Hopewell Grove Rehabilitation And Healthcare
Inspection history, citations, penalties and survey trends for this long-term care facility in Chillicothe, Ohio.
- Location
- 60 Marietta Road, Chillicothe, Ohio 45601
- CMS Provider Number
- 365694
- Inspections on file
- 24
- Latest survey
- February 26, 2026
- Citations (last 12 mo.)
- 10 (1 serious)
Citation history
Health deficiencies cited at Hopewell Grove Rehabilitation And Healthcare during CMS and state inspections, most recent first.
A resident with paraplegia, existing stage IV ischial pressure injury, suprapubic catheter, and ostomy was admitted with recommendations for specialized surgical follow-up that were not carried out, and the facility repeatedly failed to implement or correctly enter detailed wound care orders from a WCNP, including use of a wound vac, Santyl, Dakin’s solution, medical-grade honey, and appropriate dressings. The resident, fully dependent for bed mobility, was not consistently placed on a turning/repositioning program, and preventive measures such as heel elevation and low air loss support were delayed or incompletely care-planned, while serial wound assessments documented progressive worsening and new unstageable and stage IV pressure injuries to the ischia and sacrum. Elevated WBC results indicating infection risk were obtained, but one significantly abnormal result was not documented as reported to a practitioner, and the resident ultimately requested transfer to the hospital, where osteomyelitis of a sacral stage IV ulcer was diagnosed and treated. Another resident at risk for skin breakdown developed an in-house unstageable pressure ulcer when prevention strategies were not implemented, and a third resident lacked adequate pressure ulcer prevention measures and care, demonstrating a pattern of failure to provide ordered pressure ulcer treatments and prevention across multiple residents.
Surveyors found multiple food storage and labeling deficiencies in the kitchen and walk-in refrigerator, including loose flour in a dirty bin, open cereal and taco shells without dates, and several opened refrigerated items such as cheese, salad mix, deli meats, boiled eggs, and sliced ham that were undated, improperly sealed, or visibly spoiled. Additional issues included unlabeled containers with unknown brown and white-clear liquids and food stored in a metal pan containing an unknown red liquid. Dietary staff acknowledged that facility policy requires opened and leftover foods to be covered, labeled, dated, and properly sealed, and confirmed that some items were likely expired and that the storage conditions were not acceptable.
The facility did not effectively use its QAPI program to identify and address ongoing issues in pressure ulcer prevention and treatment, despite holding monthly QA meetings that were supposed to review trends such as falls, pressure ulcers, antibiotic use, and weight loss. The Administrator confirmed that in multiple consecutive months no residents with ongoing pressure ulcer issues were identified or discussed, even though survey findings later showed noncompliance in pressure ulcer care that resulted in substandard quality of care, including Immediate Jeopardy for a resident and Actual Harm for another. This practice conflicted with the facility’s own QAPI policy, which required continuous review of resident care trends and targeted performance improvement, including pressure ulcer care.
Surveyors found that multiple medications, including insulin glargine, ophthalmic drops, and an inhaler, were open but not labeled with the date opened, and one insulin vial remained in use beyond its 28-day post-opening expiration period. Observations of two medication carts with LPNs revealed unlabeled insulin vials taken from an emergency drug box, unlabeled eye drops, and an unlabeled inhaler, as well as insulin that had been opened for 34 days despite facility policy requiring dating on opening and prohibiting use of outdated drugs.
The facility did not timely implement and enter advance directive code status orders for two residents. One resident was discharged from the hospital with a DNRCCA status, but the facility delayed initiating any code status order and then entered the resident as Full Code despite signed DNRCCA paperwork later uploaded to the EHR. Another resident with multiple chronic conditions had DNRCCA paperwork signed and uploaded, but no corresponding code status order was entered into the EHR after readmission. Staff interviews confirmed these delays and omissions occurred despite facility policy requiring nurses to obtain and enter physician orders reflecting residents' executed advance directives.
The facility failed to adequately plan and document safe, goal-directed transfers and discharges for two residents. One resident with a history of substance abuse and an established plan to discharge to family was transferred to another nursing facility while intoxicated after a fall, with no clear documentation of why his original discharge plan changed, how the receiving facility was selected, or how it would better meet his needs. Another resident with multiple medical and psychiatric diagnoses, admitted after alcohol detox and scheduled to transfer to a VA inpatient rehab program, was instead discharged home without a physician order, without being processed as an AMA discharge, and without documentation explaining the change from the planned transfer or how her discharge goals and needs were addressed.
A resident with multiple psychiatric diagnoses and mildly impaired cognition had Level II PASARR recommendations that were not implemented by facility staff. The PASARR outcome required 1:1 staffing due to a history of head banging and fire starting, removal of self-injurious items from reach, group therapy with a trained group therapist, a behavior management safety plan, and ongoing evaluation of psychotropic medications. Record review and interview with the staff member serving as Social Service Director confirmed that none of these interventions had been addressed or put into place, even though the resident had not displayed head banging, self-injurious behavior, or fire starting since admission.
The facility failed to consistently assess, document, and treat non‑pressure wounds according to hospital discharge instructions, physician orders, and wound consultant plans for multiple residents. One resident with a diabetic heel ulcer continued to receive an outdated treatment regimen and had heels left unoffloaded in bed despite a wound NP’s revised orders and recommendations. Another resident with bilateral lower extremity wounds and a right elbow skin tear had no documented wound assessments or treatments for extended periods after admission and after new wound orders were written, including an order that initially lacked a specified wound site. A third resident with bilateral plantar diabetic foot ulcers was admitted with detailed hospital wound care instructions, but the admission assessment noted no skin impairments, and there were no wound orders, assessments, or TAR treatments for several days. A fourth resident readmitted with a left below‑knee amputation incision and a right 5th toe diabetic ulcer had non‑pressure wounds noted historically, yet on readmission there were no specific wound locations, measurements, or treatment orders, and no TAR treatments were documented for several days until wound orders and measurements were later entered.
Surveyors found that the facility failed to enforce its smoking policy and to maintain appropriate fall-prevention devices. One resident, identified as an independent smoker, was observed keeping cigarettes and a lighter in his room, despite a policy requiring smoking materials to be controlled by staff and stored in locked boxes near the designated smoking area. Another resident with dementia, COPD, schizoaffective disorder, polyneuropathy, and muscle weakness, and assessed as high risk for falls, had experienced multiple falls from bed while asleep; a perimeter mattress was added as a fall-prevention intervention, after which no further in-bed falls were documented. The facility later removed the perimeter mattress from the fall-prevention care plan and substituted bed grab bars under a mobility care plan, without documentation that the mattress impaired mobility or that the new device was intended for fall prevention.
The facility failed to follow its antibiotic stewardship policy and McGeer’s criteria when managing antibiotics for three residents treated for suspected UTIs. One resident with bladder cancer and a catheter continued on Cefuroxime even though she had no documented UTI symptoms, her urine culture showed pseudomonas aeruginosa below McGeer’s CFU threshold, and Cefuroxime was not listed on the sensitivity report; the stewardship form also lacked clear physician attribution and symptom documentation. A second resident with diabetes and CKD received Keflex for a UTI despite only a single mildly elevated temperature, no urinary symptoms, and a culture whose sensitivity report did not include Keflex, with no evidence the prescriber reviewed this mismatch; the DON later acknowledged the stewardship form incorrectly stated repeated fevers and McGeer’s criteria being met. A third resident with diabetes and hypertension was given a full course of Macrobid for a UTI, but no stewardship evaluation was completed and there was no documented physician follow-up after a urine culture showed mixed organisms below McGeer’s CFU threshold, contrary to policy requiring culture results to guide starting, continuing, modifying, or discontinuing antibiotics.
Two residents in an LTC facility suffered harm due to the facility's failure to assess, develop, and implement a comprehensive pressure ulcer prevention program. One resident was readmitted with known pressure ulcers and did not receive ordered treatments or a specialized mattress, leading to a hospital transfer for infection. Another resident developed a stage III pressure ulcer without adequate prevention measures, and there was no readmission assessment or treatment for existing ulcers. The facility lacked a contracted wound care company, and physicians were unaware of the treatment deficiencies.
The facility failed to provide adequate staffing, resulting in late medication administration for a resident and missed scheduled showers for another. An LPN confirmed the late administration was due to covering additional duties, while a CNA noted that staffing issues led to missed showers. The facility's policy to provide necessary staffing was not followed.
The facility failed to maintain dignity for three residents with indwelling urinary catheters. A resident's catheter was not changed as scheduled, and the collection bags for all three residents were not covered with privacy bags, making the urine visible from the hallway. These actions were confirmed by LPNs and violated the facility's dignity policy.
A facility failed to provide a resident with a bed that accommodated their size and lacked physician-ordered enabler bars for bed mobility. The resident, with multiple diagnoses including pressure ulcers and obesity, was observed in a regular bed without enabler bars, leading to difficulties in repositioning. An LPN confirmed the bed's inadequacy and the absence of an air mattress, highlighting non-compliance with resident accommodation requirements.
The facility failed to complete timely comprehensive admission assessments for two residents. One resident, with multiple diagnoses including pressure-induced deep tissue damage, was readmitted but not assessed until two days later, and the assessment remained incomplete. Another resident, with serious health conditions, was readmitted without any readmission or wound assessments conducted. These deficiencies were identified during a complaint investigation.
A facility failed to provide routine bathing for a resident dependent on staff for personal hygiene. Despite being scheduled for showers twice a week, there was no documented evidence of showers being given on four occasions. The resident had a complex medical history and required substantial assistance with daily activities. This deficiency was confirmed by a Regional Nurse and investigated under specific complaint numbers.
The facility failed to provide proper care for residents with indwelling urinary catheters. A resident did not have their catheter changed as ordered, and another resident lacked documented catheter care. Interviews confirmed these deficiencies, affecting the quality of care for these residents.
Two residents experienced deficiencies in care due to improper maintenance of enteral feeding tubes and medication administration. One resident's peg-tube leaked due to a cracked connector, and the facility lacked a replacement, leading to makeshift solutions. Another resident's peg-tube clogged during medication administration, resulting in medication leakage and improper procedure adherence. The facility failed to provide necessary equipment and follow protocols, impacting resident care.
A facility failed to provide a resident with a physician-ordered chest vest for chest physiotherapy, essential for airway clearance. The resident, with a complex medical history including acute respiratory failure and COPD, was admitted without the chest vest, and it arrived several days later. This delay was confirmed by the Regional Nurse, leading to a deficiency finding.
A facility failed to maintain accurate medical records and adhere to physician-ordered treatments for a resident with pressure ulcers and other medical conditions. The resident's comprehensive assessment was delayed, and wound care treatments were not performed as ordered, with dressings left unchanged for several days. This deficiency was discovered during a complaint investigation.
The facility failed to maintain infection control practices during a pressure ulcer dressing change for a resident and did not implement enhanced barrier precautions for another resident with a peg-tube. An LPN used the same gloves for handling soiled dressings and clean wounds, and another LPN administered medication without the required gown and gloves, leading to potential infection risks.
A resident in hospice care received incorrect doses of Morphine due to a transcription error in the facility's physician orders. The resident, who was moderately cognitively impaired and required substantial assistance, was supposed to receive 10 mg every hour as needed, but the facility's orders incorrectly stated 20 mg doses, leading to multiple administrations of the higher dose.
A facility failed to follow Enhanced Barrier Precautions (EBP) for a resident with a wound. A cognitively intact resident with multiple diagnoses, including an unstageable pressure ulcer, was observed receiving wound care without the RN wearing a gown, contrary to the facility's EBP policy. The RN confirmed the oversight, and the absence of a sign indicating EBP status was noted during a complaint investigation.
A resident with a history of IV drug use did not receive scheduled doses of Suboxone due to the medication not being available, leading to withdrawal symptoms and hospitalization. The facility failed to document the omission or notify the physician, violating their medication administration policy.
A resident with dementia and a need for assistance with personal care was left without timely toileting assistance. Despite expressing an urgent need, the resident was instructed by an STNA to use an incontinence brief and was left unattended on the toilet for an extended period while the STNA assisted another resident. The facility's policy required staff to provide needed assistance with ADLs, which was not followed.
A facility failed to provide timely toileting services to residents, notably affecting a resident who waited 14 minutes for assistance despite being cognitively intact and needing limited help with ADLs. Observations and interviews revealed that call light response times often exceeded 10 minutes, with no established policy on acceptable wait times. The issue was highlighted by resident complaints and call light audits showing response times from five to 19 minutes.
The facility failed to timely submit MDS assessments for four residents, affecting compliance with state regulations. An LPN confirmed that the MDS assessments for residents with various diagnoses, including encephalopathy, schizophrenia, and non-Hodgkin lymphoma, were not submitted within the required timeframe.
The facility failed to ensure residents were placed in enhanced barrier precautions (EBP) appropriately and that staff wore the necessary PPE when interacting with these residents. Observations revealed that staff were not consistently following EBP protocols, and the Director of Nursing confirmed that training included inaccurate information, leading to improper PPE usage.
The facility failed to assist a resident with significant cognitive impairment in obtaining an appropriate decision maker. The resident's girlfriend, who exhibited risky behavior, was considered the decision maker despite Ohio not recognizing common law marriage. The resident's son, listed as the emergency contact, was unresponsive, and the facility did not initiate the guardianship process.
The facility failed to ensure the resident notice letter was accurately completed for three residents reviewed for Beneficiary Notification. One resident did not receive a SNF ABN when transitioning from Medicare Part A services to long-term care, another was not issued a NOMNC before being discharged home with Hospice services, and a third resident also did not receive a SNF ABN. Interviews with the Administrator and Business Office staff confirmed these deficiencies.
The facility failed to document the reason for a resident's transfer to the hospital. The resident, initially planned for discharge home, presented with an altered mental status and was transferred to the hospital without proper documentation of the change in condition, physician notification, or discharge location.
The facility failed to accurately complete an annual MDS assessment by omitting a PTSD diagnosis for a resident, despite it being present in previous assessments. An LPN confirmed the diagnosis should have been included.
A facility failed to develop a comprehensive care plan for a resident diagnosed with PTSD, despite the resident's multiple diagnoses and the requirement for such a plan. This was confirmed through a medical record review and an LPN interview.
The facility failed to update care plans for a resident at risk of elopement and two residents experiencing significant weight loss. Despite incidents of elopement and ongoing weight loss, the care plans remained unchanged, not reflecting necessary interventions and physician orders.
A resident experienced significant weight loss, dropping from 227.8 pounds to 193.2 pounds over about five weeks, without timely interventions or updates to the care plan. The dietician did not assess the resident until weeks later, and there was a lack of communication regarding changes in nutritional supplements. The DON confirmed the need for timely interventions, but no evidence of such actions was provided.
A resident was prescribed two antibiotics without a valid diagnosis, and the DON could not determine the reason for the prescriptions.
The facility failed to ensure that influenza and pneumonia vaccinations were offered and provided to two residents. One resident did not receive the required follow-up dose of the pneumonia vaccine, and another resident did not receive the flu vaccine despite consent being obtained. The facility's policy required these vaccinations to be offered unless contraindicated.
The facility failed to ensure nurse aides received a performance review at least every 12 months, affecting three STNAs out of four personnel records reviewed. Specifically, two STNAs did not have any 90-day or annual evaluations on record, and one STNA did not have any annual evaluations documented. This deficiency was confirmed during an interview with the Administrator, who verified that the facility did not have any records of the required evaluations being completed. This issue has the potential to affect all 61 residents in the facility.
Failure to Implement Ordered Pressure Ulcer Treatments and Prevention Measures
Penalty
Summary
The deficiency involves the facility’s failure to provide ordered pressure ulcer treatments and to implement effective pressure injury prevention and management for multiple residents, most notably a resident with paraplegia, a suprapubic catheter, an ostomy, and a known stage IV left ischial pressure ulcer with osteomyelitis on admission. Hospital records at admission documented orthopedic surgery’s recommendation for follow-up at a tertiary center for possible debridement and plastic surgery consultation for wound coverage/closure, but there was no evidence this recommendation was carried out. On admission, the resident’s skin impairment was documented only as “pressure” without location, assessment, or measurements, and the initial wound evaluation described a left buttock stage IV ulcer with minimal detail. A wound vac treatment was ordered but not documented as completed on multiple days, and the care plan initially lacked key interventions such as turning and repositioning, heel elevation, and a low air loss mattress, despite the resident’s dependence on staff for bed mobility and transfers. Subsequent wound consultant nurse practitioner (WCNP) visits documented progressive worsening of the resident’s left ischial ulcer and the development and deterioration of additional pressure-related wounds, including a left heel unstageable ulcer, bilateral buttocks (gluteal dermatosis progressing to unstageable and then stage IV sacral involvement), and a right ischial unstageable ulcer. The WCNP repeatedly specified detailed treatment regimens (e.g., hydrogel, medical-grade honey, calcium alginate with silver, Santyl, Dakin’s solution-moistened gauze, zinc oxide, collagen, low air loss mattress, turning/repositioning, and heel floating), but the facility frequently failed to enter these orders correctly into the electronic record, omitted treatments entirely, or implemented incorrect treatments and frequencies. For example, there was no treatment order entered for the bilateral buttocks gluteal dermatosis after the 07/16/25 WCNP visit, no updated order for the left ischial ulcer at that time, and no treatment documented on the TAR for the buttocks on several days. Later, when Dakin’s solution and Santyl were ordered in the WCNP plan, the facility did not clarify the Dakin’s concentration, did not obtain Dakin’s or Santyl from the pharmacy for extended periods, and continued to provide incorrect or incomplete wound care. There was no documentation that the resident refused wound care or repositioning. As the weeks progressed, wound measurements and descriptions documented by the WCNP showed increasing size, depth, undermining, slough, eschar, exposed deeper tissues (including muscle/fascia and subcutaneous tissue), malodor, and increased exudate in the left ischial, right ischial, and bilateral buttocks/sacral areas. Despite these changes and the resident’s total dependence for bed mobility, the MDS showed the resident was not on a turning/repositioning program, and the plan of care and interventions remained nonspecific or incomplete. Laboratory monitoring revealed elevated white blood cell (WBC) counts, with a WBC of 14.9 reported and acknowledged by the facility practitioner, and a subsequent WBC of 18.6 reported to the facility without documented notification to the practitioner or triage service. The resident ultimately requested transfer to the emergency room after being informed of the lab results and was hospitalized with osteomyelitis of the sacral stage IV pressure ulcer, requiring IV antibiotics and ongoing treatment for the left and right ischial ulcers. After a later hospital stay, the resident returned with documented wound care orders for sacral and bilateral ischial ulcers, but on readmission there were no corresponding treatment orders or documented treatments for these wounds on the first days back in the facility. Additional deficiencies were identified for other residents. One resident, admitted at risk for pressure ulcer development and altered skin integrity, developed an in-house unstageable pressure ulcer when the facility failed to implement pressure ulcer prevention strategies. Another resident had failures in ensuring pressure ulcer prevention measures and care were in place, though this did not rise to the level of actual harm. Across these residents, the survey findings showed repeated failures to implement ordered wound treatments, to obtain and correctly use prescribed wound care products, to clarify incomplete orders (such as missing Dakin’s solution concentration), to consistently document and carry out preventive interventions like turning, repositioning, and heel protection, and to timely communicate abnormal laboratory findings related to wound status to medical providers.
Removal Plan
- LPN #1077 initiated skin inspection on all current residents with verifying interventions; all residents were assessed with treatments initiated for newly identified areas (Resident #11 protective dressing for loose toenail; Resident #24 non-stick pad for abdominal blister; Resident #55 bordered foam for knee abrasion).
- The residents with pressure injury treatment orders were audited by RDCS #1050 to verify EMAR orders match WCNP orders; RDCS also audited Resident #72’s wound clinic visit note and verified orders.
- The facility held an ad hoc QAPI meeting with the Medical Director #1028 (by phone) and interdisciplinary team to discuss/address the Immediate Jeopardy; nursing education was initiated following the meeting.
- DON #1057 began education for nurses and CNAs on skin prevention, daily skin care, skin inspection, documentation of refusal of nutrition/hydration, reporting and documentation; nurses were educated on implementing treatments when skin alteration identified, ensuring interventions are in place, documenting refusals, following physician/NP orders, and reporting abnormal labs same day with documentation.
- DON #1057 provided verbal education to LPNs, CNAs, and RNs; staff not reached were instructed to receive verbal education prior to next scheduled shift and a communication message was sent to staff who had not yet received education.
- Additional education was completed by DON #1057; remaining staff who were left messages will be educated prior to next scheduled shift.
- RDCS #1050 educated the clinical management team (DON #1057, LPN #1077, LPN #1078) on auditing skin prevention, interventions, order implementation, and documentation; DON #1057 will complete pressure wound measurements/assessments with MDS RN #1071 as backup.
- VPCS #1029 and RDCS #1050 reviewed the Skin and Wound Policy for accuracy and to ensure it meets regulatory guidelines.
- The clinical management team (DON #1057, LPN #1077, LPN #1078) initiated education for all licensed nurses on changes in resident skin integrity related to decline, interventions, and notification of labs to medical professionals.
- RDCS #1050 completed an audit of wound evaluations initiated since wound rounds to identify new skin areas and verify new treatments were in place (Resident #14 skin tear treated with xeroform and kerlix; Resident #6 skin tear to left shin treated with xeroform and kerlix; Resident #22 two new diabetic ulcers treated with xeroform and kerlix; Resident #94 new sacral pressure area treated with chamosyn and leave open to air).
- DON #1057/designee will audit all new admission orders for 30 days to ensure skin treatments were implemented as ordered; if DON unavailable, RDCS #1050 will audit; audit verifies each identified area has a treatment in the EMAR and is completed by DON #1057 or LPN #1077 or LPN #1078 in DON’s absence.
- DON #1057/designee will audit weekly for 4 weeks all residents seen by wound consultants/outside wound clinics to verify treatment orders match consultant orders and were implemented timely by facility nurses.
- DON #1057 educated MDS RN #1071 on auditing skin prevention, interventions, order implementation, and documentation.
- All audit results will be reported to QAPI weekly for 4 weeks.
Improper Food Storage, Labeling, and Sanitation in Kitchen and Walk-In Refrigerator
Penalty
Summary
Surveyors identified a failure to store and label food in a sanitary manner in the facility kitchen, potentially affecting all 74 residents who consumed food prepared there. In the dry storage room, a large amount of loose flour was found lying in the bottom of a plastic bin on a shelf, and three open bags of corn flakes were observed without dates indicating when they had been opened. Soft taco shells were stored in plastic storage bags that were not labeled with dates opened. A dietary employee confirmed that all opened foods were required to be labeled with the date opened and acknowledged that the flour bin needed to be cleaned out. Inside the walk-in refrigerator, surveyors observed multiple improperly stored and apparently spoiled food items. An opened bag of shredded mozzarella cheese lay on a shelf with the top corner unsealed, no date opened, and a light red substance around the opening. An opened bag of salad mix was not closed or sealed, and some lettuce inside was light brown, wilted, and slimy. An open package of sliced hickory-smoked turkey breast, stored in a plastic bag, was dated as opened 42 days earlier, and an open package of thick-sliced bologna, also in a plastic bag, was dated as opened 47 days earlier. Two plastic bags containing peeled boiled eggs and sliced ham that was yellow and slimy were undated and were lying in the bottom of a metal pan containing an unknown thick red liquid. A plastic beverage pitcher with a brown, thick substance and a small plastic cup with a white plastic lid containing a thin white-clear fluid were both unlabeled. A dietary employee confirmed that foods should be dated when opened or prepared, that the dated bologna and turkey were likely expired, that the cup appeared to contain separated spoiled milk, that the metal pan needed to be cleaned and should not have had food lying in it, and that opened food packages should be properly closed or sealed. Facility policy required food to be stored in clean, dry, uncontaminated areas, at appropriate temperatures, covered, labeled, and dated, with leftovers used within seven days or discarded.
Failure to Use QAPI to Identify and Address Pressure Ulcer Care Issues
Penalty
Summary
The facility failed to implement and maintain a comprehensive Quality Assurance Performance Improvement (QAPI) program and plan to address care issues and concerns, particularly related to pressure ulcer care. Review of Quality Assurance (QA) committee attendance records for the previous eight months showed that QA meetings were held monthly and included discussion of falls, pressure ulcers (healing, not healing, present on admission, and in-house acquired), antibiotic use, and weight loss. However, the annual survey identified noncompliance in pressure ulcer care, including prevention and treatment, which resulted in substandard quality of care. This noncompliance led to an Immediate Jeopardy situation for one resident beginning on 08/27/25 and Actual Harm for another resident beginning on 01/12/26. During interviews, the Administrator stated that QAPI meetings were held monthly and confirmed attendance at the December 2025 and January 2026 meetings, during which no residents were identified as having ongoing issues or care needs related to pressure ulcers. The Administrator further reported that, upon review, there had been no identification of ongoing issues and care for pressure ulcers in the six months of QAPI meetings prior to his tenure (May 2025 through November 2025). This was inconsistent with the facility’s written QAPI policy, dated November 2025, which described QA as a continuous process in which the QA Committee is responsible for reviewing resident care and service trends, identifying quality issues, and developing plans of action, including review of pressure ulcer care trends based on data collection.
Failure to Properly Label and Timely Discard Opened Insulin and Ophthalmic Medications
Penalty
Summary
The deficiency involves the facility’s failure to ensure medications were labeled and stored according to professional standards and facility policy, specifically regarding dating when opened and timely discarding of insulin glargine. Surveyors reviewed records for multiple residents with conditions including type 2 diabetes mellitus, glaucoma, COPD, and other chronic illnesses. Physician orders showed that several residents were prescribed insulin glargine, ophthalmic solutions (Brimonidine and Latanoprost), and an inhaler (Budesonide-Formoterol). During observation of the C-Hall medication cart with an LPN, surveyors found that one resident’s insulin glargine, another resident’s Latanoprost eye drops, and another resident’s Brimonidine eye drops were open but not labeled with the date opened. The LPN confirmed that eye drops and insulin were supposed to be labeled with the date when opened. On the B-Hall medication cart, surveyors observed with another LPN that a vial of insulin glargine pulled from the emergency drug box and placed in the cart for a resident was not labeled with the date opened, and an inhaler for another resident was open and not labeled with the date opened. Additionally, insulin glargine for another resident was found in the cart labeled as opened 34 days prior, exceeding the 28-day expiration period after first use as specified in the facility’s Storage of Medications policy. The LPN confirmed that insulin and inhalers were to be labeled with the date opened and acknowledged the insulin glargine had been opened 34 days earlier. The facility’s policy stated that discontinued, outdated, or deteriorated drugs must not be used and that insulin glargine expires 28 days after first use or removal from the refrigerator.
Failure to Timely Implement and Enter Advance Directive Code Status Orders
Penalty
Summary
The facility failed to ensure that residents' advance directives and code status orders were obtained and implemented timely upon admission or readmission. For one resident with diagnoses including hypertensive emergency, acute pulmonary edema, and Sjogren syndrome, the hospital discharge summary identified the resident as DNR-Comfort Care Arrest (DNRCCA) at the time of admission. However, no physician order for code status was initiated until several days later, and when it was entered, the resident was listed as Full Code. Although DNRCCA paperwork was signed by the physician and later uploaded into the electronic health record, the corresponding physician order in the record continued to reflect Full Code status. For another resident with conditions including a stage 4 pressure ulcer, paraplegia, generalized anxiety disorder, major depressive disorder, and neuromuscular bladder dysfunction, DNRCCA paperwork was signed by the physician and uploaded into the electronic medical record, but no physician order for code status was entered into the record following the resident’s readmission from a hospital stay. Interviews with the Regional Director of Clinical Services, the Vice President of Clinical Services, and the DON confirmed that code status orders were either delayed, incorrect, or missing, despite the facility’s policy requiring that, after execution of the Ohio Advance Directive form, a nurse obtain a physician order consistent with the resident’s wishes and enter that order into the electronic health record.
Failure to Plan and Document Safe, Goal-Directed Transfers and Discharges
Penalty
Summary
The deficiency involves the facility’s failure to provide and document sufficient preparation and planning to ensure safe and orderly transfers and discharges, and to ensure the discharge planning process addressed each resident’s discharge goals and needs. For one resident with alcohol dependence in remission, COPD, and rheumatoid arthritis, the care plan identified a history of substance abuse and anticipated that he would purchase and drink alcohol at the facility, with interventions to monitor for misuse and notify the physician if there were concerns. His social service evaluation and care plan documented that he was admitted for skilled services and planned to discharge to the community with his daughter, with a goal of a safe transition back to the community and interventions including involving home care agencies and community supports and providing written discharge instructions. On a later date, nursing notes documented that this resident fell in the hallway, hit his head on the medication cart, and was under the influence of alcohol, with an abrasion to his left eyebrow. He was alert and oriented and refused transfer to the hospital, and neuro checks were initiated. Shortly afterward, the nurse documented that report was called to another nursing facility and that all medications were being sent with the resident. A late entry by the President of Clinical Services stated that the resident was transferred to another nursing facility per his request, even though he was noted to be intoxicated at the time. The discharge plan of care only stated that he was discharged to another nursing home and that a medication list was faxed, with no further documentation explaining how the transfer decision was made, why his prior plan to discharge to family was no longer in place, how the receiving facility was chosen, or how it would meet his needs differently. Additional documentation from the receiving facility showed that upon admission, staff there were uncertain about the amount of alcohol the resident had been consuming daily, what precautions to put in place given his limited access to alcohol, and had limited details about his fall. Later that evening, the resident complained of double vision, nausea, and had a prominent area above his left eyebrow, and he requested to go to the emergency room. Interviews at the sending facility revealed that the LPN observed the resident reeking of alcohol and appearing intoxicated, that the Administrator discussed his drinking and preferences with him, and that the Administrator did not know if the transfer had been discussed with the physician. The Administrator also stated that another facility had called asking if they had residents with behavior issues and that the resident had previously expressed a preference to move closer to another city, but the facility lacked staffing to find a placement where he wanted. There was no documentation in the record explaining the change from the original discharge plan to family, the rationale for the new facility choice, or how the transfer planning addressed his goals and needs. For a second resident with respiratory failure, alcoholic cirrhosis, diabetes, alcohol abuse, viral hepatitis, PTSD, and bipolar disorder, the physician documented that she had been admitted after a hospital stay for alcohol detoxification and hypoxia, with heavy alcohol consumption prior to admission and a history of alcohol withdrawal seizures, and that she wished to transfer to a VA inpatient rehab program when a bed became available. Social services documented that she had been accepted for an inpatient rehab program at the VA with a tentative transfer date, and that she had authorization from the VA to stay at the facility for 30 days until that transfer. A nursing note then documented that the resident came to the facility, picked up her belongings and ordered medications, and was educated on her discharge and follow-up visit at the VA, with no further documentation regarding the reason for the discharge. The Business Office Manager stated that when she left for the day, the plan remained for the resident to stay until transfer to the VA, and that a discharge would require a physician’s order or be handled as an against medical advice (AMA) discharge if the physician did not agree. The resident reported by telephone that she left the facility and went home, and that she was later admitted to the VA on the planned date. She stated that someone at the facility had talked to her about her leaving the facility every day to go home after therapy, and that after that conversation she decided to discharge home. The Director of Nursing confirmed there was no physician’s order to discharge the resident, no evidence the physician was aware of the discharge home, and that the discharge was not handled as an AMA discharge. The discharge plan of care only documented that the resident was discharged home, with no documentation explaining why she was discharged home instead of transferring to the VA as previously planned, and no evidence that the discharge planning process addressed her established discharge goals and needs.
Failure to Implement Level II PASARR Recommendations
Penalty
Summary
The facility failed to ensure that Level II PASARR recommendations were implemented timely and appropriately for one resident. The resident was admitted with multiple psychiatric diagnoses, including bipolar disorder, schizoaffective disorder, personality disorder, anxiety disorder, obsessive compulsive disorder, post-traumatic stress disorder, and attention deficit hyperactivity disorder, and was assessed as having mildly impaired cognition on a quarterly MDS assessment. A Notice of PASRR Level II Outcome dated 08/25/25 specified several recommendations: 1:1 staffing due to a history of head banging and fire starting, keeping self-injurious items out of reach, provision of group therapy with a trained group therapist, development of a behavior management safety plan to decrease inappropriate behaviors and ensure safety, and ongoing evaluation of the effectiveness of current psychotropic medications on target symptoms. Record review and staff interview showed that these PASARR recommendations were not addressed or implemented as required. The Business Office Manager, who was serving as Social Service Director at the time the Level II PASARR recommendations were issued, confirmed that the recommended 1:1 staffing, environmental controls to remove self-injurious items, group therapy, behavior management safety plan, and ongoing psychotropic medication evaluation had not been put into place. The same staff member also confirmed that the resident had not exhibited head banging, self-injurious behavior, or fire starting since admission, but the PASARR-directed interventions still had not been implemented.
Failure to Assess and Treat Non‑Pressure Wounds per Orders and Wound Consults
Penalty
Summary
The deficiency involves the facility’s failure to document and treat non‑pressure skin areas according to physician and consultant orders, as well as failure to accurately implement updated wound care plans. For one resident with reduced mobility, severe protein‑calorie malnutrition, and a left heel open wound identified on admission, the admission assessment documented an open area with black scabbing and a wound evaluation measured the wound. A physician order was entered to cleanse the left heel wound, apply Medihoney, and cover with nonstick dressing, Kerlix, and ACE wrap daily. A wound consultant NP later assessed the wound as a diabetic foot ulcer, documented new measurements, and ordered a different treatment regimen using medical‑grade honey, abdominal dressing, rolled gauze, and daily changes, along with recommendations to float the heels in bed. Despite this, the physician orders were not updated to reflect the consultant’s plan, the Treatment Administration Record showed the original, incorrect treatment continued for several days, and observations on two separate dates found the resident in bed with heels not elevated. Another resident admitted with type 2 diabetes with neuropathy, malnutrition, CKD stage 3, and a history of circulatory disease had vascular wounds to both lower extremities and additional unclear‑etiology wounds documented during a prior hospital stay, with specific orders to cleanse and dress bilateral lower extremity wounds every other day. The facility’s admission assessment only noted a skin tear and did not document or measure the bilateral lower extremity wounds. The plan of care referenced impaired skin integrity and treatments per physician/NP orders, but the TAR showed no wound treatments completed for the bilateral lower extremities for several days after admission. When a wound consultant NP later assessed a left shin venous ulcer and a right elbow skin tear and ordered specific treatments, the TAR again showed no documented treatments for the left shin venous ulcer or the right elbow skin tear for multiple days. A subsequent consult documented healing of the left shin ulcer and right elbow tear and identified a new right shin skin tear with a detailed treatment plan; however, the initial physician order for this new wound did not specify the site, and the TAR showed no treatments documented for the right shin wound until a later order explicitly identified the right shin. A third resident admitted with cellulitis of the left lower limb, type 2 diabetes with neuropathy, CKD stage 3, venous insufficiency, and bilateral plantar diabetic foot ulcers had hospital discharge instructions for daily cleansing and dressing of bilateral lower extremity diabetic ulcers using normal saline, Xeroform, Adaptec calcium alginate, gauze, ABD, Kerlix, and ACE bandage. The admission assessment documented no skin impairments despite the reason for admission being cellulitis of the left foot. For several days after admission, there were no physician orders for bilateral diabetic foot ulcer treatments and no wound treatments documented on the TAR, and the medical record contained no measurements or assessments of the left and right lateral plantar diabetic foot ulcers. A progress note later documented a telephone order for daily treatments to the bilateral diabetic foot ulcers and to contact outside wound care, and physician orders were then entered for wound cleanser, Xeroform, and Kerlix to the bilateral diabetic foot ulcers. A wound overview completed later documented measurements for both plantar ulcers, confirming their presence and size during the period when they had not been assessed or treated per the hospital discharge instructions. A fourth resident with acute hematogenous osteomyelitis, a left below‑knee amputation, type 2 diabetes, CKD, peripheral vascular disease, and a right lateral 5th toe diabetic ulcer had documented skin impairments of a left BKA surgical wound and right lateral 5th toe diabetic ulcer prior to a hospital transfer. After a hospital stay unrelated to the non‑pressure wounds, the resident was readmitted with discharge instructions that did not include non‑pressure wound care orders. The readmission assessment noted a vascular skin impairment and a surgical incision but did not specify locations or provide assessments and measurements. For several days following readmission, there were no physician orders for treatment of the left BKA surgical wound or the right lateral 5th toe diabetic ulcer, and the TAR showed no wound treatments completed. The medical record contained no assessments or measurements of these wounds during that period. Later, physician orders were entered for cleansing and leaving the right 5th toe ulcer open to air twice daily and for daily cleansing and sterile dressing of the left BKA incision, and a wound overview documented measurements for both wounds, indicating they had been present but not previously assessed or treated during the earlier days after readmission.
Failure to Enforce Smoking Policy and Maintain Effective Fall-Prevention Devices
Penalty
Summary
The deficiency involves the facility’s failure to implement its smoking policy and maintain a hazard‑free environment for a resident identified as an independent smoker. The facility’s smoking policy required that residents smoke only in designated areas and that resident smoking materials be retained and distributed by staff during designated smoking times and/or when independent residents choose to smoke. The Administrator stated that independent smokers were not allowed to keep cigarettes and lighters in their rooms and were instead to lock these items in a box by the exit door to the smoking area, where they would remain until the next smoking time. However, observation showed that one resident, admitted with diagnoses including CVA with hemiplegia/hemiparesis, diabetes, and hypertension and assessed with intact cognition, had cigarettes and a lighter stored in his coat pocket in his room and reported that he believed it was permissible to store them there. The Administrator later confirmed that the written smoking policy did not address the practice of independent smokers keeping their cigarettes in a locked box by the exit door, despite that practice having been in place since around October. The deficiency also involves the facility’s failure to consistently implement appropriate assistive devices for fall prevention for another resident at high risk for falls. This resident, admitted with dementia, COPD, schizoaffective disorder, polyneuropathy, and muscle weakness, had a BIMS score of 15 and required supervision or touching assistance with multiple mobility and ADL tasks. The resident had experienced a fall while asleep, sliding off the side of the bed, with documentation noting no injury. The care plan identified the resident as at risk for falls related to generalized weakness, and after a subsequent fall from bed while asleep, a perimeter mattress was added as an intervention. Progress notes and the care plan documented the perimeter mattress as a fall‑prevention measure, and there were no documented falls from bed after the perimeter mattress was put in place. Later, the perimeter mattress intervention was resolved in the care plan without a fall‑prevention intervention replacing it, and bilateral assist rails (grab bars) were added under a mobility‑focused care plan rather than under fall prevention. A therapy screening by a PTA requested evaluation for grab bars in place of the perimeter mattress, but there was no documentation that the perimeter mattress negatively affected the resident’s mobility or that bed mobility with the perimeter mattress had been problematic. The DON confirmed that the resident had no falls while the perimeter mattress was in use, that the decision to initiate grab bars was discussed in a morning meeting based on a belief that the perimeter mattress might affect mobility, and that there was no documentation supporting that concern. The PTA confirmed that her screening was for mobility, not fall prevention, and that occupational therapy, which included bed mobility, had no concerns with the perimeter mattress; she also stated that, in this case, the grab bars were for mobility and not fall prevention, while the resident’s prior falls had occurred while asleep in bed.
Failure to Implement Antibiotic Stewardship and Apply McGeer’s Criteria for UTI Management
Penalty
Summary
The deficiency involves the facility’s failure to implement its antibiotic stewardship policy and McGeer’s criteria when monitoring and managing antibiotic use for residents with suspected urinary tract infections (UTIs). For one resident with malignant neoplasm of the urethra, chronic kidney disease, obstructive and reflux uropathy, and an indwelling catheter, the catheter was accidentally dislodged and replaced in the emergency room, where a urinalysis showed blood and leukocytes and the resident was diagnosed with a UTI. She was started on Cefuroxime, which was continued despite the resident denying dysuria, fever, flank pain, chest pain, or dyspnea, and despite a subsequent urine culture showing pseudomonas aeruginosa at levels below McGeer’s threshold and without Cefuroxime listed as an effective antibiotic. The facility’s antibiotic stewardship evaluation documented that McGeer’s criteria were not met but still recorded a physician justification that did not specify which physician provided it or what symptoms were present. For a second resident with diabetes, chronic kidney disease, and an indwelling catheter, an admission order was written for Keflex for a UTI. The facility’s antibiotic stewardship evaluation stated that the resident had a UTI with onset that day, was not experiencing pain related to the infection, and had repeated oral temperatures of 99°F, and concluded that McGeer’s criteria were met based on fevers and a urine culture with at least 10^5 CFU/mL. The urine culture later showed >100,000 CFU/mL of proteus mirabilis, but the sensitivity report did not include Keflex, and facility documentation noted that Keflex’s effectiveness for UTIs depends on local resistance patterns and that culture and sensitivity testing is crucial before prescribing. Keflex was administered until it was discontinued early due to diarrhea, and there was no evidence that the physician reviewed the continued use of Keflex when it was not listed on the sensitivity report. The DON later stated that the stewardship evaluation was marked in error, as the resident had only one slightly elevated temperature and not repeated fevers. For a third resident with diabetes and hypertension, who had a catheter and was sent to the emergency room for decreased urinary output and concern for kidney injury, hospital records documented burning urinary pain but also noted denial of abdominal or flank discomfort, fevers, chills, hematuria, or dysuria. The resident was started on Macrobid for a UTI and completed a five-day course, and a physician progress note indicated the plan to continue Macrobid and follow up on urine culture results to ensure appropriate coverage. The subsequent urine culture showed 10,000–50,000 CFU/mL of pseudomonas aeruginosa and escherichia coli, which did not meet McGeer’s threshold of >100,000 CFU/mL, and there was no evidence of physician follow-up on the antibiotic choice in light of these results. The DON confirmed that an antibiotic stewardship evaluation was not completed for this antibiotic use and that the physician did not reassess the need for Macrobid when the culture results did not support antibiotic therapy, contrary to the facility’s policy requiring communication of culture and sensitivity results to determine whether antibiotics should be started, continued, modified, or discontinued.
Failure to Provide Comprehensive Pressure Ulcer Care
Penalty
Summary
The facility failed to assess, develop, and implement a comprehensive and individualized prevention program to prevent the development of avoidable pressure ulcers for two residents. Resident #43 was readmitted to the facility with known pressure ulcers and was at high risk for skin breakdown. However, there was no comprehensive assessment of the known pressure ulcers upon readmission. The resident's physician ordered treatments for pressure ulcers were not provided as ordered, and the resident was not placed on a specialized mattress despite having a stage IV pressure ulcer. The resident was later sent to the hospital for suspected infection requiring surgical intervention. Resident #49, who was cognitively impaired and at high risk for pressure ulcer development, was found to have a stage III pressure ulcer without evidence of adequate and individualized pressure ulcer prevention interventions in place prior to its development. The resident was readmitted to the facility with pressure ulcers, but there was no readmission assessment or physician-ordered treatments for the unstageable pressure ulcer to the sacrum/coccyx, left ischium, and stage II pressure ulcer to the left heel. The facility failed to provide documented evidence that the readmission assessment, comprehensive wound assessment, and physician-ordered treatments were completed. The facility's failure to provide appropriate pressure ulcer care and prevent new ulcers from developing resulted in actual harm to both residents. The facility did not have a contracted wound care company in place, and the residents' primary care physicians were unaware of the lack of treatment and assessments. The facility's policies on wound care and pressure-reducing devices were not followed, leading to inadequate care and management of the residents' pressure ulcers.
Inadequate Staffing Leads to Missed Care and Late Medication Administration
Penalty
Summary
The facility failed to ensure adequate staffing to meet the needs of its residents, affecting two specific residents and potentially impacting all 67 residents. On one occasion, a Licensed Practical Nurse (LPN) was observed administering morning medication to a resident via a peg-tube at 11:15 A.M., which was due at 6:00 A.M. The LPN confirmed that the medication was administered late due to staffing shortages, as there were only three nurses on duty, requiring her to cover additional responsibilities. Another resident, who had multiple complex medical conditions and required substantial assistance with personal care, was not provided with scheduled showers on four occasions. A Certified Nursing Assistant (CNA) confirmed that inadequate staffing was the reason for missed showers. The facility's policy stated that staffing should meet the care and service needs of the resident population, but this was not adhered to, leading to the identified deficiencies.
Failure to Maintain Dignity for Residents with Indwelling Catheters
Penalty
Summary
The facility failed to ensure residents with indwelling urinary catheters were treated in a dignified manner, affecting three residents. Resident #43, who was admitted with multiple diagnoses including neurogenic bladder and retention of urine, had an indwelling urinary catheter that was not changed as scheduled. Additionally, the catheter collection bag was not covered with a privacy bag, making the urine visible from the hallway. This was confirmed by an LPN during an interview. Resident #49, with a history of cerebrovascular accident and neuromuscular dysfunction of the bladder, also had an indwelling urinary catheter. Observations revealed that the catheter collection bag was not contained in a privacy bag, allowing the urine to be visible from the hallway. This was confirmed by an LPN during an interview. The resident's care plan included specific interventions for catheter management, but these were not followed. Resident #48, admitted with obstructive uropathy, was observed with the catheter bag on the floor and later hanging on a walker, both times without a privacy cover. The facility's policy on dignity, which emphasizes care that promotes residents' well-being and self-esteem, was not adhered to in these instances. This deficiency was investigated under a specific complaint number, indicating non-compliance with dignity standards.
Failure to Provide Adequate Bed and Enabler Bars for Resident
Penalty
Summary
The facility failed to accommodate the needs of a resident by not providing a bed that matched the resident's size and lacked physician-ordered enabler bars to assist with bed mobility. The resident, who was admitted with multiple diagnoses including cellulitis, pressure ulcers, and obesity, was observed during wound care to be in a regular bed with a parameter mattress. The absence of enabler bars and the inadequacy of the bed size were noted, as the resident's legs fell from the bed when repositioned, indicating the bed was too small for the resident's size. An interview with an LPN confirmed that the resident's bed was too small, limiting the resident's ability to turn and reposition, which is necessary for off-loading pressure ulcers. The LPN also confirmed that the resident was not provided with an air mattress despite having pressure ulcers and verified the absence of enabler bars as ordered by the physician. This deficiency was investigated under a specific complaint number, indicating non-compliance with the requirement to reasonably accommodate the needs and preferences of each resident.
Failure to Complete Timely Admission Assessments for Two Residents
Penalty
Summary
The facility failed to complete comprehensive admission assessments in a timely manner for two residents, which was identified during a complaint investigation. Resident #43 was readmitted to the facility with multiple diagnoses, including pressure-induced deep tissue damage of the sacral region. Despite being readmitted on 02/05/25, the comprehensive readmission assessment was not initiated until 02/07/25 and was still incomplete at the time of review. This delay was confirmed by an interview with the Regional Nurse. Similarly, Resident #49, who was readmitted with a range of serious health conditions including cerebrovascular accident with right-sided hemiplegia and severe protein-calorie malnutrition, did not have a readmission assessment completed. The resident was readmitted on 02/11/25, but as of 02/13/25, the Director of Nursing confirmed that no readmission assessment or wound assessments had been conducted. This deficiency was noted as an incidental finding during the investigation.
Failure to Provide Routine Bathing for Dependent Resident
Penalty
Summary
The facility failed to ensure that a resident who was dependent on staff for personal hygiene received routine bathing. The resident, who had a complex medical history including acute respiratory failure, multiple sclerosis, and functional quadriplegia, was scheduled for showers every Monday and Thursday. However, there was no documented evidence that the resident received the scheduled showers on four specific dates. This lack of documentation was confirmed by a Regional Nurse during an interview. The resident's admission evaluation indicated a preference for bathing at bedtime, and the comprehensive Minimum Data Set assessment showed the resident had no cognitive deficit but required substantial assistance with personal hygiene and other activities of daily living. The facility's policy on shower/tub baths emphasized the importance of cleanliness and skin observation, yet the facility did not adhere to this policy for the resident in question. This deficiency was investigated under specific complaint numbers.
Failure to Provide Proper Indwelling Catheter Care
Penalty
Summary
The facility failed to ensure proper care for residents with indwelling urinary catheters, affecting two residents. Resident #43, who was admitted with multiple diagnoses including neurogenic bladder and retention of urine, had a physician's order to change the Foley catheter and bag every month. However, there was no evidence that the catheter was changed as ordered on the specified date. An interview with the resident confirmed the catheter was not changed, and an LPN corroborated this oversight. Additionally, the resident's catheter collection bag was not in a privacy bag, making the urine visible from the hallway. Resident #73, who had a moderate cognitive deficit and was dependent on staff for toileting, also did not receive appropriate catheter care. The resident's medical record lacked a completed Foley catheter justification assessment and did not contain physician orders or documentation of catheter care. An interview with the DON confirmed the absence of documented evidence for the resident's catheter care. This deficiency was investigated under a specific complaint number.
Deficiencies in Enteral Feeding Tube Maintenance and Medication Administration
Penalty
Summary
The facility failed to maintain the enteral feeding tubes of two residents, leading to deficiencies in their care. Resident #72, who had a complex medical history including multiple sclerosis, dysphagia, and severe protein calorie malnutrition, experienced a leaking peg-tube due to a cracked connector. Despite the issue, the facility did not have a replacement connector, resulting in staff using a towel to manage the leakage. Interviews with staff confirmed that the leaking persisted throughout the resident's stay, indicating a lack of proper equipment and maintenance. Resident #50, with a history of acute respiratory failure, diabetes, and dysphagia, also faced issues with their peg-tube. During a medication administration, the LPN encountered a clogged peg-tube and attempted to flush it, causing water to spray onto the resident. The facility lacked piston-type syringes necessary for the procedure, leading to medication leakage. Additionally, the LPN did not follow the facility's policy of administering medications separately and failed to use enhanced barrier precautions during the procedure. These incidents highlight the facility's failure to ensure proper maintenance and operation of enteral feeding tubes, as well as adherence to medication administration protocols. The lack of necessary equipment and failure to follow established procedures contributed to the deficiencies observed in the care of these residents.
Failure to Provide Physician-Ordered Chest Vest for Resident
Penalty
Summary
The facility failed to provide a resident with the physician-ordered chest vest for chest physiotherapy, which is essential for clearing airways by dislodging mucus and moving secretions. The resident, who had a complex medical history including acute respiratory failure with hypoxia, multiple sclerosis, and chronic obstructive pulmonary disease, was admitted to the facility from an acute care hospital. Despite the physician's order for chest physiotherapy via chest vest three times a day, the resident's admission evaluation and baseline plan of care did not address the use of the chest vest. The resident arrived at the facility without the chest vest, and it was not until several days later that the percussion wrap arrived and was placed in the resident's room. This delay in providing the necessary equipment for chest physiotherapy was confirmed by the Regional Nurse, who acknowledged that the chest vest had not arrived in a timely manner. This deficiency was identified during an investigation under Complaint Number OH00162365.
Failure to Maintain Accurate Medical Records and Adhere to Treatment Orders
Penalty
Summary
The facility failed to maintain a complete and accurate medical record for a resident with multiple medical conditions, including pressure ulcers. The resident was readmitted to the facility from the hospital for wound care, with an ostomy and an indwelling urinary catheter. Despite the resident's condition, a comprehensive readmission assessment was not completed until two days after readmission, and it was still in progress at the time of review. The medical record lacked a documented comprehensive assessment of the resident's pressure ulcers and other wounds, which were critical to the resident's care plan. Additionally, the facility did not adhere to physician-ordered treatments for the resident's pressure ulcers and other wounds. The Treatment Administration Record (TAR) indicated that treatments were not performed as ordered. Observations revealed that dressings on the resident's wounds had not been changed daily as required, with some dressings being several days old and exhibiting signs of neglect, such as saturation with blood-tinged drainage and a foul odor. This deficiency was identified during a complaint investigation, highlighting a significant lapse in the facility's wound care management and documentation practices.
Infection Control Deficiencies in Wound Care and Peg-Tube Management
Penalty
Summary
The facility failed to maintain proper infection control practices during a pressure ulcer dressing change for a resident with multiple medical conditions, including cellulitis, pressure ulcers, and an indwelling urinary catheter. The resident's medical record indicated a lack of comprehensive assessment of the pressure ulcers, and the dressing changes were not performed as ordered. During an observation, an LPN used the same gloves to handle soiled dressings and clean wounds, placed soiled dressings next to clean supplies, and did not change dressings daily as required, potentially introducing infection to the wounds. Another deficiency was noted in the care of a resident with an indwelling medical device, specifically a peg-tube. The resident's care plan included enhanced barrier precautions due to the presence of the peg-tube, but these precautions were not implemented during a medication administration procedure. An LPN attempted to administer medication via the peg-tube without using the required gown and gloves, and the facility lacked the appropriate syringes for the procedure, resulting in medication leakage onto the resident. The facility's failure to implement enhanced barrier precautions and maintain proper infection control practices during high-contact care activities for residents with chronic wounds and indwelling medical devices was identified as a deficiency. The lack of adherence to physician orders and facility policies regarding infection control and barrier precautions contributed to the potential spread of infection among residents.
Medication Transcription Error Leads to Overdose
Penalty
Summary
The facility failed to ensure the correct transcription of a resident's pain medication order, leading to medication errors. Resident #64, who was moderately cognitively impaired and required substantial assistance for daily activities, was admitted to hospice care with a diagnosis of sepsis. The hospice medication report initially ordered Morphine concentrate 100 mg/5 ml to be administered as 10 mg every hour as needed. However, a subsequent order changed the dosage to 20 mg every two hours. The facility's physician orders incorrectly transcribed this as 20 mg/5 ml, resulting in the resident receiving 20 mg doses at incorrect intervals. The controlled drug receipt/record disposition indicated that Morphine was dispensed as 20 mg/1 ml and was administered multiple times on 12/17/24, with each administration being 1 ml (20 mg) of Morphine concentrate. Interviews with the Hospice Director Physician and the Director of Nursing confirmed the transcription error, with the DON verifying that the resident should have received lower doses at specific times. This transcription error led to the resident receiving higher doses of Morphine than intended, as verified by the DON.
Failure to Follow Enhanced Barrier Precautions for Wound Care
Penalty
Summary
The facility failed to adhere to Enhanced Barrier Precautions (EBP) for a resident with a wound, as observed during a complaint investigation. Resident #37, who is cognitively intact, was admitted with multiple diagnoses including cerebral infarction, hemiplegia, type two diabetes mellitus, and an unstageable pressure ulcer. On January 14, 2025, a Registered Nurse (RN) was observed performing wound care on Resident #37 without wearing a gown, which is a requirement under the facility's EBP policy for residents with chronic wounds. The RN confirmed during an interview that Resident #37 should have been on EBP and acknowledged the absence of a sign indicating EBP status. The facility's policy, dated January 1, 2024, mandates the use of gown and gloves during high-contact care activities, such as wound care, for residents with chronic wounds. This oversight was identified as an incidental finding during the course of the complaint investigation, affecting one of the three residents reviewed for wounds.
Failure to Administer Suboxone Timely
Penalty
Summary
The facility failed to ensure timely administration of medication as ordered by the physician, resulting in actual harm to a resident. Resident #52, who had a history of intravenous drug use, was admitted with an order for Suboxone to be administered every twelve hours for opioid dependence. However, the resident did not receive the scheduled doses on the evening of admission and the following morning due to the medication not being available. There was no documentation in the resident's medical record explaining the omission or any notification to the physician about the missed doses. As a result of the missed doses, Resident #52 experienced withdrawal symptoms, including nausea, sweating, and discomfort, which led to the resident being transported to the hospital for further evaluation and treatment. Interviews with staff confirmed the medication was unavailable, and the resident's condition was consistent with withdrawal symptoms due to the missed doses. The facility's policy required medications to be administered according to the prescriber's written orders, which was not adhered to in this case.
Failure to Provide Timely Toileting Assistance
Penalty
Summary
The facility failed to provide timely toileting assistance to a dependent resident, identified as Resident #57, who was admitted with diagnoses including dementia and a need for assistance with personal care. The resident's medical record and care plan indicated a self-care deficit requiring staff assistance for activities of daily living, including toileting. On the day of the incident, Resident #57 was observed crying in her room, expressing an urgent need to use the bathroom. A State tested Nursing Assistant (STNA) entered the room, acknowledged the resident's need, but instructed her to use the incontinence brief instead, promising to return later for cleanup. The STNA left the room, and Resident #57 continued to cry for help. The STNA returned after several minutes, assisted the resident onto the toilet, and instructed her to use the call light when ready to be assisted off. However, the STNA was then observed attending to another resident, leaving Resident #57 unattended on the toilet for an extended period. The STNA eventually returned to assist Resident #57 off the toilet. The STNA confirmed in an interview that she was unable to provide timely assistance due to attending to other residents. The facility's policy required staff to provide needed assistance with activities of daily living, which was not adhered to in this instance.
Delayed Call Light Response for Residents
Penalty
Summary
The facility failed to provide timely toileting services to dependent residents, specifically affecting Resident #24. The resident, who was cognitively intact and required limited assistance with activities of daily living, experienced delays in call light response times. On one occasion, Resident #24's call light was observed ringing for 14 minutes before being answered by a State tested Nursing Assistant (STNA). During this time, two nurses, including a Licensed Practical Nurse (LPN), were present at the nursing desk adjacent to the resident's room but did not respond to the call light. Interviews with staff confirmed that call light response times could take 10 minutes or longer, and there was no established policy on acceptable wait times. The issue of delayed call light response was further corroborated by interviews with other residents and staff, as well as a review of Resident Council meeting minutes and call light audits. Resident #45 reported waiting 25 minutes for assistance, resulting in incontinence. The Assistant Director of Nursing (ADON) confirmed that all staff, including nurses, were expected to answer call lights. The facility had conducted call light audits in response to concerns raised by the Ombudsman and Resident Council, revealing response times ranging from five to 19 minutes. The deficiency was investigated under Complaint Number OH00155464.
Failure to Timely Submit MDS Assessments
Penalty
Summary
The facility failed to timely submit Minimum Data Set (MDS) assessments for four residents, affecting their compliance with state regulations. Resident #16, who had diagnoses including encephalopathy and schizophrenia, was discharged on 12/21/23, but no discharge MDS was completed. Similarly, Resident #52, with diagnoses such as diverticulitis and type two diabetes mellitus, was discharged, but their MDS discharge assessment was not submitted to CMS until 05/22/24. Licensed Practical Nurse (LPN) #40 confirmed these delays during an interview on 05/22/24. Resident #57, who had diagnoses including anemia and pneumonia, also had their discharge MDS assessment delayed, with it not being submitted to CMS until 05/22/24. Additionally, Resident #61, with diagnoses such as hypertension and non-Hodgkin lymphoma, experienced the same issue, with their discharge MDS assessment not being submitted until 05/22/24. LPN #40 verified these delays and acknowledged that the MDS should have been submitted within 14 days of discharge.
Failure to Implement Enhanced Barrier Precautions and PPE Usage
Penalty
Summary
The facility failed to ensure residents were placed in enhanced barrier precautions (EBP) appropriately and that staff wore the necessary personal protective equipment (PPE) when interacting with these residents. This deficiency affected six residents who were identified to be in EBP. Observations revealed that no residents were identified as requiring EBP when care was provided. Specific instances included a restorative aide performing range of motion exercises with a resident without being aware of the resident's isolation status and not using appropriate PPE. Additionally, another resident had no isolation signs or PPE available at their door despite being placed in EBP. A licensed practical nurse (LPN) was observed performing wound care without wearing the required PPE, contrary to the facility's policy and signage instructions. The medical records of the affected residents indicated various diagnoses and conditions that necessitated EBP, such as wounds requiring dressing changes, catheters, and tracheostomies. Despite these requirements, staff were not consistently following the EBP protocols. The Director of Nursing (DON) confirmed that the facility had provided training on EBP, but it included inaccurate information, leading to staff not adhering to the correct PPE usage. The DON acknowledged that all staff providing hands-on care should wear PPE, but this was not being practiced consistently. The facility's policy stated that signage should be posted at room entrances with instructions for PPE use, which was not observed in practice for the six residents identified in the report.
Failure to Assist Resident in Obtaining Appropriate Decision Maker
Penalty
Summary
The facility failed to ensure a resident was provided assistance in obtaining a resident representative to make appropriate decisions on behalf of the resident. Resident #56, who had significant cognitive impairment and diagnoses including vascular dementia, unsteadiness on feet, generalized weakness, failure to thrive, and malnutrition, was involved in this deficiency. The facility staff educated the resident's girlfriend, who was also a resident, that Resident #56 was not to be out of the building without family. However, incidents occurred where the girlfriend took Resident #56 outside the facility and cut off his wander guard, indicating risky behavior regarding resident safety. Interviews with the facility's Administrator and Corporate Nurse revealed that Resident #56's girlfriend was considered his decision maker, although Ohio does not recognize common law marriage. The resident's son, listed as the emergency contact, had not been responsive to the facility's attempts to reach him. Despite considering the guardianship process, the facility did not initiate it, believing it would not be approved due to the resident having family. The last involvement of the resident's son as a decision maker was before the current Administrator started in March 2024, and the facility could not provide a specific date of the last family involvement. The facility acknowledged the failure to initiate the guardianship process for Resident #56.
Failure to Provide Required Beneficiary Notifications
Penalty
Summary
The facility failed to ensure the resident notice letter was accurately completed for three residents reviewed for Beneficiary Notification. Resident #41, who was admitted with multiple diagnoses including Parkinson's disease and osteoporosis, did not receive a Skilled Nursing Facility Advance Beneficiary Notice of Non-Coverage (SNF ABN) when transitioning from Medicare Part A services to long-term care. Similarly, Resident #66, who had severe cognitive impairment and multiple serious health conditions, was not issued a Notice of Medicare Non-Coverage (NOMNC) before being discharged home with Hospice services. The facility did not provide any documentation that Resident #66 initiated the discharge. Resident #71, admitted with diagnoses such as sepsis and diabetes mellitus type II, also did not receive a SNF ABN when transitioning from Medicare Part A services to long-term care. The facility documented the Business Office Manager's failure to issue the required notices for these residents. Interviews with the Administrator and Business Office staff confirmed these deficiencies in issuing the necessary beneficiary notifications.
Failure to Document Reason for Hospital Transfer
Penalty
Summary
The facility failed to ensure the medical record contained documentation reflecting the reason a resident was transferred to the hospital. The resident, who had multiple diagnoses including acute metabolic acidosis, sepsis, and major depressive disorder, was initially planned to be discharged home. However, on the day of discharge, the resident presented with an altered mental status and was subsequently transferred to the hospital. The medical record did not document the change in condition, notification of the physician and resident representative(s), or the actual discharge location. Interviews with staff revealed that the discharge plan was altered due to the resident's sudden change in condition, but the necessary documentation was not completed. The facility's policy on change of condition requires informing the resident, consulting with the resident's physician, and notifying the resident's representative(s) when there is a significant change in the resident's status. This policy also mandates that documentation of such notifications be recorded in the resident's electronic medical record, which was not done in this case.
Failure to Accurately Complete Annual MDS Assessment
Penalty
Summary
The facility failed to complete an accurate comprehensive annual Minimum Data Set (MDS) assessment for a resident, specifically by omitting a diagnosis of post traumatic stress disorder (PTSD) in the active diagnoses section. This deficiency was identified during a review of the resident's medical record, which showed that the PTSD diagnosis was included in previous MDS assessments but was missing in the most recent annual comprehensive MDS assessment. An interview with a Licensed Practical Nurse (LPN) confirmed that the resident had a diagnosis of PTSD and that it should have been coded in the MDS and included in the care plan. This affected one of six residents reviewed for comprehensive assessments, with the facility census being 61.
Failure to Develop Comprehensive Care Plan for PTSD
Penalty
Summary
The facility failed to develop a comprehensive care plan for a resident diagnosed with post traumatic stress disorder (PTSD). The resident, who was admitted with multiple diagnoses including PTSD, iron deficiency anemia, cellulitis, unsteadiness on feet, morbid obesity, chronic obstructive pulmonary disease, anxiety disorder, bipolar disorder, hypertension, and hyperlipidemia, did not have a care plan addressing PTSD. This deficiency was identified during a review of the resident's medical record and confirmed through an interview with an LPN, who acknowledged that a care plan for PTSD should have been developed.
Failure to Update Care Plans for Elopement and Weight Loss
Penalty
Summary
The facility failed to ensure resident care plans were updated and included appropriate interventions for elopement and nutrition/weight loss prevention. For Resident #56, who had significant cognitive impairment and was at risk for elopement, the care plan was not updated after incidents where the wander guard was cut off and after the resident eloped from the facility. Despite staff education and changes to door codes, the care plan remained unchanged, failing to address the resident's ongoing risk for elopement effectively. For Resident #27, who had diagnoses including Parkinson's disease and diabetes, the care plan did not include new interventions after significant weight loss was observed. The resident's weight dropped from 225.8 lbs. to 193.2 lbs. over a few months, but the care plan remained unchanged since its initial creation. Despite physician orders for fortified shakes and other nutritional interventions, the care plan was not updated to reflect these changes. Similarly, Resident #51, who had diagnoses including iron deficiency and muscle wasting, experienced significant weight loss over several months. The care plan, initially created to address nutritional risk, was not updated with new interventions despite ongoing weight loss. Physician orders for various nutritional supplements and fortified foods were not reflected in the care plan, indicating a failure to update the care plan in response to the resident's changing condition.
Failure to Address Severe Weight Loss
Penalty
Summary
The facility failed to recognize and timely address severe weight loss in Resident #27, who was admitted with diagnoses including Parkinson's disease, muscle weakness, depression, diabetes, and spinal stenosis. The resident's weight dropped significantly from 227.8 pounds to 193.2 pounds over a period of about five weeks, representing a 15.19% weight loss. Despite this significant weight loss, there was no evidence of timely reweighs, interventions, or updates to the care plan after the initial assessment on 01/19/24. The dietician did not assess the resident until 04/26/24, and the first nutritional intervention was not ordered until 04/29/24. Additionally, there was a lack of communication regarding changes in nutritional supplements, and the dietician was unaware of these changes. The Director of Nursing confirmed that residents should have timely interventions after weight loss, including weight monitoring, supplements, and dietician assessments. However, there was no evidence of timely follow-up for Resident #27. The facility's policy on nutrition and hydration indicated that significant weight loss should be addressed promptly, but this was not adhered to in the case of Resident #27. The facility was unable to provide any additional evidence or documentation to support that appropriate actions were taken in a timely manner.
Unnecessary Antibiotic Use Without Valid Diagnosis
Penalty
Summary
The facility failed to ensure that a resident's drug regimen was free from unnecessary medications, specifically antibiotics, due to the absence of a valid diagnosis. This deficiency was identified during a review of the medical records for a resident with diagnoses of cerebral infarction and unsteadiness on feet. The resident had physician orders for two antibiotics, amoxicillin-potassium clavulanate and doxycycline monohydrate, both prescribed for infection. However, there was no documented supporting diagnosis for the use of these antibiotics in the medical record. An interview with the Director of Nursing confirmed the inability to determine the reason for the antibiotic prescriptions.
Failure to Administer Influenza and Pneumonia Vaccinations
Penalty
Summary
The facility failed to ensure that influenza and pneumonia vaccinations were offered and provided to residents, affecting two of the five residents reviewed. Resident #47, who had diagnoses including sepsis, vascular disease, heart failure, diabetes, and Parkinson's, consented to the flu vaccine but not the pneumonia vaccine. Despite having received a pneumococcal vaccine in an outside setting in 2021, the facility did not offer the required follow-up dose of PCV 15 or PCV20. The Administrator was unaware of the need for multiple doses of the pneumonia vaccine, and the Director of Nursing confirmed that there was no evidence of the pneumonia vaccine being offered to Resident #47. Resident #56, who had diagnoses including vascular dementia, aphagia, muscle weakness, and malnutrition, had consent for both flu and pneumonia vaccines obtained from their family. While the pneumonia vaccine was administered, there was no evidence that the flu vaccine was given, despite consent being obtained. The Director of Nursing confirmed the lack of evidence for the administration of the flu vaccine. The facility's policy stated that flu vaccinations should be offered annually from October 1st through March 31st and that pneumonia vaccinations should be offered unless contraindicated or the course had been completed.
Failure to Conduct Annual Performance Reviews for Nurse Aides
Penalty
Summary
The facility failed to ensure nurse aides received a performance review at least every 12 months, affecting three State tested Nurse Aides (STNAs) out of four personnel records reviewed. Specifically, STNA #90, hired on 07/25/23, and STNA #514, hired on 02/27/24, did not have any 90-day or annual evaluations on record. Additionally, STNA #503, hired on 07/29/14, did not have any annual evaluations documented. This deficiency was confirmed during an interview with the Administrator, who verified that the facility did not have any records of the required evaluations being completed. This issue has the potential to affect all 61 residents in the facility, as the facility census was 61 at the time of the survey.
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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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