Jag Healthcare Mansfield
Inspection history, citations, penalties and survey trends for this long-term care facility in Mansfield, Ohio.
- Location
- 50 Blymyer Avenue, Mansfield, Ohio 44903
- CMS Provider Number
- 365118
- Inspections on file
- 22
- Latest survey
- July 1, 2025
- Citations (last 12 mo.)
- 46
Citation history
Health deficiencies cited at Jag Healthcare Mansfield during CMS and state inspections, most recent first.
The facility did not document required quarterly QAA meetings with all mandated members present, as sign-in sheets were missing or incomplete for several quarters. Key committee members, such as the Medical Director, DON, and Infection Preventionist, were absent from some meetings, and the Administrator confirmed these lapses. This deficiency had the potential to affect all residents in the facility.
A resident with severe cognitive impairment and total dependence for mobility had personal items go missing, including blankets, clothing, and stuffed animals. Despite reports from the family and other residents about missing items, staff did not document, investigate, or follow up as required by facility policy. Laundry staff frequently received informal reports of missing clothing but discarded notes after searching, and no formal grievance or resolution process was followed, leading to ongoing unresolved complaints among residents.
Staff failed to provide timely wound care and assessments for two residents with chronic wounds, as wound dressings were not dated and weekly wound evaluations were not completed as required. Additionally, a resident receiving hospice care did not receive pain medication during a painful catheter procedure, and staff did not address significant changes in the resident's skin condition. These deficiencies were confirmed through observations, interviews, and record reviews.
A resident with complex medical needs and an indwelling catheter experienced delays in assessment and intervention after removing her catheter and showing signs of infection. Staff did not promptly notify the physician or hospice of significant changes, failed to follow up on lab results indicating a UTI, and did not adhere to proper infection control during catheter reinsertion. These failures in catheter care and communication had the potential to affect other residents with catheters.
Two residents experienced significant medication errors when staff failed to obtain daily weights and administer as-needed Lasix as ordered, and an RN administered insulin without priming the pen as required. These actions were not in accordance with physician orders, manufacturer instructions, or facility policy, and similar errors could potentially affect other residents receiving insulin.
The facility failed to ensure required PPE was available and used for residents on contact precautions, did not implement enhanced barrier precautions, and did not screen residents for tuberculosis as required. This affected four residents, including those with significant wounds and multiple infections.
The facility failed to ensure that a resident was offered an annual influenza vaccination as required. Despite the resident being cognitively intact and having multiple diagnoses, the last documented influenza vaccination was from the previous year, and there was no record of the resident being offered or declining the vaccination during the past influenza season. The facility's policy mandates annual offering and documentation of the influenza vaccine, which was not adhered to in this case.
The facility failed to offer the COVID-19 vaccination or document the vaccination status for three residents, despite their cognitive ability to consent. This deficiency was confirmed through staff interviews and medical record reviews.
The facility experienced Immediate Jeopardy due to financial mismanagement, resulting in unpaid bills to vendors and potential interruptions in essential services for residents. Delayed payments affected therapy services, food vendors, staffing agencies, and utility providers. Financial instability was worsened by a low census, staff turnover, and challenges in completing necessary assessments for billing. Key personnel, including the Administrator, CEO, and Business Office Manager, cited a lack of oversight and accountability. The Board of Directors was aware but did not take decisive action. Residents were directly impacted, with some requesting discharge due to the lack of therapy services and essential supplies. The deficiency affected therapy, food delivery, staffing, and communication services.
The facility failed to ensure resident mail was delivered unopened and that residents had access to a private working telephone. The CEO admitted to opening resident mail, and the phone system was non-functional due to an outstanding balance, preventing residents from making or receiving calls.
The facility failed to maintain sufficient staffing levels due to a hostile work environment and financial issues, leading to delayed resident care and significant staff turnover. The facility was unable to continue using agency staff due to non-payment, resulting in numerous unfilled nursing shifts and concerns about timely resident care.
The facility failed to ensure a full-time DON, affecting all 56 residents. The previous DON worked limited hours before the facility was left without a DON for over three months. An interim DON was brought in but requested a new assignment due to discomfort with the CEO's questioning. The facility had no plan to secure a new DON after the interim DON's contract ended.
The facility failed to provide necessary rehabilitative services, including physical and speech therapy, due to overdue payments to the therapy vendor. This affected 19 residents, some of whom requested discharge due to the lack of services. As of mid-April, the facility had not secured a new therapy provider.
The facility failed to ensure an effective governing body responsible for financial management, leading to significant cash-flow problems and service interruptions. The Administrator did not handle financial aspects, and the CEO and Board of Directors were aware of payment delays to vendors, affecting essential services for all 56 residents.
The facility failed to ensure continuous evaluations to verify financial obligations were met, potentially disrupting resident care and services. The Medical Director was unaware of financial issues, and the CEO admitted that no QAPI meeting was initiated to address the cash flow problem caused by management changes. The facility owed $271,963.63 to various vendors, leading to service interruptions.
The facility failed to provide quarterly statements of resident trust fund accounts to eighteen residents. The Administrator confirmed the oversight, and interviews with two residents corroborated the deficiency. This issue was investigated under Complaint Number OH00151839.
The facility failed to disperse resident fund accounts within 30 days for seven discharged residents, as required by policy. Interviews confirmed that trust fund monies were not returned to residents or their representatives within the stipulated timeframe, affecting residents with various medical conditions including Alzheimer's disease, major depressive disorder, and dementia.
The facility failed to ensure that residents were provided with and signed the necessary admission documentation, including the Consent to Treatment and Other Acknowledgements form and the Nursing Home Admission Agreement. This affected 41 residents, resulting in the facility not having consent to bill Medicare/Medicaid or to treat the residents.
The facility failed to ensure timely and required initial comprehensive assessments for seven residents, affecting their care. Interviews confirmed that the assessments were either still in progress or overdue, indicating a significant lapse in compliance.
The facility failed to complete quarterly comprehensive assessments for four residents, including those with chronic respiratory failure, COPD, Parkinson's disease, and end-stage renal disease. This was confirmed through interviews with the BOM and Administrator.
The facility failed to ensure a resident's discharge summary included the reconciliation of medications upon discharge. The resident's wife reported that the facility handed her paperwork to sign without going over the discharge part, including the medication list. This deficiency was confirmed by the Administrator and investigated under Complaint Number OH00151839.
A resident with severe cognitive impairment and specific dietary orders did not receive ice cream with meals from 04/11/24 to 04/15/24 because the facility ran out of ice cream and was unable to purchase more due to a maxed-out credit card. The Dietary Kitchen Manager confirmed the issue and stated that ice cream would be delivered on 04/17/24.
Failure to Hold Required QAA Meetings with All Mandated Members
Penalty
Summary
The facility failed to hold required Quality Assessment and Assurance (QAA) meetings at least quarterly with all mandated members present, as evidenced by a review of QAA meeting sign-in documentation, staff interviews, and facility policy. There was no documentation of QAA meetings for the first, second, and third quarters of 2024. For the fourth quarter of 2024, while a meeting was documented, there was no sign-in sheet to confirm the attendance of all required members. Additionally, meetings held in early 2025 were missing attendance from key members, including the Medical Director, Director of Nursing, and Infection Preventionist. The Administrator confirmed during an interview that there was no documentation of quarterly QAA meetings prior to the fourth quarter of 2024 and that not all required members were present for subsequent meetings. The facility's policy specifies that the QAA committee must include the administrator (or designee), director of nursing services, medical director, infection preventionist, and representatives from various departments as needed, and that meetings must occur at least quarterly. The lack of proper documentation and attendance had the potential to affect all residents, with a facility census of 57 at the time of the survey.
Failure to Investigate and Follow Up on Missing Resident Items
Penalty
Summary
The facility failed to properly investigate and follow up on missing personal items for a resident with severe cognitive impairment and total dependence for mobility and transfers. The resident's family reported missing blankets, clothing, and stuffed animals to staff, but could not recall specific staff names. The social worker designee stated she had not received any concerns or grievances regarding missing items from this resident or their family, and no concern logs were found at the front desk as required by facility policy. Laundry and housekeeping staff reported that missing clothing is a frequent issue, with reports received verbally or in writing, but these notes are discarded after a search is conducted, and there is no documentation or follow-up. Clothing items without names accumulate in the laundry room, and staff are often informed of missing items by residents or families but do not maintain records or communicate outcomes. Certified nursing assistants confirmed that families had reported missing items, but after searching the laundry, no further action was taken or documented. During a resident council meeting, multiple residents confirmed that missing clothing was a widespread and ongoing problem, with little to no follow-up from staff after reports were made. Review of resident council meeting minutes showed repeated complaints about missing items and a lack of documented follow-up or resolution. The facility's grievance policy requires all grievances to be recorded, investigated, and maintained, but this process was not followed for missing items, resulting in unresolved concerns for residents.
Failure to Provide Timely Wound Care, Pain Management, and Assessment
Penalty
Summary
Facility staff failed to provide appropriate wound care and pain management for multiple residents, as evidenced by direct observations, interviews, and record reviews. For one resident with bilateral lower extremity venous ulcers, wound dressings were not dated as required by facility policy, and there was no documentation or evidence that wound care was performed daily as ordered by the physician. Staff interviews confirmed that wound dressings were not dated, and the Treatment Administration Record lacked documentation of wound care on specific days. The Director of Nursing verified that wound care was not completed as required. Another resident with a left heel wound and diabetic foot ulcer did not receive weekly wound assessments as outlined in the care plan. Documentation showed that after a certain date, no further weekly wound assessments were completed, and there were no wound measurements from outside wound care appointments. The Director of Nursing confirmed the lack of weekly wound evaluations, and the facility's wound care policy did not specify the required frequency for wound assessments. A third resident receiving hospice care did not receive pain medication during a painful catheter reinsertion procedure, despite expressing pain and having PRN pain medication available. The hospice nurse did not offer pain medication before or during the procedure, and the resident repeatedly verbalized pain. Additionally, staff failed to address a change in the resident's condition, as deep redness was observed in the peri area, buttocks, and under the breasts, but no treatment orders were obtained or implemented at the time. Staff interviews confirmed these deficiencies in care and communication.
Failure to Provide Timely Catheter Care and Notify Physician of Changes in Condition
Penalty
Summary
A resident with multiple complex medical conditions, including heart failure, bilateral leg amputations, obesity, diabetes with polyneuropathy, and neurogenic bladder, was admitted to the facility and received hospice services. The resident was dependent on staff for all activities of daily living and had an indwelling catheter in place. The care plan included monitoring for signs and symptoms of urinary tract infection (UTI) and ensuring catheter patency and urinary output every shift. Despite these interventions, documentation revealed that the resident exhibited symptoms of a possible UTI, such as cloudy and foul-smelling urine, increased confusion, and agitation. A urine sample was collected for urinalysis and culture, but there was no timely follow-up or documentation of the results, and neither the primary care physician nor hospice was notified promptly of the findings, which later showed significant bacterial growth requiring antibiotic treatment. On a separate occasion, the resident was found by staff to have removed her indwelling catheter, resulting in visible blood and blood clots in her brief and on the bed. The catheter, with an inflated balloon, was observed lying on the mattress. Despite the resident's change in condition and the presence of trauma, the nurse on duty did not immediately assess or address the situation, citing workload and staffing shortages. The nurse delayed reinsertion of the catheter, waiting for hospice staff to arrive, and did not notify the primary physician of the catheter removal. When hospice staff attempted to reinsert the catheter, proper infection control procedures were not followed, and the catheter was not successfully placed on the first attempt. The resident subsequently removed the catheter again, and there was continued delay in assessment and notification of the physician. Throughout these events, there was a lack of timely assessment, intervention, and communication with the primary care physician and hospice regarding significant changes in the resident's condition, including catheter removal, signs of infection, and laboratory results. The facility failed to ensure appropriate catheter care, prompt response to changes in condition, and effective communication, which affected the resident directly and had the potential to impact other residents with indwelling catheters.
Failure to Prevent Significant Medication Errors in Medication Administration
Penalty
Summary
The facility failed to ensure residents were free from significant medication errors, as evidenced by two separate incidents involving medication administration. For one resident with multiple diagnoses including heart failure and Alzheimer's disease, staff did not obtain daily weights as ordered by the physician on multiple occasions. Additionally, when the resident experienced weight gains greater than three pounds in 24 hours, the as-needed Lasix was not administered as prescribed. The Director of Nursing confirmed that both the daily weights and the administration of Lasix were not completed according to physician orders. Facility policy required medications to be administered safely, timely, and as prescribed, which was not followed in this case. In another incident, a resident with type two diabetes mellitus and moderate cognitive impairment was ordered to receive Humalog insulin via pen, including a sliding scale for blood sugar regulation. During observation, an RN administered insulin without priming the insulin pen as required by manufacturer instructions. The RN acknowledged the omission during a concurrent interview. Facility policy indicated that nursing staff should have access to manufacturer instructions for insulin administration. These failures were identified during a complaint investigation and had the potential to affect additional residents receiving insulin via pen.
Infection Control Deficiencies
Penalty
Summary
The facility failed to ensure all required personal protective equipment (PPE) was available and used for residents on contact precautions, failed to implement enhanced barrier precautions as required, and failed to ensure residents were screened for tuberculosis infection as required. This affected four residents reviewed for infection control practices. The census was 41. Resident #10 was admitted with multiple diagnoses including osteomyelitis, bacteremia, and ESBL resistance. Despite being on contact isolation for ESBL, the isolation cart outside the resident's room lacked gloves and gowns. LPN #110 confirmed the absence of these items and admitted to only wearing gloves while administering medication due to the unavailability of gowns. The supply room also lacked isolation gowns. Additionally, Resident #10 had not undergone the required two-step Mantoux screening for tuberculosis. Resident #30, diagnosed with severe malnutrition and respiratory failure, was also on contact isolation for ESBL. Similar to Resident #10, the isolation cart outside Resident #30's room lacked gloves and gowns. LPN #120 confirmed the absence of these items and admitted to only wearing gloves while administering medication. Resident #30 also had not undergone the required two-step Mantoux screening for tuberculosis. Furthermore, the facility failed to implement enhanced barrier precautions for residents with wounds requiring dressings, as confirmed by LPN #120 and the Director of Nursing (DON). Resident #50 and Resident #60, both with significant wounds, were not placed under any type of isolation precautions, and neither had been screened for tuberculosis as per the facility's policy.
Failure to Offer Annual Influenza Vaccination
Penalty
Summary
The facility failed to ensure that residents were offered influenza vaccinations annually as required. This deficiency was identified during a review of Resident #40's medical record, which revealed that the resident, who was admitted with multiple diagnoses including schizophrenia, chronic obstructive pulmonary disease, type two diabetes, dementia, anemia, delusional disorder, auditory hallucinations, and a complete traumatic amputation of the left lower leg at the knee level, did not receive an influenza vaccination nor had the resident declined it during the past influenza season. The last documented influenza vaccination for Resident #40 was dated 10/14/22, and the quarterly Minimum Data Set (MDS) indicated that the resident was cognitively intact and had not been offered the vaccination. An interview with the Director of Nursing (DON) and a Licensed Practical Nurse (LPN) confirmed that Resident #40 had not received the influenza vaccination nor had they declined it. The facility's influenza vaccine policy, dated 2002, mandates that all residents and employees who have contact with residents be offered the influenza vaccine annually between October 1st and November 30th, unless medically contraindicated or refused for personal or religious reasons. The policy also requires appropriate documentation in the residents' medical records indicating the date of receipt or refusal of the vaccination. This policy was not followed in the case of Resident #40.
Failure to Document COVID-19 Vaccination Status
Penalty
Summary
The facility failed to offer the COVID-19 vaccination or obtain documentation of residents' vaccination status for three residents. Resident #10, who was admitted with multiple diagnoses including osteomyelitis, bacteremia, and pneumonia, had no documented COVID-19 vaccinations, history of vaccinations, or declination of vaccinations in their medical record. Similarly, Resident #30, admitted with severe calorie protein malnutrition and acute respiratory failure, also had no documented COVID-19 vaccination status. Resident #50, who had diagnoses including anemia, metabolic encephalopathy, and an unstageable pressure ulcer, had no documentation of COVID-19 vaccinations or declination in their medical record. All three residents were noted to be cognitively intact or had mild cognitive impairment according to their MDS assessments. The deficiency was confirmed through an interview with the Director of Nursing (DON) and a Licensed Practical Nurse (LPN), who verified the lack of documentation for the COVID-19 vaccination status or declination for the three residents. The facility census at the time was 41, and the deficiency was investigated under Complaint Number OH00153390.
Immediate Jeopardy Due to Financial Mismanagement Impacting Essential Services
Penalty
Summary
The facility in question was found to be in Immediate Jeopardy due to financial mismanagement that resulted in unpaid bills to various vendors, leading to potential interruptions in essential services for residents. The deficiency stemmed from a pattern of delayed payments to vendors, including therapy services, food vendors, staffing agencies, and utility providers. The facility's financial instability was exacerbated by a low census, staff turnover, and challenges in completing necessary assessments for billing purposes. The lack of timely payments resulted in critical services being suspended, such as therapy services for residents, food delivery, and even the threat of utility disconnection. Key personnel, including the Administrator, CEO, and Business Office Manager, were interviewed and revealed a lack of oversight and accountability in managing the facility's finances. The CEO acknowledged the cash flow issues but failed to implement a plan to address the outstanding balances and ensure timely payments to vendors. The facility's Board of Directors was aware of the financial challenges but did not take decisive action to rectify the situation, leading to a cascading effect on resident care and services. Residents were directly impacted by the deficiency, with some requesting discharge due to the lack of therapy services and essential supplies. The deficiency extended beyond financial implications, affecting essential services such as therapy, food delivery, staffing, and even communication due to phone service interruptions. The facility's inability to meet its financial obligations jeopardized the well-being and safety of residents, as evidenced by residents not receiving necessary therapy services, facing food shortages, and experiencing disruptions in communication with their families.
Failure to Ensure Privacy and Communication Access
Penalty
Summary
The facility failed to ensure resident mail was delivered unopened and that residents had access to a private working telephone. Observations revealed that the Business Office Manager's desk contained opened mail addressed to several residents. The CEO admitted to opening the mail, believing it was permissible for Medicaid and Medicare correspondence. The facility's policy indicated that residents had the right to receive and send sealed, unopened correspondence, which was not adhered to in this instance. Additionally, the facility's phone system was not operational, preventing residents from making or receiving calls. Staff confirmed that they had to use personal cell phones for communication, including contacting physicians. Several residents reported relying on the facility phone to communicate with family members, and some did not have personal cell phones. The phone service provider indicated that the service was interrupted due to an outstanding balance and a broken contract, requiring a significant payment to resume services. Interviews with the Administrator revealed a lack of awareness regarding the phone system's status and the CEO's efforts to resolve the issue. Despite attempts to contact the facility over several days, the phone system remained non-functional. The Administrator indicated that the CEO was working on obtaining a new phone company, but no timeline or details were provided. The facility's failure to maintain a working phone system and ensure the privacy of resident mail represents non-compliance with their policies and regulations.
Staffing Deficiency Due to Hostile Work Environment and Financial Issues
Penalty
Summary
The facility failed to maintain sufficient levels of staff to meet the total care needs of all residents due to a hostile work environment and insufficient funds to maintain staffing agency contracts. Interviews with various staff members, including the scheduler, CEO, and former MDS nurse, revealed that the facility was heavily reliant on agency staff to cover nursing shifts. However, due to non-payment of agency bills, the facility was unable to continue using agency staff, leading to numerous unfilled nursing shifts from 04/01/24 to 04/30/24. This resulted in delayed resident care, including answering call lights and providing incontinence care in a timely manner. The report also highlighted significant staff turnover and resignations, including the former MDS nurse, business office manager, and several other key administrative and nursing staff. Interviews with these individuals revealed concerns about a hostile work environment, including allegations of fraud, retaliation, and unethical behavior by administrative staff. The facility's CEO was reported to have created increased anxiety and panic among the staff by communicating financial issues and stating that the facility's bank accounts were frozen, leading to further staff call-offs and concerns about receiving paychecks. Additionally, the facility's phones were disconnected, causing family members to contact staff on their personal cell phones with concerns about resident care. The facility's wide assessment form indicated that the staffing levels were not being met, and the facility's admission agreement stated that it would provide necessary care and services, which it failed to do. The deficiency was investigated under Complaint Numbers OH00152329 and OH00152153.
Failure to Maintain Full-Time Director of Nursing
Penalty
Summary
The facility failed to ensure a registered nurse (RN) served as a full-time director of nursing (DON), which had the potential to affect all 56 residents residing in the facility. The previous DON worked only 7.50 hours on one day and 6.75 hours on another day before the facility was left without a DON from early December to mid-March. During this period, the facility did not have a full-time DON, and the RN staff currently working in the building did not want to take on the role. An interim DON was brought in on March 18, but she requested a new assignment due to feeling uncomfortable with the CEO's questioning about her taking the full-time DON position. The interim DON's contract was set to end on April 18, and there was no evidence that the facility had a plan in place to secure a new DON or interim DON after that date. Interviews with the Administrator and the interim DON confirmed the lack of a full-time DON during the specified period. The interim DON's discomfort with the CEO's questioning led her to request a new assignment, and her staffing agency confirmed that her contract would not be extended. This deficiency was investigated under Complaint Numbers OH00152205 and OH00152153, highlighting the facility's failure to maintain a full-time DON as required by regulations.
Failure to Provide Rehabilitative Services Due to Payment Issues
Penalty
Summary
The facility failed to ensure residents were provided with necessary rehabilitative services, including physical therapy, speech-language pathology, and occupational therapy. This deficiency affected 19 residents and had the potential to impact all 56 residents in the facility. The issue arose due to the facility's failure to make timely payments to the contracted therapy vendor, resulting in the termination of therapy services. Despite partial payments made in March, the facility was still past due by $55,180.95 for services rendered in January and February. Consequently, the therapy vendor terminated services on April 5, 2024, leaving residents without necessary rehabilitative care. Several residents, including those with severe cognitive impairments and conditions such as dementia, diabetes, cerebral infarction, and hemiplegia, were directly affected. For instance, one resident receiving speech therapy for dysphagia and another receiving gait training were left without services from April 6 to April 12, 2024. Interviews with residents and staff confirmed the lack of therapy services, and some residents requested discharge due to the unavailability of these essential services. As of mid-April, the facility had not secured a new therapy provider, and negotiations with potential vendors were still ongoing.
Failure to Ensure Effective Governing Body and Financial Management
Penalty
Summary
The facility failed to ensure an effective governing body that was legally responsible for establishing and implementing policies regarding the management and operation of the facility, including compliance with all financial obligations for the delivery of care. The Administrator, who began employment on 03/20/23, indicated she did not handle any financial aspects of the facility. The CEO and the Board of Directors were responsible for the financial management, but the facility faced significant cash-flow problems, resulting in payment delays to multiple vendors. This affected the delivery of essential services, including food, therapy, and utilities, potentially impacting all 56 residents in the facility. Interviews with the CEO and Business Office Manager revealed that the facility was on payment plans with multiple vendors due to cash-flow issues. The Business Office Manager noted that the facility was unable to process payments for resident care and that bills were not paid timely. Outstanding balances to various vendors totaled $271,963.63, leading to service interruptions, including a water shut-off notice, phone service interruption, food delivery hold, and termination of therapy services. A Board Member confirmed that financial issues were discussed in board meetings, but there was no awareness of disconnection notices. The Administrator confirmed that she did not govern or manage the business office manager or human resources manager, and these positions reported to the CEO. The Administrator-Skilled Nursing/Assisted Living agreement indicated that the Administrator was responsible for the overall operation of the facility, including financial aspects, but this was not being effectively managed. The facility did not have a policy on the governing body to provide during the investigation.
Failure to Ensure Financial Solvency and Continuous Evaluations
Penalty
Summary
The facility failed to ensure continuous evaluations were in place to verify financial obligations were met as planned, which could potentially disrupt resident care and services. The Medical Director was unaware of the facility's financial issues and confirmed that no concerns were raised about supplies, food, medications, or resident care during the recent QAPI meeting. The CEO revealed that the facility had a cash flow issue due to changes in management, including the recent resignation of the MDS coordinator and the Business Office Manager, which led to delays in completing resident MDS assessments and generating payments for resident care. The CEO admitted that no QAPI meeting was initiated to develop a plan to ensure timely vendor payments, and the facility was considering options such as finding new staff or shutting down the facility. During an on-site investigation, it was found that the facility had a general fund balance of $6,971.18 and owed a total of $271,963.63 to various vendors, including registered dietitians, supply vendors, staffing vendors, pharmacy collections, medical supplies, food vendors, IT services, therapy services, phone services, monitoring services, oxygen vendors, and water/sewer services. Delinquent balances led to a water shut-off notice, phone service interruption, food delivery hold, and termination of therapy services. The facility's Performance Improvement Committee policy and procedure, revised in 2007, required the establishment of a committee to monitor and evaluate the quality of care, but the facility failed to address the financial solvency issues through this committee.
Failure to Provide Quarterly Resident Fund Statements
Penalty
Summary
The facility failed to provide residents with quarterly statements of their resident trust fund accounts. This deficiency affected eighteen residents who had resident fund accounts. A review of the Trust-Current Account Balance form dated 04/01/24 revealed that these residents were not given quarterly balance statements. During an interview, the Administrator confirmed that the quarterly statements were not provided and could not specify when the last statements were issued. Additionally, interviews with two residents confirmed that they had not received their quarterly fund statements. The facility's Resident Rights policy, dated 03/21/24, states that residents may maintain a resident fund account for day-to-day expenses, but this policy was not followed as required. This deficiency was investigated under Complaint Number OH00151839.
Failure to Disperse Resident Funds Timely
Penalty
Summary
The facility failed to ensure that resident fund accounts were finalized and dispersed within 30 days as required, affecting seven discharged residents. Resident #92 was admitted with Alzheimer's disease and muscle weakness, and was discharged after being admitted to the hospital for sepsis. The resident's fund balance of $40.00 was not returned within the required timeframe. Similarly, Resident #93, who had major depressive disorder and muscle weakness, was discharged with family, but their fund balance of $45.90 was not returned within 30 days. Resident #94, who had abnormal posture and dementia, passed away, and their fund balance of $2,146.88 was not returned to the estate within the required period. Resident #95, with chronic obstructive pulmonary disease and diabetes, was discharged with family, but their fund balance of $40.00 was not returned timely. Resident #96, who had sarcopenia and dementia, was transferred to another facility, but their fund balance of $3,788.40 was not returned within 30 days. Resident #97, with Alzheimer's disease and hypertension, was discharged to their wife, but their fund balance of $10.00 was not returned within the required timeframe. Lastly, Resident #98, with Alzheimer's disease and anxiety disorder, was admitted to the hospital and did not return, but their fund balance of $60.00 was not returned within 30 days. Interviews with the Business Office Manager confirmed that the trust fund monies for these residents were not returned to the residents or their representatives within the required 30-day period. The facility's Resident Rights policy allows residents to maintain a fund account for personal expenses, but the facility failed to comply with the policy by not dispersing the funds within the stipulated timeframe. This deficiency was identified through a review of medical records and trust account balance forms, highlighting a systemic issue in the management of resident funds upon discharge, eviction, or death.
Failure to Provide and Obtain Signed Admission Documentation
Penalty
Summary
The facility failed to ensure that residents admitted were provided with a description of the requirements and procedures for establishing eligibility for Medicaid, including the right to request an assessment of resources, as well as information concerning Medicare and Medicaid eligibility and coverage. This deficiency affected 41 residents whose records were reviewed for admission documentation. The review revealed that the Consent to Treatment and Other Acknowledgements form was not signed by the resident or their representative, nor was it witnessed by a facility representative. Additionally, the Nursing Home Admission Agreement, which describes the daily room rate, the right to an assessment of resources, and the authorization to bill Medicaid or Medicare for services rendered, was also not signed or witnessed as required. For instance, Resident #2 was admitted with diagnoses including hypertension, heart failure, and chronic kidney disease. The admission documentation for this resident lacked the necessary signatures on both the Consent to Treatment and Other Acknowledgements form and the Nursing Home Admission Agreement. Similar deficiencies were found in the records of other residents, such as Resident #3, who was admitted with hyperglycemia, diabetes, and hypertension, and Resident #5, who was admitted and readmitted with diagnoses including encephalopathy, chronic obstructive pulmonary disease, and hypertension. In each case, the required forms were not signed by the resident or their representative, nor were they witnessed by a facility representative. The issue was confirmed during an interview with Social Service Designee (SSD) #828, who acknowledged that the facility did not ensure the 41 residents had signed admission agreements. This lack of signed documentation resulted in the facility not having consent to bill Medicare/Medicaid for services rendered or a consent to treat while the residents were admitted. This deficiency represents non-compliance investigated under Complaint Number OH00151839.
Failure to Complete Timely Comprehensive Assessments
Penalty
Summary
The facility failed to ensure initial comprehensive assessments were completed timely and as required for seven residents. Resident #3 was admitted with diagnoses including non-traumatic subarachnoid hemorrhage, diabetes, and hypertension, but their comprehensive assessment was still in progress. Similarly, Resident #5, who was admitted and readmitted with acute kidney failure, chronic obstructive pulmonary disease, and hypertension, also had an incomplete assessment. Resident #11, admitted with end-stage renal disease, polyneuropathy, and legal blindness, had a comprehensive assessment that was due but not completed on time. Resident #22, with unspecified dementia, hyperlipidemia, and essential hypertension, also had an incomplete assessment. Resident #45, admitted and readmitted with type two diabetes and unsteadiness on the feet, had an overdue comprehensive assessment. Resident #130, admitted and discharged with Crohn's disease and age-related physical debility, had an incomplete discharge assessment. Lastly, Resident #133, admitted and discharged with diseases of the tongue, bipolar disorder, and dysphagia, also had an incomplete assessment. Interviews with the Business Office Manager and the Administrator confirmed that the comprehensive assessments for these residents were not completed timely. The assessments were either still in progress or overdue, indicating a failure in the facility's process to ensure timely and required initial comprehensive assessments. This deficiency affected seven out of the 24 residents reviewed for comprehensive assessments, highlighting a significant lapse in the facility's compliance with assessment requirements.
Failure to Complete Quarterly Comprehensive Assessments
Penalty
Summary
The facility failed to ensure comprehensive assessments were completed quarterly as required, affecting four residents. Resident #13, initially admitted with chronic respiratory failure, other lack of coordination, and diabetes, had an incomplete quarterly Minimum Data Set (MDS) 3.0 comprehensive assessment. This was confirmed by the Business Office Manager (BOM) during an interview. Similarly, Resident #33, with diagnoses including chronic obstructive pulmonary disease, muscle wasting, and major depressive disorder, also had an incomplete quarterly MDS 3.0 assessment, as confirmed by the Administrator during an interview. Resident #90, admitted with Parkinson's disease, heart failure, and anemia, had an incomplete discharge MDS 3.0 assessment, which was confirmed by the Administrator. Lastly, Resident #126, with end-stage renal disease, lack of coordination, and unsteadiness on the feet, had an incomplete Discharge Return Anticipated comprehensive assessment. This was confirmed by the BOM. These deficiencies indicate a failure to complete required comprehensive assessments in a timely manner for the affected residents.
Failure to Reconcile Medications Upon Discharge
Penalty
Summary
The facility failed to ensure that Resident #90's discharge summary included the reconciliation of the resident's medications upon discharge. Resident #90, who had diagnoses including Parkinson's disease, heart failure, and anemia, was admitted on an unspecified date and discharged on 02/16/24. The discharge summary did not include a list of the resident's current medications or the last dose administered, and this information was not provided to the resident or their representative upon discharge. This was confirmed by the Administrator during an interview on 03/28/24. Additionally, Resident #90's wife reported that at the time of discharge, the facility handed her paperwork to sign without going over the discharge part of the paperwork, including the resident's medication list. The facility's undated Discharge Policy and Procedure stated that residents had the right to be informed of policies at the time of admission, transfer, and/or discharge, and that written communication would be provided to ensure a safe and orderly process. This deficiency was investigated under Complaint Number OH00151839.
Failure to Provide Ordered Food Items
Penalty
Summary
The facility failed to provide Resident #29 with food items as ordered and planned. Resident #29, who was admitted with diagnoses including Alzheimer's disease, anemia, and dysphagia oropharyngeal phase, had a physician's order for a regular diet with pureed texture, thin liquids with no straw, and ice cream with all meals. Despite this, the resident did not receive ice cream from 04/11/24 to 04/15/24 because the facility ran out of ice cream on 04/10/24 and was unable to purchase more due to a maxed-out credit card. This was confirmed by the Dietary Kitchen Manager during an interview on 04/15/24, who stated that ice cream would be delivered with the food delivery truck on 04/17/24. The deficiency was investigated under Complaint Number OH00152329.
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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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