Franciscan Care Ctr Sylvania
Inspection history, citations, penalties and survey trends for this long-term care facility in Toledo, Ohio.
- Location
- 4111 Holland Sylvania Rd, Toledo, Ohio 43623
- CMS Provider Number
- 365907
- Inspections on file
- 40
- Latest survey
- February 24, 2026
- Citations (last 12 mo.)
- 27 (1 serious)
Citation history
Health deficiencies cited at Franciscan Care Ctr Sylvania during CMS and state inspections, most recent first.
The facility failed to maintain adequate nursing staff and to respond promptly to resident call lights. Staffing records showed that nurse staffing fell below the facility’s minimum requirement on multiple days, and call light logs documented that dozens of residents had call lights activated for more than 30 minutes before staff responded. Several residents reported routinely waiting over 30 minutes for assistance after activating their call lights. The facility’s own policy requires timely response to call lights by any staff who see or hear them, but this was not consistently followed.
The facility failed to maintain CNA staffing levels in accordance with its own facility assessment and staffing policy, which called for a CNA-to-resident ratio of 1:15–18. On multiple overnight shifts, only two CNAs were assigned despite censuses ranging from the high 60s to low 70s, resulting in each CNA being responsible for approximately 34–36 residents. The Administrator confirmed the census counts, overnight staffing assignments, and resulting CNA-to-resident ratios, and this deficiency affected all residents in the facility.
A resident with multiple chronic conditions and intact cognition, who required maximal assistance for ADLs, developed a new large open area on the coccyx identified by a CNA during incontinence care. An RN assessed the area and applied cream, but there was no documentation that the physician was notified of this new wound, despite facility policy requiring prompt physician consultation for significant changes in condition. The physician later confirmed he had only seen coccyx redness previously and was not informed of the open wound until a later date, contrary to his expectation of same-day notification for new wounds.
Two residents who were dependent on staff for ADLs did not receive required grooming and feeding assistance. One resident with intact cognition but significant physical limitations and dependence for hygiene was observed with long, coarse facial hair and reported that staff did not assist with grooming her facial hair as often as she preferred. Another blind resident with impaired cognition, multiple comorbidities, and a care plan requiring staff assistance with eating and meal setup was observed in bed with her meal tray placed out of her view and reach, and no staff entered to assist her during the meal period. The resident stated she was unaware her lunch was present and had not been assisted, while a CNA confirmed no assistance had been provided, a housekeeper described moving the tray without seeing staff assist, and dietary staff confirmed the resident should receive assisted dining in accordance with facility policies on ADLs and meal supervision.
Surveyors found that the facility failed to implement and document ordered pressure ulcer-related treatments and prevention measures for two residents. For one resident with stage 4 pressure ulcers and lymphedema, physician-ordered Tubigrip compression stockings were not consistently documented as applied or removed as directed, despite policy requiring wound treatments to be recorded. For another resident with multiple comorbidities and high dependence for care, the care plan called for turning and repositioning and a pressure-relieving mattress, but the resident did not have the specialized mattress, staff reported that turning and repositioning were not done routinely, and there were multiple dates with no documentation that repositioning occurred.
Surveyors found that a mechanical lift used to transfer a dependent resident with lumbar spinal stenosis and impaired upper and lower extremities was missing five of six safety latches on its hooks during an observed transfer from bed to a shower bed. Two CNAs performing the transfer confirmed the latches were missing and did not know how long they had been absent. Review of the manufacturer’s manual showed staff were required to check sling attachments and hardware before each use, and facility policy called for use of a maintenance checklist to ensure a safe, functional environment, but the lift was nonetheless in use without the required safety latches.
A resident with CHF, muscle weakness, prior small bowel resection, and impaired cognition required assistance with ADLs and supervision with eating, and was care planned for nutrition/hydration risk and weight monitoring with supplements. The facility failed to obtain the resident’s scheduled monthly weight and did not identify that the resident, who had decreased appetite and moderate reduction in food intake, experienced a significant unplanned weight loss between one month and the next recorded weights. The diet technician later confirmed the weight was missed despite daily IDT meetings and that the resident frequently refused meals without staff notifying nursing or dietary, contrary to the facility’s weight monitoring policy requiring at least monthly weights and weekly weights for residents with weight loss.
A resident with multiple comorbidities, skin integrity issues, and orders for Triamcinolone cream and Nystatin powder had prescription topical medications applied by a CNA instead of a licensed nurse. The CNA, unsure of the correct application sites, relied on the resident’s directions and applied the cream and powder to various areas, including an underarm area the resident identified as psoriasis. An LPN had provided the prescription cream and powder to the CNA without clear instructions and did not assess the questioned skin area when entering the room, focusing instead on a different open area. The DON later confirmed that prescription creams and powders should be applied and assessed by nursing staff, consistent with facility medication administration policy.
A resident with impaired cognition, blindness, and multiple conditions including Type II DM, hypothyroidism, hypokalemia, and adult failure to thrive was care planned to require feeding assistance, meal setup using a clock system, and monitoring of nutritional intake. During an observed lunch meal service, meal trays were delivered on the hall and to rooms, but the resident did not receive a lunch tray over an extended period. A CNA, unfamiliar with the facility and residents, did not verify that all residents had trays, and an RN reported that the resident typically refused meals and preferred Cheerios, confirming that no lunch tray was offered.
An LPN was observed to be intoxicated while on duty, left the facility during their shift, and was reported to police by a resident. The LPN was arrested for public intoxication after exhibiting signs of impairment. Despite facility policy requiring timely reporting of such incidents, the event was not reported to the State Survey Agency. The LPN was responsible for the care of 13 residents during this time.
A nurse was reported by a resident to be intoxicated while on duty, leading to police involvement and the nurse's arrest for disorderly conduct and public intoxication. Although the nurse was responsible for the care of 13 residents during the shift, the facility only interviewed two residents and did not assess or interview all potentially affected individuals, failing to conduct a complete investigation as required by facility policy.
The facility failed to ensure timely wound assessments, prompt physician notification, and completion of ordered treatments for pressure ulcers in two residents. One resident suffered actual harm when a newly discovered wound was not assessed or treated promptly, leading to progression to a stage IV ulcer, while another resident did not receive required wound care or documentation for a stage III ulcer. The DON confirmed missed treatments and lack of documentation for both cases.
Two residents with significant ADL needs did not consistently receive scheduled showers or bed baths as ordered, with documentation and interviews confirming multiple missed bathing opportunities. Both residents required staff assistance for bathing due to medical conditions, and staff interviews verified that if bathing was not documented, it was not completed.
Two residents with complex medical conditions were not properly monitored or assessed for constipation, despite physician orders and facility protocols requiring daily monitoring and intervention after three days without a bowel movement. Documentation showed extended periods without bowel movements and no evidence that as-needed medications or assessments were provided, as confirmed by interviews with the DON and other staff.
A resident with a neurogenic bladder and chronic medical conditions had their indwelling Foley catheter removed by a nurse without a physician's order after reporting severe urinary pain. The nurse had attempted to obtain an order from urology but did not receive a response before proceeding with the removal at the resident's request. Facility protocol requires a physician's order for catheter removal, which was not obtained in this case.
Hazardous chemicals were left unsecured in various areas, allowing a resident with a history of compulsive and self-harming behaviors to access and apply these substances to his body on multiple occasions. This resulted in chemical burns, hospitalization, and serious health complications. Staff and medical records confirmed the resident's need for supervision and the facility's failure to consistently secure hazardous materials.
The facility did not address or follow up on 30 out of 75 resident grievances and multiple concerns raised during Resident Council meetings, including issues with medication administration, food quality, staffing, and care preferences. Documentation and follow-up actions were inconsistent, and interviews with the DON and Administrator confirmed that required grievance procedures were not followed.
The facility did not provide enough nursing staff to meet resident care needs, as shown by the absence of CNAs during a key shift and missing documentation of ADL care for several residents with complex medical conditions. Staff and resident interviews confirmed delays in care, unmet needs, and inadequate staffing, with the facility's own staffing ratios not being met.
Surveyors found persistent foul urine odors throughout multiple halls and the dining area, confirmed by staff and residents as a common issue. The odors were not linked to specific residents or rooms, and facility policies requiring odor control and routine cleaning were not effectively implemented.
The facility did not conduct thorough investigations for five self-reported incidents involving six residents with various medical conditions, including COPD, CHF, diabetes, stroke, and dementia. Required steps such as staff and resident interviews, assessments of similar residents, and staff education were not completed, as confirmed by the Administrator. This was not in accordance with the facility's policy on abuse, neglect, and exploitation.
Multiple residents with complex medical needs did not have proper documentation in their medical records to support that daily living care and treatments were provided as required. In several cases, care tasks and medication administrations were not recorded in the appropriate records, and two nurses were found to have falsely documented wound care as completed when it was not, without noting resident refusals.
A CNA failed to perform hand hygiene before and after delivering and setting up meal trays, handling contaminated items, and assisting multiple residents with their meals. This resulted in unsanitary meal service for eight residents, contrary to facility policy requiring hand hygiene between resident contacts and after handling contaminated objects.
A resident with dementia was the subject of an alleged abuse report made by their family to the DON, but the DON failed to notify the Administrator or initiate the required SRI process until several days later. This delay violated facility policy, which requires immediate reporting of abuse allegations to the Administrator and authorities.
A resident with multiple medical conditions was newly diagnosed with schizophrenia and exhibited increased behaviors, but the facility did not complete an updated PASRR assessment or notify the state mental health agency as required. The DON confirmed the omission, which was not in accordance with facility policy.
A resident with a right above-the-knee amputation did not receive wound care as ordered after a physician updated the treatment to twice daily Betadine application. The facility continued to provide care once daily and did not update the medical record to reflect the new order, with documentation and staff interviews confirming the discrepancy.
A resident was not seen by a provider throughout their entire admission, as confirmed by the absence of physician progress notes in the medical record. The resident was cognitively intact, and facility policy stated that residents should receive care from medical practitioners as needed.
A resident with a history of schizophrenia, paranoia, and hoarding behaviors repeatedly acquired and mixed hazardous chemicals despite requiring 24-hour supervision. Staff were aware of the ongoing behaviors but did not implement timely, individualized psychosocial interventions or update the care plan in response to escalating risks. The situation resulted in the resident sustaining chemical burns to both feet, requiring hospital and burn center treatment.
The facility failed to provide sufficient nursing staff to meet resident needs, resulting in multiple residents missing scheduled showers, baths, and assistance with eating and repositioning. Staff confirmed that care tasks were not completed due to inadequate staffing, and facility records showed consistent understaffing below identified needs and state minimum requirements. Leadership acknowledged ongoing staffing shortages despite efforts to fill shifts.
The facility did not submit required direct care staffing information to CMS for a full quarter, as shown by review of the PBJ Staffing Data Report. The Administrator confirmed the omission and stated that Human Resources was responsible for the submission, but it was not completed. This failure had the potential to affect all 68 residents in the facility.
Several dependent residents with complex medical and cognitive needs did not receive scheduled showers or feeding assistance as required by their care plans. Documentation and staff interviews confirmed that showers and baths were frequently missed, and residents were sometimes left without help during meals, primarily due to insufficient staffing and high care demands.
Surveyors found that multiple dependent residents with significant medical conditions were not repositioned or provided incontinence care as frequently as required by their care plans and physician orders. Observations and staff interviews revealed that residents remained in the same position for extended periods, sometimes exceeding four hours, and staff were often unaware of when repositioning last occurred. Documentation confirmed infrequent repositioning, and residents reported that turning and repositioning did not occur as scheduled.
Surveyors found that several residents dependent on staff for ADLs did not receive timely incontinence care, with some remaining soiled for extended periods and staff unable to confirm when care was last provided. Additionally, a resident with an indwelling urinary catheter did not receive proper catheter care or have appropriate physician orders documented, and staff failed to follow facility policy for catheter maintenance.
A resident with multiple chronic conditions and chronic pain did not receive her prescribed Roxicodone for several days because the medication was not reordered in a timely manner. Staff confirmed the medication was unavailable and only acetaminophen was administered during this period, resulting in the resident experiencing significant pain until the medication was received from the pharmacy.
A resident with complex medical needs did not receive a physician-ordered medication, Rifaximin, for several days because the facility ran out of the medication and did not obtain a new supply in a timely manner. The medication was documented as unavailable and not administered, and there was no evidence the physician was notified of the missed doses. The error was identified after the resident’s family raised concerns, and the DON confirmed the lapse in medication administration.
A resident with multiple medical conditions was served a meal that did not match the physician-ordered mechanically soft diet, despite clear documentation and a meal ticket specifying the required texture. The resident received whole food instead of ground meat, and an LPN confirmed the error during the meal service.
Staff did not use required PPE, specifically gowns, when providing high-contact care to a resident with an indwelling urinary catheter on enhanced barrier precautions. Gloves were used, but no gowns were donned, and there was no signage posted to instruct staff on PPE requirements. Staff were unaware of the resident's EBP status, and the facility's policy for signage and PPE availability was not followed.
The facility failed to ensure a safe and orderly discharge for two residents, resulting in deficiencies in discharge planning and coordination of home health care services. One resident was discharged without timely coordination of home health care services, leading to a delay in receiving necessary support and equipment. Another resident experienced a delay in the coordination of home health care services and equipment due to a delay in receiving therapy notes and the unavailability of a Certified Nurse Practitioner to sign the discharge paperwork.
The facility failed to provide scheduled bathing for three residents, who were either severely or moderately cognitively impaired and dependent on assistance for personal hygiene. Despite being scheduled for showers twice a week, these residents received fewer showers than planned, with some only receiving bed baths. The DON and Administrator confirmed the discrepancies, and the facility was transitioning to an electronic medical record system, which may have contributed to the oversight.
A facility failed to maintain sanitary conditions during meal service, affecting four residents and potentially impacting all residents receiving meals. A staff member was observed touching food and surfaces with the same gloves without washing hands between glove changes, contrary to facility policy. Interviews confirmed the breach in protocol, and the DON verified that all residents received meals from the kitchen.
The facility failed to ensure proper labeling and removal of expired medications in two medication rooms and one cart. Expired benzonate capsules and ipratropium solution were found in the C-Hall storage room. A vial of Lantus insulin was open beyond the recommended period, and folic acid tablets lacked opening and expiration dates. Similar issues were noted in the B-Hall storage room, confirmed by the DON.
The facility failed to implement fall interventions for a cognitively impaired resident with a history of falls, as a fall mat was not placed as required. Additionally, a hazardous cleaner was left unsecured in another resident's room, contrary to facility policy. These deficiencies posed risks to residents, including those who were independently mobile but cognitively impaired.
A resident with multiple medical conditions, including COPD and CKD, had an uncovered indwelling catheter drainage bag visible from the hallway and to visitors. Despite the resident's preference for the bag to be covered and placed out of sight, the facility did not comply, which was confirmed by a staff member. This action was contrary to the facility's dignity policy, which aims to enhance residents' well-being and self-esteem.
A facility failed to ensure a dependent resident had access to their call light. The resident, with severe cognitive impairment and multiple medical conditions, was observed lying in bed with the call light tied to the bedrail and hanging toward the floor, making it inaccessible. An STNA confirmed the call light's inaccessibility.
A facility failed to complete a PASARR for a resident who experienced a significant change in mental health diagnosis, including schizoaffective disorder, paranoid delusions, and hallucinations. Despite the facility's policy requiring a PASARR review for such changes, no evidence of a review request was found in the resident's medical record.
A facility failed to include the use of a psychotropic medication for depression in a resident's care plan. The resident, diagnosed with depressive disorder and anxiety, had a physician's order for Zoloft 100 mg daily. However, the care plan did not address this medication, as confirmed by an RN. The facility's policy requires care plans to include measurable objectives and timeframes.
The facility failed to include two residents in the development and periodic review of their care plans, despite being cognitively intact and requiring assistance with daily activities. The facility's policy required care plan meetings upon admission, quarterly, and with significant changes, but these were not documented or conducted for the residents.
The facility failed to monitor and implement interventions for constipation for three residents. One resident did not have a documented bowel movement for 13 days despite having orders for constipation medications. Another resident had no documented bowel movements for nearly a month and did not receive PRN Milk of Magnesia. A third resident also had multiple days without documented bowel movements and did not receive the PRN medication. The DON confirmed the lack of documentation and interventions.
A resident with cognitive impairments and multiple diagnoses did not receive follow-up care as recommended by an audiologist and optometrist. The resident was identified with a cataract and needed new glasses, but no optometry visits occurred in 2023 or 2024. Additionally, the resident's hearing issues were not addressed following an audiologist's recommendation for ear wax removal and re-evaluation. Interviews confirmed the lack of follow-up care, violating the facility's policy on resident well-being.
A resident with a stage four pressure ulcer did not receive a thorough wound assessment or appropriate pressure-reducing devices upon admission. Observations showed the resident on an unsuitable mattress and without a pressure-reducing cushion while seated. The facility's policies for skin assessment and pressure ulcer care were not followed, as confirmed by the DON.
A facility failed to obtain physician orders for a resident's indwelling urinary catheter and did not provide proper catheter care. The resident, with a history of urinary tract infections, had no documented orders for catheter placement or maintenance. Observations revealed improper cleaning techniques by staff, contrary to facility policy.
Insufficient Staffing and Delayed Call Light Response
Penalty
Summary
The deficiency involves the facility’s failure to provide sufficient nursing staff to meet resident needs and to ensure timely response to call lights. Review of the facility’s staffing tool showed that staffing levels fell below the Minimum Staffing Requirement on three identified dates. Review of call light system logs for a four-day period showed that 42 residents had call lights that remained activated and unanswered for 30 minutes or longer before staff responded. The facility’s own policy, dated 12/01/25, states that call lights will relay to staff or a centralized location to ensure appropriate response and that all staff who see or hear an activated call light are responsible for responding or notifying appropriate personnel. Multiple resident interviews corroborated the call light data, with several residents reporting that call lights were not responded to in a timely manner and that they often waited more than 30 minutes for a response. These interviews occurred over two days and consistently described prolonged wait times for assistance. The Administrator confirmed that staffing fell below the Minimum Staffing Requirement on the identified dates, and an RN confirmed that 42 residents had call lights unanswered for 30 minutes or longer during the reviewed period. This deficiency was investigated under Complaint Number 2743940.
Failure to Maintain CNA Staffing Levels per Facility Assessment
Penalty
Summary
The deficiency involves the facility’s failure to administer operations in a manner that ensured adequate staffing in accordance with its own facility assessment and staffing policy. The facility assessment dated 11/15/25 specified that CNAs would be staffed at a ratio of one CNA to every 15 to 18 residents. The facility’s written staffing policy dated 11/05/25 stated that there shall be a sufficient number of trained staff members on duty to ensure each resident’s physical, social, and emotional health, care, and safety needs are met in accordance with their individualized care plans, and that staffing levels would be based on day-to-day resident needs, activity, and intensity of staff assistance. Surveyor review of census and overnight staffing records showed that on three consecutive nights the facility did not meet its stated CNA staffing ratios. With a census of 69 residents, only two CNAs were on duty, resulting in each CNA being responsible for 34.5 residents. On the following night, with a census of 70 residents, two CNAs were again assigned, resulting in each CNA being responsible for 35 residents. On the third night, with a census of 71 residents, two CNAs were assigned, resulting in each CNA being responsible for 35.5 residents. The Administrator confirmed the overnight census numbers, the number of CNAs assigned on those nights, and the calculated CNA-to-resident ratios. This failure affected all residents in the facility, with a reported census of 71 residents at the time of the survey.
Failure to Promptly Notify Physician of New Coccyx Wound
Penalty
Summary
The deficiency involves the facility’s failure to promptly notify a physician of a resident’s change in condition, specifically the development of a new open skin area on the coccyx. The resident was admitted with multiple diagnoses including COPD, cardiac arrhythmia, OSA, CHF, lymphedema, RA, atherosclerotic heart disease, HTN, morbid obesity, major depressive disorder, and anxiety. A recent quarterly MDS showed a BIMS score of 13, indicating relatively intact cognition, and documented that the resident had unilateral upper extremity impairment and required maximal assistance for hygiene, toileting, rolling, and transferring. The most recent skin assessment dated 02/11/26 documented no skin impairments. On 02/18/26, during incontinence care, a CNA observed a large open area on the resident’s coccyx and notified an RN, who assessed the area and applied a cream. The CNA confirmed this was a new skin impairment. Review of the medical record the following day showed no documentation that the physician had been notified of this new wound. The RN who completed the 02/11/26 skin assessment confirmed there were no skin impairments at that time. The physician reported that when he last saw the resident on 02/11/26, the coccyx was reddened but not open, and he confirmed he was not notified of the new wound until 02/19/26, stating his expectation that new wounds be reported the same day they are discovered. Facility policy titled “Notification of Change” required prompt consultation with the resident’s physician when there was a significant change in condition, including deterioration in health, which was not followed in this instance.
Failure to Provide Required Grooming and Feeding Assistance for Dependent Residents
Penalty
Summary
The deficiency involves the facility’s failure to provide necessary ADL assistance with grooming and feeding to residents who were dependent on staff. One resident with multiple diagnoses including COPD, cardiac arrhythmia, generalized muscle weakness, osteoarthritis, OSA, CHF, lymphedema, RA, atherosclerotic heart disease, HTN, morbid obesity, major depressive disorder, and anxiety had a quarterly MDS showing relatively intact cognition (BIMS 13) but unilateral upper extremity impairment and dependence or need for maximal assistance with all functional abilities, including hygiene. During observation, this resident was noted to have multiple long, coarse hairs on her chin and upper lip. In a concurrent interview, she stated the facility did not assist her with grooming her facial hair as much as she liked and that it bothered her when the hair was long enough to be visible. A CNA later verified the presence of the long, coarse facial hair. Another resident, admitted with diagnoses including Type II diabetes mellitus, hypothyroidism, hypokalemia, adult failure to thrive, and anxiety disorder, had a quarterly MDS indicating impaired cognition (BIMS 8) and a need for assistance with meals and dependence on staff for ADL care. The care plan documented an ADL self-care performance deficit related to impaired vision and arthritis, with interventions for staff to assist with eating, encourage self-feeding if possible, and use a clock system to describe plate setup because the resident was blind. The care plan also identified risk for nutrition and hydration deficits related to multiple conditions and diuretic use, with interventions including providing ordered supplements and monitoring intake and weight. The facility’s assisted dining list also identified this resident as requiring assistance with eating. During a lunch observation period, this blind resident was in bed on her right side with the head of the bed elevated, while her meal tray was placed on the left side of the bed, out of her line of sight, and an additional tray with milk, a nutritional supplement, and a fruit cup was left on a chair near the door. No staff entered the room to assist her with eating during the observation. The resident reported she was not aware her lunch was on the bedside table and that no staff had been in to assist her. A CNA confirmed the resident had not been assisted to eat and acknowledged she had not been in the room and did not know who had set up the tray. A housekeeper reported moving the tray from the chair to the bedside table after noticing it, and stated she did not see staff assisting the resident and tried to help when she could. A dietary technician confirmed the resident should be assisted at meals and offered the facility meal, with an alternative if refused. These events occurred despite facility policies stating that residents unable to carry out ADLs would receive necessary services for grooming and that staff would supervise and assist with meals, including arranging trays so residents could reach items and opening containers.
Failure to Implement and Document Pressure Ulcer Treatments and Prevention Interventions
Penalty
Summary
The deficiency involves the facility’s failure to provide ordered pressure ulcer-related treatments and to implement documented pressure ulcer prevention interventions. For one resident with multiple serious conditions including osteomyelitis, stage 4 pressure ulcers, cellulitis, lymphedema, neuropathy, and a non-pressure chronic ulcer, the physician ordered Tubigrip compression stockings with specific instructions for application and removal. Review of the Treatment Administration Record over several months showed multiple dates on which there was no documentation that the Tubigrips were applied as ordered, and additional dates with no documentation that they were removed at bedtime as ordered. An RN confirmed the lack of documentation for both the application and removal of the Tubigrips on the identified dates, despite facility policy requiring that wound treatments be documented on the TAR or in the electronic health record. The deficiency also includes failure to implement and document pressure ulcer prevention measures for another resident with multiple comorbidities such as COPD, cardiac arrhythmia, CHF, lymphedema, RA, morbid obesity, and mental health diagnoses, who required maximal assistance for mobility and self-care. The resident’s care plan called for assistance with turning and repositioning and the use of a pressure-relieving mattress. Observation showed the resident did not have a pressure-relieving mattress on the bed, and nursing staff confirmed its absence. Staff also reported that the resident was not turned and repositioned every two hours or routinely, and record review revealed multiple dates with no documentation that turning and repositioning occurred. Facility policy stated that turning and repositioning would be implemented as part of a systemic approach to pressure injury prevention and that the frequency would be documented in the plan of care.
Mechanical Lift Used for Dependent Resident with Missing Safety Latches
Penalty
Summary
Surveyors identified a deficiency related to the facility’s failure to maintain a mechanical lift in safe working condition and to ensure the environment was free from accident hazards. One resident, admitted with lumbar spinal stenosis and documented as cognitively intact with a BIMS score of 15, was assessed as having impaired upper and lower extremities bilaterally and being dependent for all functional abilities, including toileting, bathing, dressing, hygiene, turning/repositioning, and transferring. During an observation of incontinence care and a transfer from bed to a shower bed using a mechanical lift, surveyors noted that five of the six safety latches on the lift hooks were missing. During the same observation, the two CNAs performing the transfer confirmed that five of the six safety latches were missing and were unable to state how long the latches had been absent. Review of the mechanical lift manufacturer’s user manual showed that staff were required to check all sling attachments and hardware each time the lift was used to ensure proper connection and patient safety. Additionally, review of the facility’s Maintenance Inspection policy indicated the facility would use a maintenance checklist to assure a safe, functional, sanitary, and comfortable environment for residents, staff, and the public. Despite these requirements, the lift was in use with missing safety latches at the time of the observed transfer.
Failure to Obtain Monthly Weight Resulting in Unrecognized Significant Weight Loss
Penalty
Summary
The deficiency involves the facility’s failure to obtain a required monthly weight for a cognitively impaired resident with multiple medical conditions, resulting in an unrecognized, significant unplanned weight loss. The resident had diagnoses including unspecified systolic congestive heart failure, muscle weakness, and unspecified intestinal obstruction, and required a wheelchair for mobility, supervision or touching assistance with eating, and substantial assistance with ADLs. The care plan identified self-care performance deficits related to limited mobility, anemia, cognitive communication impairment, polyneuropathy, hypotension, and congestive heart failure, and included interventions such as setting up meal trays, encouraging self-feeding, offering assistance or finger foods, opening and cutting food, and notifying the nurse if the resident was not eating. The care plan also identified risk for nutrition and hydration deficits related to a recent small bowel resection and planned significant weight gain, with interventions including weighing as ordered, providing supplements as ordered, and monitoring for signs and symptoms of malnutrition and significant weight loss. Despite these identified risks and interventions, the medical record showed that the resident’s weight was recorded as 142 lbs in early December, but no weight was obtained in January, contrary to the facility’s weight monitoring policy that required monthly weights for all residents and weekly weights for residents with weight loss. Subsequent weights in early February showed a drop to 123.6 lbs and then 121.4 lbs. A dietician progress note documented that the resident reported decreased appetite, had a moderate decrease in food intake over the prior three months, was receiving Ensure daily and was receptive to increasing it to twice a day, and had a mini nutrition score indicating malnutrition, with a notation that no January weight was recorded. In an interview, the diet technician confirmed the resident had a significant weight loss, should have been weighed weekly, and was not weighed in January, stating the missed weight must have been overlooked during daily interdisciplinary team meetings and acknowledging that the resident frequently refused to eat and that staff should have notified nursing or the diet technician if the resident was refusing meals.
Unlicensed Staff Applied Prescription Topical Medications Without Nurse Assessment
Penalty
Summary
The deficiency involves the facility’s failure to ensure that prescription topical treatments were administered by a licensed nurse, as required by facility policy and professional standards. A cognitively intact resident with cerebral palsy, osteoarthritis, morbid obesity, a break in skin integrity, and risk for skin breakdown had physician orders for Triamcinolone Acetonide 0.1% cream to the shoulders and thighs twice daily for psoriasis, and Nystatin powder to the thighs and under the breasts twice daily for fungus. The resident’s care plan included treatments as ordered and weekly skin checks, as well as interventions for ADL self-care deficits and transfers with a mechanical lift and two-person assist. On observation, a CNA was seen performing ADL care and applying a cream from a four-ounce cup and powder to the resident’s under-breast area and bilateral thighs. The CNA was unsure where the prescription cream should be applied and relied on the resident’s directions, including application to the left armpit, which the resident identified as an area of psoriasis. The CNA questioned whether the area was psoriasis, stating it looked like a pimple. Shortly afterward, an LPN entered the room; the CNA asked if the left armpit area was psoriasis, and the LPN did not respond. The LPN measured and treated a new open area on the resident’s abdominal fold but did not assess the left armpit area. Interviews confirmed that the nurse had given the prescription Triamcinolone cream and Nystatin powder to the CNA to apply, that the CNA was unsure of the correct application sites, and that the LPN was uncertain whether CNAs should be applying prescription creams and powders and had not instructed the CNA on where to apply them. The DON confirmed that nurses should be applying prescription creams and powders and observing and charting on areas of concern, and that the LPN should have assessed the left armpit area. Facility policy stated that medications are to be administered by licensed nurses or other staff legally authorized to do so.
Failure to Provide Ordered Lunch Meal to Dependent, Visually Impaired Resident
Penalty
Summary
The deficiency involves the facility’s failure to ensure a resident received a nourishing, palatable, well‑balanced diet that met the resident’s nutritional needs. The resident had multiple diagnoses including Type II DM, hypothyroidism, hypokalemia, adult failure to thrive, and anxiety disorder, and was blind with impaired cognition (BIMS score of eight). The care plan documented ADL self‑care performance deficits related to impaired vision and arthritis, required staff assistance with meals, and specified that staff should help the resident eat, encourage self‑feeding when possible, and use the clock system to describe plate setup. The resident was also care planned as being at risk for nutrition and hydration deficits due to multiple medical conditions and diuretic use, with interventions including providing ordered supplements and monitoring intake and weight. Facility documentation identified the resident as requiring feeding assistance. On the observed lunch meal service date, surveyors noted that the resident was in her room at 11:39 A.M. with no meal tray present. Hall trays were delivered to the hallway at 11:52 A.M., and to resident rooms by 11:58 A.M., yet from 12:02 P.M. through 12:40 P.M. the resident still did not have a lunch tray. A CNA interviewed at 12:45 P.M. stated she was unaware the resident had not received a lunch tray, explained she was unfamiliar with the residents and the facility’s lunch tray process because it was her first time in the facility, and confirmed she did not check to ensure all residents had their lunch trays. An RN interviewed at 12:49 P.M. stated the resident always refuses meals and was not offered a tray because the resident likes Cheerios, further stating the resident would not allow a plate to sit on the tray table and again confirming that lunch was not offered to the resident.
Failure to Report Alleged Neglect by Impaired Nurse
Penalty
Summary
The facility failed to report an allegation of neglect involving a nurse to the State Survey Agency, Ohio Department of Health, as required by policy. On the night in question, an LPN arrived for work, received report, and then left the facility with another LPN and a CNA to go to a gas station, returning after approximately 15 minutes. During this shift, a resident called 9-1-1 to report that the nurse was intoxicated and smelled of alcohol. Upon police arrival, the LPN exhibited signs of impairment, including glossy eyes and slurred speech, and was subsequently arrested for disorderly conduct due to public intoxication. The police requested that the RN on duty contact a supervisor, and administrative staff were notified. Despite the incident and the facility's policy requiring all alleged violations to be reported to the Administrator, state agency, and other required agencies within specified timeframes, the facility did not file a Self-Reported Incident (SRI) for this event. Staff interviews confirmed that the CNA observed the LPN's intoxication and attempted to notify the Administrator and RN on duty. The LPN was responsible for 13 residents during the shift in question. The failure to report the allegation of neglect as required constitutes the identified deficiency.
Failure to Thoroughly Investigate Alleged Resident Neglect by Impaired Nurse
Penalty
Summary
The facility failed to conduct a complete and thorough investigation into possible resident neglect by a nurse who was reported to be intoxicated while on duty. On the night in question, a resident called 9-1-1 to report that her nurse was intoxicated and smelled of alcohol. Police arrived and observed the LPN with glossy eyes, slurred and abnormal speech, and behaving in a disorderly manner, including speaking loudly and using vulgar language in front of residents. The LPN was subsequently arrested for disorderly conduct and public intoxication. Facility records showed that the LPN was responsible for the care of 13 residents during this shift. Despite the seriousness of the allegations and the facility's policy requiring immediate and thorough investigation of suspected neglect, the facility only interviewed two residents and did not assess or interview all 13 residents assigned to the LPN. The Director of Nursing reviewed medical records and medication administration records for these residents and determined that no medication or care had been provided by the LPN during the shift. However, the lack of direct assessment or interviews with all potentially affected residents constituted a failure to follow the facility's own investigative procedures.
Failure to Provide Timely Pressure Ulcer Assessment and Treatment
Penalty
Summary
The facility failed to provide adequate and timely pressure ulcer care for two residents, resulting in actual harm to one. For a resident with multiple comorbidities including diabetes and peripheral vascular disease, staff did not promptly assess a newly discovered open wound, nor did they notify the physician or obtain treatment orders in a timely manner. The wound was left unaddressed for several days, during which time it increased in size and severity, eventually being classified as a stage IV pressure ulcer. Even after wound care orders were obtained, staff did not consistently perform the ordered treatments, as evidenced by multiple missed dressing changes documented in the treatment administration records. Another resident, who was at high risk for skin breakdown and required total care, also did not receive timely wound assessments or treatments as ordered for a stage III pressure ulcer. There was a lack of documentation regarding wound assessments, measurements, and descriptions, and several ordered dressing changes were not completed. The facility's own policy required prompt physician notification and adherence to treatment orders, but these procedures were not followed for either resident. Interviews with the Director of Nursing confirmed the absence of required documentation and the failure to complete wound care treatments as ordered. The deficiencies affected two of three residents reviewed for pressure ulcers, with one resident experiencing actual harm due to the lack of timely intervention and ongoing missed treatments.
Failure to Provide Timely Bathing for Dependent Residents
Penalty
Summary
The facility failed to ensure that dependent residents received timely bathing as required by their care plans and physician orders. Medical record reviews for two residents revealed that scheduled showers or bed baths were not consistently offered or completed on the designated days. One resident, with diagnoses including dementia, peripheral vascular disease, COPD, and chronic pain syndrome, required substantial assistance with ADLs and had physician orders for showers or bed baths twice weekly. Documentation showed missed bathing opportunities on several scheduled days, and the resident reported that showers were not provided because staff were too busy. Another resident, with hemiplegia, cerebral vascular accident, sickle-cell disease, and seizures, also required staff assistance for bathing and had similar orders for regular showers. Records indicated multiple missed or undocumented showers on scheduled days, and the resident confirmed that showers were not completed as expected. Interviews with the DON and CNAs confirmed the absence of documentation for bathing on the missed dates and verified that if the electronic medical record was blank, the shower task was not completed. The facility's policy required that care and services for ADLs, including bathing, be provided based on the resident's assessment and needs. The deficiency was identified through medical record review, resident and staff interviews, and facility policy review, and was investigated under multiple complaint numbers.
Failure to Monitor and Intervene for Constipation in Two Residents
Penalty
Summary
The facility failed to monitor and intervene appropriately for constipation in two residents with significant medical histories, including chronic obstructive pulmonary disease, diabetes, heart disease, and other chronic conditions. For one resident, records showed a six-day period without a bowel movement, despite physician orders for both scheduled and as-needed medications for constipation and an order to monitor for medication side effects, including constipation. There was no documentation that the resident was assessed for constipation or offered the as-needed medication during this period. For the second resident, a five-day period without a bowel movement was documented, despite orders for daily and twice-daily medications for constipation and instructions to monitor for constipation every shift. Again, there was no documentation of assessment for constipation during this time. Interviews with the DON, Administrator, and an RN confirmed that the facility's standard of practice is to monitor daily bowel movements, assess for constipation, and initiate interventions after three days without a bowel movement. The absence of documentation and lack of intervention for both residents was confirmed by the DON. The findings were based on medical record review, staff interviews, and reference to national clinical guidelines, and represent continued non-compliance from a previous survey.
Catheter Removed Without Physician Order
Penalty
Summary
Staff failed to obtain a physician's order prior to removing an indwelling urinary catheter from a resident with a history of bacteremia, chronic kidney disease, and neuromuscular dysfunction of the bladder. The resident, who was always incontinent of bowel and bladder and dependent on staff for all activities of daily living, had an intact cognitive function and was under hospice care. The care plan indicated the presence of an indwelling Foley catheter due to neurogenic bladder, with interventions to monitor for pain or discomfort related to the catheter. On the day of the incident, a nurse contacted urology to request an order for catheter removal but did not receive a return call or order. Later, the resident reported severe urinary pain, and after administering pain medication, the nurse removed the Foley catheter at the resident's request without a physician's order. The resident was subsequently transferred to the hospital to rule out a urinary tract infection. Review of facility protocol confirmed that a physician's order is required for catheter removal, and the Director of Nursing verified that no such order was present in the medical record.
Failure to Secure Hazardous Chemicals Resulting in Resident Harm
Penalty
Summary
The facility failed to ensure that hazardous chemicals were properly stored in secured areas and kept out of the reach of residents. Multiple observations and staff interviews revealed that cleaning chemicals, germicidal wipes, mouthwash, and other potentially harmful substances were found unsecured in resident rooms, common areas, and unlocked storage rooms. These chemicals were accessible to residents, despite facility policies requiring that such items be locked away when not in use. Several doors to storage rooms containing hazardous materials were found unlocked or with malfunctioning locks, and chemicals were left unattended on housekeeping carts and countertops. A resident with a history of compulsive behaviors, poor decision-making, and mental health issues, including schizophrenia with disorganized thoughts and paranoia, was able to access and apply hazardous chemicals to his body on multiple occasions. The resident had previously been found with wound cleanser, scissors, and various cleaning chemicals in his room, and had a documented pattern of taking unsafe items from around the facility. On two separate incidents, the resident applied cleaning chemicals to his feet and peri-area, resulting in second-degree chemical burns and subsequent hospitalization, including admission to a burn unit and later to the ICU for sepsis evaluation. Staff discovered the incidents after responding to the resident's complaints of pain and upon finding chemical containers in the resident's room. Medical records and staff interviews confirmed that the resident required 24-hour supervision, had a care plan noting self-harm behaviors, and had previously been redirected for taking unsafe items. Despite these known risks, hazardous chemicals remained accessible in the environment, and staff were not consistently ensuring that chemicals were secured. The facility's failure to secure hazardous chemicals directly resulted in serious physical harm to the resident, including chemical burns and hospitalization.
Removal Plan
- Hold a Quality Assurance and Performance Improvement (QAPI) meeting.
- Search the facility for unsecured hazardous chemicals and secure any found.
- Remove spray bottles of bleach solution and odor control from public bathrooms.
- Remove odor control and multi surface peroxide from nurses' stations, resident rooms, activity room, and common sitting areas.
- Relocate spray bottles of odor control, multi surface peroxide, floor cleaner, and bleach solution from the top of housekeeping carts into a locking compartment on each cart.
- Conduct a facility wide audit to ensure all hazardous chemicals are properly stored, supply room doors and cabinets are locked, housekeeping carts are locked, and all hazardous chemicals are secured within the housekeeping cart if not in use.
- Complete skin assessments on all residents.
- Complete door audits to ensure all hazardous material storage rooms have properly functioning doors and that the doors lock securely.
- Educate all staff on policies related to chemical storage, how to handle chemicals and hazardous materials, what to do if hazardous materials get on you or the resident's skin, safe storage locations for harmful chemicals, ensuring storage locations are secured, and what to do if a hazardous storage location is not secured.
- Educate any staff not yet educated at the start of their first scheduled shift.
- Educate new hires during new hire orientation on chemical storage, how to handle chemicals and hazardous materials, what to do if hazardous materials get on you or the resident's skin, safe storage locations for harmful chemicals, ensuring storage locations are secured, and what to do if a hazardous storage location is not secured.
- Conduct random audits with staff to ensure understanding of where to find pertinent policies to ensure the safe storage of harmful chemicals. Reeducate employees unable to speak to the policies and the safe storage of hazardous chemicals.
- Continue audits until specific interventions identified, and policies and procedures are operationalized to prevent the same actions or practices from occurring in the future.
- Address any concerns or questions regarding hazardous chemicals immediately.
- Verify completion of education on policies related to chemical storage, how to handle chemicals and hazardous materials, what to do if hazardous materials get on you or the resident's skin, safe storage locations for harmful chemicals, ensuring storage locations are secured, and what to do if a hazardous storage location is not secured by all staff.
- Conduct audits of the facility to ensure all hazardous chemicals are properly stored, supply room doors and cabinets are locked, housekeeping carts are locked when not in use.
- Conduct audits on doors where hazardous materials are kept.
- Secure or repair any door found to be unsecured or in need of repair. Enter work orders for any door found unsecured and in need of repair in the electronic work order system for tracking and reporting.
- Provide audit results to the Administrator.
- Review audits in Quality Assurance (QA) and monitor in the QAPI meeting until deemed compliant.
Failure to Address and Follow Up on Resident Grievances and Council Concerns
Penalty
Summary
The facility failed to address and follow up on resident grievances and concerns in a timely manner, as evidenced by a review of facility documents, staff interviews, and policy review. Out of 75 grievances filed between April 2025 and September 2025, 30 had not been followed up on. Additionally, multiple concerns raised during Resident Council meetings from June through October 2025—including issues with untimely medication administration, undercooked food, staffing, staff approach, and showers—were not addressed or followed up on. The facility census at the time was 70 residents, indicating that the failure had the potential to affect all residents. Further review revealed inconsistencies in documentation and follow-up actions. For example, meeting minutes from August 2025 indicated that an LPN had been counseled for untimely medication administration, but the personnel file contained no documentation to support this. Interviews with the DON and Administrator confirmed that the grievances and concerns had not been addressed as required by facility policy, which designates the Administrator as the Grievance Official responsible for oversight and written decisions. The facility's policy also requires action and communication regarding Resident Council concerns, which was not followed.
Failure to Provide Sufficient Nursing Staff for Resident Care Needs
Penalty
Summary
The facility failed to provide sufficient nursing staff to meet the daily needs of all residents, as evidenced by the absence of Certified Nursing Assistants (CNAs) on duty during a specific shift and lack of documentation for care provided. Medical record reviews for three residents with significant care needs, including diagnoses such as obstructive hypertrophic cardiomyopathy, myasthenia gravis, schizophrenia, Parkinson's disease, and adult failure to thrive, revealed gaps in documentation of activities of daily living (ADL) care, particularly between 3:00 P.M. and 7:00 P.M. on a specified date. For these residents, task sheets showed either no documentation or infrequent documentation of personal hygiene and toileting assistance, despite their dependence on staff for these tasks. Interviews with residents, their representatives, and staff confirmed ongoing staffing shortages, especially the absence of CNAs during the identified shift. Residents and their representatives reported delays in call light responses, unmet care needs, and instances where residents remained in soiled briefs or received late medications. Staff interviews corroborated these accounts, with LPNs and CNAs stating that they sometimes worked without adequate support, leading to prioritization of care and difficulty fulfilling all resident needs. The facility's own assessment tool outlined required CNA-to-resident ratios for each shift, which were not met during the period in question. Timecard reviews confirmed no CNAs were present during the critical hours, and the administrator was unable to verify that required care was provided outside of what was documented. Multiple complaints and interviews further substantiated the deficiency in staffing and the resulting lack of timely and adequate care for residents.
Failure to Control Foul Odors in Resident Halls and Dining Area
Penalty
Summary
Surveyors observed intermittent foul urine odors throughout A, B, and C halls, as well as in the adjacent dining room, during multiple visits. These odors were not associated with any specific resident, resident rooms, or soiled utility rooms. Staff interviews, including with an LPN and an activities assistant, confirmed that the urine odor was common on most days. Resident interviews and a representative also confirmed that the foul odor was bothersome and present throughout the hallways. Review of facility policies revealed that the facility was required to provide a clean and homelike environment, with specific instructions to minimize odors by reporting lingering odors and cleaning needs to the housekeeping department. The facility also had a policy for routine cleaning and disinfection to ensure a sanitary environment. Despite these policies, the persistent foul urine odor indicated a failure to maintain a safe, clean, and comfortable environment for residents on the affected halls.
Failure to Complete Thorough Investigations for Self-Reported Incidents
Penalty
Summary
The facility failed to conduct thorough investigations for five self-reported incidents (SRIs) involving six residents. The review found that for each of these incidents, the facility did not obtain staff interviews or statements, did not conduct resident interviews, did not assess other residents with similar conditions, and did not provide staff education related to the incidents. These failures were confirmed by the Administrator, who acknowledged that these investigative steps were not completed as required by facility policy. The residents involved had a range of medical conditions, including chronic obstructive pulmonary disease (COPD), diabetes mellitus, congestive heart failure (CHF), cerebral vascular accident (CVA), systemic lupus, dementia, and vascular dementia. Some residents were cognitively intact, while others had cognitive impairment. The facility's policy on abuse, neglect, and exploitation requires immediate and thorough investigations, including interviews with all involved parties and complete documentation, but these procedures were not followed for the incidents reviewed.
Failure to Accurately Document Care and Medication Administration
Penalty
Summary
The facility failed to ensure accurate and complete documentation in resident medical records, affecting multiple residents. For several residents, including those with complex medical histories such as obstructive hypertrophic cardiomyopathy, myasthenia gravis, and pressure ulcers, there was a consistent absence of documentation to support that daily living cares were provided on multiple days and shifts. Task sheets for these residents often lacked entries for personal hygiene and other activities of daily living, despite their dependence on staff for these tasks. Interviews with the administrator confirmed these documentation gaps for the reviewed periods. In one case, a resident's narcotic count sheets indicated that tramadol was removed and presumably administered on specific days, but there was no corresponding documentation in the medication administration record (MAR) as required by facility policy. The LPN responsible admitted to only documenting administration on the narcotic count sheet and not in the MAR, even though the resident confirmed receiving the medication. Facility policy clearly stated that all administered medications must be documented in the MAR, which was not followed in this instance. Additionally, for a former resident with multiple wounds and a history of sepsis and kidney disease, the treatment administration record (TAR) indicated that wound care was completed on certain days. However, an internal investigation revealed that two nurses had signed off on wound care that was not actually performed, and failed to document the resident's refusal of treatment. Both nurses were disciplined for falsifying electronic medical record documentation, which led to misleading records indicating that care was provided when it was not. Facility policy required that wound treatments be documented in accordance with physician orders, including the effectiveness of the treatment, which was not done in these cases.
Failure to Perform Hand Hygiene During Meal Tray Service
Penalty
Summary
The facility failed to ensure that meal trays were served in a clean and sanitary manner, as observed during meal tray service to eight residents. Certified Nurse Assistant (CNA) #525 repeatedly did not perform hand hygiene before or after retrieving meal trays from the cart, delivering trays to residents' bedside tables, setting up meal trays, or after handling potentially contaminated items such as bedside tables, dirty water cups, trash bags, and cleaning up spills. The CNA also failed to perform hand hygiene after touching her face, picking up items from the floor, and after assisting residents with their meals, including cutting up food with silverware from the meal tray. These actions were directly observed during a meal service period, and the CNA confirmed during interview that she did not perform hand hygiene as required between resident contacts, after cleaning, or after handling trash. Review of the facility's hand hygiene policy indicated that all staff are required to perform proper hand hygiene to prevent the spread of infection, specifically between resident contacts and after handling contaminated objects. The failure to follow these procedures was observed to affect all eight residents who received meal trays during the observation period.
Failure to Timely Report Alleged Abuse
Penalty
Summary
The facility failed to timely report an allegation of abuse involving a resident with dementia who was cognitively impaired at the time of the incident. The resident's family reported the alleged abuse to the former Director of Nursing (DON), but the DON did not notify the Administrator or initiate the required Self-Reported Incident (SRI) process until three days later. According to facility policy, allegations of abuse must be reported to the Administrator and appropriate authorities immediately, but not later than two hours after the allegation is made if abuse or serious bodily injury is involved, or within 24 hours if not. The delay in reporting was confirmed through record review, staff interviews, and examination of the facility's SRI and policy documents. The Administrator only became aware of the incident after being informed by the former DON several days after the initial report from the resident's family. This resulted in a delay in both the suspension of the alleged perpetrator and the initiation of the investigation, constituting non-compliance with the facility's abuse reporting policy.
Failure to Notify State Agency of Significant Change in Mental Health Condition
Penalty
Summary
The facility failed to notify the appropriate state agency, the Ohio Department of Mental Health, of a significant change in a resident's mental health condition as required by regulation. Record review showed that a resident was admitted with multiple diagnoses, including anxiety and epilepsy, and later received new diagnoses of disorganized schizophrenia and schizophrenia. Despite these new mental health diagnoses and an increase in behaviors, there was no evidence in the medical record that an updated PASRR assessment was completed or that the state agency was notified. Staff interviews confirmed that no updated PASRR was completed at the time of the new diagnoses, and the Director of Nursing acknowledged that a PASRR should have been conducted. Facility policy requires prompt referral to the state mental health authority for a level II resident review when a resident exhibits a newly evident or possible serious mental disorder. The failure to follow this policy and regulatory requirement resulted in the deficiency.
Failure to Update and Follow Wound Care Orders
Penalty
Summary
The facility failed to ensure that wound care orders for a resident with a right above-the-knee amputation (RAKA) were accurate and completed as ordered. The resident, who was cognitively intact and required assistance with activities of daily living, had a history of disruption of wound healing, infection following procedure, dehiscence of amputated stump, gangrene, acidosis, and peripheral vascular disease. Physician orders initially directed that Betadine be applied to the surgical incision and wrapped with fluff gauze once daily. However, after a follow-up with a vascular surgeon, the wound care order was changed to Betadine application twice daily. This updated order was communicated to the facility but was not reflected in the resident's medical record or implemented in practice. Documentation and observation revealed that wound care was only being performed once daily, and on at least one occasion, the dressing was not changed as documented. Staff interviews confirmed that the wound care orders had not been updated in the system to reflect the new instructions from the vascular surgeon, and the facility's policy required treatments to be provided in accordance with physician orders. The inaccuracy in the medical record and failure to follow the most current wound care orders resulted in the deficiency.
Failure to Ensure Required Physician Visits During Admission
Penalty
Summary
A review of the medical record, staff interviews, and facility policy revealed that a resident was not seen by a provider during the entire admission period from 05/07/25 through discharge on 08/21/25. The medical record for this resident, who was cognitively intact according to the five-day Minimum Data Set (MDS) assessment, showed no physician progress notes for the duration of the stay. Facility assessment documentation indicated that residents should expect a standard of care from medical practitioners and other healthcare professionals necessary to provide the required support and care. This deficiency was identified during an investigation under Complaint Number 2572811.
Failure to Address Psychosocial Needs and Prevent Harm from Hazardous Behaviors
Penalty
Summary
The facility failed to timely address the psychosocial needs and implement individualized interventions for a resident with a history of mental disorder, paranoia, hoarding behaviors, and a pattern of acquiring hazardous chemicals. The resident, who had diagnoses including schizophrenia with disorganized thoughts, anxiety, and paranoia, was noted to have intact cognition but poor decision-making skills. Despite being identified as requiring 24-hour supervision and having a care plan that included interventions for behaviors potentially causing harm to self or others, the resident continued to obtain and hoard facility chemicals over several months. Staff interviews and record reviews revealed that the resident's behaviors, including acquiring and mixing cleaning chemicals, were known to the staff and had been ongoing. On one occasion, staff found a spray bottle in the resident's room containing mixed chemicals, and on a prior day, other cleaning chemicals were also found and removed. The psychiatric nurse practitioner was unaware of the recent escalation in behaviors and hospitalizations, despite noting an increase in behaviors earlier in the year. The administrator confirmed that while the resident was educated about not having chemicals, there was no evidence that the interdisciplinary team addressed the increase in behaviors or implemented a psychosocial plan of care. The deficiency culminated when the resident was found with wet, blistered, and inflamed feet, which upon assessment were determined to be partial thickness burns. The resident was sent to the hospital and subsequently transferred to a burn center for treatment. The facility's policy required person-centered behavioral health care and regular review of care plans, especially when interventions were not effective or when there was a change in condition, but there was no documentation that these requirements were met in this case.
Failure to Provide Adequate Nursing Staff to Meet Resident Needs
Penalty
Summary
The facility failed to provide adequate nursing staff each day to meet the needs of all residents, as evidenced by multiple documented instances of missed care and insufficient staff coverage. Several residents with significant care needs, including those with cognitive impairment, mobility limitations, and dependence on staff for activities of daily living (ADLs), did not receive scheduled showers, baths, or assistance with eating. For example, one resident who was dependent on staff for bathing and feeding missed 16 scheduled baths over three months and was observed not receiving assistance with meals, resulting in uneaten food. Staff interviews confirmed that showers and other care tasks were often not completed due to inadequate staffing levels. Another resident, who was dependent on staff for all ADLs and at risk for pressure ulcers, received only one documented bath or shower in a month and was not repositioned as required, with documentation showing only seven repositioning entries over a month. Staff reported that they were unable to provide timely incontinence care and repositioning due to the high workload and lack of sufficient staff. Additional residents also missed scheduled showers or received only bed baths, with staff confirming that the extensive care needs and lack of available staff prevented them from completing required care tasks. Review of staffing schedules and Payroll Based Journal (PBJ) reports revealed that the facility consistently scheduled fewer licensed nurses and CNAs than identified as necessary to meet resident needs. On multiple days, the facility did not meet the state minimum staffing requirement of 2.5 hours of direct resident care per resident per day. The facility also triggered for excessively low weekend staffing and had a one-star staffing rating, indicating ongoing issues with staffing sufficiency. Facility leadership acknowledged the staffing shortages and confirmed that even with management staff assisting, there were not enough staff to meet resident care needs.
Failure to Submit Required Staffing Data to CMS
Penalty
Summary
The facility failed to submit required direct care staffing information to CMS for Quarter Four of 2024, as mandated by federal regulations. Review of the Payroll-Based Journal (PBJ) Staffing Data Report showed that the facility did not submit staffing data for the period of July 1 to September 30, 2024. During an interview, the Administrator confirmed that the data was not submitted and stated that Human Resources was responsible for the submission, but it was not completed. The Administrator was unable to provide a reason for the failure to submit the required data. The facility's policy indicated that staffing data should be collected and submitted monthly before the 15th of each month. This deficiency had the potential to affect all 68 residents in the facility, as reflected by the facility census.
Failure to Provide Scheduled Showers and Feeding Assistance to Dependent Residents
Penalty
Summary
The facility failed to provide necessary care and assistance with activities of daily living (ADLs), specifically feeding assistance and scheduled showers, to dependent residents. Multiple residents with significant medical conditions and cognitive or physical impairments were affected. For example, one resident with congestive heart failure, chronic kidney disease, and other comorbidities was documented as dependent on staff for ADLs and at risk for pressure ulcers, yet received only one shower or bath over a month-long period, despite care plans indicating the need for more frequent hygiene support. Staff interviews confirmed that scheduled showers were often missed due to insufficient staffing and the extensive care needs of residents. Another resident with severe cognitive impairment, morbid obesity, and chronic respiratory failure was dependent on staff for bathing and had physician orders for regular showers or bed baths. Documentation revealed missed scheduled baths, and the facility administrator verified the lack of evidence that these were provided as ordered. Similarly, a resident with metabolic encephalopathy, hemiparesis, and diabetes, who was dependent on staff for ADLs, missed at least one scheduled shower or bed bath, with both the resident and assigned CNA confirming that showers were frequently not provided due to staff shortages and high workload. A further case involved a resident with a history of stroke, dysphagia, and moderate cognitive impairment, who required staff assistance for bathing and feeding. Documentation showed that this resident missed 16 scheduled baths over three months. Observations and interviews with the resident, her POA, and staff revealed that she was not consistently assisted with eating or bathing, often due to inadequate staffing. On multiple occasions, the resident was left without assistance during meals, resulting in uneaten food, and her hygiene needs were unmet. Staff interviews consistently cited lack of sufficient staff as the reason for these deficiencies.
Failure to Provide Timely Repositioning and Pressure Ulcer Prevention
Penalty
Summary
The facility failed to provide timely repositioning and offloading for dependent residents at risk for pressure ulcers, as evidenced by observations, medical record reviews, and staff interviews. Three residents with significant mobility limitations and multiple comorbidities, including congestive heart failure, chronic kidney disease, fractures, diabetes, and malnutrition, were identified as not receiving repositioning at the frequency required by their care plans and physician orders. Documentation showed that one resident was only repositioned five times over a month, and another only seven times, despite orders for repositioning at least every two hours. Direct observations revealed that residents remained in the same position in bed for extended periods, sometimes exceeding four hours without repositioning or incontinence care. Staff interviews confirmed a lack of awareness regarding when residents were last repositioned, and there was no consistent communication between shifts about residents' care needs. In several instances, residents were found soiled and had not received care since the previous shift, further indicating lapses in routine care and monitoring. Residents themselves reported infrequent repositioning, with one stating that repositioning occurred only once during an eight-hour shift. Staff confirmed these accounts, acknowledging that they had not provided care or repositioned residents for several hours after assuming responsibility. These findings demonstrate a pattern of non-compliance with established care protocols for pressure ulcer prevention among dependent residents.
Failure to Provide Timely Incontinence and Catheter Care
Penalty
Summary
The facility failed to provide timely and appropriate incontinence care for three residents who were dependent on staff for activities of daily living and were incontinent of bowel and bladder. Observations revealed that residents remained soiled for extended periods, with staff unable to confirm when incontinence care was last provided. In one instance, a resident was found incontinent of liquid stool and urine, with visible skin excoriation, and had not received care for over two hours since the start of the shift. Staff interviews confirmed a lack of communication regarding the timing of previous care, resulting in residents not being checked or changed as needed. Additionally, the facility did not ensure proper catheter care or maintain appropriate physician orders for a resident with an indwelling urinary catheter. The medical record lacked documentation of routine catheter care, a diagnosis for catheter use, and specific maintenance orders. During perineal care, staff failed to cleanse the catheter tubing as required by facility policy, and this omission was verified by staff interview. The facility policy specified that catheter care should be performed every shift and as needed, including cleaning the catheter tubing, but this was not followed. The deficiencies were identified through observations, medical record reviews, staff interviews, and policy review. The affected residents had significant medical histories, including chronic illnesses and mobility impairments, making them reliant on staff for personal hygiene and at risk for complications from inadequate care. The findings were substantiated under multiple complaint investigations.
Failure to Ensure Timely Availability of Prescribed Pain Medication
Penalty
Summary
The facility failed to ensure that medications were available for administration as ordered by the physician for a resident with multiple chronic conditions, including congestive heart failure, chronic kidney disease, osteoarthritis, and chronic pain related to fibromyalgia. The resident was cognitively intact, dependent on staff for activities of daily living, and at risk for pressure ulcers. Physician orders included acetaminophen and Roxicodone for pain management. Review of the Medication Administration Record showed that the resident received Roxicodone for pain on one occasion, but there was no evidence of administration after that date. Observation and interviews revealed that the resident experienced significant pain and reported being without her preferred pain medication, Roxicodone, for several days, during which only acetaminophen was administered. Staff confirmed that Roxicodone was unavailable for administration for approximately five days due to a failure to reorder the medication in a timely manner. The medication was not received from the pharmacy until several days after it had run out, resulting in the resident not receiving her prescribed pain management.
Failure to Administer Prescribed Medication Due to Unavailability
Penalty
Summary
A deficiency occurred when a resident with multiple complex medical conditions, including anemia, cirrhosis, hepatic encephalopathy, chronic kidney disease, and diabetes, did not receive a prescribed medication, Rifaximin, as ordered by the physician. The resident was admitted with a partial supply of Rifaximin, which ran out three days after admission. The medication was then unavailable for administration from 12/23/24 through 12/27/24, as documented in the Medication Administration Record and nursing progress notes. During this period, the medication was not administered, and the pharmacy did not deliver a new supply until 12/31/24. There was no evidence in the medical record that the physician was notified about the unavailability of Rifaximin during the period it was not administered. The issue was discovered when the resident’s daughter inquired about the missed medication, prompting staff to address the situation. The Director of Nursing confirmed the medication was not available or administered during the specified dates, resulting in a significant medication error for the resident.
Failure to Provide Physician-Ordered Mechanically Soft Diet
Penalty
Summary
A deficiency occurred when a resident with multiple diagnoses, including psychosis, COPD, major depressive disorder, and morbid obesity, was not provided with the physician-ordered mechanically soft diet. The resident's care plan and physician orders specified a mechanical soft texture, thin consistency, and no straws, with the meal ticket on the tray also indicating the need for a mechanical soft diet. Despite these clear instructions, the resident was served a chicken patty on a bun with tomato and lettuce, which did not meet the required texture modification. During the meal observation, the resident expressed confusion about how to eat the meal and confirmed that she was supposed to receive ground meat, not whole food items. An LPN interviewed at the time verified that the resident had been given the wrong textured diet and did not receive the ground meat as required. This failure to provide the appropriate meal texture as ordered by the physician and indicated in the care plan and meal ticket led to the cited deficiency.
Failure to Apply PPE During High-Contact Care for Resident on Enhanced Barrier Precautions
Penalty
Summary
Staff failed to apply appropriate personal protective equipment (PPE) when providing high-contact care to a resident on enhanced barrier precautions (EBP). The resident, who had multiple diagnoses including congestive heart failure, chronic kidney disease, and an indwelling urinary catheter, was dependent on staff for activities of daily living and was incontinent of bowel and bladder. Observations revealed that staff entered the resident's room and provided incontinence and catheter care wearing only gloves, without donning gowns or any additional PPE as required for EBP. There was no signage posted at the room entry to indicate the need for PPE, and staff were unaware that the resident was on EBP due to the presence of an indwelling catheter. Interviews with the involved certified nursing assistants confirmed their lack of awareness regarding the resident's EBP status and the absence of instructional signage. The facility's policy required clear signage at the room entry, indicating the type of precautions, required PPE, and high-contact care activities necessitating gown and glove use. The policy also specified that EBP should be implemented for residents with indwelling medical devices, such as urinary catheters, and that gowns and gloves should be available outside the resident's room. These requirements were not met during the observed care episodes.
Deficiencies in Discharge Planning and Coordination of Home Health Care Services
Penalty
Summary
The facility failed to ensure a safe and orderly discharge for two residents, resulting in deficiencies in discharge planning and coordination of home health care services. Former Resident #8 was discharged to home without timely coordination of home health care services. Although the resident's daughter had informed the Social Service Designee (SSD) of the need for home health care and the chosen companies, the referral was not sent until after the resident's discharge. This delay, compounded by the holiday period, resulted in the home health care company not contacting the resident until several days after discharge, leaving the resident without necessary support and equipment. Similarly, Former Resident #9 experienced a delay in the coordination of home health care services and equipment. The SSD did not complete the referral for home health care services until two days after the resident's discharge, due to a delay in receiving therapy notes and the unavailability of a Certified Nurse Practitioner to sign the discharge paperwork. This resulted in a delay in the resident receiving a wheeled walker and other necessary care. The facility's policy on discharge planning was not followed, leading to these deficiencies in ensuring residents were prepared for a safe discharge.
Failure to Provide Scheduled Bathing
Penalty
Summary
The facility failed to ensure that residents were provided with scheduled bathing, affecting three residents. Resident #9, who was severely cognitively impaired and dependent on assistance for personal hygiene, was scheduled for showers twice a week but only received bed baths on three occasions and refused a shower once during a specified period. Resident #50, with moderate cognitive impairment, was scheduled for showers twice a week but only received three out of five scheduled showers. Resident #68, also severely cognitively impaired and dependent on assistance, was scheduled for showers twice a week but only received bed baths on three occasions during the same period. The Director of Nursing (DON) and the Administrator confirmed the discrepancies in the bathing schedule for these residents. The facility was in the process of transitioning their shower documentation to an electronic medical record system, which may have contributed to the oversight. The facility's policy stated that residents would be provided showers as per request or schedule, but this was not adhered to, resulting in non-compliance. This deficiency was investigated under a complaint and represented continued non-compliance from a previous survey.
Failure to Maintain Sanitary Conditions During Meal Service
Penalty
Summary
The facility failed to ensure meals were served in a sanitary manner, affecting four residents and potentially impacting all residents receiving meals from the kitchen. During an observation, a staff member was seen wearing gloves and directly touching hamburger buns, lettuce, and tomatoes, then touching plates, counters, scoop handles, tongs, and a bag containing hamburger buns without changing gloves or washing hands. This process was repeated multiple times while plating meals for four residents. Interviews with the staff member and the Dietary Manager confirmed that the staff member did not wash hands between glove changes, which is against the facility's policy. The Director of Nursing verified that all residents received meals from the kitchen. The facility's policies on hand washing and disposable gloves require hand washing after handling soiled equipment or utensils, before putting on gloves, and whenever gloves are changed or removed, to prevent cross-contamination.
Medication Labeling and Expiration Deficiencies
Penalty
Summary
The facility failed to ensure that medications were properly labeled and that expired medications were not available for use, affecting two medication rooms and one medication cart. During an observation of the C-Hall medication storage room, two expired blister cards of benzonate 100 mg capsules were found, with expiration dates of 03/28/23 and 05/12/24, respectively. Additionally, an ipratropium 0.03% nasal solution with an expiration date of 02/28/23 was also found. The Director of Nursing (DON) confirmed these medications were expired. Further observations revealed issues with the C-Hall medication cart, where a vial of Lantus insulin glargine injection was found to be open beyond the manufacturer's recommended 28-day usage period. Additionally, a bottle of folic acid 1 mg tablets was found open without a marked opening date or expiration date. Similar issues were observed in the B-Hall medication storage room, where another bottle of folic acid 1 mg tablets was found open without a marked opening date or expiration date. The DON verified these findings during the observations.
Failure to Implement Fall Interventions and Secure Hazardous Chemicals
Penalty
Summary
The facility failed to ensure that fall interventions were in place for Resident #23, who was at risk for injury due to falls. The resident had a history of falls and was severely cognitively impaired, requiring maximum assistance for daily activities. Despite the care plan specifying the use of a floor mat as a fall precaution, the mat was observed leaning against the wall instead of being placed on the floor next to the resident's bed. This oversight was confirmed by a State tested Nursing Assistant (STNA) and a Licensed Practical Nurse (LPN), both of whom acknowledged the resident's history of frequent falls. Additionally, the facility did not secure chemicals with precautionary labels, as evidenced by a 22-ounce bottle of Powerhouse All Purpose Cleaner with Bleach found on the windowsill in Resident #42's room. The cleaner's label warned of potential skin and eye irritation and advised keeping it out of reach of children and pets. Despite this, the bottle remained accessible in the resident's room over two consecutive days. This was verified by an STNA, and the facility's policy required such cleaning supplies to be stored separately and according to label instructions. The presence of the cleaner posed a potential risk to three independently mobile but cognitively impaired residents in the building.
Failure to Maintain Resident Dignity by Not Covering Catheter Bag
Penalty
Summary
The facility failed to uphold the dignity and respect of a resident by not covering the drainage bag of an indwelling urinary catheter. This deficiency was identified during a review of the medical record, observation, and interviews with both the resident and staff. The resident, who was cognitively intact, expressed a preference for the drainage bag to be covered and placed on the opposite side of the bed to avoid visibility from the hallway and to visitors entering the room. Despite this preference, the drainage bag remained uncovered and visible, which was confirmed by a State tested Nursing Assistant. The resident involved had a range of medical conditions, including chronic obstructive pulmonary disease, hypertension, obstructive and reflux uropathy, peripheral vascular disease, atrial fibrillation, chronic kidney disease, major depressive disorder, dementia, and anxiety disorder. The facility's policy on dignity, dated February 2021, emphasized that each resident should be cared for in a manner that promotes their well-being and self-esteem. However, the facility's failure to cover the drainage bag did not align with this policy, affecting the resident's sense of dignity and privacy.
Inaccessible Call Light for Dependent Resident
Penalty
Summary
The facility failed to ensure access to the call light for a dependent resident, identified as Resident #27, who was reviewed for call lights in reach. The resident had a medical history that included metabolic encephalopathy, hemiplegia affecting the right dominant side, hemiparesis following cerebral infarction affecting the right dominant side, schizoaffective disorder, anxiety disorder, and hydrocephalus. The most recent annual Minimum Data Set (MDS) assessment indicated that the resident was severely cognitively impaired and dependent on staff for showering, bathing, personal hygiene, and was always incontinent of bowel and bladder. During an observation, it was noted that the resident was lying in bed with the call light tied to the right bedrail and hanging down toward the floor, making it inaccessible to the resident. The call light was modified with a bulb type of activation. An interview with a State tested Nursing Assistant (STNA) confirmed that the call light was indeed tied to the bedrail and inaccessible to the resident.
Failure to Complete PASARR for Resident with New Mental Health Diagnosis
Penalty
Summary
The facility failed to ensure the Pre Admission Screen and Resident Review (PASARR) forms were completed for a resident who experienced a change in mental health diagnosis. This deficiency affected one of the two residents reviewed for PASARR compliance. The resident in question was admitted with multiple diagnoses, including cerebral infarction, chronic obstructive pulmonary disease, type II diabetes, anxiety disorder, major depressive disorder, dementia, hallucinations, and schizoaffective disorder bipolar type. The schizoaffective disorder diagnosis was added on 07/07/23, indicating a significant change in the resident's mental health condition. Despite this change, the facility did not complete a new PASARR screening following the addition of the schizoaffective disorder diagnosis. The resident's medical record showed no evidence of a PASARR review request being submitted after the diagnosis was updated. The Director of Social Services confirmed that a PASARR review should have been requested due to the significant change in the resident's mental health condition, which included paranoid delusions and hallucinations. The facility's policy required prompt referral to the state mental health authority for a level II resident review when a resident exhibited a newly evident or possible serious mental disorder.
Failure to Include Psychotropic Medication in Care Plan
Penalty
Summary
The facility failed to include the use of a psychotropic medication for depression in the comprehensive care plan for Resident #67. The resident, who was admitted with diagnoses of systolic depressive disorder and anxiety, had a physician's order dated 05/16/24 for Zoloft 100 mg daily to manage depression. However, upon review, it was found that the care plan did not address the use of this medication. This oversight was confirmed during an interview with RN #495 on 06/11/24, who verified the absence of a care plan for the psychotropic medication. The facility's policy on comprehensive care plans, dated 10/24/22, mandates that care plans should include measurable objectives and timeframes to meet the resident's needs as identified in their comprehensive assessment.
Failure to Include Residents in Care Planning Meetings
Penalty
Summary
The facility failed to ensure that residents were included in the development of their care plans and did not hold care planning meetings to periodically review these plans. This deficiency affected two residents, one of whom was admitted with diagnoses including chronic obstructive pulmonary disease, type II diabetes, heart failure, and cerebral infarction. Despite being cognitively intact and requiring assistance with daily activities, the resident reported not participating in care planning meetings. The last documented care plan meeting for this resident was held seven months prior, without the resident's participation, and there was no evidence of a quarterly care plan meeting being conducted. Another resident, admitted with conditions such as systolic heart failure, hypertension, and chronic kidney disease, also reported not having a care plan meeting since admission. The facility's policy required care plan meetings to be held upon admission, quarterly, and with significant changes in condition. However, interviews with staff confirmed the absence of documentation indicating that these meetings had occurred for the resident. The facility's failure to adhere to its policy on care planning and resident participation was evident in these cases.
Failure to Monitor and Address Constipation in Residents
Penalty
Summary
The facility failed to monitor and implement interventions for constipation as ordered for three residents. Resident #52, who was severely cognitively impaired and dependent on staff for toileting, did not have a documented bowel movement for 13 days. Despite having orders for docusate and polyethylene glycol for constipation, there were no additional interventions documented during this period. The Director of Nursing confirmed the lack of documentation and interventions. Resident #23, also severely cognitively impaired and dependent on staff, had no documented bowel movements for nearly a month. Although there was an order for PRN Milk of Magnesia, it was not administered. Similarly, Resident #30, who was moderately cognitively impaired and dependent on staff, had multiple days without documented bowel movements and did not receive the PRN Milk of Magnesia as ordered. The Director of Nursing verified the absence of documentation and administration of the PRN medication for both residents.
Failure to Follow Audiologist and Optometrist Recommendations
Penalty
Summary
The facility failed to follow through with the recommendations provided by an audiologist and an optometrist for a resident. The resident, who was moderately cognitively impaired, had been diagnosed with several conditions including unspecified psychosis, cognitive communication deficit, and major depressive disorder. The resident's medical record indicated a need for corrective lenses and a follow-up optometry visit, which was not conducted. Additionally, the resident complained of blurred vision and was identified with a cataract, for which surgery was declined, and new glasses were recommended. However, there was no evidence of any optometry visits in 2023 or 2024. Furthermore, the resident had an audiology visit where ear pain was reported, and the audiologist recommended consulting with a physician for wax removal and re-evaluating hearing afterward. Despite these recommendations, the resident did not receive the necessary follow-up care or treatment for ear wax removal. Interviews with the Director of Social Services and the Director of Nursing confirmed that the resident had not received the recommended follow-up care for both vision and hearing issues, which was a failure to adhere to the facility's policy on promoting residents' well-being and dignity.
Inadequate Pressure Ulcer Care for Resident
Penalty
Summary
The facility failed to ensure a thorough wound assessment and appropriate pressure ulcer care for Resident #28, who was admitted with a stage four pressure ulcer on the left buttock. Upon admission, there were no physician orders for pressure-reducing devices, and the initial assessment lacked wound measurements or descriptions. Subsequent observations revealed the resident was placed on a standard pressure reduction mattress, which was not suitable for stage four pressure ulcers, as confirmed by the Director of Nursing (DON). Additionally, the resident was observed sitting in a recliner without a pressure-reducing cushion, which was verified by both a Nursing Assistant and the Rehabilitation Director. The facility's policies required a full body skin assessment upon admission and documentation of wound characteristics, which were not followed. The DON acknowledged the absence of a thorough wound assessment within 24 hours of admission and the lack of appropriate pressure-reducing devices. The facility's failure to adhere to its own policies and manufacturer guidelines for pressure ulcer care resulted in inadequate care for Resident #28, who had a significant medical history including multiple sclerosis, hypertension, and dementia.
Failure in Catheter Care and Documentation
Penalty
Summary
The facility failed to obtain and document physician orders for the use and maintenance of an indwelling urinary catheter for Resident #64, who was admitted with multiple diagnoses including neuromuscular dysfunction of the bladder. Despite the care plan addressing the need for catheter care to prevent infections, there was no current physician order specifying the placement, size, or maintenance of the catheter. This oversight was compounded by the resident's history of urinary tract infections, as evidenced by multiple antibiotic treatments for infections caused by Escherichia Coli and Staphylococcus. Additionally, the facility did not provide proper catheter care as observed during an interaction with a State tested Nurse Aide (STNA). The STNA failed to secure the catheter to the resident's thigh and did not follow proper cleaning techniques, such as using a clean part of the cloth for each wipe and separating the labia to expose the urinary meatus. These actions were contrary to the facility's policy on catheter care, which emphasizes the importance of using the smallest catheter size for effective drainage and proper cleaning methods to prevent infections.
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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