanitary Kitchen Environment and Proper Food Management
Penalty
Summary
The facility failed to ensure a clean and sanitary kitchen environment, which included proper labeling and dating of food, discarding expired food, and appropriate monitoring of the low-temperature dish machine. During an observation of the kitchen, several issues were noted: packs of sliced cheese and turkey in the walk-in cooler lacked labels and dates, a loosely wrapped package of hard-boiled eggs was not labeled or dated, and various other food items had illegible or missing dates. Additionally, the walk-in freezer had debris and ice build-up, and the slicer had unidentifiable debris on it. In the dishroom, the temperature and sanitizer log was incomplete, and test strips for the chlorine sanitizer were unavailable. The dry stock room contained moldy and expired bread, further indicating a lack of proper food management practices. Interviews with the District Dietary Manager (DDM) confirmed these findings and the failure to adhere to the facility's food storage policies. Further inspection of the dish machine revealed that the facility had obtained chlorine test strips, but the sanitizer concentration was insufficient, as indicated by the faint purple color on the test strips. The DDM confirmed that the sanitizer was not meeting the required parts per million (ppm) for effective sanitation. The facility's policy on warewashing, which required maintaining dish machine water temperatures and completing temperature and sanitizer concentration logs, was not followed. This deficiency was investigated under Complaint Number OH00152455.
Improper Trash and Biohazardous Waste Management
Penalty
Summary
The facility failed to ensure that trash, including biohazardous waste, was collected and stored appropriately, potentially affecting all 57 residents. During an observation with the District Dietary Manager (DDM), multiple dumpsters were found in the parking lot area behind the facility. The designated dietary dumpster was open and surrounded by debris, including cut-up onions, leaves, Christmas lights, a broken dresser, chair, and couch. Additional trash, such as snow plow markers, a box, and takeout containers, were found outside another dumpster. A red biohazard barrel and a bookshelf were also improperly stored in a wooden open gated area near the dumpster. The DDM confirmed that the dumpster area was not reasonably clean and that the biohazardous waste should not have been in the parking lot. Further observation with the Director of Maintenance (DOM) revealed additional debris, including a large pile of mattresses and chairs, near the dietary dumpster. The biohazard barrel remained in the wooden open gated area. The DOM also showed the surveyor the first-floor biohazard room on the Critical Recovery Unit (CRU), which was overflowing with at least five red bags and a large box with a red bag. The DOM confirmed that the biohazardous waste barrel should not have been outside and that the biohazard room was overly full, indicating the need for waste pickup. Facility policies reviewed indicated that the area surrounding the exterior dumpster should be free of rubbish and that medical waste should be stored in designated biohazard rooms, protected from animals, and not providing a food source for insects and rodents.
Failure to Ensure Washing Machines Reach Required Temperatures
Penalty
Summary
The facility failed to ensure that washing machines reached the minimum required temperatures for hot water processing, potentially affecting all 57 residents. Observations revealed that the soiled linen laundry room contained three washers without temperature gauges or logs. The laundry cycles listed on the wall lacked temperature information. During an observation, a laundry aide used a yellow plate thermometer to measure the wash cycle temperature, which read a maximum of 150.6 degrees Fahrenheit. Interviews with the Housekeeping and Laundry Supervisor, Director of Maintenance, and other staff indicated uncertainty about the exact temperatures reached during wash cycles. The facility did not have documentation to confirm that the washing machines met the required 160 degrees Fahrenheit for hot water processing. The Director of Nursing, who also served as the facility's infection preventionist, and the Regional Clinical Director were unable to provide adequate evidence that the washing machines met the required temperature. Review of the User's Guide for the washers and a letter from Ecolab recommended washing with detergent in water at or above 160 degrees Fahrenheit for 25 or more minutes. The deficiency was investigated under Complaint Number OH00152455 and represented continued non-compliance from a previous survey dated 03/05/24.
Failure to Serve Appropriate Food Quantities
Penalty
Summary
The facility failed to ensure foods were served in appropriate quantities, affecting 49 residents receiving food from the kitchen. Specifically, the menu for Week 1, Tuesday lunch indicated that residents were to receive one cup (eight ounces) of baked macaroni and cheese. However, during lunch service, Cook #141 was observed using a gray #8-scoop, serving only four ounces of both regular and pureed macaroni and cheese, which is half the amount specified in the menu. This discrepancy was confirmed during an interview with the Dietary District Manager and Dietetic Technician Registered, who acknowledged that the serving size did not follow the menu as written. Additionally, the review of the diet list revealed that four residents were ordered nothing-by-mouth (NPO) and four other residents were scheduled to receive a different entree due to their regular No Added Salt (NAS) diet. Despite these specific dietary requirements, the facility did not adhere to the prescribed menu and serving sizes, leading to non-compliance. This deficiency was investigated under Complaint Numbers OH00152484 and OH00152455.
Failure to Report Misappropriation of Resident Property
Penalty
Summary
The facility failed to ensure an allegation of misappropriation of property was reported to the State agency. This affected one resident who reported that her lockbox containing between twenty and fifty dollars, a checkbook, and a bank card went missing from her room. The items were noted missing on 03/31/24 and reported to a facility nurse on 04/01/24. Despite the resident and the Long Term Care Ombudsman raising the issue with the facility's management, the incident was not reported to the State agency as required by the facility's policy. The resident's progress notes also lacked documentation of the missing lockbox. The resident, who had diagnoses including major depressive disorder, epilepsy, and hemiplegia, was admitted to the facility on an unspecified date and had mild or no cognitive impairment according to her Minimum Data Set assessment. The facility's Administrator confirmed that the alleged theft was not reported to the State agency and that the situation had been ongoing since before she began working at the facility. The facility's Abuse and Misappropriation policy required that any allegations be investigated and reported within required timeframes, which was not adhered to in this case.
Latest citations in Ohio
A resident with intact cognition receiving Medicare Part A skilled services for metabolic encephalopathy had services discontinued while benefit days remained, but the facility did not issue the required Skilled Nursing Facility Advance Beneficiary Notice (SNF ABN). The Social Services Director later confirmed that no SNF ABN was provided and reported she believed only a Notice of Medicare Non-Coverage (NOMNC) was needed when all skilled services were stopped. This practice conflicted with the facility’s written policy, which required SNF ABNs to be issued when extended care items or services were initiated, reduced, or terminated due to expected non-coverage by Medicare.
Surveyors identified that the facility exceeded the acceptable medication error rate when two residents with type 2 DM received insulin doses that were not administered according to orders or manufacturer instructions. In two separate observations, an LPN administered Novolog and another LPN administered insulin glargine and insulin lispro without priming the insulin pens, and the insulin lispro and Novolog were given after the residents had already consumed a significant portion of their breakfast meals, despite orders for administration before meals. Manufacturer information for both insulin products required priming before each injection to ensure accurate dosing, and facility policy required medications, including insulin, to be administered safely, timely, and in accordance with prescriber orders and specified time frames.
Surveyors found that the facility failed to document tray line food temperatures for multiple meals served from two dining room kitchenettes, despite having a “Trayline Taste & Temperature Log” and a policy requiring food to be stored, prepared, distributed, and served according to professional food safety standards. Review of logs showed repeated missing entries for breakfast, lunch, and dinner services in both the Harrison and McClellan dining areas, and the Senior Director of Culinary Services confirmed that temperatures had not been recorded for those meals, potentially affecting all residents receiving meals from those kitchenettes.
The facility failed to conduct and document required periodic care conferences for two residents, despite multiple comprehensive, quarterly, and significant change MDS assessments and a policy requiring periodic care conferences with resident and/or family participation. One resident with Parkinson’s disease, post-stroke hemiplegia, TIA, DMII, and depression had only two documented care conferences over a year, while another resident with aphasia, cerebrovascular disease, DMII, gait difficulty, coagulation defect, depression, and muscle weakness had no documented care conferences in the past year, aside from a declined invitation to the representative. The UCC confirmed that care conferences were expected to occur quarterly and that no additional documentation existed for either resident.
A resident with Alzheimer's disease and type II DM, who required extensive assistance with ADLs and was receiving scheduled Lantus and sliding-scale Humalog, experienced a severely elevated blood glucose level. The on-call provider was notified and ordered an additional dose of lispro insulin with a directive to recheck the blood glucose after administration. Nursing staff administered the extra insulin but did not document any follow-up blood glucose check, and the DON confirmed that this reevaluation was required by the facility's abnormal blood glucose policy and was not completed or documented.
A resident with Parkinson’s disease, dementia, and hypothyroidism was prescribed levothyroxine once daily along with other medications. A consultant pharmacist’s monthly drug regimen review recommended that levothyroxine be given in the morning on an empty stomach, 30–60 minutes before food, per manufacturer instructions. The medical record contained no documented physician response to this recommendation, and the MAR showed the drug scheduled for morning administration while the resident was observed eating breakfast and receiving the medication at the same time. An LPN confirmed administering levothyroxine during the meal, and the DON verified there was no documentation explaining whether or why the pharmacist’s recommendation was or was not followed, resulting in a failure to act on and document the identified irregularity.
A resident with severe cognitive impairment, multiple comorbidities, documented gait and balance abnormalities, and a high fall risk was care planned and assessed by therapy to require contact guard assistance and use of a gait belt for transfers and ambulation. While being assisted by a CNA from a recliner to the bathroom with a walker, the CNA did not apply a gait belt, even though the resident had a known tendency to lean backward when standing. As the CNA reached to open the bathroom door, the resident lost balance and fell backward, striking the back of the head, and was later found by an LPN without a gait belt in place, contrary to the facility’s gait belt policy and the resident’s assessed needs.
A resident with CKD stage five requiring peritoneal dialysis (PD) was admitted with pre-admission physician orders for three daily PD exchanges and monitoring for peritonitis (fever, abdominal pain, cloudy effluent), but these monitoring orders were not entered into the facility’s physician orders. The care plan referenced PD and general monitoring but did not specifically address peritonitis monitoring. Paper PD flowsheets showed incomplete and inconsistent documentation of exchanges and resident condition, including missing condition/comments for individual treatments and no record of one ordered PD exchange. The PD cycler flowsheet lacked effluent descriptions on multiple days. The PD nurse reported facility staff were expected to monitor effluent and symptoms, and the DON confirmed the absence of specific peritonitis monitoring orders, lack of an order for the PD cycler, and documentation gaps, despite a facility policy requiring ongoing assessment and monitoring for complications before, during, and after dialysis treatments.
A nurse was observed preparing multiple oral medications for a resident with depression, traumatic brain injury, anxiety, and impaired cognition by pushing tablets and capsules from unit-dose cards directly into her ungloved hand and then using her fingers to place them into a medication cup. In a follow-up interview, the RN confirmed this practice and acknowledged that the correct procedure is to dispense medications directly from the card into the cup, contrary to the facility’s medication administration policy requiring adherence to good nursing principles and practices.
A resident with Alzheimer’s disease, diabetes, anxiety, significant ADL dependence, and behavioral symptoms was observed seated in a chair positioned against the nursing station with a locked wheelchair placed directly in front, also against the nursing station, effectively restricting movement. An LPN confirmed both wheelchair wheels were locked and that it should not have been placed there, while a CNA stated she had positioned the wheelchair to prepare for lunch, was unable to complete the transfer, and left it in place, acknowledging this was wrong. This arrangement conflicted with the facility’s restraint policy, which prohibits physical restraints except when alternatives are ineffective for treating a medical symptom and defines restraints as devices adjacent to the body that cannot be easily removed and that restrict freedom of movement or access to the body.
Failure to Issue Required SNF ABN When Discontinuing Medicare Part A Services
Penalty
Summary
The deficiency involves the facility’s failure to issue a Skilled Nursing Facility Advance Beneficiary Notice (SNF ABN) when Medicare Part A services were discontinued for a resident who still had available benefit days. The resident was admitted with a diagnosis of metabolic encephalopathy and had intact cognition per the Minimum Data Set assessment. The facility’s own SNF Beneficiary Notification Review documented that Medicare Part A skilled services began on 02/11/26 and the last covered day was 03/11/26, and that the facility initiated discharge from Medicare Part A services before the resident’s benefit days were exhausted. Despite this, no SNF ABN was provided to the resident or the resident’s representative. During interviews, the Social Services Director stated that the SNF ABN was issued hours prior to the last covered day but, upon reviewing her files, confirmed that no SNF ABN had actually been issued for this resident. She further explained that she believed an SNF ABN was only required if one skilled service remained and that if all skilled services were being discontinued, only the Notice of Medicare Non-Coverage (NOMNC) needed to be issued. The Administrator, however, stated that a resident should always receive both a SNF ABN and a NOMNC when Medicare Part A services are discontinued and benefit days remain. Review of the facility’s written policy dated 03/28/23 showed that the facility was required to issue SNF ABNs for initiation, reduction, or termination of extended care items or services when Medicare payment was not expected, which did not occur in this case.
Plan Of Correction
This Plan of Correction is submitted as required under State and Federal law. This Plan of Correction does not constitute an admission on the part of the Facility that the findings cited are accurate, that the findings constitute a deficiency or that the scope and severity regarding the deficiency cited are correctly applied. Any changes to the Facility's policies and procedures should be inadmissible in any proceeding on that basis. Without admitting or denying the validity or the existence of the alleged noncompliance, the Facility submits this Plan of Correction with the intention that it be inadmissible by any third party in any civil or other action against the facility or any employee, agent, officer, director or shareholder of the Facility. The Facility is utilizing this Plan of Correction as its allegation of substantial compliance as of 05/29/2026 F-0582 Corrective action for resident/s: On 5/14/26 Resident #34 was informed of rights and responsibilities related to Advanced Beneficiary Notice and voiced understanding of information for future reference by administrator. Identification of other residents who may be affected: Any resident receiving skilled services from nursing or therapy services. The Administrator audited all residents who were discharged from skilled services in the past 30 days to ensure they were issued a Notice of Non-Coverage and Advanced Beneficiary Notice on 5/29/26. No non-compliance was noted. Measures for systemic change: On 5/14/2026 Business Office Manager, Director of Rehab, Minimum Data Set nurse, Director of Nursing and Social Services Director were educated on proper procedure of issuing of Notice Of Medicare Non Coverage and Advanced Beneficiary Notice by administrator. All upcoming discharges from skilled services will be reviewed weekly at Utilization Review meeting to ensure notices will be delivered timely. How Corrective Action will be monitored: Administrator or designee to complete audits of all residents being discharged from skilled services to ensure they were issued a Notice of Non-Coverage and Advanced Beneficiary. This audit will be completed weekly x 4 weeks, then monthly x 2 months. Corrective action will be initiated for any noted non-compliance. Audit findings will be reviewed as part of the monthly quality assurance process to determine the need for further monitoring. Date of Compliance 5/29/26
Insulin Administration Errors and Failure to Prime Insulin Pens
Penalty
Summary
The deficiency involves the facility’s failure to maintain a medication error rate below 5%, with surveyors identifying 3 errors out of 28 medication administration opportunities, resulting in a 10.71% error rate. For one resident with type 2 diabetes mellitus and moderate cognitive impairment, the physician’s order directed Novolog insulin 10 units via subcutaneous pen-injector to be given before meals. During an observed medication pass, the LPN administered 10 units of Novolog insulin without priming the pen and did so after the resident had already consumed approximately 50% of the breakfast meal. The LPN later confirmed she did not prime the pen and acknowledged that the insulin was ordered to be administered prior to meals. Manufacturer instructions for the Novolog FlexPen specified that an air shot (priming) must be performed before each injection to ensure proper dosing. Another resident, also diagnosed with type 2 diabetes mellitus and with intact cognition, had orders for insulin glargine 35 units subcutaneously twice daily and insulin lispro 20 units subcutaneously before meals, plus 12 units subcutaneously if blood glucose was between 251 mg/dL and 300 mg/dL. During an observed medication administration, an LPN administered 35 units of insulin glargine and 32 units of insulin lispro without priming the insulin pens and after the resident had consumed approximately 90% of the breakfast meal, despite orders for insulin lispro to be given before meals. The LPN later stated she could not remember if she had primed the pen and acknowledged that the insulin was ordered to be administered prior to meals. Manufacturer information for insulin lispro stated that the pen must be primed before each injection to confirm insulin delivery and remove air, and that failure to prime could result in too much or too little insulin. The DON confirmed the expectation that insulin be administered as ordered, including priming each pen with two units before dialing the prescribed dose, and facility policy required medications, including insulin, to be administered safely, timely, and in accordance with prescriber orders and required time frames.
Plan Of Correction
This Plan of Correction is submitted as required under State and Federal law. This Plan of Correction does not constitute an admission on the part of the Facility that the findings cited are accurate, that the findings constitute a deficiency or that the scope and severity regarding the deficiency cited are correctly applied. Any changes to the Facility's policies and procedures should be inadmissible in any proceeding on that basis. Without admitting or denying the validity or the existence of the alleged noncompliance, the Facility submits this Plan of Correction with the intention that it be inadmissible by any third party in any civil or other action against the facility or any employee, agent, officer, director or shareholder of the Facility. The Facility is utilizing this Plan of Correction as an allegation of substantial compliance as of 5/29/2026. F-0759 Corrective action for resident/s: Residents #21 and #22 were assessed and evaluated by nurse and Director of Nursing 5/14/26. Resident #21 and #22 both denied any adverse effects and none were noted upon assessment by the Director of Nursing on 5/14/2026. Notification made to physician on 5/14/2026. LPN # 2 competency Eval on insulin administration with the Director of Nursing completed 5/14/2026. Identification of other residents who may be affected: Diabetic residents on assignment of LPN #2/station 2 have the potential to be affected and were assessed by the DON/Designee on 5/14/26 and found to be within normal limits. Measures for systemic change: All Nurses were educated by the Director of Nursing on the steps for Insulin administration per competency, diabetes clinical protocol policy, Medication and treatment orders policy, administering medications policy, and Obtaining fingerstick Glucose Level policy On 5/14/2026. How Corrective Action will be monitored: Director of Nursing and Assistant Director of Nursing will complete insulin administration audits on 5 nurses. This audit will be completed weekly x 4 weeks, then monthly x 2 months. Corrective action will be initiated for any noted non-compliance. Audit findings will be reviewed as part of the monthly quality assurance process to determine the need for further monitoring. Date of Compliance: 5/29/2026
Failure to Document Tray Line Food Temperatures in Dining Room Kitchenettes
Penalty
Summary
The deficiency involves the facility’s failure to document tray line food temperatures for meals served from the Harrison and McClellan Dining Room kitchenettes, as required by professional standards for food service safety and the facility’s own policy. Review of the “Trayline Taste & Temperature Log” (revised September 2018) showed missing temperature documentation for multiple meals from the Harrison Dining Room kitchenette, including dinner on 03/30/26 and 03/31/26, lunch and dinner on 04/01/26 and 04/02/26, dinner on 04/07/26, and lunch and dinner on 04/08/26 and 04/10/26. The Senior Director of Culinary Services confirmed during interview that tray line food temperatures were not documented on the log for these meals. Similarly, review of the same log for the McClellan Dining Room kitchenette revealed that tray line food temperatures were not documented for dinner on 04/01/26, breakfast and lunch on 04/02/26, and lunch and dinner on 04/07/26. The Senior Director of Culinary Services also verified these omissions during interview. The facility census at the time was 27 residents, and the governing “Food and Nutrition” policy, approved on 09/07/21, stated that the facility must store, prepare, distribute, and serve food in accordance with professional standards for food service safety.
Plan Of Correction
F812 The facility will continue to ensure food temperatures are completed before meals are served for all residents. To ensure compliance with this standard the following measures have been taken: 1. Immediately 4/15/26 culinary supervisor #224 was re-educated by Dietary Manager to this standard and policy "Food and Nutrition" which includes documentation of food temperatures. 2. All dietary staff have been re-educated to the standard and policy "Food and Nutrition" during the month of April 2026. 3. Audits of food temperature documentation to be completed by Dietary Manager 4 x per week for 4 weeks then weekly for 4 weeks. 4. Administrator to validate audits/compliance and provide additional training as needed. Administrator will present to QAPI committee for ongoing monitoring and further direction.
Failure to Conduct and Document Required Care Conferences
Penalty
Summary
The deficiency involves the facility’s failure to complete and document comprehensive care conferences at required intervals in accordance with care plan regulations and facility policy. For one resident with Parkinson’s disease with dyskinesia, cognitive communication deficit, hemiplegia and hemiparesis following cerebral infarction, transient cerebral ischemic attack, type II diabetes mellitus, and major depressive disorder, the record showed multiple MDS assessments over a one-year period, including annual, quarterly, and significant change assessments. However, only two care conferences were documented during the last 12 months, despite the expectation that care conferences be conducted quarterly with the resident and family when possible. The Unit Care Coordinator confirmed that no additional care conference documentation existed for this resident beyond the notes dated 04/21/25 and 01/02/26. A second resident, with diagnoses including aphasia following cerebrovascular disease, cerebral infarction, type II diabetes mellitus, unsteadiness on feet, difficulty in walking, coagulation defect, depression, and muscle weakness, also had multiple MDS assessments completed over the review period, including quarterly and annual assessments. The record contained a note that a care conference was offered to the resident’s representative, who declined to attend, but there was no documentation of any care conferences for the most recent 12 months. The Unit Care Coordinator confirmed that no other care conference documentation was available for this resident. Facility policy stated that periodic care conferences involving the resident, family, and the interdisciplinary team are part of the care planning process, but the required periodic care conferences and corresponding documentation were not completed for these two residents.
Plan Of Correction
THIS PLAN OF CORRECTION SERVES AS BERKELEY SQUARE'S CREDIBLE ALLEGATION OF SUBSTANTIAL COMPLIANCE AS OF June 1, 2026. Without admitting or denying the validity or existence of the alleged deficiencies, Berkeley Square provides the following Plan of Correction: F657 The facility will continue to document completion of care conferences at the required intervals for all residents, including residents #04 & #15. To ensure compliance with this standard the following measures have be taken: 1. The social service designee and the inter- disciplinary team were re-educated by the administrator to the facility policy "Care Conference" on 4/29/26 and verbalized understanding. 2. Care conferences for resident #04 and resident #15 were conducted on or before 4/29/2026 by the interdisciplinary team. 3. Review of all other residents was conducted by the social service designee to validate and ensure that care conference schedule is up to date with timely care conferences scheduled for them on 4/15/2026. Audits of care conferences to be completed weekly for four weeks and then monthly after that by the social service designee. Documentation of the care conference including any identified concerns in the medical record. Administrator to validate audits/compliance and provide additional training as needed. Administrator will present results of these audits to QAPI committee for ongoing monitoring and further direction.
Failure to Reevaluate Blood Glucose After Treatment for Hyperglycemia
Penalty
Summary
The facility failed to ensure that a resident with diabetes received treatment in accordance with professional standards of practice when nursing staff did not reevaluate the resident's blood glucose after treatment for severe hyperglycemia. The resident, admitted with diagnoses including Alzheimer's disease, type II diabetes mellitus, and depression, had physician orders for Humalog insulin on a sliding scale before meals, Lantus insulin 25 units daily, and lisinopril 5 mg daily. The resident required extensive assistance with activities of daily living, including transfers, toileting hygiene, eating, and bathing. On the evening in question, the resident's blood glucose was documented as 532 mg/dL, and the on-call provider was notified. The provider gave a new order to administer an additional 8 units of lispro (Humalog) and to recheck the blood glucose in 30 minutes. The electronic medication administration record showed that the blood glucose of 532 mg/dL was obtained at 9:00 p.m. and that the additional 8 units of lispro were administered at 9:21 p.m. However, there was no documentation in the resident's chart that the blood glucose was rechecked after the additional insulin was given. In an interview, the DON confirmed there was no evidence of reevaluation and verified that, according to the facility's "Abnormal Blood Glucose Procedure" policy, the resident should have been reevaluated and that the evaluation step should have been included in the progress note documentation.
Plan Of Correction
F684 The facility will continue to ensure all residents, including #03, receive treatment in accordance with professional standards of practice and reevaluated for hyperglycemia. To ensure compliance with this standard the following measures have been taken: 1. The director of nursing assessed resident #03, reviewed documentation and orders and found no ill effects immediately 4/16/26. 2. All licensed nurses were re-educated to facility policy "Blood Glucose Monitoring" by the Director of Nursing/designee in April 2026. 3. Audits of like-residents that require blood sugar checks to be completed by the director of nursing/designee two times a week for 4 weeks and then monthly after that to validate correct follow through when there is abnormally high blood glucose result. The Administrator will bring results of these audits to the QAPI committee for ongoing monitoring and further direction.
Failure to Act on Pharmacist Drug Regimen Recommendation for Thyroid Medication
Penalty
Summary
The deficiency involves the facility’s failure to ensure that pharmacy recommendations from the monthly drug regimen review were acted upon and documented for a resident. The resident was admitted with diagnoses including Parkinson’s disease, dementia, and hypothyroidism, and had current physician orders for levothyroxine 150 mcg once daily, buspirone 50 mg twice daily, and losartan 100 mg once daily. A medication regimen review dated 11/25/2025 included a consultant pharmacist recommendation that levothyroxine be administered consistently in the morning on an empty stomach, at least 30–60 minutes before food, per manufacturer instructions. There was no specific physician response in the medical record to this recommendation, and the facility’s policy stated that consulting pharmacist reviews are sent to nursing and addressed with the primary care provider or consulting specialist for review and follow-up. Review of the resident’s medication administration record for April 2026 showed levothyroxine scheduled for 9:00 a.m. On observation, the resident was seen eating breakfast in the dining area at 8:03 a.m., and an LPN reported administering the levothyroxine 150 mcg to the resident while the resident was in the dining area eating breakfast. The DON confirmed there was no evidence in the resident’s medical record explaining why the consultant pharmacist’s recommendation from 11/25/2025 was or was not acted upon. This lack of documented physician review and action on the pharmacist’s identified irregularity constituted noncompliance with the drug regimen review requirements.
Plan Of Correction
F756 The facility will continue to ensure the pharmacy recommendations from the monthly drug regimen review by a licensed pharmacist are acted upon for all residents, including #08. To ensure compliance with this standard the following measures have been taken: 1. Resident #08 was assessed by the registered nurse and med review completed by 4/28/26. After review of resident's drug regime's, it was discovered that resident #8 had 2 separate medication recommendations on the same form, to be reviewed by two separate practitioners, pharmacy has been instructed and agreed to separate meds on individual forms. 2. Licensed nurses re-educated to facility policy "Drug Regimen Review" by Director of nursing/designee in April 2026 and no later than 5/8/26. Licensed nurses are responsible for ensuring the reviews and recommendations are given to the physician for timely review. 3. Review of all other current residents Drug Regimen orders completed by Director of nursing/designee on 4/16/26 to ensure recommendations were followed up on/reviewed by the physician and address concerns if needed. 4. Audit of drug regime recommendations, pharmacy recommendations, and physician follow up to be completed weekly for four weeks by the Director of nursing/designee. Administrator will present results of these audits to the QAPI committee for ongoing monitoring and further direction.
Failure to Use Required Gait Belt During Ambulation Resulting in Resident Fall
Penalty
Summary
The deficiency involves the facility’s failure to ensure that a required gait belt was used while assisting a high fall‑risk resident with ambulation, resulting in a fall with head injury. The resident had multiple diagnoses including metabolic encephalopathy, hypertension, osteoarthritis, muscle weakness, gait and mobility abnormalities, major depressive disorder, anxiety, and visual hallucinations. Admission and subsequent MDS and fall risk assessments documented that the resident was severely cognitively impaired, required moderate to maximal assistance with transfers and ambulation, could not independently come to a standing position, exhibited loss of balance while standing, used an assistive device, and had decreased muscle coordination. The resident had a history of falls prior to admission and was assessed as being at high, later moderate, risk for falls. The resident’s fall care plan identified her as at risk for falls and included interventions such as providing maximum to moderate assistance with transfers and walking short distances, use of a walker and wheelchair, and following the facility’s fall protocol. Therapy notes and care conference documentation indicated that the resident leaned backwards when standing, required contact guard to minimal assistance for bed mobility and transfers, and needed constant verbal cueing for safe sequencing during toilet transfers. The physical therapist confirmed that the resident was to use a gait belt with staff when ambulating, and the DON verified that therapy had assessed the resident as requiring contact guard assistance and a gait belt for ambulation and transfers. On the day of the incident, a CNA was assisting the resident from her recliner to the bathroom using a walker. The CNA walked beside the resident, providing guidance and support, and reported having a hand on the resident while assisting her. As they approached the bathroom door, the CNA reached for the doorknob to open it, and at that moment the resident began to lose her balance and fell backwards to the floor, striking the back of her head. The nurse who responded found the resident on her back at the foot of the bed with her feet near the bathroom, noted a red raised area on the back of the head, and documented that the resident was not wearing a gait belt and that the gait belt was on the dresser. In the facility’s investigative summary and in interviews, the CNA acknowledged that she did not have a gait belt on the resident while ambulating her, despite the resident’s assessed need for hands‑on assistance and gait belt use per facility policy and the resident’s care and therapy plans.
Failure to Implement PD Orders and Monitor Resident Receiving Peritoneal Dialysis
Penalty
Summary
The deficiency involves the facility’s failure to implement pre-admission physician orders for peritoneal dialysis (PD) and to provide ongoing monitoring for a resident with chronic kidney disease (CKD) stage five who required PD. Pre-admission orders dated 11/14/25 specified three daily PD exchanges at 6:00 A.M., 2:00 P.M., and 10:00 P.M., and directed staff to monitor for signs and symptoms of peritonitis, including fever, abdominal pain, and cloudy effluent. These monitoring orders were not entered into the facility’s physician orders. The resident’s care plan noted the need for PD and included general monitoring interventions (labs, signs of bleeding, bacteremia, septic shock, and significant vital sign changes), but did not specifically address the ordered monitoring for peritonitis. Review of PD documentation showed incomplete and inconsistent charting of treatments and resident condition. The paper peritoneal flowsheet had columns for time of PD and condition/comments, including instructions to call the nurse immediately for cloudy fluid, abdominal pain, or fever. However, the first entry on 11/15/26 at 2:00 P.M. only noted that the PD nurse completed the exchange, and the 10:00 P.M. entry that day had no condition/comment documentation. Subsequent days (11/16/25, 11/17/25, and 11/18/25) contained only one condition/comment entry per day rather than for each exchange, and there was no documentation that the 6:00 A.M. PD on 11/18/25 was completed. The PD cycler flowsheet starting 11/19/25 lacked any description of the effluent on multiple days. The PD nurse from the dialysis company stated facility staff were expected to monitor effluent for cloudiness and assess for abdominal pain and fever, and the DON confirmed there was no electronic physician order for peritonitis monitoring or for use of the PD cycler, that the paper charting did not allow for effluent description or symptom documentation for each treatment, and that PD was not documented at one ordered time. The facility’s dialysis policy required ongoing assessment and monitoring for complications before, during, and after treatments, which was not reflected in the documentation for this resident.
Improper Infection Control During Medication Administration
Penalty
Summary
Surveyors identified a deficiency in infection prevention and control related to medication administration for Resident #29. The resident was admitted on 02/28/14 with diagnoses including depression, traumatic brain injury, and anxiety, and had impaired cognition per a quarterly MDS assessment. During an observation on 03/25/26 at 6:58 A.M., RN #281 prepared the resident’s medications by removing an Amoxicillin-Pot Clavulanate tablet from the medication card and pushing it directly into her ungloved hand, then using her fingers to place the pill into a medication cup. The same process was observed for multiple other medications, including Escitalopram Oxalate, Furosemide, Sennosides, Lyrica, and Vitamin D, each being pushed from the card into the RN’s ungloved hand and then transferred by her fingers into the medication cup before administration to Resident #29. In a subsequent interview at 7:27 A.M. the same day, RN #281 confirmed she had placed each medication into her ungloved hands prior to administration and acknowledged that the proper procedure was to push the pills directly from the card into the medication cup. Review of the facility’s “Medication Administration – General guidelines” policy, revised 10/08/25, stated that medications are to be administered in accordance with good nursing principles and practices. This practice failure was cited as a deficiency under Complaint Number 2681777.
Improper Use of Wheelchair as a Physical Restraint
Penalty
Summary
Surveyors identified a deficiency related to the facility’s failure to ensure a resident was free from physical restraints. Resident #7, admitted with diagnoses including Alzheimer’s disease, diabetes mellitus, and anxiety disorder, was documented on a recent MDS as rarely understood and dependent for ADLs except eating. The resident ambulated independently on the unit without an assistive device and had documented verbal and other behaviors occurring one to three days during the look-back period. The care plan noted the resident had potential to be physically aggressive, chase staff, throw objects, and be combative with care, with interventions such as offering choices, administering medications as ordered, and intervening early when agitation occurred. During an observation and interview, Resident #7 was found sitting in a chair with the right arm of the chair positioned against the nursing station and a wheelchair placed directly in front of him. The left arm of the wheelchair was also against the nursing station, and both wheelchair wheels were locked, creating a barrier that appeared to restrain the resident, who was sleeping with his knees touching the locked wheelchair. An LPN confirmed both wheelchair wheels were locked and that the wheelchair should not have been placed in front of the resident. A CNA reported she had placed the wheelchair there in preparation to get the resident up for lunch, was unable to transfer him, and left the wheelchair in that position, acknowledging it was wrong to keep it there. The facility’s physical restraint policy stated that physical restraints are not used except when alternatives are not appropriate or effective for treating a medical symptom and defined physical restraints as any device attached or adjacent to the body that the individual cannot easily remove and that restricts freedom of movement or access to the body.
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