Flint Ridge Nrsg & Rehab Ctr
Inspection history, citations, penalties and survey trends for this long-term care facility in Newark, Ohio.
- Location
- 1450 West Main Street, Newark, Ohio 43055
- CMS Provider Number
- 365485
- Inspections on file
- 32
- Latest survey
- November 21, 2025
- Citations (last 12 mo.)
- 2
Citation history
Health deficiencies cited at Flint Ridge Nrsg & Rehab Ctr during CMS and state inspections, most recent first.
A resident with significant mobility issues and a history of falls was not consistently transferred using a gait belt or walker as recommended by PT. Despite updated care plans and staff education protocols, CNAs did not use these assistive devices during transfers, and the DON was unaware of the specific PT recommendations. This failure to follow therapy guidance and ensure appropriate interventions led to a fall and a deficiency finding.
A registered nurse was observed administering medications to multiple residents without performing hand hygiene between each resident, as required by facility policy. This lapse in infection control practices affected several residents during both noon and afternoon medication passes and was confirmed by the nurse during an interview. Facility policies emphasize hand hygiene as a primary infection prevention measure.
The facility did not consistently serve meals at safe and appetizing temperatures, with hot foods such as chicken and vegetables observed below the required 135°F at the point of service. Two residents were directly affected, including one who did not receive ordered beverages and another whose family reported cold food. Multiple residents expressed dissatisfaction with meal temperatures and delivery delays, indicating a widespread issue.
Surveyors observed multiple deficiencies in food storage and handling, including unlabeled and expired food items, an unclean ice machine, and a dusty fan pointed at clean dishware. Staff were also seen using improper food thermometer techniques and failing to change gloves or perform hand hygiene after handling packaging, contrary to facility policy.
Two residents did not have baseline care plans completed within 48 hours of admission. One resident with severe cognitive impairment, incontinence, and multiple pressure ulcers had a delayed care plan, while another cognitively intact resident with multiple comorbidities and frequent bladder incontinence had no baseline care plan documented. These deficiencies were confirmed by nursing staff.
The facility did not hold required care plan conferences for two residents, one with end stage renal disease and mild cognitive impairment and another with chronic illnesses and intact cognition who was on hospice. Both residents and the Social Services Director confirmed that no recent formal care conferences had occurred, despite ongoing informal communication with families.
Two residents did not receive timely or adequate assistance with ADLs, including delays in transfers due to missing equipment and lack of proper fingernail care despite documentation stating otherwise. Staff failed to document required attempts to provide showers and did not individualize care plans for hygiene needs, resulting in resident discomfort and distress.
A resident with severe cognitive impairment and multiple comorbidities developed a Stage 4 pressure ulcer. Despite a care plan that included frequent repositioning, specialized mattress, and daily wound treatments, multiple wound care treatments were missed over several months without documented reasons. Staff interviews and record reviews confirmed the lack of documentation and inconsistent adherence to physician-ordered wound care.
A resident with a contractured wrist and a history of hemiplegia did not receive appropriate follow-up care or monitoring, as there were no active physician orders, care plan interventions, or therapy reassessments addressing the contracture after an initial refusal of a splint. Facility leadership confirmed the absence of a process for therapy follow-up, and documentation errors further contributed to the lack of proper management.
A resident with severe cognitive and physical impairments was found in a bed where staff had placed a large triangular cushion between the mattress and bed frame, tilting the mattress and creating a gap between the bed and wall. Staff used the cushion to prevent the resident from rolling out of bed, but this setup was not part of the care plan and was not approved by the DON. The arrangement created a potential entrapment hazard, as confirmed by the bed manufacturer's instructions, and staff were unclear about the cushion's purpose and safety.
A resident with multiple chronic conditions and prescribed anticonvulsant, antidepressant, and diuretic medications did not receive physician-ordered laboratory tests to monitor medication levels and efficacy as required every six months. The last documented labs were completed several months prior, and the DON confirmed the oversight, which was not in accordance with facility policy for processing and arranging laboratory tests.
A resident with an indwelling catheter and multiple medical conditions received several courses of antibiotics for UTIs without the facility obtaining required urine cultures and sensitivities to confirm the appropriateness of the medications. Facility leadership confirmed that antibiotics were administered after hospital discharge without necessary lab tests, contrary to the facility's antibiotic stewardship policy.
A resident receiving enteral feeding experienced severe weight loss due to the facility's failure to implement timely nutritional interventions and notify the dietician of significant weight changes. Despite the resident's complex medical history, including protein-calorie malnutrition and discontinued dialysis, the facility did not revise the care plan or follow its policy to notify the dietician of weight changes, leading to a 13.8% weight loss within 30 days.
A resident with multiple pressure ulcers was not comprehensively assessed for pain, leading to actual harm during wound care. Despite clear signs of pain, no pain medication was administered prior to treatment, and the facility failed to develop an individualized pain management plan. The facility's policy on pain assessment and management was not followed, resulting in the resident experiencing significant discomfort.
The facility failed to maintain a safe and homelike environment, with issues such as mislabeled rooms, potential mold, exposed electrical wires, and missing amenities in resident rooms. The Maintenance Director confirmed these deficiencies, and the facility lacked a policy for maintaining a safe environment.
The facility failed to provide the ordered serving size and whole milk for breakfast, affecting several residents. The breakfast menu included whole milk, but due to a shortage, residents received 2% milk instead. Additionally, the breakfast casserole was served in smaller portions than required. This deficiency was noted during a complaint investigation.
The facility failed to maintain a clean and sanitary kitchen, affecting nearly all residents. Observations revealed flaking paint, rust, dust, and grease buildup on the stove hood and exhaust fans. Additionally, maintenance issues included a loose gas line face plate, a bent stove panel, and improperly installed griddle knobs. Staff confirmed the poor condition and lack of a cleanliness policy.
A resident with multiple diagnoses, including dysphagia and cognitive communication disorder, was not served their meal at the same time as others at their table, leading to a lack of a dignified dining experience. The resident was observed watching others eat until their meal was served later. Staff interviews confirmed the delay, and the facility's policy emphasizes the importance of a dignified dining experience.
A resident with Charcot's joint and diabetes mellitus experienced multiple room changes without receiving the required written notice. The facility's policy mandated written or verbal notice at least 24 hours in advance, but this was not followed, as confirmed by the DON and the resident. The resident only received written notice for a later room change.
A resident with multiple medical conditions, including a moderate intellectual disability and pressure ulcers, required assistance with meals. However, the facility failed to provide necessary meal setup and assistance, leaving the resident's breakfast tray out of reach and unopened. An STNA confirmed the resident's need for assistance but did not provide the correct consistency of liquids, leading to a deficiency.
A resident admitted with multiple pressure ulcers did not receive timely and comprehensive care. The facility failed to document a deep tissue pressure injury and delayed ordering treatments for existing ulcers. Preventative measures were not implemented, and during treatment observation, infection control procedures were not followed. Nursing staff confirmed the lack of a dressing and delayed treatment implementation.
The facility failed to safely transport oxygen tanks for two residents requiring supplemental oxygen. One resident with dementia and COPD was assisted by an STNA who improperly secured the oxygen tank in a wheeled carrier. Another resident with end-stage renal disease and COPD was transported with an unsecured oxygen tank in a rolling cart. Both instances were verified by an LPN, and the facility's policy requires secure fastening of oxygen tanks.
A facility failed to implement timely enteral feeding recommendations for a resident, resulting in significant weight loss. Despite a dietitian's advice to increase feeding volume and flushes, these were not promptly executed. The care plan was not updated to reflect changes like dialysis discontinuation and weight loss. Interviews revealed a lack of communication and timely action, contributing to the resident's nutritional decline.
A resident with chronic obstructive pulmonary disease and dependence on supplemental oxygen did not receive oxygen per physician orders. An STNA incorrectly set the oxygen flow rate, and the resident was later observed without oxygen, despite orders for continuous administration. The facility's policy required reviewing physician's orders, which was not followed.
The facility failed to maintain accurate medical records for three residents, leading to documentation and assessment deficiencies. A resident's deep tissue pressure injury was not documented, and another resident's weight records showed discrepancies. Additionally, there were inconsistencies in a resident's catheter care plan and physician orders. The DON confirmed these issues during interviews.
The facility failed to follow infection control protocols during incontinence care for a resident with pressure ulcers, as staff did not change gloves or wash hands appropriately. Additionally, another resident's urinary catheter bag and tubing were observed dragging on the floor, contrary to the facility's catheter care policy.
Failure to Implement Therapy Recommendations for Safe Transfers
Penalty
Summary
A deficiency was identified when a resident with multiple complex diagnoses, including sarcoid myocarditis, muscle weakness, and difficulty walking, experienced a fall during a transfer from a recliner to a wheelchair. The fall occurred when the resident's knees buckled, and the CNA assisted the resident to the floor and then to a wheelchair with a two-person stand and pivot. The root cause investigation determined that the fall was due to the resident's leg weakness, and the resident's fall risk assessment was updated from low to moderate following the incident. Despite recommendations from the physical therapist for staff to use a front-wheeled walker and a gait belt during transfers, interviews with CNAs revealed that these assistive devices were not being used. The resident confirmed that staff did not use a gait belt or walker when transferring, even though the physical therapist had recommended their use. The care plan and Kardex were updated to indicate a two-person assist for transfers after the fall, but did not specify the use of a gait belt or walker as recommended by therapy. The Director of Nursing confirmed that using a gait belt is considered standard of care and that staff are educated on therapy recommendations through a communication binder and updates to the Kardex system. However, the DON was not aware of the specific PT recommendation for the use of a walker during transfers for this resident. The facility's falls protocol requires staff to identify and implement pertinent interventions based on assessment, but the lack of adherence to therapy recommendations for assistive devices contributed to the deficiency.
Failure to Perform Hand Hygiene During Medication Administration
Penalty
Summary
A deficiency was identified when a registered nurse failed to perform hand hygiene during medication administration on the Main Unit hallway. Observations revealed that the nurse prepared and administered medications to multiple residents consecutively without sanitizing or washing hands between residents. This occurred during both the noon and afternoon medication administration periods, affecting nine residents directly and potentially impacting all 28 residents on the Main Unit hallway. The nurse only sanitized hands once during the observed period, despite handling medications for several residents in succession. During an interview, the nurse confirmed not performing hand hygiene between residents and acknowledged that facility policy requires hand sanitizing or washing before preparing medications and after administration. Review of facility policies indicated that hand hygiene is considered the primary means to prevent the spread of healthcare-associated infections, and staff are expected to follow established infection control procedures during medication administration. The deficiency was discovered incidentally during a complaint investigation.
Failure to Maintain Safe and Palatable Food Temperatures During Meal Service
Penalty
Summary
The facility failed to ensure that meals were served at appropriate and safe temperatures, as required by food safety standards. During meal service, observations revealed that hot foods such as baked chicken and mixed vegetables were served below the required 135°F, with temperatures recorded at 126.1°F and 118°F, respectively. These findings were confirmed by the Dietary Manager. Additionally, a resident reported not receiving their preferred beverages, such as milk and apple juice, which were ordered but not provided with the meal. Another resident's family member reported that food often arrived cold to the room. Residents expressed ongoing dissatisfaction with the temperature of meals during a resident council meeting, stating that food frequently arrived cold due to delivery delays. The facility's policy requires potentially hazardous foods to be maintained above 135°F or below 41°F, but observations and resident interviews indicated that this standard was not consistently met. The issue affected at least two residents directly and had the potential to impact the majority of residents in the facility.
Deficient Food Storage, Preparation, and Handling Practices
Penalty
Summary
Multiple deficiencies in food storage, preparation, and service were observed in the facility's kitchen. Surveyors found undated and unlabeled shredded cheese, expired shredded cheese, opened cinnamon rolls and peas in the freezer without labels or expiration dates, and several bags of opened cereal and coffee cake mix lacking expiration dates. Additionally, the ice machine was found to have black grime and water dripping onto the ice, and a fan covered in dust was directed at clean dishware. These conditions were confirmed by the dietary manager during interviews. Further observations revealed improper food handling practices, including inconsistent use of food thermometers where the uncleaned part of the thermometer was inserted into food, and inadequate hand hygiene. A dietary staff member was seen touching food and utensils with gloved hands after handling packaging materials without changing gloves or washing hands. These actions were confirmed by both the staff member and the dietary manager. Facility policies require proper labeling, dating, storage, and hand hygiene, but these were not followed as observed.
Failure to Complete Timely Baseline Care Plans for New Admissions
Penalty
Summary
The facility failed to complete baseline care plans within 48 hours of admission for two residents. For one resident with diagnoses including schizoaffective disorder, bipolar disorder, hypothyroidism, chronic embolism and thrombosis, and anxiety, the baseline care plan was not signed as complete until several days after admission. This resident had severe cognitive impairment, was dependent for most activities of daily living, was always incontinent of bowel and bladder, and had multiple pressure ulcers, including a stage four ulcer and three unstageable ulcers. The delay in completing the baseline care plan was confirmed by a registered nurse during an interview. For another resident with diagnoses such as acute kidney failure, dementia, COPD, atrial fibrillation, hypertension, and hyperlipidemia, no baseline or initial care plan was present in the medical record at the time of review. This resident was cognitively intact but required assistance with several activities of daily living and was frequently incontinent of bladder. The absence of a baseline care plan for this resident's admission was confirmed by the Director of Nursing during an interview.
Failure to Hold Required Care Plan Conferences
Penalty
Summary
The facility failed to ensure that care plan conferences were held for two residents as required. For one resident with multiple diagnoses including end stage renal disease, diabetes, and mild cognitive impairment, there was no evidence of a recent care conference. The resident stated she did not recall ever having a meeting to discuss her care or treatment goals. The Social Services Director confirmed that the most recent care conference was held over a year prior, and although staff communicated with the resident's family, no formal care conference had taken place. Similarly, another resident with diagnoses such as chronic obstructive pulmonary disease, heart failure, and intact cognition, who was also receiving hospice services, reported not having attended a care conference. The Social Services Director verified that the last care conference for this resident occurred more than a year ago, and no recent formal care conference had been conducted, despite ongoing informal communication with the resident's family.
Failure to Provide Timely ADL Assistance and Proper Hygiene Care
Penalty
Summary
The facility failed to provide timely and adequate assistance with activities of daily living (ADLs) for two residents. One resident with multiple diagnoses, including hemiplegia, malnutrition, and muscle weakness, required supervision or maximum assistance for most ADLs. Despite documentation in shower and bath logs indicating that fingernail care was performed, direct observation revealed that the resident's fingernails were long, yellow, and causing discomfort due to digging into the palm of a contractured hand. There was no individualized care plan addressing fingernail maintenance or shower refusals, and nursing progress notes lacked documentation of the required three attempts to offer showers per bathing day. Another resident, also with hemiplegia and additional chronic conditions such as diabetes and vascular dementia, required maximum assistance for transfers and other ADLs. The resident requested assistance to get out of bed early in the morning but was not assisted for approximately four hours due to staff being unable to locate the resident's wheelchair. The wheelchair was eventually found after a surveyor intervened. During this period, the resident expressed distress and frustration over the delay. Staff interviews confirmed communication issues regarding the location and identification of assistive devices, and documentation did not reflect adherence to facility policies for accommodating resident needs and providing necessary equipment. Facility policies required daily cleaning and trimming of fingernails, proper documentation of refusals, and ensuring assistive devices were accessible, but these were not followed in the cases observed.
Failure to Provide Consistent Pressure Ulcer Care and Missed Wound Treatments
Penalty
Summary
The facility failed to ensure a comprehensive wound management program for a resident with a Stage 4 pressure ulcer. The resident, who had multiple comorbidities including severe cognitive impairment, diabetes, and immobility, was identified as high risk for pressure ulcers. The care plan included interventions such as a pressure-relieving mattress, repositioning every two hours, use of barrier cream, nutritional supplements, daily skin assessments, and physician-ordered wound treatments. Despite these interventions, review of the Medication Administration Record (MAR) and Treatment Administration Record (TAR) revealed multiple missed wound treatments over several months, with no documented explanations for the missed administrations. These missed treatments included cleansing, packing, and application of various dressings, all of which were ordered to be performed daily or by shift. Interviews with nursing staff, the ADON, and the wound care provider confirmed that the wound progressed from moisture-associated skin damage to an unstageable wound and then to Stage 4, with the wound peaking in size before showing improvement. The Director of Nursing verified that there was no documentation to support that wound treatments were provided as ordered on the identified dates. Facility policy required adherence to physician-ordered wound treatments, but this was not consistently followed, as evidenced by the lack of documentation and missed treatments.
Failure to Follow Up on Contractured Wrist Care
Penalty
Summary
The facility failed to provide appropriate follow-up care and monitoring for a resident with a contractured left wrist. The resident, who had a history of hemiplegia and hemiparesis following a cerebral infarction, muscle weakness, and other significant medical conditions, was observed to have a visibly contractured left wrist. Despite this, there were no active physician orders, care plan interventions, or documented goals addressing the contracture. The care plan did not include any positioning or splinting interventions, nor were there measures to prevent injury from fingernails pressing into the palm. Therapy documentation showed that the resident declined a wrist splint on one occasion, but there was no evidence of follow-up or reassessment by therapy until prompted by a surveyor's inquiry months later. Interviews with facility leadership confirmed that there was no policy or process in place to ensure therapy follow-up after an initial refusal of a splint. Additionally, physician documentation inaccurately identified the affected arm, and no further documentation was available to address the contracture. The lack of ongoing assessment and intervention resulted in the resident's contracture not being properly managed.
Improper Mattress Positioning Creates Accident Hazard
Penalty
Summary
The facility failed to ensure the resident environment was free of potential accident hazards for a resident with significant cognitive and physical impairments, including Alzheimer's disease, dementia, schizoaffective disorder, repeated falls, and dependence on staff for transfers and mobility. The resident's care plan included interventions to prevent sliding out of a wheelchair and to encourage non-skid footwear, but did not address measures to prevent rolling out of bed. Observations revealed that staff placed a solid triangular-shaped cushion between the mattress and the bed frame, causing the mattress to tilt toward the wall and creating a two-to-three-inch gap between the bed and the wall. This setup made it possible for the resident to slide into the gap and become trapped, especially given her inability to free herself due to her condition. Interviews with staff indicated a lack of understanding regarding the purpose and safety of the cushion placement, with one CNA stating it was used to prevent the resident from rolling out of bed, while the LPN was unaware of its purpose. The DON was not aware that staff were using the cushion in this manner and stated that it should not be done. Review of the bed manufacturer's manual indicated that the mattress should be snug against all mattress retainers and warned that improper installation of components could lead to entrapment issues. The facility's failure to identify and address this hazardous setup resulted in a deficiency related to accident prevention and environmental safety.
Failure to Obtain Timely Laboratory Monitoring for Medication Management
Penalty
Summary
The facility failed to obtain physician-ordered laboratory studies to ensure therapeutic medication levels for a resident. The resident, who had multiple diagnoses including chronic kidney disease stage four, epilepsy, and other chronic conditions, was prescribed several medications such as levetiracetam (an anticonvulsant), potassium supplement, fluvoxamine (an antidepressant), and diuretics (aldactone and lasix). Physician orders required a complete metabolic panel and levetiracetam level to be performed every six months to monitor medication efficacy and safety. Record review showed that the last complete metabolic panel and levetiracetam level were completed on 09/16/24, with no subsequent laboratory testing found after that date. The DON confirmed that the required laboratory tests, which were due in March, had not been completed as ordered. Facility policy required staff to process test requisitions and arrange for tests to be completed, but this was not followed, resulting in the missed laboratory monitoring for the resident.
Failure to Ensure Appropriate Antibiotic Use and Monitoring
Penalty
Summary
The facility failed to ensure appropriate monitoring and administration of antibiotics for a resident with a history of multiple complex medical conditions, including urinary retention, obstructive and reflux uropathy, and an indwelling catheter. Over several months, the resident received multiple courses of antibiotics for urinary tract infections (UTIs), including Ciprofloxacin, Amoxicillin-Clavulanate, Nitrofurantoin, Cefepime, Ertapenem, Sulfamethoxazole-Trimethoprim, and Doxycycline. Record review revealed that, in several instances, antibiotics were administered without obtaining a urine culture and sensitivity to confirm the appropriateness of the prescribed medication. Specifically, after the resident returned from the emergency department, antibiotics were given without evidence of a culture and sensitivity being completed, and in another instance, Doxycycline was administered despite the absence of sensitivity results for that medication. Interviews with the DON and Director of Clinical Services confirmed that the facility did not obtain urinalysis or urine culture and sensitivity when residents returned from the hospital with antibiotic orders, even if the hospital had not completed those tests. This practice was inconsistent with the facility's own antibiotic stewardship policy, which requires review of discharge paperwork for antibiotic orders and communication of lab results to the prescriber to guide antibiotic therapy decisions. The failure to obtain and review appropriate laboratory data prior to administering antibiotics led to the deficiency identified during the survey.
Failure to Prevent Severe Weight Loss in Resident Receiving Enteral Feeding
Penalty
Summary
The facility failed to prevent a severe weight loss for a resident who received all nutrition via enteral feedings. The resident, admitted with multiple diagnoses including acute and chronic respiratory failure, atrial fibrillation, and protein-calorie malnutrition, experienced a significant weight loss of 10.55% within a few days and a total of 13.8% within 30 days of admission. Despite the care plan's interventions to monitor and report signs of malnutrition, there was no evidence that the care plan was revised to reflect changes in dialysis and weight loss, nor was the dietician notified in a timely manner. The resident's weight fluctuated significantly, with a noted weight loss from 126.1 pounds to 112.8 pounds within a short period. The facility did not implement new nutritional interventions or notify the physician or dietician of the weight loss. The dietician's recommendations to increase the enteral feeding duration and water flushes were not implemented promptly, and the facility failed to notify the dietician of the resident's discontinued dialysis, which could have impacted the resident's nutritional needs. Interviews with the Director of Nursing and the Registered Dietitian revealed that the facility did not have a system in place to notify the dietician of significant weight changes promptly. The dietician expected timely updates to the electronic medical record to make appropriate recommendations, but the facility's failure to enter weights and notify her of changes led to a delay in addressing the resident's nutritional needs. The facility's policy required immediate notification of the dietician for weight changes of 5% or more, but this was not followed, contributing to the resident's severe weight loss.
Failure in Pain Management for Resident with Pressure Ulcers
Penalty
Summary
The facility failed to provide comprehensive pain management for a resident with multiple pressure ulcers, resulting in actual harm. Resident #37, who was admitted with diagnoses including moderate intellectual disability, schizoaffective disorder, and multiple pressure ulcers, was not properly assessed for pain. The resident was unable to verbalize pain and was assessed through non-verbal cues such as negative vocalization and facial expressions. However, from the time of admission until the incident, there were no additional pain assessments or documentation addressing the resident's pain, nor was a baseline plan of care developed for pain management related to the pressure ulcers. On the day of the incident, Resident #37 was observed yelling and moaning during wound care for a Stage IV pressure ulcer, indicating pain. Despite these clear signs, there was no evidence that the facility identified the yelling and moaning as pain-related or provided any pain medication prior to the dressing change. The Assistant Director of Nursing and the Nurse Practitioner involved in the treatment did not intervene to address the resident's pain, and the treatment was completed without any pain management. The facility's policy required staff to assess pain using a consistent approach and to anticipate situations where pain might increase, such as during wound care. However, this protocol was not followed, as evidenced by the lack of pain assessment and intervention for Resident #37. The Director of Nursing acknowledged that it was not usual practice to neglect pain medication prior to dressing changes, and the expectation was for residents to be assessed and treated for pain if they exhibited signs of discomfort.
Facility Fails to Maintain Safe and Homelike Environment
Penalty
Summary
The facility failed to ensure a safe, clean, and homelike environment for its residents, as evidenced by several deficiencies observed during a survey. The facility's map did not accurately reflect the current use of rooms, with a room occupied by residents being labeled as a storage room. This discrepancy was confirmed by the Maintenance Director, who acknowledged that the room had been approved for resident use but was not updated on the facility maps. Additionally, the room lacked proper labeling, with resident names taped over the storage room sign. Further observations revealed unsafe conditions in resident rooms, including black speckled areas on the drywall, which had not been tested for mold, and exposed electrical wires resulting from the removal of baseboard heating systems. These conditions had persisted since the renovations began, and the rooms remained occupied. Another room was found with loose electrical outlet faceplate covers, cracked bathroom tiles, and missing amenities such as a shower curtain and a toilet paper holder, making it difficult for residents to access necessary items. The facility did not have a policy available for maintaining a safe environment at the time of the survey.
Deficiency in Providing Ordered Serving Size and Whole Milk
Penalty
Summary
The facility failed to provide the ordered serving size and ensure the availability of whole milk for the breakfast meal, affecting seven residents who were supposed to receive whole milk. The breakfast menu included hot or cold cereal, juice, an eight-ounce glass of whole or 2% milk, six ounces of juice, four ounces of breakfast casserole, and a slice of toast. However, during the observation, it was noted that the milk cooler did not contain whole milk, and residents were instead given 2% milk. Additionally, the breakfast casserole was served using a three-ounce spoodle instead of the required serving size. Dietary Aide #320 confirmed that the facility had run out of whole milk the previous day due to a holiday, and the milk delivery was expected later that afternoon. This deficiency was identified during a complaint investigation and affected the nutritional needs of the residents involved.
Kitchen Sanitation and Maintenance Deficiencies
Penalty
Summary
The facility failed to maintain a clean and sanitary kitchen, which had the potential to affect all residents except seven who did not receive anything by mouth. During an observation of the kitchen, several issues were identified, including large loose, flaking paint with exposed rust on the stove hood, heavy dust and grease buildup on the stove hood, electrical outlet boxes, wire guards, and behind the dishwasher storage racks. Additionally, dust and grease buildup was observed on the exhaust fans above the trayline service area. Further observations revealed that the face plate covering the gas line was loose and hanging down, and the lower front panel of the six-burner stove was bent, creating a gap to the underlying electrical and service wires. The knobs on the griddle were installed backwards, the gas flame was unsymmetrical, and the left front half of the griddle would not light. A warning sticker on the stove indicated that improper installation or maintenance could cause property damage, injury, or death. Interviews with staff confirmed the poor condition of the kitchen and the absence of a policy regarding kitchen cleanliness. This deficiency was investigated under Complaint Number OH00156069.
Failure to Provide Dignified Meal Experience
Penalty
Summary
The facility failed to provide a dignified meal experience for Resident #24, who was observed sitting at a dining table without being served a meal while other residents at the same table were eating. Resident #24, who has diagnoses including cerebral infarction, hypertension, dysphagia, and cognitive communication disorder, was admitted on an unspecified date. During the observation on 09/03/24, Resident #24 was seen watching other residents eat and looking around the dining room until their meal was finally served at 12:05 P.M., after the other residents had already started eating. An interview with STNA #621 confirmed that Resident #24 was not served their meal at the same time as the other residents because they normally eat in their room, and their meal was delivered with the hall trays. The Director of Nursing verified that all residents at a table should be served meals simultaneously and emphasized the importance of treating residents with respect and dignity. The facility's policy on dignity, revised in February 2021, states that residents should be cared for in a manner that promotes their well-being and self-esteem, including a dignified dining experience. This deficiency was identified during the investigation of Complaint Number OH00156069.
Failure to Provide Written Notice for Room Changes
Penalty
Summary
The facility failed to provide written notice before changing a resident's room, affecting one resident out of three reviewed for room changes. The resident, who was cognitively intact and admitted with diagnoses including Charcot's joint and diabetes mellitus, experienced multiple room changes without receiving the required written notification. Specifically, there was no documented evidence of written notice for room changes on two occasions. The Director of Nursing confirmed the absence of written notices for these room changes, and the resident reported only receiving written notice for a later room change. The facility's policy required written or verbal notice at least 24 hours in advance, with documentation in the resident's medical record, which was not adhered to in this case.
Failure to Assist Resident with Meals
Penalty
Summary
The facility failed to provide necessary assistance with meals for a resident, leading to a deficiency. Resident #37, who was admitted with diagnoses including moderate intellectual disability, acute respiratory failure, pressure ulcers, and schizoaffective disorder, required limited assistance with eating. The resident was on a regular, puree texture, nectar thick liquids diet and was dependent on assistance for meals. However, during an observation, it was noted that the resident's breakfast tray was out of reach, with all food items sealed and unopened, indicating a lack of meal setup and assistance. Further observations revealed that the drinks were at room temperature, and the food was not steaming, suggesting it had been left unattended for some time. An STNA confirmed that the resident needed assistance with meal setup but could eat independently afterward. Despite this, the STNA only opened the juice and milk, which were not in the correct consistency, and reported that the resident refused the meal. The DON confirmed the meal delivery times, indicating a delay in providing the necessary assistance to the resident.
Failure to Provide Timely Pressure Ulcer Care
Penalty
Summary
The facility failed to provide timely and comprehensive pressure ulcer care for a resident admitted with multiple pressure ulcers. Upon admission, the resident was identified as being at very high risk for pressure ulcer development, with existing ulcers on the sacrum, left inner ankle, and right heel. However, the facility did not document the presence of a deep tissue pressure injury on the left heel during the admission assessment, and no baseline plan of care for skin integrity or pressure ulcers was initiated. There was a delay in ordering treatments for the resident's pressure ulcers, with no treatments ordered for the sacrum ulcer until two days after admission, and for the other ulcers until three days after admission. Preventative measures to prevent further decline or new ulcer development were also not ordered during this period. When treatments were eventually ordered, they included a wet-to-dry dressing and a low air loss mattress, but these were not implemented immediately upon admission. During an observation of the resident's sacrum pressure ulcer treatment, it was noted that the incontinence product was saturated, and there was no dressing covering the ulcer as ordered. The staff involved in the care did not follow proper infection control procedures, such as changing gloves and washing hands after providing care. Interviews with nursing staff confirmed the lack of a dressing and the failure to implement ordered treatments promptly. The facility's policy required a full assessment and documentation of pressure sores, which was not adhered to in this case.
Unsafe Transportation of Oxygen Tanks
Penalty
Summary
The facility failed to ensure the safe transportation of oxygen tanks for residents requiring supplemental oxygen. Resident #57, who has diagnoses including unspecified dementia and chronic obstructive pulmonary disease, was observed being assisted by a State tested Nurse Aide (STNA) who improperly secured the oxygen tank. The STNA removed the oxygen regulator from an empty tank, attached it to a new tank, and placed the full tank into a wheeled carrier. However, the carrier was wedged between the push handle and the lower metal frame, compromising the safety of the transport. This was verified by an interview with a Licensed Practical Nurse (LPN). Similarly, Resident #89, with diagnoses including end-stage renal disease and chronic obstructive pulmonary disease, was observed being transported with an unsecured oxygen tank. The tank was placed in a rolling two-wheel cart carrier, which was wedged between the geri-chair push handle and the lower metal frame, failing to secure the tank during transport. This observation was also confirmed by an LPN. The facility's policy on oxygen administration, revised in April 2024, requires that oxygen tanks be securely fastened, which was not adhered to in these instances.
Failure to Implement Enteral Feeding Recommendations Timely
Penalty
Summary
The facility failed to implement timely enteral feeding recommendations for a resident, leading to significant weight loss. The resident, who was admitted with multiple diagnoses including acute and chronic respiratory failure, atrial fibrillation, and protein-calorie malnutrition, was receiving nutrition primarily through a feeding tube. Despite recommendations from a registered dietitian to increase the feeding volume and flushes, these were not implemented promptly, resulting in a significant weight loss of over 13 pounds in a short period. The care plan for the resident was not updated to reflect changes in the resident's condition, such as the discontinuation of dialysis and the observed weight loss. The registered dietitian's recommendations were not acted upon until two days after they were made, and there was no evidence of communication to the dietitian about the resident's weight changes until much later. The facility's policy required immediate notification of the dietitian in writing for significant weight changes, which was not followed. Interviews with the director of nursing and the registered dietitian revealed a lack of timely communication and implementation of dietary recommendations. The dietitian expected to be informed of weight changes and other significant developments, but the facility failed to notify her promptly. This lack of communication and delay in implementing dietary recommendations contributed to the resident's continued weight loss and nutritional decline.
Failure to Administer Oxygen Per Physician Orders
Penalty
Summary
The facility failed to ensure that a resident received oxygen per physician orders, affecting one resident diagnosed with unspecified dementia, chronic obstructive pulmonary disease, and dependence on supplemental oxygen. The resident was ordered to receive continuous oxygen at 2 liters per minute via nasal cannula. However, during an observation, a State tested Nurse Aide (STNA) was seen setting the oxygen flow rate to 3 liters per minute, which was verified by a Licensed Practical Nurse (LPN) as incorrect according to the physician's orders. Additionally, the Director of Nursing confirmed that a nurse should be responsible for changing oxygen tanks and setting the flow rate. Further observations revealed that the resident was not wearing oxygen while sitting in the lobby, despite the physician's order for continuous oxygen. A Medical Records staff member confirmed the resident's order for oxygen and notified a nurse. A Registered Nurse (RN) later attempted to obtain the resident's oxygenation level but was initially unsuccessful. After applying supplemental oxygen at the correct flow rate, the resident's oxygenation level was recorded at 100%. The facility's policy on oxygen administration required reviewing physician's orders, which was not adhered to in this instance.
Inaccurate Medical Records and Documentation Deficiencies
Penalty
Summary
The facility failed to maintain accurate medical records for three residents, leading to deficiencies in documentation and assessment. Resident #37 was admitted with multiple diagnoses, including a deep tissue pressure injury (DTPI) on the left heel, which was not documented between admission and a later date. Additionally, the sacrum ulcer was inaccurately assessed as a vascular ulcer instead of a pressure ulcer, and there was no staging for other pressure ulcers upon admission. The Director of Nursing (DON) confirmed these discrepancies during interviews, highlighting the lack of proper documentation and assessment. Resident #2's medical records showed inconsistencies in weight documentation, with a significant discrepancy between the recorded weight and the actual weight after dialysis. The DON confirmed that the weight difference was due to actual weight loss, not a scale error, and acknowledged the need for education to address scale variances. For Resident #28, there were inconsistencies in the physician's orders and care plan regarding the size of the suprapubic catheter balloon, which were not clarified with the physician. The DON verified that the urologist was not changing the catheter as per the monthly schedule, and the care plan contained conflicting information about the catheter balloon size.
Infection Control Deficiencies in Incontinence and Catheter Care
Penalty
Summary
The facility failed to implement proper infection control protocols during incontinence care for Resident #37, who was admitted with diagnoses including moderate intellectual disability, schizoaffective disorder, multiple pressure ulcers, and anxiety. During an observation, a Licensed Practical Nurse, a Registered Nurse, and a State tested Nurse Aide were involved in the treatment of a sacrum pressure ulcer. The State tested Nurse Aide did not change gloves after providing incontinence care and repositioning the resident, and subsequently left the room without washing hands. This was in violation of the facility's hand hygiene policy, which requires handwashing after glove removal and before moving from a soiled to a clean body site. Additionally, the facility did not maintain proper infection control for Resident #28, who had a suprapubic catheter due to neurogenic bladder. During an observation, the resident's urinary catheter bag and tubing were seen dragging on the floor as the resident moved in her wheelchair. An Activity Aide and a State tested Nurse Aide verified the observation, and the catheter tubing and bag were subsequently secured. This was contrary to the facility's catheter care policy, which mandates that catheter tubing and drainage bags be kept off the floor.
Latest citations in Ohio
A resident with intact cognition receiving Medicare Part A skilled services for metabolic encephalopathy had services discontinued while benefit days remained, but the facility did not issue the required Skilled Nursing Facility Advance Beneficiary Notice (SNF ABN). The Social Services Director later confirmed that no SNF ABN was provided and reported she believed only a Notice of Medicare Non-Coverage (NOMNC) was needed when all skilled services were stopped. This practice conflicted with the facility’s written policy, which required SNF ABNs to be issued when extended care items or services were initiated, reduced, or terminated due to expected non-coverage by Medicare.
Surveyors identified that the facility exceeded the acceptable medication error rate when two residents with type 2 DM received insulin doses that were not administered according to orders or manufacturer instructions. In two separate observations, an LPN administered Novolog and another LPN administered insulin glargine and insulin lispro without priming the insulin pens, and the insulin lispro and Novolog were given after the residents had already consumed a significant portion of their breakfast meals, despite orders for administration before meals. Manufacturer information for both insulin products required priming before each injection to ensure accurate dosing, and facility policy required medications, including insulin, to be administered safely, timely, and in accordance with prescriber orders and specified time frames.
Surveyors found that the facility failed to document tray line food temperatures for multiple meals served from two dining room kitchenettes, despite having a “Trayline Taste & Temperature Log” and a policy requiring food to be stored, prepared, distributed, and served according to professional food safety standards. Review of logs showed repeated missing entries for breakfast, lunch, and dinner services in both the Harrison and McClellan dining areas, and the Senior Director of Culinary Services confirmed that temperatures had not been recorded for those meals, potentially affecting all residents receiving meals from those kitchenettes.
The facility failed to conduct and document required periodic care conferences for two residents, despite multiple comprehensive, quarterly, and significant change MDS assessments and a policy requiring periodic care conferences with resident and/or family participation. One resident with Parkinson’s disease, post-stroke hemiplegia, TIA, DMII, and depression had only two documented care conferences over a year, while another resident with aphasia, cerebrovascular disease, DMII, gait difficulty, coagulation defect, depression, and muscle weakness had no documented care conferences in the past year, aside from a declined invitation to the representative. The UCC confirmed that care conferences were expected to occur quarterly and that no additional documentation existed for either resident.
A resident with Alzheimer's disease and type II DM, who required extensive assistance with ADLs and was receiving scheduled Lantus and sliding-scale Humalog, experienced a severely elevated blood glucose level. The on-call provider was notified and ordered an additional dose of lispro insulin with a directive to recheck the blood glucose after administration. Nursing staff administered the extra insulin but did not document any follow-up blood glucose check, and the DON confirmed that this reevaluation was required by the facility's abnormal blood glucose policy and was not completed or documented.
A resident with Parkinson’s disease, dementia, and hypothyroidism was prescribed levothyroxine once daily along with other medications. A consultant pharmacist’s monthly drug regimen review recommended that levothyroxine be given in the morning on an empty stomach, 30–60 minutes before food, per manufacturer instructions. The medical record contained no documented physician response to this recommendation, and the MAR showed the drug scheduled for morning administration while the resident was observed eating breakfast and receiving the medication at the same time. An LPN confirmed administering levothyroxine during the meal, and the DON verified there was no documentation explaining whether or why the pharmacist’s recommendation was or was not followed, resulting in a failure to act on and document the identified irregularity.
A resident with severe cognitive impairment, multiple comorbidities, documented gait and balance abnormalities, and a high fall risk was care planned and assessed by therapy to require contact guard assistance and use of a gait belt for transfers and ambulation. While being assisted by a CNA from a recliner to the bathroom with a walker, the CNA did not apply a gait belt, even though the resident had a known tendency to lean backward when standing. As the CNA reached to open the bathroom door, the resident lost balance and fell backward, striking the back of the head, and was later found by an LPN without a gait belt in place, contrary to the facility’s gait belt policy and the resident’s assessed needs.
A resident with CKD stage five requiring peritoneal dialysis (PD) was admitted with pre-admission physician orders for three daily PD exchanges and monitoring for peritonitis (fever, abdominal pain, cloudy effluent), but these monitoring orders were not entered into the facility’s physician orders. The care plan referenced PD and general monitoring but did not specifically address peritonitis monitoring. Paper PD flowsheets showed incomplete and inconsistent documentation of exchanges and resident condition, including missing condition/comments for individual treatments and no record of one ordered PD exchange. The PD cycler flowsheet lacked effluent descriptions on multiple days. The PD nurse reported facility staff were expected to monitor effluent and symptoms, and the DON confirmed the absence of specific peritonitis monitoring orders, lack of an order for the PD cycler, and documentation gaps, despite a facility policy requiring ongoing assessment and monitoring for complications before, during, and after dialysis treatments.
A nurse was observed preparing multiple oral medications for a resident with depression, traumatic brain injury, anxiety, and impaired cognition by pushing tablets and capsules from unit-dose cards directly into her ungloved hand and then using her fingers to place them into a medication cup. In a follow-up interview, the RN confirmed this practice and acknowledged that the correct procedure is to dispense medications directly from the card into the cup, contrary to the facility’s medication administration policy requiring adherence to good nursing principles and practices.
A resident with Alzheimer’s disease, diabetes, anxiety, significant ADL dependence, and behavioral symptoms was observed seated in a chair positioned against the nursing station with a locked wheelchair placed directly in front, also against the nursing station, effectively restricting movement. An LPN confirmed both wheelchair wheels were locked and that it should not have been placed there, while a CNA stated she had positioned the wheelchair to prepare for lunch, was unable to complete the transfer, and left it in place, acknowledging this was wrong. This arrangement conflicted with the facility’s restraint policy, which prohibits physical restraints except when alternatives are ineffective for treating a medical symptom and defines restraints as devices adjacent to the body that cannot be easily removed and that restrict freedom of movement or access to the body.
Failure to Issue Required SNF ABN When Discontinuing Medicare Part A Services
Penalty
Summary
The deficiency involves the facility’s failure to issue a Skilled Nursing Facility Advance Beneficiary Notice (SNF ABN) when Medicare Part A services were discontinued for a resident who still had available benefit days. The resident was admitted with a diagnosis of metabolic encephalopathy and had intact cognition per the Minimum Data Set assessment. The facility’s own SNF Beneficiary Notification Review documented that Medicare Part A skilled services began on 02/11/26 and the last covered day was 03/11/26, and that the facility initiated discharge from Medicare Part A services before the resident’s benefit days were exhausted. Despite this, no SNF ABN was provided to the resident or the resident’s representative. During interviews, the Social Services Director stated that the SNF ABN was issued hours prior to the last covered day but, upon reviewing her files, confirmed that no SNF ABN had actually been issued for this resident. She further explained that she believed an SNF ABN was only required if one skilled service remained and that if all skilled services were being discontinued, only the Notice of Medicare Non-Coverage (NOMNC) needed to be issued. The Administrator, however, stated that a resident should always receive both a SNF ABN and a NOMNC when Medicare Part A services are discontinued and benefit days remain. Review of the facility’s written policy dated 03/28/23 showed that the facility was required to issue SNF ABNs for initiation, reduction, or termination of extended care items or services when Medicare payment was not expected, which did not occur in this case.
Plan Of Correction
This Plan of Correction is submitted as required under State and Federal law. This Plan of Correction does not constitute an admission on the part of the Facility that the findings cited are accurate, that the findings constitute a deficiency or that the scope and severity regarding the deficiency cited are correctly applied. Any changes to the Facility's policies and procedures should be inadmissible in any proceeding on that basis. Without admitting or denying the validity or the existence of the alleged noncompliance, the Facility submits this Plan of Correction with the intention that it be inadmissible by any third party in any civil or other action against the facility or any employee, agent, officer, director or shareholder of the Facility. The Facility is utilizing this Plan of Correction as its allegation of substantial compliance as of 05/29/2026 F-0582 Corrective action for resident/s: On 5/14/26 Resident #34 was informed of rights and responsibilities related to Advanced Beneficiary Notice and voiced understanding of information for future reference by administrator. Identification of other residents who may be affected: Any resident receiving skilled services from nursing or therapy services. The Administrator audited all residents who were discharged from skilled services in the past 30 days to ensure they were issued a Notice of Non-Coverage and Advanced Beneficiary Notice on 5/29/26. No non-compliance was noted. Measures for systemic change: On 5/14/2026 Business Office Manager, Director of Rehab, Minimum Data Set nurse, Director of Nursing and Social Services Director were educated on proper procedure of issuing of Notice Of Medicare Non Coverage and Advanced Beneficiary Notice by administrator. All upcoming discharges from skilled services will be reviewed weekly at Utilization Review meeting to ensure notices will be delivered timely. How Corrective Action will be monitored: Administrator or designee to complete audits of all residents being discharged from skilled services to ensure they were issued a Notice of Non-Coverage and Advanced Beneficiary. This audit will be completed weekly x 4 weeks, then monthly x 2 months. Corrective action will be initiated for any noted non-compliance. Audit findings will be reviewed as part of the monthly quality assurance process to determine the need for further monitoring. Date of Compliance 5/29/26
Insulin Administration Errors and Failure to Prime Insulin Pens
Penalty
Summary
The deficiency involves the facility’s failure to maintain a medication error rate below 5%, with surveyors identifying 3 errors out of 28 medication administration opportunities, resulting in a 10.71% error rate. For one resident with type 2 diabetes mellitus and moderate cognitive impairment, the physician’s order directed Novolog insulin 10 units via subcutaneous pen-injector to be given before meals. During an observed medication pass, the LPN administered 10 units of Novolog insulin without priming the pen and did so after the resident had already consumed approximately 50% of the breakfast meal. The LPN later confirmed she did not prime the pen and acknowledged that the insulin was ordered to be administered prior to meals. Manufacturer instructions for the Novolog FlexPen specified that an air shot (priming) must be performed before each injection to ensure proper dosing. Another resident, also diagnosed with type 2 diabetes mellitus and with intact cognition, had orders for insulin glargine 35 units subcutaneously twice daily and insulin lispro 20 units subcutaneously before meals, plus 12 units subcutaneously if blood glucose was between 251 mg/dL and 300 mg/dL. During an observed medication administration, an LPN administered 35 units of insulin glargine and 32 units of insulin lispro without priming the insulin pens and after the resident had consumed approximately 90% of the breakfast meal, despite orders for insulin lispro to be given before meals. The LPN later stated she could not remember if she had primed the pen and acknowledged that the insulin was ordered to be administered prior to meals. Manufacturer information for insulin lispro stated that the pen must be primed before each injection to confirm insulin delivery and remove air, and that failure to prime could result in too much or too little insulin. The DON confirmed the expectation that insulin be administered as ordered, including priming each pen with two units before dialing the prescribed dose, and facility policy required medications, including insulin, to be administered safely, timely, and in accordance with prescriber orders and required time frames.
Plan Of Correction
This Plan of Correction is submitted as required under State and Federal law. This Plan of Correction does not constitute an admission on the part of the Facility that the findings cited are accurate, that the findings constitute a deficiency or that the scope and severity regarding the deficiency cited are correctly applied. Any changes to the Facility's policies and procedures should be inadmissible in any proceeding on that basis. Without admitting or denying the validity or the existence of the alleged noncompliance, the Facility submits this Plan of Correction with the intention that it be inadmissible by any third party in any civil or other action against the facility or any employee, agent, officer, director or shareholder of the Facility. The Facility is utilizing this Plan of Correction as an allegation of substantial compliance as of 5/29/2026. F-0759 Corrective action for resident/s: Residents #21 and #22 were assessed and evaluated by nurse and Director of Nursing 5/14/26. Resident #21 and #22 both denied any adverse effects and none were noted upon assessment by the Director of Nursing on 5/14/2026. Notification made to physician on 5/14/2026. LPN # 2 competency Eval on insulin administration with the Director of Nursing completed 5/14/2026. Identification of other residents who may be affected: Diabetic residents on assignment of LPN #2/station 2 have the potential to be affected and were assessed by the DON/Designee on 5/14/26 and found to be within normal limits. Measures for systemic change: All Nurses were educated by the Director of Nursing on the steps for Insulin administration per competency, diabetes clinical protocol policy, Medication and treatment orders policy, administering medications policy, and Obtaining fingerstick Glucose Level policy On 5/14/2026. How Corrective Action will be monitored: Director of Nursing and Assistant Director of Nursing will complete insulin administration audits on 5 nurses. This audit will be completed weekly x 4 weeks, then monthly x 2 months. Corrective action will be initiated for any noted non-compliance. Audit findings will be reviewed as part of the monthly quality assurance process to determine the need for further monitoring. Date of Compliance: 5/29/2026
Failure to Document Tray Line Food Temperatures in Dining Room Kitchenettes
Penalty
Summary
The deficiency involves the facility’s failure to document tray line food temperatures for meals served from the Harrison and McClellan Dining Room kitchenettes, as required by professional standards for food service safety and the facility’s own policy. Review of the “Trayline Taste & Temperature Log” (revised September 2018) showed missing temperature documentation for multiple meals from the Harrison Dining Room kitchenette, including dinner on 03/30/26 and 03/31/26, lunch and dinner on 04/01/26 and 04/02/26, dinner on 04/07/26, and lunch and dinner on 04/08/26 and 04/10/26. The Senior Director of Culinary Services confirmed during interview that tray line food temperatures were not documented on the log for these meals. Similarly, review of the same log for the McClellan Dining Room kitchenette revealed that tray line food temperatures were not documented for dinner on 04/01/26, breakfast and lunch on 04/02/26, and lunch and dinner on 04/07/26. The Senior Director of Culinary Services also verified these omissions during interview. The facility census at the time was 27 residents, and the governing “Food and Nutrition” policy, approved on 09/07/21, stated that the facility must store, prepare, distribute, and serve food in accordance with professional standards for food service safety.
Plan Of Correction
F812 The facility will continue to ensure food temperatures are completed before meals are served for all residents. To ensure compliance with this standard the following measures have been taken: 1. Immediately 4/15/26 culinary supervisor #224 was re-educated by Dietary Manager to this standard and policy "Food and Nutrition" which includes documentation of food temperatures. 2. All dietary staff have been re-educated to the standard and policy "Food and Nutrition" during the month of April 2026. 3. Audits of food temperature documentation to be completed by Dietary Manager 4 x per week for 4 weeks then weekly for 4 weeks. 4. Administrator to validate audits/compliance and provide additional training as needed. Administrator will present to QAPI committee for ongoing monitoring and further direction.
Failure to Conduct and Document Required Care Conferences
Penalty
Summary
The deficiency involves the facility’s failure to complete and document comprehensive care conferences at required intervals in accordance with care plan regulations and facility policy. For one resident with Parkinson’s disease with dyskinesia, cognitive communication deficit, hemiplegia and hemiparesis following cerebral infarction, transient cerebral ischemic attack, type II diabetes mellitus, and major depressive disorder, the record showed multiple MDS assessments over a one-year period, including annual, quarterly, and significant change assessments. However, only two care conferences were documented during the last 12 months, despite the expectation that care conferences be conducted quarterly with the resident and family when possible. The Unit Care Coordinator confirmed that no additional care conference documentation existed for this resident beyond the notes dated 04/21/25 and 01/02/26. A second resident, with diagnoses including aphasia following cerebrovascular disease, cerebral infarction, type II diabetes mellitus, unsteadiness on feet, difficulty in walking, coagulation defect, depression, and muscle weakness, also had multiple MDS assessments completed over the review period, including quarterly and annual assessments. The record contained a note that a care conference was offered to the resident’s representative, who declined to attend, but there was no documentation of any care conferences for the most recent 12 months. The Unit Care Coordinator confirmed that no other care conference documentation was available for this resident. Facility policy stated that periodic care conferences involving the resident, family, and the interdisciplinary team are part of the care planning process, but the required periodic care conferences and corresponding documentation were not completed for these two residents.
Plan Of Correction
THIS PLAN OF CORRECTION SERVES AS BERKELEY SQUARE'S CREDIBLE ALLEGATION OF SUBSTANTIAL COMPLIANCE AS OF June 1, 2026. Without admitting or denying the validity or existence of the alleged deficiencies, Berkeley Square provides the following Plan of Correction: F657 The facility will continue to document completion of care conferences at the required intervals for all residents, including residents #04 & #15. To ensure compliance with this standard the following measures have be taken: 1. The social service designee and the inter- disciplinary team were re-educated by the administrator to the facility policy "Care Conference" on 4/29/26 and verbalized understanding. 2. Care conferences for resident #04 and resident #15 were conducted on or before 4/29/2026 by the interdisciplinary team. 3. Review of all other residents was conducted by the social service designee to validate and ensure that care conference schedule is up to date with timely care conferences scheduled for them on 4/15/2026. Audits of care conferences to be completed weekly for four weeks and then monthly after that by the social service designee. Documentation of the care conference including any identified concerns in the medical record. Administrator to validate audits/compliance and provide additional training as needed. Administrator will present results of these audits to QAPI committee for ongoing monitoring and further direction.
Failure to Reevaluate Blood Glucose After Treatment for Hyperglycemia
Penalty
Summary
The facility failed to ensure that a resident with diabetes received treatment in accordance with professional standards of practice when nursing staff did not reevaluate the resident's blood glucose after treatment for severe hyperglycemia. The resident, admitted with diagnoses including Alzheimer's disease, type II diabetes mellitus, and depression, had physician orders for Humalog insulin on a sliding scale before meals, Lantus insulin 25 units daily, and lisinopril 5 mg daily. The resident required extensive assistance with activities of daily living, including transfers, toileting hygiene, eating, and bathing. On the evening in question, the resident's blood glucose was documented as 532 mg/dL, and the on-call provider was notified. The provider gave a new order to administer an additional 8 units of lispro (Humalog) and to recheck the blood glucose in 30 minutes. The electronic medication administration record showed that the blood glucose of 532 mg/dL was obtained at 9:00 p.m. and that the additional 8 units of lispro were administered at 9:21 p.m. However, there was no documentation in the resident's chart that the blood glucose was rechecked after the additional insulin was given. In an interview, the DON confirmed there was no evidence of reevaluation and verified that, according to the facility's "Abnormal Blood Glucose Procedure" policy, the resident should have been reevaluated and that the evaluation step should have been included in the progress note documentation.
Plan Of Correction
F684 The facility will continue to ensure all residents, including #03, receive treatment in accordance with professional standards of practice and reevaluated for hyperglycemia. To ensure compliance with this standard the following measures have been taken: 1. The director of nursing assessed resident #03, reviewed documentation and orders and found no ill effects immediately 4/16/26. 2. All licensed nurses were re-educated to facility policy "Blood Glucose Monitoring" by the Director of Nursing/designee in April 2026. 3. Audits of like-residents that require blood sugar checks to be completed by the director of nursing/designee two times a week for 4 weeks and then monthly after that to validate correct follow through when there is abnormally high blood glucose result. The Administrator will bring results of these audits to the QAPI committee for ongoing monitoring and further direction.
Failure to Act on Pharmacist Drug Regimen Recommendation for Thyroid Medication
Penalty
Summary
The deficiency involves the facility’s failure to ensure that pharmacy recommendations from the monthly drug regimen review were acted upon and documented for a resident. The resident was admitted with diagnoses including Parkinson’s disease, dementia, and hypothyroidism, and had current physician orders for levothyroxine 150 mcg once daily, buspirone 50 mg twice daily, and losartan 100 mg once daily. A medication regimen review dated 11/25/2025 included a consultant pharmacist recommendation that levothyroxine be administered consistently in the morning on an empty stomach, at least 30–60 minutes before food, per manufacturer instructions. There was no specific physician response in the medical record to this recommendation, and the facility’s policy stated that consulting pharmacist reviews are sent to nursing and addressed with the primary care provider or consulting specialist for review and follow-up. Review of the resident’s medication administration record for April 2026 showed levothyroxine scheduled for 9:00 a.m. On observation, the resident was seen eating breakfast in the dining area at 8:03 a.m., and an LPN reported administering the levothyroxine 150 mcg to the resident while the resident was in the dining area eating breakfast. The DON confirmed there was no evidence in the resident’s medical record explaining why the consultant pharmacist’s recommendation from 11/25/2025 was or was not acted upon. This lack of documented physician review and action on the pharmacist’s identified irregularity constituted noncompliance with the drug regimen review requirements.
Plan Of Correction
F756 The facility will continue to ensure the pharmacy recommendations from the monthly drug regimen review by a licensed pharmacist are acted upon for all residents, including #08. To ensure compliance with this standard the following measures have been taken: 1. Resident #08 was assessed by the registered nurse and med review completed by 4/28/26. After review of resident's drug regime's, it was discovered that resident #8 had 2 separate medication recommendations on the same form, to be reviewed by two separate practitioners, pharmacy has been instructed and agreed to separate meds on individual forms. 2. Licensed nurses re-educated to facility policy "Drug Regimen Review" by Director of nursing/designee in April 2026 and no later than 5/8/26. Licensed nurses are responsible for ensuring the reviews and recommendations are given to the physician for timely review. 3. Review of all other current residents Drug Regimen orders completed by Director of nursing/designee on 4/16/26 to ensure recommendations were followed up on/reviewed by the physician and address concerns if needed. 4. Audit of drug regime recommendations, pharmacy recommendations, and physician follow up to be completed weekly for four weeks by the Director of nursing/designee. Administrator will present results of these audits to the QAPI committee for ongoing monitoring and further direction.
Failure to Use Required Gait Belt During Ambulation Resulting in Resident Fall
Penalty
Summary
The deficiency involves the facility’s failure to ensure that a required gait belt was used while assisting a high fall‑risk resident with ambulation, resulting in a fall with head injury. The resident had multiple diagnoses including metabolic encephalopathy, hypertension, osteoarthritis, muscle weakness, gait and mobility abnormalities, major depressive disorder, anxiety, and visual hallucinations. Admission and subsequent MDS and fall risk assessments documented that the resident was severely cognitively impaired, required moderate to maximal assistance with transfers and ambulation, could not independently come to a standing position, exhibited loss of balance while standing, used an assistive device, and had decreased muscle coordination. The resident had a history of falls prior to admission and was assessed as being at high, later moderate, risk for falls. The resident’s fall care plan identified her as at risk for falls and included interventions such as providing maximum to moderate assistance with transfers and walking short distances, use of a walker and wheelchair, and following the facility’s fall protocol. Therapy notes and care conference documentation indicated that the resident leaned backwards when standing, required contact guard to minimal assistance for bed mobility and transfers, and needed constant verbal cueing for safe sequencing during toilet transfers. The physical therapist confirmed that the resident was to use a gait belt with staff when ambulating, and the DON verified that therapy had assessed the resident as requiring contact guard assistance and a gait belt for ambulation and transfers. On the day of the incident, a CNA was assisting the resident from her recliner to the bathroom using a walker. The CNA walked beside the resident, providing guidance and support, and reported having a hand on the resident while assisting her. As they approached the bathroom door, the CNA reached for the doorknob to open it, and at that moment the resident began to lose her balance and fell backwards to the floor, striking the back of her head. The nurse who responded found the resident on her back at the foot of the bed with her feet near the bathroom, noted a red raised area on the back of the head, and documented that the resident was not wearing a gait belt and that the gait belt was on the dresser. In the facility’s investigative summary and in interviews, the CNA acknowledged that she did not have a gait belt on the resident while ambulating her, despite the resident’s assessed need for hands‑on assistance and gait belt use per facility policy and the resident’s care and therapy plans.
Failure to Implement PD Orders and Monitor Resident Receiving Peritoneal Dialysis
Penalty
Summary
The deficiency involves the facility’s failure to implement pre-admission physician orders for peritoneal dialysis (PD) and to provide ongoing monitoring for a resident with chronic kidney disease (CKD) stage five who required PD. Pre-admission orders dated 11/14/25 specified three daily PD exchanges at 6:00 A.M., 2:00 P.M., and 10:00 P.M., and directed staff to monitor for signs and symptoms of peritonitis, including fever, abdominal pain, and cloudy effluent. These monitoring orders were not entered into the facility’s physician orders. The resident’s care plan noted the need for PD and included general monitoring interventions (labs, signs of bleeding, bacteremia, septic shock, and significant vital sign changes), but did not specifically address the ordered monitoring for peritonitis. Review of PD documentation showed incomplete and inconsistent charting of treatments and resident condition. The paper peritoneal flowsheet had columns for time of PD and condition/comments, including instructions to call the nurse immediately for cloudy fluid, abdominal pain, or fever. However, the first entry on 11/15/26 at 2:00 P.M. only noted that the PD nurse completed the exchange, and the 10:00 P.M. entry that day had no condition/comment documentation. Subsequent days (11/16/25, 11/17/25, and 11/18/25) contained only one condition/comment entry per day rather than for each exchange, and there was no documentation that the 6:00 A.M. PD on 11/18/25 was completed. The PD cycler flowsheet starting 11/19/25 lacked any description of the effluent on multiple days. The PD nurse from the dialysis company stated facility staff were expected to monitor effluent for cloudiness and assess for abdominal pain and fever, and the DON confirmed there was no electronic physician order for peritonitis monitoring or for use of the PD cycler, that the paper charting did not allow for effluent description or symptom documentation for each treatment, and that PD was not documented at one ordered time. The facility’s dialysis policy required ongoing assessment and monitoring for complications before, during, and after treatments, which was not reflected in the documentation for this resident.
Improper Infection Control During Medication Administration
Penalty
Summary
Surveyors identified a deficiency in infection prevention and control related to medication administration for Resident #29. The resident was admitted on 02/28/14 with diagnoses including depression, traumatic brain injury, and anxiety, and had impaired cognition per a quarterly MDS assessment. During an observation on 03/25/26 at 6:58 A.M., RN #281 prepared the resident’s medications by removing an Amoxicillin-Pot Clavulanate tablet from the medication card and pushing it directly into her ungloved hand, then using her fingers to place the pill into a medication cup. The same process was observed for multiple other medications, including Escitalopram Oxalate, Furosemide, Sennosides, Lyrica, and Vitamin D, each being pushed from the card into the RN’s ungloved hand and then transferred by her fingers into the medication cup before administration to Resident #29. In a subsequent interview at 7:27 A.M. the same day, RN #281 confirmed she had placed each medication into her ungloved hands prior to administration and acknowledged that the proper procedure was to push the pills directly from the card into the medication cup. Review of the facility’s “Medication Administration – General guidelines” policy, revised 10/08/25, stated that medications are to be administered in accordance with good nursing principles and practices. This practice failure was cited as a deficiency under Complaint Number 2681777.
Improper Use of Wheelchair as a Physical Restraint
Penalty
Summary
Surveyors identified a deficiency related to the facility’s failure to ensure a resident was free from physical restraints. Resident #7, admitted with diagnoses including Alzheimer’s disease, diabetes mellitus, and anxiety disorder, was documented on a recent MDS as rarely understood and dependent for ADLs except eating. The resident ambulated independently on the unit without an assistive device and had documented verbal and other behaviors occurring one to three days during the look-back period. The care plan noted the resident had potential to be physically aggressive, chase staff, throw objects, and be combative with care, with interventions such as offering choices, administering medications as ordered, and intervening early when agitation occurred. During an observation and interview, Resident #7 was found sitting in a chair with the right arm of the chair positioned against the nursing station and a wheelchair placed directly in front of him. The left arm of the wheelchair was also against the nursing station, and both wheelchair wheels were locked, creating a barrier that appeared to restrain the resident, who was sleeping with his knees touching the locked wheelchair. An LPN confirmed both wheelchair wheels were locked and that the wheelchair should not have been placed in front of the resident. A CNA reported she had placed the wheelchair there in preparation to get the resident up for lunch, was unable to transfer him, and left the wheelchair in that position, acknowledging it was wrong to keep it there. The facility’s physical restraint policy stated that physical restraints are not used except when alternatives are not appropriate or effective for treating a medical symptom and defined physical restraints as any device attached or adjacent to the body that the individual cannot easily remove and that restricts freedom of movement or access to the body.
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