Kirtland Woods Of Journey
Inspection history, citations, penalties and survey trends for this long-term care facility in Kirtland, Ohio.
- Location
- 9685 Chillicothe Rd, Kirtland, Ohio 44094
- CMS Provider Number
- 365290
- Inspections on file
- 30
- Latest survey
- July 29, 2024
- Citations (last 12 mo.)
- 0
Citation history
Health deficiencies cited at Kirtland Woods Of Journey during CMS and state inspections, most recent first.
The facility failed to manage biohazardous materials and handle linen properly, risking infection spread. Observations showed soiled items on floors, dirty fans in the laundry area, and improper transport of clean clothes. Staff confirmed these issues, indicating non-compliance with infection control protocols.
The facility failed to maintain a safe, sanitary, and homelike environment, affecting numerous residents. Observations revealed issues such as sticky floors, unsecured toilet paper holders, and low water levels in toilets with soiled paper. Shared bedrooms and bathrooms had missing handles, protruding screws, and sticky floors. Additional deficiencies included missing window coverings, broken toilet paper holders, and missing baseboards. Bathrooms had dried feces on various surfaces, and some areas had rusted and peeling toilet risers. Maintenance staff confirmed these findings, indicating a lack of timely repairs and cleaning.
The facility did not provide dementia management training for three newly hired STNAs, potentially affecting all 103 residents. The facility's assessment required such training due to the acceptance of residents with neurological and psychiatric disorders, but the training was not completed as confirmed by the HR Director.
The facility failed to store refrigerated medications properly and allowed food items in medication carts. Observations revealed snack items in medication carts and insulin stored without a thermometer in a refrigerator. Additionally, the memory care unit's refrigerator was at a freezing temperature, below the recommended range for insulin and Tuberculin. The facility's policy requires proper storage temperatures, which were not maintained.
The facility failed to provide private closet space for 46 residents, resulting in shared closets without separation for clothing. This issue was confirmed during a facility tour and interview with the MD, affecting numerous resident pairs across the facility.
A facility failed to prevent resident-to-resident abuse involving two residents. One resident with Alzheimer's and dementia exhibited aggressive behavior despite being on multiple medications. The resident was observed hitting another resident, leading to an investigation that confirmed the incident. Staff interviews revealed that the aggressive resident was known to be restless and fidgety, and the incident occurred during a shift with many agency staff.
A facility failed to update a resident's care plan regarding contact lens use. Despite the resident's severe cognitive impairment and a recommendation from an ophthalmologist to avoid contact lenses, the care plan continued to include outdated interventions related to contact lens care. The resident's family agreed to switch to eyeglasses, but the care plan was not revised to reflect this change, as confirmed by the DON and a Regional Resource Nurse.
Two residents received incorrect meal trays due to a mix-up, affecting their dietary needs. One resident on a cardiac diet received a tray meant for another resident, while the second resident, who required a mechanical soft diet, consumed the wrong meal. Both residents expressed dissatisfaction, and a STAT chest x-ray was ordered for one to rule out aspiration.
The facility failed to document fall interventions for a resident with a history of falls and did not maintain accessible vaccination records for two other residents. A resident's care plan indicated a discontinued fall intervention, but the physician order was not updated. Additionally, two residents had incomplete immunization records, with tuberculosis and influenza vaccination statuses not properly recorded.
A resident's bathroom privacy was compromised as the facility used a curtain instead of a door, leaving gaps that allowed visibility from the hallway. The Maintenance Director confirmed the issue during a facility tour.
The facility failed to ensure a clean and homelike environment, affecting all 110 residents. Observations revealed open windows allowing hot air and insects, with torn screens and dirty light fixtures. Interviews confirmed uncertainty about window cleaning responsibilities and issues with soiled mechanical devices. The facility's housekeeping checklist lacked guidance on window cleaning, contributing to continued noncompliance.
A resident with multiple medical conditions was found unable to reach their call light, which was wrapped around the side rail and dangling on the ground. This oversight left the resident unable to request assistance for personal care needs, as confirmed by staff interviews.
A resident with multiple medical conditions, including hemiplegia and diabetes, expressed a preference to be up in her chair before lunch and back in bed by 3:00 P.M. However, staff often did not accommodate this preference, leaving her in the chair through the evening. On the day of observation, the resident was found in bed wearing a stained tee-shirt and an incontinence brief, and her lunch was brought to her room while she was still in bed. A State tested Nurse Aide was unaware of the resident's preferences, as she had not worked that hall in several weeks.
The facility failed to ensure a comfortable ambient temperature, as open windows allowed hot air to enter, affecting a resident who appeared restless due to the heat. Observations confirmed broken window controls and gaps in louvers, with room temperatures reaching 82.9°F. The National Weather Service reported high temperatures during this period.
A resident with severe cognitive impairment and a history of using contact lenses developed conjunctivitis due to the facility's failure to provide comprehensive and individualized eye care. Despite known risks and instructions from an eye physician, the resident continued to use contact lenses without proper management, leading to actual harm.
The facility failed to provide adequate assistance and supervision to prevent falls for two residents. One resident sustained a shoulder fracture due to insufficient staff assistance, and another resident was found on the floor multiple times due to improper bed positioning and lack of a floor mat.
The facility failed to complete annual performance evaluations for nurse aides as required, potentially affecting all 120 residents. Personnel files for three STNAs hired in March and April 2023 showed no evidence of annual performance evaluations. This was confirmed by the HR Business Partner during an interview.
The facility failed to properly store injectable pharmaceuticals by not dating opened containers and not maintaining clean medication storage refrigerators. An undated insulin pen was found in a medication cart for a resident with diabetes, and an undated vial of Tuberculin was found in the Central medication room refrigerator. Both medication room refrigerators had significant ice overgrowth.
The facility failed to serve meals at palatable temperatures, affecting several residents. Observations showed significant drops in food temperatures from the kitchen to the point of service, and multiple residents expressed dissatisfaction with the cold meals.
The facility failed to maintain a clean and sanitary kitchen and nursing unit refrigerators, affecting all residents. Observations included dirty walls, drawers, and dish room, as well as unclean nursing unit refrigerators. The Dietary Manager and a dietary assistant verified these findings, which were not in accordance with the facility's sanitization policy.
The facility failed to complete TB testing for a resident with multiple serious health conditions and did not accurately complete TB testing for five new employees, as required by facility policy and CDC guidelines.
The facility failed to maintain essential laundry equipment, with one washing machine and one dryer being non-functional for extended periods. This caused delays in the turnaround time for residents' clothing, potentially affecting all 120 residents. The issues were confirmed by the Housekeeping Manager and Maintenance Director, who noted difficulties in obtaining parts and indecision about repairs or replacement.
The facility failed to ensure a clean, sanitary, and homelike environment, affecting all 120 residents. Issues included an improperly taped window causing discomfort, persistent urine odor traced to a non-compliant resident's mattress, absence of a closet door, crumbling doorway, water stains, dried bowel movements, worn floor tiles, and a non-functioning paper towel dispenser. Staff acknowledged the issues but did not always take immediate action.
The facility failed to ensure handrails were in good repair, potentially affecting all residents. During an observation, a missing portion of the handrail was noted across from the 300-hall dining/activity area and next to the area where puzzles were kept. The Maintenance Assistant verified the observation and stated he did not know how long it had been that way but would get it fixed.
The facility failed to complete the required 12 hours of annual training for nurse aides, potentially affecting all 120 residents. A review of personnel files for two STNAs revealed no evidence of training. An interview with the HR Business Partner confirmed these findings. The facility policy stated that nurse aides should be competent in necessary skills and techniques.
The facility failed to ensure Resident Fund Authorizations were witnessed, affecting six residents. The Business Office Manager confirmed that the authorization forms had not been witnessed as required.
The facility failed to offer COVID-19 education and vaccination opportunities to five staff members, including an STNA, a cook, two LPNs, and an RN. The immunization status for these staff members was listed as past due, and there was no evidence of education or booster offers. The DON confirmed the lack of information regarding COVID-19 education and vaccination offers.
The facility failed to ensure accurate assessments for multiple residents, including incorrect coding of hospice services, discharge destinations, oral health status, and alarm use. These discrepancies were confirmed through interviews and record reviews, highlighting significant deficiencies in the facility's assessment processes.
The facility failed to provide baseline care plan summaries within 48 hours of admission for four residents, despite having a policy requiring it. The MDS Director confirmed that while the care plans were created, they were not provided to the residents or their responsible parties.
The facility failed to serve a resident finger food items as per physician's orders, resulting in the resident being served inappropriate food items on multiple occasions. Staff confirmed the discrepancies, indicating a failure to adhere to the prescribed dietary requirements.
The facility failed to assess two residents for influenza or pneumonia immunization status upon admission, despite having policies in place that require such assessments. Both residents had tuberculosis testing but lacked information on their immunization status for influenza and pneumonia.
The facility failed to create comprehensive care plans for three residents, neglecting to address PTSD, oral/dental status, and eye care related to contact lenses. This resulted in unaddressed medical needs and complications.
The facility failed to revise the care plan for a resident in a timely manner. Despite the discontinuation of a restorative program due to the resident's inability to participate, the care plan remained unchanged for over a month. This oversight was confirmed by the MDS Director.
The facility failed to provide activities consistently according to the care plan and preferences for a resident with dementia and other conditions. Despite the resident's interest in music, animals, group activities, and religious services, the resident was often found sitting at the nurses' station without engaging in these activities. Staff interviews and observations confirmed systemic issues in ensuring the resident's participation in preferred activities.
The facility failed to implement its abuse prevention policy by not completing job reference checks and timely state nurse aide registry (NAR) checks for new employees. This deficiency was confirmed through a review of personnel files and an interview with the HRBP, potentially affecting all 120 residents.
Inadequate Infection Control in Linen and Biohazard Management
Penalty
Summary
The facility failed to properly manage biohazardous materials and handle clean and soiled linen, which could potentially spread infection among residents. Observations revealed a feces-soiled pillowcase on the bathroom floor shared by four residents, and soiled linens placed on the laundry room floor due to a non-functioning washer. Additionally, dirty fans were found in the clean laundry area, blowing air toward clean linens, which could contaminate them. Interviews with staff confirmed these findings, indicating a lack of adherence to infection control protocols. Further observations showed a laundry worker delivering clean clothes without a proper covering, using a thin sheet that inadequately protected the clothes from contamination. In another instance, soiled linen was found on a resident's bathroom floor, and biohazardous red bags containing soiled linen and a disposable gown were improperly stored in a shared bathroom. The facility's policy on handling soiled laundry and bedding was not followed, as it required protection of clean linen from dust and soiling during transport and storage.
Facility Fails to Maintain Safe and Sanitary Environment
Penalty
Summary
The facility failed to maintain a safe, sanitary, and homelike environment, affecting 48 residents and potentially impacting all 103 residents. Observations revealed numerous issues, including sticky floors, unsecured toilet paper holders, and low water levels in toilets with soiled paper. Shared bedrooms and bathrooms had missing handles, protruding screws, and sticky floors. Interviews with staff confirmed these findings, indicating a lack of proper maintenance and cleanliness. Further observations highlighted additional deficiencies, such as missing window coverings, broken toilet paper holders, and missing baseboards in the memory care unit. Residents complained about bright lights at night due to the lack of window coverings. The facility's administrator acknowledged that repairs were planned but had been delayed since May 2024. Housekeeping staff confirmed the presence of broken toilet paper holders and the placement of toilet paper rolls in inappropriate locations. Additional issues included missing or malfunctioning closet doors, exposed screws, and broken light fixtures. Bathrooms had dried feces on various surfaces, and some areas had rusted and peeling toilet risers. The laundry room contained a blanket stuffed between dryers, covered in lint and debris, which was placed there due to concerns about critters. Maintenance staff confirmed these findings, indicating a lack of timely repairs and cleaning, contributing to an unsafe and unsanitary environment.
Lack of Dementia Management Training for Nurse Aides
Penalty
Summary
The facility failed to provide dementia management training for three State Tested Nursing Assistants (STNAs) after their hire, which had the potential to affect all 103 residents residing in the facility. The personnel files for STNA #485, #496, and #503, who were hired on 06/12/24, 06/26/24, and 07/10/24 respectively, showed no evidence of completed dementia management training. An interview with the Human Resource Director confirmed that the required training was not provided to these STNAs. The facility's assessment, effective from January 2024 through December 2024, indicated that the facility accepted residents with neurological and psychiatric mood disorders and provided special treatments for behavioral health needs, cognitive loss, and dementia. The assessment required that staff, including nurse aides, receive dementia management training, which was not fulfilled in these cases.
Improper Storage of Medications and Food in Medication Carts
Penalty
Summary
The facility failed to properly store refrigerated medications and ensure that food items were not stored inside medication carts. During an observation, it was found that the east long medication cart contained snack-sized packages of cookies, and the central medication cart contained snack-sized containers of applesauce and pudding. Additionally, the central medication room refrigerator lacked a thermometer and contained insulin pens and vials for two residents. The Unit Manager verified these findings during the observation. Further observations revealed that the memory care unit medication room refrigerator had a freezing point temperature of 32 degrees Fahrenheit, which is below the recommended storage temperature for insulin and Tuberculin. The refrigerator contained insulin pens for two residents and vials of Tuberculin used for residents and staff. The temperature log for the refrigerator showed daily checks with a maintained temperature of 35 degrees Fahrenheit, except for one day when no temperature check was recorded. The FDA guidelines recommend storing insulin and Tuberculin at 36 to 46 degrees Fahrenheit, and they should not be frozen. The facility's policy on medication storage, revised in November 2020, requires drugs and biologicals to be stored under proper temperatures.
Deficiency in Private Closet Space for Residents
Penalty
Summary
The facility failed to provide private closet space separate from roommates' clothing for 46 residents out of 103 rooms reviewed. During a facility tour, it was observed that several pairs of residents were sharing a single closet without separation for their clothing. This deficiency was confirmed through observations and an interview with the Maintenance Director. The affected residents were identified by room numbers, indicating a widespread issue across the facility.
Failure to Prevent Resident-to-Resident Abuse
Penalty
Summary
The facility failed to prevent resident-to-resident abuse, affecting two residents. Resident #104, who had diagnoses including Alzheimer's disease and dementia with agitation, was admitted for a respite stay. The resident exhibited severely impaired cognition and various behavioral symptoms, including physical and verbal aggression. Despite being on multiple medications for behavior management, Resident #104 continued to display agitation and restlessness, frequently wandering into other residents' rooms and touching them. The facility's care plan included interventions such as medication administration, redirection, and monitoring, but these measures were ineffective in preventing the resident's aggressive behavior. On the night of the incident, Resident #104 was observed being physically aggressive towards Resident #41, hitting her in her room. Staff intervened, but Resident #104 became combative, striking staff with a dry erase board and attempting to cover Resident #41's head with a pillow. Although Resident #41 was assessed and found to have a small red mark under her eye, she did not exhibit signs of distress or recall the incident. The facility's investigation confirmed the occurrence of the incident, and Resident #104 was sent to the hospital for evaluation. Interviews with staff revealed that Resident #104 was known to be restless and fidgety, often touching everything and everyone around him. The incident occurred during a shift with a high number of agency staff, which may have contributed to the lack of effective intervention. Despite previous reports of increased agitation and restlessness, the facility did not implement adequate measures to prevent the resident's aggressive behavior, resulting in the deficiency.
Failure to Update Care Plan for Resident's Contact Lens Use
Penalty
Summary
The facility failed to adequately update the care plan for a resident regarding the use of contact lenses. The resident, who had severe cognitive impairment and a history of rejecting care, was initially prescribed to have contact lenses removed every evening. However, this order was discontinued, and the resident's contact lens was eventually removed by an eye doctor. Despite the recommendation from the ophthalmologist to avoid using contact lenses and the family's agreement to switch to eyeglasses, the care plan was not updated to reflect these changes. The care plan still included interventions related to contact lens care, such as documenting refusals, family assistance with placement and cleaning, and other maintenance instructions, even though the resident was no longer wearing contact lenses. The Director of Nursing and Regional Resource Nurse confirmed that the care plan goals had changed, but the care plan itself did not reflect the updated care approach. This oversight affected the resident's care and was identified during a review of the facility's care plan revision process.
Dietary Errors Affect Two Residents
Penalty
Summary
The facility failed to provide food in the correct form to two residents, which had the potential to affect all 48 residents on the 300 unit. Resident #10, who was cognitively intact and on a cardiac diet with regular texture and thin liquids, received the wrong diet tray at lunchtime. The resident complained about not receiving her lunch tray and was later given Resident #11's tray, which included items not suitable for her cardiac diet. Despite the error, Resident #10 did not experience any issues consuming the meal, but she expressed dissatisfaction with the utensils and the meal content. Resident #11, who was cognitively impaired and on a mechanical soft texture diet with specific adaptive equipment, received and consumed the wrong diet tray intended for Resident #10. The resident's tray was supposed to include pureed corn and a grilled cheese sandwich, but instead, it contained a hamburger and other items not aligned with his dietary needs. The resident consumed most of the meal without issues but complained about the missing grilled cheese. A STAT chest x-ray was ordered to rule out aspiration, and the guardian was notified of the incident.
Documentation Failures in Fall Interventions and Immunization Records
Penalty
Summary
The facility failed to accurately document fall interventions for a resident and maintain accessible vaccination records for two other residents. For Resident #62, who had a history of muscle weakness and repeated falls, a physician order required a floor mat to be placed at the left bedside. However, during an observation, it was noted that the mat was not present, and the nursing assistant confirmed it was not listed on the Kardex. The care plan indicated that the intervention was discontinued, but the physician order was not updated to reflect this change, leading to a discrepancy in the resident's care documentation. For Residents #97 and #102, the facility did not maintain complete and accessible immunization records. Resident #97's records showed incomplete documentation of tuberculosis testing and refusal of the Pneumococcal vaccine, with the second step of the tuberculosis test recorded in different places. Resident #102's records lacked information on the influenza immunization status, although the facility had located the information but failed to enter it correctly. These documentation lapses affected the accuracy and accessibility of the residents' medical records.
Inadequate Bathroom Privacy Due to Curtain
Penalty
Summary
The facility failed to provide adequate privacy for a resident's bathroom by using a curtain instead of a door. During a facility tour, it was observed that the bathroom entrance of a resident's room was covered with a full-length curtain on a rod, which extended two to three inches away from the wall. This setup left a wide gap on both sides of the curtain, allowing visibility into the bathroom from the hallway when the bedroom door was open. The Maintenance Director confirmed these findings during the observation.
Facility Fails to Maintain Clean and Sanitary Environment
Penalty
Summary
The facility failed to maintain a clean, sanitary, and homelike environment, affecting all 110 residents. Observations on the East wing revealed open windows allowing hot air and insects to enter, with grayish-black spots on window seals, tears in screens, and dead insects on windowsills. Light fixtures contained dark spots resembling insects, and the common sitting area had windows with detached or torn screens, dead insects, dust, debris, and black and gray spots around the seals. A thick yellow substance was splashed and dried on the walls near a table and trash can. Interviews with Housekeeper #398 confirmed the presence of hot air, broken blinds, greasy substances, and dead insects, with uncertainty about who was responsible for window cleaning. The window near room [ROOM NUMBER] had gaps between glass louvers, allowing insects and outside temperatures to affect the hallway. STNA #397 verified the heat and insects near the window, and Shower Room C had a foul odor, hair, lint, and standing water with black flecks. Maintenance Director #357 confirmed these issues, including broken window controls, torn screens, and dirty light covers. Two sit-to-stand mechanical devices in the East-2 wing were soiled, with missing handle grips and caked-on substances. RN #326 confirmed the need for cleaning, stating it should occur on night shifts or after use with residents in isolation. Interviews with STNAs #359 and #353 confirmed night staff were responsible for cleaning equipment. The facility's housekeeping checklist did not address window cleaning, contributing to the continued noncompliance noted in a previous survey.
Failure to Ensure Call Light Accessibility for Resident
Penalty
Summary
The facility failed to ensure that call lights were within reach for residents, specifically affecting one resident. This resident, who had multiple medical conditions including visual hallucinations, hemiplegia, and diabetes, was admitted with a care plan that required assistance with incontinence care and ensuring the call light was accessible when in bed. During an observation, the resident was found in bed with a call light wrapped around the bottom of the side rail and dangling on the ground, making it unreachable. The resident expressed discomfort and the inability to call for assistance since early morning, highlighting the lack of adherence to the care plan. Interviews with staff confirmed the deficiency. A registered nurse acknowledged that the call light was not within reach and took steps to rectify the situation by providing the resident with the call light. A state-tested nurse aide admitted to being unaware of the resident's needs and confirmed the improper placement of the call light. This oversight resulted in the resident being unable to request necessary assistance, such as adjusting the air conditioner, changing incontinence briefs, and receiving help to get into a chair before lunch.
Failure to Honor Resident's Choice for Daily Routine
Penalty
Summary
The facility failed to honor the choices of Resident #86, who was one of five residents reviewed for choices. Resident #86 had a medical history that included visual hallucinations, hemiplegia, type two diabetes mellitus, asthma, and other conditions, and required maximal assistance for transfers and was dependent for toileting and bathing. The resident expressed a preference to be up in her chair before lunch and back in bed by 3:00 P.M., but staff often did not accommodate this preference, leaving her in the chair through the evening due to being busy or handing her off to the next shift. On the day of observation, Resident #86 was found in bed wearing a stained tee-shirt and an incontinence brief, and her lunch was brought to her room while she was still in bed. It was observed that a State tested Nurse Aide (STNA) was unaware of Resident #86's preferences and had not been informed of them, as she had not worked that hall in several weeks. The facility's policy on Resident Rights, revised in February 2021, stated that residents had the right to self-determination and a dignified existence, which was not upheld in this instance.
Facility Fails to Maintain Safe Ambient Temperature
Penalty
Summary
The facility failed to maintain a comfortable and safe ambient temperature for its residents, as evidenced by observations and interviews conducted on the East wing. On multiple occasions, windows were found open, allowing hot air to enter the building. Housekeeper #398 confirmed that the windows had screens that were loose and torn, and the glass louvers had gaps between them, which allowed hot air to flow into the facility. The knob to control the louvers was also broken, exacerbating the issue. Maintenance Director #357 acknowledged that several windows were open on hot days and confirmed the broken control knob and gaps between the louvers. Resident #73 was directly affected by this deficiency. Observations revealed that the resident appeared restless and was trying to remove her clothing due to the uncomfortable heat in her room. The window above her bed was open, and hot air was blowing into the room, which registered an ambient temperature of 82.9 degrees Fahrenheit. The Maintenance Director confirmed the room temperature was inappropriate and noted the absence of a window air conditioner. The National Weather Service reported high temperatures and heat indices during this period, further highlighting the facility's failure to provide a safe and comfortable environment for its residents.
Failure to Provide Adequate Eye Care
Penalty
Summary
The facility failed to provide comprehensive, individualized, and sufficient eye care for Resident #104, who was admitted with severe cognitive impairment and a history of using contact lenses. Despite the resident's known refusal to remove contact lenses for regular washing, the care plan did not include any focus on eye care or the management of contact lenses. This oversight led to the resident developing conjunctivitis, requiring antibiotic treatment due to the lack of routine eye care. The medical record review revealed that Resident #104 had a contact lens in the right eye since admission, which was not removed until an eye physician's visit on 12/04/23. Despite instructions from the eye physician to prevent the resident from wearing contact lenses, the resident continued to use them, and staff failed to document or follow up on this issue adequately. The resident's care plan was not updated to reflect the risks associated with contact lens use, and there was no evidence of ongoing education for the resident or family regarding these risks. Interviews with staff and family members indicated that attempts to remove the contact lens were unsuccessful, and there was a lack of communication and documentation regarding the resident's eye condition. The resident's right eye became red, swollen, and painful, leading to a diagnosis of acute conjunctivitis. The facility's failure to provide appropriate eye care and follow-up resulted in actual harm to the resident, highlighting significant deficiencies in the management of the resident's eye care needs.
Failure to Prevent Falls and Implement Fall Interventions
Penalty
Summary
The facility failed to provide adequate assistance, supervision, and assistive devices to prevent falls for two residents. Resident #57, who was moderately cognitively impaired and required two staff members for bed mobility, sustained a fall and a right shoulder fracture when only one staff member was providing care. The staff member did not follow the Kardex instructions, which indicated that two staff members were required for bed mobility. The resident's care plan had been updated to reflect the increased risk of injury due to osteoporosis, but the intervention was not followed, leading to the fall and subsequent injury. Resident #101, who had impaired cognition and was at risk for falls, was found kneeling on the floor next to the bed after attempting to pick up a dropped pill. Despite the care plan and Kardex indicating that the bed should be kept in the lowest position and a floor mat should be placed next to the bed, multiple observations revealed that these interventions were not consistently implemented. The resident's bed was often found in a high position, and the floor mat was not in place, increasing the risk of falls. The facility's policy on falls and accidents aimed to provide an environment free from accident hazards and to ensure supervision and assistive devices were used to prevent avoidable accidents. However, the facility failed to consistently implement these interventions, resulting in actual harm to Resident #57 and potential harm to Resident #101. The lack of adherence to the care plans and Kardex instructions contributed to the deficiencies observed during the survey.
Failure to Complete Annual Nurse Aide Performance Evaluations
Penalty
Summary
The facility failed to complete annual performance evaluations for nurse aides as required, potentially affecting all 120 residents. Personnel files for three State Tested Nursing Assistants (STNAs) hired in March and April 2023 showed no evidence of annual performance evaluations. This was confirmed by the Human Resource Business Partner during an interview. The facility's policy on staff competency, dated December 31, 2023, mandates that nurse aides must be competent in skills and techniques necessary to care for residents' needs.
Improper Storage and Labeling of Injectable Pharmaceuticals
Penalty
Summary
The facility failed to properly store injectable pharmaceuticals by not dating opened containers and not maintaining clean medication storage refrigerators. This was observed in two of four medication rooms and one of six medication carts, affecting one resident and potentially impacting all 120 residents in the facility. Specifically, an opened and undated insulin pen (Humalog KwikPen) was found in a medication cart for a resident with diabetes mellitus type II, and an opened and undated vial of Tuberculin purified protein derivative (Tubersol) was found in the Central medication room refrigerator. Both the [NAME] and Central medication room refrigerators had significant ice overgrowth due to lack of defrosting. The Director of Nursing (DON) confirmed these findings during the observation. The facility's policy on medication storage, revised in November 2020, mandates that nursing staff maintain medication storage and preparation areas in a clean, safe, and sanitary manner, and that discontinued, outdated, or deteriorated drugs or biologicals be returned to the dispensing pharmacy or destroyed. The deficiency was investigated under Master Complaint Number OH00153331.
Failure to Serve Meals at Palatable Temperatures
Penalty
Summary
The facility failed to ensure meals were served at palatable temperatures, affecting four residents and potentially all residents receiving food from the kitchen. Resident interviews revealed complaints about the food being served cold. Observations showed that the food temperatures were significantly lower when served compared to when they were taken from the steam table. For instance, the barbeque beef riblet temperature dropped from 188 degrees Fahrenheit to 97 degrees Fahrenheit, and the baked beans from 160 degrees Fahrenheit to 75 degrees Fahrenheit. The Dietary Manager verified the low temperatures and confirmed that the food was not to her liking. Multiple residents expressed dissatisfaction with the temperature of their meals, stating that the food was not hot when received.
Failure to Maintain Clean and Sanitary Kitchen and Refrigerators
Penalty
Summary
The facility failed to ensure a clean and sanitary kitchen and nursing unit refrigerators, which had the potential to affect all residents. During an initial tour of the kitchen, several deficiencies were observed, including an opened bulk bag of panko sitting on the floor, dirty walls with dried food splatter, and dirty drawers containing serving utensils. The dish room had a malodorous smell with gnats flying around a bucket with dirty rags, and various food crumbs and debris were found underneath the dish machine. The Dietary Manager verified these findings and mentioned that the odor was related to a plumbing issue for which a plumber had been called. Further observations revealed that the nursing unit refrigerators were also not maintained in a clean and sanitary manner. The freezer in one unit had a moderate amount of frozen spillage, while another refrigerator had dried spillage and food debris on the shelves. The memory care unit's refrigerator was missing a grill and contained various trash and debris, including an empty juice cup and food crumbs. Additionally, a dietary assistant was observed using a napkin to wipe off spillage from a pan and table, which was not in accordance with sanitary practices. The facility's policy on sanitization, revised in November 2022, stated that the food service area should be maintained in a clean and sanitary manner, which was not adhered to in these instances.
Failure to Complete TB Testing for Resident and New Employees
Penalty
Summary
The facility failed to complete admission testing for tuberculosis (TB) for Resident #419, who was admitted with multiple serious health conditions including stroke, atrial fibrillation, congestive heart failure, chronic kidney disease, heart disease, dementia, multiple myeloma, and diabetes. Despite the facility's policy requiring TB screening for all new admissions, there was no documented evidence of TB testing for Resident #419. The Director of Nursing confirmed the absence of TB testing documentation and provided a CT scan from the hospital that noted lung nodules without specifying their type. Additionally, the facility did not accurately complete TB testing for five new employees, including the Maintenance Director, two LPNs, the Human Resource Business Partner, and the Assistant Director of Nursing. The personnel files either lacked evidence of TB screening or showed incomplete two-step TB testing, with the second step not read within the required 48-to-72-hour timeframe. The facility's policy and CDC guidelines mandate TB screening and testing for all new hires, but these procedures were not followed, as confirmed by the Human Resource Business Partner.
Failure to Maintain Essential Laundry Equipment
Penalty
Summary
The facility failed to ensure that essential laundry equipment, specifically washers and dryers, were in good repair, potentially affecting all 120 residents. Observations revealed that one of three washing machines and one of four dryers were not operational. The non-functional washing machine, dedicated to residents' clothing, had been down for about seven months, causing delays in the turnaround time for residents' clothing from an eight-hour shift to 24 hours or longer. The Housekeeping Manager confirmed the issues and noted that parts for the old washing machine were obsolete, and there had been discussions about replacing it, but no further action had been taken. Additionally, one dryer had been down off and on, and another dryer had not been hooked up for a long time. The Maintenance Director corroborated the Housekeeping Manager's statements, adding that corporate had initially wanted to repair the washing machine, but the cost was nearly the same as replacing it. The Maintenance Director was unsure about the current status of the payment for the repairs or replacement. The last administrator had seemingly decided to replace the washing machine, but no further steps had been taken. The contractor had also indicated that continuing to repair the old machines would be difficult due to the unavailability of parts. This deficiency was investigated under Master Complaint Number OH00153331 and Complaint Number OH00153001.
Facility Fails to Maintain Clean and Homelike Environment
Penalty
Summary
The facility failed to ensure a clean, sanitary, and homelike environment, affecting all 120 residents. Resident #59 reported a breeze from an improperly taped window, causing discomfort at night. Observations confirmed the plastic covering was not securely taped. Additionally, there was a persistent odor of urine near the 100-hall nursing station, which was traced to Resident #6's room. The resident was non-compliant with incontinence care, and the odor was believed to be coming from the mattress, which had not been reported to management. Resident #43 also reported the absence of a closet door, which was confirmed during the observation. Further observations revealed multiple maintenance and cleanliness issues throughout the facility. The beauty shop doorway was crumbling, and there were water stains on ceiling tiles near the 300-hall dining/activity area. Resident #66's bathroom had dried bowel movement on the toilet riser, and Resident #72's room had corroded wooden drawers and smeared bowel movement in the bathroom. Resident #67's room had worn floor tiles and a dirty bathroom. The paper towel dispenser in Resident #7's room was not functioning, and a room under construction was found in disrepair with various items scattered on the floor. Interviews with staff confirmed these observations, with housekeeping and maintenance staff acknowledging the issues but not always taking immediate action. Housekeeping procedures for daily cleaning were reviewed, but the facility failed to maintain a clean and homelike environment as required. The deficiency was investigated under multiple complaint numbers, highlighting the widespread nature of the issues within the facility.
Handrails in Disrepair
Penalty
Summary
The facility failed to ensure handrails were in good repair, which had the potential to affect all residents. During an observation on 04/25/24 at 11:13 A.M., a missing portion of the handrail was noted across from the 300-hall dining/activity area and next to the area where puzzles were kept. The Maintenance Assistant (MA) verified the observation and stated he did not know how long it had been that way but would get it fixed. This deficiency was investigated under Master Complaint Number OH00153331 and Complaint Number OH00153001.
Failure to Complete Required Annual Training for Nurse Aides
Penalty
Summary
The facility failed to complete the required 12 hours of annual training for nurse aides, which had the potential to affect all 120 residents residing in the facility. A review of the personnel files for two State tested Nursing Assistants (STNAs) revealed that neither had completed any training toward the required minimum of 12 hours annually. One STNA was hired on 03/14/23, and the other on 04/25/23, with no evidence of training documented for either. An interview with the Human Resource Business Partner confirmed these findings. The facility policy titled Staff Competency, dated 12/31/23, stated that the facility would ensure nurse aides were competent in skills and techniques necessary to care for residents' needs. This deficiency was investigated under Complaint Number OH00153001.
Failure to Witness Resident Fund Authorizations
Penalty
Summary
The facility did not ensure Resident Fund Authorizations were witnessed, affecting six residents. A review of the authorization forms for these residents revealed that none had been witnessed as required. During an interview, the Business Office Manager confirmed that the facility had not had the Resident Fund Account authorization forms witnessed.
Failure to Provide COVID-19 Education and Vaccination Opportunities to Staff
Penalty
Summary
The facility failed to offer COVID-19 education and vaccination opportunities to five staff members, including a State Tested Nursing Assistant (STNA), a cook, two Licensed Practical Nurses (LPNs), and a Registered Nurse (RN). The review revealed that there was no evidence of education being provided or the vaccine being offered to these staff members, particularly when booster doses became available. The immunization status for these staff members was listed as past due, indicating a lapse in the facility's compliance with COVID-19 vaccination protocols. Specifically, the STNA's immunization dates were recorded, but there was no evidence of education or booster offers. The cook, hired in March 2023, had no information regarding education or vaccination offers. One LPN had an immunization date but no evidence of further education or booster offers, while another LPN had no evidence of education or booster offers despite being immunized. The RN, hired in January 2024, also had no evidence of education or vaccination offers upon hire. The Director of Nursing confirmed the lack of information regarding COVID-19 education and vaccination offers for these employees.
Inaccurate Resident Assessments
Penalty
Summary
The facility failed to ensure accurate assessments for multiple residents, as evidenced by discrepancies in the Minimum Data Set (MDS) 3.0 assessments. For instance, Resident #62, who was admitted with diagnoses including dementia and Alzheimer's disease, was incorrectly coded in the MDS assessment as not receiving hospice services despite being on hospice care. This error was confirmed by the MDS Director during an interview. Similarly, Resident #114's discharge MDS assessment was inaccurately coded as a discharge to a short-term general hospital, whereas the resident had actually moved out of state to live with a friend. This mistake was also acknowledged by the MDS Director upon review. Additionally, Resident #37's oral health evaluation was inaccurately documented, failing to note the resident's missing upper dentures, which were reported lost by the resident and confirmed through interviews with staff and the resident herself. The MDS Director admitted that the oral evaluation was not accurately assessed. Furthermore, the facility incorrectly coded the use of alarms for multiple residents in the memory care unit. The MDS assessments for these residents indicated daily use of alarms, but there was no evidence in the medical records to support this. The MDS Coordinators verified that the coding was based on the presence of alarmed entrance and exit doors in the memory care unit, which is not in accordance with the MDS 3.0 Resident Assessment Instrument User's Manual guidelines. This widespread inaccuracy in resident assessments highlights significant deficiencies in the facility's assessment processes.
Failure to Provide Baseline Care Plan Summaries
Penalty
Summary
The facility failed to provide residents with a summary of their baseline care plan within 48 hours of admission, affecting four residents out of 32 reviewed. Resident #105, admitted with multiple severe diagnoses including dementia with severe agitation and congestive heart failure, did not receive a summary of his baseline care plan within the required timeframe. The Minimum Data Set (MDS) Director confirmed that the baseline care plan was entered into the electronic record but not provided to the resident or his responsible party. Similar deficiencies were found for Resident #114, who was admitted with conditions such as hypotension and epilepsy, and was discharged to the hospital without receiving a summary of the baseline care plan. The MDS Director acknowledged the omission in both cases. Additionally, Resident #418, admitted with dementia and high blood pressure, and Resident #419, admitted with a stroke and chronic kidney disease, also did not receive their baseline care plan summaries within 48 hours of admission. The MDS Director confirmed that while the baseline care plans were created, they were not provided to the residents or their responsible parties. The facility's policy, last revised in March 2022, mandates that a baseline care plan be developed within 48 hours of admission and that a written summary be provided to the resident or their responsible party, which was not adhered to in these cases.
Failure to Provide Finger Food Diet as Ordered
Penalty
Summary
The facility failed to ensure that Resident #70 was served finger food items as per the physician's orders. Resident #70, who had diagnoses including dementia, schizoaffective disorder, and alcohol-induced persisting dementia, was observed on multiple occasions being served food items that did not meet the finger food diet requirements. For instance, on 04/23/24, Resident #70 was served strawberries in a liquid, which spilled down his hand and arm as he attempted to eat them. Additionally, on 04/24/24, Resident #70 was served baked beans instead of the prescribed frozen green beans for the finger food diet. Further, on 04/29/24, Resident #70 was found with a strip of bacon and a white food substance resembling hot cereal in his wheelchair, indicating he had been served oatmeal instead of finger food cereal as required by his diet plan. Interviews with staff, including a State Tested Nurse Aide (STNA) and the Dietary Manager (DM), confirmed that the food items served did not comply with the finger food diet. The DM acknowledged that the strawberries should have been drained and that the hot cereal should have been replaced with finger food cereal options like Cheerios or flakes. These observations and interviews highlight the facility's failure to adhere to the prescribed dietary requirements for Resident #70, potentially impacting his nutritional intake and overall well-being.
Failure to Assess Immunization Status Upon Admission
Penalty
Summary
The facility failed to assess residents for influenza or pneumonia immunization status upon admission, affecting two residents out of 17 reviewed for new admission. Resident #104, admitted with multiple diagnoses including high blood pressure, stroke, dementia, and chronic obstructive pulmonary disease, was found to have no information on influenza or pneumonia immunization status despite having tuberculosis testing upon admission. The Director of Nursing (DON) confirmed the lack of immunization information for Resident #104. Similarly, Resident #105, admitted with diagnoses such as dementia with severe agitation, chronic obstructive pulmonary disease, atrial fibrillation, and diabetes, also had no information on influenza or pneumonia immunization status, although tuberculosis testing was conducted upon admission. The DON confirmed the absence of immunization information for Resident #105. The facility's policies on influenza and pneumococcal vaccines, last revised in March 2022, were reviewed and indicated that all residents should be encouraged to receive these vaccines unless contraindicated, but these policies were not followed in these cases.
Failure to Formulate Comprehensive Care Plans
Penalty
Summary
The facility failed to formulate comprehensive care plans to include all necessary goals of care for three residents. Resident #21, who had multiple diagnoses including PTSD, did not have a care plan addressing PTSD. The MDS Director confirmed that no care plan was initiated for this diagnosis despite the resident having an intact cognition and PTSD listed as a diagnosis in the Admission MDS assessment. Resident #37, who required assistance with personal care and had protein-calorie malnutrition, congestive heart failure, and type II diabetes mellitus, also lacked a care plan for her oral/dental status. Despite having missing teeth and losing her upper dentures, which she reported to the staff, no care plan was initiated to address these issues. The MDS Director verified that the oral evaluation was incomplete and did not reflect the resident's actual dental condition. Resident #104, diagnosed with dementia with psychotic disturbance, aphasia, and other conditions, did not have a care plan focusing on eye care or the care of contact lenses. The resident had a history of refusing to remove contact lenses, which led to complications. Despite multiple progress notes and family concerns about the resident's eye condition, no care plan was initiated to address the risks associated with the use of contact lenses. The MDS Directors confirmed that no care planning was completed for eye care until after surveyor intervention.
Failure to Revise Care Plan in a Timely Manner
Penalty
Summary
The facility failed to revise the care plan for a resident in a timely manner. Resident #62, who was admitted with diagnoses including dementia with behaviors, Alzheimer's disease, high blood pressure, legal blindness, schizophrenia, and a stroke, was admitted to hospice services for vascular dementia with cerebral vascular disease. The resident was severely cognitively impaired, rarely understood, and demonstrated physical and verbal behaviors towards others. She was dependent on staff for all care. On 03/12/24, her restorative program for upper and lower range of motion exercises was discontinued due to her inability to actively participate in the program. However, the care plan for the restorative program remained unchanged as of 04/22/24 when the survey process began, despite the program being discontinued over a month earlier. This oversight was confirmed by the MDS Director during an interview on 04/24/24 at 11:21 A.M.
Failure to Provide Consistent Activities According to Care Plan
Penalty
Summary
The facility failed to ensure that activities were provided consistently according to the care plan and resident preferences for Resident #70. Resident #70, who had diagnoses including dementia with behavioral disturbance, schizoaffective disorder, anxiety disorder, muscle weakness, and schizophrenia, had a care plan that emphasized the importance of activities such as listening to music, being around animals, participating in group activities, going outside for fresh air, and attending religious services. Despite these preferences, the activity logs for April 2024 revealed that Resident #70 did not attend any church services or music-related activities, which were important to him as per his care plan and MDS assessment. Observations confirmed that Resident #70 was often found sitting at the nurses' station without engaging in any activities that matched his preferences. Interviews with staff and the Activity Director (AD) indicated that there were systemic issues in ensuring Resident #70's participation in activities. The AD mentioned that she often did not receive assistance from other staff to take residents to activities and that Resident #70 was frequently kept at the nurses' station. The AD also confirmed that there was no TV or music playing at the nurses' station, which further limited Resident #70's engagement in preferred activities. Additionally, the AD noted that the live entertainment scheduled for 04/29/24 was moved to an earlier time, and Resident #70 did not attend because he was likely in bed at that time. The facility's policy on activity programs, which aims to meet the interests and support the physical, mental, and psychosocial well-being of each resident, was not adhered to in the case of Resident #70. The deficiency was identified under Complaint Numbers OH00153001, highlighting the facility's failure to provide activities consistently according to the care plan and resident preferences, thereby affecting the resident's overall well-being and quality of life.
Failure to Implement Abuse Prevention Policy
Penalty
Summary
The facility failed to implement its policy and procedure for the prevention of abuse by not completing job reference checks and documenting timely state nurse aide registry (NAR) checks for new employees. This deficiency was identified through a review of personnel files for multiple staff members, including State Tested Nursing Assistants (STNAs), a receptionist, a registered nurse (RN), a maintenance director (MD), a director of nursing (DON), a unit manager licensed practical nurse (LPN), a human resource business partner (HRBP), and an assistant director of nursing (ADON). In each case, there was either no evidence of completed job reference checks or the NAR checks were not dated, indicating they may not have been conducted in a timely manner. The HRBP confirmed these findings during an interview, verifying the accuracy of the documentation review. The facility's policy, titled 'Freedom from Abuse and Neglect Policy,' mandates pre-employment screening, including reference checks and registry checks, to prevent the hiring of individuals with a history of abuse or neglect. However, the facility did not adhere to this policy, potentially affecting all 120 residents residing in the facility.
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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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