King David Post Acute Nursing & Rehabilitation Llc
Inspection history, citations, penalties and survey trends for this long-term care facility in Beachwood, Ohio.
- Location
- 27100 Cedar Rd, Beachwood, Ohio 44122
- CMS Provider Number
- 365094
- Inspections on file
- 49
- Latest survey
- February 11, 2026
- Citations (last 12 mo.)
- 50
Citation history
Health deficiencies cited at King David Post Acute Nursing & Rehabilitation Llc during CMS and state inspections, most recent first.
Surveyors found that staff, including the Maintenance Director and a Nursing Supervisor, had placed 18 unapproved coiled portable electric space heaters in exit corridors, nurses’ workstations, and dining areas on multiple units because the building’s heating system was not maintaining the required temperature range. These heaters were in common areas used by an unspecified number of residents within a census of 267 and were cited as non-compliance under two complaint investigations.
Surveyors identified two medication administration errors involving two residents, resulting in a medication error rate above five percent. In one case, an LPN crushed and administered an extended-release potassium chloride tablet against physician orders, and in another, an LPN gave only one tablet of calcium carbonate-vitamin D instead of the prescribed two. Both errors were acknowledged by the staff involved and were not in accordance with facility policy.
A resident with multiple serious medical conditions and a full code status was found unresponsive and exhibiting signs of death. Staff failed to immediately initiate CPR, with delays caused by uncertainty, lack of certification, and panic. When CPR was started, it was performed ineffectively and without proper equipment or technique, as confirmed by EMS upon arrival. Facility policy requiring immediate CPR for full code residents was not followed.
The facility did not maintain safe and palatable food temperatures for residents, as confirmed by multiple resident and staff complaints and direct observation of food temperature drops during meal delivery. Meals were served without thermal plate liners, resulting in food being cold and unappetizing by the time it reached residents, with some residents reporting insufficient portions and resorting to purchasing food elsewhere.
Two residents dependent on staff for ADL support did not receive required assistance with feeding and showers as ordered or per their care plans. One resident with dysphagia and hemiplegia was left to eat independently without staff reminders or feeding, despite a history of choking and specific physician orders. Another resident, fully dependent for bathing, experienced long gaps between showers, with incomplete or illegible documentation and no evidence of refusals or alternative arrangements. Staff were unaware of required interventions, and assignment sheets did not accurately reflect current care needs.
A resident with severe cognitive impairment and multiple chronic conditions was not consistently offered activities aligned with her documented preferences, such as music, reading, group events, and religious services. Activity calendars for the dementia unit showed no scheduled activities, and staff did not routinely encourage or remind residents to participate. Observations and interviews confirmed the resident was often alone and not engaged in meaningful activities, despite her interest in social interaction.
The facility did not ensure that changes in condition were thoroughly addressed for two residents, including failure to obtain and document required vital signs and physician-ordered assessments. Nursing staff did not consistently document vital signs or complete ordered labs and assessments, despite physician orders and facility policy requiring these actions.
A resident with multiple risk factors for falls experienced repeated falls due to the facility's failure to consistently implement and document fall prevention interventions, such as proper footwear, call light accessibility, and use of a bolster mattress. Fall investigations were incomplete, lacking key assessments and documentation, and staff confirmed that some interventions were never put in place as required by facility policy.
A resident with end-stage renal disease missed multiple dialysis appointments due to the facility's failure to provide reliable transportation, despite physician orders and a care plan specifying the need for scheduled transport. The resident, who used a wheelchair, was initially told to arrange her own transportation and faced difficulties securing appropriate services, resulting in missed treatments and inconsistent use of private vehicles.
A resident was denied re-entry to a facility after hospitalization despite being medically cleared, violating the bed-hold policy. The resident had previously received a 30-day discharge notice, which was appealed successfully. Facility staff could not provide a clear reason for the denial, and the resident's family faced challenges retrieving personal belongings and finding alternative placement.
An LTC facility failed to properly clean a glucometer between uses, affecting two residents and potentially impacting 28 others. An LPN used the glucometer on two residents without adequate cleaning, contrary to facility policy requiring thorough disinfection with Super Sani cloth wipes. Interviews confirmed the improper practices, highlighting a deficiency in infection prevention and control.
A facility failed to notify a resident's physician and family of an open wound on the resident's thigh, which was first observed by a CNA and later confirmed by an LPN. The wound was not documented, and no treatment was initiated, despite the facility's policy requiring prompt notification of changes in a resident's condition.
A resident at risk for pressure ulcers developed an open wound on the thigh, which was not documented or treated in a timely manner. Despite being observed by a CNA, the wound remained untreated until a surveyor's observation. The LPN was unaware of the wound, and the facility failed to notify the physician or family, violating facility policy.
The facility failed to administer medications on time for two residents, leading to a deficiency in pharmaceutical services. One resident received evening medications almost four hours late due to an emergency, while another received morning medications nearly two hours late due to the nurse being busy. The facility's policy requires medications to be administered within one hour of their prescribed times, which was not followed.
The facility had a medication error rate of 13.33%, affecting three residents. A resident did not receive prescribed medications due to unavailability, while two residents with diabetes had their blood sugar levels checked after meals, contrary to protocol. These actions were confirmed by staff and indicate non-compliance with the facility's medication administration policy.
The facility failed to ensure meals were served at safe and appetizing temperatures, affecting 261 residents. Despite the dishwasher being operational, meals were served on disposable dishware, leading to food cooling before reaching residents. Multiple residents reported meals being cold and requiring reheating, highlighting a deficiency in meal service quality.
The facility faced deficiencies due to staff sleeping on duty, using personal phones in care areas, and serving meals on disposable plates despite a functional dishwasher. These issues affected resident care and meal quality, with staff and administration aware of the ongoing concerns.
During a survey, staff members were found sleeping on duty in two units, affecting 90 residents. An LPN and an STNA were observed asleep, despite facility policies against such conduct. Interviews confirmed staff awareness of the rules, but the facility failed to enforce them, leading to potential neglect.
A facility failed to implement Enhanced Barrier Precautions (EBP) during wound care for a resident with multiple medical conditions, including pressure ulcers and an indwelling urinary catheter. Despite the care plan indicating the need for EBP, staff did not wear gowns during high-contact care activities, contrary to facility policy and CMS directives. This deficiency was confirmed through observation and staff interviews.
A resident at high risk for falls sustained fractures after falling from bed without a physician-ordered fall mat in place. The facility failed to accurately report the injuries and delayed notifying the attending physician and family, resulting in a 10-hour delay in treatment. The resident had a history of multiple health issues and required assistance with movements. Despite a physician order for a fall mat, it was not in place, and the facility's plan of care lacked specific interventions. Staff interviews revealed miscommunication about the resident's injuries, and the facility's policy for prompt notification was not followed.
The facility failed to maintain clean and sanitary conditions in nursing unit kitchenettes, with observations of food spillage, dried food splatter, and crumbs in various areas. The Dietary Manager confirmed that while dietary staff stocked the kitchenettes, nursing staff were responsible for cleaning them. This issue was part of a complaint investigation and showed continued noncompliance from a previous survey.
The facility's high-temperature dishwasher failed to reach the required 180°F for proper dish sanitization, affecting nearly all residents. Observations showed error codes and low rinse temperatures, confirmed by the Director of Dietary Services. Staff interviews revealed a lack of awareness about temperature requirements, and logs indicated multiple instances of insufficient temperatures.
An LPN violated a resident's rights by loudly using her personal phone in the resident's room, causing distress. The facility's policy restricts personal phone use in care areas, allowing only emergency calls with supervisor approval. The incident was confirmed by the facility's CEO.
A facility failed to keep a resident's wheelchair and ankle foot orthosis (AFOs) clean and sanitary. The resident, with a complex medical history, was observed with dried liquid and food debris on their wheelchair and AFOs. An STNA confirmed the observation, and an LPN stated that STNAs were responsible for cleaning such equipment during night shifts on shower days. This issue was found during a complaint investigation.
A resident with a stage III pressure ulcer on the left heel did not receive the ordered treatment, as the foam dressing was missing during an observation. The resident had a physician's order for specific wound care, which was not followed, leading to non-compliance. The resident's medical history included chronic conditions such as osteomyelitis and kidney disease.
The facility failed to treat two residents with respect and dignity. A resident with multiple medical conditions was left with a soiled blanket after vomiting, and another resident requiring assistance with eating did not receive help with removing a plastic wrapper from their meal. The staff involved did not follow the facility's policy on treating residents with respect and dignity.
A resident with impaired cognition was transferred to a different room without prior notification to the resident or their representative. The facility only documented communication with the resident's family the morning after the move, which was confirmed by the ADON during an interview. This deficiency was identified during a complaint investigation.
A facility failed to provide wound care as ordered for a resident with stage IV pressure ulcers. The resident, who was cognitively intact, reported that wound treatments were not completed as scheduled, and an observation confirmed that dressings had not been changed. An LPN's investigation revealed discrepancies in documentation, with a late-entry note indicating the resident refused treatment, contrary to the resident's statement.
A facility failed to provide routine catheter care and lacked appropriate orders for a resident with a suprapubic catheter, leading to a urinary tract infection. The resident's care plan included monitoring for infection symptoms, but observations and staff interviews revealed that care was not provided as required, and necessary orders were missing. The resident was prescribed antibiotics following a positive urinalysis.
A resident with multiple myeloma did not receive a prescribed Fentanyl patch on two occasions due to a canceled prescription and communication issues between the facility's electronic medical record system and the pharmacy. The error was acknowledged by the DON and Quality Assurance Nurse, highlighting a failure in adhering to the facility's pain management policy.
A resident with multiple diagnoses, including seizures and depression, was found with a medication cup containing six pills on her nightstand. The LPN left the afternoon medications for the resident to take at her convenience, contrary to the facility's policy that prohibits leaving medications at the bedside. The Unit Manager confirmed that the resident does not self-administer medications. This incident was noted during a complaint investigation.
The facility failed to provide clean silverware with meals, affecting five residents. Observations revealed breakfast trays with silverware that had a yellowish color and solidified bumps. The Dietary Manager confirmed the issue, noting that staff had been handwashing dishes due to dishwasher problems. Interviews with two residents confirmed that silverware was sometimes dirty. The facility's policy required utensils to be kept clean and in good repair.
The facility failed to respond to call lights in a timely manner, affecting three residents and potentially impacting all residents. A resident's call light went unanswered for 36 minutes while an agency STNA engaged in personal activities. Another resident reported waiting over an hour for assistance, and a third resident experienced similar delays. The facility's policy required prompt response to call lights, but this was not adhered to, leading to non-compliance.
A facility failed to provide Pedialyte as ordered for a resident with gastroenteritis and cancer, leading staff to substitute it with Powerade without notifying the physician. The pharmacy did not stock Pedialyte, and dietary services did not purchase it, resulting in staff purchasing Powerade with their own money. Management was unaware of these actions, and the resident reported inconsistencies in receiving the prescribed supplement.
A resident fell from a mechanical lift due to a broken sling strap, which was not properly examined before use. The resident, dependent on staff for transfers, was not assessed by a nurse before being moved back to bed after the fall. The facility's investigation was incomplete, and improper laundering of slings was observed, highlighting lapses in safety protocols.
A resident with multiple health issues did not receive timely incontinence care, resulting in wearing two saturated briefs for several hours. Staff interviews revealed that care was delayed due to workload, and observations showed improper handling of soiled linens. The facility's policy lacked guidance on care frequency and double briefing.
The facility failed to ensure oxygen safety for residents, with unsecured oxygen cylinders and missing signs indicating oxygen use in rooms. Three residents using oxygen therapy for conditions like respiratory failure and asthma were affected. The facility's policy required signs but did not address securing cylinders, leading to this deficiency.
A resident with diabetes received insulin administered by an LPN using a method not in accordance with manufacturer guidelines. The LPN used a regular insulin needle to draw insulin from a pen, despite having the correct needles available, due to mistrust in the pen delivery system. Facility management was unaware of this practice, and the method was not supported by facility policies or manufacturer guidelines.
The facility failed to ensure accurate completion of MDS 3.0 assessments for four residents, resulting in multiple sections being marked as 'not assessed' or left with dashes. This was due to staff not completing their assigned sections timely, as verified by an RN.
The facility failed to ensure accurate and complete medical records for four residents, including missing documentation for wound care, meal intakes, and a hospital transfer. The DON and ADON confirmed these deficiencies, which were against the facility's policy.
The facility failed to report an allegation of misappropriation to the state survey agency in a timely manner. A resident discovered unauthorized charges on her bank credit card and reported them to the Unit Manager, who then informed the Executive Director and the Director of Nursing. However, the Executive Director did not file a Self-Reported Incident until several days later, despite the facility's policy requiring such reports to be made within 24 hours.
A resident with cognitive communication deficit and major depressive disorder reported unauthorized charges on her bank card. The facility's investigation concluded there was no proof the misappropriation occurred on campus, but it lacked comprehensive interviews and follow-up actions. The facility did not fully implement its policy on misappropriation, leading to an incomplete response to the allegation.
The facility failed to ensure a resident's call light was within reach and another resident's bed was of a comfortable length, causing accessibility and comfort issues. These deficiencies were confirmed by staff and observed on multiple occasions.
The facility failed to ensure that a resident's advanced directives were accurately and consistently recorded. The resident, who had multiple medical conditions, was not consulted about her code status, and no physician order was in place to reflect her wish to be a full code. This was confirmed through medical record review and interviews with two LPNs.
The facility failed to ensure care plans reflected resident wishes regarding code status, affecting two residents. One resident's wish to be a full code was not documented, and another resident's DNR-CC order was not included in the care plan. The facility's policy requires comprehensive, person-centered care plans, which was not followed.
A facility failed to maintain proper infection control during a wound care dressing change for a resident with multiple diagnoses. An LPN placed supplies directly on the bed without a protective barrier and did not change gloves after removing the old dressing, leading to potential contamination. The facility's policy, which required a clean field and changing gloves, was not followed.
Use of Unapproved Electric Space Heaters in Resident Care and Egress Areas
Penalty
Summary
Surveyors identified a deficiency in maintaining a safe physical environment when, during an evening tour of the facility with the Maintenance Director and a Nursing Supervisor, they observed 18 unapproved coiled portable electric space heaters in use across eight resident units. These heaters were located in exit corridors, nurses’ workstations, and dining areas, which are common areas used by an unidentified number of residents within a facility census of 267. During the same tour, the Maintenance Director and Nursing Supervisor confirmed that the electric coiled space heaters had been placed throughout the building because the central heating system was not maintaining the required indoor temperature range of 71°F to 81°F. This deficiency was cited as non-compliance under two complaint investigations (Complaint Numbers 2725672 and 2721209). No specific residents, medical histories, or clinical conditions were described in the report, and the deficiency focused on the facility’s use of unapproved heating devices in resident care and egress areas due to inadequate building heat.
Medication Administration Errors Exceed Acceptable Rate
Penalty
Summary
Surveyors observed that the facility failed to maintain a medication error rate of five percent or less during medication administration, with two errors identified out of 25 opportunities, resulting in an eight percent error rate. One incident involved a resident with dysphagia, hypokalemia, dementia, and atherosclerotic heart disease, who had a physician order for potassium chloride extended release (ER) 20 mEq to be dissolved in water and not crushed. An LPN crushed the potassium chloride ER tablet and administered it in a supplement drink, contrary to the physician's order and medication guidelines. The LPN confirmed the error during an interview, and the facility pharmacist verified that the medication should not have been crushed due to its extended-release formulation. Another incident involved a resident with dementia and a fractured right femur, who had a physician order to receive two tablets of calcium carbonate-vitamin D 500 mg-5 mcg twice daily. An LPN prepared and administered only one tablet, instead of the prescribed two, and documented the administration as complete. The LPN acknowledged the error during an interview. Facility policy required staff to verify whether medications could be crushed and to check the medication label three times to ensure the correct resident, medication, dose, time, route, and documentation, but these procedures were not followed in the observed cases.
Failure to Initiate Immediate and Effective CPR for Full Code Resident
Penalty
Summary
A deficiency occurred when staff failed to initiate immediate and appropriate cardiopulmonary resuscitation (CPR) for a resident with a full code status who was found unresponsive. The resident, an elderly male with multiple significant diagnoses including end stage renal disease, dementia, severe sepsis, and metabolic encephalopathy, was noted to be dependent on staff for all activities of daily living and had severely impaired cognition. On the evening in question, the resident was last observed in the dining room and later found unresponsive, cold to the touch, with blue fingertips and signs of rigidity by two certified nursing assistants (CNAs). Upon discovering the resident's condition, the CNAs sought assistance from a registered nurse (RN), who appeared panicked and did not immediately initiate CPR. The RN left the room to verify the resident's code status and retrieve the crash cart, during which time no resuscitative efforts were started. When additional nursing staff arrived, chest compressions were eventually initiated, but not until several minutes had passed. The staff performing CPR were not all currently certified, and the compressions were described as ineffective by emergency medical services (EMS) personnel upon their arrival. No airway management or use of an automated external defibrillator (AED) was observed, and the resident was not placed on a hard surface for compressions. EMS personnel noted that the resident exhibited signs of rigor mortis and had likely been deceased for several hours prior to their arrival, despite staff statements regarding the last time the resident was seen alive. Facility policy required immediate initiation of CPR for residents with full code status, but this was not followed. The incident affected one resident directly, with the facility identifying 178 residents with full code status at the time of the survey.
Failure to Serve Meals at Safe and Palatable Temperatures
Penalty
Summary
The facility failed to ensure that meals were served at a safe and palatable temperature, affecting all residents who received meals except for those with NPO orders. Multiple residents reported that the food was cold, unappetizing, and sometimes insufficient in quantity. Staff interviews confirmed frequent complaints from residents regarding the temperature, quality, and portion size of the food, with some residents resorting to purchasing food from the facility cafe due to dissatisfaction with the provided meals. Observations revealed that food temperatures taken at the steam table in the kitchen were within acceptable ranges, but by the time meals were plated, placed on the meal cart, and delivered to residents, the temperatures had dropped significantly. No thermal plate liners were used during meal transport. A test tray demonstrated that food items, such as eggplant cheese lasagna and green beans, were below acceptable service temperatures for palatability when served to residents. The interim Certified Dietary Manager confirmed that these temperatures were not acceptable at the time of service.
Failure to Provide Required ADL Assistance for Feeding and Bathing
Penalty
Summary
The facility failed to ensure that residents dependent on staff for activities of daily living (ADL) received appropriate assistance with feeding and showers as ordered, recommended by therapy, or according to resident preference. For one resident with hemiplegia and dysphagia, the care plan and physician orders required staff to feed the resident, sit with her, and provide continuous reminders to slow down and chew food thoroughly to prevent choking. Despite these orders and a documented history of choking, staff were observed allowing the resident to eat independently at a rapid pace, taking large bites and not fully chewing or swallowing before taking additional bites. Staff assigned to the resident were unaware of the specific feeding interventions, and the assignment sheets did not accurately reflect the current orders or interventions. There was also no documented evidence that staff had been trained on the required dining interventions for this resident. Another resident, who was totally dependent on staff for bathing due to hemiplegia and impaired cognition, did not consistently receive scheduled showers or baths. Documentation revealed significant gaps between showers, with periods of up to twelve days without a bath or shower. The resident reported not receiving showers as scheduled and expressed a preference for twice-weekly showers, which were not provided. Staff interviews confirmed that the resident often appeared with greasy hair and body odor, and that requests for showers were not consistently fulfilled. Additionally, shower documentation was incomplete or illegible, making it impossible to determine which staff provided care on certain dates. The facility's own policy required residents to be bathed or showered according to their preference at least twice per week, with proper documentation and follow-up if a shower could not be given or was refused. However, there was no evidence of refusals or alternative arrangements documented for the resident who missed multiple showers. The lack of accurate documentation, staff awareness, and adherence to care plans and physician orders led to deficiencies in providing necessary ADL assistance for residents dependent on staff for feeding and bathing.
Failure to Provide Activities Meeting Resident Preferences on Dementia Unit
Penalty
Summary
The facility failed to ensure that a resident with severe cognitive impairment and multiple diagnoses, including Alzheimer's disease, congestive heart failure, glaucoma, kidney disease, and anxiety, was offered activities that met her preferences. The resident's care plan identified her interests in reading, music, being around animals, keeping up with the news, participating in group activities, getting fresh air, and attending religious services. Despite these documented preferences and care plan interventions, review of the activity calendars for several months revealed no scheduled activities for the locked dementia unit where the resident resided. Additionally, documentation and staff interviews confirmed that the resident participated in very few group activities and that activity staff did not routinely remind or encourage residents to attend group events. The activity director acknowledged that staff availability limited the ability of residents on the locked unit to attend activities held outside the unit and that there was no evidence that the resident's specific interests were consistently offered or provided. Observations over multiple days showed the resident frequently alone and not engaged in activities, despite her enjoyment of social interaction and participation in music, art, and games when these were available. The resident's guardian also reported finding her alone during visits and needing to encourage her to leave her room. The activity participation records indicated only occasional one-on-one activities, and the activity calendar did not reflect any scheduled events for the locked dementia unit. The deficiency was confirmed through record review, observation, and interviews, demonstrating a lack of activities tailored to the resident's preferences and needs.
Failure to Address Change in Condition and Document Vital Signs as Ordered
Penalty
Summary
The facility failed to ensure that changes in condition for two residents were thoroughly addressed and that vital signs and physician-ordered assessments were obtained and documented as required. For one resident with severe cognitive impairment and multiple diagnoses, including malnutrition and dementia, staff identified vomiting and notified the nurse practitioner, who ordered STAT labs and imaging. However, the required laboratory tests and stool sample were never obtained, and vital signs were not fully documented in the medical record. Multiple LPNs confirmed that the change in condition was not fully addressed, and documentation of assessments and interventions was lacking. For another resident with a history of congestive heart failure, hypertension, and respiratory failure, there was a physician's order for vital signs to be taken every four hours. Review of the Treatment Administration Record showed that nurses signed off that vitals were obtained, but there was no documentation of the specific vital signs as ordered. Electronic monitoring records showed sporadic documentation of pulse, respiration, temperature, and blood pressure, but not consistently at the required intervals, and not all parameters were recorded as ordered. Interviews with nursing staff and the Director of Nursing confirmed that the required assessments and documentation were not completed according to physician orders and facility policy. The facility's policy required thorough assessment and documentation of changes in condition, including vital signs and communication with the physician, but these steps were not consistently followed for the residents reviewed.
Failure to Implement and Document Fall Prevention Interventions and Investigations
Penalty
Summary
The facility failed to ensure that fall prevention interventions were consistently implemented and that fall incidents were thoroughly investigated for a resident with significant risk factors. The resident, who had diagnoses including muscle weakness, artificial hip joints, dementia, depression, and glaucoma, was identified as being at risk for falls upon admission. The care plan included multiple interventions such as ensuring proper footwear, keeping the call light within reach, and laying the resident down after meals. Despite these interventions, the resident experienced multiple falls, and new interventions were added over time, including a pain medication regimen, keeping the bathroom light on at night, placing the bed in a low position, and using a bolster mattress. During the investigation of two separate falls, documentation was incomplete. For the first fall, there was no evidence that vital signs or a full body assessment were completed, nor was there documentation regarding the resident's footwear at the time of the fall. For the second fall, while vital signs were recorded, there was no documentation confirming the presence of the bolster mattress, the call light being within reach, the timing of the last toileting, use of nonskid socks, or that the bed was in the lowest position. Additionally, a fall mat intervention was not documented in the care plan or fall investigation, and staff confirmed that a bolster mattress had never been in place, despite it being listed as an intervention. Interviews with staff, including a CNA and the DON, confirmed that not all required interventions were in place and that fall investigations lacked necessary information to be considered complete and thorough. The facility's policy required that all falls be reviewed and investigated, with individualized interventions implemented and care planned accordingly. The failure to ensure interventions were in place and to conduct thorough investigations led to the deficiency cited in the report.
Failure to Provide Reliable Transportation for Dialysis Appointments
Penalty
Summary
The facility failed to ensure that a resident dependent on renal dialysis was provided with reliable transportation to and from dialysis appointments. Upon admission, the resident had multiple diagnoses including a left fibula fracture, acute pain, diabetes with neuropathy, and end-stage renal disease requiring dialysis three times a week. Physician orders specified the resident's dialysis schedule and the need to be ready for transportation at a set time. Despite this, documentation showed that the resident missed scheduled dialysis sessions due to lack of transportation, and nursing notes confirmed that the resident reported not having transportation available. Further review revealed that the resident was informed by facility staff that she was responsible for arranging her own transportation, and she was provided with a list of transportation companies. The resident, who used a wheelchair, faced challenges in securing appropriate transport, as some services like Uber and Lyft were not equipped to assist her. The facility's plan of care indicated that a specific transportation provider was to be used, but this was not consistently arranged, resulting in missed dialysis sessions and the resident having to use private cars for transport on several occasions. Interviews with the resident and staff confirmed that the resident missed dialysis appointments two or three times due to transportation issues when first admitted. The facility's transportation policy stated that it would arrange transportation for medically necessary appointments, but this was not followed in the resident's case. The deficiency was identified through review of records, interviews, and progress notes, which documented the lack of reliable transportation and the resulting missed dialysis treatments.
Facility Denies Resident Re-Entry After Hospitalization
Penalty
Summary
The facility failed to permit a resident to return after hospitalization, violating the bed-hold policy. The resident, who had been living in the facility since 2022, was transferred to the hospital due to a syncopal episode. Despite being medically cleared to return, the resident was denied re-entry to the facility. The facility's staff, including the Social Service Designee and the Director of Nursing, were unable to provide a clear reason for the denial, and the Administrator cited the inability to meet the resident's needs without specifying what those needs were. The resident had received a 30-day discharge notice in November 2024, which was appealed and won, allowing the resident to remain in the facility. However, after the hospitalization in January 2025, the resident was not allowed back, and no new 30-day discharge notice was provided. Interviews with facility staff, including LPNs and CNAs, indicated that the resident was appropriate for long-term care and did not require more care than other residents. The family of the resident reported being denied access to the facility to retrieve personal belongings and had to involve the police to obtain them. The hospital Care Transition Manager confirmed that the resident was admitted to another hospital due to having no safe place to return. The facility's refusal to readmit the resident led to difficulties in finding alternative placement, as other facilities were influenced by negative comments from the original facility. The facility did not provide any policy or procedure related to discharge, and the Director of Nursing indicated a willingness to accept a citation rather than deal with the resident's family.
Improper Cleaning of Glucometer in LTC Facility
Penalty
Summary
The facility failed to ensure proper cleaning of a blood glucose meter while checking blood sugar levels for residents, which led to a deficiency in infection prevention and control. During an observation, an LPN was seen using a glucometer on Resident #127 without cleaning it before or after use. The glucometer was stored uncovered in a medication cart drawer alongside other medical supplies. The LPN then used the same glucometer on Resident #271, cleaning it only briefly with an alcohol wipe before and after use, contrary to the facility's policy requiring thorough cleaning with Super Sani cloth wipes and allowing a two-minute wet time. Interviews with the LPN and the facility's Director of Nursing (DON) and Assistant Director of Nursing (ADON) confirmed the improper cleaning practices. The facility policy mandates that blood glucose meters be cleaned and disinfected between resident uses to prevent the transmission of bloodborne diseases. The failure to adhere to these procedures affected two residents directly and had the potential to impact an additional 28 residents who also received blood glucose level checks via the same glucometer.
Failure to Notify Physician and Family of Resident's Wound
Penalty
Summary
The facility failed to notify Resident #138's physician and responsible party of a change in condition, specifically an open wound on the resident's right anterior/medial thigh. The wound was first observed by a CNA on 01/11/25, who noted it was actively bleeding and painful. Despite this, no treatment was administered, and the wound was not documented in the resident's medical records. The CNA confirmed the wound's presence during incontinent care on 01/13/25, and the LPN, who was the resident's primary care nurse, was unaware of the wound and confirmed there was no treatment order. Further review of the resident's records with the ADON and DON confirmed the absence of documentation or notification to the physician or family about the wound from 01/11/25 to 01/13/25. The Wound Care Nurse was informed of the wound on 01/11/25 but did not notify the physician or family, nor was any treatment initiated. The facility's policy requires prompt notification of changes in a resident's condition to the resident, physician, and representative, which was not followed in this case.
Failure to Provide Timely Wound Care
Penalty
Summary
The facility failed to timely assess and provide wound care for a resident, identified as Resident #138, who was at risk for pressure ulcers due to frequent incontinence and morbid obesity. Despite being cognitively intact and requiring assistance for personal hygiene, the resident developed an open wound on the anterior/medial right thigh, which was first observed by a CNA on January 11, 2025. However, no treatment was initiated, and the wound was not documented in the resident's medical records. The wound was actively bleeding and painful, yet it remained untreated until it was observed by a surveyor on January 13, 2025. The LPN responsible for the resident's care was unaware of the wound until the surveyor's observation, and there was no physician order for treatment. The facility's policy required documentation and notification of changes in a resident's condition, but these protocols were not followed. The Wound Care Nurse was informed of the wound on January 11, 2025, but neither the physician nor the resident's family was notified, and no treatment was initiated. This oversight led to a deficiency being cited under Complaint Number OH00161351.
Medication Administration Deficiency
Penalty
Summary
The facility failed to administer medications to two residents, Resident #155 and Resident #85, according to physician orders, resulting in a deficiency in pharmaceutical services. Resident #155, who was cognitively intact and required assistance with mobility and toileting, did not receive his evening medications until almost 2:00 A.M. on 01/10/25, despite the medications being signed off as administered at 10:52 P.M. The delay was due to an emergency with another resident, which caused the nurse to forget to administer the medications on time. The facility's Director of Nursing confirmed that the medications were administered late and that there was no documentation in the medical records indicating the actual time of administration or notification to the physician. Resident #85, who was also cognitively intact and used a wheelchair for mobility, did not receive her morning medications until 11:58 A.M. on 01/12/25, despite them being scheduled for administration between 8:00 A.M. and 10:00 A.M. The delay was attributed to the nurse being busy with other issues, leading to the late administration of medications. The facility's policy requires medications to be administered within one hour of their prescribed times, which was not adhered to in these cases. The facility's failure to administer medications in a timely manner as prescribed by physicians represents non-compliance with their own policy and the standards for pharmaceutical services. This deficiency was investigated under Complaint Numbers OH00161278, OH00161166, and OH00161595, highlighting the need for adherence to medication administration schedules to ensure resident safety and well-being.
Medication Administration Errors Exceeding Acceptable Rate
Penalty
Summary
The facility was found to have a medication error rate of 13.33%, exceeding the acceptable threshold of 5%. This was determined through a review of medical records, observations, staff interviews, and facility policy. The errors affected three residents out of nine observed for medication administration. The facility's policy requires medications to be administered in a safe and timely manner, in accordance with prescriber orders, and within one hour of their prescribed times unless otherwise specified. Resident #8 did not receive their prescribed Aspirin and Fish Oil due to the unavailability of these medications during the scheduled administration time. This was confirmed by the Assistant Director of Nursing. Resident #127, who has type two diabetes mellitus with diabetic chronic kidney disease, had their blood sugar checked after consuming a meal, contrary to the sliding scale insulin administration protocol, which requires blood sugar levels to be checked before meals. This was confirmed by both the resident and the LPN involved. Similarly, Resident #271, also with type two diabetes mellitus, had their blood sugar checked post-meal, and insulin was administered based on this reading. The LPN confirmed that blood sugar assessments were sometimes conducted after meals, which is against the protocol. The Director of Nursing confirmed that blood sugars should be assessed prior to meals. These deficiencies were investigated under several complaint numbers, indicating non-compliance with the facility's medication administration policy.
Facility Fails to Serve Meals at Safe and Appetizing Temperatures
Penalty
Summary
The facility failed to ensure that meals served to residents were palatable and at a safe and appetizing temperature. This deficiency was observed during interviews and inspections, where residents expressed concerns about the food being served cold or not hot enough. The issue affected 261 residents who received meal trays, with multiple residents reporting that their meals were often cold and required reheating. The facility's policy required food to be prepared and served in a manner that complied with safe food handling practices, but this was not adhered to. The deficiency was linked to the facility's decision to serve meals on disposable dishware and with plastic silverware, despite the kitchen dishwasher being operational and meeting the required rinse cycle temperature of 186 degrees Fahrenheit. The Dietary Director and Supervisor confirmed that the dishwasher was functioning correctly, but the Administrator chose not to use it until it was fully repaired, even though the issue with the rinse cycle temperature had been resolved. This decision led to meals being served on disposable dishware, which contributed to the food cooling down before reaching the residents. Observations of the kitchen and meal service revealed that while food items were initially at safe temperatures when checked at the steam table, they were significantly cooler by the time they were served to residents. A test tray confirmed that the food items were only warm and not hot, which was consistent with the residents' complaints. The facility's failure to utilize the dishwasher and serve meals on appropriate dishware resulted in meals that were not palatable, affecting the quality of care provided to the residents.
Deficiencies in Staff Conduct and Meal Service
Penalty
Summary
The facility was found to have several deficiencies related to the administration and management of resources, impacting the well-being of its residents. Observations and interviews revealed that staff members were found sleeping while on duty, which is a violation of the facility's employee handbook. This issue was observed in both the Beachwood Pavilion and Euclid Pavilion units, affecting numerous residents. Despite being aware of the rules against sleeping on the job, staff members were observed asleep, and the administration acknowledged previous deficiencies related to this issue. Additionally, staff members were observed using personal cell phones in resident care areas, which is against the facility's policy. This was noted during the survey, with staff members using their phones in common areas and even in resident rooms. The facility's employee handbook clearly states that personal phone use while on duty is prohibited, yet this guideline was not effectively enforced, as evidenced by the observations and staff interviews. The facility also failed to utilize its kitchen dishwasher in a timely manner after repairs, resulting in meals being served on disposable plates. This led to complaints from residents about the food being cold and unpalatable. Despite the dishwasher being repaired and capable of reaching the required temperatures, the administration decided not to use it until further parts were received, which was not necessary for the dishwasher's current functionality. This decision affected the quality of meals served to residents, as confirmed by multiple resident interviews.
Staff Sleeping on Duty Leads to Potential Neglect
Penalty
Summary
The facility failed to ensure residents were free from potential neglect when staff members were observed sleeping while on duty. This incident was noted during a survey conducted on the Beachwood Pavilion and Euclid Pavilion units, affecting a total of 90 residents. On the Beachwood Pavilion unit, an LPN was found asleep at the nursing station desk, unresponsive to initial attempts by the State Surveyor to wake them. Similarly, on the Euclid Pavilion unit, an STNA was observed asleep in a chair, requiring multiple attempts by the State Surveyor to be awakened. Both staff members acknowledged their actions, with the STNA apologizing for sleeping while on duty. Interviews with other staff members, including an RN and the Night Supervisor LPN, confirmed that all employees were aware of the rules against sleeping on the job, as outlined in the employee handbook. The handbook explicitly states that sleeping while on duty is an infraction that could lead to disciplinary action, including termination. Despite this, the facility did not implement these guidelines effectively, as evidenced by the observed incidents. The facility's policy on abuse, mistreatment, neglect, and exploitation was also reviewed, revealing a lack of implementation to prevent potential neglect, as staff were not adequately monitored to ensure they were awake and attentive to residents' needs.
Failure to Implement Enhanced Barrier Precautions During Wound Care
Penalty
Summary
The facility failed to implement an effective infection prevention and control program, specifically regarding Enhanced Barrier Precautions (EBP) during wound care for a resident. The resident, who had multiple medical conditions including multiple sclerosis, Crohn's disease, and Parkinson's disease, was admitted with two unhealed Stage II pressure ulcers and an indwelling urinary catheter. Despite the care plan indicating the need for EBP during high-contact care activities, such as wound care, the staff did not adhere to these precautions. During an observation, it was noted that the nursing staff and a nurse practitioner did not wear gowns while performing wound care, which is a requirement under EBP for residents with wounds and indwelling medical devices. The facility's policy on Enhanced Barrier Precautions, which aligns with the Centers for Medicare and Medicaid Services (CMS) directive, mandates the use of gowns and gloves during high-contact care to prevent the transfer of multi-drug-resistant organisms. However, the staff did not follow this policy, as confirmed in interviews where they stated that gowns were not worn because the resident did not have Methicillin-Resistant Staphylococcus aureus (MRSA). The Director of Nursing acknowledged that there was no physician order for EBP, although it was included in the resident's care plan. This oversight led to a deficiency being cited during the survey.
Failure to Implement Fall Interventions and Timely Notification
Penalty
Summary
The facility failed to implement physician-ordered fall interventions and did not accurately report assessment findings or timely notify the attending physician and resident representative following a fall. On 09/15/24, Resident #280, who was at high risk for falls, fell from her bed without a physician-ordered fall mat in place, resulting in a fractured right clavicle and fractures at the sixth and seventh ribs. The nursing staff assessed the resident and noted limited range of motion and pain but failed to report these injuries accurately to the hospice provider or notify the attending physician immediately, delaying evaluation and treatment for approximately 10 hours. Resident #280 had a medical history that included hypertension, heart failure, vertigo, anxiety, syncope, seizures, and depression. She was cognitively intact, had impairment on one side of the lower extremities, and used a wheelchair. The resident required assistance with various movements and was assessed to be at high risk for falls. Despite a physician order dated 08/20/24 to ensure a mat was next to the bed, the fall mat was not in place at the time of the fall. The facility's plan of care did not identify a mat to the floor or side bed rails as interventions. Interviews with staff and hospice personnel revealed that the facility nurse reported the fall to the on-call hospice nurse but indicated there were no apparent injuries. The hospice nurse advised continuing neurological checks and reporting any concerns. However, the hospice nurse practitioner discovered the injuries the following day during a visit. The facility's policy required prompt notification of changes in a resident's condition, but the family and attending physician were not notified until much later, contrary to the policy's requirements.
Unsanitary Conditions in Nursing Unit Kitchenettes
Penalty
Summary
The facility failed to maintain the nursing unit kitchenettes in a clean and sanitary manner, as observed during a survey. The observations revealed multiple instances of food spillage, dried food splatter, and crumbs in various kitchenettes across different nursing units. Specific issues included dirty microwaves with dried food splatter, food crumbs on counters and toasters, and refrigerators with dried substances and unlabeled food items. These unsanitary conditions were noted in the Euclid pavilion 1 and 2, Fairmont, Weinburg, Shaker, Beachwood, and Heights 1 and 2 nursing unit kitchenettes. During an interview, the Dietary Manager confirmed the findings and stated that while dietary staff stocked the kitchenettes, the nursing staff was responsible for cleaning them. The facility's policy on cleaning and disinfection, revised in August 2019, requires regular cleaning and disinfection of housekeeping surfaces, especially when visibly soiled. This deficiency was part of a complaint investigation and represented continued noncompliance from a previous survey.
Dishwasher Temperature Deficiency
Penalty
Summary
The facility failed to ensure that its high-temperature dishwasher reached the minimum required temperature for proper dish sanitization, potentially affecting all residents except three who did not consume food from the kitchen. During observations, the dishwasher exhibited error codes indicating low temperature and insufficient water levels, with final rinse temperatures consistently below the required 180 degrees Fahrenheit. The Director of Dietary Services confirmed these issues and noted that the dishwasher was shut down due to low temperatures, and a service call was placed to the manufacturer. Interviews with staff revealed a lack of awareness regarding the required final rinse temperature, and the Assistant Director of Engineering was unaware of the necessary temperature settings. The review of the dishwasher temperature logs showed multiple instances where temperatures were logged below 180 degrees Fahrenheit, and no previous logs were available upon request. This deficiency was identified during a complaint investigation, highlighting the facility's failure to maintain proper dish sanitization standards.
Staff Personal Phone Use Violates Resident's Rights
Penalty
Summary
The facility failed to uphold the resident's right to a dignified existence and self-determination by allowing staff to engage in personal conversations in resident care areas. During an observation, an LPN was found yelling into her personal cellular phone while in a resident's room, which startled the resident. The LPN did not communicate with the resident during her visit and continued her loud conversation outside the resident's room. This behavior was contrary to the facility's policy, which restricts personal phone use in resident care areas unless it is an emergency and screened through a supervisor. The incident involved a resident who expressed discomfort with staff using their phones in his room. The LPN explained that she was upset due to a personal emergency involving her children being locked out of their home. The facility's CEO confirmed that staff had been instructed on the appropriate use of personal phones in care areas and acknowledged the incident. The employee handbook clearly outlines the restrictions on personal phone use, emphasizing that only emergency calls are permitted with supervisor approval.
Failure to Maintain Clean Wheelchairs and Equipment
Penalty
Summary
The facility failed to maintain wheelchairs and durable medical equipment in a clean and sanitary manner for one resident who used a wheelchair for mobility. The resident, who had a complex medical history including traumatic brain injury, stroke, cognitive communication deficit with dementia, and other serious conditions, was observed with a wheelchair that had dried liquid substances and food debris on the foot and leg rests. Additionally, the resident's ankle foot orthosis (AFOs) were also coated with dried liquid and food debris. This observation was confirmed by the State tested Nursing Assistant (STNA) who assisted the resident. An interview with a Licensed Practical Nurse (LPN) revealed that the responsibility for cleaning the residents' wheelchairs and equipment fell to the STNAs during the night shift on the residents' shower days, which occurred twice a week. This deficiency was identified during a complaint investigation.
Failure to Provide Ordered Pressure Ulcer Treatment
Penalty
Summary
The facility failed to provide pressure ulcer treatments as ordered for a resident with a left heel stage III pressure ulcer. The resident, who had intact cognition and was frequently incontinent, had a physician's order to clean the ulcer with normal saline, pat dry, pack with hydroferablue, and cover with foam dressing every day shift on specific days, and every 12 hours as needed. However, the treatment was last applied on a specific date during the day shift, and an observation revealed that the foam dressing was missing, indicating non-compliance with the treatment order. The resident's medical history included chronic osteomyelitis, pain, depression, vitamin deficiency, chronic kidney disease, prostate cancer, anorexia, and monoclonal gammopathy. During an interview, the resident was unaware that the wound treatment was not present. The facility's policy on wound care, which was revised in October 2010, required verification of a physician's order for wound care procedures. This deficiency was part of a complaint investigation and represented continued non-compliance from a previous survey.
Failure to Treat Residents with Respect and Dignity
Penalty
Summary
The facility failed to ensure that staff treated two residents with respect and dignity, as required by their policy. Resident #68, who has multiple medical conditions including multiple sclerosis and Parkinson's disease, was left with a stained blanket after vomiting during the night. Although a state-tested nurse aide (STNA) cleaned him up, they did not replace the soiled blanket. The resident expressed his desire for a clean blanket during an interview, and the STNA acknowledged the need for a clean blanket but had not yet provided one. In another incident, Resident #24, who requires assistance with eating due to a self-care deficit, did not receive the necessary help during a meal. An STNA delivered the lunch tray but refused to remove the plastic wrapper from the ice cream container, citing her long fingernails as the reason. The resident's daughter, who was present, struggled to remove the wrapper and expressed frustration that the staff expected her to perform their duties. The STNA admitted that she assumed the daughter would handle it and typically would ask another staff member for help. An LPN confirmed that the STNA should have sought assistance from another staff member to complete the task.
Failure to Notify Resident of Room Change
Penalty
Summary
The facility failed to notify a resident or the resident's representative before transferring the resident to another room, which is a violation of the resident's rights. The resident, who had multiple medical conditions including impaired cognition, was moved from one room to another after dinner without prior notification. The only documentation of communication with the resident's family was recorded the following morning, indicating that the Assistant Director of Nursing spoke with the resident's daughter about the room change. The lack of prior notification was confirmed during an interview with the Assistant Director of Nursing, who acknowledged that there was no documentation in the medical record indicating that the resident or their representative was informed of the room change before it occurred. This deficiency was identified during an investigation under a specific complaint number, affecting one of three residents reviewed for room changes in a facility with a census of 276.
Failure to Provide Wound Care as Ordered
Penalty
Summary
The facility failed to provide wound care according to physician's orders for a resident with multiple complex medical conditions, including multiple sclerosis, Crohn's disease, and Parkinson's disease. The resident, who was cognitively intact, had two stage IV pressure ulcers on the right hip and coccyx. The care plan required wound treatments to be performed as ordered, but the Treatment Administration Record (TAR) for August 10, 2024, showed that the wound treatments were not signed off as completed. An interview with the resident confirmed that the wound treatments were not completed on that date, and the resident stated he did not refuse the treatment. An observation on August 12, 2023, revealed that the wound dressings were dated August 8, 2024, indicating they had not been changed as required. The LPN verified the dressing dates and stated an investigation would be conducted. A progress note created on August 12, 2024, claimed the resident refused treatment on August 10, 2024, and was educated on the risks and benefits of completing treatment. However, further investigation by the LPN revealed that the nurse had signed off the TAR and created a late-entry progress note, indicating the resident's refusal, which was not consistent with the resident's statement.
Failure in Catheter Care and Monitoring
Penalty
Summary
The facility failed to provide routine indwelling urinary catheter care and did not have appropriate catheter care orders in place for a resident with multiple complex medical conditions, including multiple sclerosis and a suprapubic cystostomy. The resident's medical record showed a lack of orders for cleansing the suprapubic catheter from late June to early August, and there were no current orders for changing or emptying the urinary drainage bag or monitoring for urinary tract infections. Observations revealed that the resident's urinary drainage bag was full, and interviews with staff confirmed that care had not been provided as required. The resident was cognitively intact and dependent on staff for toileting, with a care plan that included monitoring for urinary tract infection symptoms and ensuring proper catheter maintenance. However, the facility's policy on catheter care was not followed, as evidenced by missing documentation and orders. The resident developed a urinary tract infection, confirmed by a positive urinalysis, and was prescribed antibiotics. Interviews with staff, including a new unit manager, revealed gaps in the process for inputting necessary catheter care orders, contributing to the deficiency.
Failure to Administer Pain Medication as Prescribed
Penalty
Summary
The facility failed to prevent a significant medication error involving a resident who was being treated for chronic pain. The resident, diagnosed with multiple myeloma and receiving hospice services, was prescribed a Fentanyl patch to be changed every three days. However, the Medication Administration Record (MAR) indicated that the patch was not administered on two occasions, specifically on 07/16/24 and 07/19/24. The facility's-controlled drug record confirmed the absence of administration on these dates. Interviews revealed that a prescription was sent to the pharmacy on 07/10/24 but was canceled the following day, leading to the resident not receiving the medication as ordered. The Director of Nursing (DON) and the Quality Assurance Nurse acknowledged the error, with the latter stating that the nurse mistakenly signed off the medication on the MAR. The facility's policy mandates adequate pain management to ensure residents' well-being, which was not adhered to in this case. The issue was compounded by communication problems between the facility's electronic medical record system and the pharmacy system, resulting in the cancellation of the prescription. This deficiency was investigated under multiple complaint numbers, indicating a broader concern regarding medication administration practices.
Medication Security Lapse for Resident
Penalty
Summary
The facility failed to ensure medications were always secure from unauthorized access, affecting one resident out of 29 residents on the involved nurse's assignment. Resident #162, who had diagnoses including hypertension, heart failure, vertigo, anxiety, syncope, seizures, and depression, was observed with a medication cup containing six pills on her nightstand. The resident had intact cognition and was receiving antibiotics and an opioid as per the quarterly Minimum Data Set (MDS) 3.0 assessment. The physician's orders for August 2024 included medications such as Depakote, Tramadol, Tylenol, gabapentin, and a probiotic capsule. On the day of the observation, the resident complained of shoulder pain and requested her afternoon medications. Licensed Practical Nurse (LPN) #432 prepared the medications and left them on the resident's bedside table for her to take with lunch, despite the facility's policy against leaving medications at the bedside. The Unit Manager, Registered Nurse (RN) #406, confirmed that the resident does not self-administer her medications. The facility's policy, dated April 2019, stated that residents may self-administer medications only if deemed safe by the attending physician and interdisciplinary care planning team. This deficiency was identified during a complaint investigation.
Facility Fails to Provide Clean Silverware with Meals
Penalty
Summary
The facility failed to ensure residents received clean silverware with their meals, affecting five residents observed during meal service. During an observation, breakfast trays on a dietary cart contained silverware with a translucent yellowish color and small solidified bumps on the surface. The Dietary Manager confirmed the silverware was dirty and acknowledged that dietary staff had been handwashing some dishes due to dishwasher problems. Interviews with two residents further confirmed that the silverware was sometimes dirty when it arrived with meal trays. A review of the facility's Dietary Sanitation policy indicated that utensils were to be kept clean and in good repair.
Delayed Call Light Response in LTC Facility
Penalty
Summary
The facility failed to ensure that call lights were answered in a timely manner, affecting three residents and potentially impacting all residents in the facility. Resident #285, who had multiple diagnoses including Parkinson's disease and impaired cognition, activated her call light, which went unanswered for 36 minutes. During this time, an agency State Tested Nurse Aide (STNA) was observed not responding to the call light, instead engaging in personal activities such as talking on an earpiece. The STNA claimed that Resident #285 was not her responsibility, and she was unaware of the expectation to respond to all call lights. Resident #116, who also served as the resident council president, reported that his call light was often not answered for over an hour. He expressed frustration that staff would sometimes respond to his call light only to inform him they would return, but then fail to do so, particularly when he needed assistance going to bed. Similarly, Resident #139 reported waiting over an hour for her call light to be answered. She noted that staff would sometimes turn off the call light and promise to return, but would not follow through, necessitating repeated calls for assistance with activities of daily living. The facility's policy on call systems, dated September 2022, stated that residents should have a means to call staff for assistance and that calls should be answered as soon as possible. However, the observations and interviews revealed a significant delay in response times, indicating non-compliance with the facility's policy. This deficiency was investigated under Complaint Number OH00154304.
Failure to Provide Prescribed Pedialyte for Resident
Penalty
Summary
The facility failed to provide Pedialyte, an oral electrolyte solution, as ordered by the physician for a resident with non-infective gastroenteritis, colitis, malignant lung cancer, and autistic disorder. Despite the physician's order for Pedialyte to be administered three times daily, the facility did not have the product available, leading nursing staff to substitute it with Powerade without notifying the physician. This substitution occurred because the pharmacy did not stock Pedialyte, and dietary services did not purchase nutritional supplements, leaving the staff to purchase Powerade with their own money. Interviews with nursing staff revealed that the issue of obtaining Pedialyte had been ongoing, with staff having to resort to purchasing Powerade or using delivery services to obtain Pedialyte. The facility's management was reportedly aware of the issue, but there was a lack of communication and coordination between departments, including pharmacy, dietary, and central supply, regarding the procurement and availability of Pedialyte. The Assistant Director of Nursing was unaware of the staff's actions to purchase substitutes and believed that Pedialyte was available through central supply, although observations showed otherwise. The resident involved reported inconsistencies in receiving the prescribed Pedialyte, sometimes receiving Powerade or nothing at all. Despite attempts to address the issue, such as obtaining verbal orders to use Powerade temporarily, the facility did not provide documentation or evidence of past purchases of Pedialyte. This deficiency was investigated under specific complaint numbers, highlighting the facility's non-compliance with ensuring the availability of prescribed nutritional supplements.
Failure to Ensure Safe Use of Mechanical Lift Leads to Resident Fall
Penalty
Summary
The facility failed to ensure the mechanical lift sling used for transferring a resident was properly examined, resulting in the sling strap breaking and the resident falling to the floor. The resident, who had diagnoses including dementia, hypertension, and hemiplegia, was totally dependent on staff for transfers. The care plan did not include the use of a mechanical lift for transfers, despite a physician's order for a two-person assist with a mechanical lift. During the transfer, the sling strap broke, causing the resident to fall, and the investigation revealed that the sling was dated within the year framework and showed no signs of wear prior to the incident. The facility also failed to conduct a thorough nursing assessment before transferring the resident back to bed after the fall. The resident was assisted back to bed by staff without a nurse's assessment, which was against protocol. The investigation into the incident was incomplete, as it did not include interviews with all involved staff, and the facility's policies did not adequately address the need for a thorough assessment after a fall. Additionally, the competency form for the staff involved did not include instructions to examine the sling for wear before use. Furthermore, the facility did not ensure that mechanical lift slings were properly laundered. An observation revealed that slings were placed in a dryer on high heat, contrary to the procedure of air drying them. This improper laundering could contribute to the wear and tear of the slings, potentially compromising their integrity. The facility's failure to adhere to proper laundering procedures and to conduct a comprehensive investigation into the incident highlights significant lapses in ensuring resident safety.
Incontinence Care Deficiency
Penalty
Summary
The facility failed to provide timely and appropriate incontinence care for Resident #285, who was diagnosed with Parkinson's disease, diabetes, morbid obesity, urinary incontinence, and heart failure. The resident's care plan required checking every two hours and assisting with toileting as needed, but observations revealed that the resident was left with two incontinence briefs on, both saturated with urine, indicating a lack of timely care. The resident was dependent on staff for toileting and hygiene due to impaired cognition and immobility, and the care plan did not include wearing two briefs simultaneously. Interviews with staff revealed that the resident had not received incontinence care for almost four hours, despite the requirement for care every two hours. STNA #623, who was responsible for the resident's care, admitted to not providing timely care due to being occupied with other residents' needs. The Assistant Director of Nursing confirmed that residents should not have two briefs on and that care should be provided every two hours, but was unsure why the delay occurred as there were six aides on the unit. Further observations showed that the resident continued to have two briefs on during subsequent care, and soiled linens were improperly placed on the floor. STNA #638, who provided care later, denied applying two briefs and suggested it might have been done by the night shift. The Unit Manager confirmed that the resident did not have two briefs on after the night shift, indicating a lapse in care during the day shift. The facility's policy on perineal care did not address the frequency of incontinence care or the prohibition of double briefing.
Oxygen Safety Deficiency in LTC Facility
Penalty
Summary
The facility failed to ensure the safe and appropriate use of oxygen for residents, as observed during a survey. Specifically, oxygen cylinders were found unsecured and freestanding in the rooms of three residents, which is against safety protocols. Additionally, there were no signs indicating oxygen use upon entrance to these residents' rooms, which is a requirement according to the facility's policy. This deficiency was observed in the cases of three residents who were using oxygen therapy due to various medical conditions such as chronic respiratory failure, pneumonia, asthma, and congestive heart failure. Resident #51 had an order for oxygen use as needed, but there was no mention of oxygen use in her care plan, and an unsecured oxygen cylinder was found in her room. Resident #193, who required continuous oxygen due to pneumonia and asthma, also had an unsecured oxygen cylinder and lacked an oxygen use sign. Similarly, Resident #262, who was on continuous oxygen therapy for respiratory failure and COPD, did not have a sign indicating oxygen use. The facility's policy, last revised in 2010, required signs for oxygen use but did not address the proper securing of oxygen cylinders, contributing to the deficiency.
Improper Insulin Administration Method
Penalty
Summary
The facility failed to ensure the safe administration of insulin for Resident #264, who had a history of diabetes mellitus and was receiving insulin as part of her treatment plan. The resident's care plan included administering diabetic medications as ordered and monitoring blood sugar levels. During an observation, it was noted that an LPN administered insulin using a method not in accordance with the manufacturer's guidelines. Instead of using the specifically designed needle for the insulin pen, the LPN used a regular insulin needle to draw insulin from the pen and administer it to the resident. The LPN admitted to preferring this method due to a lack of trust in the insulin pen delivery system, despite having the correct needles available on her medication cart. She had not communicated her concerns about the insulin pen to the pharmacy or nursing management. The Director of Pharmacy confirmed that the guidelines did not support the method used by the LPN and that no concerns had been raised by other nurses regarding the insulin pen's accuracy. Interviews with facility management revealed that they were unaware of any issues with the insulin pen delivery system and confirmed that there was no policy allowing the use of a regular insulin needle to draw insulin from the pen. The facility's policies and the manufacturer's guidelines did not support the method used by the LPN, indicating a deviation from established procedures for insulin administration.
Inaccurate Completion of MDS Assessments
Penalty
Summary
The facility failed to ensure that assessments were accurately completed for four residents, affecting their Minimum Data Set (MDS) 3.0 assessments. Resident #77, admitted with diagnoses including dementia, anxiety, and pain, had multiple sections of the MDS assessment marked as 'not assessed' or left with dashes, including cognition, mood, behaviors, and pain. This was verified by RN #1141, who stated that the incomplete sections were due to other staff not completing their assigned parts of the assessment timely. Similar issues were found with Resident #110, who had diagnoses including dementia, diabetes, and depression. The annual MDS assessment for this resident also had multiple sections marked as 'not assessed' or left with dashes, including cognition, mood, behaviors, and preferences for routine and activities. RN #1141 confirmed these deficiencies, attributing them to staff not completing their sections on time. Resident #217, diagnosed with Alzheimer's disease, hypertension, and depression, had an incomplete quarterly MDS assessment, particularly in the section related to pain assessment. The questions were either not answered or marked as 'not assessed.' RN #1141 verified this issue, again citing staff delays in completing their sections. Lastly, Resident #281, with Alzheimer's disease and diabetes mellitus, had a comprehensive MDS assessment with multiple sections, including cognition and mood, marked as 'not assessed' or left with dashes. RN #1141 confirmed the inaccuracies, attributing them to the same issue of staff not completing their assigned sections timely.
Facility Fails to Ensure Accurate and Complete Medical Records
Penalty
Summary
The facility failed to ensure medical records were accurate and complete, affecting four residents. Resident #28 had multiple instances where wound care documentation was missing, despite physician orders for specific treatments. The Assistant Director of Nursing confirmed the missing documentation, and the facility could not provide additional records to show the treatments were completed as ordered. The facility's policy required all services provided to be documented accurately and completely, which was not adhered to in this case. Resident #43's medical record showed missing documentation for meal intakes on several dates. The Dietitian and the Director of Nursing confirmed that nursing staff, including nurses and State Tested Nursing Assistants, were responsible for documenting meal intakes, which was not consistently done. This lack of documentation was verified by the Director of Nursing and Assistant Director of Nursing. Resident #179 also had missing documentation for meal intakes on multiple dates. Similar to Resident #43, the Dietitian and the Director of Nursing confirmed the responsibility of nursing staff to document meal intakes, which was not consistently followed. Additionally, Resident #317's medical record lacked documentation related to the resident's transfer to the hospital, including the reason, condition, and timing of the transfer. The Director of Nursing and Assistant Director of Nursing verified this missing documentation, which was against the facility's policy for charting and documentation.
Failure to Timely Report Allegation of Misappropriation
Penalty
Summary
The facility failed to report an allegation of misappropriation to the state survey agency in a timely manner. This deficiency affected one resident who had unauthorized charges on her bank credit card. The resident, who was alert and oriented, along with her niece, discovered the charges and reported them to the Unit Manager. The Unit Manager then reported the incident to the Executive Director and the Director of Nursing. However, the Executive Director did not file a Self-Reported Incident until several days later, despite the facility's policy requiring such reports to be made within 24 hours. The facility's policy on abuse, mistreatment, neglect, exploitation, and misappropriation of resident property was not followed in this case. The policy mandates that allegations of misappropriation be reported to relevant state agencies within 24 hours and thoroughly investigated. The Executive Director confirmed that she was aware of the charges but did not take timely action to report the incident, leading to a delay in the investigation and reporting process.
Failure to Thoroughly Investigate Allegation of Misappropriation
Penalty
Summary
The facility failed to thoroughly investigate an allegation of misappropriation involving a resident's bank credit card. Resident #21, who had cognitive communication deficit and major depressive disorder, reported unauthorized charges on her bank card, which were discovered by her and her niece. The niece reported the suspicious charges to the Unit Manager (UM), who then informed the Executive Director (ED) and the Director of Nursing (DON). The facility's investigation concluded that there was no proof the misappropriation occurred on campus, and the charges were made in San Francisco, California. However, the facility did not conduct interviews with staff across all shifts, auxiliary staff, or other residents to determine if there were similar concerns or if staff had knowledge of any misappropriation of residents' property. Additionally, the facility did not provide a copy of the police report or evidence of further attempts to contact the niece for additional information. The facility's policy on abuse, mistreatment, neglect, exploitation, and misappropriation of resident property was not fully implemented in this case. The policy required that allegations of misappropriation be reported to relevant state agencies within 24 hours and thoroughly investigated. The facility's investigation lacked comprehensive interviews and follow-up actions, which led to the deficiency. The facility's failure to conduct a thorough investigation and follow the policy resulted in an incomplete response to the allegation of misappropriation, affecting the resident's right to be free from exploitation and misappropriation of property.
Failure to Accommodate Resident Needs
Penalty
Summary
The facility failed to ensure that Resident #764's call light was within reach and that Resident #666's bed was of a comfortable length. Resident #764, who had difficulty walking, muscle weakness, and diabetes mellitus, was observed with her call light attached to the handrail of her bed, wrapped around multiple times, and not within her reach while she was in her wheelchair across the room. This was confirmed by a Registered Nurse who verified that the call light was not accessible to the resident, contrary to the facility's policy that call lights should be within reach of residents while in bed or in a chair. Resident #666, who had hemiplegia, hemiparesis, and multiple diabetes-related conditions, including amputations, reported that his bed was not long enough, causing his left foot to press against the footboard and resulting in pain. Observations confirmed that his left foot was indeed pressed against the footboard on multiple occasions. A Licensed Practical Nurse confirmed the issue and stated that a work order would be put in to get a bed that better fit him. These deficiencies were investigated under Complaint Number OH00152850.
Failure to Ensure Accurate and Consistent Recording of Advanced Directives
Penalty
Summary
The facility failed to ensure that advanced directives were accurately and consistently recorded in the medical record for Resident #43. The resident, who was admitted with diagnoses including spondylosis of the lumbar spine, weakness, diabetes, muscle abscess, peripheral vascular disease, and bacteremia, was found to have no physician order reflecting her wish to be a full code and have all life-sustaining measures implemented. This was confirmed through a review of the resident's medical record and interviews with two Licensed Practical Nurses (LPNs), who were unable to identify the resident's code status. Further investigation revealed that Resident #43 had never been consulted about her code status by the facility staff. During an interview, the resident expressed her desire to be a full code and have all life-sustaining measures implemented. The facility's policy on Advanced Medical Directives stated that the Social Worker should routinely ascertain and document the resident's wishes regarding their code status, but this procedure was not followed in this case.
Failure to Reflect Resident Code Status in Care Plans
Penalty
Summary
The facility failed to ensure care plans reflected resident wishes regarding code status, affecting two residents. For Resident #43, the medical record revealed no physician order or care plan reflecting the resident's wish to be a full code and have all life-sustaining measures implemented. Interviews with two LPNs confirmed the absence of a care plan or physician order for the resident's code status. Additionally, the resident stated that no one at the facility had discussed her code status and wishes with her. The facility's policy requires a comprehensive, person-centered care plan that includes the resident's rights to participate in the development and implementation of their plan of care, which was not followed in this case. For Resident #28, the medical record showed a physician-signed DNR-CC order, but the resident's care plan did not reflect this code status. The DON confirmed that the code status was not included in the care plan, explaining that the facility did not include code statuses in care plans due to frequent changes. The facility's policy mandates that care plans be revised as information about the resident and their conditions change, which was not adhered to in this instance.
Infection Control Breach During Wound Care
Penalty
Summary
The facility failed to ensure proper infection control measures during a wound care dressing change for Resident #296. The resident, who had diagnoses including congestive heart failure, atrial fibrillation, hypertension, acute kidney failure, prostate cancer, and pneumonia, required substantial assistance for bed mobility, toileting, and transfers. During an observation, an LPN gathered supplies and placed them directly on the resident's bed without a protective barrier, performed hand hygiene, applied clean gloves, and removed the old dressing. However, the LPN did not perform hand hygiene or change gloves after removing the old dressing and before cleansing the wound, leading to potential contamination. The LPN placed the old dressing on unused gloves on the bed and used the same gloves to cleanse the wound, which made direct contact with the resident's bed. The facility's policy required the use of a disposable cloth to establish a clean field and changing gloves after removing the old dressing. The LPN was unaware of the errors and was instructed to write a statement after the surveyor explained the infection control breaches. The facility's policy, last revised in October 2010, outlined the correct procedure for wound care, which was not followed in this instance.
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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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