Hall Of Fame Rehabilitation And Nursing Center
Inspection history, citations, penalties and survey trends for this long-term care facility in Canton, Ohio.
- Location
- 2714 13th Street Nw, Canton, Ohio 44708
- CMS Provider Number
- 365291
- Inspections on file
- 34
- Latest survey
- March 26, 2026
- Citations (last 12 mo.)
- 8
Citation history
Health deficiencies cited at Hall Of Fame Rehabilitation And Nursing Center during CMS and state inspections, most recent first.
The facility failed to provide timely meal service according to its posted mealtimes and written policy on meal frequency. Resident council minutes documented that meals were often late, and an observation confirmed that lunch trays arrived on one floor 55 minutes after the posted delivery time, as verified by an LPN. The dietary manager acknowledged that the posted schedule indicated when trays should be delivered, despite stating it reflected tray line start times. Multiple residents reported late meals as an ongoing concern, and the issue affected several residents and had the potential to affect nearly all individuals receiving meals from the kitchen, excluding one resident who was NPO.
Surveyors identified that the facility did not maintain clean and sanitary kitchen conditions or proper food storage for residents receiving meals. Two dietary staff serving breakfast had full beards without beard coverings, and equipment such as a floor‑stand mixer, stove shelf, and nearby walls had visible food splatter, grease, dust, and residue. An unlabeled and undated bag of vanilla wafers was found in dry storage, and the walk‑in refrigerator had a ripped, moldy gasket. The dish area had missing floor tiles. These conditions were inconsistent with the facility’s written policy requiring all food preparation and service areas to be kept clean and sanitary.
The facility did not maintain a safe, orderly, and homelike environment in several resident rooms. One resident’s bathroom door had a hole, confirmed by a housekeeper. Another resident’s room had a urinal and a pair of scissors left on the floor, verified by an LPN. A third resident’s room had a long, deep gash in the lower part of the bathroom door and a trash bin with a large missing chunk on its rim, as confirmed by the DOM. These observations showed that housekeeping and maintenance services were not consistently ensuring a sanitary, comfortable environment as required by facility policy.
Surveyors found that food service staff failed to prevent food contamination by not changing gloves between tasks and directly handling food items, leading to cross-contamination during meal service. Additionally, the facility did not maintain an adequate emergency food and water supply, with expired items and insufficient quantities to meet policy requirements.
Surveyors found that the facility did not ensure a clean and sanitary environment, as evidenced by mold or mildew under a resident's bathroom sink and unsanitary conditions in a second-floor shower room, including exposed pipes and a toilet with dried stool. Staff confirmed these issues and were unaware of how long some problems had persisted, despite facility policies requiring routine cleaning and disinfection.
The facility did not provide a sufficient variety of activities to meet all residents' needs and interests, with scheduled events limited to weekdays, ending by mid-afternoon, and weekends and holidays offering only activity packets and television. Several residents reported boredom and a lack of engaging options, especially in the evenings and on weekends. The sole activities staff member worked only weekdays, had no formal training or certification for the role, and there was no evidence of additional staff support.
A resident with cognitive deficits and a history of combative behavior was observed with extremely long, thick, and curled toenails after repeatedly refusing nail care from staff and a podiatrist. Staff and medical record reviews revealed a lack of documentation regarding family notification and care conference discussions about the refusals, despite facility policy requiring proper foot care and communication.
A resident with cognitive deficits and a history of combative behavior was not provided with adequate podiatry care due to repeated refusals, lack of family notification, and insufficient documentation by untrained social services staff. The staff member responsible had not received formal training or a job description, resulting in prolonged neglect of the resident's toenail care.
The facility failed to properly store and maintain supplemental oxygen equipment for three residents, as required by their policy. Observations showed that oxygen tubing and nasal cannulas were not stored in protective bags, and equipment changes were not conducted weekly as mandated. The DON confirmed these lapses, affecting residents with conditions like COPD and congestive heart failure.
The facility failed to implement a water management program to prevent Legionella growth, lacking a comprehensive plan and documentation. Additionally, an LPN did not maintain infection control during medication administration by handling a pill with bare hands, contrary to facility policy. The resident involved had Alzheimer's, diabetes, and chronic kidney disease.
The facility failed to conduct required smoking assessments for residents who smoked, affecting four out of twelve residents. Despite being observed smoking with staff, two residents had not been reassessed since May, and two others had never been assessed since admission. An LPN confirmed the assessments were not completed quarterly as per policy.
A facility failed to ensure that a resident's advance directives were filed in the electronic medical record. Despite the resident's admission packet indicating a DNR CCA status, the signed document was found unfiled, contrary to facility policy. The resident had multiple diagnoses, including type II diabetes and Alzheimer's dementia.
A facility failed to create a comprehensive care plan for a resident with behavioral health needs, including schizophrenia and bipolar disorder. Despite the resident's moderate depression and other mental health issues, no psychosocial care plan was developed, contrary to facility policy. Staff confirmed the oversight, highlighting a lapse in adhering to the required assessment and care planning process.
A facility failed to monitor a resident on Ativan for side effects, despite the resident's complex medical history including anxiety and schizoaffective disorder. Interviews with staff confirmed the absence of a monitoring system, contrary to the facility's policy requiring ongoing evaluation of psychotropic medication effects.
The facility failed to maintain proper sanitation for resident refrigerators, affecting two residents. One resident's refrigerator contained unlabeled hamburgers, while another's had expired and moldy dip containers. Staff interviews revealed confusion over responsibility for monitoring and cleaning the refrigerators, contrary to facility policy.
A facility failed to maintain a complete and accurate medical record for a resident receiving antipsychotic medications, as required by their policy. Despite pharmacy recommendations, the facility did not document necessary AIMS assessments in the resident's medical record for over six months. Interviews confirmed that assessments were conducted by a CNP but were not included in the facility's records.
Failure to Provide Timely Meal Service According to Posted Mealtimes
Penalty
Summary
The deficiency involves the facility’s failure to ensure meals were served in a timely manner in accordance with residents’ needs, preferences, and the facility’s own posted mealtimes and policy. Resident Council minutes from two separate meetings documented that meals were often late. The facility’s posted mealtime information at the second-floor nurses’ station indicated that the second-floor meal cart was to be delivered at 11:50 A.M. During an observation on 03/23/26 at 12:45 P.M., lunch trays arrived on the second floor, and an LPN confirmed that the trays were 55 minutes late compared to the posted delivery time of 11:50 A.M. The facility’s written mealtime policy titled “Frequency of meals” stated that three regular mealtimes would be scheduled comparable to normal mealtimes in the community. During interviews conducted in conjunction with the survey, the Dietary Manager stated that the posted times represented when tray line started for the food cart, but then acknowledged that the posted mealtimes indicated trays were to be delivered to the second floor at 11:50 A.M. In a resident council meeting held during the recertification survey, five residents reported that late meals were a concern. The deficiency affected five residents reviewed for frequency of meals and had the potential to affect all 47 residents who received meals from the kitchen, with one resident identified as NPO. This issue was investigated under Complaint Number 2693841.
Unsanitary Kitchen Conditions and Improper Food Storage
Penalty
Summary
Surveyors found that the facility failed to maintain the kitchen in a clean and sanitary manner and to store food to prevent contamination and spoilage for 47 of 48 residents who received food, with one resident identified as NPO. During a kitchen tour, two dietary staff members serving breakfast were observed to have full beards without beard coverings. The floor‑stand mixer had food splatter on the backsplash, white mix on top, and dried food residue on the stand. In the dry storeroom, a bag of vanilla wafers was found open without any label or date. The walk‑in refrigerator had a ripped gasket with mold present. In the cooking area, the stove shelf had grease, dust, and food residue, the wall near the microwave had food splatter, and there were grease drippings on the stove. In the dishwashing area, floor tiles were missing. The dietary staff member interviewed confirmed these observations. Review of the facility’s kitchen sanitation policy, titled “Environment” and revised in June 2015, stated that all food preparation, service, and dining areas would be maintained in a clean and sanitary condition, which was not followed as evidenced by the unsanitary conditions and improper food storage identified during the survey conducted under Complaint Number 2693841.
Failure to Maintain Safe and Homelike Resident Room Environments
Penalty
Summary
The facility failed to ensure a safe and homelike environment as required by its policy that housekeeping and maintenance services will be provided to maintain a sanitary, orderly, and comfortable environment. For one resident, observation of the resident’s room showed a hole in the bathroom door, which was confirmed by a housekeeper. For another resident, observation of the room revealed a urinal and a pair of scissors lying on the floor, which was verified by an LPN. For a third resident, observation of the room showed a long, deep gash in the lower part of the bathroom door and a large missing chunk on the rim of the trash bin, which was confirmed by the Director of Maintenance. These conditions were identified during observations and staff interviews and affected three residents out of six reviewed for the physical environment, in a facility with a census of 48 residents.
Deficient Food Handling and Inadequate Emergency Food Supply
Penalty
Summary
Surveyors observed that food service staff failed to follow proper food handling procedures during meal tray line service. One staff member wore gloves while plating food but used the same pair of gloves to handle serving utensils, touch and open baked potatoes, and arrange meat and creamed spinach on plates without changing or disposing of the soiled gloves. The staff member also touched food items directly with gloved hands and used the same gloves to handle containers, resulting in visible food residue being transferred to adjacent containers. These actions were confirmed by both the Regional Dietary Director and the Dietary Manager during the observation period. Additionally, the facility did not maintain a sufficient emergency food and water supply as required by policy. The emergency food supply was found to be inadequate, with some items expired and insufficient quantities to meet the needs of all residents. The Dietary Manager acknowledged the shortfall and noted that the issue had been identified previously, but the necessary restocking had not yet occurred. The facility's policies required maintaining a three to seven day supply of non-perishable foods and a three day supply of bottled water, but these standards were not met at the time of the survey.
Failure to Maintain Clean and Sanitary Environment
Penalty
Summary
Surveyors observed that the facility failed to maintain a clean and sanitary environment, specifically affecting one resident and potentially impacting twenty-five others residing on the second floor. During an inspection, a large area of what appeared to be mold or mildew was found underneath a resident's bathroom sink. The resident was not present at the time of observation. Additionally, the second-floor shower room was found to have a large hole behind the toilet with exposed pipes, a large hole in the ceiling with exposed pipes, and a toilet containing a significant amount of dried stool both inside and on the outside of the bowl and lid. The housekeeper present confirmed these findings and noted that the water may have been turned off, preventing the toilet from being flushed. The Maintenance Director was unaware of the water being turned off and could not confirm how long the issue had persisted. Further observations with an LPN confirmed the presence of mold or mildew in the resident's room. The facility's policy on routine cleaning and disinfection requires cleaning of walls and visibly soiled surfaces in both common areas and resident rooms, but these standards were not met at the time of the survey. The deficiency was identified during the investigation of multiple complaints and was confirmed through direct observation and staff interviews.
Failure to Provide Sufficient and Varied Resident Activities
Penalty
Summary
The facility failed to provide a variety of activities that met the needs and interests of all residents, as evidenced by a review of the activities calendar, resident interviews, and staff interviews. The activities calendar for December 2025 showed repetitive activities, with no scheduled events later than 3:00 P.M., and a lack of staff-led activities on weekends and holidays. Activities were limited to options such as True or False, Crafts, Book Club, Bingo, Yarn Club, Bible Study, Cards, Nails, Trivia, and occasional church services, with weekends and holidays primarily offering only activity packets and television. There were no activities scheduled before 10:00 A.M. or after 3:00 P.M., and the only staff member leading activities was the Activities Director, who worked weekdays and left by 4:30 P.M. each day. Interviews with residents revealed dissatisfaction with the lack of engaging activities, particularly in the evenings and on weekends. One resident expressed boredom during these times, another noted that television was the only available option and requested more activities for veterans, and a third resident also reported boredom. Staff interviews confirmed that the Activities Director was the sole activities staff member, with no additional support, and that weekend activities were limited to passive options. The Activities Director had recently been promoted without evidence of required training or certification for the role, and there was no documentation that she had received a job description for her current position.
Failure to Provide Adequate Foot Care Due to Incomplete Documentation and Communication
Penalty
Summary
The facility failed to provide adequate foot care for a resident with a history of traumatic brain injury, aphasia, and cognitive deficits. The resident was noted to have self-care deficits and was frequently resistive or combative during attempts at nail care, both by staff and an outside podiatrist. Despite repeated refusals, there was no documentation that the resident's family was notified of the ongoing issue, nor was there evidence that refusals were discussed during care conferences. Observations revealed the resident's toenails were extremely long, thick, and curled, and staff interviews confirmed awareness of the resident's refusal and the lack of a clear plan to address the situation. Medical record reviews showed multiple missed opportunities to document and communicate the resident's refusals and the resulting condition of her toenails. The facility's policy required ensuring proper foot care, but interventions such as reapproaching the resident or educating the family were not consistently documented or implemented. The podiatrist suggested the possibility of sedation to facilitate nail care, indicating the chronic nature of the problem, but there was no evidence that this recommendation had been acted upon or communicated to the family.
Failure to Provide Adequate Social Services and Podiatry Care Due to Untrained Staff
Penalty
Summary
The facility failed to ensure that social services staff were adequately trained and performed their duties as required, specifically affecting one resident with a history of traumatic brain injury, aphasia, and cognitive deficits. This resident was rarely understood, had self-care deficits, and exhibited combative behaviors during personal care, including resistance to nail care by both staff and an outside podiatrist. Despite repeated refusals of podiatry care and ongoing issues with extremely long, thick, and curled toenails, there was no documentation that the resident's family was notified of these refusals, nor was there evidence that these issues were discussed during care conferences. Observations confirmed the resident's toenails had been neglected for an extended period, and the podiatrist noted the condition may have persisted for years. Further review revealed that the staff member responsible for social services, who also served as the Activities Director, had not received official training for the social services role, had not been provided with a job description, and was unaware of all required duties. The personnel file lacked a signed job description, and the staff member admitted to learning the role informally and not documenting care refusals or family notifications as required. Facility policy required proper treatment and care to maintain foot health, but this was not followed in the resident's case.
Improper Storage and Maintenance of Oxygen Equipment
Penalty
Summary
The facility failed to ensure that supplemental oxygen delivery devices were changed weekly and stored properly, affecting three residents who were reviewed for supplemental oxygen use. Resident #12, diagnosed with pneumonia, congestive heart failure, and hypertension, had physician's orders for supplemental oxygen and DuoNeb via nebulizer. Observations revealed that the oxygen tubing and nasal cannula were not stored in protective plastic bags, and the equipment was not changed as per the schedule. Similarly, Resident #24, with chronic obstructive pulmonary disease, diabetes mellitus, and vascular dementia, had oxygen equipment improperly stored and not in protective bags. Resident #28, dependent on supplemental oxygen, also had equipment not stored correctly, and the nasal cannula was not changed since the specified date. The Director of Nursing and Assistant Director of Nursing confirmed that the facility's policy required weekly changes of oxygen tubing and nebulizer equipment and that these should be stored in protective bags when not in use. However, they verified that the equipment for Residents #12, #24, and #28 was not stored correctly, and Resident #28's nasal cannula had not been changed as required. The facility's policy on oxygen administration was not followed, leading to this deficiency, which was investigated under Complaint Number OH00161386.
Deficiencies in Water Management and Medication Administration
Penalty
Summary
The facility failed to develop and implement a comprehensive water management program to prevent the growth of Legionella, as required by the Centers for Disease Control (CDC) guidance. The facility's documentation included a blank section in the CDC toolkit for identifying buildings at increased risk, and there was no water management plan or diagram available. Interviews with the Licensed Practical Nurse/Assistant Director of Nursing/Infection Preventionist and the Chief Operating Officer confirmed the absence of a legionella water management plan. The facility's policy stated that a water management team should be established to develop and implement the program, but this was not effectively executed. Additionally, the facility did not maintain proper infection control during medication administration for one resident. During an observation, an LPN was seen pushing medication out of a card, causing a pill to fall into the narcotic drawer. The LPN then picked up the pill with her bare hand and placed it into a medication cup before continuing to gather other medications for the resident. This action was verified by the LPN during an interview, and it was contrary to the facility's policy, which stated that staff should not touch medication with their bare hands. The resident involved in the medication administration deficiency had a medical history that included Alzheimer's disease, diabetes mellitus, and chronic kidney disease. The facility's failure to adhere to its own policies and CDC guidelines resulted in deficiencies related to both water management and medication administration, highlighting lapses in infection prevention and control practices.
Failure to Conduct Required Smoking Assessments
Penalty
Summary
The facility failed to ensure that smoking assessments were completed for residents who smoked, as required by their policy. This deficiency affected four residents out of the twelve who smoked at the facility. Resident #15, who was admitted with vascular dementia and a history of traumatic brain injury, had not had a smoking safety screen since May 23, 2023, despite being moderately cognitively impaired. Similarly, Resident #35, with diagnoses including muscle weakness and repeated falls, had not been reassessed for smoking safety since May 24, 2023. Both residents were observed smoking in the designated area with staff present, but their assessments were not updated quarterly as mandated by the facility's policy. Additionally, Residents #38 and #192 had not received any smoking assessments since their admission, despite their participation in smoking activities. Resident #38, with chronic kidney disease and mobility issues, and Resident #192, with psychoactive substance abuse and bipolar disorder, were both observed smoking in the designated area. Interviews with an LPN confirmed that smoking assessments were not conducted as required, highlighting a lapse in adherence to the facility's policy, which stipulates that smoking evaluations should be completed quarterly and with any change in condition.
Failure to File Advance Directives in Medical Record
Penalty
Summary
The facility failed to ensure that advance directives were present in the electronic medical record for a resident. Specifically, Resident #37, who was admitted with diagnoses including type II diabetes with ketoacidosis, dementia, cardiomyopathy, congestive heart failure, and Alzheimer's dementia, did not have an advance directive order in their electronic medical record. Although the admission packet and baseline care plan indicated a Do Not Resuscitate Comfort Care Arrest (DNR CCA) status, the Director of Nursing confirmed that the signed DNR CCA was in a pile of unfiled papers and not in the medical record as required. This oversight was contrary to the facility's policy, which mandates that advance directives be placed in the chart and communicated to staff upon admission.
Failure to Develop Comprehensive Behavioral Health Care Plan
Penalty
Summary
The facility failed to ensure a comprehensive care plan was created for a resident with significant behavioral health needs. The resident, who was admitted with diagnoses including rhabdomyolysis, acute kidney failure, anxiety disorder, other psychoactive substance abuse, and bipolar disorder, was found to have no psychosocial care plan addressing these issues. The Minimum Data Set (MDS) assessment indicated the resident was cognitively intact but experiencing moderate depression, as evidenced by a Patient Health Questionnaire (PHQ-9) score of 10. Despite these findings, the baseline care plan did not identify any psychosocial problems or interventions related to the resident's schizophrenia and bipolar disorder. Interviews with facility staff, including a Registered Nurse and the Assistant Director of Nursing, confirmed the absence of a psychosocial care plan for the resident. The facility's policy on Behavioral Health Services emphasized the need for a comprehensive assessment and person-centered care plan, which was not adhered to in this case. The policy required the development of a comprehensive care plan within seven days after the completion of the MDS assessment, which was not fulfilled, leading to the deficiency.
Failure to Monitor Anti-Anxiety Medication Side Effects
Penalty
Summary
The facility failed to adequately monitor a resident on anti-anxiety medications, specifically Ativan, which was prescribed at a dosage of 0.5 mg to be taken orally twice a day for anxiety. The resident, who was cognitively intact, had a medical history that included anxiety, schizoaffective disorder bipolar type, depression, falls, hypertension, and suicidal ideations. Despite the prescription, there were no orders in place to monitor the side effects of the anti-anxiety medication, which is a requirement according to the facility's policy on the use of psychotropic medications. Interviews with the LPN/ADON and the DON confirmed that the Certified Nurse Practitioner was responsible for monitoring resident medications and side effects, yet there was no system in place for the nursing staff to monitor potential side effects related to the resident's anti-anxiety medication. The COO/RN also verified the lack of monitoring. The facility's policy stated that the effects of psychotropic medications should be evaluated on an ongoing basis through various assessments, but this was not adhered to in the case of the resident.
Improper Sanitation of Resident Refrigerators
Penalty
Summary
The facility failed to ensure proper sanitation for resident refrigerators, specifically for two residents out of eight reviewed. Resident #9's refrigerator contained two hamburgers on a Styrofoam plate that were neither labeled nor dated. Resident #17's refrigerator had multiple containers of Lays dip, some of which were expired, and one had a visible black thick layer of mold on top. These observations were made during a survey conducted with a registered dietitian, who confirmed the findings and noted previous concerns about the lack of monitoring of resident refrigerators. Interviews with housekeeping staff and a state-tested nurse aide revealed a lack of clarity regarding responsibility for monitoring and cleaning the inside of resident refrigerators. Housekeepers reported that they only cleaned the top and sides of the refrigerators, assuming that aides were responsible for monitoring them. Conversely, the nurse aide believed that housekeepers were responsible for cleaning the refrigerators. The facility's policy indicated that staff should assist residents with food brought in by family or visitors if the residents were unable to do so themselves, but there was no evidence of consistent monitoring or cleaning of the refrigerators.
Incomplete Medical Record Documentation for Antipsychotic Monitoring
Penalty
Summary
The facility failed to maintain a complete and accurate medical record for a resident diagnosed with anxiety, schizoaffective disorder bipolar type, depression, falls, hypertension, and suicidal ideations. The resident was cognitively intact and received routine antipsychotic medications, including Abilify and Geodon, which could cause involuntary movements. Despite pharmacy recommendations, the facility did not document an Abnormal Involuntary Movement Scale (AIMS) or other appropriate assessments in the resident's medical record within the previous six months. The last documented AIMS assessment in the facility's records was dated several months prior. Interviews with facility staff, including an LPN/ADON and the DON, confirmed the absence of additional AIMS assessments in the resident's medical record. The COO/RN revealed that AIMS assessments were completed by a CNP but were not part of the facility's medical records. Documentation provided indicated that the CNP had conducted AIMS assessments outside of the facility's records. The facility's policy required all assessments and services to be documented accurately and timely in the resident's medical record, which was not adhered to in this case.
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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