Grand The
Inspection history, citations, penalties and survey trends for this long-term care facility in Dublin, Ohio.
- Location
- 4500 John Shield Pkwy, Dublin, Ohio 43017
- CMS Provider Number
- 366435
- Inspections on file
- 34
- Latest survey
- December 2, 2025
- Citations (last 12 mo.)
- 2
Citation history
Health deficiencies cited at Grand The during CMS and state inspections, most recent first.
A resident with Alzheimer's disease, bilateral hearing loss, and a primary language barrier was not provided with appropriate communication aids as outlined in her care plan and facility policy. Staff inconsistently used translation apps, often relied on hand gestures or the resident's daughter for communication, and failed to ensure the resident could effectively express her needs, leading to ongoing frustration and unmet care needs.
Two residents experienced significant medication errors when one received an antibiotic as intermittent infusions instead of a continuous IV infusion as ordered, and another had insulin doses administered late on multiple occasions. Errors resulted from incorrect order entry, lack of proper verification, and failure to document medication administration in real time, contrary to facility policy.
The facility failed to report and investigate allegations of physical abuse in a timely manner, affecting two residents. An altercation between two residents resulted in injuries, and the incident was not immediately reported to the Administrator. Additionally, a resident's representative reported staff-to-resident abuse during a care conference, but these allegations were not investigated or reported. The facility did not adhere to its policy on abuse reporting, leading to a deficiency under two complaint numbers.
The facility failed to investigate allegations of staff-to-resident physical abuse involving two residents. One resident was reportedly held down and flipped during incontinence care, causing pain, while another was allegedly dragged down the hallway by staff. Despite these reports being made during a care conference, no investigation was initiated, and the incidents were not reported to the Administrator, violating the facility's abuse policy.
A facility failed to maintain a medication error rate below five percent, resulting in a rate of 6.89%. A resident was affected when an LPN administered medications incorrectly, including crushing an enteric-coated Aspirin and omitting part of a prescribed Senna-S dose. The errors were confirmed by the LPN and reported to the DON.
The facility did not have a registered nurse (RN) on duty for at least eight consecutive hours a day, seven days a week, as required. This was confirmed through staffing schedules and staff interviews, revealing several dates without RN coverage. The Director of Nursing (DON) and unit managers were unaware of this regulatory requirement, potentially affecting all 92 residents.
The facility did not designate a licensed charge nurse for the 7:00 A.M. to 7:00 P.M. shift on weekends and holidays, directing staff to an on-call list instead. The DON confirmed that the nightshift supervisor and unit manager cover other shifts, but on weekends and holidays, the on-call manager is only available by phone. There is no specific job description for a charge nurse, and any nurse could be considered in charge of their unit.
The facility failed to maintain safe flooring on the 200 hall, affecting 25 residents, with torn and loose carpet sections identified but not repaired. Additionally, a resident with cognitive impairments had clothing improperly stored in the shower instead of the closet, which was not in line with the facility's policy for a homelike environment.
A resident with multiple health conditions did not receive timely Beneficiary Notices regarding Medicare/Medicaid coverage, leading to a lack of awareness about potential liability for non-covered services. The facility's policy requires advance notice, but the SNF ABN was issued after coverage ended, confirmed by staff interviews.
A resident, who was cognitively intact and had multiple diagnoses, made an abuse allegation against a staff member. The facility's receptionist reported the allegation to the administrator, but it was not reported to the state agency until the next day, violating the facility's policy requiring immediate reporting.
A facility failed to develop a comprehensive care plan for a resident with significant weight loss and nutritional risk. Despite losing 76.8 pounds in three months, no care plan addressed the resident's nutritional status. The clinical dietitian confirmed the absence of an active nutrition care plan, contrary to facility policy requiring timely and updated care plans.
A resident with multiple health conditions, including Parkinson's disease and dementia, experienced a significant delay in receiving podiatry services due to the podiatry group's poor availability. Despite a request made in April for podiatry care due to painful and thickened nails, the resident was not seen until July, leading to frustration and concerns from the resident and their family about the facility's communication and service timeliness.
A resident with multiple medical conditions requiring maximum assistance for transfers was inadequately assisted during a sit-to-stand lift transfer. Despite facility policy requiring two staff members, an STNA conducted the transfer alone, risking the resident's safety. The STNA cited unavailability of other staff as the reason for proceeding alone.
A resident experienced a significant weight loss of 22.6 pounds over six months without proper re-assessment, monitoring, or physician notification. Despite meal intakes being documented as adequate, no root cause analysis was conducted. The resident, who disliked the facility's food, purchased his own meals and refused supplements. The facility's dietitian and DON confirmed the lack of documentation and physician notification.
A resident with dementia and other medical conditions experienced unmanaged pain over two days, despite vocalizing discomfort. Observations and interviews confirmed the absence of pain relief interventions, contrary to the facility's pain management policy.
The facility failed to follow its medication administration policy, which requires dispensing and documenting medications for one resident at a time. Observations revealed LPNs administering medications to multiple residents simultaneously, with one LPN stacking cups of pills and another preparing multiple unlabeled cups. This affected residents with complex medical conditions, and the DON confirmed the policy violation.
A facility failed to secure medications from dispensing to administration, as observed when a resident's medications were left unattended at the bedside. The resident, with multiple diagnoses including Parkinson's and dementia, was not assessed for self-medication. An LPN confirmed this was against standard practice, and the DON stated medications should not be left unless self-medication is approved. Facility policy requires medications to be secured unless under direct nurse supervision.
A facility failed to document communication between hospice and facility staff for a resident on hospice care. Despite the resident's complex medical history, there was no record of hospice visits or communication since admission to hospice. Staff interviews confirmed the absence of documentation, although verbal communication was reported.
A facility failed to adhere to its antibiotic stewardship program, resulting in inappropriate antibiotic use for a resident. Despite the absence of microorganisms in the urine culture and not meeting the criteria for a UTI, the resident was prescribed Bactrim. The decision was based on a change in mental status, but the urinalysis showed only yeast presence. The DON confirmed the resident did not meet the criteria for antibiotic initiation, indicating a lapse in policy adherence.
The facility failed to provide written notification of transfers to an acute care facility to the family and/or LTC Ombudsman for two residents. One resident with moderate cognitive impairment was transferred to the hospital without Ombudsman notification. Another resident, who was cognitively intact, experienced a change in condition and was also transferred without proper notification. Interviews confirmed the lack of evidence for written notifications, despite facility policy requiring such notices.
Failure to Provide Dignified Communication for Resident with Language and Hearing Barriers
Penalty
Summary
A deficiency was identified when the facility failed to provide a dignified experience for a resident with communication barriers, specifically by not utilizing alternate communication methods as outlined in the resident's care plan and facility policy. The resident, who had diagnoses including Alzheimer's disease, bilateral hearing loss, and a language barrier due to primarily speaking Russian, was observed to lack access to a communication board in her room. Staff interactions with the resident were limited, with some staff not speaking to her or relying solely on hand gestures and simple English phrases, despite her care plan recommending the use of translation applications and communication aids. Interviews with staff revealed inconsistent use of translation applications, with some staff not having the app on their phones and others only using it if hand gestures were ineffective. The resident and her daughter both reported ongoing difficulties in communication, with the resident expressing frustration and stress due to her needs not being understood or met, including issues with medication administration timing and requests for assistance. The facility often relied on the resident's daughter to translate, rather than consistently using professional translation aids or services as required by policy. Review of the facility's policy confirmed that communication assistance should be provided through various aids and that family members should not be used as interpreters unless specifically requested by the resident after being offered a professional interpreter. Despite this, the facility's practice did not align with policy requirements, resulting in the resident experiencing daily struggles to communicate her needs and participate meaningfully in her care.
Significant Medication Errors in Antibiotic and Insulin Administration
Penalty
Summary
Two residents experienced significant medication errors due to failures in medication administration and order entry. One resident, admitted with multiple complex diagnoses including pseudomonas infection and a history of urogenital implants, was prescribed cefepime as a continuous 24-hour IV infusion. However, upon admission, the antibiotic order was incorrectly entered as a twice-daily short infusion rather than a continuous infusion. This error persisted for several days, with the medication being administered incorrectly each shift. The discrepancy was eventually identified after the resident's infectious disease physician and family raised concerns, revealing that the facility had not followed the hospital's discharge prescription for continuous infusion. Another resident with a history of diabetes mellitus and other chronic conditions was prescribed sliding scale insulin to be administered subcutaneously before meals. Review of the medication administration record for this resident showed that insulin was administered late on 22 occasions within a single month. The scheduled times for insulin administration were not adhered to, with doses being given significantly after the prescribed times. Staff interviews indicated that some nurses believed they had a window of time for administration, and some attributed the discrepancies to delayed documentation rather than actual late administration. The facility's policies required that medications be administered and documented in real time, and that orders be accurately entered and verified by nursing staff. Despite these policies, the errors occurred due to incorrect order entry, lack of proper verification, and failure to document medication administration at the time it was given. These actions and inactions led to significant medication errors affecting two residents.
Failure to Timely Report and Investigate Abuse Allegations
Penalty
Summary
The facility failed to report allegations of physical abuse to the Ohio Department of Health in a timely manner, affecting two residents. An altercation occurred between two residents, resulting in bruises and scratches. The incident was not reported immediately to the Administrator, and the Self-Reported Incident (SRI) was initiated approximately five hours after the event. This delay in reporting violated the facility's policy on timely reporting of abuse. Additionally, a representative of one of the residents reported incidents of staff-to-resident abuse during a care conference. The representative alleged that staff members held a resident down by the wrists and dragged another resident down the hallway. Despite these serious allegations being reported during the care conference, the Director of Nursing (DON) and Unit Manager present did not report or investigate these claims, and no SRIs were initiated for these allegations. The facility's policy on abuse requires immediate reporting of all allegations to the administration and the state survey agency. However, the facility did not adhere to this policy, as evidenced by the lack of timely reporting and investigation of the reported incidents. This deficiency was investigated under two complaint numbers, indicating a failure to comply with state regulations regarding abuse reporting.
Failure to Investigate Allegations of Staff-to-Resident Abuse
Penalty
Summary
The facility failed to investigate allegations of staff-to-resident physical abuse involving two residents. Resident #77, who has severe cognitive impairment and other medical conditions, was reportedly held down by the wrists by one staff member while another staff member flipped the resident back and forth to remove soiled clothing, causing the resident to scream in pain. This incident was reported by the resident's representative during a care conference attended by the Director of Nursing (DON), Unit Manager (UM) #54, and a hospice nurse. Additionally, the representative reported witnessing two staff members dragging Resident #78, who has Lewy body disease and other conditions, down the hallway by the arms while the resident screamed. Despite these reports being made during the care conference, the DON and UM #54 confirmed that no investigation was initiated, and the incidents were not reported to the Administrator. The facility's Self-Reported Incidents (SRIs) records showed no entries related to these allegations. The facility's policy on abuse, which mandates investigation and protective actions, was not followed. This deficiency was investigated under Complaint Numbers OH00162859 and OH00162858.
Medication Error Rate Exceeds Acceptable Threshold
Penalty
Summary
The facility failed to maintain a medication error rate below five percent, resulting in a rate of 6.89% based on 29 medication opportunities and two errors. This deficiency affected one resident, who was admitted with multiple diagnoses including cerebrovascular disease, hypertension, and type two diabetes mellitus. The errors involved the administration of medications that did not align with the physician's orders. Specifically, the resident was prescribed chewable Aspirin 81 mg and Senna-S 8.6-50 mg. However, during medication administration, an LPN administered an enteric-coated Aspirin tablet crushed in applesauce, which is contraindicated, and a Senna 8.6 mg tablet, omitting the 50 mg Docusate component. The LPN confirmed these errors, and the DON was notified. The facility's policy on medication administration emphasizes the importance of adhering to physician orders and professional standards, which was not followed in this instance.
Failure to Maintain RN Coverage
Penalty
Summary
The facility failed to ensure that a registered nurse (RN) was on duty for at least eight consecutive hours a day, seven days a week, as required by regulations. This deficiency was identified through a review of staffing schedules and confirmed by staff interviews. Specifically, there were no RNs scheduled on several dates, including Sundays and Saturdays, as well as a Friday when the RN unit manager was on vacation. The Director of Nursing (DON) and unit managers were unaware of the regulatory requirement for RN coverage, which has the potential to affect all 92 residents residing in the facility.
Failure to Designate Charge Nurse on Weekends and Holidays
Penalty
Summary
The facility failed to designate a licensed charge nurse for all tours of duty, specifically for the 7:00 A.M. to 7:00 P.M. shift on weekends and observed holidays. The daily staffing postings for June and July 2024 did not identify a charge nurse for these times, instead directing staff to an on-call list at the front desk. Interviews with the Director of Nursing (DON) confirmed that the nightshift supervisor acts as the charge nurse from 7:00 P.M. to 7:00 A.M., and the unit manager is the charge nurse during weekdays. However, on weekends and holidays, the on-call manager is considered the charge nurse and is only available by phone. The DON also revealed that there is no specific job description for a charge nurse, and any nurse could be considered in charge of their unit. An interview with a state tested nursing assistant (STNA) indicated that if there were concerns not addressed by the unit nurse, she would contact the unit manager directly, as she was not aware of a designated charge nurse.
Deficiencies in Flooring Maintenance and Homelike Environment
Penalty
Summary
The facility failed to maintain the flooring in good condition on the 200 hall, affecting all 25 residents residing there. Observations revealed torn, frayed, and loose carpet sections, creating potential tripping hazards. Despite identifying the issue in March 2024 and obtaining a quote for repairs in May 2024, no repairs or replacements had been completed by July 2024. The Maintenance Director confirmed that the facility was working on a staged approach, prioritizing other areas first, and had not yet planned for the full replacement or repair of the 200 hall. Additionally, the facility failed to provide a homelike environment for a resident with cognitive impairments and multiple health conditions, including hemiplegia and vascular dementia. Observations showed that the resident's clothing was hung in the shower rather than the closet, which was mostly empty and had ample space. Staff interviews confirmed uncertainty about why the clothing was not stored in the closet, and the situation was acknowledged as not providing a homelike environment. The facility's policy on maintaining a homelike environment was not adhered to, as unresolved environmental concerns were not reported to the administrator.
Failure to Provide Timely Beneficiary Notices
Penalty
Summary
The facility failed to provide timely Beneficiary Notices to a resident, affecting their awareness of Medicare/Medicaid coverage and potential liability for services not covered. The resident, who had diagnoses including congestive heart failure, subarachnoid hemorrhage, and acute respiratory failure, was admitted and discharged within a specific period. The review of the medical records showed that the Notice of Medicare Non-Coverage (NOMNC) was given with the last day of coverage specified, but the Skilled Nursing Facility Advance Beneficiary Notice (SNF ABN) was not provided in a timely manner. Specifically, the SNF ABN was issued after the resident's covered days had ended, which was confirmed by staff interviews. The facility's policy on Advanced Beneficiary Notice of Non-Coverage requires that the notice be provided in advance to allow the beneficiary or their representative to make an informed decision. However, in this case, the SNF ABN was provided after the coverage had ended, and in one instance, only verbal notification was given on the last covered day. The staff confirmed these lapses during interviews, indicating a failure to adhere to the facility's policy, which mandates that the notice be delivered, signed, and a copy provided to the beneficiary with enough time for consideration.
Delayed Reporting of Abuse Allegation
Penalty
Summary
The facility failed to report an allegation of abuse to the state agency in a timely manner, affecting one resident. The resident, who was cognitively intact, had a range of diagnoses including pain in the left leg, morbid obesity, and anxiety disorder. On the day of the incident, the resident made an abuse allegation against a staff member, which was reported to the facility administrator by the receptionist. However, the administrator did not report the allegation to the state agency until the following day, despite the facility's abuse policy requiring immediate reporting, but not later than two hours after the allegation is made if it involves abuse or results in serious bodily injury.
Failure to Develop Comprehensive Nutrition Care Plan
Penalty
Summary
The facility failed to develop a comprehensive care plan for a resident who was at nutritional risk and had experienced significant weight loss. The resident, who had a history of severe protein calorie malnutrition and was at risk of malnutrition due to dysphagia and the need for alternative nutrition, lost 76.8 pounds in three months, equating to a 29.3% weight loss. Despite these significant changes, there was no care plan addressing the resident's nutritional status or weight loss. The clinical dietitian confirmed that the resident did not have an active nutrition care plan since a specified date, despite the facility's policy requiring a comprehensive, person-centered care plan to be developed within seven days of the completion of the required MDS assessment. The policy also mandates that care plans be revised as the resident's conditions change, which did not occur in this case.
Failure to Provide Timely Podiatry Services
Penalty
Summary
The facility failed to provide timely podiatry services to a resident, identified as Resident #67, who was admitted with diagnoses including muscle weakness, Parkinson's disease, dementia, unsteadiness on feet, and acute kidney failure. The resident, who was cognitively intact and required assistance for mobility, had requested podiatry services due to thickened, dystrophic, and painful nails, which increased the risk of infection. Despite a request for podiatry services being made at the end of April, the resident was not seen until July 10, 2024, after being rescheduled multiple times due to the podiatry group's lack of availability. Interviews with the resident and their family members revealed frustration and concerns about the lack of timely ancillary services and poor communication from the facility. The Director of Nursing confirmed that the resident did not receive timely podiatry services due to the podiatry group's poor availability, resulting in a delay of 10 weeks from the initial request. Observations noted that the resident's toenails were protruding, indicating the need for the requested podiatry care.
Inadequate Assistance During Mechanical Lift Transfer
Penalty
Summary
The facility failed to provide adequate assistance during a transfer involving a sit-to-stand lift for a resident with multiple medical conditions, including chronic obstructive pulmonary disease, Parkinson's disease, hemiplegia, unsteadiness on feet, visual disturbances, and heart failure. The resident required maximum assistance for transfers and had a physician's order for a mechanical lift with two-person assistance. However, a video recording showed that a State tested Nursing Assistant (STNA) conducted the transfer alone, almost causing the resident to hit his head on the lateral bar. Interviews with staff confirmed that the facility's policy required two staff members for such transfers, but the STNA proceeded alone due to the unavailability of other staff members. The STNA explained that the nurse was occupied with medication administration, and the other STNA was engaged in other duties. The facility's policy and the Kwikpoint safety guide both indicated that two or more caregivers are necessary for safe operation of the lift, highlighting a breach in protocol during the incident.
Failure to Address Significant Weight Loss in Resident
Penalty
Summary
The facility failed to re-assess, monitor, and notify the physician following a significant weight loss in a resident. The resident, who was cognitively intact and had multiple diagnoses including chronic obstructive pulmonary disease, type II diabetes, and depression, lost 22.6 pounds over six months, equating to a 16.7% weight loss. Despite documented meal intakes between 76-100%, there was no evidence of physician notification or a root cause analysis to determine the reason for the weight loss. The resident confirmed the weight loss and stated a preference for purchasing his own food due to disliking the facility's meals. Interviews with the dietitian and corporate dietitian revealed concerns about the accuracy of weight measurements and a lack of documentation regarding the weight loss. The dietitian noted that the resident refused supplements and medications that could stabilize his weight. The Director of Nursing confirmed the absence of physician notification and documentation of the weight loss, despite offering interventions that the resident declined. The resident was scheduled for discharge to an assisted living facility, where he could have more control over his eating patterns.
Failure to Manage Resident's Pain
Penalty
Summary
The facility failed to manage a resident's complaints of pain, affecting one resident out of three reviewed for pain management. The resident, who had a history of dementia with agitation, anxiety disorder, and other medical conditions, was admitted with a care plan that included interventions for pain management. Despite the resident's complaints of left shoulder pain on two consecutive days, there was no documentation of any pharmacological or non-pharmacological interventions for pain relief during this period. Observations noted the resident vocalizing and grimacing, indicating discomfort, yet no caregivers addressed these pain concerns. Interviews with the resident's representative and facility staff confirmed the resident experienced pain and did not receive any pain medication during the specified time. The facility's policy on pain management emphasizes recognizing and managing residents' pain to maintain their well-being. However, the staff failed to adhere to this policy, as evidenced by the lack of pain management interventions and communication regarding the resident's non-verbal pain indicators.
Medication Administration Policy Violation
Penalty
Summary
The facility failed to adhere to its medication administration policy, which mandates that medications be dispensed, administered, and documented for one resident at a time. During observations, it was noted that an LPN was administering medications to multiple residents simultaneously by stacking cups of pills labeled with room numbers. This practice was confirmed by the LPN, who admitted to not knowing the specific medications in each cup, although they were documented as given in the computer system. This affected several residents, including those with complex medical conditions such as chronic kidney disease, heart failure, multiple sclerosis, and cognitive impairments. Further observations revealed another LPN preparing and carrying multiple medication cups without labeling them, intending to administer them to different residents. This was done while waiting for residents to come out for breakfast, and the LPN confirmed the practice of preparing multiple cups at once. The Director of Nursing acknowledged that the facility's policy requires medications to be dispensed and documented one resident at a time. The failure to follow this policy was observed in residents with various medical conditions, including dementia, heart failure, and chronic pain syndrome.
Medication Security Deficiency
Penalty
Summary
The facility failed to ensure medications were secure from the time they were dispensed until administered, as observed during an annual survey. This deficiency was identified when medications were left unattended at the bedside of a resident diagnosed with Parkinson's disease, muscle weakness, cognitive communication deficit, dementia, depression, and anxiety. The resident, who was cognitively intact according to a recent assessment, did not have orders for self-administration of medications. Despite this, medications including carbidopa-levodopa and citalopram hydrobromide were found left at the resident's bedside. An interview with an LPN confirmed that leaving medications unattended was not part of standard nursing practice. The Director of Nursing also confirmed that medications should not be left in a resident's room unless the resident has been assessed and approved to self-medicate. The facility's policy on medication and treatment storage, dated August 2023, mandates that all medications must be kept secured in a locked compartment unless under direct supervision of the nurse administering them.
Lack of Hospice Communication Documentation
Penalty
Summary
The facility failed to ensure timely communication between hospice staff and facility staff for a resident receiving hospice care. The resident, who was admitted to hospice services, had multiple diagnoses including malignant neoplasms, chronic kidney disease, and a history of transient ischemic attack. Despite being on hospice care, there was no documentation of communication or hospice visits in the resident's medical record or the hospice communication book since the admission to hospice. Interviews with facility staff, including a registered nurse and the Director of Nursing, confirmed the lack of documentation. The RN acknowledged that the hospice RN visited the resident but agreed that there was no documentation to reflect any hospice visits. The DON confirmed the absence of hospice notes in both the communication book and the resident's chart, although verbal communication with hospice staff was reported. The DON had requested that the hospice notes be faxed to the facility.
Inappropriate Antibiotic Use Due to Lapse in Stewardship Program
Penalty
Summary
The facility failed to implement its antibiotic stewardship program effectively, leading to inappropriate antibiotic use for a resident. The resident, who had a history of chronic obstructive pulmonary disease, type two diabetes mellitus, hypertension, muscle weakness, anxiety, and diverticulitis, was admitted with a care plan that included monitoring for urinary tract infection (UTI) symptoms. Despite the absence of microorganisms in the urine culture and not meeting the criteria for a UTI requiring antibiotics, the resident was prescribed Bactrim for a UTI. The decision to start antibiotics was based on a change in mental status and increased confusion, but the urinalysis showed only yeast presence without any bacterial infection. The Director of Nursing confirmed that the resident did not meet the criteria for antibiotic initiation, as there were no additional symptoms such as fever or blood in the urine. The facility's policy required the use of specific criteria for initiating antibiotics, which were not met in this case. The resident remained on antibiotics due to transitioning to hospice care, highlighting a lapse in the facility's adherence to its antibiotic stewardship policy.
Failure to Notify Ombudsman of Resident Transfers
Penalty
Summary
The facility failed to provide written notification of transfer to an acute care facility to the family and/or long-term care Ombudsman for two residents. Resident #87, who had a moderate cognitive impairment and was her own responsible party, was transferred to the hospital and did not return. There was no documentation indicating that the Ombudsman was notified of this discharge. The facility's Administrator confirmed the lack of evidence for written notification to the Ombudsman. Similarly, Resident #51, who was cognitively intact, experienced a change in condition and was transferred to the hospital. The facility also failed to provide evidence of Ombudsman notification for this resident's discharge. Interviews with the Administrator and Director of Nursing confirmed the absence of written notifications to residents' representatives. The facility's policy required that a copy of the transfer/discharge notice be provided to the resident/representative and Ombudsman, which was not adhered to in these cases.
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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