Englewood Health And Rehab
Inspection history, citations, penalties and survey trends for this long-term care facility in Englewood, Ohio.
- Location
- 425 Lauricella Court, Englewood, Ohio 45322
- CMS Provider Number
- 365088
- Inspections on file
- 33
- Latest survey
- April 2, 2025
- Citations (last 12 mo.)
- 0
Citation history
Health deficiencies cited at Englewood Health And Rehab during CMS and state inspections, most recent first.
A resident with multiple medical conditions and moderate cognitive impairment was prescribed sertraline for anxiety, but there was no documentation that the resident's representative was notified of this new medication order. The medication was administered for several days and later discontinued at the family's request, with the DON confirming the lack of notification and absence of a relevant facility policy.
A resident with multiple medical conditions and significant ADL and incontinence care needs did not have a comprehensive, person-centered care plan developed as required by facility policy. The lack of documentation was confirmed through medical record review and staff interview.
A resident with multiple medical conditions and total bowel incontinence did not receive timely incontinence care after activating the call light for assistance. Despite a strong odor and the resident's request, staff response was delayed, with a CNA turning off the call light and leaving before returning about ten minutes later to provide care. The facility lacked a comprehensive care plan for the resident's ADL and incontinence needs, and staff did not follow policy for prompt hygiene support.
A resident with multiple chronic conditions and arterial ulcers did not receive wound care as ordered on a specific date, and after experiencing two seizures, was not sent to the ED as directed by a physician. Documentation was lacking for both the wound care and the required notification and transfer following the second seizure, with staff interviews confirming these omissions.
A resident with multiple medical conditions, including schizophrenia and anxiety, did not receive sertraline as ordered due to a delay in processing a psychiatry medication order. The medication was not started promptly, resulting in a missed dose, and was later refused and discontinued. Facility policy requiring timely administration of medications was not followed.
Two residents in the facility did not receive their prescribed Gabapentin medication as ordered due to unavailability and awaiting delivery from the pharmacy. Resident #11, with conditions including diabetes and COPD, missed several doses in December, confirmed by the DON. Similarly, Resident #12, with a history of stroke and diabetes, also missed doses for the same reason. The facility's policy required medications to be administered as per prescriber orders, which was not followed.
A facility was found deficient in medication storage practices when an RN discovered an unmarked medication cup with 16 tablets in the medication cart. The RN did not know the identity of the medication and disposed of it. This incident potentially affected eleven residents, as the facility policy requires medications to be stored in their original containers.
The facility failed to ensure proper medication administration and storage for two residents. An LPN did not observe a resident with cognitive impairment consume medications, and an RN improperly stored another resident's medications mixed in pudding. These actions were against the facility's policies.
A resident with a history of diabetes and peripheral vascular disease experienced a delay in receiving an x-ray for an ankle injury due to miscommunication among staff. The physician verbally ordered an x-ray after the resident reported pain and swelling, but the order was not documented, leading to a delay in diagnosis and treatment of fractures. This deficiency was identified during a complaint investigation.
The facility failed to maintain an ice machine in a sanitary manner and properly store food items, leading to potential foodborne illness risks. Observations revealed expired bread, buildup in the ice machine, and multiple unlabeled and undated food items in the Dogwood unit refrigerator. The Dietary Manager and an LPN confirmed these findings, and the facility lacked policies on food storage and kitchen equipment maintenance.
The facility failed to obtain written authorization to manage a resident's personal funds. A resident's fund account was opened and later closed without the necessary signed and dated authorization form, contrary to the facility's policy.
The facility failed to ensure accurate MDS assessments for two residents. One resident with multiple diagnoses had extensive dental issues not reflected in the MDS, while another resident with a contracture did not receive a recommended splint, leading to inaccurate MDS coding.
The facility failed to include dental care in the comprehensive plan of care for a resident with multiple diagnoses and cognitive impairment. Despite significant dental issues and multiple dental visits, the care plan did not reflect the resident's dental needs or services provided. Observations and interviews confirmed the deficiency.
The facility failed to provide adequate nail care for a resident with severe cognitive impairment and limited mobility. The resident was observed multiple times with excessively long fingernails and a brown substance under them, despite the care plan requiring staff to assist with ADLs. The DON confirmed the need for nail care.
The facility failed to assess, monitor, and implement wound care interventions for a resident with a newly identified venous wound. Despite the presence of the wound, there were no physician orders or progress notes related to it until it was documented by the wound care physician. The resident was observed without the recommended low air loss mattress and had an undated dressing, indicating a lack of proper wound care management and documentation.
A facility failed to timely assess, monitor, and treat a resident's pressure ulcers, including not following a wound physician's recommendation for a low air loss mattress. The resident's pressure ulcers were not properly documented or treated upon readmission from the hospital, leading to inadequate care.
The facility failed to ensure that wrist/hand splints were applied and documented as recommended by OT for two residents, affecting their care and mobility. Observations and interviews revealed a lack of knowledge, documentation, and follow-through with therapy recommendations.
The facility failed to document a physician's orders for catheter care for a resident with an indwelling urinary catheter, leading to inconsistencies in catheter changes and adherence to facility policy. Interviews and observations revealed miscommunication and confusion regarding proper protocols.
The facility failed to adequately monitor and address significant weight loss in two residents, leading to a deficiency in providing sufficient food and fluids to maintain their health. Despite recommendations for reweights and fortified foods, these interventions were not consistently implemented, and the Registered Dietitian was not informed of the significant weight loss.
The facility failed to ensure that a resident received medications as ordered by the physician. After the removal of a PEG-tube, medications were still documented as administered via PEG-tube instead of orally, as confirmed by the resident, an LPN, and the DON. This discrepancy highlights a failure to follow the facility's policy on administering medications.
The facility failed to ensure psychotropic medications were given with adequate indications for use and that a resident's as-needed anti-anxiety medication order had a stop date. This affected three residents, including one prescribed sertraline for insomnia, another prescribed Seroquel for dementia-related psychosis, and a third with an as-needed Ativan order lacking a stop date.
The facility failed to ensure medications were properly stored, affecting two residents. One resident was found with unauthorized medications at her bedside, and another resident had multiple medications and supplements without corresponding physician orders or assessments. Interviews confirmed that these items should not have been at the bedside without proper authorization.
The facility failed to collaborate with hospice in developing a comprehensive plan of care for a resident receiving hospice services. The hospice plan of care included various provider visits, but these were not reflected in the facility's plan of care, and no care plan meetings were held between hospice and facility staff.
The facility failed to ensure medications were handled in a sanitary manner during administration. An RN and an LPN did not clean the medication cart surface before handling medications, leading to unsanitary practices. The DON confirmed that staff should not touch medications with bare hands or administer medications dropped onto the cart surface.
Failure to Notify Resident Representative of New Medication Order
Penalty
Summary
The facility failed to notify a resident's representative of a new medication order, specifically sertraline 25 mg prescribed for anxiety. Medical record review showed that the resident, who had diagnoses including acute kidney failure, diabetes mellitus, schizophrenia, and anxiety, was admitted with moderate cognitive impairment and required supervision for several activities of daily living. The sertraline was ordered by a physician and administered for several days, with the resident refusing doses on two occasions before the medication was discontinued at the family's request. There was no documentation in the medical record indicating that the resident's representative was informed of the initiation of sertraline. The Director of Nursing confirmed that there was no evidence of such notification and stated that the facility did not have a policy for notifying representatives about new medication orders. The facility's policy required prompt notification of the resident, physician, and representative regarding changes in the resident's condition or status, but this was not followed in this instance.
Failure to Develop Comprehensive Care Plan for ADL and Incontinence Needs
Penalty
Summary
The facility failed to develop a comprehensive, person-centered care plan to address a resident's Activities of Daily Living (ADL) and incontinence care needs. Medical record review for a resident admitted with multiple diagnoses, including sepsis, convulsions, hypertension, cerebral infarction, atrial fibrillation, diabetes mellitus, and hypothyroidism, showed that the resident was cognitively intact but required substantial to maximum assistance with toilet hygiene, bathing, transfers, and bed mobility. The resident also had an indwelling catheter and was always incontinent of bowel, as documented in a quarterly Minimum Data Set (MDS) assessment. Despite these needs, there was no documentation indicating that a comprehensive, person-centered care plan addressing the resident's ADL and incontinence needs had been developed. This was confirmed during an interview with the Administrator, who acknowledged the absence of such documentation until the date of the interview. The facility's policy requires the interdisciplinary team to develop and implement a care plan with measurable objectives and timeframes, but this was not done for the resident in question.
Failure to Provide Timely Incontinence Care for Dependent Resident
Penalty
Summary
A deficiency occurred when the facility failed to provide timely incontinence care for a dependent resident who required substantial to maximum assistance with activities of daily living (ADLs), including toileting and hygiene. The resident, who had multiple medical diagnoses such as sepsis, convulsions, hypertension, cerebral infarction, atrial fibrillation, diabetes mellitus, and hypothyroidism, was cognitively intact but always incontinent of bowel and had an indwelling catheter. The medical record review revealed there was no comprehensive, person-centered care plan developed to address the resident's ADL and incontinence needs. On the day of the incident, the resident activated his call light to request assistance for incontinence care. Despite a strong odor being noted outside the resident's room, staff response was delayed. An LPN was observed at the nurses' station, and no other staff were present in the hall. A CNA eventually responded, turned off the call light, informed the resident she would return, and left without providing immediate care. The CNA returned approximately ten minutes later to complete the incontinence care. The resident reported frequent waits of up to 45 minutes for call light responses. Facility policy required staff to provide necessary support for hygiene and elimination needs, but this was not followed in this instance.
Failure to Complete Wound Care and Follow Physician Orders After Change in Condition
Penalty
Summary
The facility failed to provide wound care as ordered and did not send a resident to the emergency department (ED) as directed by a physician following a change in condition. Medical record review showed that a resident with multiple diagnoses, including chronic kidney disease, diabetes, and peripheral vascular disease, was admitted with arterial ulcers and had a physician's order for daily wound care to the left heel. Documentation for the treatment administration record did not show that the wound care was completed on the specified date, and the Director of Nursing confirmed the absence of documentation for this treatment. Additionally, the resident experienced a seizure, after which the physician ordered immediate labs and instructed staff to send the resident to the ED if another seizure occurred. The following day, the resident had a second seizure, but there was no documentation that the physician was notified or that the resident was sent to the ED as ordered. Staff interviews confirmed that the nurse responsible was unaware of the second seizure until returning to work later, and the resident was only sent to the hospital after a family request. Facility policies required staff to follow physician orders for treatments and to promptly notify physicians and representatives of changes in condition, which was not done in this case.
Failure to Administer Medication as Ordered
Penalty
Summary
A deficiency occurred when a resident with diagnoses including acute kidney failure, diabetes mellitus, schizophrenia, and anxiety did not receive medication as ordered. The resident was assessed as having moderate cognitive impairment and required supervision for several activities of daily living. Medical records showed that a psychiatry consult on 01/31/25 included an order to start sertraline 25 mg daily for anxiety, but the medication was not ordered until 02/14/25. As a result, the resident did not receive the sertraline as prescribed on 02/15/25. The Medication Administration Record indicated the resident received sertraline from 02/16/25 through 02/19/25, and refused the medication on 02/20/25 and 02/21/25, after which it was discontinued. The Director of Nursing confirmed that the initial psychiatry note contained the order for sertraline, but there was a delay in entering the order into the system, resulting in a missed dose. Facility policy requires medications to be administered in a safe and timely manner, as prescribed, but this was not followed in this instance. The deficiency was identified during a complaint investigation and was based on medical record review, staff interview, and policy review.
Medication Administration Deficiency Due to Unavailability
Penalty
Summary
The facility failed to administer medications as ordered by the physician, affecting two residents. Resident #11, who was admitted with diagnoses including diabetes mellitus type two, COPD, and breast cancer, was on hospice care. The resident had a physician's order for Gabapentin 100 mg capsule three times a day starting on 12/04/24. However, the December 2024 Medication Administration Record (MAR) showed that several doses were not administered on 12/06/24, 12/07/24, 12/08/24, and 12/09/24 due to the medication being unavailable in the pyxis and awaiting delivery from the pharmacy. This was confirmed by the Director of Nursing (DON) during an interview. Similarly, Resident #12, who had diagnoses including stroke, diabetes mellitus type two, and COPD, also had a physician's order for Gabapentin 100 mg capsule three times a day starting on 12/04/24. The December MAR indicated that doses were missed on 12/06/24, 12/16/24, and 12/17/24 for the same reason of unavailability and awaiting delivery from the pharmacy. The facility's policy on administering medication, last revised in 04/2019, stated that medications were to be administered in accordance with prescriber orders, which was not adhered to in these instances. This deficiency was investigated under Complaint Number OH00160802.
Medication Storage Deficiency
Penalty
Summary
The facility failed to ensure that medications were stored in their original containers, as observed during a survey. During an observation, a Registered Nurse (RN) was seen preparing to administer medications and opened the top drawer of the medication cart, revealing an unmarked medication cup containing 16 white, oblong tablets among other over-the-counter medications. The RN confirmed that the medication had been present at the start of her shift and admitted to not knowing what the medication was, leading her to dispose of it. This incident had the potential to affect eleven residents whose medications were stored in the medication cart. The facility's policy, dated 2001, mandates that medications and biologics be stored in the packaging, containers, or other dispensing systems in which they were received.
Medication Administration and Storage Deficiencies
Penalty
Summary
The facility failed to ensure proper medication administration and storage practices, affecting two residents. For Resident #84, who has moderate cognitive impairment and multiple diagnoses including congestive heart failure and diabetes, the LPN administered ten oral medications but did not observe the resident consume them. There was no documentation or physician order allowing the resident to self-administer medications, which is against the facility's policy that requires staff to remain with the resident until all medications are taken. For Resident #24, who has severe cognitive impairment and multiple health issues such as diabetes and kidney failure, the RN prepared medications by crushing them and mixing them with pudding. However, when the resident could not be awakened, the RN stored the uncovered medication cup in the top drawer of the medication cart, which is not in accordance with the facility's policy. The policy mandates that medications should be stored in their original packaging or containers, and only the issuing pharmacy is authorized to transfer medications between containers. This improper storage was confirmed by the DON and the RN.
Delayed Care for Ankle Injury Due to Miscommunication
Penalty
Summary
The facility failed to provide timely care and treatment for a resident with an ankle injury. The resident, who had a history of type II diabetes mellitus with diabetic retinopathy and peripheral vascular disease, reported left ankle pain and swelling after a fall. The physician examined the resident and verbally ordered an x-ray to rule out a fracture or dislocation. However, due to a lack of written documentation and communication issues, the x-ray was not ordered until the following day, delaying the diagnosis of acute nondisplaced medial and lateral malleolar fractures. The delay in obtaining the x-ray was compounded by miscommunication among the nursing staff. The LPNs involved were under the impression that the x-ray had already been ordered, based on verbal communication from the physician. This misunderstanding led to a failure to verify the order in the medical record, resulting in a delay in the resident receiving appropriate care. The deficiency was identified during a complaint investigation, highlighting a breakdown in the facility's process for ensuring timely medical interventions.
Sanitation and Food Storage Deficiencies
Penalty
Summary
The facility failed to ensure an ice machine was maintained in a sanitary manner and food items were stored properly to prevent potential foodborne illness. Observations revealed expired loafs of wheat bread on the bread rack and white-colored buildup in the interior crevasses and on the ledge of the ice machine that were in contact with the ice. The Dietary Manager confirmed these findings. Additionally, the facility did not have a policy on food storage, expired food, or maintenance of kitchen equipment, affecting 81 out of 83 residents who receive their meals from the kitchen. Further observations of the Dogwood unit nutritional refrigerator revealed multiple unlabeled and undated food items, including open bottles of water, boxes of pizza, a covered salad, an expired yogurt cup, an expired container of french dip, a coffee cup with an exposed drinking spout, an opened stick of butter with red color dots, an expired salad, a container of pineapple, and two bags of restaurant leftovers. An LPN verified these findings. The facility's policy on food brought in by family and visitors stated that such food should be labeled and stored in a manner distinguishable from facility-prepared food, and perishable food should be discarded within three to five days.
Failure to Obtain Written Authorization for Managing Resident's Personal Funds
Penalty
Summary
The facility failed to ensure appropriate written authorization was obtained to manage a resident's personal funds. Resident #246, admitted with a primary diagnosis of unspecified heart failure, had a non-transferring resident fund account that was opened without the necessary signed and dated authorization form. The account was opened with a cash deposit of $245.00 and was later closed. The Business Office Manager admitted to depositing the money without obtaining the resident's signature on the required paperwork before the resident was discharged. The facility's policy required written agreement from the resident for the facility to act as the fiduciary of the resident's funds, which was not followed in this case.
Inaccurate MDS Assessments for Two Residents
Penalty
Summary
The facility failed to ensure that Minimum Data Set (MDS) assessments were completed and coded accurately for two residents. Resident #59, who had multiple diagnoses including acute kidney failure, chronic heart failure, and diabetes mellitus, was found to have extensive dental issues that were not accurately reflected in the MDS. Despite multiple dental visits and visible signs of dental decay and inflamed gums, the MDS indicated no issues with mouth or facial pain, discomfort, or difficulty with chewing. The MDS RN admitted to not visually examining Resident #59's oral cavity, leading to incorrect coding in the MDS assessment. Resident #57, diagnosed with cerebral infarction, vascular dementia, and other conditions, had a recommendation from Occupational Therapy for a right wrist/hand splint to address a contracture. Despite this recommendation and documented communication with a procurement company, the splint was not provided, and the MDS did not reflect the need for it. Observations confirmed the absence of the splint, and interviews with staff revealed a lack of awareness about the Occupational Therapy recommendation, resulting in an inaccurate MDS assessment for Resident #57.
Failure to Include Dental Care in Comprehensive Plan of Care
Penalty
Summary
The facility failed to ensure the comprehensive plan of care for Resident #7 included dental care. Resident #7, who was admitted on 06/30/21, had multiple diagnoses including end stage renal disease, hypertensive chronic kidney disease, and type 2 diabetes. The resident required set up assistance for oral hygiene and had no broken or loosely fitting dentures or mouth pain initially. However, the plan of care was silent on dental services despite the resident's cognitive impairment and need for dental care. Dental services records revealed significant dental issues, including heavy plaque, moderate to severe periodontal disease, and pain related to seven teeth, which were not addressed in the care plan. The resident had multiple dental visits, including extractions and a dental cleaning, but the care plan did not reflect these needs or services provided. Observations and interviews confirmed the deficiency. On 04/24/24, an observation revealed the resident had one remaining tooth, and the resident expressed a desire for new dentures to eat preferred foods. The Director of Nursing verified that the care plan did not include dental concerns and acknowledged that it should have. The facility's policy review indicated adherence to the RAI Manual, which mandates a comprehensive plan of care for each resident, including measurable objectives and timetables to meet their medical, nursing, mental, and psychological needs identified in the comprehensive assessment.
Failure to Provide Adequate Nail Care for Dependent Resident
Penalty
Summary
The facility failed to provide adequate nail care for a resident who was dependent on staff for activities of daily living (ADL). Resident #57, who had severe cognitive impairment, impaired range of motion on the right side, and required a two-person mechanical lift for transfers, was observed on multiple occasions with fingernails extending approximately one-half to three-quarters of an inch beyond the tip of the fingers and with a brown substance under the nails. Despite the care plan indicating that staff should monitor and assist with ADLs, the resident's fingernails remained in poor condition over several days. The Director of Nursing confirmed the need for ADL care for the resident's fingernails during an interview at the bedside.
Failure to Implement and Document Wound Care Interventions
Penalty
Summary
The facility failed to accurately assess, monitor, and implement wound care interventions for a newly identified non-pressure skin condition affecting Resident #24. The resident, who was admitted with multiple diagnoses including congestive heart failure and hypertension, was found to have a new venous wound on the right medial calf. Despite the presence of this wound, there were no physician orders or progress notes related to the wound from 01/01/24 to 04/25/24. The wound was only documented by the wound care physician on 04/25/24, who noted the wound's dimensions and prescribed a treatment plan. However, the resident was observed without the recommended low air loss mattress and had an undated dressing on the wound, indicating a lack of proper wound care management and documentation prior to the physician's assessment. Interviews with the wound care physician, LPNs, and the Director of Nursing confirmed the presence of the new venous wound and the absence of prior treatment orders or assessments. The facility's wound care policy, which requires detailed documentation of wound care and any changes in the resident's condition, was not followed. This deficiency in wound care management and documentation affected the resident's treatment and care, as evidenced by the lack of appropriate interventions and monitoring for the newly identified wound.
Failure to Timely Assess and Treat Pressure Ulcers
Penalty
Summary
The facility failed to timely assess, provide ongoing monitoring, and implement treatments for a resident's pressure ulcers. Resident #24, who had a history of multiple pressure ulcers, was admitted to the facility with several diagnoses including congestive heart failure and hypertension. Despite having a care plan that included interventions such as pressure-reducing cushions and mattresses, turning and repositioning, and weekly wound assessments, the facility did not adhere to these protocols. Upon readmission from the hospital, the resident's pressure ulcers were not assessed, measured, or staged, and the existing treatment orders were not updated or followed correctly. The resident's medical records revealed that the facility did not conduct a comprehensive skin assessment upon readmission, and there were significant gaps in the documentation and treatment of the resident's pressure ulcers. For instance, the resident had a physician's order for wound care that was not implemented until much later, and the wound care physician's recommendation for a low air loss mattress was not followed. Observations confirmed that the resident was lying on a regular mattress instead of the recommended low air loss mattress, which could have contributed to the worsening of the pressure ulcers. Interviews with the facility's staff, including Licensed Practical Nurse Unit Managers, confirmed that the necessary assessments and treatments were not conducted in a timely manner. The facility's wound care policy and prevention of pressure injuries policy were not adhered to, leading to inadequate care for the resident's pressure ulcers. The failure to implement the wound physician's recommendations and the lack of proper documentation and monitoring contributed to the deficiency in the resident's care.
Failure to Apply and Document Wrist/Hand Splints as Recommended by OT
Penalty
Summary
The facility failed to ensure that a wrist/hand splint was applied as recommended by occupational therapy (OT) for two residents. Resident #57, who had multiple diagnoses including cerebral infarction and vascular dementia, was recommended by OT to use a right wrist/hand splint for 8 hours a day. However, there was no documentation in the care plan or care conference notes regarding the splint, and observations revealed that the splint was not in place. Emails between the facility and a procurement company indicated awareness of the need for the splint, but it had not been provided by the time of the surveyor's observations. Interviews with staff confirmed the lack of knowledge and documentation regarding the splint recommendation, making the MDS assessment inaccurate for Resident #57. Resident #59, who had a range of medical conditions including acute kidney failure and chronic heart failure, was observed with a left hand contracture and a blue soft foam splint on the bedside table. The resident stated that therapy had given her the splint and that facility staff were supposed to help her put it on every evening. However, there were no physician orders or documented monitoring for the splint application. Interviews with staff, including an LPN and the Director of Nursing (DON), confirmed the absence of orders and documentation for the splint. The Interim Director of Therapy also verified that there were no active therapy progress notes related to the splint. The facility's failure to ensure the application and documentation of wrist/hand splints as recommended by OT affected the care and mobility of both residents. This deficiency was observed through record reviews, staff and resident interviews, and direct observations, highlighting a lapse in following through with therapy recommendations and proper documentation in the residents' care plans.
Failure to Document Physician's Orders for Catheter Care
Penalty
Summary
The facility failed to document a physician's orders for catheter care in a resident's medical record, specifically for a resident with multiple diagnoses including neuromuscular dysfunction of the bladder. The resident had an indwelling urinary catheter and the care plan included specific interventions for catheter care. However, the physician orders for changing the Foley catheter were not documented in the resident's medical record for several months, despite the facility's policy requiring catheter changes every 30 days and as needed. Observations and interviews confirmed the absence of these orders and the inconsistency in following the facility's policy and the CDC guidelines for catheter care. The resident's medical record showed multiple instances where the catheter was changed due to issues such as leakage and occlusion, but these changes were not consistently documented with a physician's order. Interviews with nursing staff and the Director of Nursing (DON) revealed confusion and miscommunication regarding the proper protocol for catheter changes. The DON eventually obtained a physician's order, but it was noted that the order was influenced by the DON's interpretation of CDC guidelines, which differed from the facility's standard practice. Further interviews with the Nurse Practitioner (NP) responsible for the resident's urology care confirmed that the orders should have included both regular 30-day changes and as-needed changes for occlusions. The facility was unable to provide a policy related to the time frames for indwelling Foley catheter replacements upon request, highlighting a gap in documentation and adherence to established protocols. This deficiency affected the quality of care provided to the resident and demonstrated a lack of proper documentation and communication within the facility.
Failure to Monitor and Address Significant Weight Loss
Penalty
Summary
The facility failed to adequately monitor and address significant weight loss in two residents, leading to a deficiency in providing sufficient food and fluids to maintain their health. Resident #28 experienced a 21.62% weight loss over four months, with weights fluctuating significantly. Despite recommendations from the Dietetic Technician (DT) for reweights and fortified foods, these interventions were not consistently implemented. The Registered Dietitian (RD) was not informed of the significant weight loss, and the resident continued to lose weight without timely assessments or interventions. Resident #84, who was moderately cognitively impaired and dependent on a feeding tube, experienced a 12.97% weight loss within six days. The DT recommended a reweight due to a potential weight error, but this reweight was not completed. The RD was not made aware of the weight loss, and no weight loss interventions were put in place during this period. The resident's nutritional needs were not adequately monitored or addressed, leading to a significant deficiency in care. The facility's weight assessment and intervention policy, dated March 2022, was not effectively followed. Both residents experienced significant weight loss without timely reweights, assessments, or appropriate interventions. The lack of communication between the DT and RD further exacerbated the issue, resulting in inadequate nutritional care for the residents.
Failure to Administer Medications as Ordered
Penalty
Summary
The facility failed to ensure that a resident received medications as ordered by the physician. Resident #45, who was admitted with multiple diagnoses including a right above-knee amputation, acute respiratory failure, and moderate protein-calorie malnutrition, had a PEG-tube removed on 04/17/24. Despite the removal of the PEG-tube, the Medication Administration Record (MAR) indicated that medications were still being documented as administered via PEG-tube from 04/17/24 to 04/23/24. This discrepancy was confirmed through interviews with the resident, an LPN, and the Director of Nursing (DON), all of whom acknowledged that the medications were being given orally, contrary to the documented route of administration in the physician's orders. The facility's policy on administering medications, which requires verification of the right method (route of administration), was not followed in this instance. Resident #45, who is cognitively intact and requires various levels of assistance for daily activities, confirmed that he was taking all his medications by mouth after the PEG-tube removal. However, the physician's orders were not updated to reflect this change until 04/24/24. The LPN and DON both confirmed that the medications were being administered orally, despite the orders stating they should be given via PEG-tube. This failure to follow the physician's orders and update the route of administration in the MAR constitutes a deficiency in the facility's pharmaceutical services.
Inadequate Indications for Psychotropic Medications and Missing Stop Date for PRN Order
Penalty
Summary
The facility failed to ensure that psychotropic medications were given with adequate indications for use and that a resident's as-needed anti-anxiety medication order had a stop date. This deficiency affected three residents. Resident #28 was prescribed sertraline (Zoloft) 100 mg for insomnia, which is not an appropriate diagnosis for this medication. The Director of Nursing (DON) confirmed that insomnia is not an appropriate indication for sertraline, as it is typically prescribed for major depressive disorder, obsessive-compulsive disorder, panic disorder, post-traumatic stress disorder, social anxiety disorder, and premenstrual dysphoric disorder. Additionally, insomnia is a common adverse reaction to sertraline, further indicating its inappropriate use for this resident's condition. Resident #28 was moderately cognitively impaired and required varying levels of assistance with daily activities, including supervision and moderate assistance for tasks such as toileting, dressing, and transfers. The resident was also on an antidepressant during the Minimum Data Set (MDS) review period, highlighting the need for careful medication management and appropriate indications for use. Resident #42 was prescribed Seroquel (quetiapine fumarate) 50 mg for Behavioral and Psychological Symptoms of Dementia (BPSD) related to unspecified dementia. However, the Black Box Warning and prescribing information for Seroquel indicate that it is not approved for the treatment of dementia-related psychosis and carries an increased risk of mortality in elderly patients with dementia-related psychosis. The DON confirmed that the diagnosis of BPSD related to unspecified dementia is not an adequate indication for the use of Seroquel. Resident #42 was moderately cognitively impaired and required varying levels of assistance with daily activities, including supervision and moderate assistance for tasks such as toileting, dressing, and transfers. The resident's use of antipsychotic medication during the MDS assessment period further underscores the need for appropriate indications and careful monitoring. Resident #55 had an as-needed order for Ativan 0.5 mg every six hours for anxiety, but the order did not include a 14-day stop date, and no re-evaluation was conducted for the continued use of the anti-anxiety medication. The DON verified that the as-needed Ativan order was not written with a stop date, which is a critical oversight in medication management. Resident #55 had impaired cognition and required total assistance for eating, toileting, bed mobility, and transfers. The resident's plan of care included interventions for respiratory status and anxiety, highlighting the importance of proper medication management and re-evaluation to ensure the resident's well-being.
Failure to Properly Store Medications
Penalty
Summary
The facility failed to ensure medications were properly stored, affecting two residents. Resident #24, who was cognitively intact and required various levels of assistance for daily activities, was found with three pills in a medication cup on her bedside table. There were no physician orders or nursing assessments indicating that Resident #24 could store or administer her own medications. Interviews with the RN and DON confirmed that Resident #24 was not authorized to self-administer medications, and the facility's policy required physician and interdisciplinary team approval for self-administration of medications, which was not obtained in this case. Resident #63, who had impaired cognition and required maximal assistance for bed mobility, toileting, and transfers, was found with multiple medications and supplements at her bedside, including Balance of Nature dietary supplements, nystatin powder, and a medication cup with ointment. None of these items had corresponding physician orders, and there were no assessments indicating that Resident #63 could self-administer medications. Interviews with the resident, an LPN, and the Unit Manager confirmed that these items should not have been at the bedside without proper orders and assessments. The facility's policy on administering medications, dated April 2019, stated that only licensed or permitted individuals could prepare, administer, and document medication administration. Both residents were found with medications at their bedside without proper authorization, assessments, or physician orders, indicating a failure to adhere to the facility's medication administration policy.
Failure to Collaborate with Hospice in Care Planning
Penalty
Summary
The facility failed to collaborate with hospice in the development of a comprehensive plan of care for a resident receiving hospice services. Medical record review revealed that the resident, who had multiple diagnoses including dementia and malnutrition, was admitted to hospice but the facility's plan of care did not include any details about hospice visits or services. Interviews with hospice and facility staff confirmed that there were no care plan meetings or conferences to develop a coordinated plan of care for the resident. The hospice plan of care specified various provider visits, including skilled nursing and State Tested Nursing Assistant (STNA) visits, but these were not reflected in the facility's plan of care. The facility's policy required collaboration with hospice representatives for care planning, but this was not followed. The deficiency affected one resident out of the facility's census of 83.
Unsanitary Medication Handling
Penalty
Summary
The facility failed to ensure resident medications were handled in a sanitary manner during medication administration. For Resident #70, the Registered Nurse (RN) did not perform hand hygiene or clean the top of the medication cart before removing medications. The RN touched various surfaces and medication boxes, then pushed a pill out of a blister pack onto the uncleaned medication cart surface. The RN picked up the pill with bare hands and placed it into the medication cup with other medications, which were then administered to the resident. The RN confirmed the unsanitary handling of the medication and the absence of hand sanitizer on the medication cart during the observation. For Resident #63, the Licensed Practical Nurse (LPN) also did not clean the top of the medication cart before starting medication administration. The LPN placed a lidocaine patch and medication cart keys on the uncleaned surface, then pushed a tablet from a bubble pack onto the cart surface. The LPN used two spoons to pick up the tablet and placed it into the medication cup, which was then administered to the resident. The LPN confirmed the unsanitary handling of the medication and acknowledged that the medication should have been disposed of instead of being administered. The Director of Nursing (DON) verified that staff should not touch medications with bare hands or administer medications that have been dropped onto the medication cart surface.
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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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