Laurels Of Huber Heights The
Inspection history, citations, penalties and survey trends for this long-term care facility in Huber Heights, Ohio.
- Location
- 5440 Charlesgate Road, Huber Heights, Ohio 45424
- CMS Provider Number
- 365627
- Inspections on file
- 39
- Latest survey
- January 20, 2026
- Citations (last 12 mo.)
- 4
Citation history
Health deficiencies cited at Laurels Of Huber Heights The during CMS and state inspections, most recent first.
A cognitively intact resident with multiple comorbidities, including ESRD on dialysis and an infected back surgical wound, experienced a change in wound status with purulent and bloody drainage documented by nursing staff. Wound care was provided per existing orders, but the RN did not document notifying the physician or the resident’s representative of this new development. The wound physician later reported being unsure if he had been notified, and the DON confirmed that no notification was recorded, despite facility policy requiring practitioner and representative notification for changes in status.
Two residents admitted with significant wounds did not receive timely wound assessments or prompt initiation of treatment. In both cases, initial nursing assessments lacked measurements and detailed descriptions of wounds, and comprehensive evaluations were delayed by several days. Although physician orders for wound care were eventually obtained and treatments administered, the facility did not follow its policy requiring immediate documentation and intervention for skin impairments upon admission.
A resident with multiple comorbidities was admitted with several skin impairments, but the facility did not complete a full pressure ulcer assessment or initiate wound treatment in a timely manner. Documentation showed that wounds were not measured or described upon admission, and treatment was delayed until several days later, contrary to facility policy requiring prompt evaluation and intervention.
An LPN was observed handling oral medications with bare hands before administering them to a resident with multiple chronic conditions. This action was not in accordance with the facility's infection control and medication administration policies, which require hand hygiene and prohibit direct hand contact with medications.
Two residents receiving TPN had their Medication Administration Records signed by LPNs, despite TPN administration being outside the LPN scope of practice. Interviews confirmed LPNs did not administer the TPN but documented as if they had, contrary to facility policy and state regulations.
Staff did not follow enhanced barrier precautions during wound care for a resident with multiple wounds and severe cognitive impairment. Despite clear signage and care plan instructions requiring the use of gloves and gowns for high-contact care, an LPN, a CNA, and a wound physician performed wound care activities without donning gowns. All involved staff later acknowledged the lapse, and the DON confirmed the absence of proper PPE storage outside the room.
A resident with multiple health conditions and severe cognitive impairment was assessed as an unsafe smoker and expressed a desire to smoke. The facility's policy required supervision for unsafe smokers, but the DON confirmed that no supervised smoking was offered, effectively prohibiting the resident from smoking. This was contrary to the facility's policy, leading to a deficiency in honoring the resident's smoking rights.
The facility failed to follow its abuse policy by not reporting allegations of abuse and neglect in a timely manner, not suspending accused staff, and delaying investigations. A resident with quadriplegia reported aggressive behavior by a nurse, and another resident was involved in an allegation of medication withholding. The facility did not document staff education on abuse prevention, contrary to its policy.
The facility failed to report allegations of abuse to the state agency in a timely manner, affecting two residents. One resident reported concerns about staff behavior, including an incident with a nurse described as aggressive. Despite a complaint from the insurance company, no investigation was initiated. Another resident was involved in an incident where a nurse allegedly threatened to withhold medications, but the investigation was delayed. The facility did not adhere to its policy on abuse prohibition, resulting in a deficiency.
The facility failed to conduct timely investigations and protect residents during abuse allegations. A resident reported concerns about staff behavior, including an incident with a nurse, but the facility did not initiate an investigation or suspend the accused nurse. Another resident was involved in an incident where a nurse allegedly threatened to withhold medications, but the facility delayed the investigation. The facility did not follow its policy requiring immediate investigation and suspension of accused staff.
A resident with severe cognitive impairment, assessed as an unsafe smoker, was able to access and smoke a lit cigarette butt unsupervised, resulting in a small burn on their thigh. The facility's policy required supervision and control of smoking materials for unsafe smokers, but the resident's behavior of seeking cigarette butts led to the incident, indicating a lapse in supervision.
A facility failed to document a crucial phone call in a resident's medical record. The call involved allegations from a former roommate that a nurse threatened to withhold medications. The social worker confirmed the call but did not document it or ask further questions.
A facility failed to maintain appropriate enhanced barrier precautions (EBP) and hand hygiene during wound and incontinence care for a resident with an unstageable pressure ulcer. Staff did not don gowns or change gloves as required by facility policy, leading to a deficiency. Interviews confirmed the lack of adherence to EBP and hand hygiene protocols.
The facility failed to maintain adequate water temperatures in the shower rooms on the 400 hall, with temperatures not reaching the required 105 degrees Fahrenheit, potentially affecting 42 residents. Observations and logs confirmed that water temperatures consistently remained below the required level since October 2024. The issue was acknowledged by the Administrator and Maintenance Director, who confirmed that a local plumbing company was contracted to address the problem.
A resident with moderate cognitive impairment and an indwelling urinary catheter experienced a delay in response to a call light, which was on for 22 minutes without being addressed by staff. The resident had activated the call light due to concerns with a leaking catheter. The facility's policy requires timely response to call lights, which was not followed in this instance.
A resident with type two diabetes, vascular dementia, and glaucoma was unable to reach her call light, which was found behind a dresser by an LPN. The resident reported it had been out of reach all night. The facility's policy requires call lights to be within reach, which was not followed, leading to a deficiency finding.
A resident with multiple health issues developed a large blister on their leg, and while the Nurse Practitioner was informed, the family was not notified, contrary to the facility's policy. Interviews confirmed the lack of documentation for family notification.
A resident with severe cognitive impairment was found with a bruise and later a black eye, with no clear explanation for the injuries. Despite reports from hospice RN and STNA, the facility failed to notify the Ohio Department of Health as required by their abuse policy. The investigation suggested the resident may have hit her face on a chair, but the facility did not file a Self-Reported Incident (SRI) or assess other cognitively impaired residents for similar injuries.
A resident with severe cognitive impairment was found with a bruise of unknown origin, and the facility failed to conduct a thorough investigation or protect the resident from potential abuse. The investigation did not include interviews with other staff or assessments of other residents, and the incident was not reported as required by facility policy.
Failure to Notify Physician and Representative of Change in Wound Status
Penalty
Summary
The deficiency involves the facility’s failure to ensure timely notification of a physician and resident representative when a resident’s wound status changed. The resident was admitted with multiple diagnoses including spinal stenosis, end-stage renal disease on dialysis, anemia, and type 2 diabetes, and had an infected back surgical wound and an infected finger awaiting amputation. The admission MDS showed the resident was cognitively intact and required varying levels of assistance with ADLs while using a wheelchair. The care plan included monitoring for complications related to end-stage renal disease and infection. Progress notes from the wound nurse documented an infected back surgical wound and, on a later date, a large amount of bloody/purulent drainage from the back wound, with the wound cleansed, packed with Iodoform gauze, and dressed per treatment orders. A subsequent physician order directed daily and PRN wound care to the lower back, including cleansing with normal saline, packing with Iodoform gauze, and covering with a dry dressing. On a later date, an RN documented purulent drainage from the back wound and that the dressing was changed per the physician’s order, but there was no documentation that the physician or family were notified of this change in the wound’s condition. The wound physician later stated he was unsure if he had been notified about pus or drainage from the thoracic surgery site and indicated he would not have changed treatment until he returned to the facility. The DON confirmed that the RN had not notified a physician or the family in the progress note and stated she would have expected at least notification of the on-call physician for any new development. The RN could not recall whether she had notified the physician or family and verified that no such notification was documented. Facility policy required informing the resident, consulting with the practitioner, and notifying the resident representative when there was a change in status, including significant changes in health status.
Failure to Timely Assess and Initiate Treatment for Wounds Upon Admission
Penalty
Summary
The facility failed to complete wound assessments at the time of admission and did not timely initiate treatment for wounds for two out of three residents reviewed. For one resident with multiple medical conditions including diabetes, peripheral vascular disease, and a recent amputation, the admission assessment noted several skin issues but did not include measurements or detailed descriptions. Comprehensive wound evaluations were not completed until five days after admission, and physician-ordered treatments were not initiated until six days after admission. The resident was subsequently seen weekly by a wound physician, but initial documentation and intervention were delayed. Another resident admitted with a history of diabetes and chronic foot ulcers also did not have wound measurements or descriptions documented at admission, despite having visible surgical wounds. Although a physician order for wound care was obtained the day after admission and treatments were administered as ordered, the wounds were not measured or fully assessed until five days post-admission. Staff interviews confirmed the lack of timely wound assessment and documentation. Facility policy required baseline total body skin evaluations and prompt documentation of wound characteristics and interventions upon admission, which was not followed in these cases.
Failure to Timely Assess and Treat Pressure Ulcers on Admission
Penalty
Summary
The facility failed to complete pressure ulcer assessments upon admission and did not timely initiate treatment for pressure ulcers for one resident. Upon admission, the resident had multiple medical diagnoses, including aftercare following surgical amputation, peripheral vascular disease, end stage renal disease, and diabetes mellitus. The initial nursing comprehensive assessment documented the presence of a right toe amputation and redness to the buttocks, coccyx, and heels, but did not include measurements or detailed descriptions of these skin issues. Wound and skin evaluations were not completed until five days after admission, at which point multiple wounds were identified and measured, including vasculitic injuries, deep tissue injuries (DTIs), and moisture-associated skin damage. However, there was no documentation that treatment for these wounds was initiated until the day after the evaluation was completed. Staff interviews and policy review confirmed that the facility's policy required a baseline total body skin evaluation and prompt initiation of appropriate interventions and physician orders for any skin impairments upon admission. The medical record lacked evidence that these requirements were met for the resident in question, as wounds were not evaluated or treated in a timely manner. The deficiency was identified during a complaint investigation and was based on the facility's failure to follow its own skin management policy for new admissions with existing skin impairments.
Failure to Follow Infection Control Procedures During Medication Administration
Penalty
Summary
A deficiency was identified when a Licensed Practical Nurse (LPN) failed to follow infection control procedures during medication administration for a resident with multiple medical diagnoses, including cerebral infarction, dysphagia, vascular dementia, hypertension, and diabetes mellitus. The LPN was observed preparing medications by placing aspirin, Oyster Calcium, and senna tablets directly into her bare hands before transferring them into a medication cup. The medications were then crushed and mixed with applesauce prior to administration to the resident. During an interview, the LPN confirmed that she had handled the medications with her bare hands. Review of the facility's medication administration policy revealed that staff are required to perform hand hygiene before medication preparation and avoid touching the inside of medication cups or medications with bare hands. The policy also states that any medication coming into contact with bare hands should be disposed of and replaced. The observed actions were not in accordance with the facility's policy, resulting in a deficiency finding.
Improper Documentation and Administration of TPN by LPNs
Penalty
Summary
The facility failed to ensure that the administration of total parenteral nutrition (TPN) was completed in accordance with professional standards of practice, specifically regarding the roles and responsibilities of nursing staff. Medical record reviews for two residents with complex medical histories, including surgical aftercare, intestinal fistulas, colostomy status, protein-calorie malnutrition, and lymphoma, revealed that TPN was ordered and administered over several months. Both residents had care plans and physician orders specifying TPN administration, with instructions for registered nurses (RNs) to mix and manage the TPN solutions. However, review of the Medication Administration Records (MAR) showed that licensed practical nurses (LPNs) repeatedly signed off on the administration of TPN for both residents. Interviews with the Director of Nursing (DON) and LPNs confirmed that LPNs did not actually administer the TPN but signed the MAR as if they had, sometimes indicating that they were signing off for the RNs. The DON and LPNs acknowledged that LPNs are not permitted to initiate or maintain TPN, as it is outside their scope of practice according to the Ohio Revised Code. Facility policy review confirmed that only licensed nursing staff authorized by state law should prepare, administer, and record medications, and that LPNs are specifically prohibited from initiating or maintaining TPN. The deficiency was identified through a combination of medical record review, staff interviews, and policy review, and it affected two of three residents reviewed for IV administration.
Failure to Implement Enhanced Barrier Precautions During Wound Care
Penalty
Summary
Staff failed to implement enhanced barrier precautions during wound care for a resident with multiple complex medical conditions, including cerebral infarction, heart failure, end stage renal disease, type two diabetes, and severe vascular dementia. The resident required extensive assistance with activities of daily living and had several wounds requiring dressings, as documented in the care plan and active physician orders. The care plan specifically included enhanced barrier precautions as an intervention for skin impairment. Signage outside the resident's room indicated that enhanced barrier precautions were required, including the use of gloves and gowns for high-contact care activities such as wound care. During an observed wound care session, an LPN, a CNA, and a wound physician entered the resident's room and performed wound care activities, including removing and applying dressings, without donning gowns as required by the enhanced barrier precautions protocol. All three staff members later confirmed in interviews that they did not wear gowns and acknowledged that the resident was supposed to be under enhanced barrier precautions. The Director of Nursing also confirmed the lack of appropriate personal protective equipment storage outside the resident's room at the time of the incident.
Failure to Honor Resident Smoking Rights
Penalty
Summary
The facility failed to honor the smoking rights of a resident who was assessed as an unsafe smoker. The resident, who had a history of cerebrovascular accident, coronary artery disease, viral hepatitis, dementia, seizure disorder, and diabetes, was admitted to the facility and expressed a desire to smoke. Despite being severely cognitively impaired and requiring assistance for daily activities, the resident was found to be seeking cigarette butts and asking other residents for cigarettes. The care plan indicated that the resident was to be supervised while smoking, and the facility's policy required staff to maintain smoking paraphernalia and supervise unsafe smokers. However, the Director of Nursing confirmed that the facility did not offer supervised smoking for residents assessed as unsafe smokers, effectively prohibiting the resident from smoking on the facility grounds. This was contrary to the facility's smoking policy, which stated that unsafe smokers should be supervised and provided with smoking materials at designated times. The resident, when interviewed, was unaware of the reasons for being prohibited from smoking, indicating a lack of communication and adherence to the facility's policy on resident rights and smoking supervision.
Failure to Report and Investigate Abuse Allegations
Penalty
Summary
The facility failed to adhere to its abuse policy in several instances, leading to deficiencies in handling allegations of abuse and neglect. For Resident #87, the facility did not report an allegation of neglect to the state agency in a timely manner. The resident, who was cognitively intact and required assistance with activities of daily living, expressed concerns about staff behavior, including an incident with a wound nurse described as physically aggressive. Despite these concerns, the facility did not initiate a Self-Reported Incident (SRI) for the complaint received from the insurance company, nor did they suspend the accused nurse pending investigation. In another case involving Resident #61, who was moderately cognitively impaired, the facility delayed initiating an investigation into allegations that a nurse threatened to withhold medication. The allegation was reported by a hospital social worker to the facility's social worker, who then informed the Administrator. However, the facility did not begin the investigation until several days later, and the resident was not interviewed until even later. This delay in response was contrary to the facility's policy, which mandates immediate investigation and reporting of such allegations. The facility's policy requires that all staff be educated on abuse prevention and that any allegations be thoroughly investigated and reported. However, the facility failed to document staff education on abuse prevention following the investigation of Resident #87's case. Additionally, the facility did not suspend the accused staff member during the investigation, as required by their policy. These failures highlight significant lapses in the facility's adherence to its own abuse prevention and reporting protocols.
Failure to Timely Report Allegations of Abuse
Penalty
Summary
The facility failed to report allegations of abuse to the state agency in a timely manner, affecting two residents. Resident #87, who was cognitively intact and required assistance with activities of daily living, reported concerns about staff behavior, including an incident with a wound nurse, RN #131, whom the resident described as physically aggressive and abusive in language. Despite receiving a complaint from the resident's insurance company, the facility did not initiate a Self-Reported Incident (SRI) or conduct an investigation into these concerns, as the Administrator did not believe there was enough information to identify abuse. RN #131 was not informed of the allegations, nor was she suspended pending an investigation. Resident #61, who was moderately cognitively impaired and required assistance with activities of daily living, was involved in another incident where a hospital social worker reported that a former roommate alleged a facility nurse threatened to withhold medications. The facility delayed initiating an investigation and interviewing Resident #61, starting the process eight days after the initial report. The Social Worker, SW #87, did not document the phone call from the hospital social worker in the resident's record and only reported it to the Administrator the following day. The facility's policy on abuse prohibition requires that all allegations of abuse, neglect, or mistreatment be thoroughly investigated and reported to the appropriate state agencies. However, in both cases, the facility did not adhere to this policy, resulting in a deficiency. The Administrator confirmed the lack of timely investigation and reporting in both incidents, which were not aligned with the facility's established procedures for handling such allegations.
Failure to Investigate and Protect Residents During Abuse Allegations
Penalty
Summary
The facility failed to conduct timely and thorough investigations and did not protect residents during abuse investigations by suspending accused staff. This deficiency affected two residents. Resident #87, who was cognitively intact and required assistance with activities of daily living, reported concerns about staff behavior, including an incident with a wound nurse who was allegedly physically aggressive and abusive in language. Despite these allegations, the facility did not initiate a Self-Reported Incident (SRI) regarding the complaint from the insurance company, nor did they suspend the accused nurse pending investigation. The facility also lacked documentation of staff education on abuse and neglect prevention. Resident #61, who was moderately cognitively impaired and required assistance with activities of daily living, was involved in another incident where a former roommate alleged that a facility nurse threatened to withhold medications. The facility delayed initiating an investigation into this allegation, waiting eight days after being informed by a hospital social worker. The facility did not interview Resident #61 until nine days after the initial report. The facility's policy required immediate suspension of accused staff and thorough documentation and investigation of abuse allegations, which was not followed in this case. The facility's failure to adhere to its Abuse Prohibition Policy, which mandates immediate investigation and suspension of accused staff, resulted in noncompliance. The policy also required staff to be educated on abuse prevention, which was not documented. These deficiencies were investigated under Complaint Number OH00161688, highlighting the facility's inadequate response to abuse allegations and failure to protect residents during investigations.
Failure to Supervise Unsafe Smoker Leads to Incident
Penalty
Summary
The facility failed to provide adequate supervision to prevent accidents involving a resident who was identified as an unsafe smoker. The resident, who had a history of severe cognitive impairment and required assistance with daily activities, was assessed as unsafe to smoke due to an inability to handle smoking materials safely. Despite this assessment, the resident was able to access cigarette butts and smoke unsupervised, leading to an incident where the resident's clothing caught fire, resulting in a small reddened area on the resident's thigh. The facility's policy required that unsafe smokers be supervised and wear protective gear while smoking, and that staff maintain control of all smoking materials. However, the resident was able to obtain a lit cigarette butt, indicating a lapse in supervision and control of smoking materials. Interviews with staff confirmed that the resident had a behavior of seeking out cigarette butts and that the incident occurred when the resident was unsupervised, highlighting a failure to adhere to the facility's smoking policy and ensure the resident's safety.
Incomplete Medical Record Documentation
Penalty
Summary
The facility failed to maintain a complete medical record for a resident, which is a deficiency in safeguarding resident-identifiable information and maintaining medical records according to professional standards. A review of the medical record for a resident, who was admitted with diagnoses including occlusion and stenosis of the right carotid artery and diabetes, revealed a lack of documentation regarding a phone call from a hospital social worker to the facility's social worker. This call, which occurred on January 15, 2025, involved allegations made by a former roommate of the resident, claiming that a facility nurse had threatened to withhold the resident's medications. The facility's social worker confirmed the call took place but admitted to not documenting it in the resident's medical record, nor did she inquire further into the allegations.
Failure to Maintain Enhanced Barrier Precautions and Hand Hygiene
Penalty
Summary
The facility failed to ensure staff maintained appropriate enhanced barrier precautions (EBP) and hand hygiene during wound care and incontinence care for Resident #23. The resident, who was admitted with diagnoses including a fracture of the superior rim of the left pubis, heart failure, and atrial fibrillation, had an unstageable pressure ulcer on the buttock. Despite the presence of this wound, there were no physician's orders for EBP for the resident. During an observation, a registered nurse and a certified nursing assistant did not don gowns prior to providing wound care, and the CNA did not change gloves during or after incontinence care, using soiled gloves to touch various objects in the resident's room. Interviews with the CNA and RN confirmed the lack of gown use during care and improper glove use. The facility's policy on EBP indicated that residents with wounds should have EBP in place, requiring staff to wear gloves and gowns during high-contact care. Additionally, the facility's hand hygiene policy emphasized the importance of hand washing before and after resident contact and after removing personal protective equipment. The failure to adhere to these policies resulted in the deficiency noted in the report.
Failure to Maintain Adequate Water Temperatures in Shower Rooms
Penalty
Summary
The facility failed to ensure that water temperatures in the shower rooms on the 400 hall reached a comfortable level for residents, specifically not reaching the required 105 degrees Fahrenheit. Observations revealed that the water temperatures in the shower stalls only reached a maximum of 90 degrees Fahrenheit. This issue was confirmed by the Maintenance Director, who denied any recent hot water concerns despite the documented evidence. The deficiency was noted to potentially affect 42 residents residing on the 300 and 400 halls, as these residents used the 400 hall shower room. Review of the facility's water temperature logs showed that the hot water temperatures had consistently been below 105 degrees Fahrenheit since October 2024. Specific temperatures recorded included 89 degrees Fahrenheit on December 17, 2024, 90 degrees Fahrenheit on December 16, 2024, and 88 degrees Fahrenheit on December 10, 2024. The Administrator and Maintenance Director acknowledged the ongoing hot water issues and confirmed that a local plumbing company had been contracted to address the problem. This deficiency was investigated under Complaint Numbers OH00160422 and OH00160868.
Failure to Timely Respond to Resident Call Light
Penalty
Summary
The facility failed to ensure timely response to a resident's call light, affecting one resident out of six reviewed for call light responsiveness. The resident, who had been admitted with diagnoses including type two diabetes mellitus, hypertension, major depressive disorder, and acute kidney failure, was observed with a call light on for 22 minutes without being addressed by staff. The resident had moderate cognitive impairment, was frequently incontinent of bowel, and had an indwelling urinary catheter. During the observation, a Licensed Practical Nurse (LPN) was seen sitting at the nurse's station and later walking past the resident's room without addressing the call light. The resident had activated the call light due to concerns with a leaking urinary catheter and expressed that call lights often take a while to be answered. The facility's policy requires call lights to be answered in a timely manner, which was not adhered to in this instance. The Administrator confirmed that the delay in response was not timely and that any staff member, including the LPN, should have addressed the call light. This deficiency was investigated under a specific complaint number.
Call Light Accessibility Deficiency
Penalty
Summary
The facility failed to ensure that a resident's call light was kept within reach, affecting one of six residents reviewed for call lights. The resident, who was admitted with diagnoses including type two diabetes mellitus, vascular dementia, and glaucoma, was found to be cognitively intact according to a significant change Minimum Data Set (MDS) assessment. During an observation, an LPN asked the resident to use her call light for assistance, but the resident was unable to find it and stated it had been out of reach all night. The LPN discovered the call light behind a dresser drawer cabinet, confirming it was not within the resident's reach. The facility's policy requires call lights to be within a resident's reach, which was not adhered to in this instance. This deficiency was investigated under Complaint Number OH00160868.
Failure to Notify Family of Resident's Health Change
Penalty
Summary
The facility failed to notify the family of Resident #90 about a significant change in the resident's health status, specifically regarding impaired skin integrity. Resident #90, who had diagnoses including gram-negative sepsis, congestive heart failure, a non-pressure chronic ulcer of the left lower leg, and renal disease, was noted to have a large intact blister on the calf of the right leg on 04/29/24. The staff notified the Nurse Practitioner, who ordered the wound care physician to see the resident. However, there was no documentation of family notification regarding this change in condition. Interviews with the Licensed Practical Nurse and the Director of Nursing confirmed the absence of documentation related to family notification about the blister. The facility's policy on Change of Condition Notification, dated 02/14/2024, requires notifying the resident's representative of changes in condition, including deterioration in health. This deficiency was identified during an investigation under Complaint Number OH00154584.
Failure to Report Injury of Unknown Origin
Penalty
Summary
The facility failed to notify the Ohio Department of Health (ODH) of an injury of unknown origin involving a resident, which is a requirement under their abuse policy. The incident involved a resident with severe cognitive impairment and multiple health conditions, including heart disease and dementia. The resident was found with a bruise on the right cheek, and later a black eye, with no clear explanation for the injuries. The hospice RN and a State tested Nursing Assistant (STNA) reported the bruising to the Unit Manager (UM), but the facility did not file a Self-Reported Incident (SRI) as required. The investigation into the incident revealed that the resident was agitated during care, and it was suggested that the resident may have hit her face on a chair. However, the facility's Director of Nursing (DON) and UM did not consider the bruising as an injury of unknown origin that needed to be reported. Additionally, there was no assessment of other cognitively impaired residents for similar injuries. The facility's policy mandates that such incidents be reported to the state agency within a specific timeframe, which was not adhered to in this case.
Failure to Investigate Injury of Unknown Origin
Penalty
Summary
The facility failed to thoroughly investigate an injury of unknown origin and did not protect a resident from potential abuse. Resident #10, who was severely cognitively impaired and required assistance for mobility and personal care, was found with a bruise on the right cheek by a hospice RN. The origin of the bruise was unknown, and the incident was not reported as a Self-Reported Incident (SRI). The facility's investigation was incomplete, as it did not include interviews with other staff who might have had knowledge of the incident, nor did it assess other cognitively impaired residents for similar injuries. The Director of Nursing confirmed that the facility did not initiate a full abuse investigation related to the bruising, and the Unit Manager did not consider filing an SRI. The facility's policy requires thorough investigation of abuse allegations, including injuries of unknown origin, and protection of residents during investigations. However, the investigation did not include measures to protect the resident or education of other staff. The deficiency was identified under Complaint Number OH00154913.
Latest citations in Ohio
A resident with intact cognition receiving Medicare Part A skilled services for metabolic encephalopathy had services discontinued while benefit days remained, but the facility did not issue the required Skilled Nursing Facility Advance Beneficiary Notice (SNF ABN). The Social Services Director later confirmed that no SNF ABN was provided and reported she believed only a Notice of Medicare Non-Coverage (NOMNC) was needed when all skilled services were stopped. This practice conflicted with the facility’s written policy, which required SNF ABNs to be issued when extended care items or services were initiated, reduced, or terminated due to expected non-coverage by Medicare.
Surveyors identified that the facility exceeded the acceptable medication error rate when two residents with type 2 DM received insulin doses that were not administered according to orders or manufacturer instructions. In two separate observations, an LPN administered Novolog and another LPN administered insulin glargine and insulin lispro without priming the insulin pens, and the insulin lispro and Novolog were given after the residents had already consumed a significant portion of their breakfast meals, despite orders for administration before meals. Manufacturer information for both insulin products required priming before each injection to ensure accurate dosing, and facility policy required medications, including insulin, to be administered safely, timely, and in accordance with prescriber orders and specified time frames.
Surveyors found that the facility failed to document tray line food temperatures for multiple meals served from two dining room kitchenettes, despite having a “Trayline Taste & Temperature Log” and a policy requiring food to be stored, prepared, distributed, and served according to professional food safety standards. Review of logs showed repeated missing entries for breakfast, lunch, and dinner services in both the Harrison and McClellan dining areas, and the Senior Director of Culinary Services confirmed that temperatures had not been recorded for those meals, potentially affecting all residents receiving meals from those kitchenettes.
The facility failed to conduct and document required periodic care conferences for two residents, despite multiple comprehensive, quarterly, and significant change MDS assessments and a policy requiring periodic care conferences with resident and/or family participation. One resident with Parkinson’s disease, post-stroke hemiplegia, TIA, DMII, and depression had only two documented care conferences over a year, while another resident with aphasia, cerebrovascular disease, DMII, gait difficulty, coagulation defect, depression, and muscle weakness had no documented care conferences in the past year, aside from a declined invitation to the representative. The UCC confirmed that care conferences were expected to occur quarterly and that no additional documentation existed for either resident.
A resident with Alzheimer's disease and type II DM, who required extensive assistance with ADLs and was receiving scheduled Lantus and sliding-scale Humalog, experienced a severely elevated blood glucose level. The on-call provider was notified and ordered an additional dose of lispro insulin with a directive to recheck the blood glucose after administration. Nursing staff administered the extra insulin but did not document any follow-up blood glucose check, and the DON confirmed that this reevaluation was required by the facility's abnormal blood glucose policy and was not completed or documented.
A resident with Parkinson’s disease, dementia, and hypothyroidism was prescribed levothyroxine once daily along with other medications. A consultant pharmacist’s monthly drug regimen review recommended that levothyroxine be given in the morning on an empty stomach, 30–60 minutes before food, per manufacturer instructions. The medical record contained no documented physician response to this recommendation, and the MAR showed the drug scheduled for morning administration while the resident was observed eating breakfast and receiving the medication at the same time. An LPN confirmed administering levothyroxine during the meal, and the DON verified there was no documentation explaining whether or why the pharmacist’s recommendation was or was not followed, resulting in a failure to act on and document the identified irregularity.
A resident with severe cognitive impairment, multiple comorbidities, documented gait and balance abnormalities, and a high fall risk was care planned and assessed by therapy to require contact guard assistance and use of a gait belt for transfers and ambulation. While being assisted by a CNA from a recliner to the bathroom with a walker, the CNA did not apply a gait belt, even though the resident had a known tendency to lean backward when standing. As the CNA reached to open the bathroom door, the resident lost balance and fell backward, striking the back of the head, and was later found by an LPN without a gait belt in place, contrary to the facility’s gait belt policy and the resident’s assessed needs.
A resident with CKD stage five requiring peritoneal dialysis (PD) was admitted with pre-admission physician orders for three daily PD exchanges and monitoring for peritonitis (fever, abdominal pain, cloudy effluent), but these monitoring orders were not entered into the facility’s physician orders. The care plan referenced PD and general monitoring but did not specifically address peritonitis monitoring. Paper PD flowsheets showed incomplete and inconsistent documentation of exchanges and resident condition, including missing condition/comments for individual treatments and no record of one ordered PD exchange. The PD cycler flowsheet lacked effluent descriptions on multiple days. The PD nurse reported facility staff were expected to monitor effluent and symptoms, and the DON confirmed the absence of specific peritonitis monitoring orders, lack of an order for the PD cycler, and documentation gaps, despite a facility policy requiring ongoing assessment and monitoring for complications before, during, and after dialysis treatments.
A nurse was observed preparing multiple oral medications for a resident with depression, traumatic brain injury, anxiety, and impaired cognition by pushing tablets and capsules from unit-dose cards directly into her ungloved hand and then using her fingers to place them into a medication cup. In a follow-up interview, the RN confirmed this practice and acknowledged that the correct procedure is to dispense medications directly from the card into the cup, contrary to the facility’s medication administration policy requiring adherence to good nursing principles and practices.
A resident with Alzheimer’s disease, diabetes, anxiety, significant ADL dependence, and behavioral symptoms was observed seated in a chair positioned against the nursing station with a locked wheelchair placed directly in front, also against the nursing station, effectively restricting movement. An LPN confirmed both wheelchair wheels were locked and that it should not have been placed there, while a CNA stated she had positioned the wheelchair to prepare for lunch, was unable to complete the transfer, and left it in place, acknowledging this was wrong. This arrangement conflicted with the facility’s restraint policy, which prohibits physical restraints except when alternatives are ineffective for treating a medical symptom and defines restraints as devices adjacent to the body that cannot be easily removed and that restrict freedom of movement or access to the body.
Failure to Issue Required SNF ABN When Discontinuing Medicare Part A Services
Penalty
Summary
The deficiency involves the facility’s failure to issue a Skilled Nursing Facility Advance Beneficiary Notice (SNF ABN) when Medicare Part A services were discontinued for a resident who still had available benefit days. The resident was admitted with a diagnosis of metabolic encephalopathy and had intact cognition per the Minimum Data Set assessment. The facility’s own SNF Beneficiary Notification Review documented that Medicare Part A skilled services began on 02/11/26 and the last covered day was 03/11/26, and that the facility initiated discharge from Medicare Part A services before the resident’s benefit days were exhausted. Despite this, no SNF ABN was provided to the resident or the resident’s representative. During interviews, the Social Services Director stated that the SNF ABN was issued hours prior to the last covered day but, upon reviewing her files, confirmed that no SNF ABN had actually been issued for this resident. She further explained that she believed an SNF ABN was only required if one skilled service remained and that if all skilled services were being discontinued, only the Notice of Medicare Non-Coverage (NOMNC) needed to be issued. The Administrator, however, stated that a resident should always receive both a SNF ABN and a NOMNC when Medicare Part A services are discontinued and benefit days remain. Review of the facility’s written policy dated 03/28/23 showed that the facility was required to issue SNF ABNs for initiation, reduction, or termination of extended care items or services when Medicare payment was not expected, which did not occur in this case.
Plan Of Correction
This Plan of Correction is submitted as required under State and Federal law. This Plan of Correction does not constitute an admission on the part of the Facility that the findings cited are accurate, that the findings constitute a deficiency or that the scope and severity regarding the deficiency cited are correctly applied. Any changes to the Facility's policies and procedures should be inadmissible in any proceeding on that basis. Without admitting or denying the validity or the existence of the alleged noncompliance, the Facility submits this Plan of Correction with the intention that it be inadmissible by any third party in any civil or other action against the facility or any employee, agent, officer, director or shareholder of the Facility. The Facility is utilizing this Plan of Correction as its allegation of substantial compliance as of 05/29/2026 F-0582 Corrective action for resident/s: On 5/14/26 Resident #34 was informed of rights and responsibilities related to Advanced Beneficiary Notice and voiced understanding of information for future reference by administrator. Identification of other residents who may be affected: Any resident receiving skilled services from nursing or therapy services. The Administrator audited all residents who were discharged from skilled services in the past 30 days to ensure they were issued a Notice of Non-Coverage and Advanced Beneficiary Notice on 5/29/26. No non-compliance was noted. Measures for systemic change: On 5/14/2026 Business Office Manager, Director of Rehab, Minimum Data Set nurse, Director of Nursing and Social Services Director were educated on proper procedure of issuing of Notice Of Medicare Non Coverage and Advanced Beneficiary Notice by administrator. All upcoming discharges from skilled services will be reviewed weekly at Utilization Review meeting to ensure notices will be delivered timely. How Corrective Action will be monitored: Administrator or designee to complete audits of all residents being discharged from skilled services to ensure they were issued a Notice of Non-Coverage and Advanced Beneficiary. This audit will be completed weekly x 4 weeks, then monthly x 2 months. Corrective action will be initiated for any noted non-compliance. Audit findings will be reviewed as part of the monthly quality assurance process to determine the need for further monitoring. Date of Compliance 5/29/26
Insulin Administration Errors and Failure to Prime Insulin Pens
Penalty
Summary
The deficiency involves the facility’s failure to maintain a medication error rate below 5%, with surveyors identifying 3 errors out of 28 medication administration opportunities, resulting in a 10.71% error rate. For one resident with type 2 diabetes mellitus and moderate cognitive impairment, the physician’s order directed Novolog insulin 10 units via subcutaneous pen-injector to be given before meals. During an observed medication pass, the LPN administered 10 units of Novolog insulin without priming the pen and did so after the resident had already consumed approximately 50% of the breakfast meal. The LPN later confirmed she did not prime the pen and acknowledged that the insulin was ordered to be administered prior to meals. Manufacturer instructions for the Novolog FlexPen specified that an air shot (priming) must be performed before each injection to ensure proper dosing. Another resident, also diagnosed with type 2 diabetes mellitus and with intact cognition, had orders for insulin glargine 35 units subcutaneously twice daily and insulin lispro 20 units subcutaneously before meals, plus 12 units subcutaneously if blood glucose was between 251 mg/dL and 300 mg/dL. During an observed medication administration, an LPN administered 35 units of insulin glargine and 32 units of insulin lispro without priming the insulin pens and after the resident had consumed approximately 90% of the breakfast meal, despite orders for insulin lispro to be given before meals. The LPN later stated she could not remember if she had primed the pen and acknowledged that the insulin was ordered to be administered prior to meals. Manufacturer information for insulin lispro stated that the pen must be primed before each injection to confirm insulin delivery and remove air, and that failure to prime could result in too much or too little insulin. The DON confirmed the expectation that insulin be administered as ordered, including priming each pen with two units before dialing the prescribed dose, and facility policy required medications, including insulin, to be administered safely, timely, and in accordance with prescriber orders and required time frames.
Plan Of Correction
This Plan of Correction is submitted as required under State and Federal law. This Plan of Correction does not constitute an admission on the part of the Facility that the findings cited are accurate, that the findings constitute a deficiency or that the scope and severity regarding the deficiency cited are correctly applied. Any changes to the Facility's policies and procedures should be inadmissible in any proceeding on that basis. Without admitting or denying the validity or the existence of the alleged noncompliance, the Facility submits this Plan of Correction with the intention that it be inadmissible by any third party in any civil or other action against the facility or any employee, agent, officer, director or shareholder of the Facility. The Facility is utilizing this Plan of Correction as an allegation of substantial compliance as of 5/29/2026. F-0759 Corrective action for resident/s: Residents #21 and #22 were assessed and evaluated by nurse and Director of Nursing 5/14/26. Resident #21 and #22 both denied any adverse effects and none were noted upon assessment by the Director of Nursing on 5/14/2026. Notification made to physician on 5/14/2026. LPN # 2 competency Eval on insulin administration with the Director of Nursing completed 5/14/2026. Identification of other residents who may be affected: Diabetic residents on assignment of LPN #2/station 2 have the potential to be affected and were assessed by the DON/Designee on 5/14/26 and found to be within normal limits. Measures for systemic change: All Nurses were educated by the Director of Nursing on the steps for Insulin administration per competency, diabetes clinical protocol policy, Medication and treatment orders policy, administering medications policy, and Obtaining fingerstick Glucose Level policy On 5/14/2026. How Corrective Action will be monitored: Director of Nursing and Assistant Director of Nursing will complete insulin administration audits on 5 nurses. This audit will be completed weekly x 4 weeks, then monthly x 2 months. Corrective action will be initiated for any noted non-compliance. Audit findings will be reviewed as part of the monthly quality assurance process to determine the need for further monitoring. Date of Compliance: 5/29/2026
Failure to Document Tray Line Food Temperatures in Dining Room Kitchenettes
Penalty
Summary
The deficiency involves the facility’s failure to document tray line food temperatures for meals served from the Harrison and McClellan Dining Room kitchenettes, as required by professional standards for food service safety and the facility’s own policy. Review of the “Trayline Taste & Temperature Log” (revised September 2018) showed missing temperature documentation for multiple meals from the Harrison Dining Room kitchenette, including dinner on 03/30/26 and 03/31/26, lunch and dinner on 04/01/26 and 04/02/26, dinner on 04/07/26, and lunch and dinner on 04/08/26 and 04/10/26. The Senior Director of Culinary Services confirmed during interview that tray line food temperatures were not documented on the log for these meals. Similarly, review of the same log for the McClellan Dining Room kitchenette revealed that tray line food temperatures were not documented for dinner on 04/01/26, breakfast and lunch on 04/02/26, and lunch and dinner on 04/07/26. The Senior Director of Culinary Services also verified these omissions during interview. The facility census at the time was 27 residents, and the governing “Food and Nutrition” policy, approved on 09/07/21, stated that the facility must store, prepare, distribute, and serve food in accordance with professional standards for food service safety.
Plan Of Correction
F812 The facility will continue to ensure food temperatures are completed before meals are served for all residents. To ensure compliance with this standard the following measures have been taken: 1. Immediately 4/15/26 culinary supervisor #224 was re-educated by Dietary Manager to this standard and policy "Food and Nutrition" which includes documentation of food temperatures. 2. All dietary staff have been re-educated to the standard and policy "Food and Nutrition" during the month of April 2026. 3. Audits of food temperature documentation to be completed by Dietary Manager 4 x per week for 4 weeks then weekly for 4 weeks. 4. Administrator to validate audits/compliance and provide additional training as needed. Administrator will present to QAPI committee for ongoing monitoring and further direction.
Failure to Conduct and Document Required Care Conferences
Penalty
Summary
The deficiency involves the facility’s failure to complete and document comprehensive care conferences at required intervals in accordance with care plan regulations and facility policy. For one resident with Parkinson’s disease with dyskinesia, cognitive communication deficit, hemiplegia and hemiparesis following cerebral infarction, transient cerebral ischemic attack, type II diabetes mellitus, and major depressive disorder, the record showed multiple MDS assessments over a one-year period, including annual, quarterly, and significant change assessments. However, only two care conferences were documented during the last 12 months, despite the expectation that care conferences be conducted quarterly with the resident and family when possible. The Unit Care Coordinator confirmed that no additional care conference documentation existed for this resident beyond the notes dated 04/21/25 and 01/02/26. A second resident, with diagnoses including aphasia following cerebrovascular disease, cerebral infarction, type II diabetes mellitus, unsteadiness on feet, difficulty in walking, coagulation defect, depression, and muscle weakness, also had multiple MDS assessments completed over the review period, including quarterly and annual assessments. The record contained a note that a care conference was offered to the resident’s representative, who declined to attend, but there was no documentation of any care conferences for the most recent 12 months. The Unit Care Coordinator confirmed that no other care conference documentation was available for this resident. Facility policy stated that periodic care conferences involving the resident, family, and the interdisciplinary team are part of the care planning process, but the required periodic care conferences and corresponding documentation were not completed for these two residents.
Plan Of Correction
THIS PLAN OF CORRECTION SERVES AS BERKELEY SQUARE'S CREDIBLE ALLEGATION OF SUBSTANTIAL COMPLIANCE AS OF June 1, 2026. Without admitting or denying the validity or existence of the alleged deficiencies, Berkeley Square provides the following Plan of Correction: F657 The facility will continue to document completion of care conferences at the required intervals for all residents, including residents #04 & #15. To ensure compliance with this standard the following measures have be taken: 1. The social service designee and the inter- disciplinary team were re-educated by the administrator to the facility policy "Care Conference" on 4/29/26 and verbalized understanding. 2. Care conferences for resident #04 and resident #15 were conducted on or before 4/29/2026 by the interdisciplinary team. 3. Review of all other residents was conducted by the social service designee to validate and ensure that care conference schedule is up to date with timely care conferences scheduled for them on 4/15/2026. Audits of care conferences to be completed weekly for four weeks and then monthly after that by the social service designee. Documentation of the care conference including any identified concerns in the medical record. Administrator to validate audits/compliance and provide additional training as needed. Administrator will present results of these audits to QAPI committee for ongoing monitoring and further direction.
Failure to Reevaluate Blood Glucose After Treatment for Hyperglycemia
Penalty
Summary
The facility failed to ensure that a resident with diabetes received treatment in accordance with professional standards of practice when nursing staff did not reevaluate the resident's blood glucose after treatment for severe hyperglycemia. The resident, admitted with diagnoses including Alzheimer's disease, type II diabetes mellitus, and depression, had physician orders for Humalog insulin on a sliding scale before meals, Lantus insulin 25 units daily, and lisinopril 5 mg daily. The resident required extensive assistance with activities of daily living, including transfers, toileting hygiene, eating, and bathing. On the evening in question, the resident's blood glucose was documented as 532 mg/dL, and the on-call provider was notified. The provider gave a new order to administer an additional 8 units of lispro (Humalog) and to recheck the blood glucose in 30 minutes. The electronic medication administration record showed that the blood glucose of 532 mg/dL was obtained at 9:00 p.m. and that the additional 8 units of lispro were administered at 9:21 p.m. However, there was no documentation in the resident's chart that the blood glucose was rechecked after the additional insulin was given. In an interview, the DON confirmed there was no evidence of reevaluation and verified that, according to the facility's "Abnormal Blood Glucose Procedure" policy, the resident should have been reevaluated and that the evaluation step should have been included in the progress note documentation.
Plan Of Correction
F684 The facility will continue to ensure all residents, including #03, receive treatment in accordance with professional standards of practice and reevaluated for hyperglycemia. To ensure compliance with this standard the following measures have been taken: 1. The director of nursing assessed resident #03, reviewed documentation and orders and found no ill effects immediately 4/16/26. 2. All licensed nurses were re-educated to facility policy "Blood Glucose Monitoring" by the Director of Nursing/designee in April 2026. 3. Audits of like-residents that require blood sugar checks to be completed by the director of nursing/designee two times a week for 4 weeks and then monthly after that to validate correct follow through when there is abnormally high blood glucose result. The Administrator will bring results of these audits to the QAPI committee for ongoing monitoring and further direction.
Failure to Act on Pharmacist Drug Regimen Recommendation for Thyroid Medication
Penalty
Summary
The deficiency involves the facility’s failure to ensure that pharmacy recommendations from the monthly drug regimen review were acted upon and documented for a resident. The resident was admitted with diagnoses including Parkinson’s disease, dementia, and hypothyroidism, and had current physician orders for levothyroxine 150 mcg once daily, buspirone 50 mg twice daily, and losartan 100 mg once daily. A medication regimen review dated 11/25/2025 included a consultant pharmacist recommendation that levothyroxine be administered consistently in the morning on an empty stomach, at least 30–60 minutes before food, per manufacturer instructions. There was no specific physician response in the medical record to this recommendation, and the facility’s policy stated that consulting pharmacist reviews are sent to nursing and addressed with the primary care provider or consulting specialist for review and follow-up. Review of the resident’s medication administration record for April 2026 showed levothyroxine scheduled for 9:00 a.m. On observation, the resident was seen eating breakfast in the dining area at 8:03 a.m., and an LPN reported administering the levothyroxine 150 mcg to the resident while the resident was in the dining area eating breakfast. The DON confirmed there was no evidence in the resident’s medical record explaining why the consultant pharmacist’s recommendation from 11/25/2025 was or was not acted upon. This lack of documented physician review and action on the pharmacist’s identified irregularity constituted noncompliance with the drug regimen review requirements.
Plan Of Correction
F756 The facility will continue to ensure the pharmacy recommendations from the monthly drug regimen review by a licensed pharmacist are acted upon for all residents, including #08. To ensure compliance with this standard the following measures have been taken: 1. Resident #08 was assessed by the registered nurse and med review completed by 4/28/26. After review of resident's drug regime's, it was discovered that resident #8 had 2 separate medication recommendations on the same form, to be reviewed by two separate practitioners, pharmacy has been instructed and agreed to separate meds on individual forms. 2. Licensed nurses re-educated to facility policy "Drug Regimen Review" by Director of nursing/designee in April 2026 and no later than 5/8/26. Licensed nurses are responsible for ensuring the reviews and recommendations are given to the physician for timely review. 3. Review of all other current residents Drug Regimen orders completed by Director of nursing/designee on 4/16/26 to ensure recommendations were followed up on/reviewed by the physician and address concerns if needed. 4. Audit of drug regime recommendations, pharmacy recommendations, and physician follow up to be completed weekly for four weeks by the Director of nursing/designee. Administrator will present results of these audits to the QAPI committee for ongoing monitoring and further direction.
Failure to Use Required Gait Belt During Ambulation Resulting in Resident Fall
Penalty
Summary
The deficiency involves the facility’s failure to ensure that a required gait belt was used while assisting a high fall‑risk resident with ambulation, resulting in a fall with head injury. The resident had multiple diagnoses including metabolic encephalopathy, hypertension, osteoarthritis, muscle weakness, gait and mobility abnormalities, major depressive disorder, anxiety, and visual hallucinations. Admission and subsequent MDS and fall risk assessments documented that the resident was severely cognitively impaired, required moderate to maximal assistance with transfers and ambulation, could not independently come to a standing position, exhibited loss of balance while standing, used an assistive device, and had decreased muscle coordination. The resident had a history of falls prior to admission and was assessed as being at high, later moderate, risk for falls. The resident’s fall care plan identified her as at risk for falls and included interventions such as providing maximum to moderate assistance with transfers and walking short distances, use of a walker and wheelchair, and following the facility’s fall protocol. Therapy notes and care conference documentation indicated that the resident leaned backwards when standing, required contact guard to minimal assistance for bed mobility and transfers, and needed constant verbal cueing for safe sequencing during toilet transfers. The physical therapist confirmed that the resident was to use a gait belt with staff when ambulating, and the DON verified that therapy had assessed the resident as requiring contact guard assistance and a gait belt for ambulation and transfers. On the day of the incident, a CNA was assisting the resident from her recliner to the bathroom using a walker. The CNA walked beside the resident, providing guidance and support, and reported having a hand on the resident while assisting her. As they approached the bathroom door, the CNA reached for the doorknob to open it, and at that moment the resident began to lose her balance and fell backwards to the floor, striking the back of her head. The nurse who responded found the resident on her back at the foot of the bed with her feet near the bathroom, noted a red raised area on the back of the head, and documented that the resident was not wearing a gait belt and that the gait belt was on the dresser. In the facility’s investigative summary and in interviews, the CNA acknowledged that she did not have a gait belt on the resident while ambulating her, despite the resident’s assessed need for hands‑on assistance and gait belt use per facility policy and the resident’s care and therapy plans.
Failure to Implement PD Orders and Monitor Resident Receiving Peritoneal Dialysis
Penalty
Summary
The deficiency involves the facility’s failure to implement pre-admission physician orders for peritoneal dialysis (PD) and to provide ongoing monitoring for a resident with chronic kidney disease (CKD) stage five who required PD. Pre-admission orders dated 11/14/25 specified three daily PD exchanges at 6:00 A.M., 2:00 P.M., and 10:00 P.M., and directed staff to monitor for signs and symptoms of peritonitis, including fever, abdominal pain, and cloudy effluent. These monitoring orders were not entered into the facility’s physician orders. The resident’s care plan noted the need for PD and included general monitoring interventions (labs, signs of bleeding, bacteremia, septic shock, and significant vital sign changes), but did not specifically address the ordered monitoring for peritonitis. Review of PD documentation showed incomplete and inconsistent charting of treatments and resident condition. The paper peritoneal flowsheet had columns for time of PD and condition/comments, including instructions to call the nurse immediately for cloudy fluid, abdominal pain, or fever. However, the first entry on 11/15/26 at 2:00 P.M. only noted that the PD nurse completed the exchange, and the 10:00 P.M. entry that day had no condition/comment documentation. Subsequent days (11/16/25, 11/17/25, and 11/18/25) contained only one condition/comment entry per day rather than for each exchange, and there was no documentation that the 6:00 A.M. PD on 11/18/25 was completed. The PD cycler flowsheet starting 11/19/25 lacked any description of the effluent on multiple days. The PD nurse from the dialysis company stated facility staff were expected to monitor effluent for cloudiness and assess for abdominal pain and fever, and the DON confirmed there was no electronic physician order for peritonitis monitoring or for use of the PD cycler, that the paper charting did not allow for effluent description or symptom documentation for each treatment, and that PD was not documented at one ordered time. The facility’s dialysis policy required ongoing assessment and monitoring for complications before, during, and after treatments, which was not reflected in the documentation for this resident.
Improper Infection Control During Medication Administration
Penalty
Summary
Surveyors identified a deficiency in infection prevention and control related to medication administration for Resident #29. The resident was admitted on 02/28/14 with diagnoses including depression, traumatic brain injury, and anxiety, and had impaired cognition per a quarterly MDS assessment. During an observation on 03/25/26 at 6:58 A.M., RN #281 prepared the resident’s medications by removing an Amoxicillin-Pot Clavulanate tablet from the medication card and pushing it directly into her ungloved hand, then using her fingers to place the pill into a medication cup. The same process was observed for multiple other medications, including Escitalopram Oxalate, Furosemide, Sennosides, Lyrica, and Vitamin D, each being pushed from the card into the RN’s ungloved hand and then transferred by her fingers into the medication cup before administration to Resident #29. In a subsequent interview at 7:27 A.M. the same day, RN #281 confirmed she had placed each medication into her ungloved hands prior to administration and acknowledged that the proper procedure was to push the pills directly from the card into the medication cup. Review of the facility’s “Medication Administration – General guidelines” policy, revised 10/08/25, stated that medications are to be administered in accordance with good nursing principles and practices. This practice failure was cited as a deficiency under Complaint Number 2681777.
Improper Use of Wheelchair as a Physical Restraint
Penalty
Summary
Surveyors identified a deficiency related to the facility’s failure to ensure a resident was free from physical restraints. Resident #7, admitted with diagnoses including Alzheimer’s disease, diabetes mellitus, and anxiety disorder, was documented on a recent MDS as rarely understood and dependent for ADLs except eating. The resident ambulated independently on the unit without an assistive device and had documented verbal and other behaviors occurring one to three days during the look-back period. The care plan noted the resident had potential to be physically aggressive, chase staff, throw objects, and be combative with care, with interventions such as offering choices, administering medications as ordered, and intervening early when agitation occurred. During an observation and interview, Resident #7 was found sitting in a chair with the right arm of the chair positioned against the nursing station and a wheelchair placed directly in front of him. The left arm of the wheelchair was also against the nursing station, and both wheelchair wheels were locked, creating a barrier that appeared to restrain the resident, who was sleeping with his knees touching the locked wheelchair. An LPN confirmed both wheelchair wheels were locked and that the wheelchair should not have been placed in front of the resident. A CNA reported she had placed the wheelchair there in preparation to get the resident up for lunch, was unable to transfer him, and left the wheelchair in that position, acknowledging it was wrong to keep it there. The facility’s physical restraint policy stated that physical restraints are not used except when alternatives are not appropriate or effective for treating a medical symptom and defined physical restraints as any device attached or adjacent to the body that the individual cannot easily remove and that restricts freedom of movement or access to the body.
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