Grande Pointe Healthcare Commu
Inspection history, citations, penalties and survey trends for this long-term care facility in Richmond Heights, Ohio.
- Location
- Three Merit Dr, Richmond Heights, Ohio 44143
- CMS Provider Number
- 366008
- Inspections on file
- 38
- Latest survey
- March 3, 2026
- Citations (last 12 mo.)
- 5
Citation history
Health deficiencies cited at Grande Pointe Healthcare Commu during CMS and state inspections, most recent first.
A cognitively impaired, independently ambulatory resident with multiple comorbidities and vascular dementia was care planned as an elopement risk and ordered to wear a wanderguard with daily checks. Despite this, the resident told staff he was going to meet a friend, left the unit fully dressed, and was later found to be absent from his room, with evening medications not administered and his whereabouts unknown to staff throughout the night. A CNA on the evening shift twice noted the resident’s absence but did not notify the nurse, and other staff who knew the resident walked frequently did not identify him as exit seeking. The resident ultimately spent the night at a family member’s home and returned the next morning without injury, revealing that he had left the facility without staff awareness, constituting a failure to provide adequate supervision to prevent an unsupervised departure.
A resident with a stage four sacral pressure ulcer did not have specific wound care orders from a wound nurse practitioner transcribed into the electronic medical record. Although the care plan and general physician orders called for wound vac dressing changes, the detailed instructions for wound care were omitted, contrary to facility policy requiring transcription of physician orders.
A CNA failed to remove soiled gloves after providing incontinence care to a resident with multiple health conditions and then applied Vaseline to the resident's skin using the same gloves, contrary to infection control protocols.
Surveyors found that a resident did not receive appropriate care for continence or incontinence, including improper catheter care and insufficient measures to prevent UTIs. These lapses resulted in a deficiency related to the standard of care for residents with bowel and bladder needs.
The facility's kitchen was not maintained in a clean and sanitary manner, affecting all residents except three who received nothing by mouth. Observations revealed dirty dessert plates, food crumbs, and grease on kitchen equipment, and a dirty floor. The Mobile Dietary Manager confirmed these findings, which violated the facility's policy requiring cleanliness in food preparation and service areas.
The facility failed to provide adequate supervision during resident smoking breaks, affecting four residents. An Activity Leader supervised from inside the building, unable to see all residents clearly. This led to unsafe practices, such as a resident passing a lit cigarette to another and improper disposal of cigarette butts. The facility's policy requires staff supervision for residents unable to demonstrate safe smoking habits, which was not adequately followed.
The facility failed to provide trauma-informed care for two residents with PTSD. One resident had generic triggers in her care plan, and staff were unaware of her PTSD diagnosis. Another resident's care plan lacked specific interventions, and staff were unaware of his PTSD diagnosis or triggers. Interviews revealed staff's lack of awareness, and neither resident received counseling services. Facility policies on personalized care and behavior management were not effectively implemented.
A resident with dementia was not protected from sexual abuse by another resident with a history of physical aggression. The facility lacked care-planned interventions and failed to assess the residents' capacity to consent to sexual activity, contributing to the deficiency.
The facility failed to comply with its hiring policies by employing a maintenance staff member with a past domestic violence charge, a disqualifying offense. Despite a background check revealing this charge, the staff member was hired without completing the necessary personal care standards. This oversight was confirmed by facility management and violated both facility policy and the Ohio Revised Code.
The facility failed to implement its abuse policy by not checking potential applicants against the Ohio NAR and completing required background checks before they began working with residents. This affected six out of seven personnel files reviewed, including a CNA, a Dietary Aide, an LPN, Maintenance Staff, and a Receptionist, potentially impacting all 158 residents.
A facility's memory care unit was understaffed, leading to insufficient supervision of residents. On a night shift, only one LPN and two CNAs were present, below the recommended staffing levels. This resulted in a lack of supervision when two residents engaged in a consensual sexual act. The facility's assessment lacked specific guidelines for adjusting staffing based on resident needs or behaviors.
The facility failed to inform the attending physicians of two residents involved in a consensual sexual encounter in a secured dementia unit. Despite the incident being deemed unsubstantiated, the attending physicians were not promptly notified, as confirmed by interviews and lack of documentation. Facility policies did not adequately address communication procedures for significant changes in resident condition.
A facility failed to thoroughly investigate a resident-to-resident sexual abuse allegation involving two residents with cognitive impairments. The incident was witnessed by a CNA, but the investigation lacked a comprehensive timeline and detailed staff statements. Both residents reported the interaction as consensual, but the facility did not document their relationship history or context adequately.
A resident with a history of falls and multiple medical conditions fell and sustained a major injury after raising their bed to a high position. The facility's investigation was inadequate, lacking detailed witness statements and timely documentation. Staff interviews revealed inconsistencies and a lack of recall about the incident.
A resident at high risk for pressure ulcers developed Stage III ulcers and a full-thickness wound due to the facility's failure to implement care plan interventions, such as turning and repositioning, and timely incontinence care. The facility also failed to properly evaluate and treat the wounds, and delayed a nutritional consult, contrary to their skin care policy.
Two residents with severe cognitive impairment were not provided timely incontinence care, resulting in them being found in soaked beds and wearing two incontinence briefs. The STNA admitted to not changing the briefs since the start of her shift due to being too busy. The facility's policy on maintaining skin integrity and providing dignified care was not followed.
The facility failed to maintain a medication error rate below 5%, resulting in a 7.69% error rate. Two residents were affected: one received an incorrect inhaler and the other took more inhalations than prescribed due to lack of instruction from an LPN. The facility's policy on medication administration was not followed.
A facility failed to properly store and dispose of controlled substances, leading to the misappropriation of medications for seven residents. The deficiency was discovered through a review of medical records and a self-reported incident investigation. Missing narcotic sheets and medications were found, with significant quantities unaccounted for. The DON discovered the discrepancies in a Unit Manager's desk, who admitted to misplacing narcotics. Facility policies on medication management were not followed.
A resident with an unstageable pressure ulcer experienced severe pain due to the facility's failure to implement an effective pain management program. Pain medication was delayed, and there was inadequate pain assessment and documentation. Communication lapses among staff further contributed to the resident's prolonged discomfort.
A resident with a history of serious medical conditions was admitted to a facility with an unstageable sacral pressure ulcer. Despite the facility's policy requiring treatment orders and documentation, there were no treatment orders for the ulcer from admission until two days later, and no evidence of daily monitoring or treatment. Interviews confirmed the lack of treatment orders and documentation, highlighting a failure to implement timely care planned interventions.
A resident with multiple health issues, including polyneuropathy, was at risk for falls, but the facility failed to implement individualized care plan interventions. The resident experienced an unwitnessed fall, and the subsequent investigation was incomplete, lacking necessary documentation and follow-up. The facility did not adhere to its fall prevention and management policy.
A resident with chronic kidney disease did not receive scheduled dialysis due to communication failures and misinformation. The resident was admitted to the facility from a hospital, and staff incorrectly believed dialysis had been performed prior to admission. This led to the resident missing a scheduled dialysis session, as the facility did not verify the dialysis status upon admission. The resident's family filed a complaint, and the facility's policy on hemodialysis care was not adequately followed.
A resident with complex medical needs did not receive prescribed medications due to communication and verification failures in a LTC facility. Insulin was not administered on time, and intravenous cefazolin was missed during dialysis sessions due to lack of proper documentation and communication among staff.
A resident with dementia and other medical conditions was left in a soiled condition for approximately seven hours due to the failure of an STNA to provide timely incontinence care, despite multiple requests from the charge nurse. The resident's care plan required total assistance for toileting and hygiene, which was not met, leading to the resident having BM all over his body, hands, and bed by the time he was finally cleaned up.
Failure to Supervise Cognitively Impaired Resident Who Left Facility Unnoticed
Penalty
Summary
The deficiency involves the facility’s failure to provide adequate supervision to ensure that a resident with moderately impaired cognition did not leave the facility without staff awareness. The resident had multiple medical diagnoses, including non-traumatic intracerebral hemorrhage, hypertensive chronic kidney disease, end stage renal disease with dependence on dialysis, anxiety, and vascular dementia without behavioral, psychotic, or mood disturbance. A physician order directed that the resident wear a wanderguard bracelet on the ankle, with staff instructed to check its placement and function daily on day shift. The resident’s care plan identified him as an elopement risk who wandered aimlessly, with interventions to maintain the wanderguard, check its placement and function, provide diversionary activities, and redirect as appropriate. An MDS assessment documented moderately impaired cognition, independent ambulation, and instances of wandering, and noted that the resident had not utilized a wander or elopement alarm during the lookback period. On the evening of the incident, the resident was last seen by staff in the late afternoon to early evening after telling staff he was going to the lobby to meet a friend. Later that evening, while passing medications, staff noted the resident was not in his room, and he remained absent through the night without staff knowing his whereabouts. The resident’s evening medications, including antihypertensive drugs and other treatments, were documented as not administered. Staff interviews indicated that a CNA who began the 7:00 P.M. shift noticed the resident was not in his room during initial rounds and again on a second check, but did not notify the nurse at that time, despite recognizing later that he should have done so. Another CNA reported seeing the resident fully dressed near the vending area stating he was going to the front to visit a friend, but there is no indication that this observation triggered any verification of his location or status afterward. By early morning, nursing staff confirmed the resident was still missing, and a facility-wide search and missing resident response were initiated. The facility’s own elopement policy defined elopement as a resident leaving the premises or a safe area without authorization and/or necessary supervision, particularly when the facility is unaware of the resident’s departure or whereabouts. The resident later reported that he had left with a friend and spent the night at a family member’s home before returning. Upon return, assessments showed intact skin, no visible injuries, no pain or discomfort, and mental status at baseline, and he received breakfast and dialysis as scheduled. Despite the facility leadership characterizing the event as an unauthorized leave of absence, the survey findings focused on the lack of adequate supervision and failure to ensure that a cognitively impaired, independently ambulatory resident with a documented elopement risk and ordered wanderguard did not leave the facility without staff awareness. The facility’s investigation timeline documented that all doors and windows, including the wanderguard system, were later checked and found to be in working order, suggesting that the resident’s departure occurred without triggering staff response through the existing monitoring systems. Staff accounts showed that the resident was known to walk around frequently but was not considered exit seeking by some CNAs, and one CNA reported that the resident had eloped a few weeks earlier. The combination of the resident’s known wandering behavior, his elopement-risk care plan, the presence of a wanderguard order, and staff failure to promptly report and act on his absence contributed to the deficiency in supervision that allowed him to leave the facility without staff knowledge.
Failure to Transcribe Physician Orders for Pressure Ulcer Care
Penalty
Summary
A deficiency was identified when the facility failed to transcribe a physician's order for pressure ulcer treatment into the electronic medical records for a resident with a stage four pressure ulcer. The resident, who had diagnoses including a stage four sacral pressure ulcer, stroke with right-sided weakness, and malnutrition, was dependent on staff for activities of daily living. The care plan and physician orders indicated the use of a negative pressure wound vac and dressing changes three times a week, but the physician orders lacked specific details about the type of dressing or treatments to be used. A progress note from a wound nurse practitioner provided detailed instructions for wound care, including cleansing with Dakins solution, applying skin prep and stoma paste, and using a transparent drape and black foam with the wound vac set to negative 125 mmHg. However, these specific orders were not transcribed into the resident's medical record. The facility's wound nurse confirmed that the detailed wound care orders should have been included in the physician orders, and facility policy required that physician orders be transcribed into the electronic medical records.
Infection Control Breach During Incontinence Care
Penalty
Summary
A deficiency was identified when a certified nursing assistant (CNA) failed to follow appropriate infection control procedures during incontinence care for a resident with a history of stroke, right-sided weakness, muscle weakness, and malnutrition. The resident was dependent on staff for toileting and was incontinent of bowel and bladder. During observed care, the CNA provided incontinence care while wearing gloves but did not remove the soiled gloves after completing the task. Instead, the CNA proceeded to apply Vaseline to the resident's arms and legs using the same soiled gloves. The CNA acknowledged during interview that she should have removed the soiled gloves after providing incontinence care.
Deficient Bowel/Bladder and Catheter Care Leading to UTI Risk
Penalty
Summary
The report identifies a deficiency related to the provision of care for residents who are continent or incontinent of bowel and bladder, as well as the management of catheter care and the prevention of urinary tract infections (UTIs). Surveyors found that appropriate care was not consistently provided to residents in these areas. Specific failures included inadequate attention to the needs of residents with continence or incontinence issues, improper catheter care, and insufficient measures to prevent UTIs. These deficiencies were observed through direct surveyor findings, indicating lapses in the standard of care required for residents with these needs.
Kitchen Sanitation Deficiency
Penalty
Summary
The facility failed to maintain the kitchen in a clean and sanitary manner, which had the potential to affect all residents except three who received nothing by mouth. During a kitchen tour, several white dessert plates were observed with dried brownish substances and crumbs. Additionally, the oven, stove, tilt skillet, and steamer had various food crumbs and grease on their surfaces. The floor in front of these kitchen appliances was dirty with a moderate amount of dark-colored debris. The Mobile Dietary Manager confirmed these findings during the observation. The facility's policy, dated September 2017, requires all food preparation, service, and dining areas to be maintained in a clean and sanitary condition.
Inadequate Supervision During Resident Smoking Breaks
Penalty
Summary
The facility failed to ensure adequate supervision to prevent accidents related to smoking safety, affecting four residents who were reviewed for smoking. During a resident smoke break, two residents were observed smoking outside the building while the Activity Leader supervised from inside through a glass door. One resident arrived late and positioned herself with her back to the door, making it difficult for the Activity Leader to see her. Another resident passed his lit cigarette to the late-arriving resident to light her cigarette, which went unnoticed by the Activity Leader. Additionally, a resident discarded his cigarette on the ground instead of using the designated receptacle, which was located thirty feet from the building. The Activity Leader admitted to supervising from inside the building and acknowledged that she did not see the exchange of cigarettes or the improper disposal of cigarette butts. The Activity Director confirmed that the Activity Leader should have been outside to maintain a clear view of all residents. The facility's policy on Resident Smoking Guidelines requires staff supervision for residents unable to demonstrate safe smoking habits, which was not adequately followed in this instance.
Failure to Provide Trauma-Informed Care for Residents with PTSD
Penalty
Summary
The facility failed to provide culturally competent and trauma-informed care to residents diagnosed with Post-Traumatic Stress Disorder (PTSD), affecting two residents. Resident #81, who had a history of heart disease, burns, major depressive disorder, and PTSD, was admitted without specific PTSD-related information in her social history assessments. Her care plans included generic triggers, and staff members were unaware of her PTSD diagnosis or specific triggers. Similarly, Resident #82, diagnosed with chronic PTSD, had no updated social history assessments reflecting this diagnosis. His care plan lacked specific interventions or triggers, and staff were unaware of his PTSD diagnosis or how to identify potential triggers. Interviews with various staff members, including CNAs and LPNs, revealed a lack of awareness and understanding of the residents' PTSD diagnoses and associated triggers. The Director of Nursing and a Regional RN indicated that PTSD triggers should be found in the care plans, but staff were unable to locate this information. Additionally, neither resident received counseling services in the past six months, despite their PTSD diagnoses. The facility's policies on care planning and behavior management emphasized personalized, resident-focused care and the identification of psychiatric-related behaviors, but these were not effectively implemented for the residents in question.
Failure to Protect Resident from Sexual Abuse
Penalty
Summary
The facility failed to protect a resident with dementia, deemed incompetent and unable to provide consent, from sexual abuse by another resident. The incident occurred when a resident with a history of engaging in physical activities with the victim was observed by a CNA engaging in an activity indicative of oral sex on the victim. The facility did not have care-planned interventions in place to address the aggressor's prior physical aggression towards the victim or the known relationship between the two residents. The facility's records revealed that the victim had a history of cognitive impairment and was on a secured unit due to dementia. Despite this, there was no comprehensive or individualized care plan addressing the victim's capacity to consent to sexual activity. The facility also failed to conduct further behavioral assessments or implement consistent monitoring and interventions following the incident. The aggressor, who also had dementia and was deemed incompetent, had a history of developing relationships with other residents. However, there was no documentation of any interventions or monitoring to address this behavior. The facility's failure to assess and develop a care plan for the aggressor's human sexuality needs or preferences contributed to the deficiency.
Removal Plan
- CNA #396 separated Residents #18 and #28 and placed Resident #18 on one-on-one supervision.
- CNA #396 notified the Administrator of an allegation of resident-to-resident sexual abuse.
- The Administrator notified the DON of an allegation of resident-to-resident sexual abuse.
- The DON notified RDCO/RN #219 and RDO #410 of an allegation of resident-to-resident sexual abuse.
- The DON and RDCO/RN #219 interviewed Resident #18 and Resident #28 by phone.
- The Administrator submitted a SRI report with the State Agency.
- The families of Resident #18 and Resident #28 were made aware of the allegation.
- LPN #310 called the police to report the allegation.
- LPN #310 notified On-call Physician #196 of the allegation.
- UM/LPN #368 completed skin checks on all residents on the Connections unit.
- The DON/designee provided education to the Connections unit staff on sexual abuse and behaviors.
- UM/LPN #368 placed a note at the nurses' station about not leaving Residents #18 and #28 alone behind closed doors.
- NP #195 assessed Resident #18 and Resident #28.
- LSW #245 made a referral to another facility for Resident #18 per family request.
- The DON/Designee interviewed all residents on the Connections unit regarding capacity to consent.
- Resident #18 was placed on 1:1 supervision with a physician's order.
- The DON/Designee interviewed staff on the Connections unit about knowledge of residents' sexual relationships.
- The DON/Designee educated all staff on the facility's abuse and neglect policy.
- The DON/Designee started additional skin checks on all residents on the Connections unit.
- MD/Physician #406 completed medication reviews for Resident #18 and Resident #28.
- LSW #245 completed psychosocial reviews for Resident #18 and Resident #28.
- The Administrator/designee held an ad hoc QAPI meeting to discuss the Immediate Jeopardy and abatement plan.
- LSW #245 would continue offering support to Resident #18 and Resident #28 by weekly visits for four weeks then as needed.
- All facility-reported incidents would be reviewed by DON/Designee immediately.
- All allegations of abuse would be reported to the RDCO/RN #219 by the DON or Administrator.
- The DON/Designee would educate all new staff on Abuse, Dementia and Behavioral Health management.
- The DON/Designee would observe residents weekly to look for inappropriate sexual behaviors.
- The Administrator/Designee would interview staff weekly to determine if there have been any inappropriate sexual behaviors.
- The Administrator or DON would monitor compliance during monthly QAPI meetings for three months, then as needed for one year.
- The RDCO/RN #219 would monitor compliance during monthly visits for three months then on an as needed basis.
Failure to Adhere to Hiring Policies Regarding Disqualifying Offenses
Penalty
Summary
The facility failed to adhere to its policy of hiring staff free of disqualifying offenses, as evidenced by the personnel file review of a maintenance staff member. The review revealed that the staff member, hired on 04/28/23, had a background check conducted prior to employment, which returned on 05/11/23 with no findings. However, further examination of the background check report dated 05/12/23 showed a charge for domestic violence from 12/28/95, a disqualifying offense according to the facility's policy and the Ohio Revised Code. Despite this, the staff member was employed without the necessary personal care standards being completed in their personnel file. Interviews with the Employee Lifecycle Manager and the Regional Employee Engagement Specialist confirmed the findings and acknowledged the absence of personal care standards in the staff member's file. The facility's policy, effective since 10/01/00, requires a thorough review of background checks to identify any disqualifying convictions, including domestic violence, which is explicitly listed as a prohibited offense. The Ohio Revised Code also prohibits employing individuals with such convictions in positions involving direct care to older adults, unless personal character standards are met, which was not the case here.
Failure to Implement Abuse Policy and Conduct Background Checks
Penalty
Summary
The facility failed to implement its abuse policy and procedure regarding checking potential applicants against the Ohio Nurse Aide Registry (NAR) and completing required background checks before allowing them to work with residents. This deficiency was identified during a review of personnel files, which revealed that six out of seven files lacked evidence of timely NAR checks and background checks. For instance, a Certified Nurse Aide (CNA) was hired and began working with residents before being checked against the NAR, and her file did not contain any background check documentation. Similarly, a Dietary Aide's file lacked evidence of an NAR check, and her background check was only completed months after her hire date. The facility's policy, dated 10/01/00, mandates that all candidates for employment must be checked against the Ohio NAR and undergo Ohio Bureau of Criminal Identification and Investigation (BCII) and Federal Bureau of Investigation (FBI) checks before a job offer is made. However, the review found that several employees, including a Licensed Practical Nurse (LPN), Maintenance Staff, and a Receptionist, were not checked against the NAR as required. An interview with the Regional Employee Engagement Specialist confirmed these findings and acknowledged that the facility's policy was not followed, potentially affecting all 158 residents in the facility.
Inadequate Staffing Leads to Insufficient Supervision in Memory Care Unit
Penalty
Summary
The facility failed to maintain sufficient staffing levels on the secured memory care unit, which affected the supervisory needs of residents. The facility assessment indicated that the Connections unit on the night shift should have one to two licensed nurses and two to three nurse aides. However, on the night of the incident, only one LPN and two CNAs were present, which was below the recommended staffing levels. The facility's assessment did not specify criteria for adjusting staffing levels based on resident needs or behaviors. On the night in question, a self-reported incident involved two residents engaging in a consensual sexual act. The incident was discovered by a CNA during rounds, who found one resident performing oral sex on another. Both residents were separated and interviewed, confirming their consent to the interaction. The facility determined the allegation of sexual abuse to be unsubstantiated due to the consensual nature of the act. However, the incident highlighted the lack of adequate supervision due to insufficient staffing. Interviews with staff revealed that a call-off had occurred, leaving the unit understaffed with only three staff members present. The facility's staffing procedures involved an outside company for scheduling and a call-off specialist to fill gaps, but these measures were insufficient to cover the staffing shortage on the night of the incident. The administrator confirmed that the staffing schedule was accurate and acknowledged that the facility's assessment did not provide specific guidelines for staffing adjustments based on resident needs or behaviors.
Failure to Notify Physicians of Resident-to-Resident Sexual Incident
Penalty
Summary
The facility failed to timely inform the attending physicians of two residents involved in an instance of resident-to-resident sexual abuse. This incident involved two residents, both of whom were diagnosed with dementia and were residing in a secured dementia unit. The incident was reported to have occurred when a Certified Nurse Aide found one resident performing oral sex on another resident. Both residents claimed the interaction was consensual, and the facility determined the allegation of sexual abuse to be unsubstantiated based on their statements. Despite the facility's determination, the attending physicians of both residents were not promptly informed of the incident. The attending physician for the first resident was unaware of the sexual encounter, as confirmed during a phone interview. Similarly, the attending physician for the second resident was only vaguely aware of inappropriate behavior on the unit but was not informed of the consensual nature of the incident. The Director of Nursing confirmed that there was no documentation in the residents' records indicating that their attending physicians had been notified of the incident. The facility's policy on Notification of Change in Condition requires that the resident's physician and/or representative be informed of significant changes in condition. However, the policy did not address how significant changes, such as allegations of resident-to-resident abuse, would be communicated to the attending providers. Additionally, the facility's Telehealth Services policy outlined guidelines for after-hours communication but did not specify procedures for communicating significant changes to the residents' attending physicians during off-hours.
Inadequate Investigation of Resident-to-Resident Sexual Abuse Allegation
Penalty
Summary
The facility failed to thoroughly investigate allegations of resident-to-resident sexual abuse involving two residents. The incident occurred when a CNA found a male resident kneeling in front of a female resident with his head in proximity to her vagina. Both residents were separated and interviewed, and they reported that the interaction was consensual. However, the facility's investigation was deemed insufficient as it lacked a comprehensive timeline and detailed staff statements. The male resident had a history of severe cognitive impairment, while the female resident had moderate cognitive impairment. Both residents were on a secured unit due to their dementia diagnoses. Despite their cognitive impairments, both residents expressed understanding and consent regarding the incident. The facility's investigation did not adequately document the residents' relationship history or the context of the incident, which had reportedly been ongoing for several months. The facility's policy required a thorough investigation of alleged abuse, including obtaining detailed statements from all involved parties. However, the investigation lacked statements from all staff present during the incident, and the available statements were incomplete and lacked time details. The facility did not establish a timeline of events leading up to the incident, and there was no documentation of the residents' interactions prior to the event, which could have provided context for the incident.
Inadequate Fall Investigation for Resident
Penalty
Summary
The facility failed to thoroughly investigate falls to ensure appropriate safety interventions were in place for a resident, identified as Resident #160. The resident had a history of repeated falls and was at risk due to medical conditions including type two diabetes, hypertension, obesity, aphasia following cerebral infarction, and hemiplegia and hemiparesis following a non-traumatic intracerebral hemorrhage. The resident was admitted to the facility with orders for a low bed with bilateral mats and evaluations by physical and occupational therapy. Despite these precautions, the resident experienced a fall resulting in a major injury. The incident occurred when the resident was found on the floor by a laboratory technician at approximately 4:10 A.M. The resident had raised the bed to a high position for unknown reasons and fell, hitting his head. The facility's investigation into the fall was inadequate, as it did not include detailed witness statements or information on when the resident was last seen by staff. The incident report was not completed at the time of the fall, and the post-fall investigation lacked critical details such as the last time the resident was checked or cared for by staff. Interviews with staff revealed inconsistencies and a lack of recall regarding the incident. The Director of Nursing acknowledged the deficiencies in the investigation process, including the failure to obtain complete and accurate witness statements and the lack of timely documentation. The facility's policy on fall prevention and management was not followed, as the investigation did not begin immediately after the fall, and witness statements were not adequately collected.
Failure to Prevent and Treat Pressure Ulcers
Penalty
Summary
The facility failed to provide individualized care planned interventions to prevent a resident from developing in-house pressure ulcers within 30 days of admission. The resident, who was at high risk for pressure ulcers due to severe cognitive impairment and dependence on staff for mobility and incontinence care, developed Stage III pressure ulcers on the sacral area and a new full-thickness wound on the left buttock. The resident's family expressed concerns about the lack of timely assistance with turning, repositioning, and incontinence care, which they believed contributed to the development of these wounds. The medical record review revealed that the resident's care plan included interventions such as turning and repositioning every two hours and providing peri care to prevent skin breakdown. However, there was no evidence that these interventions were consistently implemented. The resident's pressure ulcers were not properly evaluated or treated, as indicated by the lack of documentation of wound measurements and appearance, and the absence of treatment orders for the pressure ulcers. Additionally, a nutritional consult recommended for the presence of a wound was not completed in a timely manner. Interviews with facility staff confirmed the deficiencies in care. The Wound Nurse Practitioner and the Director of Nursing acknowledged that the resident's pressure ulcer was not evaluated on a specific date, and the nutritional consult was delayed. The Registered Dietician confirmed that the nutritional evaluation for the pressure ulcer was not documented until nearly a month after it was identified. The facility's policy on skin care and wound management was not followed, as evidenced by the lack of individualized interventions and failure to implement prevention strategies.
Failure to Provide Timely Incontinence Care
Penalty
Summary
The facility failed to provide timely incontinence care for two residents, leading to a deficiency. Resident #28, who has severe cognitive impairment and is always incontinent of urine and bowel, was found lying in a bed soaked with urine and feces. The resident was wearing two incontinence briefs, which were also soaked, and had not been changed since the night shift. The resident's buttocks, sacral area, and perineum were reddened, indicating potential skin breakdown. Despite the resident's repeated requests to be covered, the STNA did not provide a sheet or blanket, citing a lack of available linens in the room. Similarly, Resident #127, who also has severe cognitive impairment and is frequently incontinent, was found in a similar state. The resident's gown and bed were soaked with urine and stool, and the resident was wearing two incontinence briefs. The STNA admitted that the night shift had put on the two briefs and that she had not changed them since starting her shift at 7:00 A.M. due to being too busy. The facility's policy on routine resident care emphasizes the importance of maintaining skin integrity and providing care for incontinence with dignity, which was not adhered to in these cases.
Medication Error Rate Exceeds Acceptable Threshold
Penalty
Summary
The facility failed to maintain a medication error rate of less than 5%, resulting in a 7.69% error rate during the survey. Two errors were identified out of 26 medication administration opportunities involving two residents. The first error involved a resident with chronic respiratory failure and COPD, who was supposed to receive Spiriva Respimat inhaler as per physician orders. However, the LPN prepared and administered a different inhaler, Breo Ellipta, and initially failed to administer it correctly, signing off on the electronic record inaccurately. The second error involved a resident with anxiety disorder and COPD, who was ordered to take one inhalation of Anoro Ellipta inhaler daily. The LPN did not provide instructions on the number of inhalations, leading the resident to take four inhalations instead of the prescribed one. The facility's policy on medication administration, which emphasizes administering medication as prescribed and observing the five rights, was not adhered to, resulting in these medication errors.
Misappropriation of Controlled Substances
Penalty
Summary
The facility failed to ensure the proper storage and disposal of controlled substances, leading to the misappropriation of medications for seven residents. The deficiency was identified through a review of medical records, a self-reported incident investigation, observations, and interviews with staff and residents. The residents affected had various medical conditions, including sepsis, diabetes, chronic kidney disease, fractures, and anxiety disorders, and were prescribed medications such as Percocet, Morphine, Fentanyl, Hydrocodone, Lorazepam, Oxycodone, and Tramadol. The investigation revealed that narcotic sheets and medications were missing for the discharged residents, with significant quantities of medications unaccounted for. For instance, Resident #256 was missing 27 oxycodone pills, and Resident #257 had missing narcotic sheets and unaccounted Fentanyl patches and Morphine. Similar discrepancies were found for the other residents, with missing medications and incomplete destruction logs, indicating a failure in the facility's medication management processes. The Director of Nursing (DON) discovered the missing narcotics and narcotic sheets in Unit Manager #7's desk, who was subsequently suspended pending investigation. The Unit Manager admitted to being sloppy with job duties and misplacing narcotics but denied stealing them. The facility's policies on discontinued medications and controlled substance disposal were not followed, contributing to the misappropriation of medications.
Failure in Pain Management for Resident with Pressure Ulcer
Penalty
Summary
The facility failed to develop and implement a comprehensive and effective pain management program for a resident, leading to actual harm. The resident, who was admitted with an unstageable pressure ulcer to the sacrum, experienced moderate to severe pain that interfered with daily activities, including therapy and hemodialysis treatments. Despite the resident's complaints of pain, pain medication was not ordered until three days after admission and was not administered until five days after admission. The resident's medical records revealed a lack of comprehensive pain assessment and documentation. The Medication Administration Record (MAR) indicated monitoring for pain every shift, but there was no pain rating recorded, making it unclear if the resident's pain was assessed. The care plan included interventions for pain management, but there was no specific care plan for pain related to the resident's pressure ulcer. Additionally, there was no evidence that non-pharmacological interventions were implemented to manage the resident's pain. Interviews with facility staff highlighted communication and procedural failures. The Director of Nursing (DON) acknowledged that medication orders should be verified promptly to ensure timely administration. However, the resident's pain medication orders were delayed, and there was a lack of communication among staff regarding the resident's pain and medication needs. The Certified Nurse Practitioner (CNP) admitted to missing the initial pain medication order, and the physician's orders for increased pain medication were not executed. These oversights contributed to the resident's prolonged pain and discomfort.
Failure to Implement Timely Pressure Ulcer Treatment
Penalty
Summary
The facility failed to implement timely care planned interventions for a resident's unstageable sacral pressure ulcer. The resident, who had a medical history including sepsis, pneumonia, type two diabetes mellitus, and end-stage renal disease, was admitted to the facility with a sacral pressure ulcer. Despite the presence of the ulcer, there were no treatment orders documented from the time of admission until two days later. The resident's medical records and progress notes did not show evidence of daily monitoring or treatment of the pressure ulcer during this period. Upon admission, the resident's nursing evaluation incorrectly noted that treatment orders were in place for the pressure ulcer, which was not the case. The resident's care plan included interventions for impaired skin integrity, but these were not executed as there were no treatment orders documented. The facility's policy required obtaining a physician order for treatment and documenting it on the Treatment Administration Record (TAR), which was not followed. Interviews with the Director of Nursing, Unit Manager, and Certified Nurse Practitioner confirmed the absence of treatment orders for the pressure ulcer from the time of admission until two days later. Additionally, there was no documented evidence of treatments being completed on specific dates, even after treatment orders were eventually established. This deficiency was identified during an investigation under a master complaint number.
Failure to Implement Fall Prevention and Conduct Thorough Investigation
Penalty
Summary
The facility failed to ensure that Resident #156 had individualized care planned interventions for falls and did not conduct a thorough investigation or accurate follow-up evaluation after a fall. Resident #156, who had a history of sepsis, pneumonia, type two diabetes mellitus with diabetic chronic kidney disease, and diabetic polyneuropathy, was at risk for falls due to polyneuropathy. Despite being identified as at risk for falls, the care plan did not include interventions related to the resident's confusion, disorientation, and dizziness. Additionally, there was no documented evidence that the resident's nurse was notified of the resident's pain or dizziness, which was noted by the physical therapist. On 04/26/24, Resident #156 was ordered to have orthostatic hypotension checks, but there was no documented evidence that these checks were completed as ordered. The resident experienced a fall on 04/27/24, which was unwitnessed, and the subsequent investigation was incomplete. The fall investigation did not include a witness statement from the aide who found the resident on the floor, and neurological checks were not initiated despite the fall being unwitnessed. The documentation inaccurately stated that there was no noted drop in blood pressure from lying to standing, although no such measurements were taken. Interviews with facility staff revealed a lack of communication and follow-through regarding the resident's care and fall risk. The Director of Nursing confirmed that the fall investigation was improperly conducted and that necessary interventions and notifications were not completed. The facility's policy on fall prevention and management was not adhered to, as the care plan did not address all relevant risk factors, and the post-fall procedures were not followed.
Failure to Provide Scheduled Dialysis
Penalty
Summary
The facility failed to ensure that a resident requiring dialysis received treatment on scheduled days as per physician orders. The resident, who had a history of sepsis, pneumonia, type two diabetes mellitus with diabetic chronic kidney disease, and diabetic polyneuropathy, was dependent on renal dialysis. After being admitted to the facility from a hospital, the resident did not receive dialysis on the scheduled day of 04/22/24, despite having physician orders for dialysis on Monday, Wednesday, and Friday. The deficiency occurred due to a series of communication failures and misunderstandings. The Intake Coordinator for the dialysis company was informed that the resident had received dialysis on 04/21/24 at the hospital, which was incorrect. This misinformation led to the resident not being scheduled for dialysis on 04/22/24. Interviews with facility staff revealed that there was no proper verification of the resident's dialysis status upon admission, and the chaotic environment on the night of admission contributed to the oversight. Further investigation revealed that the resident's family had filed a complaint regarding the dialysis issues, and the resident was not properly approved for dialysis prior to admission due to insurance and scheduling issues. The Director of Nursing confirmed that the resident missed the scheduled dialysis session on 04/22/24, and the facility's policy on hemodialysis care and monitoring was not adequately followed, resulting in a lack of coordination and collaboration between the nursing home and the dialysis facility.
Medication Administration Errors in LTC Facility
Penalty
Summary
The facility failed to ensure that a resident received medications as per physician orders, resulting in significant medication errors. The resident, who had a complex medical history including sepsis, pneumonia, diabetes with chronic kidney disease, and dependence on renal dialysis, was admitted to the facility from a hospital. Upon admission, there was a lack of proper communication and verification of medication orders, leading to the resident not receiving the prescribed insulin glargine at the scheduled time. The insulin was available in the automated medication dispensing system, but due to delays in verifying orders, it was not administered. Additionally, the resident was prescribed intravenous cefazolin to be administered during dialysis sessions. However, there were inconsistencies in the documentation and administration of this medication. On one occasion, the cefazolin was not administered because the dialysis nurse was not informed by the facility nurses that it needed to be given. Furthermore, there was a lack of proper documentation on the Dialysis Hand Off Communication Reports, which contributed to the oversight in medication administration. Interviews with facility staff, including the Director of Nursing, Unit Manager, and nurses involved, revealed a breakdown in communication and adherence to medication administration protocols. The staff acknowledged the errors and the chaotic environment on the night of the resident's admission, which contributed to the oversight. The facility's policy on medication administration emphasizes the importance of verifying and administering medications as prescribed, but this was not followed, leading to the deficiency.
Failure to Provide Timely Incontinence Care
Penalty
Summary
The facility did not ensure timely incontinence care for Resident #131, who was dependent on staff for toileting and hygiene due to impaired cognition and physical limitations. On the day of the incident, the resident was left in a soiled condition for approximately seven hours, despite multiple requests from the charge nurse to the assigned State Tested Nursing Assistant (STNA) #606 to clean the resident. The STNA failed to provide the necessary care, citing being busy with other tasks and waiting for assistance from another aide who was also occupied. This resulted in the resident having bowel movement (BM) all over his body, hands, and bed by the time he was finally cleaned up in the late afternoon. The medical record for Resident #131 indicated that he had diagnoses including dementia, diabetes, hypertension, and heart failure, and was always incontinent of urine and frequently incontinent of bowel. The care plan specified that the resident required total assistance for toileting and hygiene and needed to be turned and repositioned every two hours to prevent skin breakdown. Despite these documented needs, the resident did not receive timely incontinence care on the day in question, as confirmed by multiple staff interviews and witness statements. The Director of Nursing (DON) verified that Resident #131 did not receive timely incontinence care on the specified date. The facility's policy on perineal care emphasized the importance of cleanliness, comfort, and infection prevention, but these standards were not met in this instance. The failure to provide timely care was documented in witness statements and an Employee Corrective Action Form, which indicated that the STNA received a final written warning for the policy violation and insubordination.
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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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