Heatherdowns Rehab & Residential Care Center
Inspection history, citations, penalties and survey trends for this long-term care facility in Toledo, Ohio.
- Location
- 2401 Cass Rd, Toledo, Ohio 43614
- CMS Provider Number
- 365737
- Inspections on file
- 38
- Latest survey
- January 28, 2026
- Citations (last 12 mo.)
- 5
Citation history
Health deficiencies cited at Heatherdowns Rehab & Residential Care Center during CMS and state inspections, most recent first.
The facility failed to maintain an adequate hot water supply on two halls, affecting multiple residents who experienced a lack of hot water for several days. After hot water was initially lost due to a faucet left running in a mechanical room, a maintenance assistant restored acceptable temperatures but did not continue monitoring. CNAs and an LPN later reported that there was still no hot water, and a resident’s family member reported that a shower could not be completed and that hot water had been out for several days. A central supply staff member stated she was not informed of the issue until contacted by the DON, and maintenance logs showed no work orders submitted for hot water concerns during this period. Plumbing records later confirmed one hot water tank was inoperable and another required a new gas valve, contributing to the ongoing lack of hot water.
A resident with intact cognition and multiple medical conditions, including lumbar spinal stenosis and acute cystitis, had documented care plan needs for assistance with ADLs and a stated preference that hygiene choices were very important. On one occasion, staff did not provide requested washing, citing lack of hot water in the resident’s room, even though hot water was available elsewhere in the facility. The resident’s family observed the lack of hot water, later received a call from the resident reporting that staff refused to wash her, and reported that staff dressed the resident without completing hygiene, causing the resident distress. This was inconsistent with facility policy requiring adequate nursing care and honoring reasonable resident requests.
A resident with lumbar spinal stenosis and recent hospitalization for back and leg pain was admitted with PRN oxycodone ordered and a care plan calling for analgesics and non-pharmacologic pain interventions. Over several days, pain assessments documented increasing pain levels, but oxycodone was never administered, the prescription was not initially faxed to the pharmacy, and staff did not obtain available oxycodone from the contingency box after being instructed to do so. The resident’s daughter repeatedly reported the resident’s pain to the DON, and when the resident requested an ice pack, staff stated none were available despite multiple ice packs being present on the units. As a result, the resident did not receive ordered pharmacologic or available non-pharmacologic pain interventions during this period.
A deficiency was cited when a CNA did not follow approved catheter care procedures for a resident with a urinary catheter, using soap and water instead of an alcohol pad to clean the drainage bag spout after emptying. This action was not in accordance with facility policy and state CNA procedure regulations, which require the use of an alcohol wipe to maintain infection control standards.
A resident who was dependent on staff for all transfers and required a mechanical lift, oxygen, and specialized equipment was discharged home without these essential supports. The resident was left in a standard wheelchair for several hours without care, resulting in a pressure ulcer and subsequent hospital admission. Facility staff did not coordinate with home health or community resources prior to discharge, and the discharge was arranged by a staff member who was no longer present at the facility.
The facility failed to follow proper hand hygiene, food handling, and sanitation practices. A CNA did not sanitize hands between assisting residents, and an employee prepared food without washing hands or changing gloves between tasks. Additionally, food items in residents' refrigerators were not labeled or dated, and the dish machine's chlorine concentration was not monitored, compromising sanitation.
The facility failed to label multiuse insulin pens and vials with the date opened, affecting four residents with diabetes. Observations revealed undated insulin pens and vials on medication carts, verified by LPNs. The facility's policy requires medications to be stored to maintain integrity, but this was not followed.
The facility failed to provide adequate meal portions and did not follow the prescribed menu, affecting all residents except one. Observations revealed incorrect scoop sizes were used for serving, and wheat bread was not provided as indicated. Staff interviews confirmed these discrepancies, and the Dietary Manager was unable to determine the correct portion size for a #6 scoop.
The facility failed to ensure proper infection control during food preparation and wound care. A staff member prepared food with an open wound without wearing gloves, and an LPN did not change gloves between handling soiled and clean dressings for a resident with Alzheimer's and a fractured acetabulum. These actions violated the facility's hygiene and wound care policies.
The facility failed to maintain resident dignity for two residents. A resident with mild cognitive impairment had a full urinal placed on the overbed table next to his breakfast tray, causing discomfort. Another resident, who is cognitively impaired and dependent on staff for dressing, was observed with her breast exposed during feeding assistance, without the privacy curtain drawn. These actions were contrary to the facility's dignity policy.
A resident reported $2.00 stolen from her room to a CNA, but no resolution was offered, and the incident was not reported to administration. The DON was unaware of the theft until informed by surveyors, revealing a failure to follow the facility's policy on reporting and investigating misappropriation. Both the CNA and an LPN knew of the allegation but did not report it, violating the policy requiring staff to report such incidents within 24 hours.
A resident with paraplegia, who was always incontinent and required staff assistance for hygiene, was left with wet bedding after staff changed only the brief and chux pad. An LPN verified the wet pad and bottom sheet with a yellow stain, indicating a failure to provide adequate hygiene assistance as per the facility's ADL policy.
A resident with multiple health conditions, including acute kidney failure and osteoarthritis, experienced pain due to long, thick, and yellowed toenails with fungus. The resident, who was cognitively intact, reported being unable to trim her toenails and stated that staff were aware of the issue. The DON confirmed the need for podiatry care, which was not promptly provided as per facility policy.
The facility failed to maintain a medication error rate below five percent, with two errors observed in 26 opportunities, resulting in a seven percent error rate. A resident with hypertension received an incorrect dose of Lasix, and another resident with osteoarthritis received an incorrect dose of Tylenol. Both errors were confirmed by the respective LPNs involved.
A resident with paraplegia and multiple medical conditions experienced a fall due to improper repositioning by a CNA, who failed to follow the care plan requiring two caregivers. The resident, who was at risk for falls, was able to lower himself to the floor using a mobility bar, avoiding injury. The facility's fall prevention protocols were not consistently implemented, leading to non-compliance.
A facility failed to adequately prepare and coordinate services for a resident's discharge to home. The resident, with complex medical needs, was discharged without necessary wound care instructions or supplies, and the home health agency was not notified. This led to a delay in the resident receiving required care, as the home health agency was not contacted until several days post-discharge, and a physician evaluation was delayed.
The facility failed to provide ordered pressure ulcer treatments for three residents, leading to deficiencies in care. One resident with severe cognitive impairment did not receive prescribed treatments for heel ulcers, while another with paraplegia and stage 4 ulcers experienced missed treatments over several months. A third resident, at risk for pressure injuries, developed a pressure wound due to inconsistent application of preventive measures. The facility's policies on physician orders and wound care were not followed.
The facility failed to ensure medications were administered per physician orders and to maintain an accurate system of dispensing and administering controlled substances, affecting three residents. Discrepancies were found between the CSAR and MAR for various medications, indicating a lack of proper documentation and administration practices.
The facility failed to evaluate, provide care, and conduct ongoing assessments for a resident's skin alteration. Despite having a care plan for an open blister on the right leg, a scabbed area on the left leg was not documented or treated, as confirmed by the DON.
Failure to Maintain Consistent Hot Water Supply on Two Halls
Penalty
Summary
The deficiency involves the facility’s failure to maintain hot water temperatures at acceptable levels for residents on the Middle North and North Back halls. On one occasion, hot water was left running in Mechanical Room Five, which resulted in no hot water being available on those halls. A maintenance assistant responded, turned off the faucet, and confirmed that the hot water tank temperature returned to an acceptable range, with spot checks in two resident rooms and the nourishment room also within acceptable limits. However, there was no subsequent monitoring of water temperatures over the following days to ensure that hot water was consistently maintained. In the days that followed, staff and family reports indicated that there was no hot water on the affected halls for multiple days. The DON became aware of the initial hot water outage after CNAs reported the issue, and a group message was sent to management. Later, a resident’s family member reported that the resident’s shower could not be completed because there was no hot water and stated that staff had told them the hot water had been out for three days, including over a weekend. Nursing staff, including an LPN and a CNA who worked during this period, confirmed that there was no hot water on the Middle North and North Back halls on at least one of those days. Despite these conditions, review of the maintenance work order log for the period in question showed no evidence that staff had submitted any work orders regarding hot water concerns. A central supply staff member, who was present on some of the days when hot water was reportedly unavailable, stated that staff did not inform her of the problem until later, when the DON contacted her after receiving the family complaint. When she then investigated, she was told there had been no hot water for three days. Subsequent review of plumbing vendor documents confirmed that one hot water tank serving the affected halls was inoperable and another required a new gas valve, contributing to the lack of hot water for the identified residents on those halls.
Failure to Honor Resident’s Personal Hygiene Preferences
Penalty
Summary
The facility failed to honor a resident’s stated preferences for daily personal care and hygiene. The resident was admitted with diagnoses including lumbar spinal stenosis with neurogenic claudication, acute cystitis without hematuria, anxiety, and depression. An admission MDS dated 01/08/26 documented intact cognition with a BIMS score of 15 and indicated that hygiene choices were very important to the resident. The resident required supervision or touching assistance with ADLs, including bathing, and the care plan dated 01/04/26 identified ADL self-care needs related to deconditioning and weakness, with interventions to assist with personal hygiene. On 01/04/26, the resident requested to be washed, but staff did not provide the requested hygiene care, citing a lack of hot water in the resident’s room, despite hot water being available elsewhere in the facility. According to the DON, the resident’s family called on 01/05/26 with concerns that the resident had not been washed as requested the previous day due to the hot water issue. The family reported that during their visit they noted there was no hot water, and later the resident called them stating staff would not wash her for that reason. The family further stated that staff dressed the resident without completing any hygiene, which upset the resident. Facility policy on Resident Rights and Facility Responsibilities stated that residents had the right to adequate and appropriate nursing care and to have all reasonable requests honored.
Failure to Provide Timely Pharmacologic and Non-Pharmacologic Pain Management
Penalty
Summary
The deficiency involves the facility’s failure to provide timely pain management interventions for a resident admitted with significant back and leg pain and diagnoses including lumbar spinal stenosis with neurogenic claudication, acute cystitis without hematuria, anxiety, and depression. The resident was discharged from the hospital to the facility with an order for oxycodone 5 mg by mouth every eight hours as needed for pain for up to three days, and physician orders at the facility directed staff to assess pain and discomfort every shift and administer oxycodone 5 mg PO every eight hours as needed. The resident’s care plan identified risk for pain due to lumbago with sciatica and neuropathy, with interventions to administer analgesics as ordered, offer non-pharmacological pain interventions, and notify the physician if interventions were unsuccessful or if the pain complaint represented a significant change. Pain assessments documented pain levels ranging from two to six over several days, yet the Medication Administration Record showed that oxycodone was not administered from the date of admission through several subsequent days. The DON confirmed that the oxycodone prescription was not faxed to the pharmacy upon admission, so the medication was not received in the regular delivery, and that this omission was not identified until several days later. During this period, the resident’s daughter frequently reported to the DON, in person and by phone, that the resident was in pain. The DON stated that once the missing prescription was discovered, nursing staff were instructed to obtain the medication from the contingency box, where oxycodone was available, but an LPN did not contact the pharmacy for authorization to remove the narcotic from the contingency supply, and the medication was not accessed. The DON also reported that when the resident requested an ice pack to help ease pain, nursing staff told the resident there were no ice packs available, despite multiple ice packs being present at each nurses’ station. The DON verified that from admission through several days afterward, the resident did not receive ordered pain medication or non-pharmacological interventions such as cold compresses, contrary to the facility’s pain management policy, which required provision of pain management services and allowed for non-pharmacological measures including cold compresses.
Failure to Follow Approved Catheter Care Procedures
Penalty
Summary
A deficiency was identified when a Certified Nursing Assistant (CNA) failed to follow approved procedures for urinary catheter care for a resident with a history of urinary tract infection, urine retention, and hydronephrosis. The resident had a physician's order for a 16 French urinary catheter with a 10 ml balloon and required catheter care every shift and as needed. During an observation, the CNA donned personal protective equipment, placed a barrier under the graduated cylinder, emptied the urinary drainage bag, and wiped the tip of the spout with a wet wash cloth before returning it to the holder. Upon interview, the CNA confirmed that the correct procedure was to clean the urinary bag spout with an alcohol pad, as outlined in both facility policy and state CNA procedure regulations, but admitted to using soap and water instead. The facility's policy and resource documents specified the use of an alcohol wipe for cleaning the spout after emptying the bag. This failure to adhere to established infection control procedures constituted the deficiency.
Failure to Ensure Safe Discharge with Required Equipment and Services
Penalty
Summary
A deficiency occurred when a resident, who was dependent on others for care and required a mechanical lift for transfers, was discharged home without the necessary equipment and services to meet her care needs. The resident had multiple diagnoses, including COPD with acute exacerbation, muscle weakness, schizophrenia, acute respiratory failure with hypoxia, chronic atrial fibrillation, hypertension, diabetes, and Parkinson's disease. The resident was cognitively intact but required total assistance for activities of daily living, including toileting, dressing, and transfers, and had an order for oxygen therapy. Prior to discharge, the care plan indicated the resident was at risk for self-performance deficits and was dependent for transfers, with no evidence of skin breakdown or pressure ulcers. On the day of discharge, the resident was sent home without oxygen, a working hospital bed, or a Hoyer lift, all of which were necessary for her care. The resident's husband was also ill and unable to provide assistance. The resident was left in a standard wheelchair for approximately six hours without any care, including incontinence care, resulting in the development of a pressure ulcer. EMS was called after the resident was found unable to care for herself, and she was transported to the hospital, where an open wound and saturated brief were noted. Hospital records confirmed the presence of a pressure ulcer and concerns about the lack of home care services and equipment. Interviews with facility staff and external care coordinators revealed that the facility did not coordinate with the resident's waiver service coordinator or home health services prior to discharge. The discharge was arranged by a social services designee who was no longer employed at the facility at the time of discharge, and the resident was discharged with only a standard wheelchair, as transportation could not accommodate her specialized chair. The facility's discharge policy required that discharge planning be based on the resident's needs and that all necessary resources be arranged, but this was not followed in this case, resulting in actual harm to the resident.
Deficiencies in Hand Hygiene, Food Handling, and Sanitation Practices
Penalty
Summary
The facility failed to adhere to proper hand hygiene protocols during meal service, as observed with a Certified Nursing Assistant (CNA) who did not perform hand hygiene between assisting two residents. The CNA assisted one resident back to their wheelchair and then immediately began feeding another resident without sanitizing her hands, despite acknowledging the presence of a hand sanitizer dispenser in the dining room. This oversight was confirmed during an interview with the CNA, who admitted to not following the facility's hand hygiene policy. Additionally, the facility did not maintain proper food handling and sanitation practices in the kitchen. An employee was observed preparing sandwiches without washing hands before donning gloves and touched multiple unsanitary surfaces with the same gloves used to handle food. The employee also failed to properly clean or sanitize utensils between uses, potentially contaminating food items. This was confirmed during an interview with the employee, who was unaware of any residents with peanut allergies, further highlighting the lack of adherence to food safety protocols. The facility also neglected to label and date food items stored in residents' refrigerators, as observed in both the North and South Hall refrigerators. Items such as leftover containers, hard-boiled eggs, and various meats and juices were found undated and unlabeled. Interviews with staff confirmed the oversight and acknowledged that the facility policy required labeling and dating of food items. Furthermore, the facility failed to monitor the chlorine concentration in the dish machine, which was found to be below the required level for proper sanitization. The Dietary Manager confirmed the lack of training for staff on using test strips to monitor chlorine levels, and the dish machine logs only recorded water temperatures, not chlorine concentrations, as required by facility policy.
Failure to Date Insulin Pens and Vials
Penalty
Summary
The facility failed to label multiuse insulin pens and vials with the date opened, which is necessary to ensure medication integrity. This deficiency was identified during an observation of the medication carts on two different units. Specifically, an opened and undated Lantus insulin pen for one resident, an opened and undated Humalog insulin pen for another resident, and an opened and undated Lantus multiuse vial for a third resident were found on the back north unit. Additionally, an opened and undated Humalog insulin pen for a fourth resident was found on the back south unit. These findings were verified by interviews with the respective LPNs present during the observations. The residents involved in this deficiency had diagnoses of diabetes mellitus and were receiving insulin as part of their treatment. The medical records revealed that two of the residents were cognitively impaired, while the other two were cognitively intact. The facility's policy on medication storage, which was undated, stated that medications should be stored in a manner that maintains the integrity of the product and ensures the safety of the residents, in accordance with Ohio Department of Health guidelines. However, the failure to date the insulin pens and vials upon opening indicates a lapse in adherence to this policy.
Inadequate Meal Portions and Menu Non-Compliance
Penalty
Summary
The facility failed to ensure that meal portions served to residents met the nutritional guidelines as outlined in their menu and USDA standards. During an observation of the lunch meal service, it was noted that residents on a regular diet received a four-ounce scoop of pork vegetable stir fry instead of the prescribed #6 scoop, which is approximately five and one-third ounces. Similarly, residents on mechanical soft and pureed diets received inadequate portions of pork chops, with mechanical soft diets receiving a total of four ounces and pureed diets receiving only two ounces, contrary to the menu's specifications. Additionally, the facility did not provide wheat bread as part of the meal, as indicated in the menu. Interviews with the dietary staff confirmed these discrepancies. The staff member responsible for plating the meals acknowledged using incorrect scoop sizes and was unable to measure the portion of broccoli served due to the use of slotted spoons without measurement lines. The Dietary Manager confirmed the failure to follow the menu and was unable to determine the correct portion size for a #6 scoop. This deficiency had the potential to affect all residents in the facility, except for one resident who did not receive nutrition from the kitchen.
Infection Control and Hand Hygiene Deficiencies
Penalty
Summary
The facility failed to ensure proper infection prevention and control during food preparation and meal service. During an observation, a staff member was seen preparing food without wearing disposable gloves, despite having an actively bleeding hand. Blood was observed on the serving utensil used to portion broccoli. The staff member washed her hands and applied a bandage but continued to handle food without gloves, even after the bandage was applied. This was in violation of the facility's personal hygiene policy, which requires employees with open sores to wear appropriate personal protective equipment. Additionally, the facility did not adhere to proper hand hygiene protocols during wound care for a resident with Alzheimer's disease and a fractured acetabulum. An LPN was observed removing a soiled dressing from the resident's heel without changing gloves before cleansing the wound and applying a new dressing. This was contrary to the facility's wound care policy, which mandates hand hygiene and glove changes between handling soiled dressings and applying new ones. The failure to follow these procedures was confirmed by the LPN during an interview.
Failure to Maintain Resident Dignity
Penalty
Summary
The facility failed to maintain resident dignity for two residents, as observed during a survey. Resident #42, who has mild cognitive impairment and is continent of bladder, was found in bed with a full urinal of dark-colored urine placed on the overbed table where his breakfast tray was also delivered. This situation was confirmed by a CNA, and the resident expressed discomfort with the urinal being on the table where he ate. Resident #43, who is cognitively impaired and dependent on staff for dressing, was observed with her left breast exposed while being assisted with feeding by a CNA. The resident was in a semi-private room, and the privacy curtain was not drawn, making her exposed breast visible to her roommate. The CNA confirmed the exposure and did not take action to cover the resident. The facility's policy on dignity, which emphasizes treating residents with respect and maintaining their quality of life, was not adhered to in these instances.
Failure to Report and Investigate Misappropriation Allegation
Penalty
Summary
The facility failed to implement its policies and procedures related to reporting and investigating allegations of misappropriation, affecting one resident. Resident #16, who was cognitively intact, reported to a CNA that $2.00 was stolen from her room within the past six months. Despite this report, no resolution was offered, and the money was not returned. The Director of Nursing (DON) was unaware of the incident until informed by the survey team, indicating a lapse in communication and procedure adherence by the staff. Further investigation revealed that both the CNA and an LPN were aware of the allegation but did not report it to the administration for investigation. The facility's policy, dated 07/01/20, mandates that staff report alleged violations of misappropriation to the administrator within 24 hours, with final investigation results reported within five business days. This policy was not followed, as evidenced by the lack of awareness and action by the administration until the survey team intervened.
Inadequate Hygiene Assistance for Dependent Resident
Penalty
Summary
The facility failed to provide adequate hygiene assistance for a dependent resident, identified as Resident #31, who was affected by this deficiency. Resident #31, who was admitted with a diagnosis of paraplegia, was cognitively intact and always incontinent of bowel and bladder, requiring staff assistance for toileting and personal hygiene. The care plan for Resident #31 included staff assistance with cleaning following toilet use. However, during an interview and concurrent observation, Resident #31 reported being incontinent of urine and soaked through his bedding. Although staff changed his brief and chux pad, they left the bedding wet underneath him. This was verified by an LPN, who observed the wet pad and bottom sheet with a yellow stain. The facility's policy on Activities of Daily Living (ADLs) required appropriate care and services for residents unable to carry out ADLs independently, including support and assistance with elimination and incontinence care.
Failure to Provide Timely Podiatry Care
Penalty
Summary
The facility failed to ensure that a resident's podiatry needs were met, affecting one resident reviewed for podiatry services. The resident, who was admitted with diagnoses including acute kidney failure, essential hypertension, bipolar disorder, anxiety disorder, bilateral primary osteoarthritis of the hip, and muscle weakness, was found to have long, thick, and yellowed toenails with fungus, causing her pain. The resident, who was cognitively intact, reported being unable to trim her toenails herself and stated that the staff were aware of the condition. An interview with the Director of Nursing confirmed the resident's toenails were long and required trimming by a podiatrist. The facility's policy on Ancillary Services, revised in August 2024, states that the facility will assist residents in obtaining prompt podiatry care.
Medication Error Rate Exceeds Acceptable Threshold
Penalty
Summary
The facility failed to maintain a medication error rate of less than five percent, as evidenced by two medication errors observed during 26 medication administration opportunities, resulting in a seven percent error rate. This deficiency affected two residents. Resident #1, who was cognitively intact and diagnosed with hypertension, was prescribed 40 mg of Lasix daily. However, on the observed date, LPN #668 administered only 20 mg of Lasix, which was confirmed during an interview with the LPN. Similarly, Resident #51, who was also cognitively intact and suffered from osteoarthritis with frequent pain, was prescribed two tablets of Tylenol 650 mg twice daily. During the medication administration observation, LPN #634 administered two tablets of Tylenol 500 mg instead. This error was also confirmed in an interview with the LPN. The facility's policy on medication dispensing requires verification of the right drug, dose, route, time, and customer prior to administration, which was not adhered to in these instances.
Failure to Safely Reposition Resident Leads to Fall
Penalty
Summary
The facility failed to ensure that a resident was repositioned in bed safely, leading to a fall incident. The resident, who was paraplegic and had multiple medical conditions including stage four pressure ulcers and osteoarthritis, required extensive assistance with bed mobility and was totally dependent on staff for transfers and toilet use. Despite being cognitively intact, the resident was at risk for falls due to incontinence and the need for assistive devices. The care plan indicated that the resident should be repositioned with the assistance of two caregivers, but this was not consistently followed. On the day of the incident, the resident was being assisted by a CNA when he lost his balance and was lowered to the floor using the bed's mobility bar. The CNA was turning the resident to his right side when his weak leg gave out, causing him to slide off the bed. The resident was able to hold onto the bar and lower himself to the floor, avoiding injury. The incident was witnessed, and the resident was assessed with no injuries noted. However, it was documented that the resident had been repositioned 63 times in the last month by only one staff member, contrary to the care plan's requirement for two caregivers. Interviews with the resident and staff revealed that the CNA responsible for the incident was no longer working at the facility. The Director of Nursing confirmed that the resident had been repositioned improperly, leading to the fall. The facility's policy on managing falls and fall risk was not adhered to, as the interventions to prevent falls were not consistently implemented. This deficiency was investigated under a specific complaint number, indicating non-compliance with the facility's fall prevention protocols.
Inadequate Discharge Planning and Coordination
Penalty
Summary
The facility failed to ensure adequate preparation and coordination of services prior to the discharge of a resident to their home. The resident, who was cognitively intact, required substantial assistance with activities of daily living and had multiple complex medical conditions, including diabetic foot ulcers and a right below-knee amputation. The discharge plan was initiated with an undetermined plan to return home or remain in long-term care. However, upon discharge, the facility did not provide necessary wound care instructions or supplies, nor did they notify the home health agency of the resident's discharge. The physician's discharge orders included specific wound care treatments, such as negative pressure wound therapy and dressing changes, but these were not communicated to the home health agency. Consequently, the resident was not contacted for an initial visit by the home health agency until several days after discharge, and the required physician evaluation by the community primary care physician was delayed. The Director of Nursing confirmed that no education or supplies were provided to the resident or their representative for wound dressing changes at the time of discharge, and there was no evidence of notification to the home health agency.
Failure to Provide Ordered Pressure Ulcer Care
Penalty
Summary
The facility failed to provide pressure ulcer treatments as ordered for three residents, leading to deficiencies in care. Resident #60, who had severe cognitive impairment and was dependent for all activities of daily living, had unstageable pressure ulcers on both heels. Despite physician orders for daily treatment, the treatment records showed multiple instances where the prescribed care was not administered. The Director of Nursing confirmed that if treatments were not documented, they were not completed, indicating a lapse in following the treatment plan. Resident #64, diagnosed with paraplegia and stage 4 pressure ulcers, also did not receive the required wound care as per physician orders. The treatment records revealed numerous missed treatments over several months. An interview with the resident highlighted concerns about the inconsistency between the care provided and the physician's orders. Observations confirmed that the treatments did not align with the prescribed care, as different materials were used than those ordered by the physician. Resident #8, who was at risk for pressure injuries, developed an unstageable pressure wound due to the facility's failure to implement preventive measures. Despite orders for preventive skin preparation and heel boots, these interventions were not consistently applied. The Director of Nursing verified that the lack of documentation indicated non-completion of these preventive measures, resulting in the development of a facility-acquired pressure wound. The facility's policies on physician orders and wound care were not adhered to, contributing to these deficiencies.
Medication Administration and Documentation Deficiencies
Penalty
Summary
The facility failed to ensure medications were administered per physician orders and to maintain an accurate system of dispensing and administering controlled substances. This deficiency affected three residents. For Resident #77, there were discrepancies between the controlled substance administration record (CSAR) and the medication administration record (MAR) for lorazepam, morphine sulfate, and hydrocodone/acetaminophen. Medications were removed but not documented as administered on the MAR, and vice versa, indicating a lack of proper documentation and administration practices. For Resident #26, similar issues were observed. The CSAR and MAR did not match for tramadol, morphine sulfate, and lorazepam. Doses were removed from the CSAR but not documented on the MAR, and some doses were documented on the MAR but not on the CSAR. This inconsistency highlights a failure in the facility's medication administration process. Resident #18 also experienced discrepancies in medication administration. The CSAR showed doses of morphine sulfate and lorazepam being removed, but these were not consistently documented on the MAR. Interviews with staff, including an LPN and the Director of Nursing (DON), confirmed that multiple nurses failed to document narcotic medications properly. The facility's policy on medication administration was not followed, leading to these deficiencies.
Failure to Document and Treat Skin Alteration
Penalty
Summary
The facility failed to evaluate, provide care and treatment, and conduct ongoing assessments for a resident's skin alteration. Resident #4, who had diagnoses including congestive heart failure, chronic kidney disease, type II diabetes mellitus, and dementia, was admitted with no initial skin breakdown but was at risk for skin issues. The care plan included interventions for an open blister from cellulitis on the right lower extremity, requiring regular monitoring and treatment. However, the facility did not document or treat a scabbed area on the resident's left lower leg, which was observed during a survey but not recorded in the medical records or weekly assessments. Observations and interviews revealed that the resident had a scabbed area on the left lower leg that had not been addressed or documented by the staff. The Director of Nursing confirmed the oversight and acknowledged that the scab should have been included in the resident's medical record for proper monitoring and treatment. The facility's policy on skin care mandates weekly skin evaluations to identify and assess new or existing skin alterations, which was not followed in this case, leading to the deficiency.
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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