Galion Meadows Skilled Nursing And Rehabilitation
Inspection history, citations, penalties and survey trends for this long-term care facility in Galion, Ohio.
- Location
- 935 Rosewood Dr, Galion, Ohio 44833
- CMS Provider Number
- 365351
- Inspections on file
- 25
- Latest survey
- December 11, 2025
- Citations (last 12 mo.)
- 15
Citation history
Health deficiencies cited at Galion Meadows Skilled Nursing And Rehabilitation during CMS and state inspections, most recent first.
Surveyors identified that the facility did not maintain a pleasant, homelike environment due to persistent strong urine odors in resident areas and unclean wheelchairs for several residents. Multiple staff, residents, and family members confirmed the ongoing odor and lack of wheelchair cleaning, despite facility policy stating wheelchairs should be cleaned regularly. Affected residents had conditions such as cognitive impairment, muscle weakness, hemiplegia, and Parkinson's disease.
Staff failed to follow infection prevention protocols, including not performing hand hygiene before and after resident care, not donning required PPE such as gowns and gloves for residents on Enhanced Barrier Precautions, and not disinfecting a glucometer between use on two residents. These deficiencies were confirmed through staff interviews, observations, and review of facility policies and CDC guidance.
A resident with severe cognitive impairment sustained a skin tear during a mechanical lift transfer, but the responsible party was not notified of the incident or new wound care orders. Staff interviews revealed confusion about notification responsibilities, and the facility's policy requiring timely notification of the resident's representative was not followed.
A resident with severe cognitive impairment and an indwelling catheter did not have urine output documented as ordered by the physician, and new areas of skin breakdown were not timely assessed or treated. Staff failed to record required information in the medical record, and multiple open wounds were observed without corresponding documentation or treatment orders. The Wound Care Nurse was unaware of the new wounds, and CNAs reported the wounds had been present for over a week.
A resident with severe mobility and cognitive impairments sustained a significant skin tear on the right foot during a transfer with a mechanical lift. The injury occurred when the resident's foot became caught under a wheelchair foot pedal while two CNAs were transferring the resident; one CNA was distracted by staff issues, and the other was occupied holding the resident's head due to the lack of a headrest on the manual wheelchair provided by therapy. The incident resulted in a painful wound with active bleeding.
A resident with diabetes received insulin injections from an RN who failed to prime the insulin pens before use, as required by both facility policy and manufacturer instructions. The RN also administered insulin doses later than ordered and delayed subsequent doses. These actions resulted in two medication errors out of 27 opportunities, causing the facility's medication error rate to exceed 5%.
A resident with type II diabetes mellitus received insulin injections from an RN who failed to prime the insulin pens before administration, despite facility policy and manufacturer instructions requiring priming before each use. The RN stated he only primed new pens, and the DON confirmed that priming should occur before every injection. This resulted in a significant medication error for the resident.
A resident with multiple chronic conditions experienced significant and ongoing weight increases over several months. Despite the dietitian's requests for re-weights after each significant gain, these were not completed in a timely manner, and a full nutritional assessment was not performed after the weight changes. Staff interviews and policy review confirmed that required procedures for monitoring and responding to significant weight changes were not followed.
A resident with multiple chronic conditions did not receive prescribed pregabalin for neuropathy due to the facility's failure to ensure a valid prescription was received and processed by the pharmacy. The medication was not administered for several days following the resident's return from the hospital, except for a brief period when an on-call CNP provided a short-term supply. The resident was not informed about the interruption in her pain medication, and facility leadership confirmed the medication was not available or given as ordered.
A resident with significant mobility deficits and a history of falls was injured during van transport when their electric wheelchair was not properly secured using the required four-point securement system and shoulder belt. The driver relied on the wheelchair's positioning belt, which is not intended for vehicle restraint, and there was no formal staff training or documentation on the use of the van's safety systems. The resident sustained injuries requiring hospital admission.
A resident's court-appointed guardian was not notified about the initiation or charges for therapy services, nor was informed consent obtained for dental services after the resident switched to private pay. The resident, who had significant cognitive and medical issues, received multiple therapy and dental services without proper guardian notification or updated consent documentation.
Two residents did not receive care as ordered: one did not have required lab tests completed before a nephrology appointment, resulting in the appointment being rescheduled, and another did not receive all required neurological assessments after a fall with a head injury while on anticoagulant therapy. Staff interviews and record reviews confirmed that care and monitoring were not provided as ordered, and notifications to family and medical staff were delayed.
A resident with severe cognitive impairment and multiple medical conditions received midodrine for hypotension despite physician orders to hold the medication if systolic blood pressure exceeded 120 mmHg. The medication administration record did not reflect the hold parameters, leading to 47 doses being administered when the resident's blood pressure was above the specified limit. The DON confirmed the discrepancy between the physician's order and the MAR.
A resident with multiple chronic conditions and severe cognitive impairment did not have physician-ordered laboratory tests completed prior to a scheduled specialist appointment. The omission was confirmed through medical record review, family interviews indicating missed or rescheduled appointments, and verification by the DON.
A resident with multiple chronic conditions and severe cognitive impairment received a wound dressing change during which the ADON did not change gloves or perform hand hygiene after removing a soiled dressing and before applying ointment to the wound, contrary to facility policy.
The facility's dishwasher failed to reach the required minimum temperature for proper sanitization, potentially affecting all residents receiving food from the kitchen. An observation revealed the dishwasher's wash temperature was 110°F, below the required 120°F. Missing temperature documentation was noted in the facility's Dish Machine log, and the issue was discovered during a complaint investigation.
The facility failed to provide scheduled showers for three residents who required assistance, missing multiple opportunities over nearly two months. One resident, with Parkinson's disease, received only four baths instead of the scheduled twice-weekly showers. Another resident, with schizophrenia and diabetes, also missed 11 scheduled showers. A third resident, with multiple sclerosis and quadriplegia, missed six scheduled showers due to staffing issues. Staff confirmed difficulties in completing ADL care timely due to increased demands.
A facility failed to ensure proper PPE use for a resident on COVID-19 precautions. Staff entered the resident's room without required eye protection and N-95 masks, despite clear signage. The resident, with COVID-19 and other health issues, required isolation. The facility's policies on PPE and transmission-based precautions were not followed, affecting the safety of all residents.
The facility did not have a registered nurse (RN) on duty for at least eight consecutive hours on two consecutive days, as required. This was confirmed through staff schedules, pay records, and interviews with the Administrator and DON. The absence of an RN had the potential to affect all 50 residents in the facility.
Failure to Maintain Clean Environment and Wheelchairs
Penalty
Summary
Surveyors found that the facility failed to maintain a safe, clean, and homelike environment for residents, as evidenced by persistent strong foul odors of urine throughout the North and South units and unclean wheelchairs for multiple residents. Observations and interviews with residents, family members, and staff confirmed that the odor was present in resident living areas over multiple days, and both nursing and housekeeping staff acknowledged the ongoing issue. The Director of Nursing also confirmed the presence of the odor during the survey. Additionally, the facility failed to ensure that residents' wheelchairs were clean. Three residents who used wheelchairs were observed to have wheelchairs with thick coatings of grime, dust, dirt, dried spills, food particles, and unidentified stains. Residents and family members reported that staff did not clean the wheelchairs, and staff interviews confirmed that cleaning was supposed to occur on shower days and as needed, but this was not being done. The affected residents had various diagnoses, including cognitive impairment, muscle weakness, hemiplegia, and Parkinson's disease.
Infection Control Failures in Hand Hygiene, PPE Use, and Equipment Disinfection
Penalty
Summary
Multiple deficiencies in infection prevention and control practices were observed among staff during medication administration, resident care, and use of medical equipment. A registered nurse failed to perform hand hygiene after exiting a resident's room and before preparing and administering insulin injections to another resident. The nurse also did not wash hands before donning gloves, exited the room with the same gloves, and handled medication equipment without performing hand hygiene. These actions were confirmed by the nurse during the interview. Certified nursing assistants did not follow Enhanced Barrier Precautions (EBP) when providing care to residents with indwelling catheters. Specifically, staff did not don isolation gowns or perform hand hygiene before or after providing catheter care, despite signage indicating EBP requirements. One CNA provided catheter care to a resident with an indwelling catheter and then entered another resident's room without washing or sanitizing hands. Another CNA and an LPN also failed to don gowns or perform hand hygiene as required during high-contact care activities for residents on EBP. A medication technician used a single glucometer for blood sugar assessments on two residents without cleaning or disinfecting the device between uses, contrary to CDC guidance and manufacturer instructions. The technician also failed to remove gloves or perform hand hygiene between residents. The Director of Nursing confirmed that staff were expected to clean glucometers between each use and to perform hand hygiene before and after resident care. Facility policies and CDC guidance reviewed during the investigation supported these requirements, but staff interviews and observations revealed consistent non-compliance.
Failure to Notify Resident Representative of Incident and Change in Condition
Penalty
Summary
The facility failed to notify a resident's representative of an incident involving the resident, specifically a skin tear sustained during a mechanical lift transfer. The resident, who had diagnoses including hemiplegia, hemiparesis following cerebral infarction, and cognitive communication deficit, was assessed as severely cognitively impaired. Documentation showed that the resident's son was listed as the responsible party and emergency contact. Despite this, there was no record that the son was informed of the skin tear or the subsequent new wound care orders. The son only learned of the injury days later during a visit, after inquiring about his father's comments regarding his foot. Staff interviews revealed confusion and inconsistency regarding notification responsibilities. The ADON stated she did not notify the family because she believed the resident was sometimes alert and oriented, and typically notified the resident directly. The DON admitted to not checking the responsible party information and assumed the resident was his own responsible party. Other staff confirmed the resident's cognitive status fluctuated, with orientation primarily to self and inconsistent recognition of others. Facility policy required notification of the resident's representative within 24 hours of any incident or change in condition, unless otherwise instructed by the resident, but this was not followed in this case.
Failure to Document Urine Output and Timely Assess Skin Breakdown
Penalty
Summary
The facility failed to provide appropriate treatment and care according to physician orders and the resident's needs for one resident. Specifically, staff did not document or record urine output as ordered by the physician for a resident with an indwelling catheter. Review of the medical record, Medication Administration Record (MAR), and Treatment Administration Record (TAR) showed no documentation of urinary output, and this was confirmed by the Regional Director of Clinical Services. The physician order required urine output to be recorded every shift, but this was not done. Additionally, the facility failed to timely assess and treat new areas of skin breakdown for the same resident. Observations revealed multiple open wounds and areas of redness and scabbing in the peri area, buttocks, thigh, and coccyx, which had been present for over a week. Certified Nursing Assistants (CNAs) reported the wounds but there was no documentation or treatment orders for these wounds in the medical record. The Wound Care Nurse was unaware of the new wounds and confirmed there were no treatment orders or documentation for them. The resident was severely cognitively impaired, dependent on staff for care, and had a history of resolved wounds, but the new wounds were not assessed or treated in a timely manner.
Resident Injury During Mechanical Lift Transfer Due to Inadequate Supervision
Penalty
Summary
A deficiency occurred when a resident with severe cognitive impairment, hemiplegia, morbid obesity, and significant mobility deficits was injured during a transfer using a mechanical lift. The resident, who was dependent on staff for bed mobility and required two-person assistance for transfers, sustained a skin tear on the right foot after it was caught under the foot pedal of a manual wheelchair during the transfer. The incident happened while two CNAs were transferring the resident from a chair to bed using a Hoyer lift. One CNA was distracted due to interpersonal issues with another staff member and did not notice the resident's foot was caught, resulting in a skin tear with moderate bleeding. The resident's care plan specified the need for two-person assistance, and the transfer was being performed with two staff present, but one was preoccupied and failed to ensure the resident's safety. Further contributing factors included the use of a manual wheelchair without a headrest, which was provided by therapy after the resident experienced a decline and could no longer use his personal electric wheelchair with a headrest. During the transfer, one CNA had to hold the resident's head due to the lack of a headrest, limiting her ability to ensure the resident's extremities were clear of hazards. The wound was later assessed as a large skin tear with bruising and active bleeding, causing pain to the resident. Staff interviews confirmed that the distraction and the need to support the resident's head during the transfer contributed to the incident.
Medication Error Rate Exceeds 5% Due to Improper Insulin Pen Administration
Penalty
Summary
The facility failed to maintain a medication error rate below five percent, as two errors were identified out of 27 observed opportunities, resulting in a 7.4% error rate. The errors involved a resident with type II diabetes mellitus who was severely cognitively impaired and required daily insulin injections. During medication administration, a registered nurse did not prime either of the two insulin pens before administering them to the resident, contrary to manufacturer instructions and facility policy. The nurse stated that he only primed insulin pens if they were brand new, and did not perform the priming step for pens that had been previously used. Additionally, the nurse administered the resident's morning insulin doses significantly later than the prescribed times and delayed the next scheduled dose due to the late administration. The DON confirmed that insulin pens should be primed before each use and that medications should be administered according to physician orders. Facility policy and insulin pen manufacturer instructions both require priming before each injection to ensure proper dosing and function.
Failure to Prime Insulin Pens Prior to Administration
Penalty
Summary
A deficiency was identified when nursing staff failed to prime insulin pens prior to administering insulin to a resident with type II diabetes mellitus. The resident, who was severely cognitively impaired and required daily insulin injections, had physician orders for Basaglar and Admelog insulin pens to be administered at specific times. During an observed medication administration, a registered nurse attached new needles to both insulin pens, dialed in the prescribed doses, but did not perform the required priming procedure before injecting the insulin subcutaneously. The nurse later confirmed that he only primed insulin pens if they were brand new, contrary to manufacturer instructions and facility policy, which require priming before each use to ensure proper dosing. Further review of the resident's care plan and physician orders confirmed the necessity of administering medications as prescribed and in a timely manner. The Director of Nursing verified that insulin pens should be primed before every use and that medications must be given according to physician orders. The facility's policy and the insulin pen instruction manuals both specify the need for priming before each injection to ensure the pen and needle are functioning correctly and to deliver the correct dose. The failure to prime the insulin pens constituted a significant medication error affecting the resident.
Failure to Timely Complete Nutritional Assessments and Re-Weights for Significant Weight Gain
Penalty
Summary
The facility failed to timely complete nutritional assessments and obtain re-weights for a resident who experienced significant and continued weight increases. The resident, who had multiple diagnoses including chronic kidney disease, morbid obesity, type II diabetes, and other chronic conditions, showed a pattern of substantial weight gain over several months. Despite documented requests from the dietitian for re-weights following significant weight increases, these re-weights were not performed in a timely manner. For example, after a 5.6% weight increase in one month, a re-weight was requested but not completed until nearly a month later. Similarly, after another significant weight gain, a re-weight was again delayed by several weeks. Additionally, a full nutritional assessment was not completed after any of the significant weight increases, with the last assessment having been done months prior to the continued weight gains. Staff interviews confirmed that nurse aides obtain weights as directed by nursing staff, and that the dietitian relies on timely notification and completion of re-weights to perform further assessments. The facility's policy requires monthly weights and timely evaluation of significant weight changes by the multidisciplinary team, but these procedures were not followed. The dietitian confirmed that her requests for re-weights were not completed within her preferred timeframe, and that she was not notified promptly of significant weight changes. This resulted in a lack of timely intervention and assessment for the resident experiencing ongoing weight increases.
Failure to Obtain and Administer Ordered Medication
Penalty
Summary
The facility failed to obtain and administer a prescribed medication, pregabalin, to a resident following their return from a hospital admission. The resident, who had diagnoses including chronic kidney disease, convulsions, morbid obesity, type II diabetes mellitus, anxiety disorder, major depressive disorder, and lymphedema, had a care plan that included pain management with medications as ordered by a physician. Upon readmission, a physician ordered pregabalin 75 mg twice daily for neuropathy, but the medication was not administered from the evening of admission through several days, as documented in the medication administration record and progress notes. The lack of administration was due to the facility's failure to ensure a valid prescription was received and processed by the pharmacy. The pharmacy required a new prescription for the changed dosage, but did not receive it despite notifications to the facility's nurse practitioner and follow-up attempts. The resident did not receive pregabalin for multiple days, except for a brief period when an on-call nurse practitioner provided a three-day supply. The resident was unaware of the reason for the interruption in her pain medication, and facility leadership confirmed the medication was not available or administered as ordered during the specified periods.
Failure to Properly Secure Resident During Transport Results in Injury
Penalty
Summary
A deficiency occurred when a resident with multiple complex medical conditions, including congestive heart failure, diabetes, and a history of falls, was not properly secured during transport in the facility's van. The resident, who was cognitively intact but required extensive assistance for mobility and used an electric wheelchair, was being transported to an outside appointment. During the trip, the van driver had to make a sudden stop, causing the resident's wheelchair to tip forward and the resident to fall, resulting in injury. The incident led to the resident being admitted to the hospital for pain control and monitoring after sustaining a head injury and significant back pain. The investigation revealed that the resident's wheelchair was equipped with a positioning belt, which is not designed for use as a seatbelt in a motor vehicle. The facility's transport van was equipped with a four-point wheelchair securement system (Q'Straint) and a shoulder and pelvic belt restraint, which are required to be used together for safe transport. However, the driver only used the wheelchair's positioning belt and did not secure the resident with the van's shoulder belt. There was also uncertainty about whether the wheelchair was properly attached to the van floor at the time of the incident, as conflicting accounts were given by staff and the resident. Further review found that the facility did not have a formal training policy or documentation for staff responsible for operating the van and its securement systems. Training was informal and undocumented, with no checklists or records of topics covered. The lack of proper use of the securement system and inadequate staff training directly contributed to the resident's injury during transport.
Failure to Notify Guardian and Obtain Informed Consent for Therapy and Dental Services
Penalty
Summary
The facility failed to notify a resident's court-appointed guardian about the initiation and potential charges for therapy services, as well as failed to obtain informed consent prior to starting dental services. Record review showed that the resident, who had multiple diagnoses including Parkinson's disease, dementia, and malnutrition, was rarely or never understood and had a guardian appointed. Despite multiple therapy orders and treatments, there was no documentation that the guardian was informed of the therapy evaluations, treatments, or the associated charges. Billing statements confirmed that charges were incurred for occupational, speech, and physical therapy, but the guardian was not notified. Additionally, after the resident switched from Medicaid to private pay, there was no evidence that updated consent was obtained for dental services or that the guardian was notified of a dental visit. The previous ancillary consent form had been signed by the resident's wife for other services while the resident was on Medicaid, but no updated consent was documented after the change in payor status. The administrator confirmed that no updated informed consent was obtained and that billing for ancillary services was handled by the service providers, not the facility.
Failure to Complete Physician-Ordered Labs and Neurological Assessments
Penalty
Summary
The facility failed to provide appropriate treatment and care according to physician orders and resident needs in two separate cases. For one resident with severe cognitive impairment and multiple chronic conditions, the facility did not complete physician-ordered laboratory tests, including a urinalysis and several blood draws, prior to a scheduled nephrology appointment. As a result, the laboratory work was not available for the appointment, leading to the appointment being rescheduled. Family interviews confirmed that missed or delayed laboratory tests had resulted in rescheduled or missed appointments for this resident. The Director of Nursing verified that the laboratory tests were not completed as ordered. In another case, a resident with severe cognitive impairment, multiple diagnoses, and on anticoagulant therapy experienced a fall resulting in a head injury. The care plan required neurological assessments at specific intervals following the fall. While initial 15-minute checks were completed, subsequent 30-minute and hourly checks were missed or incomplete. Documentation showed that the nurse responsible was passing medications on another hall during the missed assessments. Additionally, at one assessment time, only vital signs were taken, and the resident could not be fully assessed as she was sleeping. The Director of Nursing confirmed that the neurological checks were not completed as required and that family and medical staff notifications about the fall and injury were delayed. Interviews with staff and review of records confirmed that the required care and monitoring were not provided according to physician orders and facility protocols. The deficiencies affected two of three residents reviewed for quality of care and treatment, as verified by the Director of Nursing and staff interviews.
Failure to Follow Medication Hold Parameters for Blood Pressure Medication
Penalty
Summary
The facility failed to ensure that the parameters for administering midodrine, a medication used to treat low blood pressure, were correctly entered into the medical record and followed during administration for a resident with multiple diagnoses including Alzheimer's disease, neuromuscular dysfunction, dysphagia, type 2 diabetes, schizoaffective disorder/bipolar type, and depressive disorder. The physician's order specified that midodrine should be held if the resident's systolic blood pressure (SBP) was greater than 120 mmHg. However, review of the medication administration records showed that the resident received 47 doses of midodrine when their SBP was above this threshold, with the highest recorded blood pressure at the time of administration being 169/103 mmHg. The Director of Nursing confirmed that the hold parameters were present in the physician's order but were not reflected on the medication administration record, resulting in the medication being given contrary to the specified parameters.
Failure to Complete Physician-Ordered Laboratory Tests
Penalty
Summary
The facility failed to obtain physician-ordered laboratory tests for one resident with multiple chronic conditions, including Alzheimer's disease, dementia, chronic obstructive pulmonary disease, and chronic heart failure. The resident, who had severely impaired cognition, was admitted on 01/15/25 and had a follow-up nephrology appointment scheduled for 07/20/25, with laboratory tests ordered to be completed on 07/14/25. These tests included a complete blood count, hepatic function panel, magnesium, microalbumin/creatinine ratio, renal function panel, sodium, protein/creatinine ratio, and urinalysis. Review of the medical record showed no evidence that the laboratory tests were completed as ordered. Family interviews confirmed that the facility had not completed the ordered tests prior to appointments, resulting in rescheduled or missed appointments. The Director of Nursing verified that the laboratory tests were not completed as ordered.
Failure to Follow Infection Control Protocol During Wound Care
Penalty
Summary
During a wound dressing change for Resident #28, who had diagnoses including Alzheimer's disease, type 2 diabetes, major depressive disorder, and chronic kidney disease, the Assistant Director of Nursing (ADON) failed to follow established infection control procedures. The resident, who had severe cognitive impairment, was being treated for a skin tear on the right lower leg. The ADON removed the soiled dressing while wearing gloves, placed the soiled dressing on a paper towel on an over-bed table, and did not remove her gloves or perform hand hygiene before proceeding to the next steps of the wound care process. The ADON then used her gloved finger, which may have been contaminated from removing the soiled dressing, to apply ointment directly to the wound before covering it with a new dressing. At the time of observation, the ADON confirmed that she did not change gloves or perform hand hygiene between removing the old dressing and applying the new treatment. Review of the facility's wound care policy indicated that gloves should be changed and hand hygiene performed between these steps, but these procedures were not followed during the observed dressing change.
Dishwasher Temperature Deficiency
Penalty
Summary
The facility failed to ensure that the dishwasher reached the minimum temperature required to properly sanitize dishware, which had the potential to affect all residents receiving food from the kitchen. During an observation, the dishwasher, model ES 2400, was noted to have a wash temperature of 110 degrees Fahrenheit and a rinse cycle of 130 degrees Fahrenheit. Dietary Aide #200 confirmed that the wash cycle was only 110 degrees Fahrenheit and believed it should be at 120 degrees Fahrenheit. A review of the facility's Dish Machine log for November 2024 showed missing temperature documentation for several days and meals, while other entries recorded temperatures of 120 degrees Fahrenheit. The dishwasher guidelines specified a minimum wash temperature of 120 degrees Fahrenheit. This issue was discovered incidentally during a complaint investigation.
Failure to Provide Scheduled Showers for Dependent Residents
Penalty
Summary
The facility failed to provide adequate assistance with activities of daily living (ADL) for residents who required help with bathing and showers. This deficiency affected three residents who were dependent on staff for these services. Resident #38, diagnosed with Parkinson's disease and other conditions, was scheduled for showers twice a week but only received four baths over nearly two months, missing 11 scheduled opportunities. The resident expressed a preference for bed baths due to her inability to get out of bed, but the facility did not document reasons for missed baths. Resident #52, with diagnoses including schizophrenia and diabetes, also required substantial assistance for showers. Despite being scheduled for showers twice weekly, he only received four showers over the same period, missing 11 opportunities. The resident expressed a desire for timely showers, but again, there was no documentation explaining the missed care. Resident #41, who has multiple sclerosis and quadriplegia, was similarly affected. Scheduled for showers twice a week, he only received two showers in a month, missing six opportunities. The resident reported being told that showers were missed due to staffing issues, despite a recent schedule change intended to accommodate him. Interviews with staff confirmed that they were unable to complete ADL care timely due to increased demands following the closure of a dementia unit.
Inadequate PPE Use for Resident on COVID-19 Precautions
Penalty
Summary
The facility failed to implement its infection control policies, specifically regarding the use of personal protective equipment (PPE) for staff entering the room of a resident on droplet/contact precautions due to a positive COVID-19 test. Observations revealed that staff, including a physical therapist, a rehab services manager, and a state-tested nurse assistant, entered the resident's room without the required eye protection and N-95 masks, despite a sign on the door indicating the need for such precautions. Interviews with the staff confirmed the lack of appropriate PPE, and the Director of Nursing acknowledged that eye protection was not available for the resident in question or another resident in contact isolation. The resident involved had been admitted with diagnoses including hypoxic ischemic encephalopathy, hemiplegia, and COVID-19 acute respiratory disease. The resident was cognitively intact and required varying levels of assistance for daily activities. The facility's policy on PPE and transmission-based precautions was not followed, as PPE was not maintained outside the resident's room for easy access. This deficiency was identified during a complaint investigation and had the potential to affect all 52 residents in the facility.
Failure to Maintain RN Coverage
Penalty
Summary
The facility failed to comply with the requirement of having a registered nurse (RN) on duty for at least eight consecutive hours a day, seven days a week. This deficiency was identified during a review of the nursing staff schedule and pay records, which revealed that no RN was present or working in the facility on 06/15/24 and 06/16/24. Interviews with the Administrator and the Director of Nursing (DON) confirmed the absence of an RN on these dates. This non-compliance had the potential to affect all 50 residents residing in the facility, as the facility census was 50.
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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