Kimes Nursing & Rehab Ctr
Inspection history, citations, penalties and survey trends for this long-term care facility in Athens, Ohio.
- Location
- 75 Kimes Lane, Athens, Ohio 45701
- CMS Provider Number
- 366250
- Inspections on file
- 23
- Latest survey
- March 9, 2026
- Citations (last 12 mo.)
- 11 (1 serious)
Citation history
Health deficiencies cited at Kimes Nursing & Rehab Ctr during CMS and state inspections, most recent first.
An agency LPN prepared and administered evening medications for two roommates at the same time in a dark room, placing both sets of pills into labeled cups and later admitting this practice. As a result, a resident who had no orders for benzodiazepines or opioids was erroneously given his roommate’s Xanax, Percocet, and Gabapentin, while his own ordered medications were documented as given. Shortly after administration, the roommate reported to a CNA that his pain medications did not feel like they had worked, and later stated that he believed the medications had been mixed up. The affected resident became increasingly lethargic over the evening, but despite abnormal presentation and staff concern, the LPN did not promptly notify a physician or report a suspected med error, and only contacted the on-call provider and EMS after the resident became unresponsive, hypotensive, and bradycardic. EMS and hospital records documented unresponsiveness, pinpoint pupils, hypotension, bradycardia, treatment with Narcan and Atropine, ICU admission, and a urine drug screen positive for benzodiazepines and oxycodone, confirming a significant medication error and associated deterioration in the resident’s condition.
The facility did not update the state survey agency regarding changes in its administrative leadership, including an interim Administrator who served for several months and the current Administrator. A review of the EIDC website showed that these administrators were not listed as required, and the current Administrator acknowledged that the facility had failed to report these changes. This non-compliance affected all residents and was identified during a complaint investigation.
The facility did not maintain an effective training program for new CNAs, as evidenced by two CNAs lacking required education in compliance and ethics, the QA program, behavioral health, and effective communication. Review of personnel files showed missing training modules for these staff members, and HR confirmed that the required training had not been completed. This issue was identified as an incidental finding during a complaint investigation affecting all residents.
A cognitively intact resident with multiple chronic conditions, who was not ordered any benzodiazepines or opioids, became progressively lethargic and then unresponsive after an agency LPN prepared and administered bedtime medications for him and his roommate at the same time. The roommate later reported he believed their medications had been switched, noting his usual gabapentin and oxycodone were missing and that he did not experience his typical pain relief, while his roommate quickly became "out of it" and difficult to arouse. Staff initially attributed the affected resident’s lethargy to fatigue from a room change, did not promptly notify the physician when the change in condition was first observed, and allowed his condition to worsen over several hours before calling EMS, who found him hypotensive, bradycardic, unresponsive with pinpoint pupils, and later documented a urine drug screen positive for benzodiazepines and oxycodone—drugs ordered for the roommate but not for the affected resident. Despite these findings and consistent reports from the roommate and family, facility leadership did not substantiate a medication error or clearly correlate the resident’s change in condition to a suspected medication mix-up.
A resident with intact cognition reported to staff, through her son and in her own interview, that one of several lottery tickets she had received, which she believed to be a $250 winner, was missing while the other non-winning tickets remained in her room. The resident and her son searched the room without finding the ticket, and multiple staff, including CNAs, RNs, and the ADON, later confirmed seeing lottery tickets on the bedside table but could not account for the missing winning ticket. The situation was recognized by the social worker, Administrator, and DON as a potential misappropriation that should be reported to the state under facility policy, yet neither the Administrator nor the DON submitted the required state report within the mandated timeframe, resulting in a failure to report an allegation of misappropriation.
The facility failed to provide scheduled showers to three dependent residents who required staff assistance with ADLs due to conditions such as dementia, muscle weakness, hypertension, cancer, osteoarthritis, cognitive deficits, and pain. Care plans and MDS assessments documented that each resident needed staff help with bathing/showering, and the facility’s shower schedules specified twice-weekly showers on designated shifts. However, shower records showed multiple missed shower dates for each resident, and the ADON confirmed that these residents did not receive their scheduled showers and that no additional documentation existed to show the care was provided.
A resident with type II DM, hidradenitis suppurativa, and MASD had a care plan and physician orders for daily non-pressure wound care, including cleansing with chlorhexidine, application of clindamycin gel, calcium alginate or ABD pads, and nystatin powder to the peri-wound area. Review of treatment administration records showed multiple days on which the ordered daily wound treatments were not documented as completed. The ADON confirmed that these wound care treatments were not performed as ordered and that there was no documented reason for the missed treatments or additional supporting documentation.
Surveyors found that the facility did not implement care-planned fall-prevention interventions for two high-risk residents. One resident with severe cognitive impairment, gait abnormalities, and a history of multiple falls had a care plan requiring her walker to be kept within reach in her room, but during observation only her wheelchair was at bedside and no walker was accessible; a CNA familiar with her care needs was unaware she had a walker and confirmed it was not in reach. Another resident with hemiplegia, muscle weakness, and dependence for transfers had a care plan requiring provision of a reacher/grabber and encouragement to use it when items fell, yet she was observed in bed without the device in reach, later found stored on a distant nightstand; the resident confirmed it was not accessible, and an LPN verified that the reacher/grabber was a planned fall-prevention intervention that was not in place.
Surveyors observed an RN enter the room of a resident on transmission-based precautions for Covid-19 to administer morning medications wearing only an N-95 respirator and gloves, without a required gown, despite the facility’s Covid-19 policy mandating a respirator, gown, gloves, and eye protection for confirmed Covid-19 cases. The resident, who had multiple comorbidities including CHF, CKD, hypertensive heart disease, and morbid obesity, reported it was the tenth and final day of isolation following a positive Covid-19 test. A PPE cart was present outside the room, but the RN stated there were no gowns in it and admitted she did not check other carts, even though she knew a gown was required. The Droplet Precautions sign identifying the resident’s status was not prominently displayed, resting diagonally on a handrail and partially obscured by hallway equipment, and the medical record lacked a specific physician order detailing the need for and duration of Covid-19 TBP.
The facility failed to enforce its COVID-19 infection prevention and control policy during an outbreak affecting all residents. Despite posted instructions requiring N95 masks at all times, multiple night-shift staff, including LPNs and CNAs, were observed working without any masks, even while caring for residents with confirmed COVID-19. Some staff stated they were unsure of mask requirements or did not believe masks were effective. In addition, a CNA entered the room of a resident on droplet/contact precautions for COVID-19 wearing a gown, gloves, and an N95 mask but no eye protection, later stating she did not know eye protection was required, while an RN confirmed it was. Facility records showed numerous residents had recently tested positive for COVID-19, and the written policy required source control and full PPE (N95, gown, gloves, eye protection) for staff entering rooms of residents with suspected or confirmed infection, which was not consistently followed.
Three residents with severe cognitive impairment and dependent on staff for bathing did not receive scheduled showers on multiple occasions, as confirmed by care records and staff interviews. Staff reported that showers were missed during periods of inadequate staffing, with priority given to other essential care tasks. The DON confirmed that residents' shower preferences were documented and that the missed showers occurred as indicated in the records.
Two residents with significant medical conditions did not receive timely or accurate pressure ulcer care, including a nurse treating the wrong site and delays in initiating ordered treatments. Nursing staff also failed to document wound assessments on the correct dates, and treatments were not started promptly after physician orders, contrary to facility policy.
A resident with dementia and chronic respiratory failure was allegedly physically abused by a CNA during care. The incident was witnessed by another CNA, who delayed reporting it. The facility failed to notify law enforcement or the resident's family, and the Administrator did not substantiate the allegation due to insufficient evidence. This represents non-compliance with the facility's abuse prevention policy.
The facility failed to offer pneumococcal vaccinations to several residents, as revealed by a review of medical records and consent forms. The affected residents, who had various medical conditions, either did not have a record of receiving the vaccine or had no physician orders for it. The facility's consent process relied on residents or their families to request the vaccine, and there was no specific consent form for pneumococcal vaccination. The DON acknowledged the lack of proof that residents were asked about receiving the vaccine.
A resident was transferred to the hospital due to an elevated sodium level, but the facility failed to provide the resident's representative with a bed-hold notice as required. The facility's policy requires informing residents or their representatives of the bed-hold policy upon admission and prior to transfers, but documentation was missing in this case, as confirmed by the Social Service Director.
A facility failed to ensure accurate PASARR documentation for a resident, omitting an anxiety disorder diagnosis despite it being documented since the previous year. This discrepancy was confirmed through record review and staff interviews.
The facility failed to develop comprehensive care plans for two residents, one requiring management for anticoagulant therapy and the other for anxiety disorder. A resident with complex medical conditions, including end-stage renal disease and heart disease, was prescribed Eliquis without a corresponding care plan. Another resident with anxiety disorder lacked a specific and patient-centered care plan. These deficiencies were confirmed by the DON.
The facility failed to ensure hospice records were available for a resident receiving hospice care, impacting continuity of care. Additionally, another resident with chronic edema did not have compression stockings applied as ordered by the physician. Observations showed the resident without stockings, and staff interviews revealed a lack of awareness and adherence to the physician's orders.
The facility failed to implement fall prevention interventions for two residents at risk for falls. One resident, with a history of falls and fractures, did not have a visual reminder to use the call light, leading to a fall and hip fracture. Another resident, with severe cognitive impairment, fell due to the absence of dycem in the wheelchair, as required by the care plan. The DON confirmed these deficiencies.
A facility failed to assess and create a care plan for a resident with PTSD, despite the resident having multiple diagnoses including chronic PTSD, heart failure, and Alzheimer's disease. The resident's medical record lacked a PTSD assessment or care plan, and staff interviews revealed a lack of awareness regarding the resident's PTSD triggers or history.
A facility failed to follow infection prevention guidelines when a STNA did not wear a gown during wound care for a resident on enhanced barrier precautions. The resident had a pressure ulcer and required specific precautions to prevent the spread of multi-drug resistant organisms. Despite clear signage and policy requirements, the STNA only wore gloves, leading to a breach in infection control protocols.
A resident with a complex medical history was treated with antibiotics for a suspected UTI before culture and sensitivity results were available. The resident exhibited symptoms such as lethargy and unformed speech, leading to a physician's order for urinalysis and Rocephin. The UA/C&S results suggested contamination, but the resident had already completed the antibiotic course. The DON confirmed the premature antibiotic treatment.
The facility failed to implement physician-ordered pressure reduction devices for two residents, leading to deficiencies in pressure ulcer care. A resident with a stage I pressure ulcer was observed without the required off-loading boot and air mattress. Another resident with pressure ulcers was found on an alternating air mattress set incorrectly to a weight of 450 pounds, despite weighing only 133 pounds. These deficiencies were identified during a complaint investigation.
Significant Medication Error and Delayed Response After Wrong Medications Given
Penalty
Summary
The deficiency involves a failure to ensure that a resident was free from significant medication errors when an agency LPN did not follow proper medication administration procedures. The LPN prepared and administered evening/bedtime medications for two roommates at the same time, in a dark room, by popping both residents’ pills into separate cups labeled with their names. The LPN later admitted that she prepared both residents’ medications together and that the room was dark when she administered the medications. One resident, who was not ordered any benzodiazepines or opioid pain medications, was instead given medications that were ordered for his roommate, including Xanax 2 mg PO, Percocet (Oxycodone/Acetaminophen) 10–325 mg PO, and Gabapentin 800 mg PO. The resident who received the wrong medications had a history that included dementia with Lewy Bodies, neurocognitive disorder, mood disorder, major depressive disorder, anxiety disorder, CHF, hypertension, cirrhosis, muscle weakness, difficulty walking, and insomnia. His active orders included medications such as Abilify, Aspirin, Atorvastatin, Vitamin D, Plavix, Aricept, Fluoxetine, Lactulose, Magnesium Oxide, Melatonin, Remeron, Potassium Chloride, Sennosides, and Tamsulosin, with PRN orders for Acetaminophen, artificial tears, Mucinex, and Zofran. He had no orders for benzodiazepines or opioids. On the evening in question, the LPN documented administering his scheduled evening/bedtime medications around 8:44 P.M. and noted that he complained of being tired after a room change earlier that day. Shortly thereafter, his roommate complained to a CNA that his pain medications did not feel like they had worked, stating he could usually tell within 10 minutes when they took effect, suggesting concern that he had not received his usual medications. The facility also failed to timely identify and correlate the reported medication mix-up with the resident’s subsequent change in condition. Around 8:53 P.M., the LPN found the resident lethargic but responsive to touch and able to follow simple commands, with vital signs within acceptable ranges. The resident’s wife reported that he had not awakened during her visit. Despite the roommate’s report that he believed the medications had been mixed up and the LPN’s own acknowledgment that both residents’ medications had been prepared together, the LPN did not notify a physician of a possible medication error or seek medical guidance at that time. Throughout the night, the resident remained lethargic, and staff noted that something seemed “off,” but no provider was contacted until approximately 1:15 A.M., when the resident was found unresponsive, hypotensive, and bradycardic. EMS was then called, and the resident was transferred to the hospital with an altered mental status and unresponsiveness. Hospital evaluation, including a urine drug screen, showed the presence of benzodiazepines and oxycodone, which matched medications ordered for the roommate and not for the resident, confirming that a significant medication error had occurred and contributed to the resident’s serious deterioration in condition. Additional documentation from EMS and the hospital further described the resident’s condition following the error. EMS records indicated that the resident was unresponsive with pinpoint pupils, hypotension, bradycardia, and a Glasgow Coma Scale score of seven, and he received multiple doses of Narcan and Atropine en route. The ED provider note documented hypotension, bradycardia, poor responsiveness, and initial miotic pupils with partial response to Narcan, and the clinical impression included acute encephalopathy and unresponsiveness. The hospital history and physical described acute hypoxic respiratory failure and multifocal pneumonia, with progressive respiratory decline requiring endotracheal intubation and ICU admission. These findings, together with the positive urine drug screen for benzodiazepines and oxycodone in a resident without orders for those medications, were included in the facility’s investigation file as evidence of the significant medication error and its impact on the resident’s condition. The facility’s internal investigation gathered statements from the involved LPN, another LPN who assessed the resident, and a CNA. The agency LPN confirmed that she had prepared both roommates’ medications at the same time, in the dark, and that the roommate later complained that his medications did not feel effective. The second LPN reported that the resident’s condition appeared abnormal and that she eventually insisted he be sent out when he no longer responded as before. The CNA reported that the resident initially seemed at his baseline but later became more lethargic and took a “drastic turn” after his wife left. The DON acknowledged that the incident was possibly medication-related and that the resident’s transfer to the hospital for unresponsiveness was logged as an incident. Collectively, these actions and inactions—improper preparation and administration of medications, failure to promptly recognize and act on the reported medication mix-up, and delayed notification of a physician despite progressive lethargy—constituted the deficiency in ensuring the resident was free from significant medication errors.
Removal Plan
- The Vice President of Clinical Services created a performance improvement plan (PIP), presented it to the Director of Nursing (DON), and the DON assigned the Assistant Director of Nursing (ADON) to assist with medication audits designed to address medication pass performance criteria.
- The DON began an investigation for a possible medication error requiring a resident to be sent to the hospital.
- The DON interviewed the nurse involved and obtained the nurse’s statement of the incident.
- The DON interviewed the nurse working the night of the event and obtained the nurse’s statement.
- The DON interviewed the CNA who worked with the resident the night of the event.
- The DON interviewed the resident’s roommate to obtain a statement.
- The facility provided education on proper medication administration and the five rights of medication administration.
- The DON initiated an in-service on safe medication administration techniques and change of condition with nurses currently on shift regarding the possible medication error.
- The facility implemented a plan for the DON/designee to educate nurses on changes of condition and the five rights of medication administration followed by medication administration audits.
- The facility completed education for all current full-time licensed nurses and implemented a plan for new and agency nurses to be educated upon hire/scheduling by unit managers.
- The facility continued the process for an agency nurse resource guide binder to be available for agency staff to review.
- The DON/ADON began auditing changes in condition per the established schedule, with results reviewed through QAPI and issues addressed as needed.
- The DON/ADON began medication audits per the established schedule, including audits of resident identification/picture identification availability, with results reviewed through QAPI and issues addressed as needed.
- The DON conducted interviews with nurses who had worked prior to the incident/event.
- The ADON completed skin checks and health assessments on residents with low BIMS scores to identify changes in condition or possible medication adverse effects.
- The Vice President of Clinical Services and DON reviewed current policies and procedures for medication administration and change in condition.
- The physician assessed the roommate resident for possible medication adverse effects and reviewed medications for the affected resident.
- The DON reviewed the agency staff process and provided report forms to nursing staff at the beginning of shift to inform nurses how residents take their medication, and identified additions needed to the process including five rights and change in condition policy/education.
- Social Services conducted resident interviews regarding life satisfaction, abuse/neglect, and comfort reporting concerns.
- The DON completed a one-on-one in-service with the nurse involved on safe medication administration and change in resident conditions.
- The DON initiated an in-service for nursing staff on when to notify the DON regarding accidents/incidents, significant changes, medication errors, and emergencies, and implemented education upon hire for new nurses.
- The facility placed the nurse involved on the Do Not Return list.
- The facility implemented a requirement for all residents to have a picture in their chart and completed an immediate audit to verify compliance.
- The physician reviewed medications for the affected resident upon return from the hospital.
- The provider reviewed and approved all medications and documents for the affected resident.
- Social Services interviewed residents to identify concerns about receiving other residents’ medications.
- The facility implemented a plan to discuss the incident at the next QAPI meeting and to review audit results through QAPI with issues addressed as needed.
Failure to Notify State Agency of Administrator Changes
Penalty
Summary
The facility failed to notify the state survey agency of changes in administrative personnel, specifically changes in the Administrator position, affecting all 59 residents in the facility. Review of the Enhanced Information Dissemination and Collection (EIDC) website showed that neither the current Administrator nor the interim Administrator who served from November 2025 through January 2026 were listed as required. In an interview, the current Administrator confirmed that the facility had not informed the state survey agency of these changes in administrators, including the current Administrator. This deficiency was identified as an incidental finding of non-compliance during the investigation of Complaint Number 2735791. No additional resident-specific clinical information, medical history, or condition at the time of the deficiency was provided in the report.
Failure to Ensure Required Training for CNAs
Penalty
Summary
The facility failed to maintain an effective training program for staff, affecting all 59 residents in the facility. Record review of personnel files showed that one CNA hired on 12/19/25 did not have documented training in compliance and ethics, the quality assurance program, effective communication, or behavioral health. Another CNA hired on 10/08/25 did not have documented training in compliance and ethics, the quality assurance program, or behavioral health. During an interview on 03/04/26 at 3:04 P.M., the HR staff member confirmed that the required training had not been completed for these CNAs. This deficiency was identified as an incidental finding of non-compliance during the investigation of Complaint Number 2735791.
Failure to Recognize and Report Change in Condition Related to Suspected Medication Error
Penalty
Summary
The deficiency involves the facility’s failure to timely identify and report a significant change in condition for a cognitively intact resident, and to properly correlate that change to a suspected medication error. The resident had multiple diagnoses including dementia with Lewy Bodies, mood and anxiety disorders, CHF, hypertension, cirrhosis, and insomnia, but his MDS showed he was cognitively intact, had no communication issues, and was not ordered any benzodiazepines or opioids. His active orders included antidepressants, antipsychotic adjunct therapy, dementia medication, cardiac and GI medications, sleep aids, and bowel regimen, with PRN orders limited to acetaminophen, artificial tears, Mucinex, and Zofran. He did not have any orders for Xanax, oxycodone, or other narcotic pain medications. On the evening in question, an agency LPN prepared bedtime medications for the resident and his roommate at the same time, popping both residents’ pills into separate labeled cups at the medication cart. She crushed the cognitively intact resident’s pills in pudding and later gave the roommate’s pills whole, acknowledging that the room was dark when she administered the roommate’s medications. The roommate later reported that he believed he had received his roommate’s medications and that his own usual large gabapentin pill and the bitter-tasting oxycodone were missing from what he was given. He stated he did not experience his usual pain relief within 10–15 minutes and complained to staff that he had not received his correct medications. He also reported telling staff that his roommate had been given his medications and that this was why the roommate became unresponsive, and he stated that no one from the facility assessed him or investigated his report of a medication mix-up. After the agency LPN administered the bedtime medications, the resident complained of being tired following a room change and was assisted to bed. Around 8:53 p.m., the resident’s wife arrived and reported that he had not awakened during her visit. The LPN found him lethargic but able to follow commands, with vital signs within normal limits, and attributed his condition to fatigue from the move. Throughout the night, the LPN and another LPN noted that “something seemed off,” but they continued to attribute his lethargy to the room change and sleepiness. The resident’s condition progressively worsened; by approximately 1:15 a.m. he was more lethargic, then unresponsive to verbal and painful stimuli, with hypotension and borderline oxygen saturation. Only at that point was the on-call physician notified and EMS summoned. EMS and hospital records documented hypotension, bradycardia, unresponsiveness, pinpoint pupils, administration of Narcan and Atropine, and a urine drug screen positive for benzodiazepines and oxycodone—medications not ordered for the resident but ordered for his roommate. Despite these findings and the roommate’s contemporaneous statements, the DON reported she did not substantiate a medication error and did not clearly link the resident’s change in condition to a medication mix-up, reflecting a failure to promptly recognize, correlate, and report the suspected medication error and associated change in condition to the physician. Hospital documentation further described the resident as presenting with acute encephalopathy, acute hypoxic respiratory failure, shock, and unresponsiveness with pinpoint pupils and low blood pressure and heart rate. The ED and ICU notes referenced multiple doses of Narcan, a positive urine drug screen for benzodiazepines and oxycodone, and family and roommate concerns that the resident had received his roommate’s medications, including opioids and gabapentin. Subsequent hospital records from a tertiary facility noted that the encephalopathy was likely multifactorial on a background of Lewy Body dementia, with possible contributions from polypharmacy and anoxic brain injury in the setting of prolonged downtime and suspected receipt of the roommate’s opioids and gabapentin, though this could not be definitively confirmed. Within the facility, however, the change in condition was initially attributed to fatigue from a room move, the resident was allowed to remain in a progressively worsening state for several hours before EMS was called, and the facility did not substantiate or clearly document a medication error despite objective toxicology findings and consistent reports from the roommate and family. The facility’s internal investigation collected staff statements, MARs for both residents, controlled drug records, and hospital records. The agency LPN acknowledged that she prepared both residents’ medications at the same time and that it was possible she could have popped pills into the wrong cup or grabbed the wrong cup when crushing medications, though she denied intentionally giving the wrong medications. Another LPN recalled the roommate saying that the agency nurse had given the lethargic resident his pills, and that EMS administered Narcan due to pinpoint pupils. The DON confirmed that the resident’s urine drug screen was positive for benzodiazepines and oxycodone, and that the roommate was ordered Xanax and oxycodone at bedtime, but she stated she could not be certain the resident did not receive these drugs from another source and therefore did not substantiate a medication error. This sequence of events demonstrates that the resident’s significant change in condition was not promptly recognized as potentially medication-related, was not timely reported to the physician when first observed, and was not adequately correlated with the suspected medication error despite contemporaneous reports and objective toxicology findings.
Failure to Report Allegation of Misappropriation of Resident Property
Penalty
Summary
The deficiency involves the facility’s failure to report an allegation of misappropriation of resident property to the state as required by regulation and facility policy. Resident #10 was admitted with diagnoses including muscle weakness and hypertension, and her care plan and MDS documented intact cognition with no behaviors or history of making false allegations. A grievance report documented that the resident’s son had brought five lottery tickets to the resident; when he returned, the resident reported that one ticket, which she stated was a $250 winner, was missing while the other four tickets remained present but were not winners. According to the grievance documentation and interviews, the resident’s son searched the room, including dressers, drawers, and the trashcan, but could not locate the winning ticket. The social worker then assisted in searching the room without success. Resident #10 confirmed that her son had brought her four or five scratch-off tickets, that one was a $250 winner, and that she later noticed the winning ticket was missing after leaving the room for an activity and returning. She stated she did not throw the ticket away, did not see anyone else throw it away, and did not witness another resident or staff member take it, but believed someone must have taken it. Multiple staff members, including CNAs, RNs, agency nurses, and the ADON, were interviewed; several recalled seeing lottery tickets on the resident’s bedside table on various days, but none could confirm the number of tickets or what happened to the winning ticket. Interviews with facility leadership established that the situation was recognized as a potential misappropriation. The social worker stated that allegations of abuse or misappropriation would be reported to the state by the Administrator or DON. The Administrator acknowledged that a missing lottery ticket worth $250 constituted an allegation of misappropriation that should have been reported to the state and stated that such allegations should be reported immediately, but confirmed he did not report it and was unsure of his responsibility. The DON stated that allegations of misappropriation are to be reported to the state immediately upon suspicion or discovery, but confirmed she had not reported the allegation and had not been informed of the situation until later in the week. Review of the facility’s Abuse Investigation and Reporting policy showed that all reports of misappropriation must be promptly reported to appropriate agencies, with allegations reported within two hours, which did not occur in this case.
Failure to Provide Scheduled Showers and ADL Assistance
Penalty
Summary
The deficiency involves the facility’s failure to provide scheduled showers and personal care to dependent residents who required assistance with activities of daily living (ADLs). One resident with dementia, muscle weakness, diabetes, and impaired mobility had a care plan dated 08/27/25 indicating a need for assistance with self-care, ADLs, and mobility, with a goal to remain clean, dry, dressed, groomed, and free of odors. Interventions included dependent shower assistance by one helper, and an MDS dated 11/18/25 showed the resident required maximum assistance for bathing. The shower schedule showed this resident was to receive showers on Mondays and Fridays on dayshift, but shower records revealed missed showers on 02/20/26 and 02/27/26. Another resident with hypertension and cancer had a care plan dated 08/15/25 indicating dependence on staff for bathing/showering due to pain, limited mobility, limited range of motion, and weakness, with a goal to maintain current ADL function. An MDS showed this resident was dependent on staff for bathing and had refused care on four to six days during the review period. The shower schedule indicated showers on Tuesday and Friday dayshift, but shower records showed missed showers on 12/26/25 and 12/30/25. A third resident with hypertension, osteoarthritis, impaired mobility, weakness, cognitive deficits, and pain had a care plan dated 10/13/25 requiring assistance with self-care, ADLs, and mobility, including assistance as needed with showers twice weekly or per preference and partial assist with showers. The MDS indicated moderate assistance was needed for bathing/showering, and the shower schedule listed Tuesday and Friday nightshift. Shower records showed this resident did not receive showers on 10/21/25, 11/06/25, 11/13/25, 11/25/25, and 11/28/25. In an interview on 03/04/26 at 1:10 P.M., the ADON confirmed these residents were not provided scheduled showers and that there was no other documentation to show the showers were given.
Failure to Complete Ordered Daily Wound Care Treatments
Penalty
Summary
The facility failed to ensure that ordered non-pressure wound care treatments were completed as prescribed for one resident. The resident was admitted with type II diabetes and hidradenitis suppurativa, and an MDS assessment documented moisture associated skin damage (MASD). A care plan identified the resident as being at risk for skin impairment due to weakness, cognitive deficit, incontinence, impaired mobility, thin and fragile skin, falls, and autoimmune disease, with goals and interventions that included keeping the skin clean and dry, using lotion on dry but not broken skin, monitoring and documenting skin injuries, and following facility protocols for treatment. An order dated 11/18/25 directed daily wound care including cleansing with chlorhexidine wash, applying clindamycin gel to the wound, covering with an ABD pad, and applying nystatin powder to the peri-wound area; this order remained in effect until 12/19/25. Record review of the treatment administration record for 12/2025 showed that this daily wound care was not completed on 12/11/25, 12/12/25, 12/16/25, and 12/18/25. A subsequent order dated 12/19/25 revised the daily treatment to include cleansing with chlorhexidine wash, applying clindamycin gel, applying calcium alginate, covering with an ABD pad, and applying nystatin powder to the peri-wound. The treatment administration record for 12/2025 showed missed treatments on 12/21/25, 12/25/25, 12/30/25, and 12/31/25, and the record for 01/2026 showed missed treatments on 01/03/26, 01/04/26, and 01/05/26. In an interview, the ADON confirmed that these treatments were not completed as ordered and stated there was no reason they should not have been completed and no additional documentation explaining the omissions. This deficiency was investigated under Complaint Number 2722441.
Failure to Implement Care-Planned Fall-Prevention Interventions for High-Risk Residents
Penalty
Summary
The deficiency involves the facility’s failure to implement fall-prevention interventions as outlined in residents’ care plans for residents identified as high fall risks. For one resident with multiple diagnoses including osteoporosis, gait abnormalities, cognitive impairment, and a history of multiple falls, the fall risk assessment identified her as high risk and her care plan required that her walker be kept within reach when she was in her room. During observation, the resident was lying in bed with her wheelchair at the bedside, but no walker was within reach as required by her fall-prevention care plan. A CNA who had been working at the facility for about four months reported being familiar with this resident, acknowledged that the resident was a fall risk with a history of falls, and stated that the resident was supposed to wear non-skid socks or shoes when ambulating and primarily used a wheelchair. However, the CNA was not aware that the resident had a walker and confirmed, upon returning to the room, that no walker was kept within the resident’s reach despite this being an active intervention in the resident’s fall-risk care plan. For a second resident with multiple conditions including hemiplegia, muscle weakness, reduced mobility, and total incontinence, the fall risk assessment also identified her as high risk for falls, and her care plan required that she be provided with a reacher/grabber and encouraged to use it, particularly if she dropped items on the floor. Observation found this resident in bed with an air mattress, perimeter overlay, assist bars, and call light within reach, but without a reacher/grabber in reach as specified in her care plan. The resident stated she had a reacher/grabber “around there somewhere” but confirmed it was not within reach, and a reacher/grabber was later observed stored on a nightstand in an area of the room not accessible to her. An LPN, new to the facility, confirmed that the reacher/grabber was part of the resident’s fall-prevention interventions and that it was not within the resident’s reach at the time of observation. The facility’s fall policies required identification and implementation of interventions based on resident-specific risks, but the required interventions were not in place for these residents at the time of surveyor observations.
Failure to Ensure Appropriate PPE Use for Resident on Covid-19 Transmission-Based Precautions
Penalty
Summary
The deficiency involves the facility’s failure to ensure appropriate use of personal protective equipment (PPE) for a resident on transmission-based precautions (TBP) for Covid-19. During a medication pass on the North hall, an RN entered the room of Resident #30, who verbally reported it was her tenth and final day of isolation for a positive Covid-19 test, wearing only an N-95 particulate respirator and gloves. The RN did not don a gown before entering, despite the facility’s Covid-19 policy requiring a NIOSH-approved N-95 or higher respirator, gown, gloves, and eye protection for healthcare providers entering the room of a patient with suspected or confirmed Covid-19 infection. Observation after the medication pass showed a PPE cart outside the resident’s room and a Droplet Precautions sign that was not prominently displayed, as it was resting diagonally on the handrail, partially obscured by equipment stored in the hallway. Record review showed Resident #30 was admitted on an earlier date with diagnoses including congestive heart failure, chronic kidney disease, hypertensive heart disease, and morbid obesity. Nursing progress notes documented that on a prior date the resident was tested for Covid-19 due to headache, chills without fever, and sore throat, and the test was positive. However, the active physician’s orders did not include a specific order for TBP for Covid-19 or the duration of isolation, only an open-ended order allowing Covid-19 testing as needed. In an interview, the RN confirmed she knew the resident was in isolation for Covid-19, acknowledged that a gown was required PPE for entering the room, and stated she did not wear a gown because none were available in the PPE cart and she did not check other carts. She also acknowledged that the Droplet Precautions sign was not clearly visible or posted on the door where it would be easily seen when the door was closed.
Failure to Enforce COVID-19 Source Control and PPE Requirements During Outbreak
Penalty
Summary
The deficiency involves the facility’s failure to maintain and implement its infection prevention and control program, including required COVID-19 precautions, during an active outbreak that affected all residents. Surveyors observed a sign at the facility entrance stating that staff and visitors were required to wear N95 masks at all times due to a current COVID-19 outbreak. Despite this, four of five night-shift staff members, including two LPNs and two CNAs, were observed inside the facility without any masks. One LPN acknowledged she had a resident on her unit with COVID-19 and confirmed staff were supposed to wear masks at all times. Another CNA stated she was unsure whether staff were required to wear masks at all times and reported working on the LTC unit. A second LPN, who also had a resident with COVID-19 on his unit, stated he did not believe masks worked, was not aware staff were to wear masks, and said he would only wear a regular mask, not an N95, when entering a COVID-positive resident’s room. Another CNA reported being unclear about mask use outside resident rooms and stated that staff had become more relaxed about mask use at night after several residents had COVID-19. Further observations showed improper use of personal protective equipment (PPE) for residents on isolation for COVID-19. A CNA delivering a breakfast tray to a resident on droplet/contact precautions for COVID-19 donned a gown, gloves, and an N95 mask but did not wear eye protection while providing care and handling items in the room. Upon exiting, she removed her gown and gloves, performed hand hygiene, and applied a new N95 mask, later stating she was new and did not know eye protection was required for entering the room of a resident with COVID-19. An RN confirmed that staff were required to wear eye protection when entering such rooms. Record review showed that one resident had tested positive for COVID-19 and was placed on isolation, and another resident later tested positive and was placed on droplet/contact isolation. Facility infection tracking logs documented that 18 residents had tested positive for COVID-19 over a defined period, with all but one remaining in the facility. The facility’s written COVID-19 policy required source control (mask use) for individuals in areas experiencing a SARS-CoV-2 outbreak and specified that staff entering rooms of residents with suspected or confirmed COVID-19 must use an N95 mask, gown, gloves, and eye protection, which was not consistently followed in practice.
Failure to Provide Showers per Resident Preferences Due to Staffing Shortages
Penalty
Summary
The facility failed to ensure that residents received showers according to their preferred schedules, as documented in their care plans. Three residents with severe cognitive impairment and dependent on staff for bathing did not receive showers on multiple scheduled days. Medical records and care plans indicated that these residents were to receive showers twice a week, with specific days assigned for each individual. Shower records revealed that the scheduled showers were missed on several occasions for each resident. Interviews with CNAs, LPNs, and RNs confirmed that showers were not completed when there were staffing challenges. Staff reported that, during periods of inadequate staffing, priority was given to other essential care tasks such as turning, changing, and assisting residents with eating, resulting in showers being omitted. The Acting DON confirmed that residents' shower preferences were obtained on admission and that the missed showers were accurately reflected in the records. Family members of one resident expressed concern about the resident's hygiene, noting a decline in cleanliness and the importance of showering to the resident. The deficiency was identified during an investigation under specific complaint numbers.
Failure to Provide Timely and Accurate Pressure Ulcer Care
Penalty
Summary
The facility failed to provide appropriate and timely pressure ulcer care for two residents, resulting in deficiencies in wound management and prevention. For one resident with a history of congestive heart failure, respiratory failure, diabetes, and stage four kidney disease, a physician's order was in place to treat a pressure ulcer on the left heel. However, during wound care, a registered nurse mistakenly treated the right heel, which no longer had a pressure ulcer, instead of the left heel as ordered. The nurse confirmed the error after it was pointed out, and the facility's policy required adherence to physician orders for wound treatment. Another resident, admitted after hip replacement surgery and with stage three kidney disease and hypertension, was identified as being at risk for skin breakdown. Initial skin assessments were inaccurately dated, and the resident developed pressure ulcers on the right upper buttock and coccyx, which later merged into a larger wound. Treatment for these ulcers was not initiated until several days after the wounds were first noted, despite physician orders being obtained. Additionally, deep tissue pressure injuries were identified on both heels, but treatment was delayed by a day after the injuries were discovered and orders were received. Interviews with nursing staff and the Director of Nursing confirmed that documentation was not completed on the correct dates and that treatments were not started promptly as required by facility policy. The facility's Skin Integrity Management Policy specified that treatment plans should be established and implemented for residents with pressure ulcers, but these procedures were not consistently followed for the affected residents.
Failure to Timely Report Alleged Abuse
Penalty
Summary
The facility failed to ensure timely and appropriate reporting of an allegation of physical abuse involving a resident with chronic respiratory failure, dementia with psychotic disturbance, and psychosis. The incident occurred when two CNAs were providing care to the resident, who became combative. One CNA reportedly responded to the resident's attempt to bite by pushing and smacking the resident's head. This incident was witnessed by the other CNA, who did not report it immediately. The abuse was not reported to the local law enforcement agency or the resident's family, and the facility's Administrator unsubstantiated the allegation due to a lack of evidence. The facility's policy requires immediate reporting of abuse allegations to a supervisor, with subsequent notifications to the physician, resident's family, Ombudsman, and local law enforcement. However, the report indicates a delay in reporting the incident, as the witnessing CNA did not report it until several hours later, and the Administrator did not notify the necessary parties. The deficiency was identified during the investigation of a complaint, highlighting non-compliance with the facility's abuse prevention policy.
Failure to Offer Pneumococcal Vaccinations
Penalty
Summary
The facility failed to offer pneumococcal immunizations to residents, as evidenced by the review of medical records, vaccination consent forms, and staff interviews. This deficiency affected four out of five residents sampled for immunization review. The residents involved had various medical conditions, including heart disease, diabetes, dementia, renal disease, and respiratory failure. The immunization records for these residents showed either no record of receiving a pneumococcal vaccine or an unknown type of vaccine administered years prior. Additionally, there were no physician orders for the pneumococcal vaccine for these residents. The facility's Vaccine Administration Record (VAR)/Informed Consent form allowed residents or their responsible parties to indicate their wish to receive vaccinations, including COVID-19, influenza, and others. However, the forms for the affected residents did not indicate a request for the pneumococcal vaccine. An interview with the Director of Nursing (DON) revealed that there was no specific consent form for the pneumococcal vaccine, and the facility relied on residents or their families to write in their request for this vaccine. The DON acknowledged that there was no proof that the affected residents were asked about receiving the pneumococcal vaccine, highlighting a gap in the facility's vaccination consent process.
Failure to Provide Bed-Hold Notice During Hospital Transfer
Penalty
Summary
The facility failed to provide a bed-hold notice to a resident's representative when the resident was transferred to the hospital. This deficiency was identified during a review of the medical records of a resident who was admitted to the facility with diagnoses including dementia with behavioral disturbances, unspecified intellectual disability, generalized anxiety disorder, restlessness and agitation, and hypernatremia. The resident was transferred to the hospital due to an elevated sodium level, and although the resident's sister was informed of the transfer, there was no documentation that she was provided with a bed-hold notice as required by the facility's policy. The facility's policy mandates that residents or their representatives be informed of the bed-hold policy upon admission and prior to any transfer for hospitalization or therapeutic leave. In this case, the resident's medical record lacked evidence of compliance with this policy, as confirmed by the Social Service Director. The director was unable to find any documentation indicating that the resident's representative received the necessary bed-hold notice within the required timeframe, highlighting a lapse in the facility's adherence to its own procedures.
Inaccurate PASARR Documentation for Resident
Penalty
Summary
The facility failed to ensure that the Pre-Admission Screening and Resident Review (PASARR) documents were accurate regarding a resident's current conditions and diagnoses. This deficiency was identified during a review of records and staff interviews, affecting one resident. The resident in question had a range of diagnoses, including anxiety disorder, schizoaffective disorder, dementia, and several other medical conditions. Despite having a documented diagnosis of anxiety disorder since July 2021, the PASARR completed in January 2022 did not list this diagnosis. This discrepancy was confirmed during an interview with the Marketing Director, who acknowledged the absence of the anxiety diagnosis on the PASARR document.
Deficiencies in Care Planning for Anticoagulant and Anxiety Management
Penalty
Summary
The facility failed to develop comprehensive care plans for two residents, leading to deficiencies in their care. Resident #36, who has a complex medical history including end-stage renal disease, diabetes, heart disease, and other serious conditions, was prescribed the anticoagulant medication Eliquis for acute deep venous thrombosis. Despite the critical nature of this medication, the facility did not create a care plan to manage the resident's anticoagulant therapy. This oversight was confirmed during an interview with the Director of Nursing, who acknowledged the absence of a care plan for the resident's Eliquis use. Similarly, Resident #10, who has diagnoses including heart disease, diabetes, dementia, and anxiety disorder, did not have a specific and patient-centered care plan for managing anxiety. The resident's most recent assessment indicated a need for partial assistance with certain activities, yet the care plan failed to address the anxiety disorder and its specific symptoms. This lack of a tailored care plan was also verified by the Director of Nursing, highlighting a gap in the facility's approach to individualized resident care.
Deficiencies in Hospice Documentation and Compression Stocking Application
Penalty
Summary
The facility failed to ensure the availability of hospice records for Resident #109, which is crucial for continuity of care. The resident, who was admitted with multiple diagnoses including dementia and heart failure, was receiving hospice services with a prognosis of less than six months. Despite the care plan indicating the need for hospice services and documentation, the facility did not have the necessary hospice certification, care plan, or assessment in the resident's medical record. Interviews with the LPN confirmed that the required hospice documentation was not present. Additionally, the facility did not apply compression stockings as ordered by the physician for Resident #32, who was experiencing chronic left lower extremity edema. The resident, who had dementia and other mobility issues, was ordered to have compression stockings applied daily. However, observations revealed that the resident was not wearing the stockings, and the care plans did not address the edema or the use of compression stockings. Interviews with the CNA and LPN indicated a lack of awareness and adherence to the physician's orders, with the LPN acknowledging that the treatment administration record was inaccurately initialed to reflect compliance. These deficiencies highlight lapses in the facility's adherence to care plans and physician orders, impacting the quality of care provided to residents. The absence of hospice documentation and the failure to apply prescribed compression stockings demonstrate a lack of coordination and communication among the facility's staff, affecting the residents' care and well-being.
Failure to Implement Fall Prevention Interventions
Penalty
Summary
The facility failed to implement fall prevention interventions as per the care plans for two residents at risk for falls. Resident #33, who had a history of falls and fractures, was admitted with a care plan that included using a visual reminder to prompt the use of a call light for assistance. Despite this, the resident experienced a fall resulting in a right hip fracture, as the visual reminder was not present in the room. The Director of Nursing confirmed the absence of the visual reminder, which was supposed to be in place following an interdisciplinary team review after the resident's previous fall. Resident #38, diagnosed with severe cognitive impairment and requiring substantial assistance, was also affected by the facility's failure to adhere to fall prevention measures. The care plan for this resident included the use of dycem in the wheelchair to prevent falls. However, during an incident, the dycem was not in place, leading to the resident being found on the floor. The Director of Nursing verified that the dycem was not in the wheelchair at the time of the fall, contrary to the care plan requirements.
Failure to Assess and Plan for PTSD in Resident
Penalty
Summary
The facility failed to ensure that a resident with Post Traumatic Stress Disorder (PTSD) was appropriately assessed to identify the cause of the PTSD and to minimize triggers and/or re-traumatization. This deficiency affected one resident, identified as having PTSD/trauma, within a facility census of 51. The resident had a range of pertinent diagnoses, including chronic PTSD, heart failure, morbid obesity, Alzheimer's disease, and other mental health disorders. Despite being cognitively intact and using a walker for mobility, the resident's medical record lacked an assessment or care plan for PTSD. Interviews with the Registered Social Worker and the Director of Nursing confirmed the absence of a PTSD care plan or assessment, with the staff unaware of the resident's PTSD triggers or history.
Infection Control Breach During Wound Care
Penalty
Summary
The facility failed to adhere to infection prevention guidelines by not wearing appropriate personal protective equipment during wound care for a resident. The resident, who was cognitively intact and used a wheelchair, had a right lateral heel unstageable pressure ulcer and was on enhanced barrier precautions due to their medical condition. The precautions required staff to wear gloves and gowns during high-contact activities such as wound care. However, during an observation, a State Tested Nurse Aide (STNA) assisted with the resident's wound care by only wearing gloves and not a gown, despite the clear signage on the resident's door indicating the need for enhanced barrier precautions. The STNA was observed holding the resident's leg in the air for at least two minutes without wearing a gown, and her clothing was in contact with the side of the bed. This action was in direct violation of the facility's Enhanced Barrier Precautions policy, which mandates the use of gloves and gowns for high-contact resident care activities to prevent the spread of multi-drug resistant organisms. The STNA confirmed in an interview that she did not wear a gown, acknowledging the resident was on enhanced barrier precautions.
Antibiotic Administered Before Culture Results
Penalty
Summary
The facility failed to ensure that a resident was not treated with an antibiotic prior to the return of culture and sensitivity (C&S) results. This deficiency affected a resident who was being reviewed for a urinary tract infection (UTI). The resident had a complex medical history, including neurocognitive disorder with Lewy bodies, dementia, Alzheimer's disease, and other conditions. The resident's care plan included monitoring for signs and symptoms of UTI and ensuring proper toileting and pericare. On a specific date, the resident exhibited increased lethargy, unformed speech, and had not voided in 12 hours, prompting the physician to order a straight catheterization, urinalysis (UA) with C&S, and Rocephin, an antibiotic, for three days. The UA/C&S results, collected the day after the antibiotic was started, suggested probable contamination and recommended a repeat test if clinically indicated. Despite this, the resident had already completed the three-day course of Rocephin by the time the results were received. The Director of Nursing confirmed that the resident was treated with antibiotics before the UA/C&S results were available. The physician decided not to repeat the UA, as the resident's behavior had returned to baseline.
Failure to Implement Physician-Ordered Pressure Reduction Devices
Penalty
Summary
The facility failed to implement physician-ordered pressure reduction devices for two residents, leading to deficiencies in pressure ulcer care. Resident #109, who was admitted with multiple diagnoses including a stage I pressure ulcer, was observed without the physician-ordered off-loading boot and air mattress. Despite orders to use these devices to prevent further skin breakdown, they were not in place during multiple observations on the same day. The resident's care plan included interventions such as an air mattress and off-loading boot, but these were not executed as required. Similarly, Resident #45, who had a history of pressure ulcers and required substantial assistance with mobility, was found on an alternating air mattress set incorrectly to a weight of 450 pounds, despite weighing only 133 pounds. The care plan and physician orders specified the use of an alternating air mattress, but the incorrect setting was confirmed by an LPN who was unsure of the correct weight setting. This oversight was later corrected by a Registered Nurse Clinical Compliance Specialist. These deficiencies were identified during a complaint investigation.
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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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