Hickory Ridge Nursing & Rehabilitation Center
Inspection history, citations, penalties and survey trends for this long-term care facility in Akron, Ohio.
- Location
- 721 Hickory St, Akron, Ohio 44303
- CMS Provider Number
- 365134
- Inspections on file
- 25
- Latest survey
- January 14, 2026
- Citations (last 12 mo.)
- 19
Citation history
Health deficiencies cited at Hickory Ridge Nursing & Rehabilitation Center during CMS and state inspections, most recent first.
Multiple residents with conditions such as fractures, COPD, dementia, schizophrenia, diabetes, and severe malnutrition, all care-planned for potential nutritional issues and with orders for specific breakfast beverages, did not receive their ordered orange juice or other beverages during a breakfast meal. Dietary tickets and MD orders called for specified amounts of juice and, in one case, coffee, but observations showed these items were missing from trays. Staff later reported that new tray-line employees ran out of orange juice and did not provide an alternate juice, despite facility expectations that residents not on fluid restrictions receive a set amount of juice as part of their daily fluid intake.
A CNA with a prior disciplinary history for aggressive and foul language engaged in unprofessional conduct during a smoking break, using profanities and making sexually inappropriate comments about a male resident’s genitalia in the presence of that resident and his cognitively intact roommate. Multiple staff, including LPNs and another CNA, reported hearing a loud commotion and the CNA screaming or using profanities at the smoking area while residents were present, though they could not always identify the specific target of the language. The involved residents had significant psychiatric and neurologic diagnoses, with one having impaired cognition and the other intact cognition, and both later described or confirmed the inappropriate comments and profanities, demonstrating a failure to uphold resident dignity and respect.
A resident with dementia and impaired cognition alleged that a CNA made sexually explicit and profane comments to him during a smoke break, and his cognitively intact roommate later reported hearing the same inappropriate remarks. Multiple staff, including an LPN and a CNA, described a loud commotion at the smoking area and observed the CNA yelling and using profanities, but were unsure at whom the comments were directed. The Administrator did not recognize the roommate as a direct eyewitness, did not clarify conflicting witness statements, recorded the CNA’s name incorrectly, failed to list the CNA as the alleged perpetrator in the SRI, and inaccurately documented that the CNA had no prior disciplinary actions despite a previous final written warning for similar behavior. These inaccuracies and omissions resulted in an abuse investigation that was not thorough.
Surveyors found that the facility failed to implement required safety interventions for three residents. A resident who smoked, with an order and care plan requiring a fire-retardant apron, was observed smoking without the apron and with a burn hole on their pant leg. Another resident with a history of falls and an order for a wheelchair pressure alarm was seen transferring independently from a wheelchair to a bedside commode without the alarm sounding, and an LPN confirmed the alarm was present but not functioning and that a wheelchair wheel lock was broken. A third resident with dementia, Parkinson’s, and repeated falls, who had care-planned interventions for a "call don’t fall" sign and a call light within reach, was observed sitting in a recliner with the call light clipped out of reach and no "call don’t fall" sign in the room, despite documentation indicating the sign was in place.
The facility failed to follow ordered diets and fortified nutrition interventions for three residents identified as at risk for altered nutrition. One resident with a fracture and muscle weakness, ordered double entrees with eggs, grits, and meat at breakfast, reported incorrect portion sizes, and observation confirmed he did not receive double portions or meat. Another resident with anorexia and dementia, ordered fortified cereal and fortified eggs, did not receive fortified cereal at breakfast. A third resident with chronic cardiac and pulmonary conditions, ordered a no added salt mechanical soft diet with fortified cereal and fortified eggs, also did not receive fortified cereal. These omissions were confirmed by CNAs, dietary management, and the DON against the physician orders and existing care plans that required providing the ordered diets and honoring preferences.
A resident with ESRD, diabetes, COPD, CHF, and dependence on renal dialysis received hemodialysis three times weekly at an off-site center, but the facility did not complete or document required pre- and post-dialysis assessments. The care plan and physician orders called for monitoring lung sounds, edema, AV fistula bruit and thrill, shunt site, and overall condition, yet the medical record contained no facility assessments around dialysis treatments. The only available pre-/post-treatment data (vital signs, weights, condition, and medications) came from the dialysis center’s communication forms. An LPN stated she filled out a form in a binder sent with the resident but could not produce the binder or a sample form, and the DON confirmed no facility-completed assessments could be located, despite a policy requiring assessment and monitoring for residents receiving dialysis.
The facility failed to ensure proper hand hygiene and PPE use, affecting multiple residents. A CNA and ADON did not perform hand hygiene between glove changes during incontinence care for a resident. Another resident, at risk for infection, was not provided with appropriate PPE during checks. Additionally, the CNA did not sanitize hands between delivering meal trays to different residents, contrary to facility policies.
A facility failed to specify the type of lift for a resident's safe transfers in their care plan, despite the resident being at high risk for falls due to multiple medical conditions. The care plan was revised to include a Hoyer lift without specifying the type, leading to potential safety risks. The oversight was confirmed by the facility's Administrator and Regional Clinical Director.
A resident with multiple diagnoses, including multiple sclerosis and dementia, was not consistently assisted with shaving his facial hair as required by his care plan. Despite his preference for an electric razor, the facility only provided disposable razors, which were inadequate for his needs. CNAs acknowledged the resident's need for assistance but cited a lack of time and resources as barriers to providing daily care.
The facility failed to ensure safe transfers and implement fall prevention measures for two residents. One resident fell during a transfer using a sit-to-stand lift due to a washcloth obstructing the lift's wheel, while another resident's care plan interventions, such as Dycem on the wheelchair and non-skid strips, were not in place. These deficiencies highlight a lack of adherence to safety protocols and care plans.
A facility failed to accurately document fall prevention measures for a resident at risk of falls due to multiple medical conditions. The care plan included interventions like a Dycem mat on the wheelchair and non-skid strips beside the bed, but these were missing during observations. Despite this, the treatment administration record inaccurately indicated their presence, as confirmed by staff interviews.
A resident with multiple health conditions, including dementia and diabetes, did not receive timely oral care as required by their care plan. Despite being dependent on staff for oral care, documentation showed multiple instances of missed care. Interviews and observations confirmed the deficiency, with staff attributing the responsibility to different shifts.
Failure to Provide Ordered Breakfast Beverages and Honor Resident Preferences
Penalty
Summary
The deficiency involves the facility’s failure to provide beverages according to residents’ diet orders and stated preferences, specifically related to breakfast juice service. Multiple residents had care plans identifying potential for altered nutrition and interventions that included providing diets as ordered and honoring food and beverage preferences. Physician orders and dietary tickets specified that these residents were to receive orange juice or other beverages at breakfast, but observations on the breakfast meal service showed that these ordered beverages were not provided. For one resident with a fracture, muscle weakness, and osteoarthritis, the care plan called for honoring preferences and the physician ordered a regular diet with thin liquids and double entrees, including eight ounces of orange juice at breakfast; the breakfast tray did not include orange juice, and the resident reported that portion sizes, especially at breakfast, were not correct. Another resident with anxiety disorder, schizoaffective disorder, and osteoarthritis, who was dependent on staff for eating, was ordered a regular pureed diet with thin liquids and was supposed to receive orange juice and coffee at breakfast, but neither beverage was on the tray. A resident with anorexia, vascular dementia, and major depressive disorder, whose care plan included nutrient-dense foods and honoring preferences, was ordered a regular diet with fortified cereal and eggs and was supposed to receive orange juice at breakfast, but did not receive it. Additional residents were similarly affected. A resident with multiple sclerosis, COPD, and schizophrenia, who had intact cognition and required supervision for eating, was supposed to receive eight ounces of orange juice at breakfast but did not. A resident with metabolic encephalopathy, diabetes mellitus, and severe protein-calorie malnutrition, whose care plan included nutrient-dense foods and honoring preferences, was supposed to receive four ounces of orange juice at breakfast but did not. Another resident with chronic atrial fibrillation, COPD, and nicotine dependence, with intact cognition and needing supervision for ADLs, was also supposed to receive four ounces of orange juice at breakfast but did not. Staff interviews revealed that two new employees on the tray line ran out of orange juice and did not substitute another type of juice, and facility documentation showed that residents not on fluid restriction were expected to receive four ounces of juice at breakfast as part of their average daily fluid intake.
Failure to Maintain Resident Dignity Due to CNA’s Profane and Sexually Inappropriate Comments
Penalty
Summary
The deficiency involves failure to maintain resident respect and dignity when a CNA acted in an unprofessional and verbally inappropriate manner toward a resident during a smoking break. One resident involved had dementia and other psychiatric and neurologic diagnoses, with a BIMS score of 09 indicating impaired cognition but adequate hearing, clear speech, and ability to understand others. His care plan noted he could refuse care and repetitively ask questions, requiring assistance and cueing with ADLs. Another resident involved, his roommate, had mood, anxiety, PTSD, and depression diagnoses, with a BIMS score of 15 indicating intact cognition, adequate hearing, clear speech, and understanding, and no behaviors noted. On the date of the incident, the cognitively impaired resident reported that during a smoke break the CNA told him he had a very small penis and that her husband’s was bigger, and that she was swearing at him. He stated his roommate was next to him during the smoke break and overheard the comments, and that no other staff were present. The cognitively intact roommate later confirmed that the CNA made inappropriate comments to the first resident about the size of his penis and used profanities toward him during the smoking break, again stating that no other staff were present. Multiple staff accounts described a loud commotion and profanities used by the CNA in or near the smoking area in the presence of residents. Several LPNs reported hearing a commotion from the smoking area while they were in the conference room eating, then observing the CNA in the doorway handing out cigarettes and screaming or using profanities, though they were unsure exactly to whom the profanities were directed and did not hear specific threats. One LPN stated there were residents in the smoking area, described as the usual smokers, and another LPN stated there were no residents having behaviors or noted to be agitated at that time. A CNA reported seeing the CNA and two residents arguing at the smoking door and noted that the CNA had previously been observed treating residents without respect and dignity. The CNA’s personnel file documented a prior final written warning for arguing with the appearance of aggressive behavior and use of inappropriate, abusive, or foul language toward or in the presence of a resident, employee, or visitor, and a subsequent disciplinary action for similar behavior on the date of the incident. The employee handbook classified such conduct—arguing, aggressive behavior, or use of inappropriate, abusive, or foul language toward or in the presence of a resident, employee, or visitor—as a serious work rule violation, while residents and staff interviews and documentation established that the CNA’s conduct occurred in the presence of residents and included profanities and sexually inappropriate comments toward a resident.
Failure to Thoroughly Investigate Verbal Abuse Allegation
Penalty
Summary
The deficiency involves the facility’s failure to conduct a thorough investigation of an allegation of verbal abuse toward a resident with dementia and impaired cognition. The resident had multiple neurocognitive and psychiatric diagnoses, including unspecified dementia, alcohol-induced dementia, vascular dementia, anxiety, depression, insomnia, encephalopathy, and unspecified psychosis, and had a BIMS score of 09 indicating impaired cognition. The self-reported incident concerned a CNA allegedly making sexually explicit and profane comments to the resident during a smoke break. The facility’s SRI documented that the resident denied physical contact, that assessments showed no physical injury, and that interviews and assessments of other residents and staff revealed no additional concerns, leading the facility to unsubstantiated the abuse allegation. Multiple witness statements and interviews contained inconsistencies and omissions that were not reconciled in the investigation. The roommate’s initial statement, taken by the Administrator, was documented as secondhand information from the resident, and the Administrator later acknowledged being unaware that the cognitively intact roommate had actually been present during the incident and was not asked if he personally witnessed it. In a later interview, the resident reported that the CNA made explicit comments about his genitalia and used profanity toward him during the smoke break, and the roommate corroborated hearing these same inappropriate and profane comments directed at the resident, stating no other staff were present. Despite this, the SRI did not reflect the roommate as a direct eyewitness. Staff witness accounts also conflicted and were not fully reconciled. One LPN provided a handwritten statement describing hearing a loud commotion, seeing the CNA in the smoking doorway passing out cigarettes and “screaming profanities,” and being unsure who the CNA was yelling at; she later emailed a statement with similar content but without mention of residents’ behaviors, and later verified that the typed statement was inaccurate. Another LPN reported observing the CNA cursing and yelling near a common lounge area and that the CNA was sent home for her behavior. A CNA reported seeing the CNA and two residents arguing at the smoking door and noted the CNA had previously treated residents without respect and dignity. The Administrator acknowledged errors and omissions in the SRI, including the CNA’s last name being incorrect, failure to list the CNA as the alleged perpetrator, and inaccurately documenting that the CNA had no prior disciplinary actions, despite a prior final written warning for arguing and using inappropriate or foul language in the presence of a resident, employee, or visitor. These inaccuracies and incomplete witness follow-up demonstrate that the facility did not thoroughly investigate the verbal abuse allegation as required by its abuse policy.
Failure to Implement Safe Smoking and Fall-Prevention Interventions
Penalty
Summary
The deficiency involves the facility’s failure to maintain a safe environment and adequate supervision to prevent accidents for three residents. One resident with chronic atrial fibrillation, COPD, and nicotine dependence, cognitively intact and requiring supervision for ADLs, had a physician’s order and care plan requiring use of a fire-retardant smoking apron when smoking. During observation in the designated smoking area, the resident was seen smoking without the required apron and had a cigarette burn hole on the left pant leg. A CNA confirmed the absence of the apron and stated she had previously informed a nurse that the resident needed a smoking apron. The DON later verified that both the physician’s order and care plan required the apron. A second resident, admitted with stroke, dementia, epilepsy, unsteadiness on feet, chronic kidney disease, and weakness, was cognitively intact, required supervision or touching assistance for transfers, and had two or more falls since admission. The resident had a physician’s order for a wheelchair pressure alarm with placement and function to be checked every shift, and the care plan identified fall risk with an intervention for a chair alarm. During observation, the resident self-propelled in a wheelchair and independently transferred to a bedside commode; although an alarm pad and speaker were present on the wheelchair, the alarm did not sound when the resident transferred. An LPN confirmed the alarm should have sounded, verified it was not disconnected or turned off, and that it did not function correctly. When assisting the resident back to the wheelchair, the LPN also found the left wheel lock was broken and did not lock. A third resident, admitted with Alzheimer’s disease, Parkinson’s, dementia, repeated falls, weakness, unsteadiness on feet, and a history of falling, had a physician’s order for a “call don’t fall” sign and was assessed as at risk for falls due to multiple falls in the last 90 days, cognitive behaviors, ambulation problems, and unsteady transfers. The care plan included interventions to analyze previous falls, place a “call don’t fall” sign in the room, and ensure the call light was within reach. A prior fall investigation documented that the resident had fallen while independently ambulating when the call light was not in reach, and a “call don’t fall” sign was added as a new intervention. On observation, the resident was sitting in a recliner near the hallway side of the room, with the call light clipped to the room divider curtain out of reach and no “call don’t fall” sign present. An LPN confirmed that fall-risk interventions include a “call don’t fall” sign and call light in reach, and verified both the absence of the sign and that the call light was out of reach, despite TAR documentation indicating the sign was in place.
Failure to Follow Ordered Diets and Fortified Nutrition at Breakfast
Penalty
Summary
The deficiency involves the facility’s failure to provide ordered diets and nutritional interventions as prescribed for three residents, despite identified risks for altered nutrition. One resident with a history of upper right tibia fracture, muscle weakness, and osteoarthritis had physician orders for a regular diet with regular texture, thin liquids, and double entrees at all meals, including eggs, grits, and meat at breakfast due to risk for malnutrition. His care plan directed staff to provide the ordered diet and honor preferences. He reported that portion sizes, especially at breakfast, were not correct. Observation of his breakfast tray showed he did not receive double portions and received no meat, which was confirmed by a CNA and later verified by the DON against the physician’s orders. A second resident with anorexia, vascular dementia, and major depressive disorder had orders for a regular diet with regular texture, thin liquids, and fortified cereal and fortified eggs at breakfast, with a care plan addressing potential alteration in nutrition and interventions to provide the ordered diet, honor preferences, and offer nutrient-dense foods. Observation of this resident’s breakfast showed that fortified cereal was not provided, which was confirmed by a CNA and verified by the DON against the physician’s orders. A third resident with chronic atrial fibrillation, COPD, and nicotine dependence had orders for a no added salt, mechanical soft diet with thin liquids and fortified cereal and fortified eggs at breakfast, with a care plan to provide the ordered diet and honor preferences. Observation of this resident’s breakfast tray showed that fortified cereal was not provided, which was confirmed by the Corporate Dietary Manager. The Dietary Manager reported that two new employees on the trayline being trained must have missed the fortified cereals. The facility’s “Food First Program” policy stated that honoring resident food and beverage preferences and incorporating them into the diet is an effective intervention when managing nutritional status.
Failure to Perform and Document Pre- and Post-Dialysis Assessments
Penalty
Summary
The facility failed to ensure a resident who required dialysis received ongoing assessments of condition before and after dialysis treatments, as required by facility policy and physician orders. The resident had been admitted with multiple diagnoses including end stage renal disease, diabetes mellitus, dependence on renal dialysis, morbid obesity, COPD, and CHF, and received dialysis three times per week at an off-site location. The care plan noted the resident frequently refused dialysis and included interventions such as monitoring lung sounds, edema, shunt site, bruit and thrill, and maintaining communication with the dialysis center. Physician orders included checking the left arm AV fistula for bruit and thrill every shift and documented the scheduled dialysis days and times. Medical record review revealed no evidence that the facility completed pre-treatment or post-treatment assessments related to the resident’s dialysis sessions. Although the dialysis center’s communication forms from several months documented pre- and post-treatment weights, vital signs, condition, and medications administered, these were completed by the dialysis center, not the facility. An LPN reported that the resident had a binder taken to dialysis and that she filled out a form with vital signs and any signs or symptoms of pain or sickness, but she could not produce the binder or a sample of the form. The DON confirmed she was unable to locate any pre- or post-dialysis assessments completed by facility staff and verified that the available communication forms were from the dialysis center, not the facility, despite the facility’s Dialysis Management policy requiring assessment and monitoring for complications.
Inadequate Hand Hygiene and PPE Use
Penalty
Summary
The facility failed to ensure proper hand hygiene and the implementation of enhanced barrier precautions, affecting multiple residents. Specifically, during incontinence care for Resident #65, the Assistant Director of Nursing (ADON) and a Certified Nursing Assistant (CNA) did not perform hand hygiene between glove changes. The ADON assisted with removing soiled linens and changing gloves multiple times without washing hands, while the CNA also failed to perform hand hygiene after handling soiled materials and before obtaining clean linens. Resident #8, who was at risk for infection due to multiple health conditions, was not provided with appropriate personal protective equipment (PPE) during incontinence checks. The CNA entered the resident's room and performed tasks without donning the required gown, despite signage indicating the need for enhanced barrier precautions due to the resident's wound. This oversight was confirmed by both the CNA and the ADON present during the observation. Additionally, during meal service, the CNA did not perform hand hygiene between delivering meal trays to different residents. After assisting Resident #8, who refused the meal, the CNA returned the tray without washing hands and proceeded to deliver and assist with Resident #58's meal. This lack of hand hygiene was acknowledged by the CNA, who was unaware of the requirement to sanitize hands between handling meal trays for different residents. The facility's policies on hand hygiene and infection prevention were not adhered to, as observed in these instances.
Care Plan Deficiency in Specifying Transfer Equipment
Penalty
Summary
The facility failed to ensure that the care plan for a resident clearly specified the type of lift to be used for safe transfers, leading to a deficiency. The resident, who was at high risk for falls due to multiple medical conditions including dementia, anxiety, and impaired cognition, had a care plan that initially included interventions to maintain a clutter-free environment. However, the care plan was later revised to include the use of a Hoyer lift for transfers without specifying the type of lift, such as a mechanical, power, overhead, or stand-up lift. The deficiency was identified during a review of the resident's health status note, which indicated that the resident was assessed and safely transferred using a sit-to-stand mechanical lift. Despite this assessment, the care plan was not updated to reflect the specific type of lift that should be used, leading to confusion and potential safety risks. The facility's Administrator and Regional Clinical Director confirmed the oversight during an interview, acknowledging that the care plan did not accurately reflect the resident's assessed needs for safe transfers.
Failure to Assist Resident with Daily Shaving
Penalty
Summary
The facility failed to consistently assist a resident, identified as Resident #17, with shaving his facial hair on a daily basis, as required by his care plan. Resident #17, who has multiple diagnoses including multiple sclerosis, stroke, and dementia, was admitted with a care plan indicating he needed assistance with activities of daily living (ADLs) such as bathing and grooming, including shaving. Despite this, observations and interviews revealed that Resident #17 had thick, unshaven facial hair and expressed dissatisfaction with the lack of assistance provided by the facility. He stated that he preferred an electric razor, which the facility did not provide, and that the disposable razors available were inadequate for his needs. Interviews with Certified Nursing Assistants (CNAs) revealed that while they were aware of Resident #17's need for assistance with shaving, they were unable to consistently provide this care. CNA #153 noted that the facility only had disposable razors, which were unsuitable for Resident #17's coarse facial hair, and CNA #154 admitted she did not have time to assist him daily. The nursing assistant job description requires CNAs to assist residents with ADLs, including personal hygiene, but the facility's failure to provide adequate resources and time for staff resulted in non-compliance with Resident #17's care plan. This deficiency was investigated under Complaint Number OH00161220.
Failure to Ensure Safe Transfers and Implement Fall Prevention Measures
Penalty
Summary
The facility failed to ensure the safe transfer of Resident #65, resulting in a fall. Resident #65, who had a high risk for falls due to multiple medical conditions including dementia and impaired cognition, was being transferred using a sit-to-stand lift. During the transfer, the lift tilted to one side, causing the resident to fall. The incident was attributed to a washcloth under the bed that caught on the lift's wheel, leading to the tilt. The CNA involved was aware that two staff members should assist with the lift but was alone during the transfer. Additionally, the facility did not maintain the care planned interventions for Resident #137, who was also at risk for falls due to various medical conditions such as diabetes, pulmonary disease, and visual disturbances. The care plan included specific interventions like placing a Dycem on the wheelchair and non-skid strips beside the bed, which were not in place during observations. This lack of adherence to the care plan was verified by staff, indicating a failure to implement necessary fall prevention measures. The facility's policy on fall management requires an interdisciplinary plan of care to be developed and updated as necessary to reflect each resident's safety needs. However, the failure to ensure the environment was free of hazards and to implement care plan interventions for these residents led to deficiencies in providing adequate supervision and maintaining a safe environment, as evidenced by the incidents involving Residents #65 and #137.
Inaccurate Documentation of Fall Prevention Measures
Penalty
Summary
The facility failed to ensure accurate documentation of fall prevention interventions for a resident, identified as Resident #137, who was at risk of falls due to multiple medical conditions including diabetes, pulmonary disease, and cerebral vascular disease. The resident's care plan, initiated on December 5, 2023, included specific interventions such as keeping the bed in the lowest position, using a Dycem mat on the wheelchair, and placing non-skid strips next to the bed. However, during observations on January 27 and January 28, 2025, it was noted that the Dycem mat was missing from the wheelchair and the non-skid strips were absent from the floor beside the bed. Despite the absence of these interventions, the treatment administration record (TAR) for the period from January 1 to January 27, 2025, inaccurately documented that the Dycem mat and non-skid strips were in place. Interviews with a Certified Nursing Assistant and the Assistant Director of Nursing confirmed the discrepancy between the documented interventions and the actual conditions observed in the resident's room. This deficiency was investigated under Complaint Number OH00161120, highlighting a failure to adhere to the American Nurses Association guidelines for accurate and accessible documentation, which is crucial for ensuring safe and quality nursing practice.
Failure to Provide Timely Oral Care
Penalty
Summary
The facility failed to provide timely oral care for a resident who required assistance with personal care. The resident, who had intact cognition and was dependent on staff for bed mobility, transfers, and oral care, was admitted with diagnoses including schizoaffective disorder, type two diabetes, morbid obesity, and unspecified dementia. The resident's care plan indicated a risk for oral problems due to impaired dentition, with interventions to provide oral care at least daily. However, the oral care task sheet revealed multiple instances where oral care was not documented as completed over a period of several weeks. Interviews and observations confirmed the deficiency. The resident reported not receiving daily oral care and had not received it on the morning of the survey. An STNA admitted to not completing the resident's oral care, attributing the responsibility to third shift staff. Further interviews with the ADONs verified the lack of documentation for oral care on specific dates. An observation of the resident's oral cavity revealed caked-on food debris, confirming that oral care had not been completed. This deficiency was investigated under a specific complaint number.
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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