Foundation Park Care Center
Inspection history, citations, penalties and survey trends for this long-term care facility in Toledo, Ohio.
- Location
- 1621 S Byrne Rd, Toledo, Ohio 43614
- CMS Provider Number
- 365752
- Inspections on file
- 27
- Latest survey
- February 26, 2026
- Citations (last 12 mo.)
- 9 (1 serious)
Citation history
Health deficiencies cited at Foundation Park Care Center during CMS and state inspections, most recent first.
A resident with dementia, incontinence, mobility deficits, and multiple comorbidities developed a coccyx Stage II pressure ulcer that progressively worsened to an unstageable ulcer with necrotic tissue. Although the care plan and facility policy called for monitoring skin changes, notifying clinical staff, weekly skin assessments, barrier cream use, dietitian involvement, and wound specialist management, the record showed no reassessment of the resident’s condition or investigation of the ulcer’s source as it enlarged and deteriorated. Documentation lacked evidence of nutritional assessment or support, mechanical pressure relief devices, or off-loading strategies being implemented, and later wound specialist recommendations for pressure redistribution and nutrition monitoring were not promptly documented as carried out.
A resident with severe cognitive impairment and multiple comorbidities experienced an unwitnessed fall and was found unresponsive on the bathroom floor, diaphoretic and with a head laceration. An LPN initiated neuro checks but notified the physician only by fax rather than by phone, resulting in a delayed physician response, and the resident’s representative was not informed of the fall until several hours after the incident. Facility policy required immediate notification of the physician and resident representative for incidents involving injury and symptoms such as loss of consciousness, but this was not followed, as confirmed by the DON.
A resident with multiple comorbidities and a documented fall-risk care plan was found unresponsive on the bathroom floor with a head laceration after an unwitnessed fall. An LPN and other staff moved the unresponsive resident from the floor to the bed without contacting EMS, despite the observed head injury and lack of consciousness. Although neuro checks were initiated, documentation on the neurological observation form included only vital signs and omitted required assessments of pupillary response and hand grasps, and no additional neurological assessment was recorded. These actions and omissions resulted in a failure to provide appropriate treatment and care according to the resident’s orders and care plan following the fall.
A resident with severe cognitive impairment and multiple health conditions was lowered to the floor during wound care after becoming restless in a stand-up lift. Although the physician was notified, staff did not inform the resident's representative or hospice provider as required by facility policy, and this omission was confirmed through documentation review and staff interviews.
A resident with severe cognitive impairment and multiple comorbidities was not thoroughly assessed for injuries after being lowered to the floor during a mechanical lift transfer. Although staff noted no immediate injury, a comprehensive assessment, including range of motion, was not performed as required by facility policy. The following day, the resident was found to have a fractured and dislocated femur, highlighting the deficiency in post-incident evaluation.
The facility did not promptly report suspected abuse, neglect, or theft, nor did it communicate the results of its investigation to the proper authorities as required.
Nurses and nurse aides lacked the required competencies to provide care that maximizes each resident's well-being, resulting in residents not receiving individualized care that supports their highest level of well-being.
A resident with Alzheimer's and other conditions was accidentally hit with a dinner plate during an altercation between two other residents, resulting in a laceration and bruise. The facility failed to report the incident to the state agency as required by their policy, as confirmed by the DON and a nurse.
A resident with Alzheimer's disease was accidentally hit in the face with a dinner plate during an altercation between two other residents, resulting in a forehead laceration. The incident was not reported to the state agency as required by the facility's policy, which mandates reporting within 24 hours.
A resident with Alzheimer's and dementia received Nystatin powder without a physician's order, contrary to facility policy. The medication was applied after a STNA reported skin concerns due to the resident's bra. The DON confirmed the lack of a physician order during a complaint investigation.
The facility failed to follow prescribed portion sizes and recipes for diet textures, affecting 83 residents. Observations revealed that incorrect scoop sizes were used for serving baked turkey crunch, and bread and water were improperly added to pureed diets. Interviews with dietary staff confirmed these deviations, impacting the nutritional needs of residents.
The facility failed to maintain clean floors and ensure resident rooms were free from odors. Observations revealed sticky floors in multiple areas and a strong urine odor in a resident's room. Staff interviews confirmed these issues, and it was noted that the problem with the floors occurred yearly when the air conditioning was turned off.
The facility failed to ensure medications were secure and properly labeled, affecting thirteen residents. Medications were found unsecured in residents' rooms and inappropriately stored in a medication cart. Staff confirmed these practices were against facility policy.
The facility failed to include copies of advanced directives in the medical records of two residents, despite having policies requiring such documentation at admission. This was confirmed through staff interviews and medical record reviews.
The facility failed to document a resident's bruising upon admission, despite the hospital referral form indicating a traumatic wound. Subsequent observations and staff interviews confirmed the presence of bruising, which was not recorded during the initial assessment.
The facility failed to maintain appropriate physician orders, accurately assess dialysis access sites, and ensure a dialysis catheter site was covered for a resident requiring dialysis. Observations and interviews confirmed the resident's chest catheter was frequently uncovered, and the fistula did not have a thrill or bruit. The facility's policies on dressing changes and physician orders were not followed, leading to these deficiencies.
The facility failed to implement non-pharmacological interventions for a resident with dementia who frequently refused care, resulting in the resident being heavily soiled with urine and developing blisters. Staff were not provided with specific strategies to manage the resident's behaviors, and the care plan lacked individualized interventions.
A facility failed to ensure an accurate Nutritional Assessment for a resident with dementia and congestive heart failure. The resident's fluid restriction and specific diet orders were not accurately documented, leading to discrepancies in the resident's care plan. Interviews confirmed the oversight, highlighting a deficiency in the facility's food and nutrition services.
Failure to Reassess and Intervene as Pressure Ulcer Progressed to Unstageable
Penalty
Summary
The deficiency involves the facility’s failure to implement and adjust interventions to prevent a pressure ulcer from worsening in a resident who was initially assessed as low risk for pressure ulcer development. The resident had multiple diagnoses including dementia, Alzheimer’s disease, autonomic neuropathy, edema, and incontinence, and was dependent on staff for most activities of daily living. The care plan in place identified the resident as at risk for pressure ulcer development due to cognitive impairment, incontinence, mobility and balance deficits, weak gait, decreased activity, and medications affecting sensory perception. Planned interventions included monitoring and documenting skin changes, notifying appropriate clinical staff of new breakdown, weekly skin assessments, use of barrier cream, dietitian assessment for nutritional needs, and management by a wound specialist center. On a documented date, a CNA notified an RN that the resident had an open area on the coccyx, which the RN assessed as a Stage II pressure ulcer. Barrier cream was applied, and the wound care nurse was to assess the resident. The initial wound documentation described a small Stage II ulcer with scant serosanguinous drainage and epithelial tissue. A nursing plan of care was then developed to address the coccyx skin alteration, including topical treatments such as triad paste and chamosyn with honey. However, there was no evidence in the medical record of any reassessment of the resident’s overall condition or investigation into the source of the pressure ulcer at that time, and no nutritional interventions or evaluations were documented despite the resident’s identified risk for malnutrition. Subsequent weekly wound documentation showed that the coccyx pressure ulcer progressively increased in size and changed in tissue characteristics over several weeks. The ulcer measurements increased from 1 cm by 1.5 cm by 0.1 cm to 2.0 cm by 1.5 cm by 0.1 cm, with the development of slough tissue, and eventually to 3.0 cm by 4.0 cm by 2.0 cm with foul odor and moderate necrotic tissue, at which point it was assessed as an unstageable pressure ulcer. Throughout this period of worsening, the record lacked evidence of reassessment of the resident’s condition in response to the ulcer’s progression, lacked documentation of efforts to identify the possible source of pressure, and did not show implementation of mechanical pressure relief devices, off-loading strategies, or nutritional support and evaluation. Although a wound specialist later evaluated the ulcer and made recommendations including an air pressure mattress, repositioning, frequent incontinence checks, and nutritional monitoring, the medical record did not show that these recommendations were promptly implemented, and there continued to be no documented additional interventions for mechanical off-loading or nutritional evaluation. The facility’s own skin care and pressure management policy stated that any new pressure ulcer should trigger reevaluation of the prevention plan and interventions, but the infection preventionist/wound care nurse confirmed there was no documentation that the facility attempted to determine the origin of the ulcer or implement nutritional interventions as required by the care plan and policy. The deficiency affected one resident out of three reviewed for pressure ulcer prevention and wound healing, in a facility with a census of 89 residents. The resident’s Minimum Data Set assessment had identified severely impaired cognition, rejection of care on some days, dependence on staff for ADLs, always incontinent of bowel and bladder, and an in-house acquired unstageable pressure ulcer. Despite these identified risks and the facility’s policy requirements, the medical record showed that the facility did not reassess the resident’s condition or modify interventions in response to the development and worsening of the pressure ulcer, and did not complete nutritional assessments or implement nutritional support after the ulcer was first identified.
Failure to Timely Notify Physician and Representative After Unresponsive Fall With Head Injury
Penalty
Summary
The deficiency involves the facility’s failure to ensure timely notification of the physician and resident representative when a resident was found unresponsive on the floor with a head laceration. The resident had multiple diagnoses, including dementia, COPD, type 2 diabetes with neuropathy, bladder cancer, coronary artery disease, major depression with psychotic symptoms, anxiety disorder, osteoarthritis, history of TIA, and hypertension, and had been assessed with severe cognitive impairment but independent ambulation and transfer. The care plan for fall risk required that if the resident fell or was found on the floor, staff were to assess for injury and notify the MD and responsible party. On the morning of the incident, a CNA informed an LPN that the resident had an unwitnessed fall and was lying on the bathroom floor. The LPN found the resident on the bathroom floor with his head under the sink, diaphoretic, sweaty, clammy, with a laceration to the top of the head, and unable to perform ROM due to lack of consciousness. Neuro checks were initiated. Despite the resident’s loss of consciousness and head injury, the physician was notified only by fax at 9:00 a.m., and there was no immediate telephone contact. The physician’s faxed response to send the resident to the emergency room was not received until 12:45 p.m., approximately four hours and 45 minutes after the fall, by which time the resident had already been transported to the hospital. The resident’s representative (POA) was not notified of the fall until 10:45 a.m., about two hours and 45 minutes after the incident, and was later notified again regarding the transfer to the emergency room. The facility’s policy required immediate notification of the resident, physician, and resident representative when there is an accident, significant change in status, or symptoms such as loss of consciousness. In an interview, the DON confirmed that the physician was not contacted immediately and that a telephone call should have been made instead of relying on a fax, and also confirmed the delay in notifying the resident representative.
Failure to Provide Appropriate Post-Fall Neurological Assessment and Emergency Response
Penalty
Summary
The facility failed to provide appropriate treatment and neurological assessments after a resident was found on the bathroom floor unresponsive with a head laceration following an unwitnessed fall. The resident had multiple diagnoses including dementia, COPD, type 2 diabetes with neuropathy, coronary artery disease, major depression with psychotic symptoms, anxiety, osteoarthritis, history of TIA, and hypertension, and had a care plan identifying fall risk with interventions requiring assessment for injury and completion of neuro checks after a fall with possible head injury or unwitnessed fall. On the morning in question, a CNA found the resident unresponsive on the bathroom floor; an LPN observed the resident diaphoretic, sweaty, clammy, with a head laceration and unable to perform range of motion due to lack of consciousness. Staff, including the unit manager, LPNs, and CNAs, lifted the unresponsive resident from the floor and placed him in bed, and EMS was not contacted at the time of discovery. The neurological observation form initiated at 8:00 A.M. documented only vital signs at multiple time points and did not include any documentation of pupillary responses or hand grasps, despite these being required elements on the form and part of a post-fall neurological assessment. The medical record contained no additional neurological assessment or further documentation beyond these vital signs. The LPN faxed the physician about the fall and awaited a response, notified the POA later that morning, and the DON was notified of the fall and change in condition; however, the resident remained unresponsive and never regained consciousness. The DON confirmed that the post-fall neurological assessment only contained vital signs and that staff did not contact EMS when the resident was first found unresponsive with an observed head injury, instead moving him back to bed. This sequence of actions and omissions formed the basis of the cited deficiency for failure to provide appropriate treatment and care according to orders, resident preferences, and goals.
Failure to Notify Resident Representative and Hospice Provider After Incident
Penalty
Summary
The facility failed to ensure that required notifications were made to a resident's representative and hospice provider following an incident in which the resident was lowered to the ground during care. The resident involved had a history of dementia, type II diabetes, a recent right femur fracture, generalized anxiety disorder, major depressive disorder, anemia, and a terminal diagnosis of rectal cancer. The resident was severely cognitively impaired, dependent on staff for all activities of daily living, and was receiving hospice care at the time of the incident. On the day of the incident, staff were providing wound care to the resident using a stand-up lift. During the process, the resident became restless and managed to remove his arm from the sling, resulting in staff lowering him to the floor for safety. The resident then flung his body to the side before staff could unstrap his legs from the lift. He was subsequently assisted back into his wheelchair, and no injuries or pain were noted at the time. Documentation confirmed that the resident's physician was notified of the incident, but there was no evidence that the resident's spouse or hospice provider were informed. Interviews with staff involved in the incident, including a registered nurse and a licensed practical nurse, confirmed that neither the resident's family nor hospice provider were notified about the event. Review of facility policies indicated that it was required to notify the resident, physician, and resident representative in the event of an accident or significant change in status. The lack of documentation and staff confirmation established that the required notifications were not made following the incident.
Failure to Thoroughly Assess Resident After Mechanical Lift Incident
Penalty
Summary
A deficiency occurred when staff failed to thoroughly assess a resident for injuries after an incident involving a mechanical lift transfer. The resident, who had severe cognitive impairment, was dependent on staff for all activities of daily living and had a significant medical history including dementia, diabetes, a recent right femur fracture, and a terminal diagnosis of rectal cancer. During a wound care procedure, the resident became restless and managed to remove his arm from the lift sling, resulting in staff lowering him to the floor while his legs remained strapped in the lift. The resident then threw himself to the side before being fully released from the lift. Following the incident, staff assisted the resident back into his wheelchair and noted no immediate signs of pain or injury. However, there was no documentation of a comprehensive injury assessment, such as a range of motion evaluation, being performed at that time. Staff interviews confirmed that only a basic physical check was conducted, and no range of motion assessment was completed. The facility's policy required a thorough assessment for injuries after such incidents, but this was not followed. The following day, a hospice aide reported concerns about the resident's leg, which was then found to be rotated inward. An x-ray revealed a right femur fracture with severe dislocation, and the resident was sent to the hospital for further treatment. The deficiency was identified due to the lack of a thorough post-incident assessment as required by facility policy, despite the presence of multiple staff members during and after the event.
Failure to Timely Report Suspected Abuse, Neglect, or Theft
Penalty
Summary
The facility failed to timely report suspected abuse, neglect, or theft and did not report the results of the investigation to the proper authorities. This deficiency was identified based on the facility's lack of prompt action in notifying the appropriate agencies when an incident of suspected abuse, neglect, or theft occurred. The report indicates that the required notifications and investigation results were not communicated as mandated.
Inadequate Nursing Staff Competency
Penalty
Summary
Nurses and nurse aides did not demonstrate the necessary competencies to provide care that maximizes each resident's well-being. The deficiency was identified due to a lack of appropriate skills and knowledge among the nursing staff, which impacted their ability to meet the individualized needs of residents. This failure resulted in residents not receiving care in a manner that supports their highest level of well-being.
Failure to Report Resident-to-Resident Altercation
Penalty
Summary
The facility failed to implement its policy regarding the requirement to report a resident-to-resident altercation to the state agency. This incident involved a resident with Alzheimer's disease, chronic obstructive pulmonary disease, and atrial fibrillation, who was inadvertently hit in the face with a dinner plate during an altercation between two other residents. The incident resulted in a laceration and a large bruise on the resident's forehead. Despite the injury, the facility did not report the incident to the Ohio Department of Health as required by their policy. The Director of Nursing and a Registered Nurse confirmed that the resident was accidentally hit during the altercation, which was not directly involving her. The facility's policy mandates that all alleged violations involving mistreatment, neglect, abuse, exploitation, misappropriation of resident property, and injuries of unknown source must be reported to the state agency within 24 hours. However, this policy was not followed, as verified by the facility's Administrator.
Failure to Report Resident-to-Resident Altercation
Penalty
Summary
The facility failed to report a resident-to-resident altercation involving Resident #15, who was affected by the incident. Resident #15, diagnosed with Alzheimer's disease, chronic obstructive pulmonary disease, and atrial fibrillation, was in the dining room when an altercation between two other residents occurred. During the altercation, Resident #15 was accidentally hit in the face with a dinner plate, resulting in a cut to her forehead. The nursing staff assessed Resident #15, provided wound care, and initiated neurological checks. However, the incident was not reported to the state agency as required by the facility's policy. Interviews with the Director of Nursing and a Registered Nurse confirmed that Resident #15 was unintentionally struck by a plate during the altercation between two other residents. The Director of Nursing and the Administrator acknowledged that the incident was not reported to the Ohio Department of Health within the required timeframe. The facility's policy mandates that all alleged violations involving mistreatment, neglect, abuse, exploitation, misappropriation of resident property, and injuries of unknown source be reported to the state agency within 24 hours of the incident being known to staff.
Failure to Obtain Physician Order for Medication
Penalty
Summary
The facility failed to ensure that treatments were provided with a physician's order, affecting one resident who was reviewed for physician orders. The resident, diagnosed with Alzheimer's disease and dementia, had impaired cognition. A review of the medical records revealed that there were no physician orders for Nystatin powder, a medication used to treat fungal or yeast infections on the skin, from July 1, 2024, through the current date. Despite this, a progress note dated August 1, 2024, indicated that Nystatin powder was applied to the resident's skin without a documented physician order. The incident was discovered during a complaint investigation, where a State tested Nursing Assistant (STNA) reported finding marks on the resident's shoulders and under her breasts, which she attributed to the resident's bra being too tight or worn for too long. The STNA reported the skin concerns to a nurse, who then applied the Nystatin powder. The Director of Nursing confirmed that the nurse documented the application of the powder without a physician's order, which was against the facility's policy that requires medications to be administered only upon a written order from a licensed prescriber.
Failure to Follow Prescribed Portion Sizes and Recipes for Diet Textures
Penalty
Summary
The facility failed to ensure portion sizes were followed when serving all diet textures, affecting 83 residents who received food from the kitchen. Specifically, the facility did not adhere to the prescribed portion sizes for baked turkey crunch for residents on regular, mechanical soft, and pureed diets. Observations revealed that a size 16 scoop, which is two ounces, was used instead of the required 5 1/3 ounces for regular diets and four ounces for mechanical soft and pureed diets. Additionally, the preparation of pureed baked turkey crunch included the addition of five slices of bread and an unmeasured amount of water, contrary to the recipe instructions that specified using chicken broth and not water for thinning the mixture. Interviews with the dietary staff, including Cook #506 and Dietary Manager (DM) #501, confirmed these deviations from the prescribed recipes and portion sizes. Cook #506 admitted to adding extra scoops of food and using bread and water to achieve the desired texture for pureed diets. DM #501 verified that the incorrect scoop sizes were used during meal service and acknowledged that bread and water should not have been used in the preparation of pureed baked turkey crunch. This deficiency affected five residents with physician-ordered pureed diets and potentially compromised the nutritional needs of all residents receiving food from the kitchen.
Failure to Maintain Clean and Odor-Free Environment
Penalty
Summary
The facility failed to ensure that floors were adequately maintained, which had the potential to affect all 83 residents. Observations on multiple dates revealed sticky substances on the floors of the Bayview Dining Room, B Hall, and C Hall, causing shoes to stick and become tacky. Staff interviews confirmed the presence of sticky floors, and it was noted that this issue occurred yearly when the air conditioning was turned off. Additionally, it was revealed that housekeeping staff had been re-educated on the correct dilution for cleaning chemicals, but the floors remained sticky due to a staff member calling off on the day the floors were supposed to be cleaned with an auto floor scrubber. The facility also failed to ensure that resident rooms were free from odors, specifically affecting one resident with a diagnosis of dementia and incontinence issues. Observations of the resident's room on multiple occasions revealed a strong urine odor. Staff interviews confirmed the presence of the odor and indicated that the resident sometimes urinated in bed. The facility's policy for daily cleaning of care areas was reviewed, which stated that housekeeping, laundry, and maintenance staff were responsible for maintaining a sanitary and comfortable environment.
Medication Security and Labeling Deficiencies
Penalty
Summary
The facility failed to ensure medications were secure and properly labeled, affecting thirteen residents. For Resident #69, a red pill identified as amitriptyline hydrochloride 100 mg was found on a plastic cup lid on the nightstand, indicating the medication was not taken as prescribed. The resident, who has neurocognitive disorder with Lewy bodies and other conditions, confirmed the pill was from the previous night. An LPN verified the medication and acknowledged that residents should be observed taking their medications. Additionally, a pink pill identified as Levothyroxine was found on the floor of Resident #36's room, who has severe cognitive impairment and multiple health conditions. An LPN confirmed the pill's identity and its inappropriate storage on the floor. Further observations revealed that an RN was administering medications from a cart containing a clear plastic cup with several unlabeled white tablets. The RN admitted the cup was present before her shift and attempted to return the tablets to a house stock bottle of acetaminophen, which was against facility policy. The DON confirmed that medications should not be removed from their original containers until administered. The facility's policy mandates that unused medications should be disposed of properly, and any medication refusals should be documented on the medication administration record.
Failure to Document Advanced Directives in Medical Records
Penalty
Summary
The facility failed to ensure that a copy of the advanced directives was included in the medical records of two residents. Resident #59, who was admitted with multiple diagnoses including type II diabetes mellitus, dementia, and chronic kidney disease, had a physician order and care plan indicating a Do Not Resuscitate Comfort Care - Arrest (DNRCC-Arrest) directive. However, the medical record did not contain a signed copy of the advanced directive, a fact confirmed by a Registered Nurse during an interview. Similarly, Resident #236, admitted with a diagnosis of dementia, did not have any advance directive order or code status documented in the electronic medical record. This was confirmed by a Licensed Practical Nurse, who also noted the absence of a paper copy of the advance directive. The facility's policy mandates that each resident should have an advance directive in place at admission, and these directives should be documented in the medical record, which was not adhered to in these cases.
Failure to Document Skin Condition Upon Admission
Penalty
Summary
The facility failed to ensure accurate skin assessments were completed upon admission for Resident #236, who was admitted with a diagnosis of dementia. Despite the hospital referral form indicating a traumatic face superior wound with edema and bruising, the Nursing Admission Screening completed on the admission date did not document any skin concerns. Subsequent observations and interviews revealed that Resident #236 had noticeable bruising on her face, which was not recorded during the initial assessment. This discrepancy was confirmed by multiple staff members, including LPNs and an RN, who noted the bruising in later assessments and interviews with the resident. The failure to document the bruising upon admission was highlighted during an interview with RN #514, who admitted to not observing or documenting the discoloration on Resident #236's face during the initial head-to-toe assessment. Further interviews with other staff members corroborated that the bruising was present shortly after admission, indicating that the initial assessment was incomplete. The facility's policy on assessments requires that any abnormalities be documented in the medical record, which was not adhered to in this case.
Failure to Maintain Appropriate Dialysis Care and Documentation
Penalty
Summary
The facility failed to maintain appropriate physician orders, accurately assess dialysis access sites, and ensure a dialysis catheter site was covered for a resident requiring dialysis. The medical record review revealed that the resident had orders to check thrill and bruit every shift and to assess and document the condition of the central line catheter site. However, there was no documentation of a sterile dressing change for the dialysis catheter site from 03/10/24 to 05/15/24. Observations confirmed that the resident's chest catheter was frequently uncovered, and the fistula did not have a thrill or bruit, which was also confirmed by the Director of Nursing (DON). Additionally, the medication administration record (MAR) and treatment administration record (TAR) did not reflect the correct catheter site, and the order to use a sterile dressing kit did not populate on the MAR/TAR as it should have. The facility's policies on dressing changes and physician orders were not followed, leading to these deficiencies. The resident involved had diagnoses including dementia, end-stage renal disease, and dependence on renal dialysis. The care plan indicated the need for dialysis three times a week and required monitoring for signs of acute failure, edema, and weight gain. Despite these requirements, the facility failed to ensure proper documentation and assessment of the dialysis access sites. Interviews with staff, including the DON and a registered nurse, confirmed the lack of proper documentation and adherence to physician orders. The facility's failure to follow its policies and procedures for dressing changes and physician orders contributed to the deficiencies observed during the survey.
Failure to Implement Non-Pharmacological Interventions for Resident with Behavioral Issues
Penalty
Summary
The facility failed to ensure non-pharmacological behavioral interventions were assessed or implemented to address a resident's resistance to care, resulting in a lack of timely care and treatment. Resident #46, who was moderately cognitively impaired and had multiple diagnoses including dementia, frequently refused care and medications. Despite the resident's care plan outlining various interventions for managing behavioral symptoms, there was no evidence that these non-pharmacological strategies were attempted or documented by the staff. The resident's medical record lacked specific interventions and assessments to determine the underlying cause of resistance to care. Observations and staff interviews revealed that Resident #46 frequently refused care, resulting in the resident being heavily soiled with urine and developing blisters on the left posterior thigh. Staff members confirmed that they were not provided with specific interventions to manage the resident's behaviors effectively. Despite some staff being able to provide care without resistance, these successful strategies were not communicated to other caregivers. The resident's room consistently had a strong urine odor, indicating a lack of timely and appropriate care. Further interviews with staff, including STNAs and the LPN, confirmed that there were no individualized interventions established to promote the resident's acceptance of care. The Director of Nursing and Licensed Social Worker also verified that the resident's plan of care lacked specific non-pharmacological interventions, and the medical record did not contain strategies for de-escalating behaviors. This deficiency in care led to the resident being frequently soiled, developing blisters, and experiencing a strong urine odor in the room, indicating a significant lapse in the quality of care provided.
Inaccurate Nutritional Assessment for Resident with Fluid Restriction
Penalty
Summary
The facility failed to ensure an accurate Nutritional Assessment for a resident diagnosed with dementia and congestive heart failure. The resident was admitted with specific diet orders, including a no added salt diet, low fat, 2000 mg sodium, low cholesterol, and a fluid restriction of 1500 ml per day. However, the Nutritional Assessment completed on 04/12/24 did not reflect the resident's fluid restriction and inaccurately stated that fluid was encouraged. This discrepancy was confirmed by interviews with the RN and the Director of Nursing, who acknowledged the resident's fluid restriction due to congestive heart failure and risk for weight gain from fluid intake. The Registered Dietitian admitted to being unaware of the fluid restriction and the two diet orders in place for the resident, leading to an inaccurate assessment of the resident's nutritional needs. Further review of the resident's medical records revealed conflicting diet orders and fluid restrictions, which were not accurately documented in the Nutritional Assessment. The resident's fluid restriction was updated to 1800 ml per day on 05/01/24, but the initial assessment failed to capture this critical information. The failure to accurately document and assess the resident's nutritional needs and fluid restrictions highlights a significant deficiency in the facility's food and nutrition services, impacting the resident's care and well-being.
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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