Laurels Of Norworth The
Inspection history, citations, penalties and survey trends for this long-term care facility in Worthington, Ohio.
- Location
- 6830 North High Street, Worthington, Ohio 43085
- CMS Provider Number
- 365222
- Inspections on file
- 30
- Latest survey
- February 9, 2026
- Citations (last 12 mo.)
- 5
Citation history
Health deficiencies cited at Laurels Of Norworth The during CMS and state inspections, most recent first.
The facility failed to prevent and properly manage pressure ulcers for three dependent, high-risk residents by not consistently implementing and documenting ordered interventions such as turning/repositioning, heel offloading, and appropriate use of air mattresses. One resident, admitted without pressure injuries, developed an in-house unstageable heel ulcer that progressed to stage III and later an unstageable coccyx ulcer, while care plans lacked clear turning assistance and heel elevation, Braden scores were not updated with new ulcers, MASD was not measured or fully assessed, and the air mattress was set incorrectly with offloading boots not in use. Another resident with diabetes and venous insufficiency developed a facility-acquired heel deep tissue injury and MASD that were initially documented without measurements, and after multiple hospitalizations, prior offloading boot interventions were not reordered, leaving the resident on his back in bed without boots despite needing help to turn. A third resident with a stage IV sacral ulcer, severe malnutrition, and hemiplegia was totally dependent for mobility but had no explicit care plan intervention for assisted repositioning, had orders for an air mattress and offloading boots without specified settings, was observed without boots and initially without the air mattress on the bed, and later had the mattress set at maximum firmness without provider guidance, while staff reported limited education on mattress function and inconsistent documentation of repositioning.
The facility failed to ensure LPNs practiced within their professional standards and defined scope when one LPN independently assessed, measured, and staged pressure ulcers for two residents with significant cognitive and physical impairments, including heel and sacral pressure injuries. This LPN regularly performed wound assessments and staging when the wound NP was unavailable, yet facility job descriptions for treatment and unit nurse roles did not include pressure ulcer assessment or staging responsibilities, and no LPN job description was available to support this practice.
A resident with severe cognitive impairment and osteoporosis, who required two-person assistance for mechanical lift transfers, was transferred by a single CNA. During the transfer, the wheelchair slipped, causing the resident to land on the armrest and sustain a right femoral neck fracture. The incident was not immediately reported, and the injury was discovered later when the resident exhibited increased pain and bruising.
The facility did not consistently report allegations of sexual abuse and inappropriate sexual behavior to the state agency or law enforcement as required. Incidents included a resident accusing a nurse of rape, a resident reporting inappropriate touching by a roommate, and repeated public indecency by another resident. Some staff were unaware of incidents or failed to document and report them, despite internal policies and communications.
The facility did not thoroughly investigate incidents where a resident with cognitive intactness and mobility needs urinated in the courtyard in front of others, despite complaints from two residents and a police report being filed. Documentation was lacking regarding which residents were interviewed, and no formal investigation was conducted, contrary to facility policy requiring thorough investigation and reporting of abuse allegations.
The facility failed to maintain safe and sanitary food service practices. A staff member and the Dietary Manager were observed handling food and various items without changing gloves as required by the facility's policy. This improper glove use had the potential to affect all residents receiving food from the kitchen.
The facility failed to maintain a clean and sanitary environment, affecting several resident rooms and a hallway. Issues included loose wall tiles, dead bugs in light fixtures, leaking faucets, broken window ledges, sagging and discolored ceiling tiles, gouged drywall, and malfunctioning toilet pipes.
The facility failed to follow antibiotic stewardship protocols, affecting two residents. One resident was given multiple antibiotics simultaneously without proper justification or testing for MRSA, while another continued on prophylactic Bactrim without documented necessity. The facility's infection control logs lacked documentation of antibiotic use, indicating inadequate monitoring. The facility's policy discourages such practices, but adherence was not observed.
The facility failed to ensure accurate PASARR documentation for two residents, affecting their care plans. One resident's vascular dementia was not reflected in the PASARR, while another's insomnia was omitted. These inaccuracies were confirmed by a Social Services Assistant, indicating a failure to adhere to the facility's PASARR policy.
A facility failed to timely coordinate a level II evaluation for a resident with bipolar disorder and schizophrenia, as required by PASARR. Despite a change of condition indicating the need for further evaluation, there was no evidence of coordination with the state mental health agency for several months. The deficiency was confirmed through record reviews and staff interviews.
A resident with epilepsy and vision impairment did not receive timely vision services, leading to a deficiency in care. Despite being identified as needing an eye exam and new glasses, there was no documentation of receiving eyeglasses or an eyewear appointment for several months. The resident expressed concerns about his inability to read documents or participate in activities. Staff interviews revealed a lack of follow-up and coordination in obtaining necessary services, with delays in sending consent forms and scheduling appointments.
The facility failed to monitor significant weight loss in two residents, leading to deficiencies in nutrition management. One resident experienced a 10% weight loss without timely re-weight checks, while another had a 5.26% weight loss with delayed weekly weight monitoring. The facility did not adhere to its Weight Management policy, as confirmed by staff interviews.
A facility failed to document and address a resident's behavior of performing self-catheterization every two hours instead of the ordered six hours. The resident, with multiple diagnoses including paraplegia and anxiety disorder, was cognitively intact but exhibited aggressive behavior towards staff during catheter care. The lack of documentation and care planning for these behaviors was confirmed by the DON.
A resident with paraplegia and chronic pain syndrome was administered as-needed pain medications without specific parameters, leading to frequent use of Oxycodone for low pain levels. Nurses confirmed the absence of guidelines, relying on judgment and pain level, contrary to the facility's pain management policy.
A facility failed to monitor behaviors and justify the use of psychotropic medications for a resident with vascular dementia. The resident was prescribed Seroquel, Ativan, and Trazodone, but documentation did not support the need for these medications. Attempts at a gradual dose reduction of Seroquel were inadequately documented, and the diagnosis for its use was inappropriate. Staff interviews revealed a need for better monitoring and documentation of behaviors.
The facility failed to provide timely dental services for two residents, resulting in unmet dental needs. One resident, with moderate cognitive impairment, had damaged dentures and no follow-up for replacement, affecting their ability to eat. Another resident, cognitively intact, experienced sore gums due to lack of dentures, with no documented dental follow-up. Staff interviews revealed a lack of communication and coordination in addressing these issues.
The facility failed to ensure that a social worker hired for a 126-bed facility had the required one year of supervised experience in a healthcare setting. The personnel file lacked evidence of such experience, and interviews with staff confirmed the absence of documentation. This deficiency potentially affected all 115 residents.
A facility failed to prepare pureed foods properly, affecting a resident with a pureed diet order. The resident received a pureed turkey burger that lacked flavor and tasted like paste. The preparation involved unmeasured ingredients and excessive thickener, contrary to facility policy and dietician guidance.
A resident with multiple health issues, including dysphagia, was served a meal not in compliance with their prescribed pureed diet. The meal included shredded lettuce, which was not allowed per the physician's order. This was confirmed by the DON and dieticians, highlighting a deficiency in following dietary orders.
A facility failed to follow infection prevention guidelines for Enhanced Barrier Precautions (EBP) when an LPN did not wear a gown while providing care to a resident with a PEG tube. The resident had a history of cerebral infarction, diabetes, chronic kidney disease, and was always incontinent. Despite EBP signage indicating the need for gloves and a gown, the LPN only wore gloves, which was confirmed during an interview. The facility's policy required such precautions to prevent the transmission of MDROs.
Failure to Prevent and Manage Pressure Ulcers and Implement Ordered Offloading Interventions
Penalty
Summary
The deficiency involves the facility’s failure to prevent the development and worsening of pressure ulcers and to implement and maintain ordered interventions for multiple residents at risk for skin breakdown. One resident was admitted without pressure ulcers but was dependent for bed mobility, had severe cognitive impairment, and was frequently incontinent. The care plan identified risk for impaired skin integrity but did not include specific interventions for staff assistance with turning and repositioning in bed. The Braden Scale was not consistently re-evaluated when a new pressure injury developed, and there was no unavoidable pressure ulcer assessment. An in-house unstageable right heel pressure ulcer later documented as a stage III ulcer developed, and the resident subsequently developed an in-house unstageable coccyx pressure ulcer that had previously been documented only as MASD without measurements or detailed assessment. Throughout this period, there were no documented refusals of turning and repositioning, yet staff interviews confirmed the resident remained on her back much of the day and required assistance to turn. The same resident’s care plan and physician orders lacked clear, complete interventions and parameters for pressure-relieving equipment. Orders for an air pressure mattress did not include settings, and staff had not been educated on how to operate different types of air mattresses. Observations showed the air mattress set for a much higher weight than the resident’s actual weight, and the resident was observed in bed without offloading boots and with heels not elevated, despite orders for bilateral offloading boots and heel elevation. MASD to the coccyx and buttocks was documented in progress notes without measurements, detailed descriptions, or treatment orders, and there was no documented assessment by a physician, NP, or RN of the MASD area. The wound care process relied heavily on an LPN to assess, stage, and measure pressure injuries and MASD in the absence of the consulting wound NP, with no verification of accuracy by an RN, NP, or physician, and MASD areas were not routinely measured or fully described. A second resident with chronic conditions, including diabetes and venous insufficiency, required substantial assistance with bed mobility and was always incontinent. This resident developed a facility-acquired right heel deep tissue injury that was initially documented without measurements or description. After hospitalization and readmission, the resident had a right heel open area and bilateral buttocks MASD, but again the second skin sweep documented an unstageable heel ulcer and MASD without measurements or detailed descriptions. MASD was later described only as improving in progress notes, still without measurements. Following another hospitalization and readmission, the resident no longer had the heel injury or MASD, but there was no active order for offloading boots despite a history of a facility-acquired heel injury and a prior care plan intervention for offloading boots. Observations confirmed the resident remained on his back in bed without offloading boots, and he reported needing help to turn and only being turned when he asked. A third resident was admitted with severe protein-calorie malnutrition, right-sided hemiplegia, total dependence for bed mobility, and a hospital-documented stage IV sacral pressure ulcer. The admission assessment documented a coccyx pressure ulcer, and the care plan identified actual impaired skin integrity and risk for pressure injury but did not include interventions for staff assistance with turning and repositioning, despite the resident’s inability to reposition independently. Physician orders included an air pressure mattress and bilateral offloading boots, but the care plan did not add offloading boots as an intervention, and no mattress settings were specified. Subsequent skin assessments showed the sacral stage IV ulcer had deteriorated in size. Observations revealed the resident in bed without offloading boots, with the air mattress initially not on the bed and later placed on the bed at maximum firmness without physician notification or staff knowledge of appropriate settings. Staff interviews confirmed the resident was totally dependent on repositioning, that documentation of turning and refusals was inconsistent, and that staff had not been educated on the various air mattresses used. Across these residents, the facility’s own skin management policy required comprehensive admission/readmission skin evaluations with location, measurements, and characteristics documented, implementation of appropriate preventive measures for at-risk residents, documentation of interventions on the care plan, and completion of Braden Scales with significant changes. The findings showed repeated failures to measure and describe pressure areas and MASD at discovery and during follow-up, to update Braden Scales when new pressure injuries occurred, to include and implement specific turning/repositioning and heel offloading interventions in care plans, and to ensure ordered pressure-relieving devices (air mattresses and offloading boots) were correctly set up, used, and monitored. Staff interviews confirmed that CNAs did not always document turning or refusals, that care plans and Kardexes did not clearly indicate turning schedules, and that nurses did not consistently verify repositioning or have clear orders for turning frequency, contributing to the identified deficiencies in pressure ulcer prevention and care.
LPNs Performed Pressure Ulcer Staging Outside Defined Scope and Job Descriptions
Penalty
Summary
The deficiency involves the facility’s failure to ensure that LPNs practiced within their professional standards and scope of training regarding pressure ulcer assessment and staging, as required by applicable laws and accepted professional standards. For Resident #20, who had Alzheimer’s disease, depression, spinal stenosis, osteoarthritis, severe cognitive impairment, dependence for most ADLs, incontinence, and was at risk for pressure ulcers, multiple skin issue assessments were completed by LPN #1500. These assessments documented an in-house acquired right heel unstageable pressure ulcer with specific measurements and tissue composition, followed by subsequent documentation of the same right heel wound as a stage 3 pressure ulcer on later dates, with changing measurements and wound bed composition. On observation and interview, LPN #1500 confirmed that she personally measured and staged the right heel pressure ulcer and would document the assessment in the chart. The DON verified that LPN #1500 was the one who staged and measured this resident’s right heel pressure ulcer on three specific dates. For Resident #30, who was admitted with diagnoses including severe protein calorie malnutrition, hemiplegia and hemiparesis after cerebral infarction, muscle weakness, and a stage 4 sacral pressure ulcer, LPN #1500 also completed skin issue assessments. These assessments documented a sacral stage 4 pressure ulcer with detailed measurements and wound bed composition on two separate dates. The DON confirmed that LPN #1500 assessed, staged, and measured this resident’s sacral stage 4 pressure ulcer on those dates. Review of the facility job descriptions for the Treatment Nurse and Unit Manager positions showed no inclusion of pressure ulcer wound assessments, including measuring, staging, and assessments, in their essential functions. The facility was unable to provide any job description for LPNs, and thus there was no documented authorization or role definition for LPNs to perform pressure ulcer wound assessments and staging, despite LPN #1500 performing these functions for at least two residents.
Failure to Provide Adequate Supervision During Mechanical Lift Transfer Resulting in Resident Injury
Penalty
Summary
A deficiency occurred when a resident who required two-person assistance for transfers with a mechanical lift was transferred by only one staff member. The resident, who had diagnoses including chronic diastolic heart failure, osteoporosis, and multiple sclerosis, was dependent on staff for all transfers and was severely cognitively impaired. The physician's order and care plan both specified that two staff members were required for mechanical lift transfers. On the morning of the incident, a CNA transferred the resident alone using a mechanical lift. During the transfer, the wheelchair slipped because one side was not locking, causing the resident to land on the armrest of the wheelchair. The CNA corrected the resident's posture and did not notice an injury at the time, nor did he report the incident to a nurse. The resident was later found to have a new bruise and exhibited increased pain during care, which was different from her usual responses. Subsequent assessment and hospital evaluation revealed that the resident had sustained an acute right femoral neck fracture, requiring surgical intervention. The incident was not reported immediately, and the injury was only discovered after the resident displayed signs of pain and a bruise was noticed. The facility's investigation confirmed that the transfer was performed by one staff member instead of the required two, directly leading to the resident's injury.
Failure to Timely Report Allegations of Sexual Abuse and Inappropriate Sexual Behavior
Penalty
Summary
The facility failed to timely report multiple allegations of inappropriate sexual behavior, including sexual abuse and public indecency, to the state agency and/or local law enforcement as required. In one instance, a resident with multiple medical conditions and moderate cognitive impairment accused a registered nurse of rape during an episode of agitation and altered mental status. The allegation was made in the presence of EMS staff and the nurse, but was not documented or reported to the state agency. The nurse stated he informed the unit manager, who denied receiving this information, and the Director of Nursing later confirmed the allegation was not reported. Another incident involved a cognitively intact resident who reported to social services that her roommate had touched her inappropriately. The social worker notified the DON and separated the roommates, but law enforcement was not contacted because the resident's daughter declined further action. Documentation did not show that the police were notified, despite the facility's policy requiring such reporting for sexual abuse allegations. Additional deficiencies were identified regarding a resident with cognitive and behavioral issues who repeatedly exposed himself and urinated in public areas, witnessed by other residents. Although some incidents were reported to police after complaints from other residents, there was inconsistent documentation and failure to report certain incidents to the state agency. Facility staff, including the administrator and social services supervisor, were at times unaware of incidents or failed to file required incident reports, despite being notified via internal communications. The facility's own abuse prohibition policy mandates reporting such allegations to both the administrator and state authorities, which was not consistently followed.
Failure to Investigate Allegations of Inappropriate Sexual Behavior
Penalty
Summary
The facility failed to thoroughly investigate incidents involving allegations of inappropriate sexual behavior, specifically public urination by a resident in the presence of others. One resident, who was cognitively intact and required some assistance with mobility and toileting, was reported to have urinated in the courtyard in front of other residents and guests. Although a nurse documented that there were no complaints from residents present at the time, there was no documentation of which residents were interviewed or whether residents who may have witnessed the incident from inside the building were questioned. The facility Administrator confirmed that no incident or police report was filed for this event, and there was no documentation of a comprehensive investigation. A subsequent incident involved the same resident urinating in the courtyard, which led to another resident filing a police report, citing frustration with repeated occurrences. The Social Services Supervisor communicated the incident to the Administrator and DON via email, noting that two residents were upset, especially as one had visiting grandchildren. Despite this, there was no documented evidence of a formal investigation into the allegations or the residents' concerns. The facility's Abuse Prohibition Policy requires that all allegations of abuse, including sexual abuse and mistreatment, be reported, investigated, and documented, but these procedures were not followed in these cases.
Improper Glove Use in Food Service
Penalty
Summary
The facility failed to serve food in a safe and sanitary manner, as observed during a survey. A staff member, identified as [NAME] #215, was seen serving food from the steam table while wearing disposable gloves. However, he used his gloved hand to balance pasta in the serving spoon and did not change his gloves throughout the observation period. During this time, he touched various items, including meal plates, serving utensils, a dirty steam table counter, serving trays, warming lids, soup bowls, aluminum foil, and hot dog buns, without changing his gloves. This practice was contrary to the facility's policy, which requires gloves to be changed when they become soiled or contaminated. Additionally, the Dietary Manager, identified as #271, was observed assisting with serving lunch while wearing disposable gloves. He touched multiple items, such as hot dog buns, serving plates, aluminum foil, oven mitts, food pans, and the steamer door, without changing his gloves. Although he did change his gloves at certain intervals, he did not do so before touching food items and other surfaces. Interviews with both [NAME] #215 and the Dietary Manager confirmed that gloves should be changed frequently and immediately after touching food items, as per the facility's Glove Use policy. This failure to adhere to proper glove use protocols had the potential to affect all 115 residents receiving food from the kitchen.
Facility Fails to Maintain Clean and Sanitary Environment
Penalty
Summary
The facility failed to maintain a clean and sanitary environment, affecting four resident rooms and the northwest hallway. During an environmental tour, several issues were observed and verified with the Administrator. In one room, wall tiles were hanging loose behind the toilet pipe, dead bugs were found in the bathroom light fixture cover, the sink faucet had a steady leak, and a broken window ledge was fractured into loose and jagged pieces. In the northwest hallway, ceiling tiles were sagging out of their frames and discolored with a black dry substance. Another room had a five-foot gouge in the sheetrock or drywall, and wallpaper was tearing off the bathroom wall. Additionally, in another room, the main toilet pipe was spraying water when flushed, and the sink faucet had a steady drip.
Failure in Antibiotic Stewardship Protocols
Penalty
Summary
The facility failed to adhere to appropriate antibiotic stewardship protocols, affecting two residents. Resident #39 was administered four separate antibiotics simultaneously, three of which were for prophylactic reasons, without proper justification or testing to confirm the presence of MRSA. The medical records lacked documentation to support the necessity of these antibiotics, and the Director of Nursing confirmed the absence of evidence for testing or clear documentation for the concurrent administration of these antibiotics. Resident #90 was prescribed Bactrim DS for a UTI, which was discontinued, but subsequent orders for prophylactic use continued without documented necessity. The medical records and geriatrics follow-up notes did not provide clinical indications or reassessments for the continued use of Bactrim. The facility's infection control logs failed to document the resident's Bactrim use, indicating a lack of systemic monitoring for effectiveness, adverse reactions, or necessity. The facility's antibiotic stewardship policy emphasizes the importance of appropriate prescribing and discourages prophylactic antibiotic treatment and long-term maintenance use without proper justification. However, the facility did not adhere to these guidelines, as evidenced by the lack of documentation and reassessment of antibiotic use for the residents involved. The Medical Director and DON are responsible for ensuring antibiotics are prescribed appropriately, but the report indicates a failure in this responsibility.
Inaccurate PASARR Documentation for Two Residents
Penalty
Summary
The facility failed to ensure the accuracy of Pre-Admission Screening and Resident Review (PASARR) documents for two residents, affecting their care plans and assessments. For Resident #4, the medical record indicated a diagnosis of vascular dementia, which was not reflected in the PASARR screening completed on 02/28/23. This discrepancy was confirmed by the Social Services Assistant during an interview, highlighting the inaccuracy in the documentation of the resident's medical condition. Similarly, for Resident #75, the PASARR screening dated 11/06/24 failed to include insomnia as a diagnosis, despite it being part of the resident's medical history. The Social Services Assistant confirmed this omission during an interview. The facility's PASARR policy requires accurate documentation to ensure that residents' needs are met, particularly for those with serious mental illness or intellectual/developmental disabilities. The inaccuracies in the PASARR screenings for these residents indicate a failure to adhere to this policy.
Failure to Timely Coordinate Level II Evaluation for Resident
Penalty
Summary
The facility failed to ensure timely coordination with the state mental health agency for a level II evaluation for a resident with mental health diagnoses. The resident, who was admitted with bipolar disorder and schizophrenia, was found to be cognitively intact according to the Minimum Data Set (MDS) 3.0 assessment. A change of condition PASARR was completed, indicating the need for a level II evaluation. However, there was no evidence of coordination with the state mental health agency for this evaluation from the time it was required until several months later. The deficiency was identified through a review of the resident's medical records, facility policy, and staff interviews. The Social Services Assistant (SSA) acknowledged that the coordination for the level II evaluation was not initiated until months after it was required. The facility's policy states that if a level I screening indicates the presence of a mental illness or intellectual/developmental disability, the individual should be referred to the local community mental health program for a comprehensive level II screening. This process was not followed in a timely manner for the resident in question.
Failure to Provide Timely Vision Services
Penalty
Summary
The facility failed to obtain vision services in a timely manner for a resident, leading to a deficiency in care. The resident, who was admitted with diagnoses including epilepsy, was identified as needing an eye exam and new glasses to address vision impairment, which could contribute to fall risks. Despite a nurse contacting an optometry service to schedule an appointment, there was no documentation that the resident received eyeglasses or was seen for an eyewear appointment over several months. The resident expressed concerns about his vision, stating he was unable to read documents or participate in activities due to his impairment. Interviews with facility staff revealed a lack of follow-up and coordination in obtaining the necessary vision services for the resident. The Social Services Assistant admitted to not following up with the optometry provider to ensure the resident received the required services. Additionally, there was a delay in sending the consent form to the appropriate parties, further contributing to the delay in service. The facility's policy required obtaining a physician's order, consent, and making referrals to outside providers, but these steps were not effectively executed, resulting in the resident not receiving timely vision care.
Failure to Monitor Significant Weight Loss in Residents
Penalty
Summary
The facility failed to appropriately monitor the significant weight loss of two residents, leading to deficiencies in nutrition management. Resident #94, who was readmitted with chronic kidney disease and other conditions, experienced a 10% weight loss over approximately one month. The facility did not obtain a re-admission weight or conduct weekly weights as per policy. Despite a dietitian's recommendation for a re-weight within 72 hours after identifying the significant weight change, the facility delayed the re-weight attempt until 01/21/25, which was too late according to the dietitian. Resident #87, diagnosed with type II diabetes mellitus and other conditions, also experienced a significant weight loss of 5.26% over one month. The care plan required monthly weight checks and reporting of significant weight changes. Although the dietitian recommended increasing a nutritional supplement and initiating weekly weight checks, the facility did not begin weekly weights until over a month later. The resident was not added to the weekly weight list promptly, and there were gaps in weight records during this period. Interviews with facility staff, including the registered dietitians and the Director of Nursing, confirmed the lapses in following the facility's Weight Management policy. The policy required residents with significant weight changes to be weighed weekly, but this was not adhered to for the residents in question. The facility's failure to monitor and address the residents' weight loss in a timely manner contributed to the identified deficiencies.
Failure to Document and Address Resident's Catheter Care Behavior
Penalty
Summary
The facility failed to provide adequate planning, treatment, and oversight for a resident's behavior concerning catheter care. The resident, who was admitted with multiple diagnoses including paraplegia, anxiety disorder, and bipolar disorder, was cognitively intact and had a physician's order for a straight catheter procedure every six hours. However, the resident was performing self-catheterization every two hours, contrary to the physician's orders, and exhibited verbally aggressive behavior towards staff when they attempted to assist with the catheter care. The medical record review and staff interviews revealed that there was no documentation or care planning addressing the resident's behavior of performing self-catheterization more frequently than ordered. Additionally, there was no evidence of discussion, planning, or interventions related to the resident's aggressive behavior during catheter care. The Director of Nursing confirmed the lack of documentation and acknowledged the need for it, indicating a deficiency in the facility's behavioral health care and services for this resident.
Lack of Pain Medication Parameters for Resident
Penalty
Summary
The facility failed to provide specific parameters for administering as-needed pain medication for a resident, leading to the potential for unnecessary drug use. Resident #62, who was admitted with diagnoses including paraplegia and chronic pain syndrome, had physician orders for acetaminophen and Oxycodone to be administered as needed for pain. However, there were no clear guidelines on which medication should be used based on the resident's pain level. This lack of parameters resulted in Oxycodone being administered frequently for pain levels between one and seven, while acetaminophen was used less frequently and inconsistently. Interviews with registered nurses confirmed that there should have been parameters in place to guide the administration of these medications. In the absence of such guidelines, the nurses relied on their judgment and the resident's reported pain level to decide which medication to administer. The facility's pain management policy required observation and evaluation of pain intensity, followed by physician notification and implementation of new orders if necessary. However, the policy was not effectively implemented for Resident #62, as evidenced by the inconsistent administration of pain medications without clear parameters.
Inadequate Monitoring and Justification for Psychotropic Medication Use
Penalty
Summary
The facility failed to adequately monitor behaviors and provide appropriate justification for the use of psychotropic medication for a resident with vascular dementia and behavioral disturbances. The resident was prescribed Seroquel for dementia-related behaviors, Ativan for anxiety and agitation, and Trazodone for insomnia. However, the facility did not document sufficient behavioral occurrences to justify the continued use of these medications, particularly Seroquel. The resident's treatment administration record showed only seven nights of behaviors out of 25, and progress notes indicated that the resident did not appear distressed despite being prescribed Ativan for yelling and screaming. The facility's attempts at a gradual dose reduction (GDR) of Seroquel were not adequately documented, and the Certified Nurse Practitioner declined a pharmacy recommendation for GDR without sufficient explanation. Interviews with the Director of Nursing and a Psychiatric Nurse Practitioner revealed that the diagnosis for Seroquel was changed from depression to dementia with behaviors, which was not appropriate. The Psychiatric Nurse Practitioner acknowledged the need for better monitoring and documentation of behaviors to assess the success of GDR. The report highlights a lack of proper justification and monitoring for the use of psychotropic medications in this resident's care.
Failure to Provide Timely Dental Services
Penalty
Summary
The facility failed to provide timely routine dental services for two residents, leading to deficiencies in their care. Resident #103, who was admitted with multiple diagnoses including epilepsy and diabetes, had moderate cognitive impairment and no natural teeth. The resident's dentures were damaged in a motor vehicle accident, and despite the need for replacement being noted in a progress note, there was no follow-up documented for obtaining new dentures from December 2024 to February 2025. Interviews revealed that the resident was struggling to eat without dentures, and there was confusion among staff regarding the responsibility for contacting the previous dentist or hospital to address the issue. Resident #60, admitted with conditions such as epilepsy and osteoporosis, was also affected by the facility's failure to provide dental services. The resident, who was cognitively intact, complained of a sore mouth due to the lack of teeth and was placed on a mechanical soft diet when gums became sore. Despite a nursing note indicating the need for a dentist and dietician consultation, there was no documentation of dental follow-up from September 2024 to February 2025. Interviews with staff revealed a lack of follow-up after consent forms were sent to an ancillary company, and there was no clear communication or coordination to ensure the resident received the necessary dental care. The facility's policy on referrals to outside providers requires obtaining physician orders, resident consent, and ensuring progress notes from service providers are integrated into the resident's care plan. However, the facility failed to adhere to these procedures, resulting in a lack of dental care for the residents. The deficiency highlights a breakdown in communication and coordination among staff, leading to unmet dental needs for the residents involved.
Lack of Supervised Experience for Social Worker
Penalty
Summary
The facility failed to ensure that the social worker hired for a facility with 126 beds had the proper qualifications, specifically one year of supervised social work experience in a healthcare setting. The personnel file for the social worker, who held a Master's in Social Work, did not provide evidence of the required supervised experience. Although a reference check from a previous LTC facility was included, it did not confirm whether the social worker was supervised during her tenure there. Interviews with the Administrator, Social Service Liaison, and Director of Nursing confirmed the lack of evidence regarding the social worker's supervised experience prior to her employment at the facility. This deficiency had the potential to affect all 115 residents residing in the facility.
Deficiency in Pureed Food Preparation
Penalty
Summary
The facility failed to ensure that pureed foods were prepared in a manner that maintained their nutritive value, affecting a resident with a physician-ordered pureed diet. The resident, who had a history of cerebral infarct, epilepsy, malnutrition, dementia, and heart disease, was observed receiving a pureed turkey burger that did not taste like turkey and was described as tasting awful. The preparation of the pureed turkey burger by the Kitchen Manager involved using unmeasured amounts of turkey meat, hamburger buns, broth, and thickener, resulting in a mixture that lacked turkey flavor and tasted like paste or starch. Interviews with the dietician and regional dietician revealed that the preparation of pureed foods should involve blending the food first and then adding either liquid or thickener to achieve the desired consistency, but not both. The facility's policy on pureed food preparation emphasized maintaining nutritive value and taste, using regular menu items, and following recipes. However, the observed preparation did not adhere to these guidelines, leading to the deficiency noted in the report.
Failure to Adhere to Prescribed Diet Texture
Penalty
Summary
The facility failed to ensure that diet textures were served according to physician orders for a resident with specific dietary needs. The resident, who was admitted with multiple diagnoses including respiratory failure, diabetes, chronic kidney disease, and dysphagia, was ordered a mechanical texture diet with pureed vegetables. However, during an observation, it was noted that the resident received a meal tray that included shredded lettuce, which was not in compliance with the pureed vegetable order. This discrepancy was confirmed by the Director of Nursing, who acknowledged that shredded lettuce should not have been served to the resident. Further interviews with the dietician and regional dietician confirmed that pureed diets should be smooth without chunks or pieces, and that all menu items should be provided as ordered. The regional dietician also stated that any deviations from the diet restrictions should be clearly indicated on the meal ticket. The facility's failure to adhere to the prescribed diet texture for the resident represents a deficiency in compliance with dietary orders, as investigated under a specific complaint number.
Failure to Follow Enhanced Barrier Precautions
Penalty
Summary
The facility failed to adhere to infection prevention guidelines for Enhanced Barrier Precautions (EBP) when a Licensed Practical Nurse (LPN) did not wear the appropriate personal protective equipment (PPE) during the care of a resident with a percutaneous endoscopic gastrostomy (PEG) tube. The resident, who was cognitively intact and used a wheelchair, had a medical history that included cerebral infarction, type two diabetes mellitus, chronic kidney disease, and gastrostomy status. The resident was always incontinent of bowel and bladder and used a feeding tube, which required specific care as per physician orders. During an observation, it was noted that the LPN performed hand hygiene and donned gloves but failed to wear a gown while providing PEG tube care, despite the EBP signage outside the resident's door indicating the need for both gloves and a gown for high-contact activities. The LPN confirmed the oversight during an interview, acknowledging that a gown should have been worn. The facility's policy on Enhanced Barrier Precautions, dated earlier in the year, outlined the necessity of such precautions to prevent the transmission of multidrug-resistant organisms (MDROs) for residents with indwelling medical devices, such as feeding tubes.
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 metabolic encephalopathy, muscle weakness, and a history of CVA experienced a fall in his room that was not documented in the medical record until the following morning as a late entry. Two RNs acknowledged that the fall was not recorded at the time it occurred and stated that fall incidents should be documented as soon as possible after the event, resulting in a deficiency for failure to maintain timely, professionally standard medical records.
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.
A resident with cirrhosis, ascites, mood disorder, and alcohol-induced major neurocognitive disorder, and with moderately impaired cognition, was observed sitting on a shower chair in a gown with buttocks exposed and visible from the hallway through an open room door. A CNA left the room quickly after hearing another resident yell and forgot to close the door or pull the privacy curtain, and an RN confirmed the exposure, demonstrating a failure to maintain the resident’s dignity and privacy.
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.
Untimely Documentation of Resident Fall Incident in Medical Record
Penalty
Summary
The deficiency involves the facility’s failure to document a resident’s fall incident in the medical record in a timely manner, in accordance with accepted professional standards. The resident was admitted with diagnoses including metabolic encephalopathy, muscle weakness, and cerebrovascular accident. According to the medical record, a progress note was entered as a late entry on 02/20/26 at 8:21 A.M., stating that the resident had suffered a fall in his room on 02/19/26 at 8:00 P.M. There was no evidence of any documentation of the fall incident entered in the medical record at the time of, or shortly after, the fall on 02/19/26 at 8:00 P.M. During an interview on 03/30/26 at 12:05 P.M., two RNs confirmed that the fall incident was not documented until the following morning and stated that fall incidents should be entered in the medical record as soon as possible following the event. This lack of timely documentation of the fall incident constituted non-compliance with requirements to safeguard resident-identifiable information and maintain medical records in accordance with professional standards.
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.
Resident Left Exposed and Visible From Hallway Due to Failure to Maintain Privacy
Penalty
Summary
The facility failed to ensure resident dignity and privacy when a cognitively impaired resident was left exposed and visible from the hallway. The resident, who had diagnoses including cirrhosis with ascites, mood disorder, and alcohol-induced major neurocognitive disorder, had a BIMS score of eight, indicating moderately impaired cognition. During an observation, the resident was seen sitting on a shower chair in a gown with buttocks exposed, and this exposure was visible from the open room door in the hallway. A Certified Resident Care Associate and a Registered Nurse confirmed that the resident’s buttocks were visible from the hallway. The Certified Resident Care Associate reported that she had left the resident’s room quickly after hearing a resident in an adjacent room yell and, in her haste, forgot to close the door or pull the privacy curtain, resulting in the resident’s exposed state being visible to others. This incident involved one resident out of three reviewed for dignity, in a facility with a census of 52 residents, and was identified through record review, observation, and staff interviews.
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