Kettering Heights Post Acute
Inspection history, citations, penalties and survey trends for this long-term care facility in Kettering, Ohio.
- Location
- 3313 Wilmington Pike, Kettering, Ohio 45429
- CMS Provider Number
- 365616
- Inspections on file
- 43
- Latest survey
- March 20, 2026
- Citations (last 12 mo.)
- 6
Citation history
Health deficiencies cited at Kettering Heights Post Acute during CMS and state inspections, most recent first.
A resident admitted with multiple medical conditions, including a documented stage II coccyx pressure ulcer present on admission, did not have this pressure ulcer reflected in the baseline care plan. Although a Comprehensive Skin Evaluation identified the ulcer and the resident was assessed as cognitively intact, the baseline care plan omitted the pressure ulcer and contained no related interventions. During interviews, the DON and an MDS coordinator confirmed that the care plan did not address the ulcer, despite facility policy requiring a baseline plan of care to meet immediate health and safety needs within 48 hours of admission.
Two cognitively intact residents with documented pressure ulcers on admission, including an unstageable ulcer that later progressed to stage II and a sacral pressure injury, did not have any corresponding pressure-ulcer care plans or interventions in their records. Review of progress notes and skin evaluations confirmed the presence of these wounds, while care plan review showed no entries addressing them. In an interview, the MDS coordinator and the DON acknowledged that the care plans did not include the residents’ pressure ulcers, despite facility policy requiring comprehensive care plans to be developed following resident assessments.
Two cognitively intact residents with multiple chronic conditions, including COPD, DM, depression, and GERD, reported that a CNA entered their shared room, appeared confused while attempting incontinence care, then opened their closet and urinated on a box inside with the door open, allowing at least one resident to see his side profile and urine on his pants. Both residents began screaming during the incident, and one reported feeling scared, unsafe, and shaken afterward. Facility staff and documentation confirmed that the CNA had urinated in the residents' closet, constituting a failure to treat the residents with dignity and respect.
A resident with multiple comorbidities developed dry gangrene in the left foot, but staff failed to notify the physician promptly, resulting in delayed treatment and an above-knee amputation. Additionally, two residents did not receive accurate or complete skin assessments, with omissions in documentation of wounds and surgical sites. Staff interviews confirmed that facility policies and nursing standards for skin assessment and documentation were not consistently followed.
A resident did not receive appropriate care for existing pressure ulcers, and necessary interventions to prevent new ulcers were not consistently implemented. Surveyors observed lapses in pressure ulcer management protocols, resulting in a deficiency related to pressure ulcer care.
Two residents and their representatives were not provided timely access to their medical records after making valid requests, including one case involving an attorney and another involving a subpoena. Facility staff were unclear about procedures following a change in ownership and did not follow policy requiring records to be provided within two business days, resulting in significant delays.
A facility failed to address a grievance from a resident's representative, leading to a deficiency. The resident, with multiple medical conditions and moderate cognitive impairment, had a daughter who expressed concerns about care and communication. The DON did not return a call from the daughter due to foul language and the resident's discharge, despite the facility's policy requiring responses to grievances.
The facility failed to conduct quarterly care conferences for two residents, despite their medical conditions requiring regular assessments. One resident, with conditions including dementia and CHF, had their last care conference documented months prior to the deficiency finding. Another resident, with COPD and CHF, also lacked recent care conference documentation. The Regional Nurse confirmed the absence of required documentation, indicating non-compliance with facility policy.
A facility failed to implement a speech therapy recommendation to upgrade a resident's diet from dysphagia pureed to advanced dysphagia. Despite the resident tolerating a trial tray well, the diet change was not communicated to the physician, as confirmed by staff interviews. The facility's policy requires therapeutic diets to be prescribed by the attending physician.
A LTC facility failed to administer medications as ordered, resulting in significant errors for three residents. One resident received an extra dose of oxycodone instead of Lyrica due to an LPN's mistake. Another resident missed six days of doxycycline due to a pharmacy issue. A third resident did not receive multiple medications as ordered, and received lisinopril despite low blood pressure. These errors were confirmed through medical record reviews and staff interviews.
The facility failed to perform surgical wound care and PICC line dressing changes as ordered for a resident with chronic conditions, lacking documentation to support care was provided. Another resident with diabetes and osteomyelitis also did not have documented PICC line dressing changes. Staff confirmed the absence of required documentation, despite facility policies emphasizing infection prevention and proper care.
A resident with multiple medical conditions developed an unstageable pressure ulcer that was not timely assessed or reported to a physician. Despite protective skin measures, the ulcer was not documented by an STNA, although the nurse was informed. The wound nurse was notified later and assessed the ulcer, but the resident was hospitalized before new treatment orders were entered.
Two residents experienced medication administration errors. One resident received metoprolol without required blood pressure checks, and another had a lidocaine patch left on beyond the prescribed time. Staff interviews confirmed these discrepancies against physician orders.
The facility failed to follow infection control procedures during wound care and medication administration. An LPN did not wear a gown or change gloves during wound care for a resident under Enhanced Barrier Precautions. In another case, an LPN picked up a dropped medication tablet with bare hands before administering it to a resident, violating the facility's medication administration policy.
A resident with multiple health conditions did not receive prescribed eye medications due to unavailability from the pharmacy. The MAR indicated missed doses, and progress notes confirmed the medications were not available. The DON acknowledged ongoing issues with pharmacy communication to rectify the situation.
A resident did not receive their prescribed eye drops due to the facility's failure to reorder the medication on time. Despite the pharmacy's records showing the medication was ordered and dispensed, it was not available for administration on multiple occasions. Interviews with staff and family confirmed the issue, and the DON acknowledged the need for timely reordering.
The facility failed to accurately post staffing information, omitting actual hours worked and not updating for staff absences. Interviews revealed staff were unaware of the requirement to include total hours and update per shift. Discrepancies were found between posted documents and actual coverage.
Failure to Include Existing Pressure Ulcer in Baseline Care Plan
Penalty
Summary
The facility failed to ensure the baseline care plan reflected a resident’s current status of having a pressure ulcer and to create and implement a plan to meet the resident’s immediate needs within 48 hours of admission. The resident was admitted with diagnoses including gastrostomy, gastrojejunal ulcer, cognitive communication deficit, unspecified atrial flutter, and malignant neoplasm of the prostate, and was documented as cognitively intact on the most recent MDS 3.0 assessment. A Comprehensive Skin Evaluation completed shortly after admission identified a stage II pressure ulcer to the coccyx that was present on admission. However, the baseline care plan developed for the resident did not list the stage II pressure ulcer and contained no interventions related to the pressure ulcer, despite facility policy requiring a baseline plan of care to meet immediate health and safety needs within 48 hours of admission. During interview, the DON and MDS Coordinator confirmed that the care plan did not address the resident’s pressure ulcer and that no interventions were in place for this condition. This deficiency was cited as non-compliance under the referenced complaint number.
Failure to Care Plan for Residents’ Pressure Ulcers
Penalty
Summary
The deficiency involves the facility’s failure to develop comprehensive, person-centered care plans addressing pressure ulcers for two cognitively intact residents. Resident #106 was admitted with multiple medical diagnoses, including essential hypertension, paroxysmal atrial fibrillation, chronic obstructive pulmonary disease, and acute kidney failure. The most recent MDS 3.0 assessment showed the resident had an unstageable pressure ulcer upon admission. A progress note dated 02/18/26 documented that this resident had a stage II pressure ulcer, yet review of the resident’s care plan revealed no care plan or interventions addressing the stage II pressure ulcer. Resident #107 was admitted with diagnoses including rheumatoid arthritis, chronic obstructive pulmonary disease, and a cognitive communication deficit, and was also assessed as cognitively intact on the most recent MDS 3.0. A skin evaluation dated 02/05/26 documented a pressure injury to the sacrum that was present upon admission. However, review of this resident’s care plan showed no plan or interventions for a pressure ulcer. During an interview on 03/20/26, the MDS coordinator and the DON confirmed that the care plans did not address the residents’ pressure ulcers or contain related interventions. Facility policy titled “Care Planning,” dated 09/2013, requires that a comprehensive care plan for each resident be developed within seven days of completion of the resident assessment, but this was not done for these residents’ pressure ulcers.
Failure to Treat Residents With Dignity When CNA Urinated in Shared Closet
Penalty
Summary
The deficiency involves a failure to honor residents' rights to dignity and respect when a CNA urinated in the shared closet of two cognitively intact residents. One resident, admitted with diagnoses including COPD, major depressive disorder, hypertension, hyperlipidemia, anorexia, and GERD, reported that the CNA attempted to change her incontinence brief while appearing very confused and using an ill-fitting glove that did not cover his pinky finger and thumb. She stated that she then observed the CNA open the closet door and heard him urinating, recognizing the sound of the urine stream hitting a box in the closet, which led her and her roommate to begin screaming. The second resident, admitted with COPD, chronic respiratory failure with hypoxia, DM, major depressive disorder, adult failure to thrive, tachycardia, GERD, and essential hypertension, also cognitively intact, reported that she observed the CNA enter the room, open the closet door, and proceed to urinate on a box in the closet with the door left open so she could see his side profile. She stated that she began screaming loudly, saw urine on his pants, and felt very upset, scared, unsafe, and confused about why he would do this. Facility staff, including the HR manager, confirmed that the CNA urinated in the residents' closet, and documentation in the employee record identified the conduct as a violation of the facility’s code of conduct and dignity policies.
Delayed Physician Notification and Incomplete Skin Assessments Result in Harm
Penalty
Summary
The facility failed to provide timely physician notification and accurate skin assessments for residents with significant skin and wound care needs. In one case, a resident with a history of myocardial infarction, sepsis, and diabetes developed signs of dry gangrene in the left foot and ankle. Despite documentation of black and painful areas on the left foot and ankle, the physician was not notified promptly. The nurse placed a note in the doctor’s book and deferred notification to the morning shift, resulting in a delay. The physician was not made aware of the resident’s condition until two days later, at which point the resident was sent to the hospital and required an above-knee amputation due to dry gangrene and acute limb ischemia. Additionally, the facility failed to ensure the accuracy and completeness of skin assessments for two residents. For one resident, skin assessments were not performed weekly as indicated by the care plan, and documentation was inconsistent, with gaps in assessment records and failure to note significant changes. For another resident, the admission assessment and subsequent skin evaluations were incomplete and inconsistent, omitting documentation of surgical wounds, soft heels, and elbow wounds, despite these being present and referenced in hospital discharge paperwork. The DON confirmed that not all skin impairments were documented, and there was no evidence of monitoring or documentation for surgical incision sites. Interviews with staff, including the DON, LPN, and wound nurse, revealed a lack of adherence to facility policy and nursing standards regarding comprehensive skin assessments and documentation. Staff acknowledged that all skin impairments, regardless of size or type, should be documented and monitored, but this was not consistently done. The facility’s own policies required comprehensive skin assessments upon admission and as indicated, but these were not followed, leading to missed or delayed identification and treatment of significant skin and wound issues.
Failure to Provide Adequate Pressure Ulcer Care
Penalty
Summary
The facility failed to provide appropriate pressure ulcer care and prevent the development of new ulcers. This deficiency was identified through surveyor observations and review of care practices, which revealed that the necessary interventions to manage existing pressure ulcers and prevent new ones were not consistently implemented for affected residents. The report notes that residents with pressure ulcers did not receive the required care to promote healing and prevent further skin breakdown, indicating lapses in the facility's pressure ulcer management protocols.
Failure to Provide Timely Access to Resident Records
Penalty
Summary
The facility failed to provide timely access to resident records upon request, affecting two residents who had requested their medical records or had requests made on their behalf. In the first case, a resident with intact cognition had an attorney request the entire electronic nursing home chart for estate purposes. Despite multiple written requests and follow-up communications, the records were not provided for over a month. Facility staff, including the medical records staff and the administrator, were uncertain about procedures for records from before a recent change in facility ownership. Staff communications with the regional legal department revealed confusion and delays, with instructions to wait for a subpoena before releasing records, and no clear direction on handling records from the previous ownership. The attorney eventually threatened to subpoena the records due to the lack of response. In the second case, a resident with impaired cognition requested all records, and a subpoena was later issued for the documents. The medical records staff confirmed that no records had been provided since the change in ownership and was unaware of the request or the requirement to provide records in a timely manner, even for residents admitted under previous ownership. Facility policy required that records be provided within two business days of a written or oral request, but this policy was not followed. The deficiency was identified through record review, staff interviews, and policy review, confirming that the facility did not comply with its own procedures or regulatory requirements for timely access to resident records.
Failure to Address Resident Representative's Grievance
Penalty
Summary
The facility failed to address the concerns of a resident's representative, which led to a deficiency in honoring the resident's right to voice grievances without discrimination or reprisal. The medical record for a resident, who had been admitted with multiple medical diagnoses including diabetes mellitus and congestive heart failure, indicated moderate cognitive impairment and required assistance with daily activities. The resident's daughter expressed concerns about the care provided and felt her concerns were being dismissed. Despite the facility's policy stating that residents have the right to voice grievances and receive responses, the Director of Nursing (DON) did not return the daughter's call after she left a voicemail expressing her concerns. The DON acknowledged speaking with the resident's daughter about care concerns and issues with staff communication but did not follow up on a subsequent voicemail due to the use of foul language and the resident's discharge to the hospital. The facility's failure to respond to the grievance was documented in a nurse's note and confirmed during an interview with the DON. This deficiency was investigated under two complaint numbers, indicating non-compliance with the facility's grievance policy.
Failure to Conduct Quarterly Care Conferences
Penalty
Summary
The facility failed to conduct quarterly care conferences for two residents, as required by their policy and regulatory standards. Resident #08, who has medical diagnoses including dementia, COPD, hypertensive heart and chronic kidney disease, anxiety, CHF, and atrial fibrillation, was admitted on an unspecified date. The resident's quarterly MDS assessment dated 11/07/24 indicated cognitive intactness and varying levels of dependency on staff for daily activities. However, the last documented care conference for this resident was on 09/11/24, with no subsequent conferences conducted or offered. Similarly, Resident #38, with medical conditions such as COPD, CHF, chronic respiratory failure, morbid obesity, and hypertensive heart disease, was admitted on an unspecified date. The resident's quarterly MDS assessment dated 11/14/24 showed cognitive intactness and independence in daily living activities. The last care conference for this resident was documented on 05/14/24, with no further conferences conducted or offered. The Regional Nurse confirmed the absence of documentation for the required care conferences, indicating non-compliance with the facility's policy and regulatory requirements.
Failure to Implement Speech Therapy Diet Recommendations
Penalty
Summary
The facility failed to timely provide a therapeutic diet as per speech therapy recommendations for a resident with multiple medical diagnoses, including diabetes mellitus, metabolic encephalopathy, hypertensive heart disease, congestive heart failure, and dysphagia oropharyngeal. The resident was admitted with moderate cognitive impairment and required assistance with daily activities. Initially, the resident was on a mechanically altered diet with no swallowing or chewing problems and no weight loss. A speech therapy note dated 12/06/24 indicated that the resident tolerated a trial tray of a dysphagia advanced diet well, and a diet order was given to upgrade the resident's diet. However, the diet was not updated, and the nursing staff and director of rehabilitation were notified on 12/11/24. Interviews with the speech therapist and regional nurse confirmed that the resident's physician was not notified of the speech therapy recommendation to upgrade the diet. The facility's policy on therapeutic diets, revised in October 2017, states that therapeutic diets are prescribed by the attending physician to support the resident's treatment and plan of care. The deficiency was identified during a complaint investigation, indicating non-compliance with the facility's policy and procedures for managing therapeutic diets.
Significant Medication Errors in LTC Facility
Penalty
Summary
The facility failed to ensure medications were administered as ordered, resulting in significant medication errors affecting three residents. Resident #08, who was cognitively intact and had multiple medical diagnoses including dementia and COPD, received an extra dose of oxycodone instead of Lyrica due to a mistake by LPN #240. The error was documented in the nurse's notes, and the facility's investigation revealed that the LPN had not followed the physician's orders or the Five Rights of Medication Pass. Resident #95, who was also cognitively intact and had a history of chronic osteomyelitis and diabetes, did not receive doxycycline as ordered for six days due to an issue with the pharmacy discontinuing the previous order. The medication error was identified when the Nurse Practitioner noted the discrepancy, and the facility's investigation confirmed the lack of documentation for the administration of doxycycline during the specified period. Resident #100, with diagnoses including COPD and myasthenia gravis, did not receive multiple medications as ordered on a specific date, and there was no documentation to support the administration of gabapentin over several days. Additionally, the resident received lisinopril despite having a systolic blood pressure below the ordered parameter. Interviews with the Regional Nurse confirmed these discrepancies, highlighting failures in medication administration and documentation.
Deficiency in Wound and PICC Line Care
Penalty
Summary
The facility failed to ensure that surgical wound care and PICC line dressing changes were completed as ordered for residents. Specifically, Resident #95, who was admitted with chronic multifocal osteomyelitis and other conditions, did not receive surgical wound care or PICC line dressing changes as per hospital discharge orders. The medical record lacked documentation to support that these care procedures were performed according to the orders. The Treatment Administration Record (TAR) for September 2024 did not show evidence of the required care, and although wound care was documented on October 11, 2024, there was no documentation for the PICC line dressing change. Additionally, Resident #97, who had medical diagnoses including diabetes mellitus and osteomyelitis, also did not have PICC line dressing changes documented as ordered. The August and September 2024 TARs lacked evidence of the dressing changes on specified dates. Interviews with facility staff confirmed the absence of documentation for these required care procedures. The facility's policies on dressing changes and catheter care were reviewed, highlighting the importance of preventing infection and ensuring proper care, but these were not adhered to in practice.
Failure to Timely Assess and Notify Physician of Pressure Ulcer
Penalty
Summary
The facility failed to ensure timely assessment, measurement, and physician notification of a new pressure ulcer for Resident #51, who was admitted with multiple medical conditions including hypertensive heart disease, chronic kidney disease, diabetes mellitus with neuropathy, bipolar disorder, and chronic obstructive pulmonary disease. Upon admission, Resident #51 was at risk for skin breakdown but had no pressure ulcers. Despite having orders for protective skin measures, a weekly wound assessment on 10/14/24 indicated no skin breakdown. However, a subsequent assessment revealed an unstageable pressure ulcer on the left buttock, measuring 3 cm by 2.5 cm with 95% slough present, and new treatment was ordered. Interviews revealed that a State tested Nursing Assistant (STNA) observed a small open area on Resident #51's buttock on 10/22/24 but did not document it on the shower sheet, although she informed the nurse. The wound nurse was notified on 10/24/24 and conducted an assessment, notifying the physician and obtaining new treatment orders. However, Resident #51 was sent to the hospital for altered mental status before the new treatment orders were entered into the system. The facility's policy required timely assessment and physician notification for skin changes, which was not adhered to in this case.
Medication Administration Errors
Penalty
Summary
The facility failed to ensure medications were administered as ordered, affecting two residents. Resident #04, who was admitted with medical diagnoses including atherosclerosis and left hemiplegia, had a physician order for metoprolol with specific parameters to hold the medication if the systolic blood pressure (SBP) was less than 110 or heart rate was less than 60. However, the facility's Medication Administration Record (MAR) for October 2024 showed that Resident #04 received metoprolol on several occasions without documentation of blood pressure checks prior to administration. Additionally, on one occasion, the medication was administered despite the resident's SBP being 104/42, which was below the threshold set by the physician's order. Resident #14, who had diagnoses including Alzheimer's disease and hypertensive chronic kidney disease, had a physician order for a lidocaine patch to be applied to the left shoulder in the morning and removed in the evening. An observation revealed that a lidocaine patch from the previous day was still on Resident #14's shoulder when a new patch was being applied, indicating a failure to remove the patch as ordered. Interviews with staff confirmed these findings, and the facility's policy on medication administration emphasized adherence to prescriber's written orders, which was not followed in these instances.
Infection Control Deficiencies in Wound Care and Medication Administration
Penalty
Summary
The facility failed to adhere to infection control procedures during wound care for a resident with a Stage III pressure ulcer. The resident was under Enhanced Barrier Precautions (EBP) due to the risk of multidrug-resistant organisms. During an observation, an LPN was seen performing wound care without wearing a gown, as required by EBP. Additionally, the LPN did not change gloves or perform hand hygiene after removing soiled dressings and before applying new ones, which is a violation of the facility's policy on dressing changes. In another incident, the facility did not follow proper infection control procedures during medication administration for a resident. An LPN was observed dropping a gabapentin tablet onto the medication cart, picking it up with bare hands, and placing it into the resident's medication cup. This action was contrary to the facility's medication administration policy, which requires good hand hygiene and the use of gloves if direct contact with medications occurs. These deficiencies were identified during a complaint investigation.
Medication Administration Deficiency Due to Pharmacy Availability Issues
Penalty
Summary
The facility failed to ensure medications were administered as per physician orders for a resident with multiple diagnoses, including type two diabetes mellitus, diabetic retinopathy, bipolar disease, and peripheral vascular disease. The resident, who had intact cognition and required assistance for various activities, had active physician orders for Combigan Ophthalmic and Rocklatan Ophthalmic solutions to manage eye conditions. However, the September 2024 Medication Administration Record (MAR) indicated that the resident did not receive the prescribed doses of these medications on specific dates. The MAR noted 'OT' for these missed doses, which was identified as 'other' in the MAR key. Progress notes revealed that the Combigan Ophthalmic solution was unavailable from the pharmacy on two occasions, and the Rocklatan Ophthalmic solution was also not available and had to be reordered. Interviews with the resident and the Director of Nursing confirmed concerns about the availability of medications from the pharmacy. The Director of Nursing acknowledged ongoing communication efforts to address these medication issues, which were described as a work in progress. This deficiency was investigated under a specific complaint number.
Medication Unavailability for Resident
Penalty
Summary
The facility failed to ensure that routine medication was available for administration, affecting one resident. The resident, who was admitted with diagnoses including legal blindness and bipolar disorder, had an order for Rocklatan Ophthalmic Solution to be administered at bedtime. However, the medication administration record indicated that the eye drops were not available on multiple occasions in May. Interviews with the resident, their family member, and nursing staff confirmed that the medication was not reordered on time, leading to missed doses. The Director of Nursing stated that most medications were on automatic refill, but there were instances when they had to repeatedly contact the pharmacy due to delays. The pharmacy representative confirmed that the medication was ordered and dispensed on specific dates, but the facility staff did not have it available for administration. The Nurse Practitioner emphasized the importance of the medication for the resident's eye pressure, and the Administrator expected timely reordering of medications. The deficiency was investigated under a specific complaint number.
Inaccurate Staffing Documentation
Penalty
Summary
The facility failed to ensure that the posted staffing document accurately reflected the total number and actual hours worked for each discipline, as well as any staff absences due to call-offs or illness. This deficiency was identified during a review of the facility's Report of Nursing Staff Directly Responsible for Resident Care, covering the period from May 13, 2024, to June 13, 2024. The report did not include RN hours for specific dates, and discrepancies were found between the posted staffing document and the Daily Coverage Report, which indicated RN coverage that was not reflected in the posted forms. Interviews with facility staff revealed a lack of understanding regarding the requirements for posting staffing information. The Scheduler and the Director of Nursing (DON) both indicated they were unaware that the total number of actual hours worked needed to be included on the form and that updates were required per shift to reflect any call-ins. The Administrator also confirmed that the forms should include the census and staffing numbers but was unaware of the need to include actual hours worked per shift. The facility's policy on Staffing & Scheduling, last reviewed in June 2022, mandates compliance with CMS staffing requirements and the posting of staffing information at the beginning of each shift, but it appears this was not adequately followed.
Latest citations in Ohio
A resident with intact cognition receiving Medicare Part A skilled services for metabolic encephalopathy had services discontinued while benefit days remained, but the facility did not issue the required Skilled Nursing Facility Advance Beneficiary Notice (SNF ABN). The Social Services Director later confirmed that no SNF ABN was provided and reported she believed only a Notice of Medicare Non-Coverage (NOMNC) was needed when all skilled services were stopped. This practice conflicted with the facility’s written policy, which required SNF ABNs to be issued when extended care items or services were initiated, reduced, or terminated due to expected non-coverage by Medicare.
Surveyors identified that the facility exceeded the acceptable medication error rate when two residents with type 2 DM received insulin doses that were not administered according to orders or manufacturer instructions. In two separate observations, an LPN administered Novolog and another LPN administered insulin glargine and insulin lispro without priming the insulin pens, and the insulin lispro and Novolog were given after the residents had already consumed a significant portion of their breakfast meals, despite orders for administration before meals. Manufacturer information for both insulin products required priming before each injection to ensure accurate dosing, and facility policy required medications, including insulin, to be administered safely, timely, and in accordance with prescriber orders and specified time frames.
Surveyors found that the facility failed to document tray line food temperatures for multiple meals served from two dining room kitchenettes, despite having a “Trayline Taste & Temperature Log” and a policy requiring food to be stored, prepared, distributed, and served according to professional food safety standards. Review of logs showed repeated missing entries for breakfast, lunch, and dinner services in both the Harrison and McClellan dining areas, and the Senior Director of Culinary Services confirmed that temperatures had not been recorded for those meals, potentially affecting all residents receiving meals from those kitchenettes.
The facility failed to conduct and document required periodic care conferences for two residents, despite multiple comprehensive, quarterly, and significant change MDS assessments and a policy requiring periodic care conferences with resident and/or family participation. One resident with Parkinson’s disease, post-stroke hemiplegia, TIA, DMII, and depression had only two documented care conferences over a year, while another resident with aphasia, cerebrovascular disease, DMII, gait difficulty, coagulation defect, depression, and muscle weakness had no documented care conferences in the past year, aside from a declined invitation to the representative. The UCC confirmed that care conferences were expected to occur quarterly and that no additional documentation existed for either resident.
A resident with Alzheimer's disease and type II DM, who required extensive assistance with ADLs and was receiving scheduled Lantus and sliding-scale Humalog, experienced a severely elevated blood glucose level. The on-call provider was notified and ordered an additional dose of lispro insulin with a directive to recheck the blood glucose after administration. Nursing staff administered the extra insulin but did not document any follow-up blood glucose check, and the DON confirmed that this reevaluation was required by the facility's abnormal blood glucose policy and was not completed or documented.
A resident with Parkinson’s disease, dementia, and hypothyroidism was prescribed levothyroxine once daily along with other medications. A consultant pharmacist’s monthly drug regimen review recommended that levothyroxine be given in the morning on an empty stomach, 30–60 minutes before food, per manufacturer instructions. The medical record contained no documented physician response to this recommendation, and the MAR showed the drug scheduled for morning administration while the resident was observed eating breakfast and receiving the medication at the same time. An LPN confirmed administering levothyroxine during the meal, and the DON verified there was no documentation explaining whether or why the pharmacist’s recommendation was or was not followed, resulting in a failure to act on and document the identified irregularity.
A resident with severe cognitive impairment, multiple comorbidities, documented gait and balance abnormalities, and a high fall risk was care planned and assessed by therapy to require contact guard assistance and use of a gait belt for transfers and ambulation. While being assisted by a CNA from a recliner to the bathroom with a walker, the CNA did not apply a gait belt, even though the resident had a known tendency to lean backward when standing. As the CNA reached to open the bathroom door, the resident lost balance and fell backward, striking the back of the head, and was later found by an LPN without a gait belt in place, contrary to the facility’s gait belt policy and the resident’s assessed needs.
A resident with CKD stage five requiring peritoneal dialysis (PD) was admitted with pre-admission physician orders for three daily PD exchanges and monitoring for peritonitis (fever, abdominal pain, cloudy effluent), but these monitoring orders were not entered into the facility’s physician orders. The care plan referenced PD and general monitoring but did not specifically address peritonitis monitoring. Paper PD flowsheets showed incomplete and inconsistent documentation of exchanges and resident condition, including missing condition/comments for individual treatments and no record of one ordered PD exchange. The PD cycler flowsheet lacked effluent descriptions on multiple days. The PD nurse reported facility staff were expected to monitor effluent and symptoms, and the DON confirmed the absence of specific peritonitis monitoring orders, lack of an order for the PD cycler, and documentation gaps, despite a facility policy requiring ongoing assessment and monitoring for complications before, during, and after dialysis treatments.
A nurse was observed preparing multiple oral medications for a resident with depression, traumatic brain injury, anxiety, and impaired cognition by pushing tablets and capsules from unit-dose cards directly into her ungloved hand and then using her fingers to place them into a medication cup. In a follow-up interview, the RN confirmed this practice and acknowledged that the correct procedure is to dispense medications directly from the card into the cup, contrary to the facility’s medication administration policy requiring adherence to good nursing principles and practices.
A resident with Alzheimer’s disease, diabetes, anxiety, significant ADL dependence, and behavioral symptoms was observed seated in a chair positioned against the nursing station with a locked wheelchair placed directly in front, also against the nursing station, effectively restricting movement. An LPN confirmed both wheelchair wheels were locked and that it should not have been placed there, while a CNA stated she had positioned the wheelchair to prepare for lunch, was unable to complete the transfer, and left it in place, acknowledging this was wrong. This arrangement conflicted with the facility’s restraint policy, which prohibits physical restraints except when alternatives are ineffective for treating a medical symptom and defines restraints as devices adjacent to the body that cannot be easily removed and that restrict freedom of movement or access to the body.
Failure to Issue Required SNF ABN When Discontinuing Medicare Part A Services
Penalty
Summary
The deficiency involves the facility’s failure to issue a Skilled Nursing Facility Advance Beneficiary Notice (SNF ABN) when Medicare Part A services were discontinued for a resident who still had available benefit days. The resident was admitted with a diagnosis of metabolic encephalopathy and had intact cognition per the Minimum Data Set assessment. The facility’s own SNF Beneficiary Notification Review documented that Medicare Part A skilled services began on 02/11/26 and the last covered day was 03/11/26, and that the facility initiated discharge from Medicare Part A services before the resident’s benefit days were exhausted. Despite this, no SNF ABN was provided to the resident or the resident’s representative. During interviews, the Social Services Director stated that the SNF ABN was issued hours prior to the last covered day but, upon reviewing her files, confirmed that no SNF ABN had actually been issued for this resident. She further explained that she believed an SNF ABN was only required if one skilled service remained and that if all skilled services were being discontinued, only the Notice of Medicare Non-Coverage (NOMNC) needed to be issued. The Administrator, however, stated that a resident should always receive both a SNF ABN and a NOMNC when Medicare Part A services are discontinued and benefit days remain. Review of the facility’s written policy dated 03/28/23 showed that the facility was required to issue SNF ABNs for initiation, reduction, or termination of extended care items or services when Medicare payment was not expected, which did not occur in this case.
Plan Of Correction
This Plan of Correction is submitted as required under State and Federal law. This Plan of Correction does not constitute an admission on the part of the Facility that the findings cited are accurate, that the findings constitute a deficiency or that the scope and severity regarding the deficiency cited are correctly applied. Any changes to the Facility's policies and procedures should be inadmissible in any proceeding on that basis. Without admitting or denying the validity or the existence of the alleged noncompliance, the Facility submits this Plan of Correction with the intention that it be inadmissible by any third party in any civil or other action against the facility or any employee, agent, officer, director or shareholder of the Facility. The Facility is utilizing this Plan of Correction as its allegation of substantial compliance as of 05/29/2026 F-0582 Corrective action for resident/s: On 5/14/26 Resident #34 was informed of rights and responsibilities related to Advanced Beneficiary Notice and voiced understanding of information for future reference by administrator. Identification of other residents who may be affected: Any resident receiving skilled services from nursing or therapy services. The Administrator audited all residents who were discharged from skilled services in the past 30 days to ensure they were issued a Notice of Non-Coverage and Advanced Beneficiary Notice on 5/29/26. No non-compliance was noted. Measures for systemic change: On 5/14/2026 Business Office Manager, Director of Rehab, Minimum Data Set nurse, Director of Nursing and Social Services Director were educated on proper procedure of issuing of Notice Of Medicare Non Coverage and Advanced Beneficiary Notice by administrator. All upcoming discharges from skilled services will be reviewed weekly at Utilization Review meeting to ensure notices will be delivered timely. How Corrective Action will be monitored: Administrator or designee to complete audits of all residents being discharged from skilled services to ensure they were issued a Notice of Non-Coverage and Advanced Beneficiary. This audit will be completed weekly x 4 weeks, then monthly x 2 months. Corrective action will be initiated for any noted non-compliance. Audit findings will be reviewed as part of the monthly quality assurance process to determine the need for further monitoring. Date of Compliance 5/29/26
Insulin Administration Errors and Failure to Prime Insulin Pens
Penalty
Summary
The deficiency involves the facility’s failure to maintain a medication error rate below 5%, with surveyors identifying 3 errors out of 28 medication administration opportunities, resulting in a 10.71% error rate. For one resident with type 2 diabetes mellitus and moderate cognitive impairment, the physician’s order directed Novolog insulin 10 units via subcutaneous pen-injector to be given before meals. During an observed medication pass, the LPN administered 10 units of Novolog insulin without priming the pen and did so after the resident had already consumed approximately 50% of the breakfast meal. The LPN later confirmed she did not prime the pen and acknowledged that the insulin was ordered to be administered prior to meals. Manufacturer instructions for the Novolog FlexPen specified that an air shot (priming) must be performed before each injection to ensure proper dosing. Another resident, also diagnosed with type 2 diabetes mellitus and with intact cognition, had orders for insulin glargine 35 units subcutaneously twice daily and insulin lispro 20 units subcutaneously before meals, plus 12 units subcutaneously if blood glucose was between 251 mg/dL and 300 mg/dL. During an observed medication administration, an LPN administered 35 units of insulin glargine and 32 units of insulin lispro without priming the insulin pens and after the resident had consumed approximately 90% of the breakfast meal, despite orders for insulin lispro to be given before meals. The LPN later stated she could not remember if she had primed the pen and acknowledged that the insulin was ordered to be administered prior to meals. Manufacturer information for insulin lispro stated that the pen must be primed before each injection to confirm insulin delivery and remove air, and that failure to prime could result in too much or too little insulin. The DON confirmed the expectation that insulin be administered as ordered, including priming each pen with two units before dialing the prescribed dose, and facility policy required medications, including insulin, to be administered safely, timely, and in accordance with prescriber orders and required time frames.
Plan Of Correction
This Plan of Correction is submitted as required under State and Federal law. This Plan of Correction does not constitute an admission on the part of the Facility that the findings cited are accurate, that the findings constitute a deficiency or that the scope and severity regarding the deficiency cited are correctly applied. Any changes to the Facility's policies and procedures should be inadmissible in any proceeding on that basis. Without admitting or denying the validity or the existence of the alleged noncompliance, the Facility submits this Plan of Correction with the intention that it be inadmissible by any third party in any civil or other action against the facility or any employee, agent, officer, director or shareholder of the Facility. The Facility is utilizing this Plan of Correction as an allegation of substantial compliance as of 5/29/2026. F-0759 Corrective action for resident/s: Residents #21 and #22 were assessed and evaluated by nurse and Director of Nursing 5/14/26. Resident #21 and #22 both denied any adverse effects and none were noted upon assessment by the Director of Nursing on 5/14/2026. Notification made to physician on 5/14/2026. LPN # 2 competency Eval on insulin administration with the Director of Nursing completed 5/14/2026. Identification of other residents who may be affected: Diabetic residents on assignment of LPN #2/station 2 have the potential to be affected and were assessed by the DON/Designee on 5/14/26 and found to be within normal limits. Measures for systemic change: All Nurses were educated by the Director of Nursing on the steps for Insulin administration per competency, diabetes clinical protocol policy, Medication and treatment orders policy, administering medications policy, and Obtaining fingerstick Glucose Level policy On 5/14/2026. How Corrective Action will be monitored: Director of Nursing and Assistant Director of Nursing will complete insulin administration audits on 5 nurses. This audit will be completed weekly x 4 weeks, then monthly x 2 months. Corrective action will be initiated for any noted non-compliance. Audit findings will be reviewed as part of the monthly quality assurance process to determine the need for further monitoring. Date of Compliance: 5/29/2026
Failure to Document Tray Line Food Temperatures in Dining Room Kitchenettes
Penalty
Summary
The deficiency involves the facility’s failure to document tray line food temperatures for meals served from the Harrison and McClellan Dining Room kitchenettes, as required by professional standards for food service safety and the facility’s own policy. Review of the “Trayline Taste & Temperature Log” (revised September 2018) showed missing temperature documentation for multiple meals from the Harrison Dining Room kitchenette, including dinner on 03/30/26 and 03/31/26, lunch and dinner on 04/01/26 and 04/02/26, dinner on 04/07/26, and lunch and dinner on 04/08/26 and 04/10/26. The Senior Director of Culinary Services confirmed during interview that tray line food temperatures were not documented on the log for these meals. Similarly, review of the same log for the McClellan Dining Room kitchenette revealed that tray line food temperatures were not documented for dinner on 04/01/26, breakfast and lunch on 04/02/26, and lunch and dinner on 04/07/26. The Senior Director of Culinary Services also verified these omissions during interview. The facility census at the time was 27 residents, and the governing “Food and Nutrition” policy, approved on 09/07/21, stated that the facility must store, prepare, distribute, and serve food in accordance with professional standards for food service safety.
Plan Of Correction
F812 The facility will continue to ensure food temperatures are completed before meals are served for all residents. To ensure compliance with this standard the following measures have been taken: 1. Immediately 4/15/26 culinary supervisor #224 was re-educated by Dietary Manager to this standard and policy "Food and Nutrition" which includes documentation of food temperatures. 2. All dietary staff have been re-educated to the standard and policy "Food and Nutrition" during the month of April 2026. 3. Audits of food temperature documentation to be completed by Dietary Manager 4 x per week for 4 weeks then weekly for 4 weeks. 4. Administrator to validate audits/compliance and provide additional training as needed. Administrator will present to QAPI committee for ongoing monitoring and further direction.
Failure to Conduct and Document Required Care Conferences
Penalty
Summary
The deficiency involves the facility’s failure to complete and document comprehensive care conferences at required intervals in accordance with care plan regulations and facility policy. For one resident with Parkinson’s disease with dyskinesia, cognitive communication deficit, hemiplegia and hemiparesis following cerebral infarction, transient cerebral ischemic attack, type II diabetes mellitus, and major depressive disorder, the record showed multiple MDS assessments over a one-year period, including annual, quarterly, and significant change assessments. However, only two care conferences were documented during the last 12 months, despite the expectation that care conferences be conducted quarterly with the resident and family when possible. The Unit Care Coordinator confirmed that no additional care conference documentation existed for this resident beyond the notes dated 04/21/25 and 01/02/26. A second resident, with diagnoses including aphasia following cerebrovascular disease, cerebral infarction, type II diabetes mellitus, unsteadiness on feet, difficulty in walking, coagulation defect, depression, and muscle weakness, also had multiple MDS assessments completed over the review period, including quarterly and annual assessments. The record contained a note that a care conference was offered to the resident’s representative, who declined to attend, but there was no documentation of any care conferences for the most recent 12 months. The Unit Care Coordinator confirmed that no other care conference documentation was available for this resident. Facility policy stated that periodic care conferences involving the resident, family, and the interdisciplinary team are part of the care planning process, but the required periodic care conferences and corresponding documentation were not completed for these two residents.
Plan Of Correction
THIS PLAN OF CORRECTION SERVES AS BERKELEY SQUARE'S CREDIBLE ALLEGATION OF SUBSTANTIAL COMPLIANCE AS OF June 1, 2026. Without admitting or denying the validity or existence of the alleged deficiencies, Berkeley Square provides the following Plan of Correction: F657 The facility will continue to document completion of care conferences at the required intervals for all residents, including residents #04 & #15. To ensure compliance with this standard the following measures have be taken: 1. The social service designee and the inter- disciplinary team were re-educated by the administrator to the facility policy "Care Conference" on 4/29/26 and verbalized understanding. 2. Care conferences for resident #04 and resident #15 were conducted on or before 4/29/2026 by the interdisciplinary team. 3. Review of all other residents was conducted by the social service designee to validate and ensure that care conference schedule is up to date with timely care conferences scheduled for them on 4/15/2026. Audits of care conferences to be completed weekly for four weeks and then monthly after that by the social service designee. Documentation of the care conference including any identified concerns in the medical record. Administrator to validate audits/compliance and provide additional training as needed. Administrator will present results of these audits to QAPI committee for ongoing monitoring and further direction.
Failure to Reevaluate Blood Glucose After Treatment for Hyperglycemia
Penalty
Summary
The facility failed to ensure that a resident with diabetes received treatment in accordance with professional standards of practice when nursing staff did not reevaluate the resident's blood glucose after treatment for severe hyperglycemia. The resident, admitted with diagnoses including Alzheimer's disease, type II diabetes mellitus, and depression, had physician orders for Humalog insulin on a sliding scale before meals, Lantus insulin 25 units daily, and lisinopril 5 mg daily. The resident required extensive assistance with activities of daily living, including transfers, toileting hygiene, eating, and bathing. On the evening in question, the resident's blood glucose was documented as 532 mg/dL, and the on-call provider was notified. The provider gave a new order to administer an additional 8 units of lispro (Humalog) and to recheck the blood glucose in 30 minutes. The electronic medication administration record showed that the blood glucose of 532 mg/dL was obtained at 9:00 p.m. and that the additional 8 units of lispro were administered at 9:21 p.m. However, there was no documentation in the resident's chart that the blood glucose was rechecked after the additional insulin was given. In an interview, the DON confirmed there was no evidence of reevaluation and verified that, according to the facility's "Abnormal Blood Glucose Procedure" policy, the resident should have been reevaluated and that the evaluation step should have been included in the progress note documentation.
Plan Of Correction
F684 The facility will continue to ensure all residents, including #03, receive treatment in accordance with professional standards of practice and reevaluated for hyperglycemia. To ensure compliance with this standard the following measures have been taken: 1. The director of nursing assessed resident #03, reviewed documentation and orders and found no ill effects immediately 4/16/26. 2. All licensed nurses were re-educated to facility policy "Blood Glucose Monitoring" by the Director of Nursing/designee in April 2026. 3. Audits of like-residents that require blood sugar checks to be completed by the director of nursing/designee two times a week for 4 weeks and then monthly after that to validate correct follow through when there is abnormally high blood glucose result. The Administrator will bring results of these audits to the QAPI committee for ongoing monitoring and further direction.
Failure to Act on Pharmacist Drug Regimen Recommendation for Thyroid Medication
Penalty
Summary
The deficiency involves the facility’s failure to ensure that pharmacy recommendations from the monthly drug regimen review were acted upon and documented for a resident. The resident was admitted with diagnoses including Parkinson’s disease, dementia, and hypothyroidism, and had current physician orders for levothyroxine 150 mcg once daily, buspirone 50 mg twice daily, and losartan 100 mg once daily. A medication regimen review dated 11/25/2025 included a consultant pharmacist recommendation that levothyroxine be administered consistently in the morning on an empty stomach, at least 30–60 minutes before food, per manufacturer instructions. There was no specific physician response in the medical record to this recommendation, and the facility’s policy stated that consulting pharmacist reviews are sent to nursing and addressed with the primary care provider or consulting specialist for review and follow-up. Review of the resident’s medication administration record for April 2026 showed levothyroxine scheduled for 9:00 a.m. On observation, the resident was seen eating breakfast in the dining area at 8:03 a.m., and an LPN reported administering the levothyroxine 150 mcg to the resident while the resident was in the dining area eating breakfast. The DON confirmed there was no evidence in the resident’s medical record explaining why the consultant pharmacist’s recommendation from 11/25/2025 was or was not acted upon. This lack of documented physician review and action on the pharmacist’s identified irregularity constituted noncompliance with the drug regimen review requirements.
Plan Of Correction
F756 The facility will continue to ensure the pharmacy recommendations from the monthly drug regimen review by a licensed pharmacist are acted upon for all residents, including #08. To ensure compliance with this standard the following measures have been taken: 1. Resident #08 was assessed by the registered nurse and med review completed by 4/28/26. After review of resident's drug regime's, it was discovered that resident #8 had 2 separate medication recommendations on the same form, to be reviewed by two separate practitioners, pharmacy has been instructed and agreed to separate meds on individual forms. 2. Licensed nurses re-educated to facility policy "Drug Regimen Review" by Director of nursing/designee in April 2026 and no later than 5/8/26. Licensed nurses are responsible for ensuring the reviews and recommendations are given to the physician for timely review. 3. Review of all other current residents Drug Regimen orders completed by Director of nursing/designee on 4/16/26 to ensure recommendations were followed up on/reviewed by the physician and address concerns if needed. 4. Audit of drug regime recommendations, pharmacy recommendations, and physician follow up to be completed weekly for four weeks by the Director of nursing/designee. Administrator will present results of these audits to the QAPI committee for ongoing monitoring and further direction.
Failure to Use Required Gait Belt During Ambulation Resulting in Resident Fall
Penalty
Summary
The deficiency involves the facility’s failure to ensure that a required gait belt was used while assisting a high fall‑risk resident with ambulation, resulting in a fall with head injury. The resident had multiple diagnoses including metabolic encephalopathy, hypertension, osteoarthritis, muscle weakness, gait and mobility abnormalities, major depressive disorder, anxiety, and visual hallucinations. Admission and subsequent MDS and fall risk assessments documented that the resident was severely cognitively impaired, required moderate to maximal assistance with transfers and ambulation, could not independently come to a standing position, exhibited loss of balance while standing, used an assistive device, and had decreased muscle coordination. The resident had a history of falls prior to admission and was assessed as being at high, later moderate, risk for falls. The resident’s fall care plan identified her as at risk for falls and included interventions such as providing maximum to moderate assistance with transfers and walking short distances, use of a walker and wheelchair, and following the facility’s fall protocol. Therapy notes and care conference documentation indicated that the resident leaned backwards when standing, required contact guard to minimal assistance for bed mobility and transfers, and needed constant verbal cueing for safe sequencing during toilet transfers. The physical therapist confirmed that the resident was to use a gait belt with staff when ambulating, and the DON verified that therapy had assessed the resident as requiring contact guard assistance and a gait belt for ambulation and transfers. On the day of the incident, a CNA was assisting the resident from her recliner to the bathroom using a walker. The CNA walked beside the resident, providing guidance and support, and reported having a hand on the resident while assisting her. As they approached the bathroom door, the CNA reached for the doorknob to open it, and at that moment the resident began to lose her balance and fell backwards to the floor, striking the back of her head. The nurse who responded found the resident on her back at the foot of the bed with her feet near the bathroom, noted a red raised area on the back of the head, and documented that the resident was not wearing a gait belt and that the gait belt was on the dresser. In the facility’s investigative summary and in interviews, the CNA acknowledged that she did not have a gait belt on the resident while ambulating her, despite the resident’s assessed need for hands‑on assistance and gait belt use per facility policy and the resident’s care and therapy plans.
Failure to Implement PD Orders and Monitor Resident Receiving Peritoneal Dialysis
Penalty
Summary
The deficiency involves the facility’s failure to implement pre-admission physician orders for peritoneal dialysis (PD) and to provide ongoing monitoring for a resident with chronic kidney disease (CKD) stage five who required PD. Pre-admission orders dated 11/14/25 specified three daily PD exchanges at 6:00 A.M., 2:00 P.M., and 10:00 P.M., and directed staff to monitor for signs and symptoms of peritonitis, including fever, abdominal pain, and cloudy effluent. These monitoring orders were not entered into the facility’s physician orders. The resident’s care plan noted the need for PD and included general monitoring interventions (labs, signs of bleeding, bacteremia, septic shock, and significant vital sign changes), but did not specifically address the ordered monitoring for peritonitis. Review of PD documentation showed incomplete and inconsistent charting of treatments and resident condition. The paper peritoneal flowsheet had columns for time of PD and condition/comments, including instructions to call the nurse immediately for cloudy fluid, abdominal pain, or fever. However, the first entry on 11/15/26 at 2:00 P.M. only noted that the PD nurse completed the exchange, and the 10:00 P.M. entry that day had no condition/comment documentation. Subsequent days (11/16/25, 11/17/25, and 11/18/25) contained only one condition/comment entry per day rather than for each exchange, and there was no documentation that the 6:00 A.M. PD on 11/18/25 was completed. The PD cycler flowsheet starting 11/19/25 lacked any description of the effluent on multiple days. The PD nurse from the dialysis company stated facility staff were expected to monitor effluent for cloudiness and assess for abdominal pain and fever, and the DON confirmed there was no electronic physician order for peritonitis monitoring or for use of the PD cycler, that the paper charting did not allow for effluent description or symptom documentation for each treatment, and that PD was not documented at one ordered time. The facility’s dialysis policy required ongoing assessment and monitoring for complications before, during, and after treatments, which was not reflected in the documentation for this resident.
Improper Infection Control During Medication Administration
Penalty
Summary
Surveyors identified a deficiency in infection prevention and control related to medication administration for Resident #29. The resident was admitted on 02/28/14 with diagnoses including depression, traumatic brain injury, and anxiety, and had impaired cognition per a quarterly MDS assessment. During an observation on 03/25/26 at 6:58 A.M., RN #281 prepared the resident’s medications by removing an Amoxicillin-Pot Clavulanate tablet from the medication card and pushing it directly into her ungloved hand, then using her fingers to place the pill into a medication cup. The same process was observed for multiple other medications, including Escitalopram Oxalate, Furosemide, Sennosides, Lyrica, and Vitamin D, each being pushed from the card into the RN’s ungloved hand and then transferred by her fingers into the medication cup before administration to Resident #29. In a subsequent interview at 7:27 A.M. the same day, RN #281 confirmed she had placed each medication into her ungloved hands prior to administration and acknowledged that the proper procedure was to push the pills directly from the card into the medication cup. Review of the facility’s “Medication Administration – General guidelines” policy, revised 10/08/25, stated that medications are to be administered in accordance with good nursing principles and practices. This practice failure was cited as a deficiency under Complaint Number 2681777.
Improper Use of Wheelchair as a Physical Restraint
Penalty
Summary
Surveyors identified a deficiency related to the facility’s failure to ensure a resident was free from physical restraints. Resident #7, admitted with diagnoses including Alzheimer’s disease, diabetes mellitus, and anxiety disorder, was documented on a recent MDS as rarely understood and dependent for ADLs except eating. The resident ambulated independently on the unit without an assistive device and had documented verbal and other behaviors occurring one to three days during the look-back period. The care plan noted the resident had potential to be physically aggressive, chase staff, throw objects, and be combative with care, with interventions such as offering choices, administering medications as ordered, and intervening early when agitation occurred. During an observation and interview, Resident #7 was found sitting in a chair with the right arm of the chair positioned against the nursing station and a wheelchair placed directly in front of him. The left arm of the wheelchair was also against the nursing station, and both wheelchair wheels were locked, creating a barrier that appeared to restrain the resident, who was sleeping with his knees touching the locked wheelchair. An LPN confirmed both wheelchair wheels were locked and that the wheelchair should not have been placed in front of the resident. A CNA reported she had placed the wheelchair there in preparation to get the resident up for lunch, was unable to transfer him, and left the wheelchair in that position, acknowledging it was wrong to keep it there. The facility’s physical restraint policy stated that physical restraints are not used except when alternatives are not appropriate or effective for treating a medical symptom and defined physical restraints as any device attached or adjacent to the body that the individual cannot easily remove and that restricts freedom of movement or access to the body.
Trusted data from CMS and state health departments
Every citation, penalty and Plan of Correction is sourced from public CMS records (latest release May 27, 2026) and official state health department websites — never guesswork.
Trusted by long-term care providers and associations.
