Green Meadows Skilled Nursing And Rehab
Inspection history, citations, penalties and survey trends for this long-term care facility in Louisville, Ohio.
- Location
- 7770 Columbus Road Ne, Louisville, Ohio 44641
- CMS Provider Number
- 365604
- Inspections on file
- 26
- Latest survey
- February 10, 2025
- Citations (last 12 mo.)
- 0
Citation history
Health deficiencies cited at Green Meadows Skilled Nursing And Rehab during CMS and state inspections, most recent first.
The facility did not hold a required Quality Assessment and Assurance (QA) meeting in the first quarter of 2024, as mandated by their policy. The absence of attendance sheets or documentation was confirmed by the DON and Administrator, potentially impacting all 89 residents.
A long-term care facility failed to maintain a comprehensive infection control program, including delayed COVID-19 reporting, lack of staff illness policy, missing water management logs, improper medication administration, and inadequate tracking of potential outbreak illnesses. Multiple residents exhibited flu-like symptoms, but the DON did not suspect an outbreak due to the absence of elevated temperatures.
The facility failed to complete consistent staff evaluations for two CNAs, potentially affecting all residents except those on the E wing. One CNA, hired in 2022, did not receive a 90-day or yearly evaluation in 2023, with only one evaluation on file from 2024. Another CNA, hired in 2024, lacked a 90-day evaluation. The HR/Personnel Manager confirmed these oversights but was unsure of the reasons.
The facility failed to maintain a homelike environment in the memory care unit by allowing a basin to collect water from a ceiling leak outside a resident's room for months and not addressing disrepair in the walls of several residents' rooms. The resident, with Alzheimer's and other health conditions, was at moderate risk of falling, and the basin partially blocked the doorway. The Maintenance Supervisor admitted that maintenance issues were only addressed through a work order system, compromising the facility's policy on resident rights.
A resident with multiple medical conditions and a risk for falls was found on the floor after adjusting his lift chair. The facility removed the chair's remote to prevent further falls, but did not conduct a restraint assessment, violating regulations that require residents to be free from physical restraints unless medically necessary.
A facility failed to complete a Significant Change MDS assessment for a resident within 14 days of starting hospice care. The resident, with multiple health issues, began hospice services as ordered by a physician, but the required assessment was not documented. This was confirmed by the DON.
The facility failed to ensure accurate comprehensive assessments for two residents, leading to documentation deficiencies. One resident was admitted with a Stage III pressure ulcer, but MDS assessments inaccurately indicated no ulcer. Another resident with hearing loss and prescribed Ativan for anxiety was inaccurately assessed as having adequate hearing and no anti-anxiety medication use. These discrepancies were confirmed by the DON.
The facility failed to develop comprehensive care plans for three residents, resulting in unaddressed medical needs. A resident receiving oxygen lacked a care plan for its use, another with constipation and diarrhea had no care plan for gastrointestinal issues, and a third with hearing loss and dialysis access had incorrect care plan details. These deficiencies were confirmed through observations and staff interviews.
The facility failed to provide proper respiratory care and documentation for two residents. One resident received oxygen without physician's orders or a care plan, and the oxygen tubing was not dated. Another resident's oxygen cannula was improperly stored on a wheelchair without a protective bag. These issues were confirmed by staff interviews and observations.
The facility failed to monitor vital signs and weights for two residents requiring dialysis, and did not maintain adequate communication with an outside dialysis center. This resulted in missing documentation of critical health metrics and communication forms, as confirmed by the DON and Dialysis Administrative Assistant.
The facility failed to date multi-dose insulin pens when first accessed, affecting three residents prescribed insulin. Observations revealed that insulin pens for these residents were not dated, and interviews with LPNs confirmed this oversight. The facility's policy requires recording the date of opening on multi-dose containers, which was not followed.
A facility failed to ensure a physician order was written before obtaining a lab test for a resident with diabetes and stroke. Despite a pharmacy recommendation for HgbA1c monitoring every three months, tests were conducted in three consecutive months without a physician order. The DON confirmed the absence of an order for the December test, noting the resident's multiple doctors sometimes ordered tests outside the office.
The facility failed to maintain accurate and complete medical records for three residents. A resident with quadriplegia was incorrectly documented as performing ADLs independently. Another resident's bowel movement records were incomplete, and a third resident's pain management records lacked documentation of non-pharmacological interventions. These deficiencies were confirmed by the DON, an LPN, and the ADON.
A resident with multiple medical conditions was involved in an altercation with a nurse, leading to allegations of verbal abuse. The facility failed to conduct a thorough investigation, as required by its policy, by not interviewing the resident or potential witnesses and allowing the accused nurse to continue working. The investigation relied on unsigned staff statements and lacked proper documentation, resulting in a deficiency.
A facility failed to remove a fall hazard outside a resident's doorway, where a yellow basin and wet floor sign were placed to collect water from a ceiling leak. The resident, at moderate risk of falling and using a rollator, had to maneuver around these obstacles. Staff confirmed the hazard's presence for months, and the Maintenance Supervisor admitted to not fixing the leak promptly.
A facility failed to provide a resident with nectar thick liquids as ordered, due to staff not following the manufacturer's instructions for thickening liquids. This affected a resident with dysphagia and had the potential to impact other residents on thickened liquid diets.
A facility failed to administer narcotic pain medication according to physician orders and did not encourage non-pharmacologic interventions before medication administration. A resident with multiple diagnoses received hydrocodone-acetaminophen for pain levels less than five, contrary to the order for pain levels between five and ten. The DON confirmed the inappropriate administration and lack of documentation for non-pharmacologic interventions, highlighting non-compliance with facility policies.
The facility's Quality Assurance policy was found deficient as it lacked comprehensive procedures, including the role of the Infection Control Preventionist, feedback mechanisms, and monitoring systems. The policy did not address how performance improvements would be evaluated and sustained, affecting all 89 residents. This was confirmed by the Director of Nursing and the Administrator.
The facility failed to provide bed hold notices to two residents before their hospital transfers. One resident, with multiple serious diagnoses, was transferred four times without receiving a notice, as the Business Office Manager only issued notices to Medicaid residents. Another resident with end-stage renal disease was also transferred without a notice, contrary to the facility's policy.
Two residents were affected by the misappropriation of narcotic medications by an LPN, who diverted 55 oxycodone tablets from one resident and one Norco tablet from another. The incident was discovered when a narcotic card was found missing, leading to the LPN's admission of diversion. The facility's policy on abuse prevention was violated, resulting in a deficiency that was later corrected.
Failure to Conduct Required QA Meeting in First Quarter of 2024
Penalty
Summary
The facility failed to conduct a Quality Assessment and Assurance (QA) meeting during the first quarter of 2024, which is a requirement as per their policy dated September 2021. This policy mandates that the QA committee meet at least quarterly to identify and address quality assessment and assurance issues. Upon review, no attendance sheets or documentation were provided to confirm that such a meeting took place in the specified period. The Director of Nursing (DON) and the Administrator both verified the absence of records indicating that a QA meeting was held during this time. This deficiency had the potential to affect all 89 residents in the facility.
Infection Control Deficiencies in LTC Facility
Penalty
Summary
The facility failed to maintain a comprehensive infection prevention and control program, as evidenced by several deficiencies. The facility did not report a positive COVID-19 case for Resident #235 to the local health department (LHD) in a timely manner. The resident tested positive on January 26, 2025, but the LHD was not notified until February 4, 2025, which was nine days later. The Director of Nursing (DON) acknowledged the delay and could not provide evidence of an earlier notification attempt. The facility also lacked a policy for managing staff illness. Interviews revealed that management staff had been ill, but there was no clear guidance on when staff should stay home. The Administrator and Assistant Director of Nursing (ADON) confirmed the absence of a policy, and the facility defaulted to CDC guidelines, which recommend staying home for 24 to 48 hours after symptoms improve. This lack of policy could lead to inconsistent handling of staff illnesses. Additionally, the facility did not maintain water management logs for 2023, as confirmed by the Maintenance Director. There was also an observation of improper medication administration, where a Licensed Practical Nurse (LPN) failed to clean the rubber seal of a multi-use insulin pen before use. Furthermore, there was no tracking or trending of potential outbreak illnesses, despite multiple residents exhibiting flu-like symptoms. The DON did not suspect an outbreak due to the absence of elevated temperatures, but several residents reported symptoms such as vomiting and diarrhea within a short period, raising concerns about infection control practices.
Inconsistent Staff Evaluations for CNAs
Penalty
Summary
The facility failed to consistently complete staff evaluations for two Certified Nursing Assistants (CNAs), which had the potential to affect all residents except those on the E wing where the CNAs had not worked. CNA #367, hired on 11/09/22, did not receive a 90-day or yearly evaluation in 2023, with the only evaluation on file dated 11/14/24. An interview with the Human Resources (HR) / Personnel Manager confirmed the absence of these evaluations and was unsure why they were missed. Similarly, CNA #370, hired on 10/07/24, did not have a 90-day evaluation in her file, which was also confirmed by HR/Personnel Manager #316, who was uncertain about the reason for the oversight.
Facility Fails to Maintain Homelike Environment in Memory Care Unit
Penalty
Summary
The facility failed to maintain a homelike environment in the E wing, specifically in the memory care unit, by allowing a basin to collect water from a ceiling leak outside a resident's room for an extended period. This issue persisted for months, as confirmed by staff interviews, and was not addressed promptly. The resident, who had Alzheimer's disease and other health conditions, was at moderate risk of falling, and the basin partially blocked the doorway, posing a potential hazard. Additionally, the facility did not maintain the walls in several residents' rooms, which were in disrepair with gouges and marks that removed or peeled back the paint. These conditions were observed in nine residents' rooms, affecting the overall homelike atmosphere of the unit. Family members and staff confirmed that the state of the walls was not homelike and would not be acceptable in a home setting. The Maintenance Supervisor acknowledged the issues during an environmental tour and admitted that maintenance concerns were only addressed through a work order system, which did not include regular tours to identify problems. The facility's policy on resident rights emphasizes a dignified existence, which was compromised by the conditions observed in the memory care unit.
Failure to Ensure Resident is Free from Physical Restraints
Penalty
Summary
The facility failed to ensure that Resident #82 was free from physical restraints, as required by regulations. Resident #82, who had multiple medical conditions including metabolic encephalopathy, respiratory failure, and diabetes, was at risk for falls due to incontinence, decreased strength, and poor balance. The care plan included various interventions to prevent falls, such as using a bed alarm and keeping the bed in the lowest position. However, after an incident where the resident was found on the floor with the lift chair in a high position, the facility decided to place the lift chair remote in a pocket to discourage the resident from adjusting it. This action was taken without conducting a restraint assessment, which is necessary to determine if the intervention restricts the resident's freedom of movement. The Director of Nursing confirmed that the remote was taken away as an intervention to prevent the resident from falling out of the chair, as he lacked the strength to remain seated when the chair was adjusted. Despite the facility's policy stating that restraints should not be used for fall prevention and only after other alternatives have been tried unsuccessfully, the remote was removed without proper assessment. The facility's policy defines a physical restraint as any device that restricts freedom of movement and cannot be easily removed by the resident, which was applicable in this case as the resident could not access the remote to adjust the chair independently.
Failure to Complete Significant Change Assessment for Hospice Resident
Penalty
Summary
The facility failed to complete a Significant Change Minimum Data Set (MDS) assessment for a resident within 14 days of initiating hospice services. The resident, who was admitted with multiple diagnoses including cerebral infarction, protein-calorie malnutrition, and heart failure, among others, began receiving hospice care as per a physician's order dated January 12, 2025. However, a review of the medical record showed no evidence of the required assessment being completed within the specified timeframe. This deficiency was confirmed during an interview with the Director of Nursing on February 10, 2025.
Inaccurate Comprehensive Assessments for Two Residents
Penalty
Summary
The facility failed to ensure accurate comprehensive assessments for two residents, leading to deficiencies in their care documentation. Resident #82 was admitted with a Stage III pressure ulcer to the sacrum, as noted in a wound evaluation. However, both the Admission and Discharge Minimum Data Set (MDS) assessments inaccurately indicated that the resident did not have a pressure ulcer. This discrepancy was confirmed by the Director of Nursing during an interview, highlighting a failure in accurately documenting the resident's condition upon admission and discharge. Resident #44's comprehensive assessment also contained inaccuracies. The resident, who had profound hearing loss in the right ear and moderately severe high-frequency sensorineural hearing loss in the left ear, was inaccurately assessed as having adequate hearing. Additionally, the resident was prescribed Ativan for anxiety, which was administered on specific dates, yet the MDS assessment failed to reflect the use of anti-anxiety medication. The Director of Nursing confirmed these inaccuracies, indicating a failure to accurately document the resident's hearing status and medication use.
Failure to Develop Comprehensive Care Plans for Residents
Penalty
Summary
The facility failed to develop comprehensive care plans for three residents, leading to deficiencies in addressing their specific medical needs. Resident #67, who was admitted with conditions including pulmonary embolism and heart failure, was observed receiving oxygen via nasal cannula on multiple occasions. However, there were no physician orders or care plans in place for the use and maintenance of oxygen equipment, as confirmed by interviews with the LPN and the Director of Nursing (DON). Resident #71, diagnosed with multiple conditions including cerebral infarction and constipation, had physician orders for various medications to manage constipation and diarrhea. Despite this, there was no care plan addressing these gastrointestinal concerns. The resident reported experiencing constipation for several days at a time and occasionally required assistance with toileting. Interviews with the resident and a CNA confirmed these issues, and the DON verified the absence of a care plan for these concerns. Resident #44, with diagnoses including end-stage renal disease and hearing loss, had no care plan addressing their profound hearing impairment or the correct dialysis access site. The resident had a history of ear wax removal and hearing difficulties, which were not reflected in the care plan. Additionally, the care plan incorrectly focused on a dialysis catheter instead of the left upper arm fistula, which was the actual access site in use. Interviews with the resident, DON, and Assistant Director of Nursing confirmed these discrepancies.
Deficiencies in Respiratory Care and Documentation
Penalty
Summary
The facility failed to ensure proper respiratory care for Resident #67, who was admitted with diagnoses including pulmonary embolism, heart failure, hypertension, and type two diabetes mellitus. There were no physician's orders for oxygen use or maintenance of oxygen equipment, and the care plan did not include oxygen use. Observations on two separate days revealed Resident #67 was receiving oxygen via nasal cannula, but the oxygen tubing was not dated. Interviews with the LPN and the Director of Nursing confirmed the absence of orders and a care plan for oxygen use, as well as the lack of documentation for oxygen administration on specific dates. Additionally, the facility did not properly store the oxygen cannula for Resident #2, who had multiple diagnoses including cerebral infarction and heart failure. An observation showed the portable oxygen tank nasal cannula was hanging on the back of the resident's wheelchair without a protective bag. This was verified by the Director of Nursing. The facility's policy, dated September 2021, required a physician's order to determine the need for oxygen, which was not followed in these cases.
Deficiencies in Dialysis Care and Communication
Penalty
Summary
The facility failed to provide adequate dialysis care and services for two residents, leading to deficiencies in monitoring vital signs and weights before and after dialysis sessions. Resident #52, who was admitted with diagnoses including end-stage renal disease, type two diabetes mellitus, dependence on renal dialysis, and heart failure, had multiple instances where vital signs and weights were not documented on dialysis days. Specific dates were noted where pre-dialysis vital signs, weights, and other critical health metrics were missing from the records, indicating a lack of adherence to the physician's orders and facility protocols. Similarly, Resident #239, also diagnosed with end-stage renal disease and other chronic conditions, experienced lapses in documentation of vital signs and weights associated with dialysis treatments. The facility failed to maintain proper communication with the outside dialysis center, as evidenced by missing dialysis communication forms on several occasions. This lack of documentation and communication was confirmed through interviews with the Director of Nursing and the Dialysis Administrative Assistant, who acknowledged the inconsistencies in sending and receiving the necessary forms. The facility's dialysis services and coordination agreement required staff to provide a dialysis communication form with each resident, listing vital signs, weights, and any changes in condition. However, this protocol was not consistently followed, leading to gaps in the residents' medical records. The Director of Nursing verified these deficiencies, highlighting a systemic issue in the facility's management of dialysis care and communication with external providers.
Failure to Date Multi-Dose Insulin Pens
Penalty
Summary
The facility failed to ensure that multi-dose insulin pens were dated when first accessed, affecting three residents who were prescribed insulin. During medication administration observations, it was noted that a Humulin 70/30 Kwikpen and a Lantus SoloStar pen for two residents, as well as a Novolin 70/30 FlexPen for another resident, were not dated. Interviews with the LPNs administering the medications confirmed the absence of dates on the insulin pens. The facility's policy on administering medications requires that the date of opening be recorded on multi-dose containers, but this was not adhered to in these instances.
Failure to Obtain Physician Order for Lab Test
Penalty
Summary
The facility failed to ensure a physician order was written prior to obtaining a laboratory test for a resident. The resident, who had diagnoses including type two diabetes mellitus and stroke, was cognitively intact and had medication orders for diabetes management. A pharmacy recommendation requested monitoring of HgbA1c every three months. However, HgbA1c levels were obtained in October, November, and December without a corresponding physician order. The Director of Nursing (DON) confirmed the absence of an order for the December test, explaining that the resident saw multiple doctors who sometimes ordered lab tests outside the office.
Incomplete and Inaccurate Medical Records for Residents
Penalty
Summary
The facility failed to ensure the accuracy and completeness of medical records for three residents. For one resident with quadriplegia, the medical records inaccurately documented that the resident independently performed transfers and bathing, despite being dependent on staff for all activities of daily living (ADLs). This discrepancy was confirmed by the Director of Nursing (DON) during an interview. Another resident reported issues with constipation, and the review of bowel movement records revealed incomplete documentation, with missing entries for specific shifts, which was also verified by the DON. Additionally, the facility did not document non-pharmacological interventions attempted before administering pain medications to a resident with multiple medical diagnoses, including end-stage renal disease. The medication administration record (MAR) showed the administration of pain relievers, but there was no documentation of the specific non-pharmacological interventions attempted, as required by the physician's orders. This lack of documentation was confirmed during interviews with a Licensed Practical Nurse (LPN) and the Assistant Director of Nursing (ADON).
Inadequate Investigation of Alleged Verbal Abuse
Penalty
Summary
The facility failed to ensure the protection of a resident during an investigation of alleged emotional/verbal abuse and did not conduct a thorough investigation into the allegations. The incident involved a resident with multiple medical conditions, including systemic lupus erythematosus, osteomyelitis, right-sided weakness following a stroke, stage four kidney disease, and heart disease. The resident was reported to have been aggressive with a phlebotomist during a blood draw, leading to an altercation with a nurse, who was later accused of verbal abuse. The facility's investigation was inadequate, as it did not include a documented interview with the resident or other potential witnesses, such as the phlebotomist. The nurse accused of abuse was allowed to continue working during the investigation, contrary to the facility's policy, which required immediate suspension of any employee accused of abuse. The investigation relied on unsigned statements from staff members, and there was no evidence of attempts to contact the phlebotomist for an interview. The facility's policy required thorough investigation and documentation of all allegations of abuse, including interviews with witnesses and involved parties. However, the investigation lacked proper documentation and failed to follow the established procedures, resulting in a deficiency. The lack of documentation and failure to suspend the accused nurse during the investigation were significant oversights in the facility's handling of the incident.
Failure to Remove Fall Hazard Outside Resident's Doorway
Penalty
Summary
The facility failed to ensure that the area outside Resident #55's doorway was free from potential fall hazards. Resident #55, who was at moderate risk of falling due to conditions such as Alzheimer's disease, COPD, and an unsteady gait, had a yellow plastic basin and a wet floor sign blocking part of his doorway. These items were placed to collect water from a ceiling leak, creating a potential fall hazard. Despite the resident's cognitive impairment and need for supervision when walking, the basin and sign remained in place for months, requiring the resident to maneuver around them with his rollator. Interviews with staff confirmed the presence of the basin and sign for an extended period, with no immediate action taken to address the leak or remove the hazard. The Maintenance Supervisor acknowledged the ongoing leak and admitted to not calling a roofer to fix it, despite the issue persisting for about a month or two. The facility's policy on falls, which mandates identifying interventions to reduce fall risks, was not adhered to in this instance, leading to the deficiency being cited under Complaint Number OH00161264.
Failure to Provide Nectar Thick Liquids as Ordered
Penalty
Summary
The facility failed to ensure that Resident #42 received nectar thick liquids as ordered, which was necessary due to the resident's medical conditions, including oropharyngeal dysphagia, dementia, and schizophrenia. The resident's care plan and physician orders specified a diet of mechanical soft texture and nectar thick consistency liquids. However, during an observation, it was noted that the coffee provided to Resident #42 was not of the correct nectar thick consistency. Certified Nursing Assistant #368 confirmed that she had not added the correct amount of thickening product to achieve the required consistency, as per the manufacturer's instructions. Interviews with staff, including a Speech Language Pathologist and a Licensed Practical Nurse, revealed that there was a misunderstanding or lack of adherence to the manufacturer's instructions for preparing nectar thick liquids. The staff had been using an incorrect amount of thickener, resulting in liquids that were too thin for residents requiring nectar thick consistency. This deficiency was identified during a complaint investigation and had the potential to affect other residents on thickened liquids diets.
Inappropriate Administration of Narcotic Pain Medication
Penalty
Summary
The facility failed to ensure that narcotic pain medications were administered according to physician orders and that non-pharmacologic pain relief interventions were encouraged prior to medication administration. This deficiency affected a resident with multiple diagnoses, including end-stage renal disease, muscle weakness, spondylolisthesis, osteoarthritis, hydronephrosis, and chronic gout. The resident's care plan indicated a potential for pain related to these conditions, with interventions including administering medications per physician orders. However, the resident's January 2025 Medication Administration Record (MAR) showed that hydrocodone-acetaminophen was administered for pain levels less than five, contrary to the physician's order, which specified administration for pain levels between five and ten. The Director of Nursing (DON) confirmed that the medication was given inappropriately for pain levels less than five and acknowledged that non-pharmacologic interventions should have been tried and documented before administering the medication. The facility's policy on pain assessment and management emphasized recognizing pain, implementing management approaches, and using specific strategies for different pain levels. Additionally, the facility's policy on administering medications required adherence to physician orders. The deficiency was identified during a complaint investigation, indicating non-compliance with the facility's policies and procedures.
Deficiency in Quality Assurance Policy and Procedures
Penalty
Summary
The facility failed to establish comprehensive written policies and procedures related to the Quality Assurance (QA) process, which had the potential to affect all 89 residents. The existing Quality Assessment and Assurance policy, dated September 2021, outlined that the committee would include the Administrator, the Director of Nursing Services, a physician designated by the facility, and other staff members. This committee was tasked with identifying issues affecting the quality of care and services provided to residents, meeting at least quarterly to address these issues, and developing and implementing corrective plans for identified deficiencies. However, the policy was found lacking in several critical areas. The policy did not include the role or participation of the Infection Control Preventionist (ICP) in the QA process. Additionally, it failed to address procedures for feedback, data collection, and monitoring, including adverse event monitoring. The policy also lacked information on how actions taken to ensure performance improvement would be evaluated and tracked to ensure that improvements were realized and sustained. These deficiencies were confirmed by the Director of Nursing and the Administrator, who verified that the facility did not have any additional policies regarding QA beyond the corporate policy from September 2021.
Failure to Provide Bed Hold Notices Before Hospital Transfers
Penalty
Summary
The facility failed to provide bed hold notices to two residents, Resident #52 and Resident #82, prior to their transfers to the hospital. Resident #82, who had multiple diagnoses including metabolic encephalopathy and respiratory failure, was discharged to the hospital on four occasions without receiving a bed hold notice. The Business Office Manager admitted that bed hold notices were only given to Medicaid residents, which resulted in Resident #82 not receiving the required notice. Additionally, a family member of Resident #82 confirmed that they did not recall receiving any bed hold notice during the hospital transfers. Similarly, Resident #52, who had diagnoses such as end-stage renal disease and heart failure, was transferred to the hospital without a bed hold notice being provided. The Business Office Manager confirmed that Resident #52 did not receive a bed hold notice at the time of transfer. The facility's policy, dated September 2021, stated that a copy of the bed hold policy should be provided to the resident and their family or legal representative before and during a transfer for hospitalization or therapeutic leave, which was not adhered to in these cases.
Medication Misappropriation by LPN
Penalty
Summary
The facility failed to protect residents from the misappropriation of medications, specifically affecting two residents. Resident #20, who was admitted with chronic pulmonary edema, disorganized schizophrenia, and chronic respiratory failure with hypercapnia, had an order for oxycodone 5 mg to be administered as needed for pain. Similarly, Resident #28, admitted with end-stage renal disease, diabetes, and chronic gout, had an order for Hydrocodone-acetaminophen (Norco) 5-325 mg for pain management. The deficiency was identified when a Licensed Practical Nurse (LPN) reported the diversion of narcotic medications. The incident came to light when LPN #826 noticed a missing narcotic card and reported it to the nurse supervisor. Subsequently, LPN #964 admitted to diverting a total of 55 oxycodone tablets from Resident #20 and one Norco tablet from Resident #28. This admission was made to the Director of Nursing (DON) after the LPN had already left the facility. The facility's records and interviews confirmed the misappropriation of medications, which was substantiated by a self-reported incident (SRI) and further investigation by a criminal investigator. The facility's Abuse Prevention Program policy emphasizes the residents' right to be free from abuse, neglect, and misappropriation of property. However, the actions of LPN #964 violated this policy, leading to the misappropriation of narcotics intended for residents' pain management. The deficiency was identified as an incident of past noncompliance that was corrected prior to the survey, but it highlighted a significant lapse in the facility's medication administration and monitoring processes.
Latest citations in Ohio
A resident with intact cognition receiving Medicare Part A skilled services for metabolic encephalopathy had services discontinued while benefit days remained, but the facility did not issue the required Skilled Nursing Facility Advance Beneficiary Notice (SNF ABN). The Social Services Director later confirmed that no SNF ABN was provided and reported she believed only a Notice of Medicare Non-Coverage (NOMNC) was needed when all skilled services were stopped. This practice conflicted with the facility’s written policy, which required SNF ABNs to be issued when extended care items or services were initiated, reduced, or terminated due to expected non-coverage by Medicare.
Surveyors identified that the facility exceeded the acceptable medication error rate when two residents with type 2 DM received insulin doses that were not administered according to orders or manufacturer instructions. In two separate observations, an LPN administered Novolog and another LPN administered insulin glargine and insulin lispro without priming the insulin pens, and the insulin lispro and Novolog were given after the residents had already consumed a significant portion of their breakfast meals, despite orders for administration before meals. Manufacturer information for both insulin products required priming before each injection to ensure accurate dosing, and facility policy required medications, including insulin, to be administered safely, timely, and in accordance with prescriber orders and specified time frames.
Surveyors found that the facility failed to document tray line food temperatures for multiple meals served from two dining room kitchenettes, despite having a “Trayline Taste & Temperature Log” and a policy requiring food to be stored, prepared, distributed, and served according to professional food safety standards. Review of logs showed repeated missing entries for breakfast, lunch, and dinner services in both the Harrison and McClellan dining areas, and the Senior Director of Culinary Services confirmed that temperatures had not been recorded for those meals, potentially affecting all residents receiving meals from those kitchenettes.
The facility failed to conduct and document required periodic care conferences for two residents, despite multiple comprehensive, quarterly, and significant change MDS assessments and a policy requiring periodic care conferences with resident and/or family participation. One resident with Parkinson’s disease, post-stroke hemiplegia, TIA, DMII, and depression had only two documented care conferences over a year, while another resident with aphasia, cerebrovascular disease, DMII, gait difficulty, coagulation defect, depression, and muscle weakness had no documented care conferences in the past year, aside from a declined invitation to the representative. The UCC confirmed that care conferences were expected to occur quarterly and that no additional documentation existed for either resident.
A resident with Alzheimer's disease and type II DM, who required extensive assistance with ADLs and was receiving scheduled Lantus and sliding-scale Humalog, experienced a severely elevated blood glucose level. The on-call provider was notified and ordered an additional dose of lispro insulin with a directive to recheck the blood glucose after administration. Nursing staff administered the extra insulin but did not document any follow-up blood glucose check, and the DON confirmed that this reevaluation was required by the facility's abnormal blood glucose policy and was not completed or documented.
A resident with Parkinson’s disease, dementia, and hypothyroidism was prescribed levothyroxine once daily along with other medications. A consultant pharmacist’s monthly drug regimen review recommended that levothyroxine be given in the morning on an empty stomach, 30–60 minutes before food, per manufacturer instructions. The medical record contained no documented physician response to this recommendation, and the MAR showed the drug scheduled for morning administration while the resident was observed eating breakfast and receiving the medication at the same time. An LPN confirmed administering levothyroxine during the meal, and the DON verified there was no documentation explaining whether or why the pharmacist’s recommendation was or was not followed, resulting in a failure to act on and document the identified irregularity.
A resident with severe cognitive impairment, multiple comorbidities, documented gait and balance abnormalities, and a high fall risk was care planned and assessed by therapy to require contact guard assistance and use of a gait belt for transfers and ambulation. While being assisted by a CNA from a recliner to the bathroom with a walker, the CNA did not apply a gait belt, even though the resident had a known tendency to lean backward when standing. As the CNA reached to open the bathroom door, the resident lost balance and fell backward, striking the back of the head, and was later found by an LPN without a gait belt in place, contrary to the facility’s gait belt policy and the resident’s assessed needs.
A resident with CKD stage five requiring peritoneal dialysis (PD) was admitted with pre-admission physician orders for three daily PD exchanges and monitoring for peritonitis (fever, abdominal pain, cloudy effluent), but these monitoring orders were not entered into the facility’s physician orders. The care plan referenced PD and general monitoring but did not specifically address peritonitis monitoring. Paper PD flowsheets showed incomplete and inconsistent documentation of exchanges and resident condition, including missing condition/comments for individual treatments and no record of one ordered PD exchange. The PD cycler flowsheet lacked effluent descriptions on multiple days. The PD nurse reported facility staff were expected to monitor effluent and symptoms, and the DON confirmed the absence of specific peritonitis monitoring orders, lack of an order for the PD cycler, and documentation gaps, despite a facility policy requiring ongoing assessment and monitoring for complications before, during, and after dialysis treatments.
A nurse was observed preparing multiple oral medications for a resident with depression, traumatic brain injury, anxiety, and impaired cognition by pushing tablets and capsules from unit-dose cards directly into her ungloved hand and then using her fingers to place them into a medication cup. In a follow-up interview, the RN confirmed this practice and acknowledged that the correct procedure is to dispense medications directly from the card into the cup, contrary to the facility’s medication administration policy requiring adherence to good nursing principles and practices.
A resident with Alzheimer’s disease, diabetes, anxiety, significant ADL dependence, and behavioral symptoms was observed seated in a chair positioned against the nursing station with a locked wheelchair placed directly in front, also against the nursing station, effectively restricting movement. An LPN confirmed both wheelchair wheels were locked and that it should not have been placed there, while a CNA stated she had positioned the wheelchair to prepare for lunch, was unable to complete the transfer, and left it in place, acknowledging this was wrong. This arrangement conflicted with the facility’s restraint policy, which prohibits physical restraints except when alternatives are ineffective for treating a medical symptom and defines restraints as devices adjacent to the body that cannot be easily removed and that restrict freedom of movement or access to the body.
Failure to Issue Required SNF ABN When Discontinuing Medicare Part A Services
Penalty
Summary
The deficiency involves the facility’s failure to issue a Skilled Nursing Facility Advance Beneficiary Notice (SNF ABN) when Medicare Part A services were discontinued for a resident who still had available benefit days. The resident was admitted with a diagnosis of metabolic encephalopathy and had intact cognition per the Minimum Data Set assessment. The facility’s own SNF Beneficiary Notification Review documented that Medicare Part A skilled services began on 02/11/26 and the last covered day was 03/11/26, and that the facility initiated discharge from Medicare Part A services before the resident’s benefit days were exhausted. Despite this, no SNF ABN was provided to the resident or the resident’s representative. During interviews, the Social Services Director stated that the SNF ABN was issued hours prior to the last covered day but, upon reviewing her files, confirmed that no SNF ABN had actually been issued for this resident. She further explained that she believed an SNF ABN was only required if one skilled service remained and that if all skilled services were being discontinued, only the Notice of Medicare Non-Coverage (NOMNC) needed to be issued. The Administrator, however, stated that a resident should always receive both a SNF ABN and a NOMNC when Medicare Part A services are discontinued and benefit days remain. Review of the facility’s written policy dated 03/28/23 showed that the facility was required to issue SNF ABNs for initiation, reduction, or termination of extended care items or services when Medicare payment was not expected, which did not occur in this case.
Plan Of Correction
This Plan of Correction is submitted as required under State and Federal law. This Plan of Correction does not constitute an admission on the part of the Facility that the findings cited are accurate, that the findings constitute a deficiency or that the scope and severity regarding the deficiency cited are correctly applied. Any changes to the Facility's policies and procedures should be inadmissible in any proceeding on that basis. Without admitting or denying the validity or the existence of the alleged noncompliance, the Facility submits this Plan of Correction with the intention that it be inadmissible by any third party in any civil or other action against the facility or any employee, agent, officer, director or shareholder of the Facility. The Facility is utilizing this Plan of Correction as its allegation of substantial compliance as of 05/29/2026 F-0582 Corrective action for resident/s: On 5/14/26 Resident #34 was informed of rights and responsibilities related to Advanced Beneficiary Notice and voiced understanding of information for future reference by administrator. Identification of other residents who may be affected: Any resident receiving skilled services from nursing or therapy services. The Administrator audited all residents who were discharged from skilled services in the past 30 days to ensure they were issued a Notice of Non-Coverage and Advanced Beneficiary Notice on 5/29/26. No non-compliance was noted. Measures for systemic change: On 5/14/2026 Business Office Manager, Director of Rehab, Minimum Data Set nurse, Director of Nursing and Social Services Director were educated on proper procedure of issuing of Notice Of Medicare Non Coverage and Advanced Beneficiary Notice by administrator. All upcoming discharges from skilled services will be reviewed weekly at Utilization Review meeting to ensure notices will be delivered timely. How Corrective Action will be monitored: Administrator or designee to complete audits of all residents being discharged from skilled services to ensure they were issued a Notice of Non-Coverage and Advanced Beneficiary. This audit will be completed weekly x 4 weeks, then monthly x 2 months. Corrective action will be initiated for any noted non-compliance. Audit findings will be reviewed as part of the monthly quality assurance process to determine the need for further monitoring. Date of Compliance 5/29/26
Insulin Administration Errors and Failure to Prime Insulin Pens
Penalty
Summary
The deficiency involves the facility’s failure to maintain a medication error rate below 5%, with surveyors identifying 3 errors out of 28 medication administration opportunities, resulting in a 10.71% error rate. For one resident with type 2 diabetes mellitus and moderate cognitive impairment, the physician’s order directed Novolog insulin 10 units via subcutaneous pen-injector to be given before meals. During an observed medication pass, the LPN administered 10 units of Novolog insulin without priming the pen and did so after the resident had already consumed approximately 50% of the breakfast meal. The LPN later confirmed she did not prime the pen and acknowledged that the insulin was ordered to be administered prior to meals. Manufacturer instructions for the Novolog FlexPen specified that an air shot (priming) must be performed before each injection to ensure proper dosing. Another resident, also diagnosed with type 2 diabetes mellitus and with intact cognition, had orders for insulin glargine 35 units subcutaneously twice daily and insulin lispro 20 units subcutaneously before meals, plus 12 units subcutaneously if blood glucose was between 251 mg/dL and 300 mg/dL. During an observed medication administration, an LPN administered 35 units of insulin glargine and 32 units of insulin lispro without priming the insulin pens and after the resident had consumed approximately 90% of the breakfast meal, despite orders for insulin lispro to be given before meals. The LPN later stated she could not remember if she had primed the pen and acknowledged that the insulin was ordered to be administered prior to meals. Manufacturer information for insulin lispro stated that the pen must be primed before each injection to confirm insulin delivery and remove air, and that failure to prime could result in too much or too little insulin. The DON confirmed the expectation that insulin be administered as ordered, including priming each pen with two units before dialing the prescribed dose, and facility policy required medications, including insulin, to be administered safely, timely, and in accordance with prescriber orders and required time frames.
Plan Of Correction
This Plan of Correction is submitted as required under State and Federal law. This Plan of Correction does not constitute an admission on the part of the Facility that the findings cited are accurate, that the findings constitute a deficiency or that the scope and severity regarding the deficiency cited are correctly applied. Any changes to the Facility's policies and procedures should be inadmissible in any proceeding on that basis. Without admitting or denying the validity or the existence of the alleged noncompliance, the Facility submits this Plan of Correction with the intention that it be inadmissible by any third party in any civil or other action against the facility or any employee, agent, officer, director or shareholder of the Facility. The Facility is utilizing this Plan of Correction as an allegation of substantial compliance as of 5/29/2026. F-0759 Corrective action for resident/s: Residents #21 and #22 were assessed and evaluated by nurse and Director of Nursing 5/14/26. Resident #21 and #22 both denied any adverse effects and none were noted upon assessment by the Director of Nursing on 5/14/2026. Notification made to physician on 5/14/2026. LPN # 2 competency Eval on insulin administration with the Director of Nursing completed 5/14/2026. Identification of other residents who may be affected: Diabetic residents on assignment of LPN #2/station 2 have the potential to be affected and were assessed by the DON/Designee on 5/14/26 and found to be within normal limits. Measures for systemic change: All Nurses were educated by the Director of Nursing on the steps for Insulin administration per competency, diabetes clinical protocol policy, Medication and treatment orders policy, administering medications policy, and Obtaining fingerstick Glucose Level policy On 5/14/2026. How Corrective Action will be monitored: Director of Nursing and Assistant Director of Nursing will complete insulin administration audits on 5 nurses. This audit will be completed weekly x 4 weeks, then monthly x 2 months. Corrective action will be initiated for any noted non-compliance. Audit findings will be reviewed as part of the monthly quality assurance process to determine the need for further monitoring. Date of Compliance: 5/29/2026
Failure to Document Tray Line Food Temperatures in Dining Room Kitchenettes
Penalty
Summary
The deficiency involves the facility’s failure to document tray line food temperatures for meals served from the Harrison and McClellan Dining Room kitchenettes, as required by professional standards for food service safety and the facility’s own policy. Review of the “Trayline Taste & Temperature Log” (revised September 2018) showed missing temperature documentation for multiple meals from the Harrison Dining Room kitchenette, including dinner on 03/30/26 and 03/31/26, lunch and dinner on 04/01/26 and 04/02/26, dinner on 04/07/26, and lunch and dinner on 04/08/26 and 04/10/26. The Senior Director of Culinary Services confirmed during interview that tray line food temperatures were not documented on the log for these meals. Similarly, review of the same log for the McClellan Dining Room kitchenette revealed that tray line food temperatures were not documented for dinner on 04/01/26, breakfast and lunch on 04/02/26, and lunch and dinner on 04/07/26. The Senior Director of Culinary Services also verified these omissions during interview. The facility census at the time was 27 residents, and the governing “Food and Nutrition” policy, approved on 09/07/21, stated that the facility must store, prepare, distribute, and serve food in accordance with professional standards for food service safety.
Plan Of Correction
F812 The facility will continue to ensure food temperatures are completed before meals are served for all residents. To ensure compliance with this standard the following measures have been taken: 1. Immediately 4/15/26 culinary supervisor #224 was re-educated by Dietary Manager to this standard and policy "Food and Nutrition" which includes documentation of food temperatures. 2. All dietary staff have been re-educated to the standard and policy "Food and Nutrition" during the month of April 2026. 3. Audits of food temperature documentation to be completed by Dietary Manager 4 x per week for 4 weeks then weekly for 4 weeks. 4. Administrator to validate audits/compliance and provide additional training as needed. Administrator will present to QAPI committee for ongoing monitoring and further direction.
Failure to Conduct and Document Required Care Conferences
Penalty
Summary
The deficiency involves the facility’s failure to complete and document comprehensive care conferences at required intervals in accordance with care plan regulations and facility policy. For one resident with Parkinson’s disease with dyskinesia, cognitive communication deficit, hemiplegia and hemiparesis following cerebral infarction, transient cerebral ischemic attack, type II diabetes mellitus, and major depressive disorder, the record showed multiple MDS assessments over a one-year period, including annual, quarterly, and significant change assessments. However, only two care conferences were documented during the last 12 months, despite the expectation that care conferences be conducted quarterly with the resident and family when possible. The Unit Care Coordinator confirmed that no additional care conference documentation existed for this resident beyond the notes dated 04/21/25 and 01/02/26. A second resident, with diagnoses including aphasia following cerebrovascular disease, cerebral infarction, type II diabetes mellitus, unsteadiness on feet, difficulty in walking, coagulation defect, depression, and muscle weakness, also had multiple MDS assessments completed over the review period, including quarterly and annual assessments. The record contained a note that a care conference was offered to the resident’s representative, who declined to attend, but there was no documentation of any care conferences for the most recent 12 months. The Unit Care Coordinator confirmed that no other care conference documentation was available for this resident. Facility policy stated that periodic care conferences involving the resident, family, and the interdisciplinary team are part of the care planning process, but the required periodic care conferences and corresponding documentation were not completed for these two residents.
Plan Of Correction
THIS PLAN OF CORRECTION SERVES AS BERKELEY SQUARE'S CREDIBLE ALLEGATION OF SUBSTANTIAL COMPLIANCE AS OF June 1, 2026. Without admitting or denying the validity or existence of the alleged deficiencies, Berkeley Square provides the following Plan of Correction: F657 The facility will continue to document completion of care conferences at the required intervals for all residents, including residents #04 & #15. To ensure compliance with this standard the following measures have be taken: 1. The social service designee and the inter- disciplinary team were re-educated by the administrator to the facility policy "Care Conference" on 4/29/26 and verbalized understanding. 2. Care conferences for resident #04 and resident #15 were conducted on or before 4/29/2026 by the interdisciplinary team. 3. Review of all other residents was conducted by the social service designee to validate and ensure that care conference schedule is up to date with timely care conferences scheduled for them on 4/15/2026. Audits of care conferences to be completed weekly for four weeks and then monthly after that by the social service designee. Documentation of the care conference including any identified concerns in the medical record. Administrator to validate audits/compliance and provide additional training as needed. Administrator will present results of these audits to QAPI committee for ongoing monitoring and further direction.
Failure to Reevaluate Blood Glucose After Treatment for Hyperglycemia
Penalty
Summary
The facility failed to ensure that a resident with diabetes received treatment in accordance with professional standards of practice when nursing staff did not reevaluate the resident's blood glucose after treatment for severe hyperglycemia. The resident, admitted with diagnoses including Alzheimer's disease, type II diabetes mellitus, and depression, had physician orders for Humalog insulin on a sliding scale before meals, Lantus insulin 25 units daily, and lisinopril 5 mg daily. The resident required extensive assistance with activities of daily living, including transfers, toileting hygiene, eating, and bathing. On the evening in question, the resident's blood glucose was documented as 532 mg/dL, and the on-call provider was notified. The provider gave a new order to administer an additional 8 units of lispro (Humalog) and to recheck the blood glucose in 30 minutes. The electronic medication administration record showed that the blood glucose of 532 mg/dL was obtained at 9:00 p.m. and that the additional 8 units of lispro were administered at 9:21 p.m. However, there was no documentation in the resident's chart that the blood glucose was rechecked after the additional insulin was given. In an interview, the DON confirmed there was no evidence of reevaluation and verified that, according to the facility's "Abnormal Blood Glucose Procedure" policy, the resident should have been reevaluated and that the evaluation step should have been included in the progress note documentation.
Plan Of Correction
F684 The facility will continue to ensure all residents, including #03, receive treatment in accordance with professional standards of practice and reevaluated for hyperglycemia. To ensure compliance with this standard the following measures have been taken: 1. The director of nursing assessed resident #03, reviewed documentation and orders and found no ill effects immediately 4/16/26. 2. All licensed nurses were re-educated to facility policy "Blood Glucose Monitoring" by the Director of Nursing/designee in April 2026. 3. Audits of like-residents that require blood sugar checks to be completed by the director of nursing/designee two times a week for 4 weeks and then monthly after that to validate correct follow through when there is abnormally high blood glucose result. The Administrator will bring results of these audits to the QAPI committee for ongoing monitoring and further direction.
Failure to Act on Pharmacist Drug Regimen Recommendation for Thyroid Medication
Penalty
Summary
The deficiency involves the facility’s failure to ensure that pharmacy recommendations from the monthly drug regimen review were acted upon and documented for a resident. The resident was admitted with diagnoses including Parkinson’s disease, dementia, and hypothyroidism, and had current physician orders for levothyroxine 150 mcg once daily, buspirone 50 mg twice daily, and losartan 100 mg once daily. A medication regimen review dated 11/25/2025 included a consultant pharmacist recommendation that levothyroxine be administered consistently in the morning on an empty stomach, at least 30–60 minutes before food, per manufacturer instructions. There was no specific physician response in the medical record to this recommendation, and the facility’s policy stated that consulting pharmacist reviews are sent to nursing and addressed with the primary care provider or consulting specialist for review and follow-up. Review of the resident’s medication administration record for April 2026 showed levothyroxine scheduled for 9:00 a.m. On observation, the resident was seen eating breakfast in the dining area at 8:03 a.m., and an LPN reported administering the levothyroxine 150 mcg to the resident while the resident was in the dining area eating breakfast. The DON confirmed there was no evidence in the resident’s medical record explaining why the consultant pharmacist’s recommendation from 11/25/2025 was or was not acted upon. This lack of documented physician review and action on the pharmacist’s identified irregularity constituted noncompliance with the drug regimen review requirements.
Plan Of Correction
F756 The facility will continue to ensure the pharmacy recommendations from the monthly drug regimen review by a licensed pharmacist are acted upon for all residents, including #08. To ensure compliance with this standard the following measures have been taken: 1. Resident #08 was assessed by the registered nurse and med review completed by 4/28/26. After review of resident's drug regime's, it was discovered that resident #8 had 2 separate medication recommendations on the same form, to be reviewed by two separate practitioners, pharmacy has been instructed and agreed to separate meds on individual forms. 2. Licensed nurses re-educated to facility policy "Drug Regimen Review" by Director of nursing/designee in April 2026 and no later than 5/8/26. Licensed nurses are responsible for ensuring the reviews and recommendations are given to the physician for timely review. 3. Review of all other current residents Drug Regimen orders completed by Director of nursing/designee on 4/16/26 to ensure recommendations were followed up on/reviewed by the physician and address concerns if needed. 4. Audit of drug regime recommendations, pharmacy recommendations, and physician follow up to be completed weekly for four weeks by the Director of nursing/designee. Administrator will present results of these audits to the QAPI committee for ongoing monitoring and further direction.
Failure to Use Required Gait Belt During Ambulation Resulting in Resident Fall
Penalty
Summary
The deficiency involves the facility’s failure to ensure that a required gait belt was used while assisting a high fall‑risk resident with ambulation, resulting in a fall with head injury. The resident had multiple diagnoses including metabolic encephalopathy, hypertension, osteoarthritis, muscle weakness, gait and mobility abnormalities, major depressive disorder, anxiety, and visual hallucinations. Admission and subsequent MDS and fall risk assessments documented that the resident was severely cognitively impaired, required moderate to maximal assistance with transfers and ambulation, could not independently come to a standing position, exhibited loss of balance while standing, used an assistive device, and had decreased muscle coordination. The resident had a history of falls prior to admission and was assessed as being at high, later moderate, risk for falls. The resident’s fall care plan identified her as at risk for falls and included interventions such as providing maximum to moderate assistance with transfers and walking short distances, use of a walker and wheelchair, and following the facility’s fall protocol. Therapy notes and care conference documentation indicated that the resident leaned backwards when standing, required contact guard to minimal assistance for bed mobility and transfers, and needed constant verbal cueing for safe sequencing during toilet transfers. The physical therapist confirmed that the resident was to use a gait belt with staff when ambulating, and the DON verified that therapy had assessed the resident as requiring contact guard assistance and a gait belt for ambulation and transfers. On the day of the incident, a CNA was assisting the resident from her recliner to the bathroom using a walker. The CNA walked beside the resident, providing guidance and support, and reported having a hand on the resident while assisting her. As they approached the bathroom door, the CNA reached for the doorknob to open it, and at that moment the resident began to lose her balance and fell backwards to the floor, striking the back of her head. The nurse who responded found the resident on her back at the foot of the bed with her feet near the bathroom, noted a red raised area on the back of the head, and documented that the resident was not wearing a gait belt and that the gait belt was on the dresser. In the facility’s investigative summary and in interviews, the CNA acknowledged that she did not have a gait belt on the resident while ambulating her, despite the resident’s assessed need for hands‑on assistance and gait belt use per facility policy and the resident’s care and therapy plans.
Failure to Implement PD Orders and Monitor Resident Receiving Peritoneal Dialysis
Penalty
Summary
The deficiency involves the facility’s failure to implement pre-admission physician orders for peritoneal dialysis (PD) and to provide ongoing monitoring for a resident with chronic kidney disease (CKD) stage five who required PD. Pre-admission orders dated 11/14/25 specified three daily PD exchanges at 6:00 A.M., 2:00 P.M., and 10:00 P.M., and directed staff to monitor for signs and symptoms of peritonitis, including fever, abdominal pain, and cloudy effluent. These monitoring orders were not entered into the facility’s physician orders. The resident’s care plan noted the need for PD and included general monitoring interventions (labs, signs of bleeding, bacteremia, septic shock, and significant vital sign changes), but did not specifically address the ordered monitoring for peritonitis. Review of PD documentation showed incomplete and inconsistent charting of treatments and resident condition. The paper peritoneal flowsheet had columns for time of PD and condition/comments, including instructions to call the nurse immediately for cloudy fluid, abdominal pain, or fever. However, the first entry on 11/15/26 at 2:00 P.M. only noted that the PD nurse completed the exchange, and the 10:00 P.M. entry that day had no condition/comment documentation. Subsequent days (11/16/25, 11/17/25, and 11/18/25) contained only one condition/comment entry per day rather than for each exchange, and there was no documentation that the 6:00 A.M. PD on 11/18/25 was completed. The PD cycler flowsheet starting 11/19/25 lacked any description of the effluent on multiple days. The PD nurse from the dialysis company stated facility staff were expected to monitor effluent for cloudiness and assess for abdominal pain and fever, and the DON confirmed there was no electronic physician order for peritonitis monitoring or for use of the PD cycler, that the paper charting did not allow for effluent description or symptom documentation for each treatment, and that PD was not documented at one ordered time. The facility’s dialysis policy required ongoing assessment and monitoring for complications before, during, and after treatments, which was not reflected in the documentation for this resident.
Improper Infection Control During Medication Administration
Penalty
Summary
Surveyors identified a deficiency in infection prevention and control related to medication administration for Resident #29. The resident was admitted on 02/28/14 with diagnoses including depression, traumatic brain injury, and anxiety, and had impaired cognition per a quarterly MDS assessment. During an observation on 03/25/26 at 6:58 A.M., RN #281 prepared the resident’s medications by removing an Amoxicillin-Pot Clavulanate tablet from the medication card and pushing it directly into her ungloved hand, then using her fingers to place the pill into a medication cup. The same process was observed for multiple other medications, including Escitalopram Oxalate, Furosemide, Sennosides, Lyrica, and Vitamin D, each being pushed from the card into the RN’s ungloved hand and then transferred by her fingers into the medication cup before administration to Resident #29. In a subsequent interview at 7:27 A.M. the same day, RN #281 confirmed she had placed each medication into her ungloved hands prior to administration and acknowledged that the proper procedure was to push the pills directly from the card into the medication cup. Review of the facility’s “Medication Administration – General guidelines” policy, revised 10/08/25, stated that medications are to be administered in accordance with good nursing principles and practices. This practice failure was cited as a deficiency under Complaint Number 2681777.
Improper Use of Wheelchair as a Physical Restraint
Penalty
Summary
Surveyors identified a deficiency related to the facility’s failure to ensure a resident was free from physical restraints. Resident #7, admitted with diagnoses including Alzheimer’s disease, diabetes mellitus, and anxiety disorder, was documented on a recent MDS as rarely understood and dependent for ADLs except eating. The resident ambulated independently on the unit without an assistive device and had documented verbal and other behaviors occurring one to three days during the look-back period. The care plan noted the resident had potential to be physically aggressive, chase staff, throw objects, and be combative with care, with interventions such as offering choices, administering medications as ordered, and intervening early when agitation occurred. During an observation and interview, Resident #7 was found sitting in a chair with the right arm of the chair positioned against the nursing station and a wheelchair placed directly in front of him. The left arm of the wheelchair was also against the nursing station, and both wheelchair wheels were locked, creating a barrier that appeared to restrain the resident, who was sleeping with his knees touching the locked wheelchair. An LPN confirmed both wheelchair wheels were locked and that the wheelchair should not have been placed in front of the resident. A CNA reported she had placed the wheelchair there in preparation to get the resident up for lunch, was unable to transfer him, and left the wheelchair in that position, acknowledging it was wrong to keep it there. The facility’s physical restraint policy stated that physical restraints are not used except when alternatives are not appropriate or effective for treating a medical symptom and defined physical restraints as any device attached or adjacent to the body that the individual cannot easily remove and that restricts freedom of movement or access to the body.
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