Embassy Of Winchester
Inspection history, citations, penalties and survey trends for this long-term care facility in Canal Winchester, Ohio.
- Location
- 36 Lehman Dr, Canal Winchester, Ohio 43110
- CMS Provider Number
- 365644
- Inspections on file
- 44
- Latest survey
- March 5, 2026
- Citations (last 12 mo.)
- 10
Citation history
Health deficiencies cited at Embassy Of Winchester during CMS and state inspections, most recent first.
A resident with multiple comorbidities, cognitive impairment, and total dependence for transfers was moved using a Hoyer lift without adherence to required safety procedures. During the transfer, one CNA operated the lift while another removed the wheelchair and then moved to the opposite side of the bed, leaving the resident suspended in the air without anyone guiding or stabilizing the sling. In interviews, the CNAs and an LPN acknowledged that the resident was not supported while suspended and that required pre-use safety checks of the lift and sling were not performed. Review of the manufacturer’s instructions and facility policy showed that slings must be inspected before each use and that one staff member must stabilize the lift while another guides and stabilizes the resident during transfer, which did not occur.
A resident who was dependent on staff for toileting hygiene and had multiple chronic conditions, including HTN, type II DM, osteoarthritis, contractures, and dementia, received incontinence care from a CNA who failed to follow proper infection control practices. After completing the incontinence care, the CNA handed the resident a call light while still wearing the same gloves used during the care and did not perform hand hygiene. The CNA later confirmed not removing the soiled gloves or cleaning her hands before handling the call light. The facility had identified multiple residents requiring assistance with incontinence care, indicating that this deficient practice had the potential to affect others.
Surveyors found that during a lunch meal service, kitchen staff did not follow required sanitary practices: one staff member handled plates without a hair net, and the dietary manager touched her face and continued serving trays without hand hygiene, despite facility policies requiring hair restraints and proper hand hygiene. Another staff member did not fully fill a 3/4 cup scoop of beef stroganoff for residents needing regular portions, and no policy on meal portion sizes was provided. These issues affected most residents receiving meals from the kitchen and were investigated under a master complaint.
The facility failed to submit an allegation of resident-to-resident sexual abuse to the state agency as required by its abuse policy. A cognitively impaired resident reported that another cognitively intact resident with a history of sexually inappropriate behavior twice touched her breast after luring her with offers of drinks and food and later entering her room while playing pornography on his phone. Nursing documentation showed that assessments were completed and internal notifications made, and law enforcement was contacted. However, during interviews, the DON and Administrator admitted that although an SRI was initiated and the investigation completed, the Administrator became distracted while entering the report and never submitted it, and later chose not to file it when the omission was discovered, despite policy requiring timely reporting of all alleged violations to the state agency and other authorities.
A resident with dementia, multiple comorbidities, and total dependence for toileting hygiene experienced incontinence care during which a CNA, assisted by an RN, performed perineal cleansing, applied barrier cream, and placed a new brief but then handled the resident’s personal items using the same contaminated gloves without performing hand hygiene or changing gloves. The resident’s care plan documented frequent incontinence and dependence for ADLs, and facility policies required hand hygiene when moving from contaminated to clean body sites and after perineal care, which was not followed during this observed episode.
Multiple environmental deficiencies were observed throughout the facility, including stained ceiling tiles, cracked and debris-filled light fixtures, peeling and unfinished drywall, damaged paint, and dust accumulation on vents. Facility leadership confirmed these issues and cited limited maintenance resources as a contributing factor. Housekeeping staff acknowledged responsibility for cleaning fixtures and vents, while repairs were referred to maintenance.
A resident with multiple complex medical conditions was discharged to a hospital with the intention of going home on hospice, but the facility failed to accurately code the discharge status on the MDS 3.0 assessment and did not submit a timely correction to reflect the true discharge disposition.
A resident with multiple comorbidities and a pressure ulcer was found to have soiled heel-elevating boots, with visible staining and discoloration observed over multiple shifts. Despite a care plan that included the use of these boots for pressure reduction, staff confirmed the boots remained unclean and acknowledged the need for replacement or laundering.
Staff were observed not wearing name badges as required by facility policy, with some relying on temporary stickers that often fell off and others not having badges at all. Several residents reported difficulty identifying staff due to the lack of visible name badges. The Administrator and Human Resource Manager confirmed lapses in enforcing and providing permanent badges.
The facility did not ensure scheduled activities were conducted as posted, with residents reporting that activities rarely occurred and that materials were simply left out for independent use. Observations confirmed the absence of activity staff and scheduled events, particularly in the evenings and on weekends, affecting nearly all residents who participate in activities.
The facility did not complete required 90-day performance evaluations for two CNAs, potentially affecting all 88 residents. The Visiting Administrator confirmed the lack of evidence for completed evaluations.
The facility failed to maintain the kitchen's steam warmer and two-compartment sink, affecting 85 residents. A strong sewage odor was detected from the sink, and the steam oven was leaking water, requiring frequent emptying of a metal bin. Staff confirmed the issues, and a plumber later identified the odor source as improperly cleaned floor drains.
The facility failed to implement Enhanced Barrier Precautions for a resident with a feeding tube and did not follow infection control procedures during wound and catheter care for several residents. A CNA did not use PPE or follow proper hand hygiene during catheter care, and an LPN did not separate wound care for different wounds, increasing infection risk. Additionally, enhanced barrier precautions were not implemented for a resident with a PEG tube, violating infection control procedures.
The facility did not document written responses to Resident Council grievances and recommendations. Concerns were discussed in meetings, but no written resolutions were provided. The Resident Council President and Activity Director were unaware of any written responses, and the administration confirmed the absence of a resolution form. The facility also lacked a policy for Resident Council Meetings.
A resident with type 2 diabetes and dementia experienced significant weight loss over several months, but the facility failed to notify the physician after the initial report. The dietician only reported the first instance of weight loss, despite a policy requiring notification of any significant changes.
A resident with multiple chronic conditions and no cognitive impairment experienced unresolved grievances related to missing items and a cracked phone. The facility failed to conduct timely investigations or document them properly, as confirmed by interviews with staff. The administrator misplaced grievance logs, and the facility did not adhere to its policy of resolving grievances within the specified timeframe.
The facility failed to develop comprehensive care plans for three residents, leading to deficiencies in addressing their specific medical needs. A resident dependent on a ventilator lacked a care plan for oxygen therapy, another with a tracheostomy lacked a complete plan for tracheostomy management, and a third resident had no plan for poor dental status. These deficiencies were confirmed by the DON.
The facility failed to invite family or resident representatives to care conferences for two residents, one with severe cognitive deficits and another with mild cognitive impairment and blindness. The care conferences lacked documentation of invitations and attendance, contrary to the facility's policy.
A resident with a complex medical history, including dependence on a respiratory ventilator, did not receive routine nail care as required. Observations over several days showed the resident's nails were long, jagged, and dirty, which was confirmed by an LPN. The facility's policy on personal hygiene, including nail care, was not followed, leading to this deficiency.
A facility failed to implement physician-ordered Prevalon boots for a resident at high risk for skin breakdown, despite a care plan that included multiple interventions to prevent pressure ulcers. The resident, with multiple health conditions, developed a deep tissue injury on the heel, which was monitored and noted to improve. However, observations confirmed the absence of the boots, indicating a deficiency in care.
A resident with severe malnutrition and dysphagia did not receive timely enteral feeding due to a delay in replacing the Glucerna bag, resulting in a 7-hour lapse in nutrition. The LPN confirmed the oversight was due to a lack of proper handoff and documentation from the night shift.
The facility failed to provide appropriate respiratory care equipment for three residents, leading to deficiencies in their care. A resident's nasal cannula oxygen delivery tubing was not dated, and their care plan lacked a specific plan for oxygen use. Another resident with a tracheostomy did not have a spare cannula or an easily accessible ambu bag, and a third resident was missing an ambu bag in their room. Staff interviews confirmed these oversights, which contradicted facility policies.
A facility failed to maintain complete dialysis records for a resident with end-stage renal disease, missing critical weight information necessary for dialysis management. The resident, who was cognitively intact and had a complex medical history, was scheduled for dialysis three times a week. The facility only obtained the missing records after requesting them from the dialysis center, indicating a lapse in maintaining essential documentation.
A facility failed to monitor a resident's psychotropic medications properly, affecting their mental health management. The resident, with multiple diagnoses including schizoaffective disorder and dementia, was prescribed several psychotropic medications. Despite the requirement for gradual dose reductions (GDR), only one recommendation was made for Fluphenazine, which was not implemented. No other GDR recommendations were made for the resident's medications over the past year, indicating a failure to follow the facility's policies.
A resident with chronic health conditions was administered Entresto outside prescribed parameters, as the facility allowed nursing discretion without documented evidence. The DON confirmed the practice and lack of physician notification when parameters were not met.
A resident with severe cognitive impairment was inappropriately prescribed an increased dose of Olanzapine without documented justification. Despite the resident's claims of pregnancy and trouble sleeping, behavior logs showed no recorded behaviors to support the increase. Interviews confirmed the lack of documentation, highlighting a deficiency in monitoring and managing the resident's medication needs.
A facility failed to collect a urine sample for a UTI in a timely manner for a resident with multiple health conditions, including acute respiratory failure and bladder-neck obstruction. Despite a physician's order, the sample was delayed by three days, impacting the initiation of treatment. The Director of Nursing confirmed the delay, which was not justified, violating the facility's policy on timely diagnostic services.
A resident with multiple medical conditions was not provided timely dental services despite having broken, chipped, or carious teeth. The resident's oral assessments were inaccurate, and requests for dental care were unmet. Facility staff confirmed the resident had not seen the contracted dentist, and the resident was told to arrange his own transportation to see a community dentist, contrary to the facility's policy.
The facility failed to follow its antibiotic stewardship processes for two residents. One resident was prescribed Bactrim for a UTI despite lab results showing resistance, with no documented justification. Another resident received Amoxicillin for a UTI without lab confirmation or meeting infection criteria, and was not evaluated by a physician or CNP. These actions violated the facility's policy requiring antibiotics to be selected based on culture data and documented rationale.
The facility failed to administer the influenza vaccine to a resident and the pneumococcal vaccine to another, despite both having consented. The residents had various medical conditions, including diabetes and dementia. Interviews confirmed the vaccines were not given, and the facility did not follow its policy requiring documentation and administration of vaccines.
A resident with multiple medical conditions requested access to his medical records, but the facility failed to provide timely access. Despite signing authorization forms, the facility delayed initiating the process and did not offer the option to review documents online. An invoice was provided seven days after the request, contrary to the facility's policy.
The facility failed to follow physician orders for pain medication and wound care for two residents. One resident received incorrect doses of Oxycodone based on their pain levels, as confirmed by an LPN and the DON. Another resident returned from the hospital with a foot wound, but necessary wound care orders were not immediately placed, leading to a delay in care. These deficiencies were acknowledged by the facility's staff.
Unsafe Hoyer Lift Transfer and Failure to Perform Required Safety Checks
Penalty
Summary
The deficiency involves the facility’s failure to ensure safe Hoyer lift transfer practices and adherence to established procedures for a resident who required total assistance with transfers. The resident had multiple diagnoses, including essential hypertension, type II diabetes mellitus, osteoarthritis, bilateral knee contractures, dementia, and a documented need for assistance with personal care. The resident’s MDS showed dependence for chair/bed-to-chair transfers, and the care plan called for transfers using a mechanical lift with three helpers. During an observed Hoyer lift transfer, one CNA operated the lift while the other CNA secured the resident in the sling. As the resident was raised and suspended in the air, one CNA removed the wheelchair from beneath the resident and moved it away. The observation further showed that after moving the wheelchair, the second CNA went to the opposite side of the bed, leaving the resident suspended in the Hoyer lift without anyone guiding or stabilizing the resident in the sling toward the bed. In a subsequent interview, both CNAs and an LPN confirmed that staff did not provide support to the resident while the resident was suspended in the lift. When questioned about the process before initiating use of the Hoyer lift, the CNAs were unable to verbalize how to inspect the lift or assess the sling for safety prior to use and confirmed that this inspection process had not been completed. Review of the manufacturer’s manual and the facility’s Hoyer lift transfer policy showed that slings should be inspected before each use and that one person should stabilize the lift while a second person guides and stabilizes the resident and sling during transfer, which did not occur in this instance.
Failure to Perform Hand Hygiene After Incontinence Care
Penalty
Summary
Surveyors identified a deficiency in the facility’s infection prevention and control program related to hand hygiene during incontinence care for Resident #71. Resident #71 was admitted on 12/27/23 with diagnoses including essential hypertension, type II diabetes mellitus without complications, osteoarthritis, contractures of both knees, need for assistance with personal care, unspecified dementia, and other cognitive symptoms, and had a BIMS score of 10. The resident’s MDS dated 01/03/26 documented that she was dependent on staff for toileting hygiene. On 03/04/26 at 11:50 A.M., during observed incontinence care, CNA #97 completed the care and then handed the resident her call light while still wearing the same gloves used during the incontinence care. In an interview at 11:56 A.M. the same day, CNA #97 confirmed that she did not perform hand hygiene after completing the incontinence care and had handed the call light to the resident while wearing soiled gloves. The facility identified 20 residents who required assistance with incontinence care, indicating the potential scope of this deficient practice. This deficiency was based solely on the observed failure of CNA #97 to remove gloves and perform hand hygiene after providing incontinence care and before touching the resident’s call light, as well as the facility’s identification of multiple residents requiring similar care.
Noncompliant Food Handling, Hand Hygiene, and Portioning During Meal Service
Penalty
Summary
Surveyors identified a deficiency in sanitary food preparation and handling affecting 85 residents who received meals from the facility kitchen. During a lunch tray service, one dietary staff member was observed placing plates into insulated plate bases without wearing a hair net. This staff member later confirmed not wearing a hair net during lunch service, despite a facility policy requiring all employees in the kitchen to wear hair restraints that cover all hair to prevent physical contamination of food. In a separate observation during the same meal service, the dietary manager was seen touching her own face and then continuing to serve trays without performing hand hygiene. She confirmed she did not perform hand hygiene during lunch tray service, contrary to the facility’s hand hygiene policy, which requires all staff to perform proper hand hygiene procedures to prevent the spread of infection. Additional observations during the same lunch period showed another dietary staff member not fully filling a 3/4 cup scoop of beef stroganoff, leaving about 1/4 inch of space when serving residents who required a regular portion size. The dietary manager acknowledged that it is difficult to level some items when serving. The facility did not provide a policy regarding meal portion sizes. The facility census at the time was 87, with two residents identified as NPO, and the remaining 85 residents receiving food from the kitchen were affected by these practices. This deficiency was investigated under Master Complaint Number 2718652.
Failure to Report Resident-to-Resident Sexual Abuse Allegation to State Agency
Penalty
Summary
The facility failed to ensure an allegation of resident-to-resident sexual abuse was submitted to the appropriate state agency as required by its abuse, neglect, and exploitation policy. A resident with cognitive communication deficit, anxiety disorder, mood disorder, and a moderately impaired BIMS score of 10 reported to the Social Worker and Nurse Manager that another resident had entered her room, discussed buying her a drink and having food in his room, and then, after she went to his room, grabbed her breast. She further reported that he later came into her room again, playing pornography on his phone and touched her breast a second time. A nursing progress note documented that a head-to-toe assessment was completed, that the resident denied pain and declined a room change, and that the Medical Director, CNP, power of attorney, Administrator, regional staff, and DON were notified, as well as the county sheriff’s office. The alleged perpetrator was a resident with intact cognition (BIMS 15), no upper or lower extremity impairments, and a care plan documenting sexually inappropriate behaviors, including perceiving relationships with peers as more sexually oriented than they actually were and touching behaviors. His care plan included interventions such as limiting at-risk situations, redirecting him from entering other residents’ rooms without permission, and providing 1:1 care, which had been initiated prior to the survey. During interview, the DON acknowledged that there was a self-reported incident (SRI) for the sexual abuse allegation but confirmed it was not submitted to the proper state agency. The Administrator and DON stated that a complete investigation had been done but not submitted because the Administrator became distracted while entering the report and failed to hit the submit button, later deciding, after consulting corporate staff, not to submit it since it would be considered late. The facility’s written policy required reporting all alleged violations to the Administrator, state agency, adult protective services, and other required agencies within specified time frames, which did not occur in this case.
Failure to Perform Hand Hygiene During Incontinence Care
Penalty
Summary
Surveyors identified a deficiency in the facility’s infection prevention and control program related to hand hygiene during incontinence care for Resident #374. The resident, admitted on 11/27/23, had multiple medical diagnoses including unspecified dementia (moderate with psychotic disturbance), moderate protein-calorie malnutrition, essential hypertension, hyperlipidemia, anxiety, depression, atrial fibrillation, history of transient ischemic attack and cerebral infarction without residual deficits, dysarthria and anarthria, low back pain, and irritable bowel syndrome with constipation. A quarterly MDS dated 01/09/26 documented a BIMS score of 6/15 and dependence on staff for toileting hygiene. The care plan noted frequent bladder and bowel incontinence, goals for meeting toileting needs and maintaining grooming and freedom from odors, and interventions including incontinence care with each episode, application of moisture barrier, and staff assistance with all ADLs including toileting hygiene. On observation, CNA #313 and RN #255 provided perineal care to Resident #374. CNA #313 pulled the curtain, performed hand hygiene, donned PPE, prepared wash basins, then again performed hand hygiene and applied clean gloves before removing the resident’s brief and performing perineal care. After washing and drying the perineal area, CNA #313, with assistance from RN #255, turned the resident, washed and dried the buttocks, applied barrier cream, and placed a new brief. Without removing gloves or performing hand hygiene, CNA #313 then handed the resident her baby dolls using the same gloves that had been used during incontinence care. In a subsequent interview, CNA #313 confirmed not performing hand hygiene and not changing gloves during the incontinence care. Review of facility policies on Hand Hygiene and Perineal Care confirmed that staff are required to perform hand hygiene when moving from a contaminated body site to a clean body site, after handling items potentially contaminated with body fluids, and to remove gloves and perform hand hygiene after perineal care.
Failure to Maintain Clean, Safe, and Comfortable Environment
Penalty
Summary
The facility failed to maintain a clean, safe, and comfortable living environment for its residents, as evidenced by multiple observations of environmental deficiencies throughout several hallways and common areas. Surveyors noted large stains on ceiling tiles, cracked and debris-filled light fixtures, peeling and unfinished ceiling drywall, damaged paint, and visible dust accumulation on ceiling vents. Damaged drywall was observed in several locations, including areas where hand sanitizer dispensers had been removed. These issues were present in various hallways and outside multiple resident rooms, as well as in common areas such as the resident lounge and near the beauty shop. All concerns remained unaddressed during a follow-up observation later the same day. Interviews with the Administrator and housekeeping leadership confirmed the presence of these environmental and maintenance concerns. The Administrator reported that the Director of Maintenance was on leave and a newly hired assistant was still in orientation, resulting in minimal resources to address maintenance issues. The Director and Assistant Director of Housekeeping acknowledged that cleaning light fixtures and vents was their responsibility, while drywall and ceiling repairs were referred to maintenance. Review of facility policy indicated that both housekeeping and maintenance services are required to maintain a sanitary, orderly, and comfortable environment.
Failure to Accurately Complete and Submit Discharge MDS Assessment
Penalty
Summary
The facility failed to ensure that the discharge Minimum Data Set (MDS) 3.0 assessment for one resident was completed accurately and that a correction was submitted in a timely manner to reflect the resident's actual discharge disposition. The resident, who had multiple diagnoses including hypertension, cognitive communication deficit, depression, polyneuropathy, chronic pain, dementia, GERD, benign prostatic hyperplasia, acquired absence of the right leg above the knee, and schizoaffective disorder, was admitted on 06/17/19. On 03/02/25, the resident was transported to a local hospital by critical transport, and the power of attorney was notified. The discharge MDS assessment completed on the same day was coded as 'discharge - return anticipated' and marked as an unplanned discharge. However, documentation indicated that the resident was discharged to the hospital with the intention of going home on hospice services, meaning the discharge should have been coded as 'return not anticipated.' No correction to the MDS assessment was completed at the time to accurately reflect this disposition.
Failure to Maintain Clean Pressure-Reducing Devices for Resident with Pressure Ulcer
Penalty
Summary
The facility failed to ensure that pressure-reducing devices, specifically heel-elevating boots, were free from soil for a resident with significant medical conditions, including acute respiratory failure, diabetes, severe malnutrition, sepsis, and a stage 2 pressure ulcer on the left heel. The resident's care plan included the use of air mattress and boots on both feet to prevent further skin breakdown, with regular wound care and monitoring. Despite these interventions, observations during wound care revealed that both boots had visible staining on the exterior bottom portion, with ring-like formations and pink discoloration, as well as shadowing or discoloration inside the right boot. The dressing on the resident's left heel was saturated with pale yellow drainage, but there was no evidence of seepage into the boot at that time. Subsequent observations confirmed that the boots remained soiled over multiple shifts, and interviews with nursing staff and the DON acknowledged the presence of staining and the need for new or laundered boots. The failure to maintain clean pressure-reducing devices was directly observed and confirmed by staff, affecting the resident who was dependent on staff for hygiene and at high risk for skin impairment.
Failure to Ensure Staff Wore Name Badges as Required
Penalty
Summary
The facility failed to ensure that staff consistently wore name badges as required by the facility's uniform policy. Observations revealed that a Certified Nurse Assistant and an Activities Aide were not wearing name badges, with both confirming during interviews that they either never received a permanent badge or had lost theirs and were relying on temporary sticker badges that frequently fell off. Multiple residents reported that staff rarely wore name badges, making it difficult for them to identify who was providing their care. The Administrator acknowledged responsibility for ensuring compliance with the name badge policy, and the Human Resource Manager admitted to not printing permanent badges for several months or longer. Review of the facility's uniform policy confirmed that name badges are required to be worn at all times.
Failure to Provide Scheduled and Evening Activities for Residents
Penalty
Summary
The facility failed to ensure that scheduled activities were completed and that evening activities were provided for residents. Multiple residents reported that scheduled activities rarely occurred as posted, with activity materials simply left out for residents to use independently. Observations confirmed that scheduled activities, such as the 'move and groove' session, were not conducted at the designated times, and no activity staff were present in the activities room during these periods. Residents were observed waiting for scheduled activities that did not take place, and the Activities Recreation Director was unable to explain why the activities were not occurring as planned. Further review revealed that there were no scheduled activities after 2:00 P.M. on weekends and after 4:00 P.M. on weekdays, leaving residents without structured engagement during these times. The Activities Recreation Director confirmed that no evening activities were scheduled, as the activities department left for the day and no other staff facilitated activities in their absence. The facility's policy stated that activities should encourage independence and interaction, but the lack of scheduled and conducted activities affected 92 out of 93 residents who participate in activities.
Failure to Complete Staff Performance Evaluations
Penalty
Summary
The facility failed to complete staff performance evaluations as required, which had the potential to affect all 88 residents. A review of personnel records for two Certified Nursing Assistants (CNAs) revealed that they did not have a completed 90-day performance evaluation. An interview with the Visiting Administrator confirmed that there was no evidence to support that these evaluations were completed as required.
Facility Fails to Maintain Kitchen Equipment
Penalty
Summary
The facility failed to maintain the kitchen's steam warmer and two-compartment sink in a safe and operational condition, potentially affecting 85 residents. During an observation, a strong odor of sewage was detected from the two-compartment sink, which was empty at the time. This was verified by a dietary aide. Additionally, the steam oven was observed to be leaking water from the bottom left side of the door, with the water dripping into a metal bin that needed to be emptied every one to two hours. A staff member confirmed the issue with the steamer and stated it had been reported to corporate in November 2024. Interviews with the facility's administrator and maintenance director revealed that the steam oven had been replaced once before, and the maintenance director was aware of the water leak and the odor in the kitchen. The maintenance director attempted to snake the drains under the sink three weeks prior, but the odor persisted. After surveyor intervention, a plumber was called to service the drains, and it was determined that the odor was coming from floor drains due to a grease interceptor not being properly cleaned. The plumber's work receipt indicated that the kitchen sink drain was cleaned to remove a clog, and it was recommended that all drains be cleaned and the pumps be pumped.
Infection Control Deficiencies in LTC Facility
Penalty
Summary
The facility failed to implement Enhanced Barrier Precautions (EBP) for a resident with a feeding tube, as well as failed to follow infection control procedures during wound care and catheter care for several residents. Specifically, a Certified Nursing Assistant (CNA) did not use personal protective equipment (PPE) while providing catheter care to a resident, and did not follow proper hand hygiene protocols. The CNA also incorrectly used an alcohol swab on the indwelling urinary catheter, moving it up and down instead of using a circular motion from the insertion site down. In another instance, a Licensed Practical Nurse (LPN) did not separate wound care for two different wounds on a resident's buttocks, potentially increasing the risk of infection. The LPN also failed to wash or sanitize hands between glove changes during the procedure. Similarly, another LPN did not follow proper hand hygiene protocols while providing treatment to a resident with a stage IV pressure ulcer, and did not separate the treatment of different wound sites, which could lead to cross-contamination. Additionally, the facility did not implement enhanced barrier precautions for a resident with a PEG tube, despite the resident's care plan indicating the need for such precautions. Observations over several days confirmed the absence of these precautions, and interviews with nursing staff verified that enhanced barrier precautions should have been in place but were not implemented. This oversight was a violation of the facility's infection control procedures, which require adherence to standard precautions for residents with high infection risks.
Lack of Written Responses to Resident Council Concerns
Penalty
Summary
The facility failed to document in writing its responses and rationale to grievances and recommendations made by the Resident Council. This deficiency was identified through interviews and a review of Resident Council meeting notes, which revealed that while concerns were discussed during meetings, there was no documentation from the administration addressing these concerns. The Resident Council President was unaware of any written responses to the issues raised, and the Activity Director reported that concerns were communicated during daily administrative meetings but did not receive written resolutions. The Social Service Designee and the Administrator confirmed the absence of a resolution form for concerns raised at Resident Council meetings, although individual problems were recorded on grievance forms. Additionally, the facility lacked a policy specifically for Resident Council Meetings.
Failure to Notify Physician of Significant Weight Loss
Penalty
Summary
The facility failed to notify the physician after a significant weight change occurred for a resident, identified as Resident #66. The resident had a history of type 2 diabetes, metabolic encephalopathy, and unspecified dementia, and was noted to have moderate cognitive impairment. The Minimum Data Set (MDS) indicated weight loss concerns, and the care plan included interventions for maintaining adequate nutritional status. Despite these measures, the resident experienced multiple significant weight losses over a period of time, with no evidence of physician notification after the initial weight loss was reported in December 2023. The dietary progress notes indicated that the physician was notified of a significant weight loss in December 2023, with a recommendation for weekly weights. However, no further notifications were made regarding subsequent weight losses. An interview with the dietician revealed that she only notified the physician of the initial weight loss and did not report continuous trends of weight loss. The facility's policy required contacting the resident's physician regarding any significant changes, which was not adhered to in this case.
Failure to Investigate and Resolve Resident Grievances
Penalty
Summary
The facility failed to complete a timely and thorough grievance investigation and resolution for a resident's grievances. The resident, who had a BIMS score indicating no cognitive impairment, had multiple chronic conditions and required moderate assistance with showers. The grievance logs from September to December revealed several incidents of missing items and a cracked phone, but investigations were either not conducted or not documented properly. The grievance logs lacked signatures, and some investigation reports were missing entirely. Interviews with the social worker and the administrator confirmed that the investigations for the resident's grievances were not completed. The administrator admitted to misplacing all copies of the concern logs and could not provide the originals. The facility's grievance policy requires investigations to be completed within seventy-two hours and results communicated within seven days, but this was not adhered to in the resident's case.
Failure to Develop Comprehensive Care Plans for Residents
Penalty
Summary
The facility failed to develop a comprehensive plan of care for three residents, leading to deficiencies in addressing their specific medical needs. Resident #10, who was dependent on a non-invasive ventilator due to chronic obstructive pulmonary disease (COPD) and other complex medical conditions, did not have a care plan that addressed the use of oxygen therapy. Despite having physician orders for oxygen use, the resident's plan of care lacked specific interventions related to oxygen management, as confirmed by the Director of Nursing (DON). Resident #69, with a history of cerebral infarction and a tracheostomy, also lacked a comprehensive care plan addressing tracheostomy management. Although the resident's plan of care included interventions for respiratory status and tracheostomy care, it was not comprehensive enough to cover all aspects of the resident's needs, such as the use of humidified oxygen and tracheostomy suctioning. The DON verified the absence of a complete care plan for the resident's tracheostomy. Resident #18, who had multiple diagnoses including diabetes mellitus and paraplegia, did not have a care plan addressing poor dental status. The resident's admission assessment inaccurately reported the condition of the resident's teeth, which were observed to be in poor repair with obvious caries. Despite the resident's consent to receive dental services, there was no care plan in place to address the dental issues, as confirmed by the DON.
Failure to Invite Family to Care Conferences
Penalty
Summary
The facility failed to invite the family or resident representatives to care conferences for two residents, which was identified during a survey. Resident #50, who has severe cognitive deficits and multiple diagnoses including Alzheimer's disease, was admitted on an unspecified date. The review of Resident #50's care conference summary revealed that the Health Care Power of Attorney was not invited to the care conference held on 07/11/24. Interviews with the family representative and the Social Services Designee confirmed the lack of invitation and documentation for the care conferences held in July and October 2024. Similarly, Resident #70, who has a BIMS score indicating mild cognitive impairment and is blind, was also affected. The review of the Minimum Data Set (MDS) assessment and care conference records showed no documentation of who was invited or attended the care conferences held in April and September 2024. The Social Worker confirmed that the care conferences were reviewed but not updated, and the only documentation available was in the PointClickCare system. The facility's policy requires notifying residents and their representatives about care conferences, but this was not adhered to in these cases.
Failure to Provide Routine Nail Care for Dependent Resident
Penalty
Summary
The facility failed to provide routine nail care for a resident who was dependent on staff for activities of daily living (ADL). The resident, identified as Resident #10, had a complex medical history including COPD, severe protein calorie malnutrition, diabetes mellitus, and dependence on a respiratory ventilator, among other conditions. The resident's care plan indicated a need for assistance with ADLs due to weakness, depression, and cognitive issues, and specified that the resident was totally dependent on staff for tasks such as hygiene and grooming. Observations made over several days revealed that the resident's nails were long, jagged, and dirty with a brown substance, indicating a lack of proper nail care. These observations were confirmed by an LPN during an interview. The facility's policy on resident care, which includes routine personal hygiene such as nail care, was not adhered to in this instance, resulting in the deficiency noted by the surveyors.
Failure to Implement Physician-Ordered Skin Interventions
Penalty
Summary
The facility failed to ensure that off-loading skin interventions were in place as ordered by the physician for a resident with pressure ulcers. The resident, who was admitted with multiple diagnoses including COPD, severe protein calorie malnutrition, diabetes mellitus, and dependence on a respiratory ventilator, was identified as having a high risk for skin breakdown. Despite the resident's care plan, which included the use of Prevalon boots to prevent further skin impairment, these boots were not observed to be in place during multiple observations. The resident's care plan detailed several interventions to manage and prevent pressure ulcers, including the use of a bariatric pressure-reducing mattress, pressure-reducing boots, and a gel cushion for the wheelchair. The resident was also encouraged to turn and reposition frequently and to limit time in the wheelchair. Despite these measures, the resident developed a deep tissue injury on the right outer heel, which was monitored and noted to have improved over time. However, the absence of the Prevalon boots, as ordered by the physician, was a significant oversight in the resident's care. Observations on consecutive days revealed that the Prevalon boots were not in place, and this was confirmed by an LPN. The lack of adherence to the physician's orders for the use of Prevalon boots represents a deficiency in the facility's care for the resident, potentially impacting the resident's skin integrity and overall health condition.
Failure to Replace Enteral Feeding Bag Timely
Penalty
Summary
The facility failed to provide appropriate enteral feeding services for a resident, identified as Resident #189, who was dependent on a PEG tube for nutrition. The resident had multiple complex medical conditions, including severe protein-calorie malnutrition and dysphagia, necessitating the use of a feeding tube. According to physician orders, the resident was to receive enteral feeding via a Kangaroo pump with specific instructions for the rate and volume of feeding, as well as daily replacement of the feeding bag at 6:00 P.M. However, an observation revealed that the Glucerna bag was not replaced until 1:00 A.M. the following day, resulting in the resident missing 7 hours of nutrition. Interviews with the LPN confirmed the oversight, attributing it to a lack of proper handoff from the night shift and the absence of documentation justifying the delay. The facility's policy on the care and treatment of feeding tubes mandates adherence to physician orders and monitoring of the feeding tube's placement and function. The failure to replace the feeding bag as scheduled led to a significant lapse in the resident's nutritional care, as the resident typically went without feeding from 2:00 P.M. to 6:00 P.M., with the new feed expected to start at 6:00 P.M.
Deficiencies in Respiratory Care Equipment Availability
Penalty
Summary
The facility failed to ensure the provision of appropriate respiratory care equipment for three residents, leading to deficiencies in their care. Resident #10, who had a complex medical history including chronic obstructive pulmonary disease (COPD) and dependence on a non-invasive ventilator, did not have their nasal cannula oxygen delivery tubing dated as required. Observations over several days confirmed that the tubing remained undated, and interviews with staff verified that the facility's protocol for changing and dating the tubing was not followed. Additionally, the resident's care plan lacked a specific plan addressing their oxygen use. Resident #69, who had a tracheostomy and was at risk for respiratory complications, did not have a spare tracheostomy cannula at the bedside for emergency use. During a tracheostomy care procedure, it was observed that the ambu bag, which is essential for emergency situations, was not easily accessible. Interviews with staff confirmed the absence of the spare tracheostomy cannula and the inaccessibility of the ambu bag, which contradicted the facility's policy requiring these items to be readily available. Resident #9, who also had a tracheostomy and required respiratory support, was found to be missing an ambu bag in their room. The resident confirmed that the ambu bag had been used previously and not replaced. Interviews with the Director of Nursing and a Regional Registered Nurse confirmed the oversight and acknowledged that the ambu bag should have been available in the resident's room for emergencies. These deficiencies highlight lapses in the facility's system for ensuring the availability of necessary respiratory care equipment.
Incomplete Dialysis Records for Resident
Penalty
Summary
The facility failed to maintain complete dialysis communication and records for a resident requiring dialysis services, affecting the quality of care provided. The resident, who was cognitively intact, had a complex medical history including end-stage renal disease, emphysema, chronic obstructive pulmonary disease, and other significant health conditions. The resident was scheduled for dialysis three times a week, but the facility's records were missing critical weight information on multiple occasions, which is essential for proper dialysis management. Upon review, it was found that the facility did not have the necessary dialysis records on-site, and the missing information was only obtained after the facility requested it from the dialysis center. Interviews with facility staff and the dialysis center representative confirmed that the facility had not received the required records from the dialysis center in a timely manner, leading to incomplete documentation of the resident's dialysis care.
Failure to Monitor Psychotropic Medications
Penalty
Summary
The facility failed to properly monitor a resident's psychotropic medications, specifically regarding the need and appropriate dosage. This deficiency was identified during a review of medical records and staff interviews. The resident in question, who was admitted with multiple diagnoses including schizoaffective disorder, dementia, and major depressive disorder, was prescribed several psychotropic medications. These included Olanzapine, Depakote, Fluphenazine, and Venlafaxine. Despite the requirement for a gradual dose reduction (GDR) for psychotropic medications, only one recommendation for a GDR was made for Fluphenazine in January 2024, which the physician decided against implementing. No other GDR recommendations were made for the resident's other psychotropic medications over the past year. The Regional Nurse confirmed that the pharmacy reviews each resident's psychiatric notes to determine if any recommendations for irregularities, including GDRs, are necessary. However, it was acknowledged that the pharmacy did not complete any GDR recommendations for the resident's psychotropic medications, aside from the one for Fluphenazine. This oversight indicates a failure to adhere to the facility's policies and procedures for monitoring and managing psychotropic medication regimens, potentially impacting the resident's mental health management.
Failure to Monitor Medication Administration Parameters
Penalty
Summary
The facility failed to ensure adequate monitoring of a medication regimen for a resident, leading to the administration of Entresto outside the prescribed parameters. The resident, who had a history of chronic systolic heart failure, hypertension, and other significant health conditions, was prescribed Entresto with specific instructions to hold the medication if the systolic blood pressure (SBP) was below 110 mmHg or the heart rate was below 60 bpm. Despite these instructions, the medication was administered on multiple occasions when the resident's SBP was below the threshold, as confirmed by the Medication Administration Records (MAR). The Director of Nursing (DON) acknowledged that the facility's practice allowed for nursing discretion to administer Entresto if readings were only slightly outside the parameters, although there was no documented evidence of this rule in the resident's medical record or facility policies. The DON confirmed that the medication was given outside the prescribed parameters and that there was no evidence of staff notifying the physician before administering the medication under these circumstances. A written statement from the physician later confirmed the nursing discretion rule, but this was the first documented evidence of such a practice.
Inadequate Monitoring and Documentation of Psychotropic Medication Use
Penalty
Summary
The facility failed to properly monitor and document the behaviors of a resident with severe cognitive impairment, leading to an inappropriate increase in psychotropic medication. The resident, who was diagnosed with schizoaffective disorder among other conditions, was prescribed an increased dose of Olanzapine from 10 mg to 15 mg without documented justification. The behavior logs from September to December 2024 showed no recorded behaviors that would warrant such an increase, despite the resident's claims of pregnancy and trouble sleeping. Interviews with the Regional Nurse confirmed the absence of documented behaviors to support the medication increase. The psychiatrist's notes indicated the resident was answering non-sensically and had trouble sleeping, but there were no reports of aggression or irritability. The facility's failure to document and justify the medication change highlights a deficiency in monitoring and managing the resident's psychotropic medication needs.
Delay in Urine Sample Collection for UTI
Penalty
Summary
The facility failed to ensure the timely collection of a urine sample for a urinary tract infection (UTI) as ordered for a resident. The resident, who had multiple diagnoses including acute respiratory failure, type II diabetes, and bladder-neck obstruction, was dependent on a wheelchair and required assistance with personal care. The resident had an indwelling catheter and was frequently incontinent. On a specific date, a nursing note indicated mucus in the urine, and a physician's order was placed for a urine culture and sensitivity. However, the sample was not collected until three days later, delaying the availability of lab results and the initiation of appropriate treatment. The delay in collecting the urine sample was confirmed by the Director of Nursing, who acknowledged there was no justification for the three-day delay. The facility's Diagnostic Testing Services Policy requires that diagnostic tests be performed in accordance with physician orders and that results be communicated to the ordering physician within 24 hours of receipt. Despite these guidelines, the delay in sample collection resulted in a failure to provide timely diagnostic services, impacting the resident's care.
Failure to Provide Timely Dental Services
Penalty
Summary
The facility failed to ensure that a resident's oral assessments were accurate and that dental services were arranged to address the resident's poor dental status. The resident, who had multiple medical diagnoses including diabetes mellitus, paraplegia, and major depressive disorder, was admitted with his own teeth in good/fair repair. However, subsequent assessments revealed that the resident had broken, chipped, or carious teeth. Despite these findings, the resident's oral assessment inaccurately indicated no issues with his natural teeth, and the resident reported requesting dental services multiple times without receiving them. Interviews with facility staff confirmed that the resident had not seen the facility's contracted dentist, even though the dentist had visited the facility. The resident expressed a desire to see a community dentist but was informed that he would need to arrange his own transportation. The facility's policy on dental services stated that it would assist residents in obtaining routine and emergency dental care, but this was not adhered to in the case of this resident. The Director of Nursing verified that the admission assessment did not accurately reflect the resident's dental status.
Failure to Follow Antibiotic Stewardship Processes
Penalty
Summary
The facility failed to adhere to its antibiotic stewardship processes for two residents, resulting in inappropriate antibiotic prescriptions. For Resident #81, despite lab results indicating resistance to Bactrim, the antibiotic was prescribed and administered for a urinary tract infection (UTI) without documented justification. The Director of Nursing confirmed the lack of rationale for the choice of Bactrim, which contradicted the facility's policy requiring antibiotics to be selected based on culture and susceptibility data. The policy also mandates documentation of the rationale for antibiotic selection, especially when resistance is indicated, which was not followed in this case. For Resident #43, the facility administered Amoxicillin for a UTI without verifying the presence of an infection through lab results or meeting McGreer's criteria for infection. The resident returned from the hospital with an antibiotic order, but the facility failed to obtain necessary lab results to confirm the UTI diagnosis. Additionally, there was no evidence of a physician or Certified Nurse Practitioner evaluating the resident to ensure the appropriateness of the antibiotic order. The facility's policy requires reassessment of antibiotic need and documentation of an antibiotic time-out, which was not completed for this resident.
Failure to Administer Vaccines After Consent
Penalty
Summary
The facility failed to administer the influenza vaccine to one resident and the pneumococcal vaccine to another resident, despite both residents having consented to receive these vaccinations. Resident #20, who had medical diagnoses including Type II Diabetes Mellitus, vascular dementia, and cognitive communication deficit, was admitted initially in January and readmitted in March. The resident's representative consented to the influenza vaccine in October, but there was no evidence in the medical record that the vaccine was administered. Similarly, Resident #6, with medical conditions such as secondary parkinsonism, aphasia, and dementia, consented verbally to receive the pneumococcal vaccine in October, yet there was no documentation of the vaccine being given. Interviews with the Regional Nurse confirmed that both residents did not receive their respective vaccines after consent was obtained. The facility's policy, revised in June, stated that residents should be offered the influenza vaccine annually and the pneumococcal vaccines as recommended by the CDC upon admission. The policy also required documentation of the education provided to residents and their representatives about the benefits and potential side effects of the vaccines, as well as whether the immunizations were administered. However, the facility failed to adhere to this policy for the two residents in question.
Failure to Provide Timely Access to Medical Records
Penalty
Summary
The facility failed to provide a resident, who was cognitively intact, with timely access to his medical records. The resident, who had multiple complex medical conditions including end stage renal disease, emphysema, and major depressive disorder, requested access to his medical records on September 20, 2024. Despite signing the necessary authorization forms, the facility did not initiate the process of collecting the records or offer the resident the option to review his documents online. An invoice for the records was not provided to the resident until September 27, 2024, seven days after the initial request. The facility's policy stated that upon receipt of a request for medical record copies, the requesting party should be notified in writing of the cost and that records would be available two days after payment. However, the facility did not discuss the option of allowing the resident to view his records, and the delay in providing the invoice contributed to the deficiency.
Failure to Follow Physician Orders for Pain and Wound Care
Penalty
Summary
The facility failed to adhere to physician orders for as-needed pain medication administration for a resident with multiple complex diagnoses, including end-stage renal disease and chronic respiratory failure. The resident was prescribed Oxycodone with specific dosing instructions based on pain levels. However, the Medication Administration Records revealed several instances where the administered dose did not match the prescribed dose according to the resident's reported pain levels. This discrepancy was confirmed by both an LPN and the Director of Nursing, indicating that the pain medications were given outside the parameters set by the physician orders. Additionally, the facility did not follow wound care orders for another resident who returned from the hospital with a noted foot wound. Upon return, a complete assessment was conducted, but the necessary wound care orders were not immediately placed. The Director of Nursing confirmed that the wound on the resident's foot was not addressed upon return, and there were no new orders in place for wound care until two days later. This delay in implementing wound care orders was acknowledged by the facility's staff, highlighting a lapse in the coordination of care following the resident's discharge from the hospital.
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A resident with intact cognition receiving Medicare Part A skilled services for metabolic encephalopathy had services discontinued while benefit days remained, but the facility did not issue the required Skilled Nursing Facility Advance Beneficiary Notice (SNF ABN). The Social Services Director later confirmed that no SNF ABN was provided and reported she believed only a Notice of Medicare Non-Coverage (NOMNC) was needed when all skilled services were stopped. This practice conflicted with the facility’s written policy, which required SNF ABNs to be issued when extended care items or services were initiated, reduced, or terminated due to expected non-coverage by Medicare.
Surveyors identified that the facility exceeded the acceptable medication error rate when two residents with type 2 DM received insulin doses that were not administered according to orders or manufacturer instructions. In two separate observations, an LPN administered Novolog and another LPN administered insulin glargine and insulin lispro without priming the insulin pens, and the insulin lispro and Novolog were given after the residents had already consumed a significant portion of their breakfast meals, despite orders for administration before meals. Manufacturer information for both insulin products required priming before each injection to ensure accurate dosing, and facility policy required medications, including insulin, to be administered safely, timely, and in accordance with prescriber orders and specified time frames.
Surveyors found that the facility failed to document tray line food temperatures for multiple meals served from two dining room kitchenettes, despite having a “Trayline Taste & Temperature Log” and a policy requiring food to be stored, prepared, distributed, and served according to professional food safety standards. Review of logs showed repeated missing entries for breakfast, lunch, and dinner services in both the Harrison and McClellan dining areas, and the Senior Director of Culinary Services confirmed that temperatures had not been recorded for those meals, potentially affecting all residents receiving meals from those kitchenettes.
The facility failed to conduct and document required periodic care conferences for two residents, despite multiple comprehensive, quarterly, and significant change MDS assessments and a policy requiring periodic care conferences with resident and/or family participation. One resident with Parkinson’s disease, post-stroke hemiplegia, TIA, DMII, and depression had only two documented care conferences over a year, while another resident with aphasia, cerebrovascular disease, DMII, gait difficulty, coagulation defect, depression, and muscle weakness had no documented care conferences in the past year, aside from a declined invitation to the representative. The UCC confirmed that care conferences were expected to occur quarterly and that no additional documentation existed for either resident.
A resident with Alzheimer's disease and type II DM, who required extensive assistance with ADLs and was receiving scheduled Lantus and sliding-scale Humalog, experienced a severely elevated blood glucose level. The on-call provider was notified and ordered an additional dose of lispro insulin with a directive to recheck the blood glucose after administration. Nursing staff administered the extra insulin but did not document any follow-up blood glucose check, and the DON confirmed that this reevaluation was required by the facility's abnormal blood glucose policy and was not completed or documented.
A resident with Parkinson’s disease, dementia, and hypothyroidism was prescribed levothyroxine once daily along with other medications. A consultant pharmacist’s monthly drug regimen review recommended that levothyroxine be given in the morning on an empty stomach, 30–60 minutes before food, per manufacturer instructions. The medical record contained no documented physician response to this recommendation, and the MAR showed the drug scheduled for morning administration while the resident was observed eating breakfast and receiving the medication at the same time. An LPN confirmed administering levothyroxine during the meal, and the DON verified there was no documentation explaining whether or why the pharmacist’s recommendation was or was not followed, resulting in a failure to act on and document the identified irregularity.
A resident with severe cognitive impairment, multiple comorbidities, documented gait and balance abnormalities, and a high fall risk was care planned and assessed by therapy to require contact guard assistance and use of a gait belt for transfers and ambulation. While being assisted by a CNA from a recliner to the bathroom with a walker, the CNA did not apply a gait belt, even though the resident had a known tendency to lean backward when standing. As the CNA reached to open the bathroom door, the resident lost balance and fell backward, striking the back of the head, and was later found by an LPN without a gait belt in place, contrary to the facility’s gait belt policy and the resident’s assessed needs.
A resident with CKD stage five requiring peritoneal dialysis (PD) was admitted with pre-admission physician orders for three daily PD exchanges and monitoring for peritonitis (fever, abdominal pain, cloudy effluent), but these monitoring orders were not entered into the facility’s physician orders. The care plan referenced PD and general monitoring but did not specifically address peritonitis monitoring. Paper PD flowsheets showed incomplete and inconsistent documentation of exchanges and resident condition, including missing condition/comments for individual treatments and no record of one ordered PD exchange. The PD cycler flowsheet lacked effluent descriptions on multiple days. The PD nurse reported facility staff were expected to monitor effluent and symptoms, and the DON confirmed the absence of specific peritonitis monitoring orders, lack of an order for the PD cycler, and documentation gaps, despite a facility policy requiring ongoing assessment and monitoring for complications before, during, and after dialysis treatments.
A nurse was observed preparing multiple oral medications for a resident with depression, traumatic brain injury, anxiety, and impaired cognition by pushing tablets and capsules from unit-dose cards directly into her ungloved hand and then using her fingers to place them into a medication cup. In a follow-up interview, the RN confirmed this practice and acknowledged that the correct procedure is to dispense medications directly from the card into the cup, contrary to the facility’s medication administration policy requiring adherence to good nursing principles and practices.
A resident with Alzheimer’s disease, diabetes, anxiety, significant ADL dependence, and behavioral symptoms was observed seated in a chair positioned against the nursing station with a locked wheelchair placed directly in front, also against the nursing station, effectively restricting movement. An LPN confirmed both wheelchair wheels were locked and that it should not have been placed there, while a CNA stated she had positioned the wheelchair to prepare for lunch, was unable to complete the transfer, and left it in place, acknowledging this was wrong. This arrangement conflicted with the facility’s restraint policy, which prohibits physical restraints except when alternatives are ineffective for treating a medical symptom and defines restraints as devices adjacent to the body that cannot be easily removed and that restrict freedom of movement or access to the body.
Failure to Issue Required SNF ABN When Discontinuing Medicare Part A Services
Penalty
Summary
The deficiency involves the facility’s failure to issue a Skilled Nursing Facility Advance Beneficiary Notice (SNF ABN) when Medicare Part A services were discontinued for a resident who still had available benefit days. The resident was admitted with a diagnosis of metabolic encephalopathy and had intact cognition per the Minimum Data Set assessment. The facility’s own SNF Beneficiary Notification Review documented that Medicare Part A skilled services began on 02/11/26 and the last covered day was 03/11/26, and that the facility initiated discharge from Medicare Part A services before the resident’s benefit days were exhausted. Despite this, no SNF ABN was provided to the resident or the resident’s representative. During interviews, the Social Services Director stated that the SNF ABN was issued hours prior to the last covered day but, upon reviewing her files, confirmed that no SNF ABN had actually been issued for this resident. She further explained that she believed an SNF ABN was only required if one skilled service remained and that if all skilled services were being discontinued, only the Notice of Medicare Non-Coverage (NOMNC) needed to be issued. The Administrator, however, stated that a resident should always receive both a SNF ABN and a NOMNC when Medicare Part A services are discontinued and benefit days remain. Review of the facility’s written policy dated 03/28/23 showed that the facility was required to issue SNF ABNs for initiation, reduction, or termination of extended care items or services when Medicare payment was not expected, which did not occur in this case.
Plan Of Correction
This Plan of Correction is submitted as required under State and Federal law. This Plan of Correction does not constitute an admission on the part of the Facility that the findings cited are accurate, that the findings constitute a deficiency or that the scope and severity regarding the deficiency cited are correctly applied. Any changes to the Facility's policies and procedures should be inadmissible in any proceeding on that basis. Without admitting or denying the validity or the existence of the alleged noncompliance, the Facility submits this Plan of Correction with the intention that it be inadmissible by any third party in any civil or other action against the facility or any employee, agent, officer, director or shareholder of the Facility. The Facility is utilizing this Plan of Correction as its allegation of substantial compliance as of 05/29/2026 F-0582 Corrective action for resident/s: On 5/14/26 Resident #34 was informed of rights and responsibilities related to Advanced Beneficiary Notice and voiced understanding of information for future reference by administrator. Identification of other residents who may be affected: Any resident receiving skilled services from nursing or therapy services. The Administrator audited all residents who were discharged from skilled services in the past 30 days to ensure they were issued a Notice of Non-Coverage and Advanced Beneficiary Notice on 5/29/26. No non-compliance was noted. Measures for systemic change: On 5/14/2026 Business Office Manager, Director of Rehab, Minimum Data Set nurse, Director of Nursing and Social Services Director were educated on proper procedure of issuing of Notice Of Medicare Non Coverage and Advanced Beneficiary Notice by administrator. All upcoming discharges from skilled services will be reviewed weekly at Utilization Review meeting to ensure notices will be delivered timely. How Corrective Action will be monitored: Administrator or designee to complete audits of all residents being discharged from skilled services to ensure they were issued a Notice of Non-Coverage and Advanced Beneficiary. This audit will be completed weekly x 4 weeks, then monthly x 2 months. Corrective action will be initiated for any noted non-compliance. Audit findings will be reviewed as part of the monthly quality assurance process to determine the need for further monitoring. Date of Compliance 5/29/26
Insulin Administration Errors and Failure to Prime Insulin Pens
Penalty
Summary
The deficiency involves the facility’s failure to maintain a medication error rate below 5%, with surveyors identifying 3 errors out of 28 medication administration opportunities, resulting in a 10.71% error rate. For one resident with type 2 diabetes mellitus and moderate cognitive impairment, the physician’s order directed Novolog insulin 10 units via subcutaneous pen-injector to be given before meals. During an observed medication pass, the LPN administered 10 units of Novolog insulin without priming the pen and did so after the resident had already consumed approximately 50% of the breakfast meal. The LPN later confirmed she did not prime the pen and acknowledged that the insulin was ordered to be administered prior to meals. Manufacturer instructions for the Novolog FlexPen specified that an air shot (priming) must be performed before each injection to ensure proper dosing. Another resident, also diagnosed with type 2 diabetes mellitus and with intact cognition, had orders for insulin glargine 35 units subcutaneously twice daily and insulin lispro 20 units subcutaneously before meals, plus 12 units subcutaneously if blood glucose was between 251 mg/dL and 300 mg/dL. During an observed medication administration, an LPN administered 35 units of insulin glargine and 32 units of insulin lispro without priming the insulin pens and after the resident had consumed approximately 90% of the breakfast meal, despite orders for insulin lispro to be given before meals. The LPN later stated she could not remember if she had primed the pen and acknowledged that the insulin was ordered to be administered prior to meals. Manufacturer information for insulin lispro stated that the pen must be primed before each injection to confirm insulin delivery and remove air, and that failure to prime could result in too much or too little insulin. The DON confirmed the expectation that insulin be administered as ordered, including priming each pen with two units before dialing the prescribed dose, and facility policy required medications, including insulin, to be administered safely, timely, and in accordance with prescriber orders and required time frames.
Plan Of Correction
This Plan of Correction is submitted as required under State and Federal law. This Plan of Correction does not constitute an admission on the part of the Facility that the findings cited are accurate, that the findings constitute a deficiency or that the scope and severity regarding the deficiency cited are correctly applied. Any changes to the Facility's policies and procedures should be inadmissible in any proceeding on that basis. Without admitting or denying the validity or the existence of the alleged noncompliance, the Facility submits this Plan of Correction with the intention that it be inadmissible by any third party in any civil or other action against the facility or any employee, agent, officer, director or shareholder of the Facility. The Facility is utilizing this Plan of Correction as an allegation of substantial compliance as of 5/29/2026. F-0759 Corrective action for resident/s: Residents #21 and #22 were assessed and evaluated by nurse and Director of Nursing 5/14/26. Resident #21 and #22 both denied any adverse effects and none were noted upon assessment by the Director of Nursing on 5/14/2026. Notification made to physician on 5/14/2026. LPN # 2 competency Eval on insulin administration with the Director of Nursing completed 5/14/2026. Identification of other residents who may be affected: Diabetic residents on assignment of LPN #2/station 2 have the potential to be affected and were assessed by the DON/Designee on 5/14/26 and found to be within normal limits. Measures for systemic change: All Nurses were educated by the Director of Nursing on the steps for Insulin administration per competency, diabetes clinical protocol policy, Medication and treatment orders policy, administering medications policy, and Obtaining fingerstick Glucose Level policy On 5/14/2026. How Corrective Action will be monitored: Director of Nursing and Assistant Director of Nursing will complete insulin administration audits on 5 nurses. This audit will be completed weekly x 4 weeks, then monthly x 2 months. Corrective action will be initiated for any noted non-compliance. Audit findings will be reviewed as part of the monthly quality assurance process to determine the need for further monitoring. Date of Compliance: 5/29/2026
Failure to Document Tray Line Food Temperatures in Dining Room Kitchenettes
Penalty
Summary
The deficiency involves the facility’s failure to document tray line food temperatures for meals served from the Harrison and McClellan Dining Room kitchenettes, as required by professional standards for food service safety and the facility’s own policy. Review of the “Trayline Taste & Temperature Log” (revised September 2018) showed missing temperature documentation for multiple meals from the Harrison Dining Room kitchenette, including dinner on 03/30/26 and 03/31/26, lunch and dinner on 04/01/26 and 04/02/26, dinner on 04/07/26, and lunch and dinner on 04/08/26 and 04/10/26. The Senior Director of Culinary Services confirmed during interview that tray line food temperatures were not documented on the log for these meals. Similarly, review of the same log for the McClellan Dining Room kitchenette revealed that tray line food temperatures were not documented for dinner on 04/01/26, breakfast and lunch on 04/02/26, and lunch and dinner on 04/07/26. The Senior Director of Culinary Services also verified these omissions during interview. The facility census at the time was 27 residents, and the governing “Food and Nutrition” policy, approved on 09/07/21, stated that the facility must store, prepare, distribute, and serve food in accordance with professional standards for food service safety.
Plan Of Correction
F812 The facility will continue to ensure food temperatures are completed before meals are served for all residents. To ensure compliance with this standard the following measures have been taken: 1. Immediately 4/15/26 culinary supervisor #224 was re-educated by Dietary Manager to this standard and policy "Food and Nutrition" which includes documentation of food temperatures. 2. All dietary staff have been re-educated to the standard and policy "Food and Nutrition" during the month of April 2026. 3. Audits of food temperature documentation to be completed by Dietary Manager 4 x per week for 4 weeks then weekly for 4 weeks. 4. Administrator to validate audits/compliance and provide additional training as needed. Administrator will present to QAPI committee for ongoing monitoring and further direction.
Failure to Conduct and Document Required Care Conferences
Penalty
Summary
The deficiency involves the facility’s failure to complete and document comprehensive care conferences at required intervals in accordance with care plan regulations and facility policy. For one resident with Parkinson’s disease with dyskinesia, cognitive communication deficit, hemiplegia and hemiparesis following cerebral infarction, transient cerebral ischemic attack, type II diabetes mellitus, and major depressive disorder, the record showed multiple MDS assessments over a one-year period, including annual, quarterly, and significant change assessments. However, only two care conferences were documented during the last 12 months, despite the expectation that care conferences be conducted quarterly with the resident and family when possible. The Unit Care Coordinator confirmed that no additional care conference documentation existed for this resident beyond the notes dated 04/21/25 and 01/02/26. A second resident, with diagnoses including aphasia following cerebrovascular disease, cerebral infarction, type II diabetes mellitus, unsteadiness on feet, difficulty in walking, coagulation defect, depression, and muscle weakness, also had multiple MDS assessments completed over the review period, including quarterly and annual assessments. The record contained a note that a care conference was offered to the resident’s representative, who declined to attend, but there was no documentation of any care conferences for the most recent 12 months. The Unit Care Coordinator confirmed that no other care conference documentation was available for this resident. Facility policy stated that periodic care conferences involving the resident, family, and the interdisciplinary team are part of the care planning process, but the required periodic care conferences and corresponding documentation were not completed for these two residents.
Plan Of Correction
THIS PLAN OF CORRECTION SERVES AS BERKELEY SQUARE'S CREDIBLE ALLEGATION OF SUBSTANTIAL COMPLIANCE AS OF June 1, 2026. Without admitting or denying the validity or existence of the alleged deficiencies, Berkeley Square provides the following Plan of Correction: F657 The facility will continue to document completion of care conferences at the required intervals for all residents, including residents #04 & #15. To ensure compliance with this standard the following measures have be taken: 1. The social service designee and the inter- disciplinary team were re-educated by the administrator to the facility policy "Care Conference" on 4/29/26 and verbalized understanding. 2. Care conferences for resident #04 and resident #15 were conducted on or before 4/29/2026 by the interdisciplinary team. 3. Review of all other residents was conducted by the social service designee to validate and ensure that care conference schedule is up to date with timely care conferences scheduled for them on 4/15/2026. Audits of care conferences to be completed weekly for four weeks and then monthly after that by the social service designee. Documentation of the care conference including any identified concerns in the medical record. Administrator to validate audits/compliance and provide additional training as needed. Administrator will present results of these audits to QAPI committee for ongoing monitoring and further direction.
Failure to Reevaluate Blood Glucose After Treatment for Hyperglycemia
Penalty
Summary
The facility failed to ensure that a resident with diabetes received treatment in accordance with professional standards of practice when nursing staff did not reevaluate the resident's blood glucose after treatment for severe hyperglycemia. The resident, admitted with diagnoses including Alzheimer's disease, type II diabetes mellitus, and depression, had physician orders for Humalog insulin on a sliding scale before meals, Lantus insulin 25 units daily, and lisinopril 5 mg daily. The resident required extensive assistance with activities of daily living, including transfers, toileting hygiene, eating, and bathing. On the evening in question, the resident's blood glucose was documented as 532 mg/dL, and the on-call provider was notified. The provider gave a new order to administer an additional 8 units of lispro (Humalog) and to recheck the blood glucose in 30 minutes. The electronic medication administration record showed that the blood glucose of 532 mg/dL was obtained at 9:00 p.m. and that the additional 8 units of lispro were administered at 9:21 p.m. However, there was no documentation in the resident's chart that the blood glucose was rechecked after the additional insulin was given. In an interview, the DON confirmed there was no evidence of reevaluation and verified that, according to the facility's "Abnormal Blood Glucose Procedure" policy, the resident should have been reevaluated and that the evaluation step should have been included in the progress note documentation.
Plan Of Correction
F684 The facility will continue to ensure all residents, including #03, receive treatment in accordance with professional standards of practice and reevaluated for hyperglycemia. To ensure compliance with this standard the following measures have been taken: 1. The director of nursing assessed resident #03, reviewed documentation and orders and found no ill effects immediately 4/16/26. 2. All licensed nurses were re-educated to facility policy "Blood Glucose Monitoring" by the Director of Nursing/designee in April 2026. 3. Audits of like-residents that require blood sugar checks to be completed by the director of nursing/designee two times a week for 4 weeks and then monthly after that to validate correct follow through when there is abnormally high blood glucose result. The Administrator will bring results of these audits to the QAPI committee for ongoing monitoring and further direction.
Failure to Act on Pharmacist Drug Regimen Recommendation for Thyroid Medication
Penalty
Summary
The deficiency involves the facility’s failure to ensure that pharmacy recommendations from the monthly drug regimen review were acted upon and documented for a resident. The resident was admitted with diagnoses including Parkinson’s disease, dementia, and hypothyroidism, and had current physician orders for levothyroxine 150 mcg once daily, buspirone 50 mg twice daily, and losartan 100 mg once daily. A medication regimen review dated 11/25/2025 included a consultant pharmacist recommendation that levothyroxine be administered consistently in the morning on an empty stomach, at least 30–60 minutes before food, per manufacturer instructions. There was no specific physician response in the medical record to this recommendation, and the facility’s policy stated that consulting pharmacist reviews are sent to nursing and addressed with the primary care provider or consulting specialist for review and follow-up. Review of the resident’s medication administration record for April 2026 showed levothyroxine scheduled for 9:00 a.m. On observation, the resident was seen eating breakfast in the dining area at 8:03 a.m., and an LPN reported administering the levothyroxine 150 mcg to the resident while the resident was in the dining area eating breakfast. The DON confirmed there was no evidence in the resident’s medical record explaining why the consultant pharmacist’s recommendation from 11/25/2025 was or was not acted upon. This lack of documented physician review and action on the pharmacist’s identified irregularity constituted noncompliance with the drug regimen review requirements.
Plan Of Correction
F756 The facility will continue to ensure the pharmacy recommendations from the monthly drug regimen review by a licensed pharmacist are acted upon for all residents, including #08. To ensure compliance with this standard the following measures have been taken: 1. Resident #08 was assessed by the registered nurse and med review completed by 4/28/26. After review of resident's drug regime's, it was discovered that resident #8 had 2 separate medication recommendations on the same form, to be reviewed by two separate practitioners, pharmacy has been instructed and agreed to separate meds on individual forms. 2. Licensed nurses re-educated to facility policy "Drug Regimen Review" by Director of nursing/designee in April 2026 and no later than 5/8/26. Licensed nurses are responsible for ensuring the reviews and recommendations are given to the physician for timely review. 3. Review of all other current residents Drug Regimen orders completed by Director of nursing/designee on 4/16/26 to ensure recommendations were followed up on/reviewed by the physician and address concerns if needed. 4. Audit of drug regime recommendations, pharmacy recommendations, and physician follow up to be completed weekly for four weeks by the Director of nursing/designee. Administrator will present results of these audits to the QAPI committee for ongoing monitoring and further direction.
Failure to Use Required Gait Belt During Ambulation Resulting in Resident Fall
Penalty
Summary
The deficiency involves the facility’s failure to ensure that a required gait belt was used while assisting a high fall‑risk resident with ambulation, resulting in a fall with head injury. The resident had multiple diagnoses including metabolic encephalopathy, hypertension, osteoarthritis, muscle weakness, gait and mobility abnormalities, major depressive disorder, anxiety, and visual hallucinations. Admission and subsequent MDS and fall risk assessments documented that the resident was severely cognitively impaired, required moderate to maximal assistance with transfers and ambulation, could not independently come to a standing position, exhibited loss of balance while standing, used an assistive device, and had decreased muscle coordination. The resident had a history of falls prior to admission and was assessed as being at high, later moderate, risk for falls. The resident’s fall care plan identified her as at risk for falls and included interventions such as providing maximum to moderate assistance with transfers and walking short distances, use of a walker and wheelchair, and following the facility’s fall protocol. Therapy notes and care conference documentation indicated that the resident leaned backwards when standing, required contact guard to minimal assistance for bed mobility and transfers, and needed constant verbal cueing for safe sequencing during toilet transfers. The physical therapist confirmed that the resident was to use a gait belt with staff when ambulating, and the DON verified that therapy had assessed the resident as requiring contact guard assistance and a gait belt for ambulation and transfers. On the day of the incident, a CNA was assisting the resident from her recliner to the bathroom using a walker. The CNA walked beside the resident, providing guidance and support, and reported having a hand on the resident while assisting her. As they approached the bathroom door, the CNA reached for the doorknob to open it, and at that moment the resident began to lose her balance and fell backwards to the floor, striking the back of her head. The nurse who responded found the resident on her back at the foot of the bed with her feet near the bathroom, noted a red raised area on the back of the head, and documented that the resident was not wearing a gait belt and that the gait belt was on the dresser. In the facility’s investigative summary and in interviews, the CNA acknowledged that she did not have a gait belt on the resident while ambulating her, despite the resident’s assessed need for hands‑on assistance and gait belt use per facility policy and the resident’s care and therapy plans.
Failure to Implement PD Orders and Monitor Resident Receiving Peritoneal Dialysis
Penalty
Summary
The deficiency involves the facility’s failure to implement pre-admission physician orders for peritoneal dialysis (PD) and to provide ongoing monitoring for a resident with chronic kidney disease (CKD) stage five who required PD. Pre-admission orders dated 11/14/25 specified three daily PD exchanges at 6:00 A.M., 2:00 P.M., and 10:00 P.M., and directed staff to monitor for signs and symptoms of peritonitis, including fever, abdominal pain, and cloudy effluent. These monitoring orders were not entered into the facility’s physician orders. The resident’s care plan noted the need for PD and included general monitoring interventions (labs, signs of bleeding, bacteremia, septic shock, and significant vital sign changes), but did not specifically address the ordered monitoring for peritonitis. Review of PD documentation showed incomplete and inconsistent charting of treatments and resident condition. The paper peritoneal flowsheet had columns for time of PD and condition/comments, including instructions to call the nurse immediately for cloudy fluid, abdominal pain, or fever. However, the first entry on 11/15/26 at 2:00 P.M. only noted that the PD nurse completed the exchange, and the 10:00 P.M. entry that day had no condition/comment documentation. Subsequent days (11/16/25, 11/17/25, and 11/18/25) contained only one condition/comment entry per day rather than for each exchange, and there was no documentation that the 6:00 A.M. PD on 11/18/25 was completed. The PD cycler flowsheet starting 11/19/25 lacked any description of the effluent on multiple days. The PD nurse from the dialysis company stated facility staff were expected to monitor effluent for cloudiness and assess for abdominal pain and fever, and the DON confirmed there was no electronic physician order for peritonitis monitoring or for use of the PD cycler, that the paper charting did not allow for effluent description or symptom documentation for each treatment, and that PD was not documented at one ordered time. The facility’s dialysis policy required ongoing assessment and monitoring for complications before, during, and after treatments, which was not reflected in the documentation for this resident.
Improper Infection Control During Medication Administration
Penalty
Summary
Surveyors identified a deficiency in infection prevention and control related to medication administration for Resident #29. The resident was admitted on 02/28/14 with diagnoses including depression, traumatic brain injury, and anxiety, and had impaired cognition per a quarterly MDS assessment. During an observation on 03/25/26 at 6:58 A.M., RN #281 prepared the resident’s medications by removing an Amoxicillin-Pot Clavulanate tablet from the medication card and pushing it directly into her ungloved hand, then using her fingers to place the pill into a medication cup. The same process was observed for multiple other medications, including Escitalopram Oxalate, Furosemide, Sennosides, Lyrica, and Vitamin D, each being pushed from the card into the RN’s ungloved hand and then transferred by her fingers into the medication cup before administration to Resident #29. In a subsequent interview at 7:27 A.M. the same day, RN #281 confirmed she had placed each medication into her ungloved hands prior to administration and acknowledged that the proper procedure was to push the pills directly from the card into the medication cup. Review of the facility’s “Medication Administration – General guidelines” policy, revised 10/08/25, stated that medications are to be administered in accordance with good nursing principles and practices. This practice failure was cited as a deficiency under Complaint Number 2681777.
Improper Use of Wheelchair as a Physical Restraint
Penalty
Summary
Surveyors identified a deficiency related to the facility’s failure to ensure a resident was free from physical restraints. Resident #7, admitted with diagnoses including Alzheimer’s disease, diabetes mellitus, and anxiety disorder, was documented on a recent MDS as rarely understood and dependent for ADLs except eating. The resident ambulated independently on the unit without an assistive device and had documented verbal and other behaviors occurring one to three days during the look-back period. The care plan noted the resident had potential to be physically aggressive, chase staff, throw objects, and be combative with care, with interventions such as offering choices, administering medications as ordered, and intervening early when agitation occurred. During an observation and interview, Resident #7 was found sitting in a chair with the right arm of the chair positioned against the nursing station and a wheelchair placed directly in front of him. The left arm of the wheelchair was also against the nursing station, and both wheelchair wheels were locked, creating a barrier that appeared to restrain the resident, who was sleeping with his knees touching the locked wheelchair. An LPN confirmed both wheelchair wheels were locked and that the wheelchair should not have been placed in front of the resident. A CNA reported she had placed the wheelchair there in preparation to get the resident up for lunch, was unable to transfer him, and left the wheelchair in that position, acknowledging it was wrong to keep it there. The facility’s physical restraint policy stated that physical restraints are not used except when alternatives are not appropriate or effective for treating a medical symptom and defined physical restraints as any device attached or adjacent to the body that the individual cannot easily remove and that restricts freedom of movement or access to the body.
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