Laurels Of West Columbus, The
Inspection history, citations, penalties and survey trends for this long-term care facility in Columbus, Ohio.
- Location
- 441 Norton Road, Columbus, Ohio 43228
- CMS Provider Number
- 366481
- Inspections on file
- 29
- Latest survey
- October 16, 2025
- Citations (last 12 mo.)
- 9 (1 serious)
Citation history
Health deficiencies cited at Laurels Of West Columbus, The during CMS and state inspections, most recent first.
A resident with dementia and multiple chronic conditions, who was cognitively impaired but ambulatory, left the facility without staff knowledge and was found confused about a mile away. Staff were unaware of the resident's absence until notified by an off-duty CNA, and the incident was not investigated or reported to the State Survey Agency as required.
A resident with Alzheimer's disease was discharged without the required discharge summary, AMA documentation, or proper notification to the resident or her family. An LPN confirmed that the necessary documentation for a safe and orderly discharge was not completed, and facility policy requiring discharge planning and documentation was not followed.
A resident with multiple complex medical conditions did not receive ordered daily wound care and dressing changes for a cervical spine incision and JP drain site during their stay. Despite clear physician orders and documentation, staff did not perform the required treatments, and an LPN confirmed the omission without explanation. This deficiency was identified during a complaint investigation and reflected ongoing non-compliance.
A resident with multiple chronic conditions received both discontinued and new furosemide orders on two consecutive days, resulting in a significant medication error where the resident was administered 140 mg instead of the intended 80 mg daily dose. This occurred due to failure to discontinue the previous order when the new one was initiated, contrary to facility policy.
A resident with dementia and a history of elopement, wearing a Wanderguard, exited the facility undetected and was later found by hospital security in a parking lot with injuries. Staff did not hear door alarms, and the facility lacked surveillance to determine how the resident left. The resident had previously been assessed as not at risk for elopement despite cognitive impairment and wandering behaviors, and some staff reported that residents had access to door codes.
Two residents missed or had to reschedule important outside medical appointments due to errors in lab collection and medication administration. One resident missed a chemotherapy session after labs were drawn incorrectly on two occasions, while another missed a bone density test because staff gave a calcium medication without an order to hold it before the appointment. Both incidents reflect a failure to coordinate care and services needed for residents to attend scheduled appointments.
A resident with a PEG tube and multiple medical conditions was admitted with a physician's order for nocturnal Jevity 1.5 tube feeding. Due to the facility being out of Jevity 1.5, an LPN substituted Jevity 1.2 two days after admission, resulting in the resident not receiving the ordered formula for two nights.
A resident with multiple chronic conditions did not receive a physician-ordered medication for diarrhea because the medication was not available in the facility. The resident requested the medication from nursing staff on multiple occasions, but it was not in stock, and pharmacy delivery had not occurred as expected. Staff confirmed the medication was ordered but not received, and the DON stated there was no facility policy on pharmacy delivery timeframes.
A resident with multiple medical conditions, including cancer, did not have laboratory tests completed as ordered by their physician. Instead, incorrect labs were drawn on one occasion, and on another, one required test was missed, resulting in the resident missing a chemotherapy treatment. An LPN confirmed the errors in lab collection during interviews.
An LPN used a shared glucometer on two residents without cleaning it between uses, contrary to facility policy and CDC guidance. The DON confirmed the expectation for cleaning between each use, and the facility identified seven residents who received blood glucose monitoring with the same device.
Two residents who were dependent on staff for hygiene and required Hoyer lifts did not consistently receive their preferred showers due to a shortage of bariatric Hoyer pads and unclear documentation. Both residents reported not receiving showers as scheduled, with staff unable to confirm what type of bathing was provided or locate the necessary equipment, resulting in unmet care preferences and incomplete hygiene.
A resident was prescribed antipsychotic medication for depression despite having no documented diagnosis of depression or related care plan in the medical record. The MDS assessment indicated the resident was cognitively intact and showed no symptoms of depression, and facility policy requires psychoactive medication orders to be supported by clinical diagnoses or behavioral symptoms.
A facility did not conduct a thorough investigation after a resident's controlled substances went missing. Although the DON reviewed delivery records, interviewed and drug tested three nurses, and checked medication records, not all staff present during the shift were interviewed or tested, and required documentation of the resident's assessment was missing. The investigation was incomplete and did not meet the facility's policy for handling misappropriation allegations.
Two residents did not have their care plans updated to address significant needs: one resident was prescribed a diuretic for COPD, but this was not included in the care plan, as confirmed by the DON. Another resident with nicotine dependence continued to smoke outside the building despite the facility's no-smoking policy, and this behavior was not reflected in the care plan, as confirmed by both an LPN and the DON.
Two residents with a history of falls did not have required fall prevention interventions in place or properly documented. In one case, a resident's ordered perimeter mattress and enabler bars were not present after a bed change, yet staff continued to document them as in place. In another case, a resident's unwitnessed fall was not communicated to nursing staff, and required increased monitoring was not implemented. Facility policy for incident documentation and communication was not followed.
A resident with multiple serious diagnoses and identified as nutritionally at risk did not have weekly weights obtained as required by facility policy and physician orders. Only two weights were recorded over a month, revealing a significant weight gain, and staff interviews confirmed that weekly weights were neither ordered nor performed as needed.
The facility did not ensure timely and appropriate responses to pharmacy recommendations for medication management, including failure to implement accepted changes, lack of physician rationale for declined recommendations, and missing documentation of prior dose reduction attempts. These deficiencies affected three residents with complex medical and psychiatric histories, as confirmed by DON interviews and record reviews.
A resident with diabetes received insulin injections from an LPN who failed to prime the Basaglar Kwikpen and Admelog insulin pens before administration, contrary to manufacturer instructions and facility expectations. This resulted in two medication errors out of 36 opportunities, causing the facility's medication error rate to exceed 5%. The DON confirmed that nurses are expected to prime insulin pens prior to use.
A resident with diabetes and bipolar disorder was not administered Glipizide and Ziprasidone at the appropriate times in relation to meals, and missed several doses of Ziprasidone. Additionally, an LPN administered insulin using pens that were not primed as required by manufacturer instructions. The DON confirmed these practices did not meet expectations, resulting in significant medication errors.
A resident with multiple medical conditions had physician orders for several laboratory tests and a urinalysis following an incident, but these were not collected for at least four days. There was no documentation of attempts to obtain the samples or of any refusals, and the DON confirmed the orders remained unfulfilled during this period, contrary to facility expectations for prompt collection and physician notification.
The facility failed to document the administration of pain medication and completion of wound care treatments for two residents, including one with a recent surgical incision and another with a stage IV pressure ulcer. LPNs did not record medication administration or provide explanations for missed treatments, and the DON confirmed the lack of documentation for these omissions.
A resident with multiple medical conditions had their controlled substances, including Oxycodone and Diazepam, go missing after an agency nurse signed for their delivery. The medications were not available for administration, and subsequent investigation, including staff interviews and drug testing, was inconclusive. The controlled substances and related paperwork were not found, and only non-controlled medications were received by other staff.
A resident dependent on staff for ADLs, including bathing and shaving, did not receive scheduled baths or personal hygiene care over a one-month period. Staff observations confirmed the presence of significant facial hair, and interviews with CNAs, LPNs, and the DON revealed that required care was neither provided nor documented as expected.
The facility failed to coordinate timely medical appointments, monitor for bruising in a resident on antiplatelet therapy, and ensure prompt removal of surgical staples, resulting in missed wound care follow-ups, unrecognized bruising, and delayed wound management.
The facility did not ensure pain management was provided according to physician orders and professional standards. Several residents received opioid pain medications for pain levels below the prescribed thresholds, and staff failed to document pain assessments and non-pharmacological interventions as required. The DON confirmed that pain medications were administered outside of ordered parameters and that documentation was insufficient.
Two residents with cognitive and physical impairments experienced significant delays in receiving dental follow-up after their dentures went missing. The facility did not promptly initiate dental consultations or investigations, and staff were often unaware of the denture loss. Documentation showed gaps in communication and follow-up, resulting in prolonged periods without dentures and dissatisfaction with modified diets.
The facility did not notify the State LTC Ombudsman of the discharges of two residents, one who was transferred to the hospital with respiratory and pulmonary diagnoses and another who left against medical advice with hepatic and chronic conditions. In both cases, medical records lacked evidence of required notification, and the Administrator confirmed the notifications were not made, contrary to facility policy.
A resident with multiple medical conditions developed a new leg fracture that was not related to her previous injury. The facility's investigation into the injury of unknown origin was incomplete, as therapy staff were not interviewed and the investigation was closed based on incorrect information about the nature of the fracture, contrary to facility policy.
A resident did not receive a scheduled dose of Cefepime on time, as it was found on an LPN's cart hours after it was documented as administered. The facility's policy requires medications to be given within 60 minutes of the scheduled time, which was not followed.
A facility failed to prevent the misappropriation of controlled substances for two residents, involving an RN who acted erratically and tested positive for drugs. The residents did not receive their medications as ordered, and the facility's audits and education were ineffective in addressing the issue.
A facility failed to thoroughly investigate a case of controlled substance misappropriation by an RN, affecting two residents. The RN was found under the influence of drugs, and a narcotic count revealed missing medications. The investigation lacked comprehensive interviews and assessments, and audits were inadequate, failing to ensure proper medication management.
A facility failed to provide post-operative drain care for a resident with a surgical drain, as detailed in the hospital's After Visit Summary. The resident's Treatment Administration Record showed no documentation of site care or dressing changes, and interviews revealed concerns about the adequacy of care. The Director of Nursing confirmed the lack of evidence for drain care and noted the absence of a specific policy, although a procedure was in place.
The facility failed to ensure safe transfers and proper fall documentation for two residents, leading to multiple falls. One resident experienced falls due to a broken wheelchair brake and improper transfer techniques, while another fell due to staff not using the sit-to-stand lift correctly. The facility did not conduct thorough fall investigations or document incidents properly, as confirmed by interviews with the DON and Corporate Nurse.
A resident with a suprapubic catheter was not provided with the required catheter care, as evidenced by a missing entry in the Treatment Administration Record and observations of improper catheter management. The resident's catheter drainage bag was found on the floor, and the suprapubic site was reddened with dried residue, indicating a lack of care. The resident reported that catheter care was infrequently provided unless specifically requested, and an LPN confirmed the absence of a dressing and the presence of dried drainage.
A resident with a central venous access port returned from the hospital, but the facility failed to transcribe physician's orders and provide necessary IV site care. The port remained accessed without being used for medication, and the dressing was not changed within the required timeframe, leading to noncompliance with care standards.
The facility failed to maintain accurate records of controlled medications for two residents, leading to discrepancies in medication administration and inventory. One resident, receiving hospice care, had inaccurate records with crossed-out entries and unaccounted medication amounts. Another resident had inconsistencies in the narcotic sheet for Morphine PRN, with incorrect dosing times and amounts deducted. The facility's pharmacy policy requires accurate record-keeping and immediate reporting of discrepancies, which was not followed.
A resident with a history of complex medical conditions was incorrectly administered ertapenem intramuscularly instead of intravenously, as per hospital discharge instructions. The error was due to a transcription mistake by the Unit Manager, and the resident experienced discomfort from the injections. The facility lacked a specific policy for medication errors.
A facility failed to maintain an accurate medical record for a resident receiving hospice care. The MAR showed a Morphine dose given at one time, while the narcotic sheet documented a different time. An LPN's note inaccurately described care that was not provided, as the resident was found deceased at the start of her shift. Interviews confirmed discrepancies, and the facility's policy required accurate documentation.
The facility failed to ensure proper PPE was used for residents requiring enhanced-barrier precautions during wound care. Two residents with significant medical conditions and open wounds were observed receiving care without the required gowns, despite clear guidelines and available PPE. This oversight was confirmed by staff interviews and contradicted both facility policy and CDC guidance.
Failure to Investigate and Report Resident Elopement
Penalty
Summary
The facility failed to conduct an investigation and report an allegation of potential neglect related to a resident elopement to the State Survey Agency. A resident with diagnoses including senile degeneration of the brain, chronic kidney disease, hypertension, diabetes, and heart failure, and who had impaired cognition, was found outside the facility by staff after being seen at a nearby pizza restaurant. The resident, who was independent in ambulation, had asked staff to remove her oxygen to go outside to smoke and was last seen near the facility earlier in the day. She was later located about a mile away, appeared confused, and stated she was trying to find her son's house and got lost. Staff interviews confirmed that the resident had not signed herself out and that facility staff were unaware she was outside until notified by an off-duty CNA who saw her in the community. Review of self-reported incidents and interviews with facility leadership revealed that no investigation was initiated and the incident was not reported to the State Survey Agency. The facility did not provide documentation of an investigation into the elopement, and the Regional Leader confirmed that a formal investigation was not commenced because it was believed the resident had taken a temporary leave of absence, despite evidence to the contrary. This deficiency was identified during a complaint investigation and affected one of three residents reviewed for elopements.
Failure to Provide Required Discharge Documentation and Notification
Penalty
Summary
The facility failed to provide the required discharge documentation and notifications for a resident diagnosed with Alzheimer's disease who was taken home by her son. Medical record review showed that the resident's son expressed his intention to take his mother home, and staff informed him that he would need to sign against medical advice (AMA) documents. However, there was no documentation in the progress notes confirming that AMA documents were signed, nor was there evidence that a discharge summary or other required discharge information was provided to the resident or her family. Additionally, there was no record of the facility attempting to have the resident or her family sign any AMA documents. An interview with an LPN confirmed the absence of documentation supporting a safe and orderly discharge process for the resident. Review of the facility's transfer and discharge policy indicated that a discharge summary and post-discharge plan of care should be developed and reviewed with the resident and/or representative prior to discharge, and that nursing should document the discharge in the progress notes. These steps were not followed in this case, resulting in non-compliance with facility policy and regulatory requirements.
Failure to Complete Ordered Wound Care and Dressing Changes
Penalty
Summary
A deficiency occurred when the facility failed to provide ordered treatments for the care of a resident's cervical spine incision and Jackson Pratt (JP) drain site. The resident, who was admitted with multiple complex diagnoses including infection, spinal fusion, heart disease, and other chronic conditions, had clear after-visit instructions and physician orders for daily wound assessment and dressing changes. These orders included checking the cervical spine incision for redness or drainage, keeping the wound covered with a Medipore island dressing to be changed daily, and cleaning around the JP drain exit site daily. The treatment administration records reflected these orders, with instructions to cleanse the incision and JP drain site with normal saline, pat dry, and apply appropriate dressings daily. Despite these documented orders, the treatments were not completed during the resident's entire stay at the facility. The resident was admitted and discharged within a three-day period, and during this time, there was no evidence that the required wound care and dressing changes were performed. An LPN confirmed in an interview that the orders should have been in place and completed upon admission but were not, and could not provide a reason for the omission. This failure was identified during a complaint investigation and represented continued non-compliance from a previous survey.
Significant Medication Error Due to Overlapping Furosemide Orders
Penalty
Summary
A deficiency occurred when a resident with diagnoses including chronic obstructive pulmonary disease, dysphagia, orthostatic hypertension, and chronic heart failure received an incorrect dosage of furosemide due to overlapping medication orders. The resident was admitted with intact cognition and required self-care assistance. Physician orders indicated that three 20 mg furosemide tablets were to be given once daily, which was later discontinued, and a new order for one 80 mg furosemide tablet once daily was initiated. However, both the discontinued and new orders were administered simultaneously on two consecutive days, resulting in the resident receiving a total of 140 mg of furosemide per day instead of the intended 80 mg. The error was confirmed through medical record review, staff interview, and policy review. The medical director verified that the previous order should have been discontinued when the new order was started, and that the resident received additional doses of the medication on the specified days. Facility policy required medications to be administered according to physician orders, but this was not followed, resulting in a significant medication error for the resident.
Resident Elopement Due to Inadequate Supervision and Exit Alarm Failure
Penalty
Summary
A deficiency occurred when a resident with dementia, a history of elopement attempts, and a Wanderguard device was able to exit the facility without staff knowledge. The resident was found by hospital security staff lying in a hospital parking lot approximately one mile from the facility, after traveling with a walker along a multi-lane road under construction. Staff did not hear any door alarms, and the facility lacked camera surveillance to determine which door was used or how the resident exited undetected. The resident was missing for an undetermined period, and facility staff only became aware of the situation when contacted by hospital staff. The resident had been assessed as not at risk for elopement on a prior risk assessment, despite being cognitively impaired and exhibiting wandering behaviors. The Minimum Data Set (MDS) indicated severe cognitive impairment and wandering, and the care plan included interventions such as Wanderguard application and redirection. However, the resident was able to leave the facility, and staff interviews revealed inconsistent accounts regarding the last time the resident was seen and whether door alarms sounded. Some staff reported that residents had access to door codes, either by being given the codes to go outside and smoke or by observing staff entering them. Upon evaluation at the hospital, the resident was found to have sustained rib fractures, bruising, and swelling, but no new orders were issued upon return to the facility. Interviews with staff and the resident's Power of Attorney confirmed that the facility was unaware of the resident's absence until notified by the hospital. The facility's elopement policy stated that elopement should be prevented to the extent reasonably possible, but the failure to provide adequate supervision and ensure the effectiveness of exit alarms led to the resident's elopement and subsequent injury.
Failure to Ensure Residents Attend Scheduled Medical Appointments
Penalty
Summary
The facility failed to ensure that residents received the necessary care and services to attend outside medical appointments, as evidenced by two residents who missed or had to reschedule important medical visits due to errors in care coordination. For one resident with a history of cancer, malnutrition, depression, and falls, laboratory tests required for a chemotherapy appointment were not collected correctly. The lab initially drew the wrong tests, and when a STAT order was placed, the lab still failed to collect all required samples, resulting in the resident missing a scheduled chemotherapy session. Interviews confirmed that the appointment had to be cancelled and rescheduled due to these errors in lab collection. Another resident with chronic heart failure, kidney disease, and other conditions missed a scheduled bone density test because staff administered a calcium medication prior to the appointment, despite the absence of an order to hold the medication. As a result, the appointment had to be rescheduled. Both residents were cognitively intact and required varying levels of assistance with activities of daily living. The facility's policy states that residents have the right to access services outside the facility, but these incidents demonstrate a failure to coordinate care and services necessary for residents to attend their medical appointments as scheduled.
Failure to Provide Ordered Enteral Nutrition Due to Formula Substitution
Penalty
Summary
A review of the medical record and staff interviews revealed that a resident with diagnoses including malignant neoplasm of the lung, malnutrition, depression, and a history of falls was admitted with orders for nocturnal enteral feeding using Jevity 1.5 at 70 mL/hr via PEG tube. The care plan specified that tube feeding should be administered as ordered due to the resident's inability to consume adequate nutrition orally. The resident was cognitively intact and required varying levels of assistance for activities of daily living, and was coded for a feeding tube on the Minimum Data Set. Despite the physician's order for Jevity 1.5, the facility did not have this formula available upon admission. Instead, an LPN reported that Jevity 1.2 was started two days after admission, and the resident went without the ordered Jevity 1.5 for two nights. This deviation from the physician's order resulted in the resident not receiving the prescribed enteral nutrition as required.
Failure to Provide Timely Pharmacy Medication Delivery
Penalty
Summary
The facility failed to ensure that medications were available from the pharmacy for administration to a resident recently admitted with multiple complex medical conditions, including chronic diastolic heart failure, hypertension, chronic kidney disease, irritable bowel syndrome, a chronic ulcer, anxiety disorder, and an overactive bladder. The resident had care plans in place addressing risks related to diuretic therapy and ileostomy, with interventions specifying that medications should be administered as ordered. Despite an active physician order for Lomotil to manage diarrhea, the medication was not available in the medication cart when requested by the resident, who reported ongoing diarrhea and had previously asked for the medication without receiving it. Staff interviews confirmed that the Lomotil was not in stock, and the DON stated that the process for obtaining necessary medications involved drop shipping from the pharmacy, which typically took four hours. However, the medication had not arrived, and the DON acknowledged there was no facility policy specifying the timeframe for pharmacy deliveries. The lack of timely access to the ordered medication resulted in the resident not receiving needed treatment for her symptoms, as confirmed by both staff and resident interviews.
Failure to Complete Physician-Ordered Laboratory Testing
Penalty
Summary
The facility failed to ensure that laboratory testing was completed as ordered by the physician for one resident. Medical record review showed that the resident, who had diagnoses including malignant neoplasm of the lung, malnutrition, depression, and a history of falls, was admitted with orders from a chemotherapy physician to have specific labs drawn on a set schedule. On one occasion, instead of the required labs, only a Prothrombin Time (PT) and International Normalized Ratio (INR) were collected. On a subsequent attempt, all required labs except for the Comprehensive Metabolic Panel (CMP) were collected, necessitating another order for the CMP to be drawn on a later date. Interviews with the resident and an LPN confirmed that the labs were not collected as ordered, resulting in the resident missing a chemotherapy treatment. The LPN acknowledged the error in the lab collection process and described the steps taken to attempt to correct the issue, including ordering a STAT lab and reordering the missing test. The deficiency was identified during a complaint investigation and affected one resident out of three reviewed for laboratory testing.
Failure to Disinfect Glucometer Between Resident Uses
Penalty
Summary
A deficiency was identified when a Licensed Practical Nurse (LPN) failed to clean and disinfect a glucometer between uses on two residents during medication administration. Observation revealed that after checking the blood sugar of one resident, the LPN proceeded to use the same glucometer on another resident without cleaning it in between. The LPN confirmed during an interview that the glucometer was not cleaned between uses and stated that the usual practice was to clean equipment after completing the medication round, but cleaning supplies were not available on the cart that day. The Director of Nursing (DON) confirmed that the facility's expectation was to clean and disinfect multi-use items, such as glucometers, between each use. Review of the facility's policy and CDC guidance both supported the requirement for cleaning and disinfecting reusable equipment after each use. The facility identified a total of seven residents who received blood glucose monitoring with the shared glucometer in the affected area.
Failure to Provide Preferred Bathing Method Due to Equipment Shortages and Inadequate Documentation
Penalty
Summary
The facility failed to ensure that two residents received their preferred method of bathing, specifically showers, as documented in their care plans and expressed preferences. Both residents had significant physical limitations, including dependence on staff for transfers and hygiene, and required the use of a Hoyer lift with bariatric pads for safe transfers to the shower bed. Documentation in the medical records and CNA task logs did not differentiate between showers, bed baths, or refusals, making it unclear what type of bathing was actually provided. Staff interviews confirmed that there were ongoing issues with the availability and tracking of Hoyer lift pads, which directly impacted the ability to provide showers as requested by the residents. Resident #12, with diagnoses including diabetes, anxiety, depression, osteoarthritis, and chronic pain syndrome, was cognitively intact and dependent on staff for personal hygiene. She reported never refusing a shower, but stated that staff often told her there were no Hoyer lift pads available, resulting in her receiving only partial bed baths without hair washing. Staff interviews corroborated the shortage of Hoyer pads and the lack of clear documentation regarding the type of bathing provided. The unit manager and LPN were unable to confirm or provide evidence of completed showers or bed baths, and could not consistently locate the necessary equipment for transfers. Resident #23, who had multiple sclerosis, morbid obesity, hemiplegia, and was non-ambulatory, also required total staff assistance and preferred showers as documented in her care plan. Review of her records showed missed showers on scheduled days without documentation of refusals, and staff interviews revealed inconsistent documentation practices. The resident reported not receiving showers for months and only being provided with bed baths, which was visually supported by observations of unwashed hair. Staff were unable to confirm when the last shower was provided, and the necessary Hoyer pads for transfer were missing for about a week, further preventing the provision of showers.
Antipsychotic Medication Prescribed Without Supported Diagnosis
Penalty
Summary
The facility failed to ensure that the use of antipsychotic medication for a resident was based on a clinically supported diagnosis. Record review showed that a resident with diagnoses including bipolar disorder, psychoactive substance abuse, and nicotine dependence was prescribed Venlafaxine HCL for depression and Quetiapine Fumarate for depression. However, the admission MDS assessment indicated the resident was cognitively intact and had no symptoms of depression. Further, there was no current diagnosis of depression documented in the medical record, nor was there a care plan related to depression. The facility's own policy requires that psychoactive medication orders be supported by appropriate clinical diagnoses or behavioral symptoms, which was not followed in this case.
Failure to Thoroughly Investigate Missing Controlled Substances
Penalty
Summary
The facility failed to thoroughly investigate the disappearance of controlled substances prescribed to Resident #76, who had diagnoses including malignant neoplasm of the anus, depression, neoplasm-related pain, insomnia, and osteoarthritis. The resident was cognitively intact at the time of the incident. On the date in question, a nurse discovered that the resident's narcotics were missing when attempting to dispense them. Documentation showed that an agency nurse had signed for the delivery of the medications, but the narcotics were not available for administration. The facility's investigation included reviewing proof of delivery, interviewing and drug testing three nurses, and reviewing medication administration records. However, only two staff members provided witness statements, and only three nurses were drug tested, despite more staff being present during the shift. The Director of Nursing (DON) confirmed that only the three involved nurses were interviewed and did not believe nurse aides would have relevant information, so they were not interviewed. The DON also stated that an assessment of the resident was performed, but there was no documentation to support this. The facility's Abuse Prohibition Policy requires thorough investigation and documentation of all allegations of misappropriation, including assessment and documentation in the medical record, but these steps were not fully completed. The investigation was ultimately inconclusive, and not all potential witnesses or involved staff were interviewed or tested as part of the process.
Failure to Address Diuretic Use and Smoking in Resident Care Plans
Penalty
Summary
The facility failed to develop and implement complete care plans for two residents, resulting in deficiencies related to medication management and behavioral interventions. For one resident with chronic obstructive pulmonary disease, the medical record showed an active physician order for Furosemide, a diuretic, but the resident's care plan did not address the use of this medication. This omission was confirmed by the Director of Nursing during an interview, verifying that the care plan lacked necessary information regarding the resident's diuretic therapy. In a separate case, another resident with diagnoses including nicotine dependence and psychoactive substance abuse was observed to be non-compliant with the facility's no-smoking policy, regularly smoking outside the building. Despite documentation in progress notes and staff awareness of the behavior, the resident's care plan did not address smoking or related interventions. Both the LPN and the Director of Nursing confirmed that the care plan had not been updated to reflect the resident's ongoing smoking behavior and non-compliance with facility policy.
Failure to Implement and Document Fall Prevention Interventions
Penalty
Summary
The facility failed to ensure that fall prevention interventions were in place and properly documented for two residents with a history of falls. One resident, with diagnoses including cerebral palsy and epilepsy, was identified as being at risk for falls and had specific interventions ordered, such as a perimeter mattress and bilateral enabler bars, to be checked every shift. Despite these orders, after a bed change, the perimeter mattress and enabler bars were not in place, and staff continued to document in the Treatment Administration Record that these interventions were present when they were not. The resident experienced a fall while self-transferring and later reported another incident of sliding from the bed to the floor, noting the absence of the usual side rail for support. The Director of Nursing confirmed that the interventions were not included in the fall care plan and had not been in place since the bed change. Another resident, admitted with acute respiratory failure, seizure disorder, and chronic heart failure, was also assessed as being at risk for falls and required assistance with all activities of daily living. This resident experienced an unwitnessed fall, which was reported by the family directly to the physician. The post-fall assessment was documented as normal, but the event was not communicated to nursing staff, and the intervention to increase rounding frequency was not implemented because staff were unaware of the fall. The fall event form was completed six days after the incident, and no comprehensive evaluation was documented. The Director of Nursing and Nurse Practitioner confirmed that the fall was not discussed during daily rounds and that nursing staff had not reviewed the physician's progress notes where the fall was documented. Facility policy required that all resident-related incidents be documented in the medical record, with all facts collected and incident reports submitted to the Director of Nursing and administration within 24 hours. In both cases, the facility failed to follow its own policy for documentation, communication, and implementation of fall prevention interventions, resulting in a lack of adequate supervision and failure to maintain a hazard-free environment for residents at risk for falls.
Failure to Obtain Weekly Weights for At-Risk New Admission
Penalty
Summary
The facility failed to obtain weekly weights for a newly admitted resident who was identified as being at nutritional risk. Upon admission, the resident had multiple significant diagnoses, including spinal fusion, various malignant neoplasms, bacteremia, and acute kidney failure. The initial nutritional evaluation recommended monitoring weights, and the care plan identified the resident as being at risk for nutritional issues and dehydration due to cancer, corticosteroid use, and obesity. Despite these risk factors and facility policy requiring weekly weights for new admissions, only two weights were recorded over a one-month period, showing a significant weight gain of 25.1 pounds (13.4%). Interviews with the registered dietitian and the DON confirmed that weekly weights were not ordered or obtained as required. The DON stated that certified nursing assistants were responsible for obtaining weights as ordered, but there was no order for weekly weights upon admission. The facility's weight management policy specified that residents should be weighed upon admission and weekly for four weeks, but this was not followed for the resident in question.
Failure to Respond to and Document Pharmacy Recommendations for Medication Management
Penalty
Summary
The facility failed to ensure timely and appropriate responses to pharmacy recommendations for multiple residents, as required by policy and procedure. For one resident with diagnoses including cerebral palsy, diabetes, epilepsy, depression, and anxiety, the physician did not address a pharmacist's recommendation for a gradual dose reduction (GDR) of antipsychotics, failed to implement accepted recommendations to taper Metoclopramide and decrease Pantoprazole, and declined recommendations to discontinue sliding scale insulin and reevaluate duplicate topical therapies without providing a rationale. These failures were confirmed by the DON, who verified the lack of physician response, missing orders, and absent rationales in the medical record or pharmacy forms. Another resident with dementia and depression had pharmacy recommendations for GDRs of Abilify and Bupropion; the physician declined one without providing a rationale and did not address the other. A third resident with depression, bipolar disorder, and chronic constipation had pharmacy recommendations for GDRs of Aripiprazole and discontinuation of famotidine, which the physician declined, citing prior failed attempts, but there was no documentation that such attempts had occurred. These deficiencies were identified through staff interviews and record reviews, affecting three of five residents reviewed for unnecessary medications.
Medication Error Rate Exceeds 5% Due to Insulin Pen Administration Errors
Penalty
Summary
The facility failed to ensure that the medication error rate remained below five percent, resulting in a calculated error rate of 5.56% based on two errors out of 36 observed opportunities. This deficiency was identified during a review of medication administration for a resident with type two diabetes mellitus, who had physician orders for multiple types of insulin, including Basaglar Kwikpen and Admelog (Insulin Lispro) with sliding scale coverage. During a medication pass, an LPN administered the prescribed doses of insulin but did not prime the insulin pens prior to injection. The LPN confirmed in an interview that she did not prime the Basaglar Kwikpen and Admelog pens, stating she believed priming was unnecessary. The Director of Nursing clarified that the expectation was for nurses to prime insulin pens before administration. Facility policy referenced following manufacturer guidelines, which explicitly require priming the pens before each use. Observations, interviews, and review of manufacturer instructions and clinical guidance all supported the finding that the pens should have been primed, and failure to do so constituted a medication administration error.
Failure to Ensure Residents Are Free from Significant Medication Errors
Penalty
Summary
Resident #28, who has diagnoses including type two diabetes mellitus, bipolar disorder, and anxiety disorder, experienced significant medication errors related to the administration of Glipizide and Ziprasidone. The physician's orders specified that Glipizide extended release should be taken 30 minutes before meals and Ziprasidone should be taken with meals. However, the Medication Administration Record (MAR) showed that Glipizide was scheduled for 9:00 A.M., which was after the unit's breakfast time of 7:30 A.M., and Ziprasidone was scheduled for 6:00 A.M. and 8:00 P.M., not aligning with meal times. Additionally, there were multiple missed doses of Ziprasidone, and the DON confirmed the medications were not scheduled at appropriate times, with no clear reason for the missed doses. The consultant pharmacist confirmed that improper timing and missed doses could impact the effectiveness of these medications. Further, during an observation of medication administration, an LPN administered Basaglar Kwikpen insulin and Admelog (Lispro) insulin without priming the insulin pens as required by manufacturer instructions. The LPN confirmed not priming the pens, stating a belief that priming was unnecessary. The DON confirmed that the expectation was for nurses to prime insulin pens prior to administration. Facility policy referenced following manufacturer guidelines, which explicitly require priming the pens to ensure proper dosing. These actions resulted in the resident not being free from significant medication errors, as required.
Failure to Complete Physician-Ordered Laboratory Tests in a Timely Manner
Penalty
Summary
The facility failed to ensure that physician orders for laboratory work were completed in a timely manner for one resident. The resident, who had diagnoses including cerebral infarction, moderate protein-calorie malnutrition, and encephalopathy, was admitted on 05/15/25 and had intact cognition according to the MDS assessment. On 05/30/25, after an incident where the resident attempted to bite staff, the physician ordered a complete blood count (CBC), comprehensive metabolic panel (CMP), Vitamin D level, Vitamin B12, B-type natriuretic peptide (BNP), and urinalysis with culture and sensitivity. Despite these orders, the laboratory tests and urinalysis were not collected for at least four days, and there was no documentation in the medical record indicating that nursing staff attempted to obtain the samples or that the resident refused the tests. The DON confirmed that the orders remained active and unfulfilled from 05/30/25 through 06/03/25, and that the expectation was for nursing staff to attempt collection the day the order was received and to notify the physician of any refusals. The nurse practitioner who ordered the labs also confirmed she had not received any updates or reports of refusal, and expected prompt completion of the laboratory work.
Failure to Document Medication Administration and Wound Care Treatments
Penalty
Summary
The facility failed to ensure accurate and complete documentation of medication administration and treatment interventions for two residents. For one resident recently admitted after open heart surgery, there was a physician order for Acetaminophen for pain, but the Medication Administration Record (MAR) did not show that the medication was administered during the resident's stay. Interviews with LPNs revealed that although the medication was requested and reportedly given, it was not documented in the MAR, and no pain assessment was completed following the request. The nurse involved later acknowledged the lack of documentation and intended to enter it as a late entry. For another resident with a stage IV pressure ulcer and vascular dementia, review of the MAR and Treatment Administration Record (TAR) showed multiple missed treatments, including the application of off-loading boots and wound care with calcium and silver alginate, on several dates. There was no documentation in the medical record or progress notes to explain the missed treatments. The resident reported concerns about not being repositioned as ordered, and the Director of Nursing confirmed the missed treatments and lack of documentation explaining the omissions.
Failure to Prevent Misappropriation of Resident's Controlled Substances
Penalty
Summary
A deficiency occurred when a resident's controlled substances, specifically Oxycodone and Diazepam, were misappropriated and became unavailable for administration. The resident, who had diagnoses including malignant neoplasm of the anus, depression, neoplasm-related pain, insomnia, and osteoarthritis, was cognitively intact at the time. The medications were delivered to the facility and signed for by an agency nurse, but when the night nurse attempted to dispense them, the narcotics were missing. Multiple staff members, including the agency nurse and other nurses on the unit, were interviewed and drug tested, all with negative results. The investigation into the missing medications was inconclusive, as the controlled substances and their accompanying paperwork were not found, and staff who received other medications from the delivery did not receive the narcotics. The facility's review of records, witness statements, and proof of delivery confirmed that the agency nurse signed for the medications, but only non-controlled prescriptions were handed off to other staff. The missing medications were not located in the medication carts or medication room, and no missed doses were noted in the Medication Administration Records for residents on the unit. The facility's policy prohibits misappropriation of resident property, including medications, but the controlled substances for this resident were not protected from wrongful use or loss.
Failure to Provide Timely Bathing and Personal Hygiene Assistance
Penalty
Summary
Staff failed to provide timely and adequate assistance with activities of daily living (ADLs), specifically bathing and personal hygiene, to a resident who was dependent on staff for these tasks. The resident, admitted with diagnoses including left knee effusion, depression, anxiety disorder, and chronic kidney disease, had a care plan indicating a need for assistance with self-care and mobility, and a preference for baths at a specific time. Facility records showed the resident was scheduled for bed baths twice weekly and required partial to moderate assistance with personal hygiene, including shaving. However, documentation from a one-month period revealed no record of the resident receiving a bath or shaving during that time. Observations confirmed the resident had significant facial hair growth, and interviews with staff indicated that scheduled bathing and shaving were not provided or documented as required. CNAs and LPNs acknowledged the lack of documentation and confirmed that shaving should have been offered during scheduled bathing days. The DON verified that such care was expected and that documentation was only maintained electronically in the shower/bath task, which showed no evidence of care being provided during the review period.
Failure to Coordinate Care, Monitor for Bruising, and Ensure Timely Wound Management
Penalty
Summary
The facility failed to provide appropriate treatment and care according to physician orders and residents' needs, resulting in missed medical appointments, delayed wound care, and inadequate monitoring for signs of bleeding or bruising. One resident with a non-chronic pressure ulcer of the left heel and a history of surgical aftercare missed a scheduled wound care clinic appointment because the facility did not arrange transportation, despite clear documentation that a follow-up was required. The resident confirmed missing the appointment, and the DON acknowledged the lapse in scheduling. Another resident with peripheral vascular disease, a history of thrombus/embolism, and chronic pain syndrome was prescribed an antiplatelet medication with orders to monitor for bleeding and bruising. Despite documentation in the treatment administration record indicating no signs of bleeding or bruising, direct observation and interviews revealed multiple bruises on the resident's hands that had not been previously identified or monitored by staff. The DON and Administrator confirmed that the monitoring documented in the record did not reflect the resident's actual condition, as reported by the resident and her family. A third resident, admitted after abdominal surgery with staples in place, experienced a delay in staple removal. Although the staples were to be removed seven to ten days post-surgery, they remained in place for over four weeks. The resident expressed concern about the prolonged presence of staples, and both the DON and a nurse practitioner confirmed the delay, with the nurse practitioner indicating a lack of clarity regarding follow-up appointments for staple removal. No physician order for staple removal was present until well after the recommended timeframe.
Failure to Ensure Safe and Appropriate Pain Management
Penalty
Summary
The facility failed to provide safe and appropriate pain management for several residents, as evidenced by staff interviews and record reviews. For one resident with diagnoses including cerebral palsy, COPD, diabetes, and epilepsy, physician orders specified the use of acetaminophen for pain and morphine for moderate to severe pain, with non-pharmacological interventions listed. However, documentation showed morphine was administered for pain levels below the moderate threshold, and nursing staff did not consistently document the location or description of pain, nor the use of non-pharmacological interventions, as required by the care plan and professional standards. Another resident with pneumonia and generalized weakness had physician orders for Tylenol for mild pain and oxycodone for moderate to severe pain. Medication administration records revealed oxycodone was given for pain scores below the ordered parameters, including for scores of zero, two, and three, and Tylenol was administered for higher pain scores. The DON confirmed that staff did not follow the physician's pain scale parameters for medication administration. A third resident with multiple sclerosis, contractures, and chronic pain syndrome had orders for oxycodone as needed for pain and acetaminophen for mild pain, but without specific parameters for oxycodone use. Records showed oxycodone was administered for low pain levels, and acetaminophen was not used, despite being ordered for mild pain. The DON acknowledged the lack of established parameters and inappropriate administration of pain medication for this resident.
Failure to Provide Timely Dental Services and Follow-Up for Missing Dentures
Penalty
Summary
The facility failed to ensure timely follow-up and provision of dental services for residents with missing dentures, affecting two of three residents reviewed for dental concerns. For one resident with a history of stroke, dementia, and malnutrition, the facility became aware of missing bottom dentures in August but did not initiate contact with a dental provider until October. The resident was placed on a mechanical soft diet due to the loss, which she disliked, and there were multiple delays and cancellations in scheduling dental appointments, including issues with payment authorization and communication with the dental office. The process to obtain replacement dentures was prolonged, with documentation showing significant gaps between identification of the issue and follow-up actions. Another resident with hemiplegia, diabetes, and vascular dementia also experienced a lack of timely follow-up after reporting missing dentures. Although prior authorization for denture adjustments was submitted, there was no documented follow-up or evidence that the resident received any denture adjustments for several months. The resident reported the dentures as stolen and expressed dissatisfaction with the modified diet. Staff interviews revealed a lack of awareness and inconsistent reporting regarding the missing dentures, and attempts to identify found dentures were unsuccessful due to missing identification labels. Facility policy required prompt investigation and follow-up within three days for lost or damaged dentures, as well as proper documentation and referral. However, the facility did not adhere to these requirements, resulting in extended periods without dentures for the affected residents and delays in dental care coordination. The deficiency was substantiated through observations, record reviews, and staff and resident interviews.
Failure to Notify Ombudsman of Resident Discharges
Penalty
Summary
The facility failed to notify the Office of the State Long-Term Care Ombudsman regarding the discharge of two residents. For the first resident, who had diagnoses including acute and chronic respiratory failure with hypercapnia and chronic obstructive pulmonary disease, the medical record showed an admission and subsequent discharge after transfer to the hospital. There was no documentation in the medical record indicating that the Ombudsman was notified of this discharge, and the Administrator confirmed that the notification did not occur. For the second resident, who had diagnoses of hepatic encephalopathy, low back pain, alcoholic cirrhosis, and chronic viral hepatitis C, the medical record indicated that the resident left the facility against medical advice. The Minimum Data Set assessment showed the resident was cognitively independent. Again, there was no evidence in the medical record that the Ombudsman was notified of this discharge, and the Administrator verified the lack of notification. The facility's own policy required notification to the Ombudsman as soon as practicable, but this was not followed in these cases.
Failure to Thoroughly Investigate Injury of Unknown Origin
Penalty
Summary
The facility failed to conduct a thorough investigation into an injury of unknown origin for a resident who was cognitively intact and had multiple complex medical conditions, including a history of fractures. The resident developed new pain and swelling in her left leg, which was initially assessed by nursing staff and led to diagnostic testing, including a Doppler and x-ray. The x-ray revealed a new proximal tibia stress fracture, and subsequent orthopedic evaluation confirmed a new patellar fracture, unrelated to the resident's pre-existing tibia fracture. Despite these findings, the facility's investigation into the injury did not include interviews with therapy staff, who had been informed by the resident's daughter about the increased pain, and the investigation was closed based on the incorrect assumption that the new fracture was an extension of the existing injury. The facility's self-reported incident investigation was officially closed before all relevant information was obtained, and after closure, it was discovered that the initial determination regarding the nature of the fracture was inaccurate. The administrator acknowledged that the investigation should have been reopened to reflect the new information and that therapy staff should have been interviewed as part of the process. The facility's policy required a comprehensive investigation of injuries of unknown source, including interviews with all relevant staff and review of all circumstances, which was not fully followed in this case.
Medication Administration Error
Penalty
Summary
The facility failed to ensure that medications were administered without significant errors, affecting one resident. Resident #15, who was admitted with diagnoses including surgical aftercare, fournier gangrene, and type II diabetes mellitus, was prescribed Cefepime, an antibiotic, to be administered intravenously every six hours. On a specific day, the 12:00 P.M. dose was documented as administered by an LPN, but observations and interviews revealed that the dose had not been given to the resident by 2:26 P.M. Instead, the medication was found on top of the LPN's medication cart. The LPN confirmed that the dose had not been administered and acknowledged that it was incorrectly documented as given on the medication administration record (MAR). The Director of Nursing and Regional Clinical Coordinator confirmed the error, noting that the antibiotic was not administered timely and was documented prematurely, which was not in accordance with professional standards of practice. The facility's policy requires medications to be administered within 60 minutes of the scheduled time, which was not adhered to in this instance.
Misappropriation of Controlled Substances by RN
Penalty
Summary
The facility failed to prevent the misappropriation of controlled substances belonging to two residents, affecting their medication administration. Resident #83, who was cognitively intact and receiving hospice care, had orders for Lorazepam and Morphine Sulfate. On a specific date, it was noted that Resident #83 did not receive her scheduled medications, and discrepancies were found in the controlled substance records, indicating unaccounted doses of Morphine Sulfate. Similarly, Resident #67, who was also cognitively intact, had orders for Zolpidem Tartrate and Alprazolam. The facility's self-reported incident revealed that multiple controlled medications were missing for both residents. The incident involved RN #399, who was observed acting erratically and tested positive for cocaine, benzodiazepines, and opioids. This behavior prompted the Director of Nursing (DON) to conduct a narcotic count, revealing missing medications for Residents #83 and #67. The facility's investigation confirmed the misappropriation of controlled substances by RN #399, who was subsequently terminated. Interviews with the affected residents indicated that they did not receive their medications as ordered, although they reported feeling safe at the facility. The facility's audits and education following the incident were found to be ineffective. The audits did not clearly identify which residents were involved or what was being audited, and there was no thorough review of the controlled drug record forms against the Medication Administration Records (MARs). The facility's policy on abuse prohibition emphasized the need for monitoring resident care to prevent misappropriation, but the incident highlighted a failure in this regard.
Inadequate Investigation of Controlled Substance Misappropriation
Penalty
Summary
The facility failed to conduct a thorough investigation following a substantiated case of staff misappropriation of controlled substances, affecting two residents. The incident involved a registered nurse (RN) who was found to be under the influence of cocaine, benzodiazepines, and opioids while on duty. The nurse was observed behaving erratically and was subsequently removed from the facility. A narcotic count revealed missing controlled medications for two residents. The facility initiated an investigation, notified the local police, the pharmacy, and the Ohio Board of Nursing. However, the investigation was incomplete as it lacked comprehensive interviews and assessments of all potentially affected residents, and there was no evidence of a thorough review of the nurse's previous assignments to determine if this was an isolated incident. The facility's investigative file did not include statements from the RN involved, nor from any State Tested Nursing Assistants (STNAs) on duty at the time. Additionally, the investigation did not identify all residents with orders for controlled substances under the RN's care. The Director of Nursing (DON) confirmed that not all residents were assessed for pain, distress, or injuries following the incident. Furthermore, the audits conducted post-incident were inadequate, as they only involved checking the physical count of medications without verifying the administration records against the controlled drug record forms. This lack of thorough investigation and auditing represents a deficiency in ensuring resident safety and proper medication management.
Failure to Implement Post-Operative Drain Care
Penalty
Summary
The facility failed to implement post-operative drain care for one resident, identified as Resident #89, who was admitted with a midline abdominal incision requiring a wound vac, intravenous antibiotic therapy, and a post-operative surgical drain. The After Visit Summary (AVS) from the hospital provided detailed instructions for drain care, including daily cleaning of the skin around the drain tubing and changing the dressing once daily or if it became wet or dirty. However, the facility did not transcribe these instructions into the electronic health record, and there were no orders for post-operative drain site care recorded. Resident #89's Treatment Administration Record (TAR) for August and September showed no entries indicating that site care or dressing changes were provided. Interviews with a family member and the LPN Unit Manager revealed concerns about the adequacy of the drain care provided. The family member reported that a follow-up provider was concerned about the facility's monitoring and care of the post-operative drain. The LPN Unit Manager believed that the staff was performing the care but acknowledged that if it was not documented on the TAR, it was technically not completed. The Director of Nursing confirmed the absence of evidence for post-operative drain site care in Resident #89's records and stated that the facility did not have a specific policy for drain care, although a procedure was in place. The facility's procedure for surgical wound with a drain dressing application emphasized the importance of following practitioner's orders to prevent infection and protect the skin. This deficiency was investigated under Complaint Number OH00158542.
Deficiency in Safe Resident Transfers and Fall Documentation
Penalty
Summary
The facility failed to ensure the safe transfer of residents and proper documentation of falls, affecting two residents. Resident #47, who had multiple diagnoses including hemiplegia and muscle weakness, experienced several falls that were not properly documented in the incident and accident log or the medical record. The facility did not conduct thorough fall investigations to determine the root cause. For instance, Resident #47 was lowered to the floor during a transfer due to a broken wheelchair brake, and the fall investigation lacked staff statements and a detailed description of the incident. Resident #72, with diagnoses including atrial fibrillation and hemiplegia, also experienced falls during staff-assisted transfers. The fall investigations revealed that staff did not follow proper protocols, such as using the sit-to-stand lift, which led to the resident slipping off the wheelchair. The investigation did not include a proper root cause analysis, and staff admitted to improper use of equipment, which contributed to the falls. Interviews with the Director of Nursing and Corporate Nurse confirmed the lack of knowledge and improper use of equipment by staff, which resulted in falls during transfers. The facility's policy on fall management was not adequately followed, as falls were not documented, and appropriate interventions were not implemented to minimize future risks. The deficiency was investigated under Complaint Number OH00158243.
Failure to Provide Suprapubic Catheter Care
Penalty
Summary
The facility failed to provide appropriate suprapubic catheter site care for a resident, identified as Resident #46, who was at risk for urinary tract infections and catheter-related trauma. The resident had a medical history that included short bowel syndrome, ileostomy status, and neuromuscular dysfunction of the bladder, and was readmitted to the facility after a hospitalization for a urinary tract infection. The care plan for the resident included specific interventions for catheter care, such as positioning the catheter and tubing below the bladder level, checking for kinks each shift, and providing catheter care per policy. However, the Treatment Administration Record (TAR) for the resident showed a missing entry for catheter care on a specific night shift, indicating that the care was not provided as ordered by the physician. During an observation and interview, the resident was found with a urinary catheter drainage bag lying on the floor, and the suprapubic insertion site appeared reddened with visible dried residue, indicating a lack of proper care. The resident reported that catheter care was rarely provided unless specifically requested. An LPN Unit Manager confirmed the absence of a dressing on the suprapubic site and the presence of dried drainage, verifying that the catheter care was not administered as required. The facility's procedure for indwelling urinary catheter care emphasized the importance of keeping the catheter and tubing free from kinks and avoiding placing the drainage bag on the floor to prevent contamination and infection, which was not adhered to in this case.
Failure to Provide Appropriate IV Site Care
Penalty
Summary
The facility failed to provide appropriate care for a resident's central venous access upon her return from the hospital. The resident, who had medical diagnoses including short bowel syndrome and neuromuscular dysfunction of the bladder, was readmitted to the facility after being hospitalized for a urinary tract infection. Upon her return, the resident had an accessed subcutaneous port, which was supposed to be used for administering antibiotics. However, the facility did not transcribe the physician's orders for intravenous site care, and the port was not used for medication administration as intended. Observations revealed that the port's dressing, dated from the hospital stay, was not changed within the required seven-day period, and the port remained accessed without being utilized. Interviews with the resident and staff confirmed that the port had not been used since the resident's return, and the dressing had not been changed as per the standard of care. The facility's procedure for IV dressing changes was not followed, leading to noncompliance with the required care standards for intravenous access devices.
Controlled Medication Record Discrepancies
Penalty
Summary
The facility failed to properly maintain records of controlled medications for two residents, leading to discrepancies in medication administration and inventory. Resident #83, who was admitted with Huntington's Disease, epilepsy, and anxiety, was receiving hospice care and had orders for Lorazepam and Morphine Sulfate. The controlled substance record for this resident was found to be inaccurate, with crossed-out entries, out-of-order dates, and unaccounted medication amounts. The Director of Nursing (DON) and a Registered Nurse (RN) identified that at least 5.5 ml of medication was unaccounted for, raising concerns about the integrity of the medication records. Similarly, Resident #88, who had been diagnosed with heart failure, had discrepancies in the narcotic sheet for Morphine PRN. The records showed inconsistencies in the times of medication dosing and the amounts deducted from the medication cart. On one occasion, a dose of 0.25 ml was given, but 1.0 ml was deducted, and on another, 0.25 ml was given, but 0.5 ml was deducted. These discrepancies were acknowledged by the facility's Administrator, DON, and Corporate Nurse, indicating potential issues with the accuracy of the narcotic sheet and missing amounts of liquid morphine. The facility's pharmacy policy on Inventory Control of Controlled Substances requires maintaining separate records for all schedule II medications and any medication with potential for abuse. The policy mandates immediate reporting of suspected theft or loss and regular reconciliation of inventory records. However, the facility failed to adhere to these guidelines, resulting in inaccurate records and unaccounted controlled substances. This deficiency was identified during the investigation of a complaint.
Medication Administration Error Due to Incorrect Route
Penalty
Summary
The facility failed to ensure that residents were free from significant medication errors, specifically affecting one resident who was administered medication incorrectly. The resident, who had a history of short bowel syndrome, ileostomy status, and neuromuscular dysfunction of the bladder, was hospitalized for a urinary tract infection and diarrhea. Upon readmission to the facility, the resident was supposed to receive intravenous ertapenem for seven days as per the hospital discharge summary. However, the facility's records showed that the medication was administered intramuscularly for five days, contrary to the hospital's instructions. The error was identified during a review of the resident's medical records and confirmed through interviews with the resident and facility staff. The resident expressed confusion and discomfort about receiving intramuscular injections despite having an intravenous port available. The Unit Manager admitted to erroneously entering the medication order as intramuscular instead of intravenous, as indicated in the hospital's discharge documents. The Director of Nursing confirmed that the facility lacked a specific policy for medication errors, and the existing medication administration policy required contacting the physician for clarification if there were inconsistencies in medication orders.
Inaccurate Medical Record Documentation
Penalty
Summary
The facility failed to maintain an accurate medical record for a resident who was receiving hospice services. The resident had an order for Morphine Sulfate Solution to be administered as needed for pain. On the day of the resident's death, the Medication Administration Record (MAR) indicated that a dose of Morphine was given at 11:22 A.M., but the narcotic sheet documented the administration at 1:00 P.M. Additionally, a nursing note by an LPN inaccurately described care that was not provided, stating that the resident had low oxygen saturations and was monitored, when in fact, the resident was found deceased upon the LPN's arrival at the start of her shift. Interviews with the LPNs involved and the Director of Nursing confirmed discrepancies in the documentation. One LPN admitted to not remembering the documentation of the event and confirmed that the note in the medical record was not accurate. Another LPN reported seeing the resident earlier in the day and administering a pain pill, but there was inconsistency in the timing of the last visit. The facility's policy on documentation expectations emphasized the need for credible, complete, and accurate records, and the failure to adhere to this policy resulted in a deficiency related to the accuracy of the medical record.
Failure to Utilize Proper PPE for Wound Care
Penalty
Summary
The facility failed to ensure proper personal protective equipment (PPE) was utilized for residents requiring enhanced-barrier precautions (EBP) for open wounds. This deficiency was observed during wound care for two residents, both of whom had significant medical conditions and required specific wound care protocols. Resident #39, with chronic kidney disease and vascular dementia, had a stage IV pressure ulcer on the left heel and was under orders for EBP due to catheter/wound. Similarly, Resident #41, with spina bifida and paraplegia, had a stage IV pressure ulcer on the left ischium and also required EBP. During observations, it was noted that the Licensed Practical Nurse (LPN) Unit Manager and a Certified Nursing Assistant (CNA) did not don gowns while performing wound care for these residents, despite the presence of a PPE cart and signage indicating the need for EBP. The LPN and CNA only wore gloves, neglecting the gown requirement for high-contact activities such as wound care. This was confirmed during follow-up interviews where the LPN acknowledged the oversight and admitted that it was not her usual practice to wear a gown during wound rounds. The facility's policy on Enhanced Barrier Precautions, as well as CDC guidance, clearly stated the necessity of gown and glove use during high-contact resident care activities, including wound care, to prevent the transmission of multi-drug resistant organisms (MDROs). The failure to adhere to these guidelines was identified as a deficiency, affecting the care of residents with open wounds and potentially increasing the risk of infection transmission.
Latest citations in Ohio
A resident with intact cognition receiving Medicare Part A skilled services for metabolic encephalopathy had services discontinued while benefit days remained, but the facility did not issue the required Skilled Nursing Facility Advance Beneficiary Notice (SNF ABN). The Social Services Director later confirmed that no SNF ABN was provided and reported she believed only a Notice of Medicare Non-Coverage (NOMNC) was needed when all skilled services were stopped. This practice conflicted with the facility’s written policy, which required SNF ABNs to be issued when extended care items or services were initiated, reduced, or terminated due to expected non-coverage by Medicare.
Surveyors identified that the facility exceeded the acceptable medication error rate when two residents with type 2 DM received insulin doses that were not administered according to orders or manufacturer instructions. In two separate observations, an LPN administered Novolog and another LPN administered insulin glargine and insulin lispro without priming the insulin pens, and the insulin lispro and Novolog were given after the residents had already consumed a significant portion of their breakfast meals, despite orders for administration before meals. Manufacturer information for both insulin products required priming before each injection to ensure accurate dosing, and facility policy required medications, including insulin, to be administered safely, timely, and in accordance with prescriber orders and specified time frames.
Surveyors found that the facility failed to document tray line food temperatures for multiple meals served from two dining room kitchenettes, despite having a “Trayline Taste & Temperature Log” and a policy requiring food to be stored, prepared, distributed, and served according to professional food safety standards. Review of logs showed repeated missing entries for breakfast, lunch, and dinner services in both the Harrison and McClellan dining areas, and the Senior Director of Culinary Services confirmed that temperatures had not been recorded for those meals, potentially affecting all residents receiving meals from those kitchenettes.
The facility failed to conduct and document required periodic care conferences for two residents, despite multiple comprehensive, quarterly, and significant change MDS assessments and a policy requiring periodic care conferences with resident and/or family participation. One resident with Parkinson’s disease, post-stroke hemiplegia, TIA, DMII, and depression had only two documented care conferences over a year, while another resident with aphasia, cerebrovascular disease, DMII, gait difficulty, coagulation defect, depression, and muscle weakness had no documented care conferences in the past year, aside from a declined invitation to the representative. The UCC confirmed that care conferences were expected to occur quarterly and that no additional documentation existed for either resident.
A resident with Alzheimer's disease and type II DM, who required extensive assistance with ADLs and was receiving scheduled Lantus and sliding-scale Humalog, experienced a severely elevated blood glucose level. The on-call provider was notified and ordered an additional dose of lispro insulin with a directive to recheck the blood glucose after administration. Nursing staff administered the extra insulin but did not document any follow-up blood glucose check, and the DON confirmed that this reevaluation was required by the facility's abnormal blood glucose policy and was not completed or documented.
A resident with Parkinson’s disease, dementia, and hypothyroidism was prescribed levothyroxine once daily along with other medications. A consultant pharmacist’s monthly drug regimen review recommended that levothyroxine be given in the morning on an empty stomach, 30–60 minutes before food, per manufacturer instructions. The medical record contained no documented physician response to this recommendation, and the MAR showed the drug scheduled for morning administration while the resident was observed eating breakfast and receiving the medication at the same time. An LPN confirmed administering levothyroxine during the meal, and the DON verified there was no documentation explaining whether or why the pharmacist’s recommendation was or was not followed, resulting in a failure to act on and document the identified irregularity.
A resident with severe cognitive impairment, multiple comorbidities, documented gait and balance abnormalities, and a high fall risk was care planned and assessed by therapy to require contact guard assistance and use of a gait belt for transfers and ambulation. While being assisted by a CNA from a recliner to the bathroom with a walker, the CNA did not apply a gait belt, even though the resident had a known tendency to lean backward when standing. As the CNA reached to open the bathroom door, the resident lost balance and fell backward, striking the back of the head, and was later found by an LPN without a gait belt in place, contrary to the facility’s gait belt policy and the resident’s assessed needs.
A resident with CKD stage five requiring peritoneal dialysis (PD) was admitted with pre-admission physician orders for three daily PD exchanges and monitoring for peritonitis (fever, abdominal pain, cloudy effluent), but these monitoring orders were not entered into the facility’s physician orders. The care plan referenced PD and general monitoring but did not specifically address peritonitis monitoring. Paper PD flowsheets showed incomplete and inconsistent documentation of exchanges and resident condition, including missing condition/comments for individual treatments and no record of one ordered PD exchange. The PD cycler flowsheet lacked effluent descriptions on multiple days. The PD nurse reported facility staff were expected to monitor effluent and symptoms, and the DON confirmed the absence of specific peritonitis monitoring orders, lack of an order for the PD cycler, and documentation gaps, despite a facility policy requiring ongoing assessment and monitoring for complications before, during, and after dialysis treatments.
A nurse was observed preparing multiple oral medications for a resident with depression, traumatic brain injury, anxiety, and impaired cognition by pushing tablets and capsules from unit-dose cards directly into her ungloved hand and then using her fingers to place them into a medication cup. In a follow-up interview, the RN confirmed this practice and acknowledged that the correct procedure is to dispense medications directly from the card into the cup, contrary to the facility’s medication administration policy requiring adherence to good nursing principles and practices.
A resident with Alzheimer’s disease, diabetes, anxiety, significant ADL dependence, and behavioral symptoms was observed seated in a chair positioned against the nursing station with a locked wheelchair placed directly in front, also against the nursing station, effectively restricting movement. An LPN confirmed both wheelchair wheels were locked and that it should not have been placed there, while a CNA stated she had positioned the wheelchair to prepare for lunch, was unable to complete the transfer, and left it in place, acknowledging this was wrong. This arrangement conflicted with the facility’s restraint policy, which prohibits physical restraints except when alternatives are ineffective for treating a medical symptom and defines restraints as devices adjacent to the body that cannot be easily removed and that restrict freedom of movement or access to the body.
Failure to Issue Required SNF ABN When Discontinuing Medicare Part A Services
Penalty
Summary
The deficiency involves the facility’s failure to issue a Skilled Nursing Facility Advance Beneficiary Notice (SNF ABN) when Medicare Part A services were discontinued for a resident who still had available benefit days. The resident was admitted with a diagnosis of metabolic encephalopathy and had intact cognition per the Minimum Data Set assessment. The facility’s own SNF Beneficiary Notification Review documented that Medicare Part A skilled services began on 02/11/26 and the last covered day was 03/11/26, and that the facility initiated discharge from Medicare Part A services before the resident’s benefit days were exhausted. Despite this, no SNF ABN was provided to the resident or the resident’s representative. During interviews, the Social Services Director stated that the SNF ABN was issued hours prior to the last covered day but, upon reviewing her files, confirmed that no SNF ABN had actually been issued for this resident. She further explained that she believed an SNF ABN was only required if one skilled service remained and that if all skilled services were being discontinued, only the Notice of Medicare Non-Coverage (NOMNC) needed to be issued. The Administrator, however, stated that a resident should always receive both a SNF ABN and a NOMNC when Medicare Part A services are discontinued and benefit days remain. Review of the facility’s written policy dated 03/28/23 showed that the facility was required to issue SNF ABNs for initiation, reduction, or termination of extended care items or services when Medicare payment was not expected, which did not occur in this case.
Plan Of Correction
This Plan of Correction is submitted as required under State and Federal law. This Plan of Correction does not constitute an admission on the part of the Facility that the findings cited are accurate, that the findings constitute a deficiency or that the scope and severity regarding the deficiency cited are correctly applied. Any changes to the Facility's policies and procedures should be inadmissible in any proceeding on that basis. Without admitting or denying the validity or the existence of the alleged noncompliance, the Facility submits this Plan of Correction with the intention that it be inadmissible by any third party in any civil or other action against the facility or any employee, agent, officer, director or shareholder of the Facility. The Facility is utilizing this Plan of Correction as its allegation of substantial compliance as of 05/29/2026 F-0582 Corrective action for resident/s: On 5/14/26 Resident #34 was informed of rights and responsibilities related to Advanced Beneficiary Notice and voiced understanding of information for future reference by administrator. Identification of other residents who may be affected: Any resident receiving skilled services from nursing or therapy services. The Administrator audited all residents who were discharged from skilled services in the past 30 days to ensure they were issued a Notice of Non-Coverage and Advanced Beneficiary Notice on 5/29/26. No non-compliance was noted. Measures for systemic change: On 5/14/2026 Business Office Manager, Director of Rehab, Minimum Data Set nurse, Director of Nursing and Social Services Director were educated on proper procedure of issuing of Notice Of Medicare Non Coverage and Advanced Beneficiary Notice by administrator. All upcoming discharges from skilled services will be reviewed weekly at Utilization Review meeting to ensure notices will be delivered timely. How Corrective Action will be monitored: Administrator or designee to complete audits of all residents being discharged from skilled services to ensure they were issued a Notice of Non-Coverage and Advanced Beneficiary. This audit will be completed weekly x 4 weeks, then monthly x 2 months. Corrective action will be initiated for any noted non-compliance. Audit findings will be reviewed as part of the monthly quality assurance process to determine the need for further monitoring. Date of Compliance 5/29/26
Insulin Administration Errors and Failure to Prime Insulin Pens
Penalty
Summary
The deficiency involves the facility’s failure to maintain a medication error rate below 5%, with surveyors identifying 3 errors out of 28 medication administration opportunities, resulting in a 10.71% error rate. For one resident with type 2 diabetes mellitus and moderate cognitive impairment, the physician’s order directed Novolog insulin 10 units via subcutaneous pen-injector to be given before meals. During an observed medication pass, the LPN administered 10 units of Novolog insulin without priming the pen and did so after the resident had already consumed approximately 50% of the breakfast meal. The LPN later confirmed she did not prime the pen and acknowledged that the insulin was ordered to be administered prior to meals. Manufacturer instructions for the Novolog FlexPen specified that an air shot (priming) must be performed before each injection to ensure proper dosing. Another resident, also diagnosed with type 2 diabetes mellitus and with intact cognition, had orders for insulin glargine 35 units subcutaneously twice daily and insulin lispro 20 units subcutaneously before meals, plus 12 units subcutaneously if blood glucose was between 251 mg/dL and 300 mg/dL. During an observed medication administration, an LPN administered 35 units of insulin glargine and 32 units of insulin lispro without priming the insulin pens and after the resident had consumed approximately 90% of the breakfast meal, despite orders for insulin lispro to be given before meals. The LPN later stated she could not remember if she had primed the pen and acknowledged that the insulin was ordered to be administered prior to meals. Manufacturer information for insulin lispro stated that the pen must be primed before each injection to confirm insulin delivery and remove air, and that failure to prime could result in too much or too little insulin. The DON confirmed the expectation that insulin be administered as ordered, including priming each pen with two units before dialing the prescribed dose, and facility policy required medications, including insulin, to be administered safely, timely, and in accordance with prescriber orders and required time frames.
Plan Of Correction
This Plan of Correction is submitted as required under State and Federal law. This Plan of Correction does not constitute an admission on the part of the Facility that the findings cited are accurate, that the findings constitute a deficiency or that the scope and severity regarding the deficiency cited are correctly applied. Any changes to the Facility's policies and procedures should be inadmissible in any proceeding on that basis. Without admitting or denying the validity or the existence of the alleged noncompliance, the Facility submits this Plan of Correction with the intention that it be inadmissible by any third party in any civil or other action against the facility or any employee, agent, officer, director or shareholder of the Facility. The Facility is utilizing this Plan of Correction as an allegation of substantial compliance as of 5/29/2026. F-0759 Corrective action for resident/s: Residents #21 and #22 were assessed and evaluated by nurse and Director of Nursing 5/14/26. Resident #21 and #22 both denied any adverse effects and none were noted upon assessment by the Director of Nursing on 5/14/2026. Notification made to physician on 5/14/2026. LPN # 2 competency Eval on insulin administration with the Director of Nursing completed 5/14/2026. Identification of other residents who may be affected: Diabetic residents on assignment of LPN #2/station 2 have the potential to be affected and were assessed by the DON/Designee on 5/14/26 and found to be within normal limits. Measures for systemic change: All Nurses were educated by the Director of Nursing on the steps for Insulin administration per competency, diabetes clinical protocol policy, Medication and treatment orders policy, administering medications policy, and Obtaining fingerstick Glucose Level policy On 5/14/2026. How Corrective Action will be monitored: Director of Nursing and Assistant Director of Nursing will complete insulin administration audits on 5 nurses. This audit will be completed weekly x 4 weeks, then monthly x 2 months. Corrective action will be initiated for any noted non-compliance. Audit findings will be reviewed as part of the monthly quality assurance process to determine the need for further monitoring. Date of Compliance: 5/29/2026
Failure to Document Tray Line Food Temperatures in Dining Room Kitchenettes
Penalty
Summary
The deficiency involves the facility’s failure to document tray line food temperatures for meals served from the Harrison and McClellan Dining Room kitchenettes, as required by professional standards for food service safety and the facility’s own policy. Review of the “Trayline Taste & Temperature Log” (revised September 2018) showed missing temperature documentation for multiple meals from the Harrison Dining Room kitchenette, including dinner on 03/30/26 and 03/31/26, lunch and dinner on 04/01/26 and 04/02/26, dinner on 04/07/26, and lunch and dinner on 04/08/26 and 04/10/26. The Senior Director of Culinary Services confirmed during interview that tray line food temperatures were not documented on the log for these meals. Similarly, review of the same log for the McClellan Dining Room kitchenette revealed that tray line food temperatures were not documented for dinner on 04/01/26, breakfast and lunch on 04/02/26, and lunch and dinner on 04/07/26. The Senior Director of Culinary Services also verified these omissions during interview. The facility census at the time was 27 residents, and the governing “Food and Nutrition” policy, approved on 09/07/21, stated that the facility must store, prepare, distribute, and serve food in accordance with professional standards for food service safety.
Plan Of Correction
F812 The facility will continue to ensure food temperatures are completed before meals are served for all residents. To ensure compliance with this standard the following measures have been taken: 1. Immediately 4/15/26 culinary supervisor #224 was re-educated by Dietary Manager to this standard and policy "Food and Nutrition" which includes documentation of food temperatures. 2. All dietary staff have been re-educated to the standard and policy "Food and Nutrition" during the month of April 2026. 3. Audits of food temperature documentation to be completed by Dietary Manager 4 x per week for 4 weeks then weekly for 4 weeks. 4. Administrator to validate audits/compliance and provide additional training as needed. Administrator will present to QAPI committee for ongoing monitoring and further direction.
Failure to Conduct and Document Required Care Conferences
Penalty
Summary
The deficiency involves the facility’s failure to complete and document comprehensive care conferences at required intervals in accordance with care plan regulations and facility policy. For one resident with Parkinson’s disease with dyskinesia, cognitive communication deficit, hemiplegia and hemiparesis following cerebral infarction, transient cerebral ischemic attack, type II diabetes mellitus, and major depressive disorder, the record showed multiple MDS assessments over a one-year period, including annual, quarterly, and significant change assessments. However, only two care conferences were documented during the last 12 months, despite the expectation that care conferences be conducted quarterly with the resident and family when possible. The Unit Care Coordinator confirmed that no additional care conference documentation existed for this resident beyond the notes dated 04/21/25 and 01/02/26. A second resident, with diagnoses including aphasia following cerebrovascular disease, cerebral infarction, type II diabetes mellitus, unsteadiness on feet, difficulty in walking, coagulation defect, depression, and muscle weakness, also had multiple MDS assessments completed over the review period, including quarterly and annual assessments. The record contained a note that a care conference was offered to the resident’s representative, who declined to attend, but there was no documentation of any care conferences for the most recent 12 months. The Unit Care Coordinator confirmed that no other care conference documentation was available for this resident. Facility policy stated that periodic care conferences involving the resident, family, and the interdisciplinary team are part of the care planning process, but the required periodic care conferences and corresponding documentation were not completed for these two residents.
Plan Of Correction
THIS PLAN OF CORRECTION SERVES AS BERKELEY SQUARE'S CREDIBLE ALLEGATION OF SUBSTANTIAL COMPLIANCE AS OF June 1, 2026. Without admitting or denying the validity or existence of the alleged deficiencies, Berkeley Square provides the following Plan of Correction: F657 The facility will continue to document completion of care conferences at the required intervals for all residents, including residents #04 & #15. To ensure compliance with this standard the following measures have be taken: 1. The social service designee and the inter- disciplinary team were re-educated by the administrator to the facility policy "Care Conference" on 4/29/26 and verbalized understanding. 2. Care conferences for resident #04 and resident #15 were conducted on or before 4/29/2026 by the interdisciplinary team. 3. Review of all other residents was conducted by the social service designee to validate and ensure that care conference schedule is up to date with timely care conferences scheduled for them on 4/15/2026. Audits of care conferences to be completed weekly for four weeks and then monthly after that by the social service designee. Documentation of the care conference including any identified concerns in the medical record. Administrator to validate audits/compliance and provide additional training as needed. Administrator will present results of these audits to QAPI committee for ongoing monitoring and further direction.
Failure to Reevaluate Blood Glucose After Treatment for Hyperglycemia
Penalty
Summary
The facility failed to ensure that a resident with diabetes received treatment in accordance with professional standards of practice when nursing staff did not reevaluate the resident's blood glucose after treatment for severe hyperglycemia. The resident, admitted with diagnoses including Alzheimer's disease, type II diabetes mellitus, and depression, had physician orders for Humalog insulin on a sliding scale before meals, Lantus insulin 25 units daily, and lisinopril 5 mg daily. The resident required extensive assistance with activities of daily living, including transfers, toileting hygiene, eating, and bathing. On the evening in question, the resident's blood glucose was documented as 532 mg/dL, and the on-call provider was notified. The provider gave a new order to administer an additional 8 units of lispro (Humalog) and to recheck the blood glucose in 30 minutes. The electronic medication administration record showed that the blood glucose of 532 mg/dL was obtained at 9:00 p.m. and that the additional 8 units of lispro were administered at 9:21 p.m. However, there was no documentation in the resident's chart that the blood glucose was rechecked after the additional insulin was given. In an interview, the DON confirmed there was no evidence of reevaluation and verified that, according to the facility's "Abnormal Blood Glucose Procedure" policy, the resident should have been reevaluated and that the evaluation step should have been included in the progress note documentation.
Plan Of Correction
F684 The facility will continue to ensure all residents, including #03, receive treatment in accordance with professional standards of practice and reevaluated for hyperglycemia. To ensure compliance with this standard the following measures have been taken: 1. The director of nursing assessed resident #03, reviewed documentation and orders and found no ill effects immediately 4/16/26. 2. All licensed nurses were re-educated to facility policy "Blood Glucose Monitoring" by the Director of Nursing/designee in April 2026. 3. Audits of like-residents that require blood sugar checks to be completed by the director of nursing/designee two times a week for 4 weeks and then monthly after that to validate correct follow through when there is abnormally high blood glucose result. The Administrator will bring results of these audits to the QAPI committee for ongoing monitoring and further direction.
Failure to Act on Pharmacist Drug Regimen Recommendation for Thyroid Medication
Penalty
Summary
The deficiency involves the facility’s failure to ensure that pharmacy recommendations from the monthly drug regimen review were acted upon and documented for a resident. The resident was admitted with diagnoses including Parkinson’s disease, dementia, and hypothyroidism, and had current physician orders for levothyroxine 150 mcg once daily, buspirone 50 mg twice daily, and losartan 100 mg once daily. A medication regimen review dated 11/25/2025 included a consultant pharmacist recommendation that levothyroxine be administered consistently in the morning on an empty stomach, at least 30–60 minutes before food, per manufacturer instructions. There was no specific physician response in the medical record to this recommendation, and the facility’s policy stated that consulting pharmacist reviews are sent to nursing and addressed with the primary care provider or consulting specialist for review and follow-up. Review of the resident’s medication administration record for April 2026 showed levothyroxine scheduled for 9:00 a.m. On observation, the resident was seen eating breakfast in the dining area at 8:03 a.m., and an LPN reported administering the levothyroxine 150 mcg to the resident while the resident was in the dining area eating breakfast. The DON confirmed there was no evidence in the resident’s medical record explaining why the consultant pharmacist’s recommendation from 11/25/2025 was or was not acted upon. This lack of documented physician review and action on the pharmacist’s identified irregularity constituted noncompliance with the drug regimen review requirements.
Plan Of Correction
F756 The facility will continue to ensure the pharmacy recommendations from the monthly drug regimen review by a licensed pharmacist are acted upon for all residents, including #08. To ensure compliance with this standard the following measures have been taken: 1. Resident #08 was assessed by the registered nurse and med review completed by 4/28/26. After review of resident's drug regime's, it was discovered that resident #8 had 2 separate medication recommendations on the same form, to be reviewed by two separate practitioners, pharmacy has been instructed and agreed to separate meds on individual forms. 2. Licensed nurses re-educated to facility policy "Drug Regimen Review" by Director of nursing/designee in April 2026 and no later than 5/8/26. Licensed nurses are responsible for ensuring the reviews and recommendations are given to the physician for timely review. 3. Review of all other current residents Drug Regimen orders completed by Director of nursing/designee on 4/16/26 to ensure recommendations were followed up on/reviewed by the physician and address concerns if needed. 4. Audit of drug regime recommendations, pharmacy recommendations, and physician follow up to be completed weekly for four weeks by the Director of nursing/designee. Administrator will present results of these audits to the QAPI committee for ongoing monitoring and further direction.
Failure to Use Required Gait Belt During Ambulation Resulting in Resident Fall
Penalty
Summary
The deficiency involves the facility’s failure to ensure that a required gait belt was used while assisting a high fall‑risk resident with ambulation, resulting in a fall with head injury. The resident had multiple diagnoses including metabolic encephalopathy, hypertension, osteoarthritis, muscle weakness, gait and mobility abnormalities, major depressive disorder, anxiety, and visual hallucinations. Admission and subsequent MDS and fall risk assessments documented that the resident was severely cognitively impaired, required moderate to maximal assistance with transfers and ambulation, could not independently come to a standing position, exhibited loss of balance while standing, used an assistive device, and had decreased muscle coordination. The resident had a history of falls prior to admission and was assessed as being at high, later moderate, risk for falls. The resident’s fall care plan identified her as at risk for falls and included interventions such as providing maximum to moderate assistance with transfers and walking short distances, use of a walker and wheelchair, and following the facility’s fall protocol. Therapy notes and care conference documentation indicated that the resident leaned backwards when standing, required contact guard to minimal assistance for bed mobility and transfers, and needed constant verbal cueing for safe sequencing during toilet transfers. The physical therapist confirmed that the resident was to use a gait belt with staff when ambulating, and the DON verified that therapy had assessed the resident as requiring contact guard assistance and a gait belt for ambulation and transfers. On the day of the incident, a CNA was assisting the resident from her recliner to the bathroom using a walker. The CNA walked beside the resident, providing guidance and support, and reported having a hand on the resident while assisting her. As they approached the bathroom door, the CNA reached for the doorknob to open it, and at that moment the resident began to lose her balance and fell backwards to the floor, striking the back of her head. The nurse who responded found the resident on her back at the foot of the bed with her feet near the bathroom, noted a red raised area on the back of the head, and documented that the resident was not wearing a gait belt and that the gait belt was on the dresser. In the facility’s investigative summary and in interviews, the CNA acknowledged that she did not have a gait belt on the resident while ambulating her, despite the resident’s assessed need for hands‑on assistance and gait belt use per facility policy and the resident’s care and therapy plans.
Failure to Implement PD Orders and Monitor Resident Receiving Peritoneal Dialysis
Penalty
Summary
The deficiency involves the facility’s failure to implement pre-admission physician orders for peritoneal dialysis (PD) and to provide ongoing monitoring for a resident with chronic kidney disease (CKD) stage five who required PD. Pre-admission orders dated 11/14/25 specified three daily PD exchanges at 6:00 A.M., 2:00 P.M., and 10:00 P.M., and directed staff to monitor for signs and symptoms of peritonitis, including fever, abdominal pain, and cloudy effluent. These monitoring orders were not entered into the facility’s physician orders. The resident’s care plan noted the need for PD and included general monitoring interventions (labs, signs of bleeding, bacteremia, septic shock, and significant vital sign changes), but did not specifically address the ordered monitoring for peritonitis. Review of PD documentation showed incomplete and inconsistent charting of treatments and resident condition. The paper peritoneal flowsheet had columns for time of PD and condition/comments, including instructions to call the nurse immediately for cloudy fluid, abdominal pain, or fever. However, the first entry on 11/15/26 at 2:00 P.M. only noted that the PD nurse completed the exchange, and the 10:00 P.M. entry that day had no condition/comment documentation. Subsequent days (11/16/25, 11/17/25, and 11/18/25) contained only one condition/comment entry per day rather than for each exchange, and there was no documentation that the 6:00 A.M. PD on 11/18/25 was completed. The PD cycler flowsheet starting 11/19/25 lacked any description of the effluent on multiple days. The PD nurse from the dialysis company stated facility staff were expected to monitor effluent for cloudiness and assess for abdominal pain and fever, and the DON confirmed there was no electronic physician order for peritonitis monitoring or for use of the PD cycler, that the paper charting did not allow for effluent description or symptom documentation for each treatment, and that PD was not documented at one ordered time. The facility’s dialysis policy required ongoing assessment and monitoring for complications before, during, and after treatments, which was not reflected in the documentation for this resident.
Improper Infection Control During Medication Administration
Penalty
Summary
Surveyors identified a deficiency in infection prevention and control related to medication administration for Resident #29. The resident was admitted on 02/28/14 with diagnoses including depression, traumatic brain injury, and anxiety, and had impaired cognition per a quarterly MDS assessment. During an observation on 03/25/26 at 6:58 A.M., RN #281 prepared the resident’s medications by removing an Amoxicillin-Pot Clavulanate tablet from the medication card and pushing it directly into her ungloved hand, then using her fingers to place the pill into a medication cup. The same process was observed for multiple other medications, including Escitalopram Oxalate, Furosemide, Sennosides, Lyrica, and Vitamin D, each being pushed from the card into the RN’s ungloved hand and then transferred by her fingers into the medication cup before administration to Resident #29. In a subsequent interview at 7:27 A.M. the same day, RN #281 confirmed she had placed each medication into her ungloved hands prior to administration and acknowledged that the proper procedure was to push the pills directly from the card into the medication cup. Review of the facility’s “Medication Administration – General guidelines” policy, revised 10/08/25, stated that medications are to be administered in accordance with good nursing principles and practices. This practice failure was cited as a deficiency under Complaint Number 2681777.
Improper Use of Wheelchair as a Physical Restraint
Penalty
Summary
Surveyors identified a deficiency related to the facility’s failure to ensure a resident was free from physical restraints. Resident #7, admitted with diagnoses including Alzheimer’s disease, diabetes mellitus, and anxiety disorder, was documented on a recent MDS as rarely understood and dependent for ADLs except eating. The resident ambulated independently on the unit without an assistive device and had documented verbal and other behaviors occurring one to three days during the look-back period. The care plan noted the resident had potential to be physically aggressive, chase staff, throw objects, and be combative with care, with interventions such as offering choices, administering medications as ordered, and intervening early when agitation occurred. During an observation and interview, Resident #7 was found sitting in a chair with the right arm of the chair positioned against the nursing station and a wheelchair placed directly in front of him. The left arm of the wheelchair was also against the nursing station, and both wheelchair wheels were locked, creating a barrier that appeared to restrain the resident, who was sleeping with his knees touching the locked wheelchair. An LPN confirmed both wheelchair wheels were locked and that the wheelchair should not have been placed in front of the resident. A CNA reported she had placed the wheelchair there in preparation to get the resident up for lunch, was unable to transfer him, and left the wheelchair in that position, acknowledging it was wrong to keep it there. The facility’s physical restraint policy stated that physical restraints are not used except when alternatives are not appropriate or effective for treating a medical symptom and defined physical restraints as any device attached or adjacent to the body that the individual cannot easily remove and that restricts freedom of movement or access to the body.
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