Highland Oaks Health Center
Inspection history, citations, penalties and survey trends for this long-term care facility in Mcconnelsville, Ohio.
- Location
- 4114 North State Route 376 Nw, Mcconnelsville, Ohio 43756
- CMS Provider Number
- 365147
- Inspections on file
- 28
- Latest survey
- December 18, 2025
- Citations (last 12 mo.)
- 3
Citation history
Health deficiencies cited at Highland Oaks Health Center during CMS and state inspections, most recent first.
Surveyors found that three residents did not receive medications and treatments as ordered by their physicians, with missing documentation for daily weights, insulin, blood sugar checks, and other prescribed medications. The DON confirmed the omissions, and facility policy requires all medications to be administered and documented as ordered.
A resident with end stage renal disease and both a left arm fistula and a central venous catheter (CVC) for dialysis did not have documented assessments or monitoring of these access sites by facility staff, despite regular dialysis orders and facility policy requiring such oversight. Interviews and observations confirmed the presence of both access points, but the Director of Nursing acknowledged the lack of documentation.
A resident with multiple chronic conditions and urinary incontinence had a urinalysis and urine culture ordered by a nurse practitioner after reporting dysuria. Although the Medication Administration Record indicated the specimen was collected, interviews and record review confirmed the lab never received the sample, and the ordering provider was not notified of the missing results, contrary to facility policy.
A cognitively impaired resident was not protected from sexual abuse by another resident with Hepatitis C. Despite staff witnessing the incident, no investigation or interventions were implemented to prevent recurrence. The facility failed to assess the resident's ability to consent or notify the legal guardian, resulting in Immediate Jeopardy.
A long-term care facility failed to provide appropriate treatment and care for several residents, resulting in delayed medical interventions and inadequate communication with hospice services. One resident experienced harm due to delayed imaging and treatment after a fall, while another missed critical antibiotic doses due to medication unavailability. Additionally, the facility did not address edema and obtain timely Doppler testing for multiple residents, and there were significant communication issues with hospice services, leading to discrepancies in medication orders and unreported changes in resident conditions.
The facility failed to implement a comprehensive pressure ulcer prevention program, resulting in harm to two residents. One resident, at high risk for pressure ulcers, developed Stage III ulcers due to lack of assessment and intervention. Another resident with existing Stage IV ulcers did not receive proper care as per her plan, including the use of a trapeze bar and appropriate mattress settings. Staff inconsistencies and documentation failures contributed to these deficiencies.
A resident with impaired cognition exited the facility twice in one day, resulting in a fall and fracture, due to inadequate interventions. The facility also failed to secure medications on the memory care unit, posing a risk to confused residents who wandered independently.
The facility failed to conduct annual performance reviews and provide necessary training for CNAs. One CNA's file lacked a 2024 performance review, and another CNA's file showed no evidence of required annual training for the memory care unit or 12 hours of in-services. These issues were confirmed by the DON and HR, potentially affecting all 85 residents.
The facility failed to maintain essential kitchen equipment and adequate supplies, affecting meal service for all residents. Disposable plates were used due to a shortage of small plates, and there was a shortage of plastic and coffee cups, causing delays. Additionally, the oven's pilot light was unreliable, leading to insufficient food temperatures, and the issue had not been addressed by contacting a service provider.
The facility did not ensure CNAs received the required 12 hours of continuing education per year, as confirmed by employee records and staff interviews. This deficiency, affecting all 85 residents, was verified by HR and the DON.
A long-term care facility failed to ensure medications were available for residents, affecting four individuals. One resident with multiple diagnoses missed doses of antibiotics due to unavailability, and the physician was not notified promptly. Another resident with dementia and hypertension missed several medications, while a third resident with COPD and sepsis did not receive multiple medications shortly after admission. A fourth resident with insomnia did not receive Dayvigo as ordered due to insufficient delivery and insurance issues. The facility's pharmacy agreement required timely delivery, which was not met.
The facility failed to properly store and manage medications, with medication carts left unlocked and insulin flexpens undated. This affected residents across multiple halls, as medication carts were left unattended and insulin pens lacked necessary dating to track expiration, contrary to facility policy.
The facility failed to implement proper infection control practices, including enhanced barrier precautions (EBP) for residents with medical devices and wounds. Observations revealed that staff did not follow protocols for medication administration, tracheostomy care, and wound dressing changes, leading to potential cross-contamination and infection risks. The infection control log was inaccurate, and policies were not reviewed annually, affecting the safety of all residents.
The facility failed to ensure residents were treated with respect and dignity, particularly by RN #126, who was reported to be rude and rough during care. A resident under hospice care and others expressed concerns about RN #126's behavior, including yelling and rushing. Despite known issues, there was no documentation of corrective actions or communication of resolutions, violating facility policies on grievances and dignity.
A facility failed to ensure a resident with severe cognitive deficits had a legal guardian after the previous guardian was removed. Despite the resident's inability to make decisions, the facility did not have power of attorney documentation or initiate guardianship proceedings, leaving the resident without proper representation.
A facility failed to notify a resident receiving Medicaid benefits when their account balance approached the SSI resource limit, potentially affecting their eligibility. The resident's account balance exceeded $1800, and no guardian was obtained to manage the funds, as confirmed by the Business Office Manager.
The facility failed to ensure consistent and accurate documentation of code status for three residents, leading to discrepancies between medical records and actual directives. One resident's DNRCC-A status was incorrectly documented, another had no code status order despite a DNRCC-A discharge note, and a third had conflicting full code and DNR/DNI orders. These inconsistencies could have affected the residents' care decisions.
The facility failed to notify legal representatives of changes in medical orders or conditions for two residents. One resident with vascular dementia and other conditions had multiple medical orders issued without notifying their representative. Another resident with severe cognitive deficits also had new lab orders without notification. The facility's policy requires such notifications, but this was not followed.
The facility failed to report and investigate an alleged sexual abuse incident between two residents in the memory care unit. Despite staff awareness, the incident was not documented in the medical records, and no assessments or notifications were made to the legal guardians. The facility did not implement interventions to prevent further incidents, and the Director of Nursing was unaware of the situation until the surveyor's interview.
The facility failed to investigate an allegation of sexual abuse between two residents on the memory care unit. One resident, with a legal guardian due to cognitive impairment, was found in a compromising situation with another resident. Despite documentation in a psychiatric consult note, there was no evidence of an investigation or notification to the legal guardian. The care plans did not address sexually inappropriate behaviors, and no additional interventions were implemented. The facility's policy for reporting and investigating abuse allegations was not followed.
A facility failed to notify the local Ombudsman of a resident's transfer to the hospital, as required. The resident, with multiple serious health conditions, was sent to the emergency room at the family's request. The Social Service Director did not include this transfer in the monthly discharge summary sent to the Ombudsman, and could not explain the omission, resulting in a compliance deficiency.
The facility failed to ensure accurate MDS assessments for two residents, leading to deficiencies in dialysis and dental care. One resident's care plan did not address dialysis or infection risks, and the MDS inaccurately reported no dialysis services. Another resident's MDS failed to document multiple black broken teeth with caries, despite observations confirming the condition. The DON verified these inaccuracies.
A facility failed to complete a significant change MDS assessment for a resident within 14 days of their admission to hospice services. The resident, with multiple diagnoses including dementia, was admitted to hospice for senile degeneration of the brain. Despite this significant change, the required MDS assessment was not completed in time, as confirmed by an MDS Nurse.
A facility failed to complete a significant change PASARR for a resident when a new diagnosis of schizophrenia was added. The resident, with multiple health conditions including dementia and epilepsy, had schizophrenia added to their diagnoses on a specific date, but the required PASARR was not conducted. The Director of Social Services confirmed this oversight, which was against the facility's policy to screen for mental health disorders upon new admissions and readmissions.
A facility failed to ensure the accuracy of a PASARR assessment for a resident admitted with vascular dementia, PTSD, and idiopathic gout. The PASARR did not list PTSD as a serious mental illness, an oversight confirmed by the Social Services Director.
A facility failed to include a correct developmental disability diagnosis in a resident's PASARR. The resident, admitted with schizoaffective disorder, altered mental status, schizophrenia, and moderate intellectual disabilities, had a PASARR that did not reflect the intellectual disabilities diagnosis. This was confirmed by the Social Services Director.
The facility failed to create comprehensive care plans for three residents, resulting in unaddressed medical needs. A resident with multiple diagnoses lacked a care plan for dialysis and infection risk, while another's dental issues were not reflected in her care plan despite visible problems. Additionally, a resident required to wear a safety helmet had no care plan for this safety measure, as confirmed by staff.
The facility failed to update care plans for two residents with behavioral issues and did not conduct a quarterly care conference for another resident. One resident exhibited sexually inappropriate behavior without a corresponding care plan, while another showed aggression without a behavior care plan. Additionally, a resident with multiple health issues did not have a timely care conference, with staff acknowledging scheduling challenges.
A facility failed to provide a comprehensive discharge summary for a resident with a complex medical history, omitting a recapitulation of the resident's stay as required by policy. The discharge instructions only included physician orders and medications, lacking a detailed summary of the resident's medical history and care received.
A resident with severe cognitive deficits and multiple health conditions did not receive necessary nail care assistance from staff, as observed on two occasions. Despite the care plan indicating a need for assistance with ADLs, the resident's nails were long, jagged, and had a brown substance underneath, which was confirmed by a CNA.
A facility failed to timely treat a UTI for a resident, delaying antibiotic administration due to late lab results and medication delivery. Another resident did not receive routine supra-pubic catheter care as ordered, with staff unaware of the required frequency. The facility's catheter care policy lacked specificity, contributing to inconsistent care.
A facility failed to implement dietary recommendations and obtain physician-ordered daily weights for a resident with multiple health conditions, including diabetes and end-stage renal disease. The resident's care plan required increased caloric and protein intake, but the facility did not consistently obtain daily weights and did not implement the Registered Dietician's recommendations for a renal diet and double protein portions. The Director of Nursing and the RD confirmed these failures.
The facility failed to provide adequate respiratory care and medication administration for three residents. A resident with a tracheostomy lacked oxygen orders and had improperly stored respiratory equipment. Another resident did not receive medications as ordered, and a third resident used oxygen without a physician's order, with improper documentation and sanitation. Facility policies on respiratory care and medication administration were not followed.
A resident requiring dialysis did not have a care plan addressing dialysis needs or infection risks. The facility failed to provide necessary communication forms and lacked coordination with the dialysis center, as confirmed by interviews with staff and the resident. The facility's policy on dialysis care was not followed, resulting in a deficiency.
A facility failed to conduct a trauma assessment for a resident with PTSD, despite having a policy in place for trauma-informed care. The resident's care plan included interventions for PTSD, but there was no evidence of a completed trauma assessment to identify triggers and preferences. The Social Service Director confirmed the lack of assessment, indicating a lapse in following the facility's policy.
The facility failed to provide necessary psychiatric referrals and interventions for two residents with mental health and behavioral issues. One resident, with a history of dementia and PTSD, did not receive a psychiatric referral despite physician recommendations. Another resident, with severe cognitive impairment, exhibited aggressive behaviors without a care plan in place to manage these actions. Both cases highlight a lack of timely psychiatric evaluation and intervention.
The facility failed to ensure timely physician responses to pharmacy recommendations for two residents. A resident with psychiatric diagnoses continued receiving medications without physician evaluation despite pharmacist recommendations. Another resident with severe cognitive deficits did not receive recommended lab tests, even though the physician agreed to them. The facility did not adhere to its policy requiring documentation of physician responses to medication irregularities.
The facility failed to ensure residents were free from unnecessary medications, affecting three residents. A resident refused a lidocaine patch multiple times without provider notification, and another resident received incorrect oxycodone administration due to lack of pain assessment documentation. Additionally, a diabetic resident did not receive appropriate insulin coverage as per sliding scale orders, and the physician was not notified of critical blood sugar levels.
The facility failed to properly manage psychotropic medications for three residents, leading to deficiencies in medication administration and assessment. A resident was prescribed clonazepam and Zyprexa without appropriate indications or follow-up, another had Xanax incorrectly scheduled instead of as needed, and a third continued receiving Buspar despite a discontinuation order. These issues highlight lapses in medication management and adherence to facility policy.
The facility failed to obtain physician-ordered lab tests for two residents, one with a complex medical history including Parkinsonism and dementia, and another with multiple diagnoses including schizophrenia. The Director of Nursing confirmed that the tests were not conducted as ordered, despite facility policy requiring staff to arrange for such tests.
A resident with multiple diagnoses, including dental caries, had not received routine dental care since August 2023, leading to multiple black broken teeth with obvious caries. The facility's policy requires routine dental services, but the resident's medical record and an interview with the DON confirmed the lack of dental care, contrary to the resident's plan of care.
The facility failed to maintain accurate medical records for three residents, leading to deficiencies in care documentation. A resident was started on oxygen therapy without documented physician orders, another had no lab results for a prescribed medication, and a third had completed lab tests not scanned into their record. Staff confirmed these documentation gaps.
A facility failed to document an appropriate reason for prescribing Cipro 500 mg to a resident with multiple medical conditions, including cognitive deficit and incontinence. The resident's records lacked laboratory results or documentation supporting the antibiotic use, and the facility's Antibiotic Stewardship policy was not followed. The DON confirmed the absence of necessary documentation.
The facility failed to administer requested vaccinations to two residents. One resident, with multiple health conditions, consented to receive the influenza, pneumonia, and COVID-19 vaccines but did not receive the pneumonia vaccine. Another resident, with various medical issues, did not have a consent packet for the 2024-2025 season and did not receive the flu and pneumonia vaccines. The facility's policies require offering these vaccines to all residents, but this was not followed.
The facility failed to administer COVID-19 vaccinations to two residents who had requested them. One resident, with multiple health conditions including dementia and diabetes, had consented to the vaccine but did not receive it. Another resident, capable of making their own healthcare decisions, also did not receive the vaccine despite requesting it. The DON confirmed these oversights during interviews.
A resident with a recent transmetatarsal amputation and a chronic ulcer did not receive timely wound care upon admission to the LTC facility. The facility failed to implement treatment orders until two days after admission, and there was no evidence of required wound assessments. The resident's care plans were delayed, and initial treatments did not align with hospital discharge instructions. The resident expressed dissatisfaction with the care, which was only addressed after a follow-up with the podiatrist.
A resident with a UTI did not receive timely antibiotic therapy due to a failure in recognizing the medication's availability in the facility's Omnicell system. Despite having the medication in stock, nurses documented it as unavailable, resulting in missed doses. The oversight was due to a lack of recognition of the medication's listing as SMZ-TMP, which was the same as the ordered Bactrim DS.
A facility failed to provide appropriate care for a resident with a gastrostomy tube, as there were no documented treatment orders for the tube site for ten days post-admission. The resident's care plan lacked interventions for tube site care, and the treatment administration record showed no evidence of care until a later date. Interviews revealed concerns about unchanged and dirty dressings, and the DON confirmed the lack of documented care.
A facility failed to properly document and reconcile the administration of Morphine Sulfate for a resident under hospice care. The MARs showed multiple doses were given, but these were not recorded on the Controlled Drug Use Record, leading to discrepancies. The DON confirmed the missing documentation and acknowledged the failure to adhere to the facility's policy on controlled substances.
A facility failed to date medications when first accessed, affecting three medication carts and eight residents. Observations revealed multiple vials of insulin, liquid medicines, and flexpens without dates, making it unclear when they should be discarded. Staff confirmed that medications should be dated upon opening, and the facility's policy requires secure storage and discarding of outdated drugs.
Failure to Follow Physician's Orders for Medication and Treatment Administration
Penalty
Summary
The facility failed to ensure that physician's orders were followed for three residents, as evidenced by missing documentation and administration of prescribed medications and treatments. For one resident with multiple complex diagnoses, including diabetes and end stage renal disease, there was no documentation of daily weights on several specified dates as ordered, and insulin administration was not recorded on certain days. Additionally, blood sugar checks were not documented as ordered on two occasions. For another resident with Alzheimer's and other chronic conditions, there was no documented evidence that prescribed medications for anxiety, hypertension, and heart disease were administered on multiple dates. A third resident with heart disease and hypothyroidism did not have documented administration of levothyroxine on several dates. The DON confirmed during interview that there was no documented evidence these residents received their medications or treatments as ordered on the specified dates. Facility policy requires medications to be administered as ordered, with documentation on the MAR and timely physician notification of omissions. The lack of documentation and administration of ordered medications and treatments for these residents constituted a failure to follow physician's orders.
Failure to Assess and Document Dialysis Access Sites
Penalty
Summary
Facility staff failed to assess, observe, and document the care of a resident's left arm fistula site and external central venous catheter (CVC) dialysis access site. The resident, who had diagnoses including end stage renal disease, dialysis dependence, diabetes, and heart disease, was admitted with both a CVC in the left upper chest and a fistula in the left arm. Despite physician orders for dialysis three times weekly and the presence of both access points, there was no documented evidence in the resident's orders, medication administration record, treatment administration record, progress notes, or care plan that staff assessed or monitored either the CVC or fistula. Interviews confirmed that the resident regularly attended dialysis and had both access sites in place for several months. Direct observation verified the presence of both the fistula and the CVC, with appropriate dressings in place. The Director of Nursing acknowledged that the medical record did not reflect any assessment or monitoring of the dialysis access sites. Facility policy required ongoing assessment and oversight of residents before, during, and after dialysis, including monitoring for complications and infection control, but this was not documented for the resident in question.
Failure to Obtain and Report Ordered Urinalysis
Penalty
Summary
A deficiency occurred when the facility failed to obtain a urinalysis for a resident as ordered by the nurse practitioner. The resident, who had a history of traumatic brain injury, hemiplegia, hypokalemia, chronic pain, chronic kidney disease stage three, stress incontinence, and irritable bowel syndrome, was admitted with ongoing urinary incontinence. On the date of the incident, the resident complained of burning with urination, and the nurse practitioner ordered a urinalysis and urine culture and sensitivity. The resident was aware of and agreed to the order. Despite documentation in the Medication Administration Record indicating that the urinalysis was collected, a review of the medical record, lab results, progress notes, physician notes, and the facility infection control log revealed no results for the urinalysis and no evidence that the ordering provider was notified about the missing results. Interviews with an LPN confirmed that the lab did not receive a urine specimen for the resident and that no provider was contacted regarding the absence of results. Facility policy required timely notification of lab results to providers, which was not followed in this instance.
Failure to Protect Resident from Sexual Abuse
Penalty
Summary
The facility failed to protect a cognitively impaired resident from sexual abuse by another resident. On November 16, 2024, a CNA observed a resident with Hepatitis C engaging in non-consensual sexual intercourse with another resident who lacked the cognitive ability to consent. Despite the incident being reported to another CNA and an RN, no investigation was conducted, and no interventions were implemented to prevent recurrence. This lack of action resulted in Immediate Jeopardy and the potential for actual harm. The facility's records revealed that the cognitively impaired resident had a legal guardian due to being deemed incompetent. The care plan for this resident did not specify any sexually inappropriate behaviors, and there was no evidence of the resident being sexually active with others in the facility. Additionally, the facility failed to assess the resident's ability to consent to sexual activity or notify the resident's legal guardian of the incident. The other resident involved, who also had severe cognitive impairment, was not on a care plan for sexually inappropriate behaviors, and there was no evidence of additional interventions to prevent further incidents. Interviews with staff indicated that they were aware of the relationship between the two residents but did not recognize the behaviors as potentially inappropriate. The facility did not conduct a comprehensive assessment of each resident's ability to consent to the relationship or provide adequate supervision to prevent further incidents. The facility's policy on abuse and neglect required that incidents be reported to the state and thoroughly investigated, which was not done in this case.
Removal Plan
- The facility initiated an investigation related to the incident of sexual abuse involving Resident #27.
- The investigation process included speaking to Resident #21 and Resident #27 regarding the alleged incident, interviewing all residents, or assessing residents if they were not cognitively intact including skin assessments, pain assessments.
- The investigation process also included interviewing staff who worked for potential knowledge of any abuse incidents, as well as educating all staff on the abuse policy and procedure, notifying family and physician.
- Resident #21 was placed on one-on-one supervision.
- Resident #21 would remain on one-on-one services until seen by psychiatric services.
- Facility staff would complete the one-on-one supervision which would be tracked through documentation.
- Resident #21 and Resident #27's guardians were notified of the sexual abuse incident by the DON/Designee.
- A Quality Assurance Assessment (QAA) meeting was held which included the Administrator/Executive Director, DON, two unit managers, social worker, regional nurse consultant, and medical director.
- The team discussed a plan to mitigate the sexual abuse concern identified including an immediate intervention to keep all residents safe, the investigation including all education needed, interviews, assessments, discussions with all physicians, any medications that needed ordered or clarified, notifying family and the next steps including notifying the police department and filing a self-reported incident (SRI).
- Resident #21 and Resident #27's physician was notified of the sexual abuse incident by the Administrator/Designee.
- The DON/Designee assessed Resident #21 with no negative findings.
- The Administrator/Designee notified the police department of Resident #21 and Resident #27 allegedly having sexual intercourse and that the facility had started an internal investigation.
- The Administrator/Designee reported the allegation of sexual abuse involving Resident #27 to the State Agency and began a thorough investigation.
- The DON/Designee assessed non-interviewable residents on the memory care unit to ensure no signs or symptoms of sexual abuse were identified.
- The DON/Designee assessed Resident #27.
- Social Service Designee (SSD)/Designee #190 assessed Resident #21 for psychosocial well-being.
- A local Police Department (PD) Officer arrived at the facility to take a report.
- The DON informed the officer there was an allegation of intercourse between two memory impaired residents (#27 and #21) and that the facility was investigating the allegation.
- SSD #190 spoke with Resident #21's guardian.
- As a result of the conversation, the guardian agreed to transfer Resident #21 to another facility that could accommodate her sexual behaviors.
- Discharge planning was started.
- Resident #21 would remain on increased supervision as recommended by psychiatric services.
- Supervision was changed to every 15 minutes checks.
- SSD #190/Designee assessed Resident #27 for psychosocial well-being.
- SSD #190/Designee interviewed or assessed current residents and interviewed staff members with no additional allegations of sexual abuse identified.
- SSD #190/Designee assessed residents on the memory care unit for psychosocial well-being.
- The DON/Designee reviewed the orders and care plans for residents on the memory care unit to ensure interventions for sexually inappropriate behaviors were in place.
- The Administrator/Designee educated staff members on the Abuse policy including Sexual abuse and reporting and investigating abuse.
- Bloodwork was drawn for a Hepatitis panel for Resident #27.
- The DON/Designee spoke with the Nurse Practitioner regarding Resident #21.
- Orders were obtained for birth control pills.
- The resident had been started on the medication, Tagamet (a medication used to decrease libido).
- The resident's guardian was notified of these orders.
- Resident #21's plan of care was updated to include non-pharmacological interventions to deter potentially sexually inappropriate behaviors: activities of choice, offer other activities to participate in with the activities department, leave the unit with supervision to participate in other activities and socialize, going on outings when able, family trips when able and counseling with Psychiatric Nurse Practitioner.
- The facility implemented audits for the Administrator/Designee to interview three staff members weekly times four weeks to ensure no concerns of sexual abuse were identified, then as determined by the QAA Committee.
- The facility implemented audits for the DON/Designee to assess three non-interviewable residents weekly times four weeks to ensure no signs or symptoms of sexual abuse were identified, then as determined by the QAA Committee.
Deficiencies in Care and Communication in LTC Facility
Penalty
Summary
The facility failed to provide appropriate treatment and care according to orders, resident preferences, and goals, affecting six residents. Resident #41 experienced actual harm after a fall, as the facility delayed notifying the medical provider of a change in condition, resulting in a delay in treatment. The resident showed signs of discomfort and pain, but imaging services were delayed, and the resident was not transferred to the hospital until two days after the fall, where an acute fracture was diagnosed. The facility also failed to monitor and administer medications properly for Resident #31, who was on a strict antibiotic regimen following a hospital discharge. The resident missed several doses of vancomycin and meropenem due to unavailability, and laboratory tests were not conducted as ordered, leading to improper monitoring of medication levels. Additionally, the facility did not communicate effectively with hospice services for Resident #54, resulting in discrepancies in medication orders and a lack of notification regarding significant changes in the resident's condition. Furthermore, the facility did not address edema and obtain timely Doppler testing for Residents #59, #85, and #191. There were significant delays in obtaining necessary imaging services, with some residents waiting over a week for tests that should have been completed within 24 hours. The facility's contracted imaging service failed to respond promptly, and the facility did not take appropriate action to ensure timely testing, such as sending residents to the hospital when imaging services were delayed.
Failure in Pressure Ulcer Prevention and Management
Penalty
Summary
The facility failed to develop and implement a comprehensive and individualized pressure ulcer prevention program, which resulted in harm to two residents. Resident #41, who was at high risk for pressure ulcers, was readmitted to the facility with mushy heels, but the facility did not comprehensively assess or implement interventions to prevent pressure ulcer development. Despite the presence of mushy heels upon readmission, there was no documentation or intervention until the order for Prevlon boots on 01/09/25. By 01/12/25, a pressure ulcer was identified on the left heel, but no new interventions were implemented, leading to the development of Stage III pressure ulcers on both heels. Resident #1, who had a history of paraplegia and existing Stage IV pressure ulcers, did not receive appropriate interventions as per her care plan. The facility failed to ensure the use of a trapeze bar for bed mobility and did not properly inflate the low air loss mattress according to the resident's weight. Additionally, the resident reported that staff did not regularly encourage or assist with turning and repositioning, as required by her care plan. These failures contributed to the resident's ongoing risk for skin breakdown and pressure ulcer complications. Interviews with staff revealed inconsistencies in the documentation and implementation of care plans for both residents. The Director of Nursing and other staff members acknowledged the lack of documentation and failure to follow care plans, which included not assessing or documenting the condition of Resident #41's heels upon readmission and not adhering to the prescribed interventions for Resident #1. These deficiencies highlight a systemic issue in the facility's pressure ulcer prevention and management practices.
Failure to Prevent Resident Exit and Ensure Medication Safety
Penalty
Summary
The facility failed to develop and implement comprehensive, individualized, and effective interventions to prevent a fall and wandering behavior, resulting in a resident exiting the facility. The resident, who had moderately impaired cognition and wandered daily, was able to exit the building twice on the same day. The first incident occurred when the resident pushed on a door for 15 seconds to exit to the patio. Despite this, no additional interventions were implemented to prevent further exits. Later that day, the resident exited again, fell, and sustained a fracture of the left femur, requiring transport to the emergency department. The facility's investigation into the fall was inadequate, as there was no evidence of staff statements being obtained. The Director of Nursing (DON) was unaware of any additional interventions to prevent the resident's exit-seeking behavior. The facility utilized a 15-minute check form, but there was no evidence it was completed for the resident at the time of the incident. The DON also noted discrepancies in the nursing notes regarding the incident and stated that heightened checks were standard but not formally ordered. Additionally, the facility failed to ensure proper medication storage on the memory care unit, which affected one resident and had the potential to affect 18 others. Observations revealed an unlocked closet containing multiple medications, a credit card, and a dull knife, with some medications being unlabeled or improperly stored. The DON confirmed that all residents on the memory care unit were confused and wandered independently, highlighting the potential risk posed by the unsecured medications.
Deficiency in CNA Performance Reviews and Training
Penalty
Summary
The facility failed to ensure that Certified Nursing Assistants (CNAs) received performance reviews and necessary training as required. Specifically, the employee file for one CNA, hired on 06/10/22, lacked an annual performance review for 2024. This was confirmed during an interview with the Human Resource representative and the Director of Nursing (DON). Additionally, another CNA's file showed no evidence of annual training for the memory care unit or the required 12 hours of annual in-services. The DON confirmed the absence of this documentation during an interview. These deficiencies had the potential to affect all 85 residents residing in the facility.
Deficiencies in Kitchen Equipment and Supplies
Penalty
Summary
The facility failed to maintain essential kitchen equipment and adequate supplies, impacting the dining experience for all 85 residents. During a lunch observation, it was noted that disposable plates were used due to a shortage of small plates. Interviews with staff revealed that requests for additional plates had been denied, leading to the use of disposables. Additionally, the facility experienced a shortage of plastic and coffee cups, causing delays in meal service as staff had to find alternative solutions. The facility also failed to ensure the oven was in safe operational condition. During a lunch tray line observation, the mashed potatoes were found to be at an insufficient temperature of 109 degrees Fahrenheit due to issues with the oven's pilot light. Staff reported frequent problems with the pilot light going out unexpectedly, which had not been addressed by calling for service. The Dietary Manager was aware of the issue but had not contacted the new contractor due to a recent change in service providers.
Deficiency in CNA Continuing Education
Penalty
Summary
The facility failed to ensure that Certified Nursing Assistants (CNAs) received the required 12 hours of continuing education per year, which is essential for maintaining their skills in resident care, including dementia care and abuse prevention. This deficiency was identified through a review of employee records and staff interviews. Specifically, the employee files for three CNAs, hired on different dates, showed no evidence of completing the mandated continuing education hours. The Human Resource representative and the Director of Nursing confirmed that these employees had not fulfilled the educational requirements, potentially affecting all 85 residents in the facility.
Medication Availability Deficiency in LTC Facility
Penalty
Summary
The facility failed to ensure that medications were available for administration as ordered, affecting four residents. Resident #31, who was admitted with multiple diagnoses including traumatic brain injury and atrial fibrillation, did not receive several doses of meropenem and vancomycin due to unavailability. The physician was not notified of the unavailability until several days later. Interviews confirmed that the facility had ongoing issues with timely medication delivery from a pharmacy located four hours away. Resident #85, diagnosed with conditions such as dementia and hypertension, missed doses of several medications including Vitamin C, Calcium, carvedilol, clonazepam, polymyxin, and pravastatin due to unavailability. An LPN confirmed the unavailability of these medications from the pharmacy. Similarly, Resident #191, admitted with conditions like COPD and sepsis, did not receive multiple medications including amiodarone, budesonide, and Xarelto shortly after admission due to the same issue. The facility's emergency stock did not cover most of these medications, and the pharmacy agreement indicated that emergency delivery should be available. Resident #1, with diagnoses including paraplegia and insomnia, did not receive Dayvigo as ordered for several days in December and January due to the pharmacy delivering insufficient quantities. An LPN confirmed the issue and noted that the resident's insurance was not covering the medication, which was not communicated to the facility in a timely manner. The facility's contracted pharmacy was responsible for delivering medications but failed to provide adequate quantities or timely deliveries, leading to the deficiencies noted in the report.
Medication Storage and Management Deficiencies
Penalty
Summary
The facility failed to ensure proper storage and management of medications, as observed during a survey. On multiple occasions, medication carts were left unlocked and unattended, with keys left in the lock, which was confirmed by the registered nurses responsible for the carts. This occurred on the 400 hall and involved different registered nurses on separate days. The facility's policy requires medication carts to be locked when out of sight, but this was not adhered to, potentially affecting all residents on the 200, 300, and 400 halls. Additionally, the facility did not date insulin flexpens when first used, which is necessary to determine their expiration. Two insulin flexpens, belonging to different residents, were found undated in the 300 hall medication cart. The Director of Nursing confirmed that the flexpens should have been dated to ensure they were disposed of appropriately after 28 days of use. The facility's Insulin Reference Guide specifies that insulin should be stored at room temperature for up to 28 days once in use, but the lack of dating made it impossible to track this timeline accurately.
Inadequate Infection Control Practices in LTC Facility
Penalty
Summary
The facility failed to maintain appropriate infection control practices, particularly in the areas of tracheostomy care, dressing changes, medication administration, and enhanced barrier precautions (EBP). During an initial tour, it was observed that EBP was not implemented for residents with tracheostomies, enteral tubes, indwelling urinary catheters, and dialysis ports. The Director of Nursing confirmed the lack of EBP for residents with wounds and indwelling medical devices, despite the facility's policy requiring such precautions to prevent the transmission of multi-drug-resistant organisms (MDRO). Additionally, the infection control log was found to be inaccurate, failing to track nosocomial bacteria, and the infection control policies had not been reviewed annually. During medication administration, a registered nurse was observed handling medications with bare, un-sanitized hands, breaking tablets without gloves, and failing to perform hand hygiene between handling different medications. This practice was confirmed by the nurse, who admitted to not following the facility's policy on medication administration, which requires hand hygiene and the use of gloves when handling medications. This failure in practice was observed during the administration of medications to two residents, potentially compromising their safety. In the case of Resident #191, who had multiple diagnoses including a tracheostomy and gastrostomy, there was no evidence of EBP being implemented. Nurses were unaware of the requirement for EBP for residents with indwelling medical devices. During tracheostomy care, the nurse failed to maintain a sterile field, did not change gloves or wash hands after cleaning the cannula, and did not wear a gown or mask. Similarly, Resident #1, who had a stage IV pressure ulcer and other medical conditions, did not receive proper wound care. The nurse performed treatments on multiple wounds simultaneously, failed to change gloves and perform hand hygiene between treatments, and used non-disinfected scissors, increasing the risk of cross-contamination and infection.
Failure to Ensure Resident Dignity and Respect
Penalty
Summary
The facility failed to ensure that residents were treated with respect and dignity by nursing staff, specifically affecting Resident #9. Resident #9, who was admitted with multiple diagnoses including anxiety, depression, respiratory disease, diabetes, and was under hospice care, reported that RN #126 was rude and rough during care, such as pulling on her arms when administering insulin. Other residents also expressed concerns about RN #126's behavior, including yelling and rushing during care. Interviews with staff revealed that there were known issues with RN #126's behavior. The Director of Nursing (DON) acknowledged previous concerns and stated that education had been provided to RN #126, but there was no documentation of this in the personnel file. The Social Service Director (SSD) confirmed receiving multiple reports about RN #126's conduct but could not locate the concern forms or confirm that resolutions were communicated to the residents or their representatives. A review of the facility's concern log and personnel files showed a lack of evidence that RN #126 was educated or disciplined for the reported incidents. The facility's policies on grievances and dignity were not followed, as there was no documentation of resolutions being communicated to the residents or evidence of corrective actions taken. This deficiency highlights a failure in the facility's processes to address and resolve grievances effectively, impacting the residents' right to a dignified existence and self-determination.
Failure to Secure Legal Guardian for Resident
Penalty
Summary
The facility failed to ensure that a resident, who no longer had the capacity to make decisions, had a legal guardian in place. The resident, who was admitted with multiple diagnoses including secondary Parkinsonism, diabetes mellitus, aphasia, hyperlipidemia, bipolar disorder, depressive episodes, schizoaffective disorder, anxiety disorder, and dementia, was previously deemed incompetent, and a family member was appointed as the guardian. However, this guardianship was removed in 2017 due to the family member's failure to file necessary reports. Despite this removal, the facility continued to list the family member as the emergency contact and responsible party without any evidence of power of attorney documentation. Interviews with facility staff revealed that there was no financial power of attorney or guardianship in place for the resident, and the county lacked available guardians. The Business Office Manager and Secretaries indicated that a local attorney was providing guardianship services, but the facility had not initiated the process to secure a guardian for the resident. The Administrator was unaware of the local attorney's services and stated that the necessary documents would be sent to begin the guardianship process. This oversight affected the resident's ability to have their rights exercised through a legal representative.
Failure to Notify Resident of SSI Resource Limit
Penalty
Summary
The facility failed to notify a resident receiving Medicaid benefits when the amount in the resident's account reached $200 less than the SSI resource limit for one person. This oversight could potentially affect the resident's eligibility for Medicaid or SSI. The deficiency was identified during a review of financial records and a staff interview, which revealed that the facility managed the funds for the resident in question. The resident's account balance had been greater than $1800 since October 1, 2024, and as of the current review, the balance was $1950.97. The Business Office Manager confirmed that the resident received Medicaid benefits and that the balance was within $200 of the resource limit, yet no attempts were made to obtain a guardian to manage the resident's funds.
Inconsistent Code Status Documentation for Residents
Penalty
Summary
The facility failed to ensure that the code status of residents was consistent and accurately documented, affecting three residents. Resident #54 was admitted with multiple diagnoses, including malignant neoplasm of the liver and congestive heart failure. Despite having a DNRCC-A order, there was no signed code directive in the medical record or code status binder. An RN confirmed the absence of a signed directive and had to contact hospice to verify the code status, which was found to be DNRCC instead of DNRCC-A. Resident #191, admitted with conditions such as chronic obstructive pulmonary disease and acute respiratory failure, had a hospital discharge note indicating a DNRCC-A status. However, there were no orders for the resident's code status in the facility's records. An RN confirmed the lack of an order and noted that the face sheet incorrectly listed the resident as full code, which was not updated in the system. Resident #85, with diagnoses including vascular dementia and PTSD, had conflicting code status documentation. Hospital paperwork indicated a full code status, but an order in the facility's records showed a DNR/DNI status. The DON confirmed the discrepancy, stating that the family had chosen a full code status upon admission, but the order was not updated. This inconsistency could have led to the resident not being resuscitated if needed, due to the incorrect DNR order in place.
Failure to Notify Representatives of Medical Changes
Penalty
Summary
The facility failed to notify legal representatives of changes in medical orders or conditions for two residents. Resident #85, diagnosed with vascular dementia, PTSD, and idiopathic gout, had multiple instances where new medical orders were issued without notifying the resident's representative. These included orders for x-rays, COVID tests, and various medications and lab tests. Interviews with the resident's family and the Director of Nursing confirmed the lack of communication regarding these changes. Similarly, Resident #19, who has a severe cognitive deficit and multiple diagnoses including Parkinsonism and diabetes, had new lab orders issued without notifying the resident or their representative. The facility's policy requires notifying the resident's physician and representative of significant changes, but this was not adhered to in these cases. The Director of Nursing verified the oversight in communication for Resident #19.
Failure to Report and Investigate Alleged Sexual Abuse
Penalty
Summary
The facility failed to report an allegation of sexual abuse involving two residents in the memory care unit. Resident #27, who has dementia and other cognitive impairments, was involved in a sexual incident with Resident #21, who also has severe cognitive impairment and a history of mental health issues. The incident was not documented in Resident #27's medical record, and there was no evidence that the resident was assessed for injury or ability to consent, nor was the legal guardian notified. The incident was first noted in a psychiatric consult note for Resident #21, indicating that staff were trying to keep the residents apart. However, there was no documentation of the incident in Resident #27's medical record, and no evidence of an assessment or notification to the resident's legal guardian. Additionally, the facility did not implement any interventions to prevent further incidents, and there was no evidence of a comprehensive assessment or care plan regarding the ability to consent to sexual activity for Resident #27. Interviews with staff revealed that the incident was known among staff members, but it was not reported to the Director of Nursing or the State agency. The Director of Nursing was unaware of the incident until the surveyor's interview. The facility's policy requires all allegations of abuse to be reported immediately, but this protocol was not followed, resulting in a failure to report and investigate the incident as required.
Failure to Investigate Allegation of Sexual Abuse
Penalty
Summary
The facility failed to thoroughly investigate an allegation of sexual abuse involving two residents on the memory care unit. Resident #27, who had a court-appointed legal guardian due to cognitive impairment, was found in a compromising situation with Resident #21. Despite the incident being documented in Resident #21's psychiatric consult note, there was no evidence of an investigation or notification to Resident #27's legal guardian. The care plan for Resident #27 did not address sexually inappropriate behaviors, and there was no assessment of his ability to consent to sexual activity. Resident #21, also with a court-appointed legal guardian, was involved in the incident and had severe cognitive impairment. Her care plan did not include sexually inappropriate behaviors, and there was no evidence of additional interventions to prevent further incidents. A pregnancy test was ordered for Resident #21, but there was no documentation of the facility reporting the incident as sexual abuse or conducting an investigation. The facility's policy required immediate reporting and investigation of abuse allegations, which was not followed in this case. Interviews with the Director of Nursing (DON) revealed a lack of awareness of the incident and the pregnancy test for Resident #21. The DON confirmed that Resident #27 could not consent to sexual activity due to cognitive impairment and expressed expectations for staff to report such incidents immediately. However, the incident was not reported to the State agency or investigated as required by the facility's policy.
Failure to Notify Ombudsman of Resident's Hospital Transfer
Penalty
Summary
The facility failed to notify the local Ombudsman of a resident's transfer to the hospital, as required by regulations. This deficiency was identified through a review of the resident's medical records, email correspondence, and staff interviews. The resident in question was admitted to the facility with multiple diagnoses, including Hodgkin lymphoma, end-stage renal disease, and diabetes mellitus. On a specific date, the resident was sent to the emergency room at the family's request, but the facility did not document the specific change in condition that prompted this action. The transfer was noted in the resident's electronic medical record, but the notification to the Ombudsman was not completed. The Social Service Director (SSD) responsible for notifying the Ombudsman confirmed that the resident's transfer was not included in the monthly discharge summary report sent to the Ombudsman. The report listed other discharges and transfers, but not the one involving this resident. The SSD could not explain why the resident's transfer was omitted from the report, despite it occurring within the specified time frame. There was no other documented evidence that the Ombudsman had been notified of the transfer, highlighting a lapse in the facility's compliance with notification requirements.
Inaccurate MDS Assessments for Dialysis and Dental Care
Penalty
Summary
The facility failed to ensure accurate Minimum Data Set (MDS) assessments for two residents, leading to deficiencies in the areas of dental care and dialysis. For one resident, the medical record indicated a history of multiple serious health conditions, including partial traumatic amputation, osteomyelitis, and diabetes mellitus with neuropathy. Despite these conditions, the resident's care plan did not address dialysis or potential infection risks related to a central line. Furthermore, the resident's quarterly MDS assessment inaccurately reported that the resident had not received dialysis services, and there were no physician orders for offsite hemodialysis. The Director of Nursing (DON) confirmed that the MDS was not coded correctly to reflect the resident's hemodialysis needs. Another resident's medical record showed a history of metabolic encephalopathy, sepsis, epilepsy, and schizophrenia, among other conditions. The resident's admission assessment noted natural teeth without cavities or broken teeth, and the care plan included interventions for potential mouth pain. However, a later observation revealed the resident had multiple black broken teeth with obvious caries, which was not reflected in the MDS assessment. The DON verified that the oral assessments and MDS failed to accurately document the resident's dental condition.
Failure to Complete Significant Change MDS for Hospice Admission
Penalty
Summary
The facility failed to complete a significant change Minimum Data Set (MDS) assessment for a resident within 14 days of the resident's admission to hospice services. The resident, who was admitted to the facility with diagnoses including abdominal aortic aneurysm without rupture, malignant neoplasm of the prostate, and unspecified dementia, was referred to hospice by their family. The resident was admitted to hospice services for senile degeneration of the brain. Despite this significant change in the resident's condition, the required MDS assessment was not completed within the mandated timeframe. An interview with the MDS Nurse confirmed the oversight, acknowledging that the significant change MDS was not conducted as required.
Failure to Complete Significant Change PASARR for New Schizophrenia Diagnosis
Penalty
Summary
The facility failed to complete a significant change Pre-Admission Screening and Resident Review (PASARR) for a resident when a new mental health diagnosis of schizophrenia was added. This deficiency was identified during a review of the medical record for a resident who was initially admitted on an unspecified date and had a latest readmission on 06/02/23. The resident's diagnoses included metabolic encephalopathy, sepsis, acidosis, epilepsy, solitary pulmonary nodule, dementia with behavioral disturbances, and other conditions. The diagnosis of schizophrenia was added on 09/20/24, but a significant change PASARR was not completed as required. The resident's plan of care, dated 11/22/24, included various interventions to manage schizophrenia, such as maintaining a calm environment, monitoring behavior, and administering psychotropic medications. Despite these interventions, the facility did not adhere to its policy, which mandates screening for mental health disorders and intellectual disabilities for all new admissions and readmissions. The Director of Social Services confirmed that the significant change PASARR was not completed when the schizophrenia diagnosis was added, indicating a lapse in following the facility's established procedures.
PASARR Assessment Inaccuracy for Resident with PTSD
Penalty
Summary
The facility failed to ensure the accuracy of a pre-admission screening and resident review (PASARR) assessment for a resident upon admission. This deficiency affected a resident who was admitted with diagnoses including vascular dementia with agitation, post-traumatic stress disorder (PTSD), and idiopathic gout. Upon review, it was found that the PASARR completed on 11/21/24 did not list PTSD as a serious mental illness. This oversight was confirmed during an interview with the Social Services Director, who acknowledged that PTSD was not included in the PASARR for the resident.
Incorrect PASARR Diagnosis for Resident
Penalty
Summary
The facility failed to ensure that a significant change Pre-Admission Screening and Resident Review (PASARR) for a resident included the correct developmental disability diagnosis. This deficiency affected one resident who was admitted with diagnoses including schizoaffective disorder, altered mental status, schizophrenia, and moderate intellectual disabilities. However, the PASARR completed on 08/05/24 did not reflect the resident's diagnosis of moderate intellectual disabilities. This oversight was confirmed during an interview with the Social Services Director, who acknowledged that the diagnosis was not listed on the PASARR.
Failure to Develop Comprehensive Care Plans for Residents
Penalty
Summary
The facility failed to develop comprehensive care plans for three residents, leading to deficiencies in addressing their specific medical needs. Resident #30, who had multiple diagnoses including partial traumatic amputation and diabetes, lacked a care plan for dialysis and potential infection related to the central line. The resident's quarterly Minimum Data Set (MDS) assessment did not reflect the need for dialysis services, and there were no physician orders for offsite hemodialysis. The Director of Nursing confirmed the absence of a comprehensive assessment for the resident's hemodialysis needs. Resident #38, with diagnoses including schizophrenia and dementia, had a care plan that failed to address her dental issues, despite observations of multiple black broken teeth with caries. The resident's assessments did not reflect these dental problems, and the Director of Nursing verified the care plan's inadequacy. Additionally, Resident #31, who was required to wear a safety helmet due to a traumatic brain injury, had no care plan addressing this safety measure. A Registered Nurse confirmed the absence of a care plan for the safety helmet, despite the existing order for its use.
Deficiencies in Care Planning and Conferences
Penalty
Summary
The facility failed to ensure comprehensive care plans were up to date for two residents and did not complete quarterly care conferences for another resident. Resident #21, who was admitted with diagnoses including anoxic brain damage and bipolar disorder, did not have a care plan for sexually inappropriate behaviors despite an incident where she was found in a male resident's room with her shirt up. Interviews with the Social Services Director and MDS Nurse revealed confusion over responsibility for updating behavior care plans, and the Director of Nursing confirmed the care plan was not updated. Resident #71, admitted with diagnoses including atrial fibrillation and dementia, exhibited aggressive behaviors, including an incident where he wrapped his hands around a CNA's neck. Despite these behaviors being documented in the MDS, there was no care plan addressing them. Interviews with staff confirmed the absence of a behavior care plan and highlighted a lack of clarity regarding who was responsible for completing these plans. Resident #1, with multiple diagnoses including paraplegia and a Stage IV pressure ulcer, did not have a quarterly care conference despite having a quarterly MDS assessment completed. The resident reported only attending one care conference since admission and expressed a desire to participate in more. The Social Services Director acknowledged the backlog in scheduling care conferences and the difficulty in coordinating the interdisciplinary team, resulting in the resident being overdue for a care conference.
Failure to Provide Comprehensive Discharge Summary
Penalty
Summary
The facility failed to complete a discharge summary that included a recapitulation of a resident's stay, affecting one resident who was discharged to their home. The resident had a complex medical history, including conditions such as traumatic subdural hemorrhage, rhabdomyolysis, diabetes mellitus, and hypertension, among others. Upon review, it was found that the discharge instructions provided to the resident did not include a recapitulation of the resident's stay, which is a requirement according to the facility's policy. The discharge instructions only included physician orders and a list of medications, without a comprehensive summary of the resident's medical history and care received during their stay. The facility's policy mandates that a discharge summary should include a detailed recapitulation of the resident's stay, including diagnoses, medical history, treatment, and current status at the time of discharge. However, the medical record review revealed no documented evidence of such a summary for the resident in question. An interview with the Social Service Director confirmed the absence of a discharge summary that included a recapitulation of the resident's stay, indicating a lapse in adherence to the facility's discharge policy.
Failure to Provide Necessary Nail Care for Dependent Resident
Penalty
Summary
The facility failed to provide necessary personal care assistance to a resident who was dependent on staff for activities of daily living (ADLs), specifically nail care. The resident, who had a severe cognitive deficit and multiple diagnoses including Alzheimer's disease, dementia, and chronic kidney disease, was observed on two separate occasions with long, jagged nails and a brown substance underneath them. The resident's care plan indicated a need for staff assistance with ADLs, yet the observations and staff interviews confirmed that the required nail care was not provided.
Deficiencies in UTI Treatment and Catheter Care
Penalty
Summary
The facility failed to treat a resident for a urinary tract infection (UTI) in a timely manner. Resident #11, who had multiple diagnoses including osteoarthritis, major depressive disorder, and palliative care, believed she had a urine infection. A urine sample was sent for analysis on 09/30/24, and the results, which showed a significant bacterial infection, were available on 10/03/24. However, the facility did not start treatment with the prescribed antibiotic, Macrobid, until 10/07/24, due to delays in obtaining the results and the medication. Additionally, the facility failed to provide routine indwelling urinary catheter care for Resident #1, who had a supra-pubic catheter due to neuromuscular dysfunction of the bladder. The resident's care plan required catheter care every shift, but interviews revealed that staff were not aware of this requirement and were only providing care once a day. The resident confirmed she was not receiving the prescribed care and was not performing her own catheter care, contrary to what some staff believed. The facility's policy on urinary catheter care was found to be vague and did not specify the frequency of care required, contributing to the inconsistency in care provided to Resident #1. These deficiencies affected the quality of care for the residents involved, as timely treatment and proper catheter care are essential to prevent complications such as UTIs.
Failure to Implement Dietary Recommendations and Obtain Daily Weights
Penalty
Summary
The facility failed to implement dietary recommendations and obtain physician-ordered daily weights for a resident with multiple health conditions, including partial traumatic amputation, diabetes, and end-stage renal disease. The resident's care plan required increased caloric and protein intake, and the resident was on a physician-prescribed weight loss regimen. Despite these requirements, the facility did not consistently obtain the resident's daily weights as ordered by the physician, missing several days over a period of months. Additionally, the Registered Dietician (RD) recommended adding a renal diet and double protein portions to the resident's meals, but these recommendations were not implemented. The Director of Nursing confirmed the failure to obtain daily weights, and the RD verified that the dietary recommendations had not been followed. The facility's policy required weights to be obtained and documented in a timely manner, but this was not adhered to, leading to the deficiency.
Deficiencies in Respiratory Care and Medication Administration
Penalty
Summary
The facility failed to provide adequate respiratory care for three residents, leading to several deficiencies. Resident #191, who had multiple diagnoses including chronic obstructive pulmonary disease and a tracheostomy, did not have oxygen orders upon admission. Observations revealed improper storage of respiratory equipment, such as a nebulizer mouthpiece lying on a chair without a barrier and a used tracheostomy mask not discarded. Emergency tracheostomy supplies were not readily available, and staff were unsure of the resident's cannula size. The facility lacked a policy for nebulizer storage and care, and the resident's inhalation treatments were administered incorrectly, mostly orally instead of via trach. Resident #67, diagnosed with chronic obstructive pulmonary disease and other respiratory conditions, did not receive medications as ordered. During medication administration, only one tablet of Norvasc was given instead of two, and the resident was not instructed to rinse their mouth after using Breztri, as required to prevent oropharyngeal candidiasis. The facility's policy on medication administration was not followed, as the five rights of medication administration were not adhered to. Resident #57, with a history of Alzheimer's disease and dementia, was observed using oxygen without a physician's order. The resident's oxygen tubing was found on the floor and reused without proper sanitation. The facility's policy on oxygen administration was not followed, as there was no documentation of the procedure, and the oxygen setup lacked humidification. The resident's care plan did not address oxygen use, and there was no evidence of when and why oxygen therapy was initiated.
Failure to Provide Appropriate Dialysis Care
Penalty
Summary
The facility failed to provide appropriate dialysis care for a resident who required such services. The resident, who had multiple medical conditions including partial traumatic amputation, osteomyelitis, and diabetes, did not have a care plan addressing dialysis or potential infection risks related to the central line. The resident's quarterly Minimum Data Set (MDS) assessment did not reflect the receipt of dialysis services, and there were no physician orders specifying the dialysis center details or schedule. Additionally, there was no evidence of communication forms, lab results, or coordination between the facility's dietician and the dialysis center. Interviews revealed that the resident attended dialysis sessions three times a week without a communication form from the facility. The Director of Nursing was unaware that staff nurses were not providing the necessary forms. The Dialysis Registered Dietician confirmed a lack of communication with the facility, noting that the resident was weighed independently at the dialysis center. The facility's policy required specific physician orders and communication protocols, which were not followed, leading to a deficiency in the resident's dialysis care.
Failure to Conduct Trauma Assessment for Resident with PTSD
Penalty
Summary
The facility failed to adequately assess, implement, and monitor trauma-informed care for a resident with known post-traumatic stress disorder (PTSD). The resident, who was admitted with multiple diagnoses including PTSD, was not provided with a comprehensive trauma assessment to identify the causes of PTSD, triggers, and preferences to mitigate potential re-traumatization. The plan of care for the resident included interventions such as identifying and avoiding triggers, encouraging family support, and providing supportive counseling, but there was no evidence in the medical record that a trauma assessment was completed. The facility's policy on Trauma Informed Care, dated March 2019, outlines the need for staff to be trained on screening tools, trauma assessments, and identifying triggers associated with re-traumatization. However, during an interview, the Social Service Director confirmed that a trauma assessment had not been completed for the resident. This oversight affected the resident's care, as the facility did not follow its own policy to ensure appropriate and compassionate care for individuals who have experienced trauma.
Failure to Provide Psychiatric Referrals and Behavioral Interventions
Penalty
Summary
The facility failed to ensure that a resident with a history of mental health issues received appropriate psychiatric referrals and interventions. Resident #85, who was admitted with diagnoses including dementia, PTSD, insomnia, generalized anxiety, and wandering, was prescribed medications such as clonazepam and Zyprexa for anxiety and agitation. Despite physician notes indicating the need for psychiatric follow-up, there was no evidence in the medical record that such a referral was made until the issue was identified during a survey. This oversight left the resident without the necessary psychiatric evaluation and support. Additionally, the facility did not implement interventions to address aggressive behaviors in Resident #71, who was admitted with diagnoses including atrial fibrillation, dementia, and anxiety disorder. The resident exhibited severe cognitive impairment and aggressive behaviors, including an incident where he physically assaulted a CNA. Despite these behaviors, there was no care plan in place to manage the aggression, and the resident had not been seen by psychiatric services to address the increase in behaviors. The lack of timely psychiatric evaluation and intervention contributed to ongoing aggressive incidents, affecting both staff and potentially other residents.
Failure to Respond to Pharmacy Recommendations
Penalty
Summary
The facility failed to ensure timely or any response from physicians to pharmacy recommendations resulting from monthly medication regimen reviews for two residents. Resident #1, who had multiple psychiatric diagnoses, was affected by this deficiency. Over a 12-month period, the contracted pharmacist made several recommendations regarding the resident's medications, including Aripiprazole, Bupropion ER, Belsomra, Fluoxetine, and Rozerem. However, there was no documented evidence of the physician responding to these recommendations, and the resident continued to receive the medications at the same doses, contrary to the pharmacist's advice. Resident #19, who had severe cognitive deficits and multiple psychiatric and medical conditions, was also affected. The pharmacist recommended specific laboratory tests to be conducted every six months, which the physician agreed to. However, the facility's records showed no orders for these tests, and the Director of Nursing confirmed that the recommended laboratory tests were not implemented. The facility's policy required the consulting pharmacist to provide a written report of any medication irregularities to the attending physicians, who were then supposed to document their review and actions taken. If the physician did not respond timely, the pharmacist was to contact the medical director or administrator. The facility failed to adhere to this policy, as evidenced by the lack of physician responses and the continuation of medication regimens without necessary evaluations.
Failure to Ensure Residents Were Free from Unnecessary Medications
Penalty
Summary
The facility failed to ensure that residents were free from unnecessary medications, affecting three residents. Resident #85, who had multiple diagnoses including dementia and anxiety, was ordered a lidocaine patch but refused its application and removal multiple times without the provider being notified. Additionally, Resident #85 was prescribed polymyxin eye drops without specifying which eye, and the medication was not administered for the full duration as ordered due to availability issues. Resident #191, with a history of chronic obstructive pulmonary disease and other serious conditions, was prescribed oxycodone with specific parameters for administration based on pain levels. However, the facility failed to document the pain ratings and did not follow the specified parameters, leading to incorrect administration of the medication. The Nurse Practitioner confirmed that the orders were not followed as intended, and the staff did not document the necessary pain assessments. Resident #74, diagnosed with adult-onset diabetes mellitus, had orders for insulin administration based on a sliding scale. The facility failed to notify the physician when the resident's blood sugar levels were outside the specified parameters and did not administer additional insulin as ordered. The Director of Nursing confirmed the lack of documentation and adherence to the physician's orders, resulting in the resident not receiving the necessary insulin coverage during critical times.
Deficiencies in Psychotropic Medication Management
Penalty
Summary
The facility failed to ensure proper administration and assessment of psychotropic drugs for three residents, leading to deficiencies in medication management. Resident #85 was admitted with multiple diagnoses, including dementia and anxiety, and was prescribed clonazepam and Zyprexa without appropriate indications or follow-up. The resident's medical records lacked evidence of a referral to psychiatric services and an AIMS test, which is necessary for monitoring antipsychotic medication effects. Interviews with staff confirmed the absence of a psychiatric referral and the lack of a stop date for the as-needed clonazepam order. Resident #191 was admitted with a complex medical history and was prescribed Xanax for anxiety and panic disorder. However, the medication was incorrectly entered into the medical record as scheduled rather than as needed, leading to unnecessary administration. The resident expressed a desire to discontinue Xanax unless absolutely necessary, and the facility acknowledged the error in medication entry. Interviews with staff confirmed the discrepancy between the hospital discharge orders and the facility's medication administration records. Resident #19, with a history of Parkinsonism and multiple psychiatric disorders, was prescribed Buspar for anxiety. Despite a psychiatric consult recommending discontinuation of Buspar due to its redundancy with other serotonergic agents, the medication continued to be administered. The Director of Nursing verified that the discontinuation order was not implemented, resulting in continued administration of an unnecessary medication. These findings highlight the facility's failure to adhere to its policy on antipsychotic medication use and the need for proper medication management and oversight.
Failure to Obtain Physician-Ordered Lab Tests
Penalty
Summary
The facility failed to ensure that physician-ordered laboratory tests were obtained for two residents, leading to a deficiency in meeting the residents' diagnostic and monitoring needs. Resident #19, who has a complex medical history including secondary Parkinsonism, diabetes mellitus, and dementia, had physician orders for several laboratory tests to be conducted annually in July. However, there was no evidence in the medical record that these tests were performed in July 2024, nor was there documentation of the resident refusing the tests. The Director of Nursing (DON) confirmed that the tests had not been drawn, despite contacting the contracted lab for results. Similarly, Resident #38, who was readmitted with multiple diagnoses including metabolic encephalopathy and schizophrenia, had a physician order for hemoglobin A1c (HgbA1c) tests to be conducted every six months. The medical record lacked evidence that these tests were performed as ordered. The DON confirmed that the HgbA1c tests were not drawn according to the physician's orders. The facility's policy on lab results requires staff to process test requisitions and arrange for tests, but this was not adhered to in these cases.
Failure to Provide Routine Dental Care
Penalty
Summary
The facility failed to ensure that a resident received routine dental care, as required by their plan of care. The resident, who was admitted with multiple diagnoses including dental caries, had not been seen by a dentist since August 2023. Despite having natural teeth with no cavities or broken teeth noted during initial assessments, an observation in January 2025 revealed multiple black broken teeth with obvious caries. This indicates a deterioration in the resident's dental health that was not addressed in a timely manner. The facility's policy on dental services states that routine and emergency dental services should be available to meet residents' oral health needs. However, the resident's medical record and an interview with the Director of Nursing confirmed that the resident had not received dental care since August 2023. This lack of routine dental care was not in accordance with the resident's assessment and plan of care, which included interventions for potential mouth pain and the need for dental evaluation and intervention as needed.
Deficiencies in Medical Record Documentation for Residents
Penalty
Summary
The facility failed to maintain complete and accurate medical records for three residents, leading to deficiencies in care documentation. For Resident #57, there was no care plan addressing oxygen use, despite the resident experiencing wheezing and shortness of breath, and being started on oxygen therapy without documented physician orders. The resident's medical record lacked evidence of when and why oxygen therapy was initiated, and the LPN confirmed the absence of physician orders for oxygen use. Resident #11's medical record showed an order for Cipro to treat a urinary tract infection, but there were no laboratory results or documentation related to this order. The Director of Nursing confirmed the lack of documentation. For Resident #85, orders for several laboratory tests were noted, but there was no evidence in the medical record that these tests were completed. An LPN stated that the tests were completed but not scanned into the medical record, and she could not provide printed results, only showing them in the laboratory portal.
Inadequate Documentation for Antibiotic Use
Penalty
Summary
The facility failed to ensure an appropriate reason for the use of an antibiotic for a resident, which was identified during a review of the medical records. The resident, who had a history of multiple medical conditions including osteoarthritis, major depressive disorder, and hypertension, was prescribed Cipro 500 mg for a urinary tract infection. However, there were no laboratory results or documentation in the medical record to support the use of this antibiotic. The resident's quarterly Minimum Data Set (MDS) assessment indicated a moderate cognitive deficit and incontinence of both bowel and bladder, but it did not show any treatment for an infection in the past 30 days. An interview with the Director of Nursing (DON) confirmed the absence of supporting documentation for the antibiotic prescription. The facility's policy on Antibiotic Stewardship, which aims to promote the appropriate use of antibiotics, was not adhered to in this case. The policy requires providers to utilize specific criteria when considering the initiation of antibiotics, and there was no evidence that these criteria were reviewed or met before prescribing the medication to the resident.
Failure to Administer Requested Vaccinations
Penalty
Summary
The facility failed to ensure that two residents received vaccinations as requested, which was identified during a review of medical records and interviews. Resident #40, who was admitted with multiple diagnoses including dementia, UTI, COPD, and diabetes, consented to receive the influenza, pneumonia, and COVID-19 vaccines. While the resident received the influenza vaccine, there was no documented evidence of the pneumonia vaccine being administered, despite the resident's consent. This was confirmed in an interview with the Director of Nursing (DON). Resident #30, who was admitted with conditions such as partial traumatic amputation, osteomyelitis, and diabetes, did not have an immunization consent packet for the 2024-2025 season in their medical record. The resident's family member was the financial POA but not the healthcare POA, and the resident was considered their own person. The DON confirmed that the resident had not received the flu and pneumonia vaccinations as requested. The facility's policies stated that all residents should be offered these vaccines, but this was not adhered to in these cases.
Failure to Administer COVID-19 Vaccinations as Requested
Penalty
Summary
The facility failed to ensure that two residents received COVID-19 vaccinations as requested, which was identified during a review of medical records and interviews. Resident #40, who was admitted with multiple diagnoses including dementia, UTI, COPD, and diabetes, had consented to receive the COVID-19 vaccine as per the admission immunization consent packet dated 10/08/24. However, there was no documented evidence in the medical record that the resident received the vaccination. This was confirmed during an interview with the Director of Nursing (DON), who acknowledged that the resident had requested the vaccine but was not provided with it. Similarly, Resident #30, who was admitted with conditions such as partial traumatic amputation, osteomyelitis, and diabetes, did not have an immunization consent packet for the 2024-2025 season in their medical record. The resident's family member was noted as the financial POA but not the healthcare POA. The DON confirmed that the resident was capable of making their own healthcare decisions and had requested the COVID-19 vaccination, which was not administered. The DON was attempting to contact the resident's POA to address the issue.
Failure to Provide Timely Wound Care
Penalty
Summary
The facility failed to provide appropriate wound care to a resident, identified as Resident #56, who was admitted with multiple complex medical conditions, including a recent transmetatarsal amputation and a chronic non-pressure ulcer on his right heel. Upon admission, the resident's medical records did not include treatment orders for wound care, despite the presence of detailed instructions from the hospital discharge summary. The facility did not implement the necessary wound care treatments until two days after the resident's admission, resulting in a delay in care. The resident's care plans were initiated several days after admission, and the initial treatment orders were not consistent with the podiatrist's instructions from the hospital. The facility's documentation was incomplete, as there was no evidence of wound assessments being conducted upon admission or weekly thereafter, as required by the facility's policy. Interviews with staff, including RN #100 and the Director of Nursing, confirmed the absence of treatment orders and assessments, and acknowledged that the care provided did not align with the prescribed treatment plan. The resident expressed dissatisfaction with the care received, noting that wound care was not provided consistently until after a follow-up appointment with the podiatrist. The podiatrist's examination revealed that the resident's dressings had been changed only once since admission, prompting new orders for daily dressing changes. The facility's failure to adhere to its wound care policy and the lack of timely and appropriate treatment orders contributed to the deficiency identified in this report.
Failure to Administer Antibiotic Therapy Timely
Penalty
Summary
The facility failed to ensure timely administration of antibiotic therapy for a resident diagnosed with a urinary tract infection (UTI). The resident, who had a history of malignant neoplasm of the anus, hemiplegia, hemiparesis, aphasia, and dysphagia, was ordered Bactrim DS for the treatment of a UTI. Despite the order being placed on 10/17/24, the medication was not administered until 10/21/24, resulting in five missed doses. The nurses documented that the medication was unavailable and they were awaiting delivery, although the facility's Omnicell medication dispensing system had the medication in stock. The Director of Nursing confirmed that the Omnicell system contained the required medication, with 23 tablets available on 10/18/24. An RN involved in the case admitted to not recognizing the medication listed as SMZ-TMP on the Omnicell inventory as the same as Bactrim DS, leading to the oversight. This deficiency was identified during a complaint investigation, highlighting a lapse in medication administration processes within the facility.
Failure to Provide Appropriate Gastrostomy Tube Care
Penalty
Summary
The facility failed to provide appropriate care and treatment for a resident with a gastrostomy tube, as evidenced by a lack of documented care for the tube site. The resident, who had a history of hemiplegia, hemiparesis, dysphagia, and aphasia following a stroke, was admitted with a gastrostomy tube for nutritional support. Despite having physician's orders for tube feeding, there were no orders for gastrostomy site care until ten days after admission. The care plan for the resident did not include interventions for tube site care, and the treatment administration record showed no evidence of care being provided until 10 days post-admission. Interviews with the resident's representative and the facility's Director of Nursing (DON) revealed concerns about the lack of care for the gastrostomy site. The resident's representative noted that the dressing appeared unchanged and dirty, with visible drainage. The DON confirmed the absence of documented care prior to a specific date and acknowledged that the care provided was not adequately described. The deficiency was identified during an investigation under a specific complaint number.
Failure to Document Controlled Medication Administration
Penalty
Summary
The facility failed to ensure proper documentation and reconciliation of controlled medications administered to a resident. Specifically, the administration of Morphine Sulfate, a controlled narcotic pain medication, was not consistently recorded on the Controlled Drug Use Record sheets, despite being documented on the Medication Administration Records (MARs). This discrepancy was identified for a resident who was under hospice care and had been prescribed Morphine Sulfate to be administered orally every hour as needed. The MARs for September and October indicated multiple doses were given, but these were not reflected on the Controlled Drug Use Record, leading to a lack of proper reconciliation. The Director of Nursing (DON) confirmed the missing documentation during an investigation into reports of missing Morphine Sulfate. Although the DON was able to account for the liquid Morphine by reviewing the MARs and Controlled Drug Use Record, it was confirmed that not all doses recorded on the MARs were documented on the Controlled Drug Use Record. Additionally, a second sheet of the Controlled Drug Use Record, which should have contained further documentation of doses administered before the resident's discharge, was missing. The facility's policy required all controlled medications to be documented and reconciled, but this was not adhered to, resulting in the deficiency.
Medication Dating Deficiency in LTC Facility
Penalty
Summary
The facility failed to ensure that medications were properly dated when first accessed or used, affecting three of four medication administration carts and a total of eight residents. During an observation of the 400 hall medication administration cart, it was found that multiple vials of Lantus insulin for two residents were opened without any dates indicating when they were first accessed. Additionally, a bottle of Latanoprost ophthalmic solution was opened without a date, making it unclear when it should be discarded. These findings were verified by the LPN present during the observation. Further observations on the 300 hall medication administration cart revealed three bottles of liquid medicine that were opened but not dated. This included a stock bottle of Maalox, a bottle of Lactulose solution, and a bottle of syrup for different residents. The RN present confirmed that these bottles should have been dated when first opened to determine when they should be discarded. On the 200 hall, a Lantus flexpen and a Novolog flexpen were found in use without any dates indicating when they were first used. Additionally, two Tresiba flexpens were found, one of which was not dated, and the other was improperly stored. The RN confirmed that all multi-use flexpens should be dated when first used and that the unused flexpen should have been refrigerated. The facility's policy on medication storage was reviewed, revealing that drugs and biologicals should be stored securely and not used if outdated or deteriorated.
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A resident with intact cognition receiving Medicare Part A skilled services for metabolic encephalopathy had services discontinued while benefit days remained, but the facility did not issue the required Skilled Nursing Facility Advance Beneficiary Notice (SNF ABN). The Social Services Director later confirmed that no SNF ABN was provided and reported she believed only a Notice of Medicare Non-Coverage (NOMNC) was needed when all skilled services were stopped. This practice conflicted with the facility’s written policy, which required SNF ABNs to be issued when extended care items or services were initiated, reduced, or terminated due to expected non-coverage by Medicare.
Surveyors identified that the facility exceeded the acceptable medication error rate when two residents with type 2 DM received insulin doses that were not administered according to orders or manufacturer instructions. In two separate observations, an LPN administered Novolog and another LPN administered insulin glargine and insulin lispro without priming the insulin pens, and the insulin lispro and Novolog were given after the residents had already consumed a significant portion of their breakfast meals, despite orders for administration before meals. Manufacturer information for both insulin products required priming before each injection to ensure accurate dosing, and facility policy required medications, including insulin, to be administered safely, timely, and in accordance with prescriber orders and specified time frames.
Surveyors found that the facility failed to document tray line food temperatures for multiple meals served from two dining room kitchenettes, despite having a “Trayline Taste & Temperature Log” and a policy requiring food to be stored, prepared, distributed, and served according to professional food safety standards. Review of logs showed repeated missing entries for breakfast, lunch, and dinner services in both the Harrison and McClellan dining areas, and the Senior Director of Culinary Services confirmed that temperatures had not been recorded for those meals, potentially affecting all residents receiving meals from those kitchenettes.
The facility failed to conduct and document required periodic care conferences for two residents, despite multiple comprehensive, quarterly, and significant change MDS assessments and a policy requiring periodic care conferences with resident and/or family participation. One resident with Parkinson’s disease, post-stroke hemiplegia, TIA, DMII, and depression had only two documented care conferences over a year, while another resident with aphasia, cerebrovascular disease, DMII, gait difficulty, coagulation defect, depression, and muscle weakness had no documented care conferences in the past year, aside from a declined invitation to the representative. The UCC confirmed that care conferences were expected to occur quarterly and that no additional documentation existed for either resident.
A resident with Alzheimer's disease and type II DM, who required extensive assistance with ADLs and was receiving scheduled Lantus and sliding-scale Humalog, experienced a severely elevated blood glucose level. The on-call provider was notified and ordered an additional dose of lispro insulin with a directive to recheck the blood glucose after administration. Nursing staff administered the extra insulin but did not document any follow-up blood glucose check, and the DON confirmed that this reevaluation was required by the facility's abnormal blood glucose policy and was not completed or documented.
A resident with Parkinson’s disease, dementia, and hypothyroidism was prescribed levothyroxine once daily along with other medications. A consultant pharmacist’s monthly drug regimen review recommended that levothyroxine be given in the morning on an empty stomach, 30–60 minutes before food, per manufacturer instructions. The medical record contained no documented physician response to this recommendation, and the MAR showed the drug scheduled for morning administration while the resident was observed eating breakfast and receiving the medication at the same time. An LPN confirmed administering levothyroxine during the meal, and the DON verified there was no documentation explaining whether or why the pharmacist’s recommendation was or was not followed, resulting in a failure to act on and document the identified irregularity.
A resident with severe cognitive impairment, multiple comorbidities, documented gait and balance abnormalities, and a high fall risk was care planned and assessed by therapy to require contact guard assistance and use of a gait belt for transfers and ambulation. While being assisted by a CNA from a recliner to the bathroom with a walker, the CNA did not apply a gait belt, even though the resident had a known tendency to lean backward when standing. As the CNA reached to open the bathroom door, the resident lost balance and fell backward, striking the back of the head, and was later found by an LPN without a gait belt in place, contrary to the facility’s gait belt policy and the resident’s assessed needs.
A resident with CKD stage five requiring peritoneal dialysis (PD) was admitted with pre-admission physician orders for three daily PD exchanges and monitoring for peritonitis (fever, abdominal pain, cloudy effluent), but these monitoring orders were not entered into the facility’s physician orders. The care plan referenced PD and general monitoring but did not specifically address peritonitis monitoring. Paper PD flowsheets showed incomplete and inconsistent documentation of exchanges and resident condition, including missing condition/comments for individual treatments and no record of one ordered PD exchange. The PD cycler flowsheet lacked effluent descriptions on multiple days. The PD nurse reported facility staff were expected to monitor effluent and symptoms, and the DON confirmed the absence of specific peritonitis monitoring orders, lack of an order for the PD cycler, and documentation gaps, despite a facility policy requiring ongoing assessment and monitoring for complications before, during, and after dialysis treatments.
A nurse was observed preparing multiple oral medications for a resident with depression, traumatic brain injury, anxiety, and impaired cognition by pushing tablets and capsules from unit-dose cards directly into her ungloved hand and then using her fingers to place them into a medication cup. In a follow-up interview, the RN confirmed this practice and acknowledged that the correct procedure is to dispense medications directly from the card into the cup, contrary to the facility’s medication administration policy requiring adherence to good nursing principles and practices.
A resident with Alzheimer’s disease, diabetes, anxiety, significant ADL dependence, and behavioral symptoms was observed seated in a chair positioned against the nursing station with a locked wheelchair placed directly in front, also against the nursing station, effectively restricting movement. An LPN confirmed both wheelchair wheels were locked and that it should not have been placed there, while a CNA stated she had positioned the wheelchair to prepare for lunch, was unable to complete the transfer, and left it in place, acknowledging this was wrong. This arrangement conflicted with the facility’s restraint policy, which prohibits physical restraints except when alternatives are ineffective for treating a medical symptom and defines restraints as devices adjacent to the body that cannot be easily removed and that restrict freedom of movement or access to the body.
Failure to Issue Required SNF ABN When Discontinuing Medicare Part A Services
Penalty
Summary
The deficiency involves the facility’s failure to issue a Skilled Nursing Facility Advance Beneficiary Notice (SNF ABN) when Medicare Part A services were discontinued for a resident who still had available benefit days. The resident was admitted with a diagnosis of metabolic encephalopathy and had intact cognition per the Minimum Data Set assessment. The facility’s own SNF Beneficiary Notification Review documented that Medicare Part A skilled services began on 02/11/26 and the last covered day was 03/11/26, and that the facility initiated discharge from Medicare Part A services before the resident’s benefit days were exhausted. Despite this, no SNF ABN was provided to the resident or the resident’s representative. During interviews, the Social Services Director stated that the SNF ABN was issued hours prior to the last covered day but, upon reviewing her files, confirmed that no SNF ABN had actually been issued for this resident. She further explained that she believed an SNF ABN was only required if one skilled service remained and that if all skilled services were being discontinued, only the Notice of Medicare Non-Coverage (NOMNC) needed to be issued. The Administrator, however, stated that a resident should always receive both a SNF ABN and a NOMNC when Medicare Part A services are discontinued and benefit days remain. Review of the facility’s written policy dated 03/28/23 showed that the facility was required to issue SNF ABNs for initiation, reduction, or termination of extended care items or services when Medicare payment was not expected, which did not occur in this case.
Plan Of Correction
This Plan of Correction is submitted as required under State and Federal law. This Plan of Correction does not constitute an admission on the part of the Facility that the findings cited are accurate, that the findings constitute a deficiency or that the scope and severity regarding the deficiency cited are correctly applied. Any changes to the Facility's policies and procedures should be inadmissible in any proceeding on that basis. Without admitting or denying the validity or the existence of the alleged noncompliance, the Facility submits this Plan of Correction with the intention that it be inadmissible by any third party in any civil or other action against the facility or any employee, agent, officer, director or shareholder of the Facility. The Facility is utilizing this Plan of Correction as its allegation of substantial compliance as of 05/29/2026 F-0582 Corrective action for resident/s: On 5/14/26 Resident #34 was informed of rights and responsibilities related to Advanced Beneficiary Notice and voiced understanding of information for future reference by administrator. Identification of other residents who may be affected: Any resident receiving skilled services from nursing or therapy services. The Administrator audited all residents who were discharged from skilled services in the past 30 days to ensure they were issued a Notice of Non-Coverage and Advanced Beneficiary Notice on 5/29/26. No non-compliance was noted. Measures for systemic change: On 5/14/2026 Business Office Manager, Director of Rehab, Minimum Data Set nurse, Director of Nursing and Social Services Director were educated on proper procedure of issuing of Notice Of Medicare Non Coverage and Advanced Beneficiary Notice by administrator. All upcoming discharges from skilled services will be reviewed weekly at Utilization Review meeting to ensure notices will be delivered timely. How Corrective Action will be monitored: Administrator or designee to complete audits of all residents being discharged from skilled services to ensure they were issued a Notice of Non-Coverage and Advanced Beneficiary. This audit will be completed weekly x 4 weeks, then monthly x 2 months. Corrective action will be initiated for any noted non-compliance. Audit findings will be reviewed as part of the monthly quality assurance process to determine the need for further monitoring. Date of Compliance 5/29/26
Insulin Administration Errors and Failure to Prime Insulin Pens
Penalty
Summary
The deficiency involves the facility’s failure to maintain a medication error rate below 5%, with surveyors identifying 3 errors out of 28 medication administration opportunities, resulting in a 10.71% error rate. For one resident with type 2 diabetes mellitus and moderate cognitive impairment, the physician’s order directed Novolog insulin 10 units via subcutaneous pen-injector to be given before meals. During an observed medication pass, the LPN administered 10 units of Novolog insulin without priming the pen and did so after the resident had already consumed approximately 50% of the breakfast meal. The LPN later confirmed she did not prime the pen and acknowledged that the insulin was ordered to be administered prior to meals. Manufacturer instructions for the Novolog FlexPen specified that an air shot (priming) must be performed before each injection to ensure proper dosing. Another resident, also diagnosed with type 2 diabetes mellitus and with intact cognition, had orders for insulin glargine 35 units subcutaneously twice daily and insulin lispro 20 units subcutaneously before meals, plus 12 units subcutaneously if blood glucose was between 251 mg/dL and 300 mg/dL. During an observed medication administration, an LPN administered 35 units of insulin glargine and 32 units of insulin lispro without priming the insulin pens and after the resident had consumed approximately 90% of the breakfast meal, despite orders for insulin lispro to be given before meals. The LPN later stated she could not remember if she had primed the pen and acknowledged that the insulin was ordered to be administered prior to meals. Manufacturer information for insulin lispro stated that the pen must be primed before each injection to confirm insulin delivery and remove air, and that failure to prime could result in too much or too little insulin. The DON confirmed the expectation that insulin be administered as ordered, including priming each pen with two units before dialing the prescribed dose, and facility policy required medications, including insulin, to be administered safely, timely, and in accordance with prescriber orders and required time frames.
Plan Of Correction
This Plan of Correction is submitted as required under State and Federal law. This Plan of Correction does not constitute an admission on the part of the Facility that the findings cited are accurate, that the findings constitute a deficiency or that the scope and severity regarding the deficiency cited are correctly applied. Any changes to the Facility's policies and procedures should be inadmissible in any proceeding on that basis. Without admitting or denying the validity or the existence of the alleged noncompliance, the Facility submits this Plan of Correction with the intention that it be inadmissible by any third party in any civil or other action against the facility or any employee, agent, officer, director or shareholder of the Facility. The Facility is utilizing this Plan of Correction as an allegation of substantial compliance as of 5/29/2026. F-0759 Corrective action for resident/s: Residents #21 and #22 were assessed and evaluated by nurse and Director of Nursing 5/14/26. Resident #21 and #22 both denied any adverse effects and none were noted upon assessment by the Director of Nursing on 5/14/2026. Notification made to physician on 5/14/2026. LPN # 2 competency Eval on insulin administration with the Director of Nursing completed 5/14/2026. Identification of other residents who may be affected: Diabetic residents on assignment of LPN #2/station 2 have the potential to be affected and were assessed by the DON/Designee on 5/14/26 and found to be within normal limits. Measures for systemic change: All Nurses were educated by the Director of Nursing on the steps for Insulin administration per competency, diabetes clinical protocol policy, Medication and treatment orders policy, administering medications policy, and Obtaining fingerstick Glucose Level policy On 5/14/2026. How Corrective Action will be monitored: Director of Nursing and Assistant Director of Nursing will complete insulin administration audits on 5 nurses. This audit will be completed weekly x 4 weeks, then monthly x 2 months. Corrective action will be initiated for any noted non-compliance. Audit findings will be reviewed as part of the monthly quality assurance process to determine the need for further monitoring. Date of Compliance: 5/29/2026
Failure to Document Tray Line Food Temperatures in Dining Room Kitchenettes
Penalty
Summary
The deficiency involves the facility’s failure to document tray line food temperatures for meals served from the Harrison and McClellan Dining Room kitchenettes, as required by professional standards for food service safety and the facility’s own policy. Review of the “Trayline Taste & Temperature Log” (revised September 2018) showed missing temperature documentation for multiple meals from the Harrison Dining Room kitchenette, including dinner on 03/30/26 and 03/31/26, lunch and dinner on 04/01/26 and 04/02/26, dinner on 04/07/26, and lunch and dinner on 04/08/26 and 04/10/26. The Senior Director of Culinary Services confirmed during interview that tray line food temperatures were not documented on the log for these meals. Similarly, review of the same log for the McClellan Dining Room kitchenette revealed that tray line food temperatures were not documented for dinner on 04/01/26, breakfast and lunch on 04/02/26, and lunch and dinner on 04/07/26. The Senior Director of Culinary Services also verified these omissions during interview. The facility census at the time was 27 residents, and the governing “Food and Nutrition” policy, approved on 09/07/21, stated that the facility must store, prepare, distribute, and serve food in accordance with professional standards for food service safety.
Plan Of Correction
F812 The facility will continue to ensure food temperatures are completed before meals are served for all residents. To ensure compliance with this standard the following measures have been taken: 1. Immediately 4/15/26 culinary supervisor #224 was re-educated by Dietary Manager to this standard and policy "Food and Nutrition" which includes documentation of food temperatures. 2. All dietary staff have been re-educated to the standard and policy "Food and Nutrition" during the month of April 2026. 3. Audits of food temperature documentation to be completed by Dietary Manager 4 x per week for 4 weeks then weekly for 4 weeks. 4. Administrator to validate audits/compliance and provide additional training as needed. Administrator will present to QAPI committee for ongoing monitoring and further direction.
Failure to Conduct and Document Required Care Conferences
Penalty
Summary
The deficiency involves the facility’s failure to complete and document comprehensive care conferences at required intervals in accordance with care plan regulations and facility policy. For one resident with Parkinson’s disease with dyskinesia, cognitive communication deficit, hemiplegia and hemiparesis following cerebral infarction, transient cerebral ischemic attack, type II diabetes mellitus, and major depressive disorder, the record showed multiple MDS assessments over a one-year period, including annual, quarterly, and significant change assessments. However, only two care conferences were documented during the last 12 months, despite the expectation that care conferences be conducted quarterly with the resident and family when possible. The Unit Care Coordinator confirmed that no additional care conference documentation existed for this resident beyond the notes dated 04/21/25 and 01/02/26. A second resident, with diagnoses including aphasia following cerebrovascular disease, cerebral infarction, type II diabetes mellitus, unsteadiness on feet, difficulty in walking, coagulation defect, depression, and muscle weakness, also had multiple MDS assessments completed over the review period, including quarterly and annual assessments. The record contained a note that a care conference was offered to the resident’s representative, who declined to attend, but there was no documentation of any care conferences for the most recent 12 months. The Unit Care Coordinator confirmed that no other care conference documentation was available for this resident. Facility policy stated that periodic care conferences involving the resident, family, and the interdisciplinary team are part of the care planning process, but the required periodic care conferences and corresponding documentation were not completed for these two residents.
Plan Of Correction
THIS PLAN OF CORRECTION SERVES AS BERKELEY SQUARE'S CREDIBLE ALLEGATION OF SUBSTANTIAL COMPLIANCE AS OF June 1, 2026. Without admitting or denying the validity or existence of the alleged deficiencies, Berkeley Square provides the following Plan of Correction: F657 The facility will continue to document completion of care conferences at the required intervals for all residents, including residents #04 & #15. To ensure compliance with this standard the following measures have be taken: 1. The social service designee and the inter- disciplinary team were re-educated by the administrator to the facility policy "Care Conference" on 4/29/26 and verbalized understanding. 2. Care conferences for resident #04 and resident #15 were conducted on or before 4/29/2026 by the interdisciplinary team. 3. Review of all other residents was conducted by the social service designee to validate and ensure that care conference schedule is up to date with timely care conferences scheduled for them on 4/15/2026. Audits of care conferences to be completed weekly for four weeks and then monthly after that by the social service designee. Documentation of the care conference including any identified concerns in the medical record. Administrator to validate audits/compliance and provide additional training as needed. Administrator will present results of these audits to QAPI committee for ongoing monitoring and further direction.
Failure to Reevaluate Blood Glucose After Treatment for Hyperglycemia
Penalty
Summary
The facility failed to ensure that a resident with diabetes received treatment in accordance with professional standards of practice when nursing staff did not reevaluate the resident's blood glucose after treatment for severe hyperglycemia. The resident, admitted with diagnoses including Alzheimer's disease, type II diabetes mellitus, and depression, had physician orders for Humalog insulin on a sliding scale before meals, Lantus insulin 25 units daily, and lisinopril 5 mg daily. The resident required extensive assistance with activities of daily living, including transfers, toileting hygiene, eating, and bathing. On the evening in question, the resident's blood glucose was documented as 532 mg/dL, and the on-call provider was notified. The provider gave a new order to administer an additional 8 units of lispro (Humalog) and to recheck the blood glucose in 30 minutes. The electronic medication administration record showed that the blood glucose of 532 mg/dL was obtained at 9:00 p.m. and that the additional 8 units of lispro were administered at 9:21 p.m. However, there was no documentation in the resident's chart that the blood glucose was rechecked after the additional insulin was given. In an interview, the DON confirmed there was no evidence of reevaluation and verified that, according to the facility's "Abnormal Blood Glucose Procedure" policy, the resident should have been reevaluated and that the evaluation step should have been included in the progress note documentation.
Plan Of Correction
F684 The facility will continue to ensure all residents, including #03, receive treatment in accordance with professional standards of practice and reevaluated for hyperglycemia. To ensure compliance with this standard the following measures have been taken: 1. The director of nursing assessed resident #03, reviewed documentation and orders and found no ill effects immediately 4/16/26. 2. All licensed nurses were re-educated to facility policy "Blood Glucose Monitoring" by the Director of Nursing/designee in April 2026. 3. Audits of like-residents that require blood sugar checks to be completed by the director of nursing/designee two times a week for 4 weeks and then monthly after that to validate correct follow through when there is abnormally high blood glucose result. The Administrator will bring results of these audits to the QAPI committee for ongoing monitoring and further direction.
Failure to Act on Pharmacist Drug Regimen Recommendation for Thyroid Medication
Penalty
Summary
The deficiency involves the facility’s failure to ensure that pharmacy recommendations from the monthly drug regimen review were acted upon and documented for a resident. The resident was admitted with diagnoses including Parkinson’s disease, dementia, and hypothyroidism, and had current physician orders for levothyroxine 150 mcg once daily, buspirone 50 mg twice daily, and losartan 100 mg once daily. A medication regimen review dated 11/25/2025 included a consultant pharmacist recommendation that levothyroxine be administered consistently in the morning on an empty stomach, at least 30–60 minutes before food, per manufacturer instructions. There was no specific physician response in the medical record to this recommendation, and the facility’s policy stated that consulting pharmacist reviews are sent to nursing and addressed with the primary care provider or consulting specialist for review and follow-up. Review of the resident’s medication administration record for April 2026 showed levothyroxine scheduled for 9:00 a.m. On observation, the resident was seen eating breakfast in the dining area at 8:03 a.m., and an LPN reported administering the levothyroxine 150 mcg to the resident while the resident was in the dining area eating breakfast. The DON confirmed there was no evidence in the resident’s medical record explaining why the consultant pharmacist’s recommendation from 11/25/2025 was or was not acted upon. This lack of documented physician review and action on the pharmacist’s identified irregularity constituted noncompliance with the drug regimen review requirements.
Plan Of Correction
F756 The facility will continue to ensure the pharmacy recommendations from the monthly drug regimen review by a licensed pharmacist are acted upon for all residents, including #08. To ensure compliance with this standard the following measures have been taken: 1. Resident #08 was assessed by the registered nurse and med review completed by 4/28/26. After review of resident's drug regime's, it was discovered that resident #8 had 2 separate medication recommendations on the same form, to be reviewed by two separate practitioners, pharmacy has been instructed and agreed to separate meds on individual forms. 2. Licensed nurses re-educated to facility policy "Drug Regimen Review" by Director of nursing/designee in April 2026 and no later than 5/8/26. Licensed nurses are responsible for ensuring the reviews and recommendations are given to the physician for timely review. 3. Review of all other current residents Drug Regimen orders completed by Director of nursing/designee on 4/16/26 to ensure recommendations were followed up on/reviewed by the physician and address concerns if needed. 4. Audit of drug regime recommendations, pharmacy recommendations, and physician follow up to be completed weekly for four weeks by the Director of nursing/designee. Administrator will present results of these audits to the QAPI committee for ongoing monitoring and further direction.
Failure to Use Required Gait Belt During Ambulation Resulting in Resident Fall
Penalty
Summary
The deficiency involves the facility’s failure to ensure that a required gait belt was used while assisting a high fall‑risk resident with ambulation, resulting in a fall with head injury. The resident had multiple diagnoses including metabolic encephalopathy, hypertension, osteoarthritis, muscle weakness, gait and mobility abnormalities, major depressive disorder, anxiety, and visual hallucinations. Admission and subsequent MDS and fall risk assessments documented that the resident was severely cognitively impaired, required moderate to maximal assistance with transfers and ambulation, could not independently come to a standing position, exhibited loss of balance while standing, used an assistive device, and had decreased muscle coordination. The resident had a history of falls prior to admission and was assessed as being at high, later moderate, risk for falls. The resident’s fall care plan identified her as at risk for falls and included interventions such as providing maximum to moderate assistance with transfers and walking short distances, use of a walker and wheelchair, and following the facility’s fall protocol. Therapy notes and care conference documentation indicated that the resident leaned backwards when standing, required contact guard to minimal assistance for bed mobility and transfers, and needed constant verbal cueing for safe sequencing during toilet transfers. The physical therapist confirmed that the resident was to use a gait belt with staff when ambulating, and the DON verified that therapy had assessed the resident as requiring contact guard assistance and a gait belt for ambulation and transfers. On the day of the incident, a CNA was assisting the resident from her recliner to the bathroom using a walker. The CNA walked beside the resident, providing guidance and support, and reported having a hand on the resident while assisting her. As they approached the bathroom door, the CNA reached for the doorknob to open it, and at that moment the resident began to lose her balance and fell backwards to the floor, striking the back of her head. The nurse who responded found the resident on her back at the foot of the bed with her feet near the bathroom, noted a red raised area on the back of the head, and documented that the resident was not wearing a gait belt and that the gait belt was on the dresser. In the facility’s investigative summary and in interviews, the CNA acknowledged that she did not have a gait belt on the resident while ambulating her, despite the resident’s assessed need for hands‑on assistance and gait belt use per facility policy and the resident’s care and therapy plans.
Failure to Implement PD Orders and Monitor Resident Receiving Peritoneal Dialysis
Penalty
Summary
The deficiency involves the facility’s failure to implement pre-admission physician orders for peritoneal dialysis (PD) and to provide ongoing monitoring for a resident with chronic kidney disease (CKD) stage five who required PD. Pre-admission orders dated 11/14/25 specified three daily PD exchanges at 6:00 A.M., 2:00 P.M., and 10:00 P.M., and directed staff to monitor for signs and symptoms of peritonitis, including fever, abdominal pain, and cloudy effluent. These monitoring orders were not entered into the facility’s physician orders. The resident’s care plan noted the need for PD and included general monitoring interventions (labs, signs of bleeding, bacteremia, septic shock, and significant vital sign changes), but did not specifically address the ordered monitoring for peritonitis. Review of PD documentation showed incomplete and inconsistent charting of treatments and resident condition. The paper peritoneal flowsheet had columns for time of PD and condition/comments, including instructions to call the nurse immediately for cloudy fluid, abdominal pain, or fever. However, the first entry on 11/15/26 at 2:00 P.M. only noted that the PD nurse completed the exchange, and the 10:00 P.M. entry that day had no condition/comment documentation. Subsequent days (11/16/25, 11/17/25, and 11/18/25) contained only one condition/comment entry per day rather than for each exchange, and there was no documentation that the 6:00 A.M. PD on 11/18/25 was completed. The PD cycler flowsheet starting 11/19/25 lacked any description of the effluent on multiple days. The PD nurse from the dialysis company stated facility staff were expected to monitor effluent for cloudiness and assess for abdominal pain and fever, and the DON confirmed there was no electronic physician order for peritonitis monitoring or for use of the PD cycler, that the paper charting did not allow for effluent description or symptom documentation for each treatment, and that PD was not documented at one ordered time. The facility’s dialysis policy required ongoing assessment and monitoring for complications before, during, and after treatments, which was not reflected in the documentation for this resident.
Improper Infection Control During Medication Administration
Penalty
Summary
Surveyors identified a deficiency in infection prevention and control related to medication administration for Resident #29. The resident was admitted on 02/28/14 with diagnoses including depression, traumatic brain injury, and anxiety, and had impaired cognition per a quarterly MDS assessment. During an observation on 03/25/26 at 6:58 A.M., RN #281 prepared the resident’s medications by removing an Amoxicillin-Pot Clavulanate tablet from the medication card and pushing it directly into her ungloved hand, then using her fingers to place the pill into a medication cup. The same process was observed for multiple other medications, including Escitalopram Oxalate, Furosemide, Sennosides, Lyrica, and Vitamin D, each being pushed from the card into the RN’s ungloved hand and then transferred by her fingers into the medication cup before administration to Resident #29. In a subsequent interview at 7:27 A.M. the same day, RN #281 confirmed she had placed each medication into her ungloved hands prior to administration and acknowledged that the proper procedure was to push the pills directly from the card into the medication cup. Review of the facility’s “Medication Administration – General guidelines” policy, revised 10/08/25, stated that medications are to be administered in accordance with good nursing principles and practices. This practice failure was cited as a deficiency under Complaint Number 2681777.
Improper Use of Wheelchair as a Physical Restraint
Penalty
Summary
Surveyors identified a deficiency related to the facility’s failure to ensure a resident was free from physical restraints. Resident #7, admitted with diagnoses including Alzheimer’s disease, diabetes mellitus, and anxiety disorder, was documented on a recent MDS as rarely understood and dependent for ADLs except eating. The resident ambulated independently on the unit without an assistive device and had documented verbal and other behaviors occurring one to three days during the look-back period. The care plan noted the resident had potential to be physically aggressive, chase staff, throw objects, and be combative with care, with interventions such as offering choices, administering medications as ordered, and intervening early when agitation occurred. During an observation and interview, Resident #7 was found sitting in a chair with the right arm of the chair positioned against the nursing station and a wheelchair placed directly in front of him. The left arm of the wheelchair was also against the nursing station, and both wheelchair wheels were locked, creating a barrier that appeared to restrain the resident, who was sleeping with his knees touching the locked wheelchair. An LPN confirmed both wheelchair wheels were locked and that the wheelchair should not have been placed in front of the resident. A CNA reported she had placed the wheelchair there in preparation to get the resident up for lunch, was unable to transfer him, and left the wheelchair in that position, acknowledging it was wrong to keep it there. The facility’s physical restraint policy stated that physical restraints are not used except when alternatives are not appropriate or effective for treating a medical symptom and defined physical restraints as any device attached or adjacent to the body that the individual cannot easily remove and that restricts freedom of movement or access to the body.
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