Laurels Of Steubenville The
Inspection history, citations, penalties and survey trends for this long-term care facility in Steubenville, Ohio.
- Location
- 500 Stanton Boulevard, Steubenville, Ohio 43952
- CMS Provider Number
- 366363
- Inspections on file
- 26
- Latest survey
- January 5, 2026
- Citations (last 12 mo.)
- 5
Citation history
Health deficiencies cited at Laurels Of Steubenville The during CMS and state inspections, most recent first.
A hospice resident with chronic and terminal pain had multiple physician‑approved changes to Oxycodone dosing (scheduled and PRN) that were not timely implemented, and several scheduled doses were not given because the resident was sleeping, with no evidence of appropriate waste or alternative pain control. MAR entries and narcotic control sheets for Oxycodone 5 mg and 10 mg were inconsistent, with doses documented as administered but not signed out on narcotic logs, and the DON confirmed missing narcotic records and confusion between Oxycodone and Morphine orders. Hospice notes and assessments documented non‑verbal signs of pain and agitation, while the MDS showed staff‑observed indicators of pain in a severely cognitively impaired resident who could not self‑report. The resident’s family repeatedly reported that a nurse refused to administer pain medication per hospice orders, especially when the resident was sleeping, and staff interviews corroborated that a nurse did not believe in hospice and did not follow hospice pain orders. These actions and omissions led to uncontrolled end‑of‑life pain and necessitated escalation and changes in the resident’s opioid regimen to regain pain control.
A hospice resident with severe cognitive impairment and chronic pain had multiple discrepancies between the MAR and narcotic control sheets for Oxycodone, Ativan, and Morphine. Numerous controlled doses were signed out on narcotic logs but not documented on the MAR, while other doses were charted as given on the MAR without corresponding entries on the control sheets, leaving tablets and liquid doses unaccounted for and without evidence of proper wastage. The facility’s own medication administration policy requiring complete MAR documentation was not followed, staff reported that a nurse would not administer pain medication per hospice orders, and the resident’s family reported the resident did not receive pain medication as ordered.
Surveyors found that the facility did not maintain a clean and comfortable environment, with multiple rooms and common areas showing evidence of dust, debris, stained and discolored bathroom floors, overflowing trash cans, and dirty surfaces. Housekeeping staff confirmed that limited staffing made it difficult to clean every room daily, and some stains could not be removed with current cleaning methods. Facility leadership was aware of the issues but had no set plans for repairs or improvements at the time of the survey.
A resident with multiple fall risk factors, including muscle weakness and difficulty walking, did not have physician-ordered non-skid strips placed by the bed or brightly colored tape applied to the call bell. Observation confirmed these fall prevention interventions were not implemented as ordered.
An LPN failed to perform hand hygiene after disposing of a dropped medication and before administering additional medications and assisting with eye care for two residents. Additionally, a CNA used improper technique during perineal care by reusing the same area of a washcloth for multiple wipes and adjusting the bed before removing gloves and performing hand hygiene.
The facility failed to ensure over-the-counter medications had clearly labeled expiration dates, affecting 18 residents with aspirin orders. Nurses administered aspirin with illegible expiration dates, contrary to facility policy. Additionally, two residents had unsecured medications at their bedsides without orders to self-administer, violating the facility's medication security policy.
A resident with multiple medical conditions, including kidney failure, was found with an uncovered catheter bag, violating the facility's policy on dignity and privacy. The resident confirmed the absence of a cover, and a nurse acknowledged the oversight. The facility's policy required catheter bags to be concealed, but this was not adhered to, affecting the resident's dignity.
The facility failed to maintain consistent documentation of advanced directives for two residents. One resident's electronic medical record indicated a Full Code status, while a DNRCC form was also present. Another resident's record showed a Full Code status, but a DNRCC order was signed. Staff confirmed that updates to the electronic records and code status book were not made, leading to discrepancies in the residents' code status documentation.
A facility failed to ensure a clean environment for a resident with an abscess on the left gluteal fold. The resident, who required varying levels of assistance for toilet use, was on contact isolation. Bowel movement was observed on the toilet seat, and PPE was disposed of in the bathroom, where the handwashing sink was also located. This unsanitary condition was confirmed by an RN.
A resident with CHF and other health conditions experienced intense itching and significant weight gain, but the facility failed to address these issues timely. The resident's itching was attributed to arthritis and treated with a pain gel, leading to dry, flaking skin. Additionally, significant weight gain and edema were not promptly communicated to the NP, despite being documented in dietary notes and assessments. Confusion over reporting responsibilities contributed to the delay in addressing the resident's condition.
The facility failed to implement appropriate interventions and physician orders for pressure ulcer care for two residents. One resident did not receive the prescribed CMC fiber dressing for a wound, while another resident with a stage four sacral ulcer was not provided with timely interventions to address bed immobility and pressure, including the delayed provision of a low air loss mattress.
A resident with a Foley catheter and bowel incontinence did not receive appropriate care, leading to multiple UTIs and unmanaged constipation. The facility failed to document catheter care and did not activate the necessary tasks in the electronic medical record. Additionally, the resident experienced extended periods without bowel movements, with no interventions or physician notifications documented.
The facility failed to administer oxygen as ordered for two residents, with one resident receiving an incorrect oxygen flow rate and both having undated oxygen tubing. A resident with congestive heart failure had their oxygen set at three liters per minute instead of the ordered two liters, and another resident with heart disease had undated tubing. Staff confirmed the discrepancies, which affected two of three residents reviewed for oxygen use.
A facility failed to consistently complete pre and post dialysis assessments for a resident requiring hemodialysis due to end-stage kidney disease. The care plan required dialysis on specific days and included monitoring for medication side effects and access site conditions. However, documentation from February to March 2025 showed inconsistencies in recording weights, access site conditions, mental status, and medication changes. An LPN confirmed the assessments were not thoroughly completed, contrary to facility policy.
The facility failed to properly manage medications for two residents, leading to deficiencies in pain and insulin administration. A resident with cognitive impairment received narcotic pain medication without documented nonpharmacological interventions or physician contact. Another resident with diabetes received insulin outside prescribed parameters, with no interventions documented for low blood sugar levels. The facility did not adhere to its policies on pain and diabetic management, affecting the quality of care.
A facility failed to document a physician's order for STAT laboratory tests and delayed obtaining these tests for a resident with multiple health issues, including a urinary tract infection. The resident showed signs of lethargy, prompting the NP to order immediate tests, but the laboratory specimens were not collected until the next morning. The DON confirmed the delay and the absence of a written order, and the facility lacked a laboratory services policy.
A facility failed to ensure a resident's pneumonia vaccination was up to date. The resident, with multiple health conditions, had received the PPSV23 vaccine but was not administered the recommended PCV or PCV20 vaccine after one year, as per the facility's policy and the PneumoRecs Vax Advisor application. The DON confirmed the lapse in vaccination.
Failure to Implement and Follow Hospice Opioid Orders Resulting in Uncontrolled End‑of‑Life Pain
Penalty
Summary
The deficiency involves the facility’s failure to implement an effective pain management program for a hospice resident with chronic and end‑of‑life pain, including failure to timely implement and consistently administer ordered opioid medications. The resident had extensive diagnoses including chronic pain syndrome, Parkinsonism, osteoarthritis, neuropathy, prior shoulder replacement, cerebral infarction, and was receiving hospice services for terminal care. The care plan identified the resident as at risk for pain and chronic pain, with interventions to administer pain medications as ordered, monitor for effectiveness and side effects, observe for non‑verbal signs of pain, and notify the physician or hospice for breakthrough pain. The resident’s hospice plan of care included multiple analgesics (Lidocaine patch, Gabapentin, Ibuprofen, Tylenol, and Oxycodone) and recognized that the resident grimaced with movement and had constant pain despite scheduled medications. Hospice recommended increasing Oxycodone to every eight hours scheduled and every four hours as needed, with Zofran as needed, and the physician approved these changes. However, the new Oxycodone and Zofran orders dated one day were not implemented in the facility’s record until three days later at 7:43 p.m., despite narcotic control documentation showing the Oxycodone order had been received earlier. During this period, there was no evidence in the medical record that the new dosing regimen was in place. Additionally, the MAR showed that scheduled Oxycodone doses at 10:00 p.m. and 6:00 a.m. on two consecutive days were not administered because the resident was sleeping, even though the narcotic control sheet showed a 10:00 p.m. dose signed out without documentation of waste. There was also no evidence that as‑needed Oxycodone was administered over several days, despite the resident’s known chronic and hospice‑related pain and staff‑documented non‑verbal indicators of pain on the MDS. Further documentation showed ongoing inconsistencies and omissions in opioid administration and order management. Progress notes indicated that the resident’s pain had been well controlled when all scheduled Oxycodone doses were given, and that missed 2:00 a.m. doses (charted as not given because the resident was sleeping) and changes in the pain regimen were associated with increased pain noted by hospice. There was confusion between Oxycodone and Morphine orders, including a hospice order for Morphine solution as needed without clear discontinuation of Oxycodone, and later notes indicating that Oxycodone should have been continued until Morphine was started, resulting in missed Oxycodone doses. MARs and narcotic control sheets did not match for Oxycodone 5 mg and 10 mg, with doses documented as given on the MAR but not signed out on narcotic logs, and the DON confirmed there were no narcotic control records to support certain documented administrations. Hospice notes and interviews described the resident exhibiting non‑verbal signs of pain and distress (anxiety, crying, moaning, fidgeting, yelling, smacking, kicking, and tense posture), and staff and family reported that at least one nurse did not administer pain medication per hospice orders, sometimes stating the resident did not need it or was fine because she was sleeping. The surveyors concluded that these failures resulted in uncontrolled pain at end of life and required escalation and changes in the resident’s pain regimen to regain control. Additional information in the record showed that the resident’s daughter repeatedly voiced concerns that pain medications were not being administered when the resident was sleeping and that she wanted her mother awakened to receive ordered pain medication. A guest satisfaction concern form documented the daughter’s complaint that a nurse was not giving pain medication when the resident was sleeping, and anonymous staff interviews confirmed that the daughter was upset because a nurse did not administer medications per hospice orders and did not believe in hospice. The facility’s own soft file and corporate review acknowledged family concerns about pain management, and hospice documentation noted that a previous Oxycodone order had not been placed in the resident’s orders, resulting in the resident not receiving it until hospice intervened to have it added back. The DON and Administrator confirmed delays in implementing hospice orders, missed scheduled Oxycodone doses due to the resident sleeping, confusion over concurrent Oxycodone and Morphine orders, and lack of narcotic control documentation to support certain MAR entries. The surveyors determined that these actions and inactions constituted a failure to provide safe, appropriate pain management for a resident requiring such services, resulting in actual harm in the form of uncontrolled end‑of‑life pain. The record also referenced another resident who had concerns that pain medication was not provided upon request in a timely manner, though this concern was not incorporated into the facility’s investigation of pain management issues. The facility’s pain management policy stated that residents’ pain would be evaluated and identified, including in residents with dementia who cannot verbalize pain, and that behaviors such as calling out, facial expressions, refusing to eat, striking out when moved, or increased confusion could indicate pain. Despite this policy, the documentation for this hospice resident showed repeated non‑verbal signs of pain and family reports of suffering, alongside missed or delayed implementation of opioid orders, inconsistent documentation between MARs and narcotic logs, and staff decisions not to administer ordered opioids when the resident was sleeping. These documented events formed the basis of the cited deficiency for failure to provide safe, appropriate pain management.
Unaccounted and Undocumented Controlled Medications for Hospice Resident
Penalty
Summary
The deficiency involves the facility’s failure to properly manage and account for a hospice resident’s controlled pain and anxiety medications, resulting in misappropriation concerns and undocumented administration. The resident had multiple diagnoses including chronic pain syndrome, Parkinsonism, osteoarthritis, neuropathy, cerebral infarction, and severe cognitive impairment, and was non-verbal with staff-assessed indicators of pain such as non-verbal sounds and facial expressions. The resident’s care plans called for consistent pain assessment, administration of ordered pain medications (including Oxycodone, Tylenol, Ibuprofen, Gabapentin, and later Morphine and Ativan), observation for side effects, and close collaboration with hospice to provide maximum comfort. Record review showed significant discrepancies between the MARs and narcotic control sheets for Oxycodone, Ativan, and Morphine. For Oxycodone 5 mg, the narcotic control sheet indicated 60 tablets received, with 27 remaining on one date and only one tablet documented as disposed of later, but there was no narcotic control sheet documentation for 16 doses that were recorded as administered on the MAR over several days. Reconciliation indicated there should have been 11 tablets remaining if the MAR entries were accurate, and the Administrator and DON confirmed there was no control sheet to account for the 27 tablets previously remaining. For Ativan 0.5 mg, multiple doses were signed out on the narcotic control sheet on several dates but were not documented on the MAR, and several refused doses were signed out on the control sheet without any evidence of wastage. Later, when the Ativan dose was changed to 1 mg scheduled and PRN, two tablets were removed per the control sheet but not documented on the MAR. For Morphine Sulfate, the resident had PRN orders that were later increased in dose and frequency, yet the narcotic control sheet showed multiple administrations on different dates that were not signed off on the MAR, and on another date several 0.5 ml doses were removed without the nurse signing the control sheet. The facility’s medication administration policy required recording dose, route, and time on the MAR, which was not followed in these instances. Anonymous staff interviews indicated the resident’s daughter was upset because a nurse would not administer pain medication per hospice orders, and the DON and Administrator confirmed the reconciliation findings, including that a nurse did not sign off Morphine on the control sheets on a specific date. The resident’s daughter also reported that her mother did not receive pain medication as ordered by hospice.
Failure to Maintain Sanitary and Comfortable Environment
Penalty
Summary
The facility failed to maintain a sanitary, clean, and comfortable environment for residents, as evidenced by observations in 10 out of 13 rooms, one of two resident shower/bathing rooms, and common areas. Surveyors, accompanied by the Housekeeping Supervisor and Administrator, observed dusty and debris-laden handrails, dirt around baseboards, stained and discolored bathroom floors, overflowing trash cans, and dirty over-bed tables. In several rooms, there were additional issues such as bags with briefs and tissues on the floor, splatter on bathroom walls, and urine collection containers left behind toilets. The Housekeeping Supervisor verified these findings and acknowledged that some stains and discolorations could not be removed with current cleaning efforts. Further observations revealed holes in bathroom floor linoleum, rust spots, and overflowing trash cans with wet paper towels on the floor. The spa area had thick yellow and black discoloration on the tiles and walls, attributed to soap build-up. The Housekeeping Supervisor reported that only two housekeepers were scheduled daily, making it difficult to clean every room each day, with the goal being to clean each room at least every other day. The Administrator confirmed awareness of the stained bathroom floors and stated that discussions with corporate had occurred, but no definitive plans or timelines for repairs or material purchases were in place at the time of the survey.
Failure to Implement Physician-Ordered Fall Interventions
Penalty
Summary
The facility failed to implement physician-ordered fall interventions for one resident identified as being at risk for falls. The resident had multiple diagnoses, including generalized muscle weakness, difficulty walking, hypertensive heart disease, and affective mood disorder. The admission nursing assessment indicated the resident was alert and oriented, required one-person assistance for toileting and ambulation with a device, and had several fall risk factors such as muscle weakness, balance deficit, and medication use. Interventions listed in the care plan included encouraging appropriate footwear, maintaining a safe environment, PT/OT evaluation and treatment, providing diversionary activities, and ensuring the call light was within reach. Despite these interventions, a review of the resident's physician orders revealed specific directives for non-skid strips to be placed on the left side of the bed and for brightly colored tape to be applied to the call bell. During an observation with a registered nurse, it was verified that neither the non-skid strips nor the brightly colored tape had been implemented as ordered. This failure to follow physician orders for fall prevention measures constituted the identified deficiency.
Failure to Follow Infection Control Practices During Medication Administration and Incontinence Care
Penalty
Summary
The facility failed to implement appropriate infection control practices during both medication administration and incontinence care. During medication administration, an LPN was observed dropping a famotidine tablet on the floor, disposing of it, and then continuing to prepare and administer other medications to a resident without performing hand hygiene. The LPN also touched items in the resident's environment and assisted the resident to a seated position without hand hygiene. After leaving the room to obtain a replacement medication, the LPN returned and administered it to the resident, and then proceeded to assist another resident with eye care, again without performing hand hygiene. The facility's policy required hand hygiene after direct resident contact, which was not followed in these instances. During incontinence care, a CNA was observed providing perineal care to a resident using improper technique. The CNA used the same area of a washcloth to make multiple wipes in the same area of the pelvic region and then used the same area of the washcloth to clean the buttocks, moving from the coccygeal area downward. After completing care, the CNA adjusted the bed using the bed control prior to removing gloves and performing hand hygiene. The CNA later confirmed the improper technique and sequence of care. These actions were not in accordance with infection control practices outlined in the facility's policies.
Medication Labeling and Security Deficiencies
Penalty
Summary
The facility failed to ensure that over-the-counter medications had clearly labeled expiration dates, as observed in two of four medication carts. This deficiency had the potential to affect 18 residents who had orders for aspirin 81 mg. During medication administration, a nurse was unable to find an expiration date on an aspirin bottle but proceeded to administer the medication. Another nurse found the expiration date on a different aspirin bottle to be illegible and had to retrieve a new bottle. The facility's policy required the destruction and reordering of medications with illegible labels, which was not followed in these instances. Additionally, the facility failed to secure medications for two residents. One resident was found with Bengay cream at their bedside without an order to self-administer, and the facility policy required all medications to be securely locked. Another resident was observed self-administering allergy eye drops and had saline nasal spray at their bedside, which was brought in by a family member. The facility policy stated that all medications should be administered by staff and stored securely, which was not adhered to in these cases.
Failure to Ensure Privacy for Resident with Catheter
Penalty
Summary
The facility failed to ensure the privacy and dignity of a resident by not covering the catheter bag as required. Resident #289, who was cognitively intact and had multiple medical conditions including sepsis, congestive heart failure, and kidney failure, was observed in bed with an uncovered catheter urinary drainage bag. The resident confirmed that he had never seen a cover on the catheter bag, and the Registered Nurse acknowledged that all catheter bags should have a privacy cover, which was missing in this case. The facility's policy on Indwelling Urinary Catheter Care and Management, dated February 28, 2025, clearly stated that urinary drainage bags should be concealed with a dignity bag. Despite this policy, the observation on March 17, 2025, revealed non-compliance, as the catheter bag was not covered, compromising the resident's right to dignity. This deficiency was identified during a review of three residents for dignity, affecting one resident directly, with the facility having a total of five residents using catheters.
Inconsistent Advanced Directives Documentation
Penalty
Summary
The facility failed to ensure that advanced directives were consistent within the medical records of two residents. Resident #138, who had severe cognitive impairment, was documented as a Full Code in the electronic medical record, indicating that CPR should be performed if necessary. However, a Do Not Resuscitate Comfort Care (DNRCC) form was also present, indicating that no resuscitation should occur. This inconsistency was confirmed by Regional Nurse #1098, who acknowledged that the order and banner were not updated when the DNRCC form was signed. Licensed Practical Nurse (LPN) #1017 stated that she would rely on the computer banner or orders to determine a resident's code status. Similarly, Resident #139's medical record showed discrepancies in code status documentation. The face sheet and electronic health record indicated a Full Code status, while a signed DNRCC order was also present. Regional Nurse #1098 later provided a form indicating a change to Full Code, which had not yet been scanned into the system. The Director of Nursing (DON) and Regional Nurse #1098 confirmed that the code status book at the nursing station was not updated to reflect the change. This inconsistency was further verified by LPN #197 and Registered Nurse (RN) #1100, who indicated they would check the electronic health record or code book for code status information.
Failure to Maintain Sanitary Environment for Resident with Wound
Penalty
Summary
The facility failed to maintain a clean and sanitary environment for a resident with a wound, specifically affecting a resident with an abscess on the left gluteal fold. The resident's medical record indicated diagnoses of depression, emphysema, anemia, and thrombocytopenia, with varying levels of assistance required for toilet use. An order was in place to cleanse the abscess with normal saline and apply Aquacel AG with border gauze daily. However, on one occasion, bowel movement was observed on both sides of the resident's toilet seat, and the resident was on contact isolation with personal protective equipment disposed of in the bathroom. The sink for handwashing was also located inside the bathroom, necessitating staff to enter the bathroom to dispose of PPE and perform hand hygiene. This unsanitary condition was verified by a registered nurse the following day.
Failure to Address Itching and CHF Indicators
Penalty
Summary
The facility failed to timely address reports of intense itching and skin impairment for a resident with multiple health conditions, including congestive heart failure (CHF) and chronic kidney disease. On several occasions, the resident reported itching on her right shoulder, which was attributed to arthritis and treated with a pain-relieving gel. However, observations revealed dry, flaking skin with scratches, indicating a possible adverse reaction to the gel. Despite the resident's complaints and visible skin issues, there was a delay in consulting with the nurse practitioner to address the itching and flaking skin. Additionally, the facility did not make timely notifications regarding indicators of CHF for the same resident. The resident experienced significant weight gain over several months, which was documented in dietary notes and nursing assessments. Despite the weight gain and the presence of edema in the lower extremities, there was a lack of timely communication with the nurse practitioner or physician to address these changes. The resident's weight was monitored, but the significant weight gain was not consistently reported as a potential sign of worsening CHF. The facility's weight management policy required the dietary manager, unit manager, or registered dietitian to communicate weight changes to the interdisciplinary team and the attending physician. However, there was confusion about the responsibility for reporting significant weight changes, leading to delays in addressing the resident's condition. The registered dietitian acknowledged the importance of timely notifications for residents with heart problems but noted that the responsibility for reporting had shifted without clear communication, contributing to the deficiency.
Failure to Implement Pressure Ulcer Care Interventions
Penalty
Summary
The facility failed to implement appropriate interventions and physician orders for pressure ulcer care for two residents. Resident #49, who has a history of type two diabetes mellitus, quadriplegia, anemia, and peripheral vascular disease, had a physician's order to cleanse a wound on the right lateral malleolus with normal saline, apply a CMC fiber dressing, and cover it with a foam patch daily. However, on 03/18/25, RN #1212 was observed applying only a dry dressing, omitting the CMC fiber dressing, which was later confirmed by the nurse. Resident #139, with multiple diagnoses including acute and chronic respiratory failure, morbid obesity, and chronic lymphedema, was readmitted with a stage four sacral ulcer and other skin issues. The baseline care plan included interventions for skin integrity, but observations revealed that Resident #139 was often lying on her back, adding pressure to the sacrum, and refused to reposition. The facility had not implemented specific interventions to address the risk factors of bed immobility and pressure, and the resident was using a regular bariatric mattress instead of a low air loss mattress, which was only ordered on 03/18/25. The Director of Nursing acknowledged the delay in obtaining the appropriate mattress and stated that it was the responsibility of the marketing director to review referral information for equipment needs. The facility's interdisciplinary team was expected to discuss Resident #139's care after her readmission, but the necessary interventions to prevent further skin breakdown were not timely implemented, contributing to the deficiency in care.
Deficiencies in Catheter and Bowel Care for a Resident
Penalty
Summary
The facility failed to provide appropriate care for a resident who was incontinent of bladder and bowel, leading to deficiencies in preventing urinary tract infections (UTIs) and managing bowel function. The resident, who was cognitively intact, required substantial assistance with toileting and was frequently incontinent of urine and always incontinent of bowel. Despite having a Foley catheter, there was no documentation of catheter care being completed, and the catheter drainage bag was observed lying on the floor, contrary to facility policy. The resident's medical records revealed multiple instances of UTIs with bacteria such as Klebsiella and Escherichia coli. Interviews with staff indicated a lack of awareness regarding the documentation and care procedures for the Foley catheter. The catheter care task was not activated in the resident's electronic medical record, leading to a lack of documented evidence of care since the catheter's placement. Additionally, the resident experienced prolonged periods without bowel movements, with no documented interventions or physician notifications. The care plan indicated a risk for constipation, yet there was no evidence of actions taken to address this issue. Staff interviews revealed a lack of consistent procedures for monitoring and managing bowel movements, contributing to the deficiency in care.
Oxygen Administration Deficiencies in LTC Facility
Penalty
Summary
The facility failed to ensure proper administration of oxygen as ordered by the physician for two residents. Resident #289, who had multiple diagnoses including congestive heart failure and pulmonary fibrosis, was observed with his oxygen set at three liters per minute, contrary to the physician's order of two liters per minute. Additionally, the oxygen tubing was not dated, and the resident was unsure of the correct oxygen setting or when the tubing was last changed. A registered nurse confirmed the incorrect oxygen setting and the absence of a date on the tubing. Similarly, Resident #292, who had diagnoses including kidney failure and heart disease, was observed with undated oxygen tubing. The resident could not verify when the tubing was last changed. A licensed practical nurse confirmed that all tubing should have been dated 03/12/25, as per facility policy, which mandates weekly changes and dating of oxygen masks and tubing. These deficiencies affected two of the three residents reviewed for oxygen administration, with the facility identifying 18 residents utilizing oxygen.
Inconsistent Dialysis Assessments for Resident
Penalty
Summary
The facility failed to ensure that pre and post dialysis assessments were consistently completed for Resident #66, who required hemodialysis services due to end-stage kidney disease. The resident's care plan indicated the need for dialysis on specific days, and interventions included monitoring for medication side effects, checking the access site, and using a communication form to coordinate with the dialysis center. However, a review of the pre and post dialysis assessment forms from early February to mid-March 2025 revealed inconsistencies in documenting weights, the condition of the access site, mental status, and medication changes. An interview with LPN #1003 confirmed that the nurse on duty was responsible for completing the pre-dialysis form before the resident's departure and ensuring the dialysis center completed their portion upon the resident's return. The LPN acknowledged that the assessments had not been thoroughly completed and lacked documented evidence to verify that these assessments were conducted for Resident #66. The facility's policy required daily evaluations of dialysis access sites and potential complications, but this was not consistently adhered to, leading to the deficiency.
Medication Management Deficiencies in Pain and Insulin Administration
Penalty
Summary
The facility failed to ensure proper administration of pain medication and insulin for two residents, leading to deficiencies in medication management. For Resident #3, who was severely cognitively impaired and dependent on staff for most activities, the facility did not have clear parameters for administering narcotic pain medication. The resident received Tramadol for varying pain levels without documented evidence of nonpharmacological interventions being attempted first or the physician being contacted for alternative pain management strategies. The Director of Nursing confirmed the lack of documentation and the absence of a clear scale for assessing when to administer pain medication. For Resident #21, who was cognitively intact and had multiple diagnoses including diabetes mellitus, the facility failed to administer insulin according to the physician's orders. Despite having specific instructions to hold insulin if blood sugar levels were below 150, insulin was administered on several occasions when the resident's blood sugar was below this threshold. Additionally, there was no documented evidence of interventions being implemented when the resident's blood sugar dropped to 61, as per the facility's policy. The Director of Nursing confirmed that insulin was given outside of the prescribed parameters and that the physician should have been notified. The facility's policies on pain management and diabetic management were not adhered to, resulting in the improper administration of medications. The lack of documentation and failure to follow physician orders and facility policies contributed to the deficiencies identified during the survey. These actions and inactions affected the quality of care provided to the residents involved.
Failure to Obtain STAT Laboratory Tests and Document Orders
Penalty
Summary
The facility failed to ensure that a physician's order was written for laboratory tests and that these tests were obtained immediately (STAT) as ordered by the physician for a resident. The resident, who was admitted with multiple diagnoses including urinary tract infection, diabetes, and kidney failure, exhibited lethargy and minimal verbal interaction, prompting the Nurse Practitioner (NP) to order STAT laboratory tests, including a urine test, complete blood count (CBC), and complete metabolic panel (CMP). However, these orders were not documented in the medical record, and the laboratory specimens were not collected until the following morning, indicating a delay in obtaining the STAT tests. Interviews with the Director of Nursing (DON) revealed that the laboratory took up to four hours to pick up the STAT lab, and there was no written order for the laboratory work to be done on the day the NP ordered the tests. The DON confirmed the delay in the laboratory's pickup of the STAT urine culture and acknowledged the absence of a written order for the laboratory tests. Additionally, the facility lacked a laboratory services policy, which may have contributed to the oversight and delay in obtaining the necessary laboratory tests for the resident.
Failure to Update Pneumonia Vaccination for Resident
Penalty
Summary
The facility failed to ensure that a resident's pneumonia vaccination was up to date, affecting one of the five residents reviewed for vaccination status. The resident, who was admitted with diagnoses including chronic obstructive pulmonary disease, acute respiratory failure, epilepsy, chronic kidney disease, and shortness of breath, had received the pneumococcal polysaccharide vaccine 23 (PPSV23) on 11/19/23. According to the PneumoRecs Vax Advisor application and the facility's policy, residents over a certain age who have received the PPSV23 should be administered the Pneumonia conjugate vaccine 15 (PCV) or PCV20 one year after the PPSV23. However, the Director of Nursing confirmed that the resident was not up to date with her pneumonia vaccines, indicating a lapse in following the recommended vaccination schedule as per the facility's policy.
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A resident with intact cognition receiving Medicare Part A skilled services for metabolic encephalopathy had services discontinued while benefit days remained, but the facility did not issue the required Skilled Nursing Facility Advance Beneficiary Notice (SNF ABN). The Social Services Director later confirmed that no SNF ABN was provided and reported she believed only a Notice of Medicare Non-Coverage (NOMNC) was needed when all skilled services were stopped. This practice conflicted with the facility’s written policy, which required SNF ABNs to be issued when extended care items or services were initiated, reduced, or terminated due to expected non-coverage by Medicare.
Surveyors identified that the facility exceeded the acceptable medication error rate when two residents with type 2 DM received insulin doses that were not administered according to orders or manufacturer instructions. In two separate observations, an LPN administered Novolog and another LPN administered insulin glargine and insulin lispro without priming the insulin pens, and the insulin lispro and Novolog were given after the residents had already consumed a significant portion of their breakfast meals, despite orders for administration before meals. Manufacturer information for both insulin products required priming before each injection to ensure accurate dosing, and facility policy required medications, including insulin, to be administered safely, timely, and in accordance with prescriber orders and specified time frames.
Surveyors found that the facility failed to document tray line food temperatures for multiple meals served from two dining room kitchenettes, despite having a “Trayline Taste & Temperature Log” and a policy requiring food to be stored, prepared, distributed, and served according to professional food safety standards. Review of logs showed repeated missing entries for breakfast, lunch, and dinner services in both the Harrison and McClellan dining areas, and the Senior Director of Culinary Services confirmed that temperatures had not been recorded for those meals, potentially affecting all residents receiving meals from those kitchenettes.
The facility failed to conduct and document required periodic care conferences for two residents, despite multiple comprehensive, quarterly, and significant change MDS assessments and a policy requiring periodic care conferences with resident and/or family participation. One resident with Parkinson’s disease, post-stroke hemiplegia, TIA, DMII, and depression had only two documented care conferences over a year, while another resident with aphasia, cerebrovascular disease, DMII, gait difficulty, coagulation defect, depression, and muscle weakness had no documented care conferences in the past year, aside from a declined invitation to the representative. The UCC confirmed that care conferences were expected to occur quarterly and that no additional documentation existed for either resident.
A resident with Alzheimer's disease and type II DM, who required extensive assistance with ADLs and was receiving scheduled Lantus and sliding-scale Humalog, experienced a severely elevated blood glucose level. The on-call provider was notified and ordered an additional dose of lispro insulin with a directive to recheck the blood glucose after administration. Nursing staff administered the extra insulin but did not document any follow-up blood glucose check, and the DON confirmed that this reevaluation was required by the facility's abnormal blood glucose policy and was not completed or documented.
A resident with Parkinson’s disease, dementia, and hypothyroidism was prescribed levothyroxine once daily along with other medications. A consultant pharmacist’s monthly drug regimen review recommended that levothyroxine be given in the morning on an empty stomach, 30–60 minutes before food, per manufacturer instructions. The medical record contained no documented physician response to this recommendation, and the MAR showed the drug scheduled for morning administration while the resident was observed eating breakfast and receiving the medication at the same time. An LPN confirmed administering levothyroxine during the meal, and the DON verified there was no documentation explaining whether or why the pharmacist’s recommendation was or was not followed, resulting in a failure to act on and document the identified irregularity.
A resident with severe cognitive impairment, multiple comorbidities, documented gait and balance abnormalities, and a high fall risk was care planned and assessed by therapy to require contact guard assistance and use of a gait belt for transfers and ambulation. While being assisted by a CNA from a recliner to the bathroom with a walker, the CNA did not apply a gait belt, even though the resident had a known tendency to lean backward when standing. As the CNA reached to open the bathroom door, the resident lost balance and fell backward, striking the back of the head, and was later found by an LPN without a gait belt in place, contrary to the facility’s gait belt policy and the resident’s assessed needs.
A resident with CKD stage five requiring peritoneal dialysis (PD) was admitted with pre-admission physician orders for three daily PD exchanges and monitoring for peritonitis (fever, abdominal pain, cloudy effluent), but these monitoring orders were not entered into the facility’s physician orders. The care plan referenced PD and general monitoring but did not specifically address peritonitis monitoring. Paper PD flowsheets showed incomplete and inconsistent documentation of exchanges and resident condition, including missing condition/comments for individual treatments and no record of one ordered PD exchange. The PD cycler flowsheet lacked effluent descriptions on multiple days. The PD nurse reported facility staff were expected to monitor effluent and symptoms, and the DON confirmed the absence of specific peritonitis monitoring orders, lack of an order for the PD cycler, and documentation gaps, despite a facility policy requiring ongoing assessment and monitoring for complications before, during, and after dialysis treatments.
A nurse was observed preparing multiple oral medications for a resident with depression, traumatic brain injury, anxiety, and impaired cognition by pushing tablets and capsules from unit-dose cards directly into her ungloved hand and then using her fingers to place them into a medication cup. In a follow-up interview, the RN confirmed this practice and acknowledged that the correct procedure is to dispense medications directly from the card into the cup, contrary to the facility’s medication administration policy requiring adherence to good nursing principles and practices.
A resident with Alzheimer’s disease, diabetes, anxiety, significant ADL dependence, and behavioral symptoms was observed seated in a chair positioned against the nursing station with a locked wheelchair placed directly in front, also against the nursing station, effectively restricting movement. An LPN confirmed both wheelchair wheels were locked and that it should not have been placed there, while a CNA stated she had positioned the wheelchair to prepare for lunch, was unable to complete the transfer, and left it in place, acknowledging this was wrong. This arrangement conflicted with the facility’s restraint policy, which prohibits physical restraints except when alternatives are ineffective for treating a medical symptom and defines restraints as devices adjacent to the body that cannot be easily removed and that restrict freedom of movement or access to the body.
Failure to Issue Required SNF ABN When Discontinuing Medicare Part A Services
Penalty
Summary
The deficiency involves the facility’s failure to issue a Skilled Nursing Facility Advance Beneficiary Notice (SNF ABN) when Medicare Part A services were discontinued for a resident who still had available benefit days. The resident was admitted with a diagnosis of metabolic encephalopathy and had intact cognition per the Minimum Data Set assessment. The facility’s own SNF Beneficiary Notification Review documented that Medicare Part A skilled services began on 02/11/26 and the last covered day was 03/11/26, and that the facility initiated discharge from Medicare Part A services before the resident’s benefit days were exhausted. Despite this, no SNF ABN was provided to the resident or the resident’s representative. During interviews, the Social Services Director stated that the SNF ABN was issued hours prior to the last covered day but, upon reviewing her files, confirmed that no SNF ABN had actually been issued for this resident. She further explained that she believed an SNF ABN was only required if one skilled service remained and that if all skilled services were being discontinued, only the Notice of Medicare Non-Coverage (NOMNC) needed to be issued. The Administrator, however, stated that a resident should always receive both a SNF ABN and a NOMNC when Medicare Part A services are discontinued and benefit days remain. Review of the facility’s written policy dated 03/28/23 showed that the facility was required to issue SNF ABNs for initiation, reduction, or termination of extended care items or services when Medicare payment was not expected, which did not occur in this case.
Plan Of Correction
This Plan of Correction is submitted as required under State and Federal law. This Plan of Correction does not constitute an admission on the part of the Facility that the findings cited are accurate, that the findings constitute a deficiency or that the scope and severity regarding the deficiency cited are correctly applied. Any changes to the Facility's policies and procedures should be inadmissible in any proceeding on that basis. Without admitting or denying the validity or the existence of the alleged noncompliance, the Facility submits this Plan of Correction with the intention that it be inadmissible by any third party in any civil or other action against the facility or any employee, agent, officer, director or shareholder of the Facility. The Facility is utilizing this Plan of Correction as its allegation of substantial compliance as of 05/29/2026 F-0582 Corrective action for resident/s: On 5/14/26 Resident #34 was informed of rights and responsibilities related to Advanced Beneficiary Notice and voiced understanding of information for future reference by administrator. Identification of other residents who may be affected: Any resident receiving skilled services from nursing or therapy services. The Administrator audited all residents who were discharged from skilled services in the past 30 days to ensure they were issued a Notice of Non-Coverage and Advanced Beneficiary Notice on 5/29/26. No non-compliance was noted. Measures for systemic change: On 5/14/2026 Business Office Manager, Director of Rehab, Minimum Data Set nurse, Director of Nursing and Social Services Director were educated on proper procedure of issuing of Notice Of Medicare Non Coverage and Advanced Beneficiary Notice by administrator. All upcoming discharges from skilled services will be reviewed weekly at Utilization Review meeting to ensure notices will be delivered timely. How Corrective Action will be monitored: Administrator or designee to complete audits of all residents being discharged from skilled services to ensure they were issued a Notice of Non-Coverage and Advanced Beneficiary. This audit will be completed weekly x 4 weeks, then monthly x 2 months. Corrective action will be initiated for any noted non-compliance. Audit findings will be reviewed as part of the monthly quality assurance process to determine the need for further monitoring. Date of Compliance 5/29/26
Insulin Administration Errors and Failure to Prime Insulin Pens
Penalty
Summary
The deficiency involves the facility’s failure to maintain a medication error rate below 5%, with surveyors identifying 3 errors out of 28 medication administration opportunities, resulting in a 10.71% error rate. For one resident with type 2 diabetes mellitus and moderate cognitive impairment, the physician’s order directed Novolog insulin 10 units via subcutaneous pen-injector to be given before meals. During an observed medication pass, the LPN administered 10 units of Novolog insulin without priming the pen and did so after the resident had already consumed approximately 50% of the breakfast meal. The LPN later confirmed she did not prime the pen and acknowledged that the insulin was ordered to be administered prior to meals. Manufacturer instructions for the Novolog FlexPen specified that an air shot (priming) must be performed before each injection to ensure proper dosing. Another resident, also diagnosed with type 2 diabetes mellitus and with intact cognition, had orders for insulin glargine 35 units subcutaneously twice daily and insulin lispro 20 units subcutaneously before meals, plus 12 units subcutaneously if blood glucose was between 251 mg/dL and 300 mg/dL. During an observed medication administration, an LPN administered 35 units of insulin glargine and 32 units of insulin lispro without priming the insulin pens and after the resident had consumed approximately 90% of the breakfast meal, despite orders for insulin lispro to be given before meals. The LPN later stated she could not remember if she had primed the pen and acknowledged that the insulin was ordered to be administered prior to meals. Manufacturer information for insulin lispro stated that the pen must be primed before each injection to confirm insulin delivery and remove air, and that failure to prime could result in too much or too little insulin. The DON confirmed the expectation that insulin be administered as ordered, including priming each pen with two units before dialing the prescribed dose, and facility policy required medications, including insulin, to be administered safely, timely, and in accordance with prescriber orders and required time frames.
Plan Of Correction
This Plan of Correction is submitted as required under State and Federal law. This Plan of Correction does not constitute an admission on the part of the Facility that the findings cited are accurate, that the findings constitute a deficiency or that the scope and severity regarding the deficiency cited are correctly applied. Any changes to the Facility's policies and procedures should be inadmissible in any proceeding on that basis. Without admitting or denying the validity or the existence of the alleged noncompliance, the Facility submits this Plan of Correction with the intention that it be inadmissible by any third party in any civil or other action against the facility or any employee, agent, officer, director or shareholder of the Facility. The Facility is utilizing this Plan of Correction as an allegation of substantial compliance as of 5/29/2026. F-0759 Corrective action for resident/s: Residents #21 and #22 were assessed and evaluated by nurse and Director of Nursing 5/14/26. Resident #21 and #22 both denied any adverse effects and none were noted upon assessment by the Director of Nursing on 5/14/2026. Notification made to physician on 5/14/2026. LPN # 2 competency Eval on insulin administration with the Director of Nursing completed 5/14/2026. Identification of other residents who may be affected: Diabetic residents on assignment of LPN #2/station 2 have the potential to be affected and were assessed by the DON/Designee on 5/14/26 and found to be within normal limits. Measures for systemic change: All Nurses were educated by the Director of Nursing on the steps for Insulin administration per competency, diabetes clinical protocol policy, Medication and treatment orders policy, administering medications policy, and Obtaining fingerstick Glucose Level policy On 5/14/2026. How Corrective Action will be monitored: Director of Nursing and Assistant Director of Nursing will complete insulin administration audits on 5 nurses. This audit will be completed weekly x 4 weeks, then monthly x 2 months. Corrective action will be initiated for any noted non-compliance. Audit findings will be reviewed as part of the monthly quality assurance process to determine the need for further monitoring. Date of Compliance: 5/29/2026
Failure to Document Tray Line Food Temperatures in Dining Room Kitchenettes
Penalty
Summary
The deficiency involves the facility’s failure to document tray line food temperatures for meals served from the Harrison and McClellan Dining Room kitchenettes, as required by professional standards for food service safety and the facility’s own policy. Review of the “Trayline Taste & Temperature Log” (revised September 2018) showed missing temperature documentation for multiple meals from the Harrison Dining Room kitchenette, including dinner on 03/30/26 and 03/31/26, lunch and dinner on 04/01/26 and 04/02/26, dinner on 04/07/26, and lunch and dinner on 04/08/26 and 04/10/26. The Senior Director of Culinary Services confirmed during interview that tray line food temperatures were not documented on the log for these meals. Similarly, review of the same log for the McClellan Dining Room kitchenette revealed that tray line food temperatures were not documented for dinner on 04/01/26, breakfast and lunch on 04/02/26, and lunch and dinner on 04/07/26. The Senior Director of Culinary Services also verified these omissions during interview. The facility census at the time was 27 residents, and the governing “Food and Nutrition” policy, approved on 09/07/21, stated that the facility must store, prepare, distribute, and serve food in accordance with professional standards for food service safety.
Plan Of Correction
F812 The facility will continue to ensure food temperatures are completed before meals are served for all residents. To ensure compliance with this standard the following measures have been taken: 1. Immediately 4/15/26 culinary supervisor #224 was re-educated by Dietary Manager to this standard and policy "Food and Nutrition" which includes documentation of food temperatures. 2. All dietary staff have been re-educated to the standard and policy "Food and Nutrition" during the month of April 2026. 3. Audits of food temperature documentation to be completed by Dietary Manager 4 x per week for 4 weeks then weekly for 4 weeks. 4. Administrator to validate audits/compliance and provide additional training as needed. Administrator will present to QAPI committee for ongoing monitoring and further direction.
Failure to Conduct and Document Required Care Conferences
Penalty
Summary
The deficiency involves the facility’s failure to complete and document comprehensive care conferences at required intervals in accordance with care plan regulations and facility policy. For one resident with Parkinson’s disease with dyskinesia, cognitive communication deficit, hemiplegia and hemiparesis following cerebral infarction, transient cerebral ischemic attack, type II diabetes mellitus, and major depressive disorder, the record showed multiple MDS assessments over a one-year period, including annual, quarterly, and significant change assessments. However, only two care conferences were documented during the last 12 months, despite the expectation that care conferences be conducted quarterly with the resident and family when possible. The Unit Care Coordinator confirmed that no additional care conference documentation existed for this resident beyond the notes dated 04/21/25 and 01/02/26. A second resident, with diagnoses including aphasia following cerebrovascular disease, cerebral infarction, type II diabetes mellitus, unsteadiness on feet, difficulty in walking, coagulation defect, depression, and muscle weakness, also had multiple MDS assessments completed over the review period, including quarterly and annual assessments. The record contained a note that a care conference was offered to the resident’s representative, who declined to attend, but there was no documentation of any care conferences for the most recent 12 months. The Unit Care Coordinator confirmed that no other care conference documentation was available for this resident. Facility policy stated that periodic care conferences involving the resident, family, and the interdisciplinary team are part of the care planning process, but the required periodic care conferences and corresponding documentation were not completed for these two residents.
Plan Of Correction
THIS PLAN OF CORRECTION SERVES AS BERKELEY SQUARE'S CREDIBLE ALLEGATION OF SUBSTANTIAL COMPLIANCE AS OF June 1, 2026. Without admitting or denying the validity or existence of the alleged deficiencies, Berkeley Square provides the following Plan of Correction: F657 The facility will continue to document completion of care conferences at the required intervals for all residents, including residents #04 & #15. To ensure compliance with this standard the following measures have be taken: 1. The social service designee and the inter- disciplinary team were re-educated by the administrator to the facility policy "Care Conference" on 4/29/26 and verbalized understanding. 2. Care conferences for resident #04 and resident #15 were conducted on or before 4/29/2026 by the interdisciplinary team. 3. Review of all other residents was conducted by the social service designee to validate and ensure that care conference schedule is up to date with timely care conferences scheduled for them on 4/15/2026. Audits of care conferences to be completed weekly for four weeks and then monthly after that by the social service designee. Documentation of the care conference including any identified concerns in the medical record. Administrator to validate audits/compliance and provide additional training as needed. Administrator will present results of these audits to QAPI committee for ongoing monitoring and further direction.
Failure to Reevaluate Blood Glucose After Treatment for Hyperglycemia
Penalty
Summary
The facility failed to ensure that a resident with diabetes received treatment in accordance with professional standards of practice when nursing staff did not reevaluate the resident's blood glucose after treatment for severe hyperglycemia. The resident, admitted with diagnoses including Alzheimer's disease, type II diabetes mellitus, and depression, had physician orders for Humalog insulin on a sliding scale before meals, Lantus insulin 25 units daily, and lisinopril 5 mg daily. The resident required extensive assistance with activities of daily living, including transfers, toileting hygiene, eating, and bathing. On the evening in question, the resident's blood glucose was documented as 532 mg/dL, and the on-call provider was notified. The provider gave a new order to administer an additional 8 units of lispro (Humalog) and to recheck the blood glucose in 30 minutes. The electronic medication administration record showed that the blood glucose of 532 mg/dL was obtained at 9:00 p.m. and that the additional 8 units of lispro were administered at 9:21 p.m. However, there was no documentation in the resident's chart that the blood glucose was rechecked after the additional insulin was given. In an interview, the DON confirmed there was no evidence of reevaluation and verified that, according to the facility's "Abnormal Blood Glucose Procedure" policy, the resident should have been reevaluated and that the evaluation step should have been included in the progress note documentation.
Plan Of Correction
F684 The facility will continue to ensure all residents, including #03, receive treatment in accordance with professional standards of practice and reevaluated for hyperglycemia. To ensure compliance with this standard the following measures have been taken: 1. The director of nursing assessed resident #03, reviewed documentation and orders and found no ill effects immediately 4/16/26. 2. All licensed nurses were re-educated to facility policy "Blood Glucose Monitoring" by the Director of Nursing/designee in April 2026. 3. Audits of like-residents that require blood sugar checks to be completed by the director of nursing/designee two times a week for 4 weeks and then monthly after that to validate correct follow through when there is abnormally high blood glucose result. The Administrator will bring results of these audits to the QAPI committee for ongoing monitoring and further direction.
Failure to Act on Pharmacist Drug Regimen Recommendation for Thyroid Medication
Penalty
Summary
The deficiency involves the facility’s failure to ensure that pharmacy recommendations from the monthly drug regimen review were acted upon and documented for a resident. The resident was admitted with diagnoses including Parkinson’s disease, dementia, and hypothyroidism, and had current physician orders for levothyroxine 150 mcg once daily, buspirone 50 mg twice daily, and losartan 100 mg once daily. A medication regimen review dated 11/25/2025 included a consultant pharmacist recommendation that levothyroxine be administered consistently in the morning on an empty stomach, at least 30–60 minutes before food, per manufacturer instructions. There was no specific physician response in the medical record to this recommendation, and the facility’s policy stated that consulting pharmacist reviews are sent to nursing and addressed with the primary care provider or consulting specialist for review and follow-up. Review of the resident’s medication administration record for April 2026 showed levothyroxine scheduled for 9:00 a.m. On observation, the resident was seen eating breakfast in the dining area at 8:03 a.m., and an LPN reported administering the levothyroxine 150 mcg to the resident while the resident was in the dining area eating breakfast. The DON confirmed there was no evidence in the resident’s medical record explaining why the consultant pharmacist’s recommendation from 11/25/2025 was or was not acted upon. This lack of documented physician review and action on the pharmacist’s identified irregularity constituted noncompliance with the drug regimen review requirements.
Plan Of Correction
F756 The facility will continue to ensure the pharmacy recommendations from the monthly drug regimen review by a licensed pharmacist are acted upon for all residents, including #08. To ensure compliance with this standard the following measures have been taken: 1. Resident #08 was assessed by the registered nurse and med review completed by 4/28/26. After review of resident's drug regime's, it was discovered that resident #8 had 2 separate medication recommendations on the same form, to be reviewed by two separate practitioners, pharmacy has been instructed and agreed to separate meds on individual forms. 2. Licensed nurses re-educated to facility policy "Drug Regimen Review" by Director of nursing/designee in April 2026 and no later than 5/8/26. Licensed nurses are responsible for ensuring the reviews and recommendations are given to the physician for timely review. 3. Review of all other current residents Drug Regimen orders completed by Director of nursing/designee on 4/16/26 to ensure recommendations were followed up on/reviewed by the physician and address concerns if needed. 4. Audit of drug regime recommendations, pharmacy recommendations, and physician follow up to be completed weekly for four weeks by the Director of nursing/designee. Administrator will present results of these audits to the QAPI committee for ongoing monitoring and further direction.
Failure to Use Required Gait Belt During Ambulation Resulting in Resident Fall
Penalty
Summary
The deficiency involves the facility’s failure to ensure that a required gait belt was used while assisting a high fall‑risk resident with ambulation, resulting in a fall with head injury. The resident had multiple diagnoses including metabolic encephalopathy, hypertension, osteoarthritis, muscle weakness, gait and mobility abnormalities, major depressive disorder, anxiety, and visual hallucinations. Admission and subsequent MDS and fall risk assessments documented that the resident was severely cognitively impaired, required moderate to maximal assistance with transfers and ambulation, could not independently come to a standing position, exhibited loss of balance while standing, used an assistive device, and had decreased muscle coordination. The resident had a history of falls prior to admission and was assessed as being at high, later moderate, risk for falls. The resident’s fall care plan identified her as at risk for falls and included interventions such as providing maximum to moderate assistance with transfers and walking short distances, use of a walker and wheelchair, and following the facility’s fall protocol. Therapy notes and care conference documentation indicated that the resident leaned backwards when standing, required contact guard to minimal assistance for bed mobility and transfers, and needed constant verbal cueing for safe sequencing during toilet transfers. The physical therapist confirmed that the resident was to use a gait belt with staff when ambulating, and the DON verified that therapy had assessed the resident as requiring contact guard assistance and a gait belt for ambulation and transfers. On the day of the incident, a CNA was assisting the resident from her recliner to the bathroom using a walker. The CNA walked beside the resident, providing guidance and support, and reported having a hand on the resident while assisting her. As they approached the bathroom door, the CNA reached for the doorknob to open it, and at that moment the resident began to lose her balance and fell backwards to the floor, striking the back of her head. The nurse who responded found the resident on her back at the foot of the bed with her feet near the bathroom, noted a red raised area on the back of the head, and documented that the resident was not wearing a gait belt and that the gait belt was on the dresser. In the facility’s investigative summary and in interviews, the CNA acknowledged that she did not have a gait belt on the resident while ambulating her, despite the resident’s assessed need for hands‑on assistance and gait belt use per facility policy and the resident’s care and therapy plans.
Failure to Implement PD Orders and Monitor Resident Receiving Peritoneal Dialysis
Penalty
Summary
The deficiency involves the facility’s failure to implement pre-admission physician orders for peritoneal dialysis (PD) and to provide ongoing monitoring for a resident with chronic kidney disease (CKD) stage five who required PD. Pre-admission orders dated 11/14/25 specified three daily PD exchanges at 6:00 A.M., 2:00 P.M., and 10:00 P.M., and directed staff to monitor for signs and symptoms of peritonitis, including fever, abdominal pain, and cloudy effluent. These monitoring orders were not entered into the facility’s physician orders. The resident’s care plan noted the need for PD and included general monitoring interventions (labs, signs of bleeding, bacteremia, septic shock, and significant vital sign changes), but did not specifically address the ordered monitoring for peritonitis. Review of PD documentation showed incomplete and inconsistent charting of treatments and resident condition. The paper peritoneal flowsheet had columns for time of PD and condition/comments, including instructions to call the nurse immediately for cloudy fluid, abdominal pain, or fever. However, the first entry on 11/15/26 at 2:00 P.M. only noted that the PD nurse completed the exchange, and the 10:00 P.M. entry that day had no condition/comment documentation. Subsequent days (11/16/25, 11/17/25, and 11/18/25) contained only one condition/comment entry per day rather than for each exchange, and there was no documentation that the 6:00 A.M. PD on 11/18/25 was completed. The PD cycler flowsheet starting 11/19/25 lacked any description of the effluent on multiple days. The PD nurse from the dialysis company stated facility staff were expected to monitor effluent for cloudiness and assess for abdominal pain and fever, and the DON confirmed there was no electronic physician order for peritonitis monitoring or for use of the PD cycler, that the paper charting did not allow for effluent description or symptom documentation for each treatment, and that PD was not documented at one ordered time. The facility’s dialysis policy required ongoing assessment and monitoring for complications before, during, and after treatments, which was not reflected in the documentation for this resident.
Improper Infection Control During Medication Administration
Penalty
Summary
Surveyors identified a deficiency in infection prevention and control related to medication administration for Resident #29. The resident was admitted on 02/28/14 with diagnoses including depression, traumatic brain injury, and anxiety, and had impaired cognition per a quarterly MDS assessment. During an observation on 03/25/26 at 6:58 A.M., RN #281 prepared the resident’s medications by removing an Amoxicillin-Pot Clavulanate tablet from the medication card and pushing it directly into her ungloved hand, then using her fingers to place the pill into a medication cup. The same process was observed for multiple other medications, including Escitalopram Oxalate, Furosemide, Sennosides, Lyrica, and Vitamin D, each being pushed from the card into the RN’s ungloved hand and then transferred by her fingers into the medication cup before administration to Resident #29. In a subsequent interview at 7:27 A.M. the same day, RN #281 confirmed she had placed each medication into her ungloved hands prior to administration and acknowledged that the proper procedure was to push the pills directly from the card into the medication cup. Review of the facility’s “Medication Administration – General guidelines” policy, revised 10/08/25, stated that medications are to be administered in accordance with good nursing principles and practices. This practice failure was cited as a deficiency under Complaint Number 2681777.
Improper Use of Wheelchair as a Physical Restraint
Penalty
Summary
Surveyors identified a deficiency related to the facility’s failure to ensure a resident was free from physical restraints. Resident #7, admitted with diagnoses including Alzheimer’s disease, diabetes mellitus, and anxiety disorder, was documented on a recent MDS as rarely understood and dependent for ADLs except eating. The resident ambulated independently on the unit without an assistive device and had documented verbal and other behaviors occurring one to three days during the look-back period. The care plan noted the resident had potential to be physically aggressive, chase staff, throw objects, and be combative with care, with interventions such as offering choices, administering medications as ordered, and intervening early when agitation occurred. During an observation and interview, Resident #7 was found sitting in a chair with the right arm of the chair positioned against the nursing station and a wheelchair placed directly in front of him. The left arm of the wheelchair was also against the nursing station, and both wheelchair wheels were locked, creating a barrier that appeared to restrain the resident, who was sleeping with his knees touching the locked wheelchair. An LPN confirmed both wheelchair wheels were locked and that the wheelchair should not have been placed in front of the resident. A CNA reported she had placed the wheelchair there in preparation to get the resident up for lunch, was unable to transfer him, and left the wheelchair in that position, acknowledging it was wrong to keep it there. The facility’s physical restraint policy stated that physical restraints are not used except when alternatives are not appropriate or effective for treating a medical symptom and defined physical restraints as any device attached or adjacent to the body that the individual cannot easily remove and that restricts freedom of movement or access to the body.
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