Grande Oaks
Inspection history, citations, penalties and survey trends for this long-term care facility in Oakwood Village, Ohio.
- Location
- 24579 Broadway Ave, Oakwood Village, Ohio 44146
- CMS Provider Number
- 365825
- Inspections on file
- 43
- Latest survey
- October 28, 2025
- Citations (last 12 mo.)
- 7
Citation history
Health deficiencies cited at Grande Oaks during CMS and state inspections, most recent first.
Multiple rooms lacked functional soap dispensers, and staff did not consistently use hallway alcohol sanitizer before entering or after exiting resident rooms. The DON and Administrator were unaware of the issue due to lack of staff reporting, and it was unclear how hand hygiene was performed in affected rooms, contrary to facility policy requiring accessible alcohol-based hand rub.
Multiple rooms lacked working soap dispensers and several hallway hand sanitizer dispensers were non-functional, with some dispensers missing entirely. Facility leadership confirmed they were unaware of the issues due to lack of staff reporting, and could not verify that hand hygiene protocols were being followed. Additionally, a resident's room had a large hole in the wall with debris left on the floor, which had not been repaired or cleaned up.
A resident with multiple chronic conditions and intact cognition did not receive a requested soft touch pad call light, instead being provided with a push button call light that was difficult to use due to dexterity problems. Additionally, the resident's dietary preferences were not followed, as a meal included bread despite specific instructions to avoid it. Staff and management confirmed these failures to honor the resident's documented preferences.
A resident with severe cognitive impairment and ventilator dependence was placed in mitt restraints due to repeated attempts to remove medical equipment. The facility did not consistently document the ongoing need, usage, or evaluation of the restraints, nor did the care plan include specific interventions or monitoring related to restraint use. Staff interviews confirmed a lack of structured documentation and re-evaluation, despite facility policy requiring these actions.
A resident with significant medical needs did not receive an ordered topical pain-relieving gel to her knees because an LPN assumed she could self-apply it, despite her lack of dexterity. The LPN did not administer or observe the application but documented in the MAR that it was given, contrary to facility policy.
The facility did not consistently obtain and document weights as ordered by physicians for two residents with complex medical conditions, including chronic respiratory failure and obesity. Despite care plans and physician orders requiring monthly and daily weight monitoring, several weights were either not recorded or not obtained, and the DON confirmed these omissions. This failure was not in accordance with facility policy or physician directives.
The facility failed to ensure that ventilator alarms were properly monitored and functioning for two residents requiring ventilator support, resulting in delayed response to a disconnection event and alarms being turned off. Additionally, staff did not consistently follow physician orders for oxygen administration via nasal cannula during meals and medication administration for a resident with diminished lung capacity.
A resident with cognitive impairment and dependency on staff for daily care developed worsening Stage IV pressure ulcers due to the facility's failure to implement an effective pressure ulcer prevention program. Despite being informed by a CNA, an LPN did not change the resident's soiled dressings, leading to infection and hospitalization. The resident's medical history included osteomyelitis, hypertension, and dementia.
The facility did not maintain the required RN coverage for at least eight consecutive hours a day, seven days a week. A review of staffing schedules and staff punch details revealed no RN coverage on a specific day, which was confirmed by the Human Resources Director. This deficiency had the potential to affect all 49 residents in the facility.
The facility failed to serve meals at a palatable temperature, affecting 41 residents. Observations showed inconsistent meal temperature recordings and delays in meal service due to running out of rice. A test tray revealed that food was not served at the appropriate temperature, with some items being too cold and not having the correct consistency. Residents confirmed that meals were sometimes late and not warm enough, contrary to the facility's policy.
The facility failed to provide meals and snacks according to residents' needs and facility policies. Meals were delayed due to food shortages and equipment issues, and snacks were inconsistently available, with staff sometimes bringing snacks from home. These deficiencies affected residents' nutritional needs.
The facility failed to maintain sanitary conditions in food service, affecting 41 residents. The dish machine did not properly sanitize dishes, and logs for temperature and cleaning were incomplete. Additionally, an exhaust fan was heavily soiled, blowing dust towards the serving line. Facility policies required regular maintenance and logging, which were not followed.
The facility failed to ensure safe handling and storage of food brought in from outside, affecting 41 residents. Observations revealed unlabeled and undated food items in resident refrigerators, lack of temperature monitoring logs, and improper storage of employee foods and breast milk. The facility's policy requires labeling and dating of all food items, with immediate disposal of unlabeled items.
The facility inaccurately submitted staffing information to CMS by listing a Nurse Practitioner as an RN in the PBJ. The HR Director was unaware of the Nurse Practitioner's role and mistakenly entered her hours as an RN. The Administrator confirmed the error, noting the Nurse Practitioner was not working as an RN.
The facility failed to maintain cleanliness of wheelchairs and shower rooms, and ensure the functionality of phones. Observations showed soiled wheelchairs and mold-like stains in shower rooms. The phone system was non-functional, affecting communication and access. These issues were confirmed by staff and administration, highlighting a lack of adherence to cleaning schedules and communication protocols.
The facility failed to conduct quarterly smoking safety assessments for two residents, both of whom required supervision while smoking due to their medical conditions. Despite being cognitively intact and independent in daily activities, the residents' care plans required quarterly assessments, which were not completed. The facility's smoking policy lacked specificity on assessment frequency, contributing to this oversight.
A resident with a history of bipolar disorder and opioid dependence was discharged AMA to live with her son, despite a psychological evaluation indicating moderate cognitive impairment and the need for a guardian. The facility failed to address the primary POA's concerns about the discharge's safety and did not notify her until after the resident had left. The facility did not contact adult protective services or the police, leading to a deficiency in ensuring a safe discharge process.
The facility failed to provide scheduled bathing for three residents, with missing documentation and signatures on shower sheets. A resident with intact cognition did not receive a scheduled shower, and two residents dependent on staff for bathing had missing documentation of refusals. The DON confirmed the lack of adherence to bathing schedules and documentation policies.
A facility failed to complete daily weights for a resident with congestive heart failure as per physician orders. Despite the resident's care plan indicating the need for weight monitoring due to obesity, multiple dates in October and November showed missing weight records. Interviews with the resident's daughter, DON, and dietitian confirmed the non-compliance.
The facility failed to ensure required physician visits for three residents, affecting all 49 residents. A resident had no physician or NP visits since early September, while another had a gap in physician visits from mid-June to late September. A third resident had only two physician visits in July and August, with no NP notes found. The DON confirmed the lack of compliance with the facility's policy on alternating visits.
A resident with chronic kidney disease, heart failure, and sepsis did not receive prescribed intravenous antibiotics and Heparin flushes due to the unavailability of an RN. The facility's policy required medications to be administered as ordered, but multiple doses were missed, as confirmed by staff interviews and documentation.
A facility failed to follow a physician-ordered diet with modified texture for a resident with multiple medical conditions, including hemiplegia and diabetes. The resident's care plan required a pureed diet due to dental issues, but a survey revealed that the pureed rice did not meet the required smooth consistency. The Dietary Manager confirmed the deficiency.
The facility failed to provide adequate hydration between meals, affecting several residents. Observations showed hydration cups were not consistently present in rooms, and residents reported water was not offered unless requested. Staff interviews revealed inconsistencies in water delivery, despite facility policy requiring fresh water each shift. This deficiency impacted residents with specific health risks, as their fluid intake was not recorded as required.
A resident, dependent on staff for all activities of daily living, did not receive scheduled showers over a six-week period, receiving only bed baths instead. Despite being stable for showers, as confirmed by a respiratory therapist, the resident's grooming needs were neglected, resulting in a buildup of a black substance under her nails. Staff interviews and family observations confirmed the lack of showers, contrary to the facility's policy of routine bathing per resident preference.
A facility failed to maintain a medication error rate below five percent, resulting in a nine percent error rate. An LPN administered an incorrect dose of Polyethylene Glycol to a resident with multiple diagnoses, and another LPN crushed a morphine extended-release tablet without a physician's order for a resident with complex medical conditions. These actions violated the facility's medication administration policy.
A resident with multiple health conditions did not receive their anticoagulant medication, apixaban, in a timely manner. The lunch dose was administered late, and the nighttime dose was also delayed. The facility lacked a policy for scheduled medication time frames, and there was no documentation explaining the delay. The manufacturer's information indicated a risk of potentially fatal bleeding with apixaban.
The facility failed to date insulin vials after opening, affecting a resident with diabetes and potentially impacting 12 others. An LPN administered insulin from an undated vial, and further observations revealed multiple undated vials on medication carts. Interviews confirmed staff were unaware of the proper duration for insulin use after opening, violating facility policies requiring vials to be dated and discarded within 28 days.
A resident with complex medical conditions did not have their medication administration properly documented. The resident often refused medications, requiring multiple attempts by staff to administer them. An LPN failed to document the refusals and administration attempts, while another LPN was unsure of the exact time of administration but believed it was documented. The facility's policy mandates documentation of medication administration and refusals, which was not followed.
A facility failed to follow hand hygiene protocols during medication administration and incontinence care, affecting three residents. An LPN used a glucometer on two residents without disinfecting it and administered medications without washing hands. Additionally, an STNA and an LPN did not perform hand hygiene while providing incontinence care, despite changing gloves multiple times. These actions were against the facility's hand hygiene policy.
A resident diagnosed with COVID-19 was not properly isolated, and staff failed to wear appropriate PPE when entering the resident's room. The facility did not have signage indicating isolation precautions, and an LPN was unaware of the resident's COVID-19 status, leading to potential exposure of 25 residents on the same unit.
The facility failed to maintain a clean and safe environment, affecting all 46 residents. Observations revealed a leaking ceiling, missing tiles, and unsanitary conditions in the dining hall and old kitchen. Residents confirmed the presence of leaks and mobility challenges due to missing tiles. The Director of Maintenance acknowledged ongoing issues, including roof leaks and pest entry points, with no repairs initiated despite obtaining quotes. The facility's admission agreement promised a safe and comfortable environment, which was not upheld.
A resident with severe cognitive impairment and total dependence on staff was observed receiving incontinence care in front of an open window facing a parking lot, compromising their privacy. STNAs confirmed the oversight, acknowledging the need to close blinds for privacy, as per facility policy.
A resident with chronic respiratory issues and a history of UTIs did not receive prescribed Ipratropium-Albuterol aerosol treatments and Premarin vaginal cream consistently, as documented in the MAR. Interviews revealed that the aerosol order was not confirmed, leading to missed doses, and the Premarin cream was unavailable from the pharmacy on one occasion. The facility's policy required medications to be administered as ordered, indicating a failure to comply with professional standards.
The facility failed to evaluate staff showing signs of impairment, as multiple staff members reported the former DON and an RN entering the facility smelling of alcohol and exhibiting impaired behaviors. The former DON was observed yelling at staff and residents, but the facility did not obtain a statement from the RN involved, and the former DON resigned without disciplinary action.
The facility failed to ensure staff maintained a professional demeanor, affecting two residents. One resident reported being yelled at by the former DON, who appeared to be under the influence of alcohol. Multiple staff members corroborated that the former DON and an RN smelled of alcohol and conducted rounds unprofessionally. The former DON resigned the same day, and the facility did not obtain a statement from the RN.
The facility failed to ensure antibiotics were administered as ordered, affecting two residents. One resident did not receive the prescribed Ertapenem and had IV fluids infused for longer than ordered. Another resident received Ertapenem in error, but the IV fluids were not administered due to the on-call team catching the mistake. The LPN involved was terminated for the medication errors.
Failure to Maintain Functional Soap Dispensers and Ensure Hand Hygiene Compliance
Penalty
Summary
The facility failed to ensure consistent hand hygiene practices in accordance with accepted standards, specifically by not maintaining functional soap dispensers in multiple resident rooms. During a facility tour, it was observed that several rooms lacked working soap dispensers, and in one case, the dispenser was missing entirely. This issue affected residents in the south hallway, as their bathrooms did not have the necessary supplies for proper hand hygiene. The Director of Nursing (DON) and Administrator confirmed that they were unaware of the non-functional dispensers, as staff had not reported the issue. Further observations revealed that staff did not use the hallway alcohol sanitizer before entering or after exiting resident rooms, and it was unclear how hand hygiene was being performed in rooms without functional soap dispensers. The DON was unable to verify staff compliance with hand hygiene protocols in the affected area and stated that audits and education had not previously identified any issues. Review of the facility's policy indicated that alcohol-based hand rub should be accessible in every resident room, but this standard was not met in the identified cases.
Non-Functioning Hand Hygiene Dispensers and Damaged Resident Room Wall
Penalty
Summary
Surveyors observed that multiple resident rooms lacked functioning soap dispensers necessary for hand hygiene, with some dispensers missing entirely from the walls. Additionally, several alcohol-based hand sanitizer dispensers in the north hallway and outside certain rooms were found to be non-functional. These deficiencies were confirmed during a facility tour with the Administrator and DON, who acknowledged that staff had not reported the issues and could not confirm that proper hand hygiene was being maintained. One resident confirmed that her soap dispenser had not worked for several days, leading her to use her own sanitizer. Further inspection revealed that a resident's room had a significant hole in the wall behind the head of the bed, with plaster and drywall debris present on the floor next to a fall mat. The DON and Administrator confirmed that the wall damage should have been addressed and cleaned up. Review of the facility's Enhanced Barrier Precautions policy indicated a requirement for access to alcohol-based hand rub in every resident room, but did not address soap dispensers. These findings affected 14 out of 48 residents reviewed for a safe and sanitary environment.
Failure to Honor Resident Preferences for Call Light and Diet
Penalty
Summary
The facility failed to honor a resident's preferences as requested, specifically regarding the use of a call light system and dietary accommodations. The resident, who had multiple diagnoses including interstitial pulmonary disease, chronic respiratory failure, and neuropathy, required assistance with activities of daily living and had intact cognition. The care plan indicated that a soft touch pad call light should be clipped to the resident's gown at all times due to dexterity issues. However, observations and interviews revealed that the resident only had access to a push button call light, which was difficult for her to use, and the requested call pad was not provided. Staff interviews confirmed awareness of the resident's preference and the facility's agreement to provide the call pad, but it was not implemented. Additionally, the resident's dietary preferences were not honored. The resident was on a minced and moist diet with specific instructions to avoid bread and to have biscuits mashed with gravy. A photo submitted by the resident's daughter showed a roll on the resident's plate, contrary to the dietary order. The Food Service Director confirmed that the meal did not comply with the resident's preferences as documented. Facility policies required evaluation of unique resident needs and prompt reporting and resolution of issues with accommodations, but these were not followed in this case.
Failure to Document and Re-Evaluate Ongoing Use of Physical Restraints
Penalty
Summary
The facility failed to ensure proper documentation and ongoing evaluation for the use of physical restraints on a resident with multiple complex medical conditions, including acute respiratory failure, COPD, encephalopathy, ventilator dependence, and significant cognitive impairment. The resident was admitted with a history of attempting to remove life-sustaining medical equipment, leading to the use of mitt restraints as ordered by the provider. However, the provider order lacked essential details such as the specific diagnosis justifying the restraint, instructions for breaks in restraint usage, and requirements for monitoring the effectiveness of less restrictive interventions. Nursing progress notes indicated that mitt restraints were applied and skin assessments were performed on select dates, but there was no consistent documentation of the ongoing need, usage, or evaluation of the continued use of restraints as required by facility policy. The care plan did not include specific goals or interventions related to the mitt restraints, nor did it address ongoing monitoring or plans for removal. The Medication Administration Record showed that mitt restraints were signed off for each shift, but this did not substitute for the required comprehensive documentation and evaluation. Interviews with facility staff, including the DON, respiratory therapist, nurse practitioner, and LPN, revealed a lack of clarity and consistency in the documentation and management of restraints. Staff acknowledged the need for restraints due to the resident's behaviors but confirmed that there was no daily checklist or structured process for documenting alternatives attempted, ongoing re-evaluation, or effectiveness of the restraint. The facility's own policy required documentation of medical symptoms warranting restraint use, less restrictive alternatives, and ongoing re-evaluation, none of which were adequately present in the resident's record.
Failure to Administer Ordered Topical Medication and Inaccurate MAR Documentation
Penalty
Summary
A deficiency occurred when a resident with multiple complex medical conditions, including interstitial pulmonary disease, chronic respiratory failure, and neuropathy, did not receive an ordered topical pain-relieving medication (Biofreeze gel) to both knees as prescribed. The resident required assistance with activities of daily living and did not have the dexterity to self-apply the medication. Despite this, the LPN responsible for the resident did not apply the Biofreeze gel as ordered, instead leaving it on the resident's bedside table and assuming the resident could self-administer it. The LPN subsequently documented in the medication administration record (MAR) that the medication had been given, even though she neither applied it herself nor observed the resident applying it. The issue was identified when the resident and her daughter reported that the medication was not being applied as ordered. Upon interview, the LPN confirmed she had not administered the medication but had signed it off in the MAR. The facility's policy required staff to only sign the MAR after actually administering the medication. The DON confirmed that the resident was not capable of self-application and that the LPN's actions were not in accordance with facility policy.
Failure to Follow Physician Orders for Weight Monitoring
Penalty
Summary
The facility failed to follow physician orders and its own policy regarding weight monitoring for two residents. For one resident with chronic respiratory failure, tracheostomy, type II diabetes, and morbid obesity, the care plan required monthly weight monitoring due to increased risk for malnutrition. However, there was no recorded weight or documented refusal for one month, and the DON confirmed the absence of required documentation for that period. The resident was dependent on staff for activities of daily living and had intact cognition. For another resident with multiple respiratory and cardiac diagnoses, including obesity and chronic respiratory failure, the care plan also required monthly weight monitoring, and a physician order specified daily weights. A review of records showed that daily weights were missing on several specified dates, and the DON confirmed these weights were not obtained as ordered. The facility's policy required weights to be recorded at the time obtained and to follow physician orders for frequency, but this was not consistently done for these residents.
Failure to Ensure Proper Ventilator Alarm Monitoring and Oxygen Administration
Penalty
Summary
The facility failed to ensure that external ventilator alarms were properly monitored and functioning for two residents who required ventilator support. In one instance, a resident using an AVAPS ventilator experienced a disconnection of her oxygen hose, which triggered the internal alarm in her room. The call light was tied to the side of the bed and not within the resident's reach, delaying her ability to summon help. A CNA eventually responded, reattached the oxygen hose, and the alarm ceased. However, the external alarm outside the room was found to be turned off, and it was not reactivated until a respiratory therapist entered the room later. The resident and staff confirmed that the external alarm was not sounding during the incident, and the alarm log verified a patient circuit disconnect alarm lasting approximately 11 minutes. Another resident, dependent on an ACVC ventilator, was observed with the external ventilator alarm turned off during a routine walk-through. The respiratory therapist confirmed that the alarm should not have been off. Facility policy required that staff be trained and competent in the use of mechanical ventilation, including responding to alarms, but the policy for noninvasive ventilation did not specify alarm monitoring procedures. The failure to ensure alarms were active and monitored had the potential to affect additional residents using ventilators in the facility. Additionally, the facility failed to follow physician orders regarding oxygen administration for a resident who required oxygen via nasal cannula at three liters per minute during all medication administrations and meals due to diminished lung capacity and aspiration risk. Video evidence showed the resident eating lunch without her nasal cannula on, and the respiratory therapist had not transitioned her to the nasal cannula after removing the AVAPS mask. Interviews with staff confirmed that the resident was supposed to be on nasal cannula during meals and medication administration, but this was not consistently implemented.
Failure to Provide Timely Pressure Ulcer Care
Penalty
Summary
The facility failed to implement an adequate and effective pressure ulcer prevention program for a resident who was cognitively impaired, dependent on staff for activities of daily living, and incontinent of bowel. The resident had Stage IV pressure ulcers on the left lateral ankle and foot, which required timely dressing changes. On a specific date, a CNA informed an LPN that the resident's dressings were saturated with fecal material, but the LPN failed to change the dressings promptly. This inaction led to the deterioration of the ulcers, contributing to the development of sepsis and osteomyelitis, and necessitated hospitalization in the intensive care unit. The resident's medical record indicated a history of osteomyelitis, hypertension, contracture of the right knee, and dementia. The care plan required staff to continue treatments as ordered by the physician and to observe for signs of infection or worsening of the wound. Despite daily dressing orders being documented as completed, the as-needed orders were not utilized on the dates in question. The wound evaluation and management summary revealed that the pressure ulcers had worsened, with increased size and signs of infection, leading to the suspicion of osteomyelitis. Interviews with staff and review of witness statements confirmed that the dressings were not changed when they became soiled, despite the facility's policy allowing for such changes. The LPN admitted to forgetting to change the dressing after being informed by the CNA. The wound physician noted the deterioration of the wounds and ordered further medical interventions, including antibiotics and diagnostic tests. The facility's investigation and disciplinary actions highlighted the failure to provide necessary care to prevent further breakdown in the resident's wounds.
Removal Plan
- DON and LPN #206 provided nursing staff education on the facility policy titled, Wound Treatment Management, including changing the dressing if feces had seeped underneath the dressing or the dressing was soiled as well as adding an order for all residents with wounds to check the integrity of the dressing each shift and replace if needed.
- LPN #206 completed wound and dressing audits for all residents to ensure dressings were intact and the orders were correct without negative findings.
- The Administrator provided LPN #291 education and disciplinary action.
- Audits were initiated of wound dressing observations including if the dressing was clean, dry and intact as well as if the order was in place to check the integrity of the dressing each shift. These audits were to be completed by the DON or her designee three times a week for one week and then weekly thereafter for three weeks. The results would be taken to the quality assurance meetings.
Failure to Maintain Required RN Coverage
Penalty
Summary
The facility failed to ensure the presence of a registered nurse (RN) 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 staff punch details for the period from October 1, 2024, to October 31, 2024, which revealed a lack of RN coverage on October 27, 2024. An interview with the Human Resources Director confirmed the absence of RN coverage on that date. This issue had the potential to affect all 49 residents residing in the facility and was investigated under Complaint Number OH00159004.
Failure to Serve Meals at Appropriate Temperature
Penalty
Summary
The facility failed to serve meals at a palatable temperature, affecting 41 residents who received food from the kitchen. Observations revealed that meal temperatures were not consistently recorded on multiple dates, including no lunch temperatures for certain days and no dinner temperatures for several others. During an observation of the lunch tray line, it was noted that the tray line was delayed due to running out of rice, causing a delay in meal service. A test tray conducted later showed that the food was not served at the appropriate temperature, with carrots being too cold and pureed rice not having the correct consistency. Interviews with residents confirmed that meals were sometimes late and not warm enough. The facility's policy stated that meals should be served within 45 minutes of the scheduled mealtime and at an appetizing temperature. However, the test tray conducted with the Dietary Manager confirmed that the meal was served later than 45 minutes past the posted delivery time, and the food was not at the appropriate temperature, leading to the deficiency noted in the report.
Deficiency in Meal and Snack Service
Penalty
Summary
The facility failed to ensure that meals and snacks were provided in accordance with residents' needs, preferences, and requests, as well as the facility's own policies. Observations and interviews revealed that meals were not served at the posted times, and there were instances where residents were not offered snacks when there was more than a 14-hour gap between dinner and breakfast. This deficiency had the potential to affect all 41 residents receiving meals from the kitchen, with specific issues noted for several residents who did not receive meals or snacks as required. One significant issue was the delay in meal service due to running out of food items, such as rice, which caused a delay in the tray line and resulted in residents receiving their meals later than scheduled. Additionally, there were reports of dinner trays being delivered late, sometimes more than 45 minutes past the posted time, due to issues such as equipment malfunction and lack of disposable supplies. These delays were confirmed by staff interviews and observations, indicating a systemic issue in meal service delivery. Furthermore, the facility failed to consistently provide snacks to residents, as required by their policies. Interviews with staff and residents revealed that snacks were not always available, and staff sometimes had to bring snacks from home to meet residents' needs. The facility's policies stated that snacks should be available 24 hours a day, yet there were multiple reports of snacks not being delivered or available, particularly at night. This inconsistency in snack availability further contributed to the deficiency in meeting residents' nutritional needs.
Sanitation Deficiency in Food Service
Penalty
Summary
The facility failed to ensure that food was stored and served under sanitary conditions, potentially affecting 41 residents who received food from the kitchen. During an initial kitchen tour, it was observed that the low temperature dish machine reached the appropriate temperature of 125.6°F, but the chlorine chemical test strip did not change color, indicating a failure in the sanitization process. The staff member confirmed that disposable dishes would be used until the dish machine was fixed. Additionally, it was noted that temperature logs for the dish machine had not been completed since November 6, and there were no cleaning logs for September, October, or November to date. The sanitizer bucket test log and the three-compartment sink log were also incomplete past November 6. Further observations revealed that the exhaust fan near the ceiling on the back wall across from the serving line was heavily soiled with dark brown dust on the grates, which blew out towards the serving line. The facility's undated policy on sanitary conditions stated that all equipment would be maintained in a clean and sanitary fashion, with a schedule for cleaning and sanitizing established by the Food Service Director. The policy also required that dish machine temperatures be maintained at 120°F for wash with 50 parts per million Hypochlorite, and a temperature log be maintained for every meal. This deficiency was investigated under Complaint Number OH00159004.
Deficiency in Safe Food Handling and Storage
Penalty
Summary
The facility failed to ensure the safe handling and storage of food brought in from outside for residents, which could potentially affect 41 residents who received food from the kitchen. During an observation, the Dietary Manager (DM) noted several issues with the resident refrigerator on the south resident hall, including three unlabeled and undated meat sandwiches, and a lack of temperature monitoring logs for the refrigerator. Additionally, the unit microwave was found to have dried food particles stuck to its ceiling and sides. These findings were confirmed by the DM at the time of observation. Further inspection of the resident refrigerator on the skilled hallway revealed multiple concerns, such as an unlabeled and undated plastic container of ice cream, an open and undated bottle of ketchup, and several other food items that were either expired or not labeled with a resident's name. An undated and unlabeled bag of employee-pumped breast milk was also found, which was against facility policy. The Assistant Director of Nursing (ADON) confirmed that employee foods and breast milk should not be stored in the resident refrigerator. The facility's policy mandates that all food brought in for residents must be labeled with the resident's name and date, and any unlabeled items should be discarded immediately. This deficiency was investigated under Complaint Number OH00159004.
Inaccurate Staffing Information Submitted to CMS
Penalty
Summary
The facility failed to ensure accurate direct care staffing information was submitted to the Centers for Medicare and Medicaid Services (CMS). This deficiency was identified through a review of punch details and interviews, revealing that a Nurse Practitioner was incorrectly listed as a Registered Nurse (RN) in the payroll-based journal (PBJ) for several days. The Human Resources Director was unaware of the Nurse Practitioner's actual role and mistakenly entered her hours as an RN, believing her hours could still be utilized in that capacity. The Administrator confirmed that the hours should not have been entered as RN hours since the individual was working as a Nurse Practitioner during the specified time frames.
Deficiencies in Cleanliness, Phone System, and Shower Room Sanitation
Penalty
Summary
The facility failed to maintain cleanliness and sanitation standards for wheelchairs and shower rooms, as well as ensure the functionality of facility phones. Observations revealed that the power wheelchairs for three residents were heavily soiled with dried spills, food crumbs, and even a used disposable glove. The facility's schedule indicated that wheelchairs should be cleaned on resident shower days, but this was not adhered to, as confirmed by the Administrator. Additionally, the facility's phone system was not functioning properly, which hindered communication and access to the facility. The surveyor experienced difficulty entering the facility due to non-functional doorbells and phones that did not audibly ring. Interviews with staff and administration revealed that the phone system had been problematic since June 2024, with issues persisting despite attempts to address them. The facility had not communicated these issues to residents' families or provided alternative contact methods. The shower rooms were also found to be in unsanitary conditions, with black mold-like stains on the tiles and dried feces on the shower bed and floor. These findings were confirmed by the DON, who acknowledged that aides were responsible for cleaning the showers and equipment after each use. The presence of mold and feces indicates a failure to maintain a sanitary environment, which could potentially affect the health and safety of the residents.
Failure to Conduct Quarterly Smoking Safety Assessments
Penalty
Summary
The facility failed to implement care-planned interventions by not completing quarterly smoking safety assessments for residents who smoke, as required by their policy. This deficiency affected two residents, one of whom was Resident #150, who was admitted with diagnoses including spastic hemiplegia, epilepsy, and schizoaffective disorder. Despite being cognitively intact and independent in activities of daily living, Resident #150 required supervision while smoking due to a loss of upper limbs. The last smoking assessment for this resident was completed several months prior to the survey, indicating a lapse in the quarterly assessment schedule. Similarly, Resident #153, who had diagnoses including type II diabetes mellitus, opioid dependence, and bipolar disorder, was also affected by this deficiency. This resident was cognitively intact and independent in daily activities but required supervision while smoking. The care plan for Resident #153 also stipulated quarterly smoking assessments, which were not completed as required. The facility's policy on resident smoking, revised in 2021, did not specify the frequency of smoking assessments, contributing to the oversight. This deficiency was investigated under a specific complaint number.
Failure to Ensure Safe Discharge for Resident with Cognitive Impairment
Penalty
Summary
The facility failed to ensure a safe discharge for Resident #153, who had a history of type II diabetes mellitus, opioid dependence, and bipolar disorder. Despite being cognitively intact according to a BIMS score of 15, a subsequent evaluation using the Montreal Cognitive Assessment (MoCA) indicated moderate cognitive impairment, suggesting the need for a guardian. The resident expressed a desire to live with her son in New York, contrary to her daughter's wishes, who was the primary power of attorney (POA) and expressed concerns about the safety of this discharge. The facility's social worker had been in contact with the resident's son, who was listed as the third POA, and began discharge planning without adequately addressing the daughter's concerns or the psychological evaluation recommending a guardian. The resident's daughter was not informed of the discharge until after it occurred, and the facility did not contact adult protective services or the police, despite the daughter's concerns about potential harm. The Director of Nursing (DON) and other staff members were aware of the resident's desire to leave with her son and allowed the discharge against medical advice (AMA) to proceed, citing the resident's BIMS score. However, the facility did not fully consider the MoCA results or the daughter's request for a guardian, leading to a deficiency in ensuring a safe discharge process for the resident.
Failure to Provide Scheduled Bathing and Document Care
Penalty
Summary
The facility failed to ensure that scheduled bathing was provided for three residents, leading to a deficiency in care. Resident #121, who had intact cognition and was dependent on staff for bathing, did not receive a scheduled shower on one occasion, and there was no documentation of a refusal. Additionally, the shower sheets were often missing required signatures from the nurse and aide, indicating a lack of proper documentation and review. Resident #122, who also had intact cognition and was dependent on staff for bathing, preferred bed baths but did not receive scheduled bathing on two occasions. Similar to Resident #121, the shower sheets for Resident #122 were missing nurse signatures, and there was no documentation of refusals in the nursing progress notes. This indicates a failure to adhere to the facility's policy of documenting and reviewing bathing activities. Resident #155, who had moderate cognitive impairment and was dependent on staff for bathing, did not have a shower sheet provided for one scheduled day, and most of the provided shower sheets were missing nurse signatures. The Director of Nursing confirmed the missing documentation for all three residents, highlighting a systemic issue with the facility's adherence to its bathing schedule and documentation policies.
Failure to Complete Daily Weights for Resident with CHF
Penalty
Summary
The facility failed to ensure that daily weights were completed as per physician orders for a resident with congestive heart failure. The resident, who had intact cognition and was dependent on transfers, had a physician order dated 07/03/24 for daily morning weights due to their condition. However, a review of the resident's daily weight records revealed multiple dates in October and November 2024 where weights were not recorded, indicating non-compliance with the physician's order. Interviews conducted with the resident's daughter, the Director of Nursing, and the dietitian confirmed the failure to complete daily weights as ordered. The resident's care plan highlighted the risk for alteration in nutrition and/or hydration related to obesity, with an intervention to monitor weight as per physician orders. This deficiency was investigated under Complaint Number OH00159004, affecting one resident out of three reviewed for weight monitoring in a facility with a census of 49.
Failure to Ensure Required Physician Visits
Penalty
Summary
The facility failed to ensure that physician visits were completed as required for three residents, which had the potential to affect all 49 residents residing at the facility. For Resident #122, the medical record review revealed that there were no physician or nurse practitioner visits since early September 2024, with only a few visits documented in the past year. The Director of Nursing (DON) confirmed the lack of monthly alternating physician and nurse practitioner visits for this resident. Similarly, Resident #153's medical record showed a gap in physician visits between mid-June 2024 and the resident's discharge in late September 2024, despite frequent nurse practitioner visits. The DON confirmed the absence of the required alternating visits. For Resident #154, the medical record indicated only two physician visits in July and August 2024, with no nurse practitioner visit notes found. The DON again confirmed the lack of compliance with the facility's policy on alternating visits. The facility's policy allows for alternating visits between physicians and nurse practitioners, but this was not adhered to, leading to the deficiency.
Failure to Administer Medications as Ordered
Penalty
Summary
The facility failed to ensure that Resident #155 was free from significant medication errors, as evidenced by the failure to administer prescribed intravenous antibiotics and Heparin flushes according to physician orders. Resident #155, who had diagnoses including chronic kidney disease, heart failure, and sepsis, was admitted to the facility and later discharged to the hospital for gastrointestinal bleeding. During the resident's stay, there were multiple instances where Ceftriaxone and Ampicillin were not administered as ordered, and Heparin flushes were missed on several occasions. These omissions were documented in the Medication Administration Record (MAR) and nursing progress notes. Interviews with facility staff, including a Regional RN and an LPN, confirmed that the medications were not administered due to the unavailability of an RN, as LPNs were not permitted to administer intravenous medications to residents with central lines. The facility's policy on medication administration required medications to be administered as ordered by the physician, which was not adhered to in this case. The deficiency was investigated under Complaint Numbers OH00159247 and OH00159004.
Non-Compliance with Physician-Ordered Diet Texture
Penalty
Summary
The facility failed to ensure that a physician-ordered diet with modified texture was followed for a resident. This deficiency was identified during a survey where the facility's compliance with dietary requirements was assessed. The resident involved had a medical history that included acute postprocedural respiratory failure, hemiplegia, dependence on a respirator, type II diabetes mellitus, and moderate protein-calorie malnutrition. The resident's care plan indicated a risk for dental or chewing problems due to missing or broken teeth, and the physician had ordered a diet of regular no added salt double portions with pureed texture and thin liquids. During the survey, an observation of a test tray revealed that the pureed rice did not have a smooth consistency as required by the facility's policy for a Dysphagia Puree (Level 1) Diet. The rice appeared to have visible particles and was not the consistency of moist mashed potatoes or pudding, as stipulated by the policy. The Dietary Manager confirmed that the pureed rice did not meet the required smooth pureed texture. This non-compliance was investigated under a specific complaint number.
Inadequate Hydration Practices in Facility
Penalty
Summary
The facility failed to ensure adequate hydration was provided between meals, affecting four residents and potentially impacting 41 others who received food from the kitchen. Residents #121 and #122, both cognitively intact, reported that water was not consistently provided between meals unless requested. Observations confirmed that hydration cups were not consistently present in resident rooms, and the facility's policy required State Tested Nurse Aides (STNAs) to provide fresh ice water to residents each shift, which was not adhered to. Resident #121, who has chronic respiratory failure and other health issues, was at risk for dehydration due to obesity and diuretic use. Her care plan included monitoring for dehydration signs, but there was no evidence of fluid intake being recorded in her medical records for the past 30 days. Similarly, Resident #122, with conditions like congestive heart failure and moderate protein-calorie malnutrition, had no recorded fluid intake in her medical records, despite her care plan requiring meal intake, including fluids, to be recorded. Interviews with staff, including CNAs and LPNs, revealed inconsistencies in water delivery practices. Some staff were unsure of the frequency of water passing, while others confirmed that water was supposed to be provided each shift but was not consistently done. The facility's policy, revised in 2018, mandated that fresh water be delivered each shift and upon request, but this was not consistently implemented, leading to the deficiency noted in the report.
Failure to Provide Scheduled Showers for Dependent Resident
Penalty
Summary
The facility failed to provide showers for a resident who was dependent on staff for all activities of daily living, including grooming and bathing. The resident, who was severely cognitively impaired and dependent on a respirator, was scheduled to receive showers twice a week according to the facility's shower schedule. However, a review of shower sheets revealed that the resident only received bed baths or partial bed baths over a period of approximately six weeks. Interviews with staff confirmed that the resident had been receiving showers in the past, but they had stopped for reasons unknown to the staff. Observations and interviews further highlighted the deficiency, as the resident was found to have a buildup of a black substance under her nails, which was confirmed by a Licensed Practical Nurse. A State tested Nursing Assistant and the resident's family member both noted the resident's habit of digging in her stool, which contributed to the buildup under her nails. The family member also confirmed through a camera in the resident's room that showers were not being provided, despite the facility's policy stating that residents should be bathed or assisted to shower routinely and as needed per their preference.
Medication Administration Errors Lead to High Error Rate
Penalty
Summary
The facility failed to maintain a medication error rate below five percent, resulting in a nine percent error rate during a medication administration observation. This deficiency affected two residents out of three observed. Resident #32, who has multiple diagnoses including chronic respiratory, kidney, and heart failure, was administered an incorrect dose of Polyethylene Glycol by LPN #355. The nurse did not fill the cap to the top as required for the correct 17-gram dose, leading to a medication error. Additionally, Resident #40, with a complex medical history including sepsis, asthma, and quadriplegia, was administered morphine inappropriately. LPN #361 crushed a morphine extended-release tablet and mixed it with applesauce without a physician's order, contrary to the facility's medication administration policy. The policy specifies that medications requiring crushing must have a prescriber's order, and certain medications, like extended-release tablets, should not be crushed unless specifically authorized by a physician.
Failure to Administer Anticoagulant Medication Timely
Penalty
Summary
The facility failed to ensure that a resident received their anticoagulant medication, apixaban, in a timely manner. The resident, who had multiple diagnoses including interstitial pulmonary disease, chronic respiratory and heart failure, and cardiac arrhythmia, was supposed to receive apixaban 5 mg orally twice a day, at lunch and nighttime. On a specific day, the lunch dose was administered at 5:50 P.M., which was outside the designated time frame of 11:00 A.M. to 3:00 P.M. The subsequent nighttime dose was also delayed, being administered at 9:17 P.M. instead of the scheduled 7:00 P.M. The Director of Nursing (DON) confirmed that there was no facility policy addressing the scheduled medication time frames, although guidance indicated that lunch medications should be administered between 11:00 A.M. and 3:00 P.M. The clinical record lacked documentation explaining the delay in administering the lunch dose. The manufacturer's information for apixaban highlighted that peak concentration is reached within three to four hours after consumption and noted the increased risk of bleeding, which could be potentially fatal. This deficiency was investigated under a specific complaint number.
Failure to Date Insulin Vials After Opening
Penalty
Summary
The facility failed to date vials of insulin medication after opening, which was observed during a medication administration for a resident with multiple diagnoses, including diabetes mellitus. The resident's physician had ordered Lispro insulin to be administered based on a sliding scale for blood glucose levels. During an observation, an LPN administered insulin from a multi-dose vial that was not dated when opened. The LPN admitted to not knowing how long the vial could be used before discarding it. This oversight affected one resident directly and had the potential to affect 12 others who were receiving insulin injections. Further observations revealed that multiple opened multi-dose vials of insulin, including Humalog, Novolog, and Humulin R, were not dated on the medication carts. Interviews with other LPNs confirmed that they were unaware of the duration for which insulin could be used after opening. The facility's policies required that opened vials be dated and discarded within 28 days unless otherwise specified by the manufacturer. The failure to date the vials represents non-compliance with the facility's policies and procedures, as well as accepted professional principles for medication storage and labeling.
Failure to Document Medication Administration for a Resident
Penalty
Summary
The facility failed to ensure proper documentation of medication administration for a resident, identified as Resident #40, who was admitted with multiple complex medical conditions including sepsis, asthma, and quadriplegia. On a specific date, the Medication Administration Record (MAR) for Resident #40 showed no documentation of medications scheduled to be administered upon rising, as well as additional medications scheduled for later in the day. These medications included MS Contin, ProHeal, Saccharomyces boulardii, Valtrex, Baclofen, Gabapentin, Midodrine hydrochloride, Oxybutynin chloride, and Acetaminophen. Interviews with two LPNs revealed that Resident #40 often refused medications at the scheduled times, requiring staff to reapproach her multiple times. One LPN admitted to not documenting the resident's medication refusal or administration attempts in the MAR or progress notes during his shift. The other LPN, who took over the care later in the day, stated she administered the medications but was unsure of the exact time and believed she had documented the administration. The facility's policy requires documentation of medication administration and any refusals, which was not adhered to in this instance.
Infection Control Deficiency Due to Improper Hand Hygiene
Penalty
Summary
The facility failed to adhere to proper hand hygiene protocols during medication administration and the use of a glucometer, affecting three residents. An LPN was observed using a glucometer to obtain blood sugar readings for two residents without disinfecting the device between uses. Additionally, the LPN administered multiple medications to a resident without performing hand hygiene before or after the process. This lack of proper infection control measures was confirmed during an interview with the LPN. In another instance, a State Tested Nursing Assistant (STNA) and an LPN failed to perform hand hygiene while providing incontinence care to a resident. The STNA changed gloves multiple times without washing hands and handled soiled linens before touching clean items. The LPN also neglected hand hygiene after applying a moisture barrier cream and before donning new gloves. These actions were observed and verified during an interview with the staff involved. The facility's hand hygiene policy, which outlines when hand hygiene should be performed, was not followed, leading to this deficiency.
Failure to Implement COVID-19 Isolation Precautions
Penalty
Summary
The facility failed to implement appropriate infection prevention and control measures for a resident diagnosed with COVID-19, affecting 25 residents on the South unit. Resident #7, who had intact cognition and was diagnosed with COVID-19, was not properly identified for isolation-based precautions. The facility's policy required staff to follow CDC guidelines for isolation, but observations revealed that an LPN entered Resident #7's room without donning the necessary PPE, such as an N95 mask, gown, and gloves. Additionally, there was no signage on Resident #7's door indicating the required precautions, and the LPN was unaware of the resident's COVID-19 status. Interviews with staff confirmed the lack of communication and adherence to the facility's COVID-19 prevention policy. The Director of Nursing acknowledged the absence of signage and confirmed that Resident #7 was supposed to be in isolation for ten days. The facility's policy, last revised in July 2024, outlined the need for visual alerts and specific PPE for staff entering rooms of COVID-19 positive residents, which was not followed in this instance. This oversight in infection control measures potentially exposed other residents and staff to COVID-19.
Facility Maintenance Deficiencies and Environmental Hazards
Penalty
Summary
The facility failed to maintain a clean, home-like, and leak-free environment, which had the potential to affect all 46 residents. Observations revealed several issues in the main dining hall, including a missing piece of tile near the exit to the patio, a bucket collecting water from a leaking ceiling, and multiple rust-colored stains around vent grates. The ceiling showed signs of water damage, with peeling paint, wet plaster, and exposed wood beams. Additionally, cracks were visible in two skylights, and the ceiling near the vending machines was bowed with missing paint and plaster. Interviews with residents confirmed the presence of leaks and the use of buckets to collect water during rain. One resident struggled to maneuver his wheelchair over the missing tile, highlighting the impact on residents' mobility. The Director of Maintenance confirmed the ongoing issues, including an active roof leak, water stains, and attempts to seal skylight cracks. Despite obtaining quotes for repairs, no work had been done to address the roof and skylight issues. Further observations revealed unsanitary conditions in the old kitchen, with soiled floors and large stains from a previous leak. The back door had a missing door sweep and sill, allowing potential pest entry, and the screen door was damaged. The Director of Maintenance confirmed these conditions and the lack of a specific building maintenance policy. The facility's admission agreement promised a safe, clean, and comfortable environment, which was not upheld, as evidenced by the ongoing maintenance issues.
Failure to Ensure Privacy During Incontinence Care
Penalty
Summary
The facility failed to maintain privacy and dignity during incontinence care for a resident with severe cognitive impairment and total dependence on staff for activities of daily living. The resident, who had multiple diagnoses including acute and chronic respiratory failure, anoxic brain damage, and morbid obesity, was observed receiving incontinence care in front of a large window with open blinds. This window faced a parking lot where cars were parked at eye level, and a person was noted sitting inside a vehicle outside the window. Interviews with the State tested Nurse Aides (STNAs) involved in the care confirmed that the blinds were open during the procedure, and there were cars visible in the parking lot. One of the STNAs acknowledged routinely ensuring privacy by closing doors and using privacy curtains but admitted to not considering the need to close the window blinds. The facility's admission agreement and perineal care policy both emphasized the importance of maintaining resident privacy, which was not adhered to in this instance.
Medication Administration Deficiency
Penalty
Summary
The facility failed to ensure medications were administered per physician orders for a resident, affecting one out of four residents reviewed for medication administration. The resident had multiple diagnoses, including chronic respiratory failure, COPD, and a history of UTIs, and required oxygen therapy and non-invasive mechanical ventilation. The care plan included administering aerosols, bronchodilators, and medications as ordered. However, the resident did not receive the prescribed Ipratropium-Albuterol aerosol treatment on several occasions, as documented in the medication administration record (MAR). Additionally, the resident expressed concerns about not consistently receiving Premarin vaginal cream as ordered, with instances of it being administered at inappropriate times. Interviews with facility staff confirmed the discrepancies in medication administration. The Director of Respiratory Therapy noted that the Ipratropium-Albuterol order was not confirmed and was awaiting read-back to the ordering provider, resulting in missed doses. The Director of Nursing confirmed that the Premarin cream and Lidocaine patches were not administered on a specific evening due to unavailability from the pharmacy. The facility's policy on medication administration required medications to be given as ordered by the physician, highlighting a failure to adhere to professional standards of practice.
Failure to Address Staff Impairment
Penalty
Summary
The facility failed to ensure that staff showing signs of potential impairment were evaluated for competency to provide resident care. On the night in question, the former Director of Nursing (DON) and a Registered Nurse (RN) were reported by multiple staff members to have entered the facility smelling of alcohol and exhibiting impaired behaviors. Witnesses, including a Licensed Practical Nurse (LPN), State Tested Nursing Assistants (STNAs), and a Respiratory Therapist (RT), observed the former DON yelling at staff and residents, and noted the smell of alcohol. Despite these observations, the facility did not obtain a statement from the RN involved, and the former DON resigned shortly after the incident without any disciplinary action recorded in his file. The incident was first reported to the facility's administration by corporate the following morning. Interviews with various staff members confirmed that the former DON and the RN were seen going room to room, with the former DON yelling at both staff and residents. One resident confirmed that the former DON yelled at him to get back to bed, while the RT reported that the former DON yelled at him about a resident's trach mask tubing. The RT also noted the smell of alcohol on the former DON and considered calling the police if the situation escalated further. The facility's investigation into the incident was incomplete, as they failed to obtain a statement from the RN involved, who was on vacation and did not respond to multiple attempts to contact her. The Administrator and the new DON confirmed that they were unaware of the incident until the following morning and acknowledged that employees should have immediately reported such concerns to initiate an investigation. The deficiency was substantiated by multiple witness statements and interviews, highlighting a failure in the facility's process for addressing potential staff impairment and ensuring resident safety.
Unprofessional Conduct by Staff
Penalty
Summary
The facility failed to ensure staff maintained a professional demeanor when interacting with and around residents, affecting two residents. Resident #103, who is cognitively intact with a BIMS score of 15, reported that the former DON entered the building around 2:00 A.M. and yelled at him to go to bed using expletive language. Another resident, Resident #100, confirmed hearing the former DON yelling at Resident #103 and staff during the night. Multiple staff members, including an LPN and STNAs, reported that the former DON and RN #267 appeared to be under the influence of alcohol during their rounds, which included yelling at staff and residents. The facility's investigation revealed that the former DON and RN #267 smelled of alcohol and were conducting rounds in an unprofessional manner, which was corroborated by several witness statements from staff and residents. The former DON resigned on the same day of the incident, and the facility did not obtain a statement from RN #267 due to her being on vacation and subsequently being unreachable. The facility's policy on resident rights emphasizes the importance of treating residents with respect and dignity, which was not upheld in this incident.
Failure to Administer Antibiotics as Ordered
Penalty
Summary
The facility failed to ensure antibiotics were administered as ordered, affecting two residents. Resident #116 was admitted with diagnoses including dilated cardiomyopathy, ventricular tachycardia, and tracheostomy status. A text message from the Nurse Practitioner (NP) to the Licensed Practical Nurse (LPN) instructed the administration of Ertapenem and IV fluids. However, the medication administration records revealed that the Ertapenem was not administered as ordered, and the IV fluids were infused for longer than prescribed. Interviews confirmed the LPN did not administer the antibiotic and was terminated for the error. Resident #115, who was readmitted with diagnoses including dependence on a respirator ventilator, muscle weakness, and anemia, was also affected. The NP provided a verbal order for Ertapenem and IV fluids, which was texted to the LPN. The LPN signed off the medication in the computer but did not administer it. The NP confirmed that Resident #115 received the Ertapenem in error, but the IV fluids were not administered due to the on-call team catching the mistake. The Medication Administration policy dated 11/2017 states that medications should be administered by licensed nurses as ordered by the physician and in accordance with professional standards. The facility's failure to adhere to this policy resulted in significant medication errors for both residents, as confirmed by the Director of Clinical Services and the NP.
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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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