Legends Care Rehabilitation And Nursing Center
Inspection history, citations, penalties and survey trends for this long-term care facility in Massillon, Ohio.
- Location
- 2311 Nave Road Se, Massillon, Ohio 44646
- CMS Provider Number
- 366085
- Inspections on file
- 32
- Latest survey
- March 10, 2026
- Citations (last 12 mo.)
- 10
Citation history
Health deficiencies cited at Legends Care Rehabilitation And Nursing Center during CMS and state inspections, most recent first.
The facility failed to timely report an allegation of misappropriation after two Fentanyl transdermal patches ordered for a cognitively impaired resident with cancer-related pain went missing. One LPN received and counted the two patches from the pharmacy and handed the medication bag to another LPN, who stated she never received the patches and did not know she was supposed to have them. The patches were never found. The DON acknowledged the missing narcotics should have been reported to the state agency, law enforcement, and pharmacy but did not do so after being told by corporate and the Administrator that it was not misappropriation because the facility had paid for the medication. The pharmacist confirmed he was not notified, despite facility policies requiring immediate reporting and investigation of misappropriation and controlled substance discrepancies.
The facility failed to thoroughly investigate two missing Fentanyl patches prescribed for chronic pain for a cognitively impaired resident with multiple serious diagnoses. An LPN reported receiving two Fentanyl patches in a pharmacy delivery and handing the bag to another LPN, who denied ever receiving the patches, and the patches were never found. The investigation lacked complete staff statements, relied on an unsigned email as a key statement, and only three nurses were drug tested days later while other involved staff were not tested. The incident was not reported to the state agency, law enforcement, or the pharmacy, despite facility policies requiring investigation and reporting of alleged misappropriation and controlled substance discrepancies.
The facility failed to obtain and implement timely physician orders for post‑surgical wound care and anticoagulant therapy for multiple post‑operative residents. A resident with a repaired right hip fracture had no wound dressing orders for several days, reported a seeping surgical site left uncovered after dressing removal and showering, and stated staff did not assess the wound; two nurses confirmed the absence of early wound orders. Another resident with a hip fracture had no documented orders or treatments for surgical wound dressings or monitoring, and a third resident with a recent pacemaker placement lacked initial orders for pacemaker site care until later entry by a regional RN. In addition, two residents admitted after hip surgery arrived with hospital documentation and orders for Enoxaparin for extended DVT prophylaxis, yet neither had anticoagulant orders or documented preventive measures in the facility, and nursing staff acknowledged that anticoagulant therapy should have been clarified and continued.
Surveyors found that the facility failed to maintain sanitary conditions in the kitchen and did not properly label or date multiple food items. In the food preparation area, there was food debris and cardboard on the floor, a raw biscuit smashed on the floor, buildup of food debris on a steel table, splashes of dried liquids and food on the wall, and undated bowls of dried cereal on a cart. In cold storage, surveyors observed an unidentified, undated red liquid in a container, undated cherry tomatoes, and an open, undated bag of salad mix in the refrigerator, as well as an undated container of unknown soup in the freezer. Additional findings included dirty utility carts with spilled dark brown liquid, a dirty wall behind the steamer with dried liquid splashes, and a floor behind the steamer with heavy black dirt buildup. A staff member confirmed these conditions, which did not comply with the facility’s own policies for food storage and cleaning of dietary areas.
A resident with multiple serious cardiac and pulmonary conditions experienced changes in behavior and speech that prompted the designated family representative, who held HCPOA, to repeatedly request hospital transfer and report concerns such as slurred speech, reduced contact, and complaints of shortness of breath. An LPN and the DON opted to perform an in-house workup with labs, urinalysis, and chest x-ray instead of sending the resident to the hospital, and the DON cited stable vital signs and lack of MPOA paperwork on file as reasons not to transfer, despite the family member being listed as emergency contact and later submitting HCPOA documents. The chest x-ray showed pulmonary congestion and other abnormalities, but the physician later stated he was not informed that the family had requested hospital transfer due to the resident acting differently. Social Services and nursing staff acknowledged multiple communications with the family member about the resident’s condition and the MPOA paperwork, but these interactions and the DON’s assessment were not documented in the medical record. Several days later, the resident developed acute stroke-like symptoms and was sent to the hospital, where death occurred, and surveyors found that the facility failed to ensure the resident’s representative could effectively exercise the resident’s rights and that concerns were addressed in a timely manner.
A resident with multiple chronic conditions and intact cognition was started on Remeron 7.5 mg at bedtime for decreased appetite after an LPN observed reduced meal intake over several days and contacted the physician. The resident’s HCPOA had been formally designated and the paperwork submitted to the facility, but there was no documentation that this representative was notified of the new psychotropic medication or of the rationale for its initiation. The HCPOA later reported never being informed about the Remeron or any appetite issues, while the DON confirmed the absence of documentation and the LPN acknowledged she did not chart any notification despite stating she frequently spoke with the resident’s emergency contacts.
A resident with multiple chronic conditions and intact cognition was started on Remeron 7.5 mg at bedtime for decreased appetite after an LPN observed reduced meal intake over several days and contacted the physician. The resident’s HCPOA documentation had been submitted to the facility, but there was no documentation that the HCPOA was notified of the new psychotropic medication. The HCPOA later reported never being informed about the Remeron or any appetite concerns. The DON confirmed there was no documented rationale for starting the medication or evidence of representative notification, and the LPN acknowledged she did not chart any notification, resulting in a deficiency related to failure to inform the resident’s representative of a significant medication change.
A resident with multiple cardiac, pulmonary, neurologic, and vision conditions was assessed as high risk for falls and care planned for fall prevention, including keeping needed items within reach, using the call light, and wearing appropriate footwear with gripper/non‑skid socks when not in proper shoes. Despite this, the resident experienced several witnessed and unwitnessed falls while wearing only regular socks, including falls from the bedside and outside the bathroom after receiving a laxative. Physician orders required gripper/non‑skid socks and shift checks for proper placement, but the DON confirmed the resident did not have the ordered socks on at the time of a fall and there was no documentation that the resident had removed or changed them, demonstrating a failure to consistently implement ordered fall‑prevention interventions.
Surveyors found that the facility did not maintain a medication error rate below 5%, identifying 9 errors out of 25 opportunities (36%) involving a resident with multiple diagnoses, including lupus, acute respiratory failure, malnutrition, gastrostomy status, and dysphagia. An LPN prepared nine scheduled 9:00 A.M. medications ordered via PEG tube by crushing and mixing them all together in one cup and preparing to administer them as a single cocktail, despite there being no physician order to mix the medications. Facility policy on administering medication through an enteral tube required that medications not be mixed together and that each be given separately unless a specific physician order with rationale directed otherwise, making the observed practice inconsistent with both the resident’s orders and facility policy.
A resident with multiple cardiopulmonary conditions reported increased fatigue and shortness of breath, leading the physician to order labs and a chest x-ray instead of hospital transfer. The x-ray showed linear opacities, pulmonary congestion, and an elevated hemidiaphragm, with a radiology recommendation for a follow-up HRCT lung scan. Documentation showed the physician and family were informed of the x-ray results, but the DON later confirmed there was no evidence that the HRCT was ordered or scheduled, and the physician stated he did not believe the recommended HRCT was necessary. The family member reported not being informed of the CT recommendation, and surveyors cited the facility for failing to ensure timely follow-up of the recommended radiologic study.
A resident who was dependent on staff for personal hygiene was found to have yellowed, thickened fingernails with debris underneath, despite care plans and facility policy requiring regular assessment and maintenance. Weekly skin assessments did not address the nails, and both the resident and staff confirmed that the issue had not been noticed or addressed during routine care.
A resident with PTSD, anxiety, and depression did not receive trauma-informed care, as assessments and care plans lacked documentation of trauma history, triggers, or specific interventions. The resident reported ongoing night terrors and identified triggers, but staff interviews revealed limited awareness of the diagnosis or appropriate interventions.
Two residents were affected by medication administration errors when an LPN failed to prime an insulin pen as required and another LPN gave an incorrect dose of Vitamin E. These actions resulted in a medication error rate of 6.45%, exceeding the acceptable threshold.
A resident with severe cognitive impairment and multiple medical conditions was first observed with a bruise above the eye, but the injury was not immediately investigated or reported as required. Additional injuries, including bilateral eye bruising and a swollen hand, were later discovered, prompting delayed medical evaluation and reporting. Staff confirmed the initial injury was reported internally but not escalated, resulting in a deficiency for failing to follow timely investigation and reporting protocols for injuries of unknown origin.
The facility failed to protect residents from abuse, resulting in Immediate Jeopardy. A resident with a history of aggression physically assaulted two other residents, causing significant harm. The facility did not implement a comprehensive care plan to address the aggressive behaviors, nor did it ensure the safety of other residents, particularly those who were cognitively impaired and mobile.
A resident with Full Code status was found unresponsive without vital signs, but staff failed to initiate CPR or call 911, assuming hospice care implied DNR status. The resident's advance directives were not followed, leading to their death. Interviews revealed staff misunderstood the resident's code status, and facility policies were not adhered to.
The facility failed to promptly notify the family and physician of two residents upon their deaths. One resident with COPD and cerebrovascular disease was found without vital signs, and there was no documentation of immediate notification to the physician or family. Another resident with vascular dementia was also found without vital signs, and the facility did not document timely notification to the physician or family, contrary to facility policy.
The facility failed to properly investigate an incident where a resident with cognitive impairments pushed another resident, resulting in a fall and injury. The investigation lacked interviews with key witnesses, including a cognitively intact roommate who witnessed the event, and did not obtain a signed statement from a CNA who saw the incident. The facility concluded the evidence was inconclusive, despite witness accounts.
The facility failed to ensure staff were competent in implementing CPR per physician orders, affecting two residents. One resident, a Full Code, did not receive CPR due to staff assuming a DNR status because of hospice services. The time of death was inaccurately recorded by hospice instead of a physician. Another resident, a DNRCC, had their time of death called by hospice instead of notifying the primary physician. Facility policies on CPR and death documentation were not followed.
A resident with a self-care deficit due to medical conditions did not receive scheduled showers, shaving, or nail trimming as per their care plan. Despite being dependent on staff for ADL, the resident reported missed showers and grooming, confirmed by observations and staff interviews. A CNA cited time constraints as the reason for not providing care, and an LPN was unaware of the missed shower. Facility policies on grooming and hygiene were not followed.
A resident with multiple diagnoses, including insomnia, did not receive prescribed zolpidem tartrate due to delays in obtaining the medication from the pharmacy and a lack of communication with the physician. The medication was not administered for over ten days, and the issue was only discovered during a review by the DON. This deficiency was part of a complaint investigation and continued non-compliance from a prior survey.
A medication error rate of 6.5% was identified when an LPN failed to administer the correct dosage of duloxetine and nearly gave Zoloft to a resident without an order. The error was caught by a surveyor before administration. The facility's policy requires triple-checking medication labels, which was not followed.
An LPN failed to perform proper hand hygiene while administering medications to two residents, as observed during a survey. The LPN did not wash hands between handling medications for different residents or after removing gloves. This was confirmed in an interview, and it violated the facility's hand hygiene policy, which is crucial for preventing infection spread.
The facility failed to maintain a clean and sanitary kitchen, affecting 51 residents who received meals. Observations revealed dirty kitchen areas and pest control issues, with cockroaches present despite a policy for regular spraying. The facility's cleaning and pest control policies were not adhered to, leading to non-compliance.
A resident with dementia was not treated with dignity and respect by a State Tested Nurse Aide (STNA) during care. The STNA made inappropriate comments while attempting to change the resident's wet clothing, leading to the resident crying. The incident was recorded by a family member, who alleged verbal abuse. The STNA admitted to the inappropriate behavior and was terminated.
A resident with a complex medical history experienced a delay in scheduling an ultrasound after a mammogram revealed breast nodules. The facility did not document attempts to arrange the ultrasound or notify the family, leading to a deficiency identified when the Interim DON was informed by the family. The ultrasound eventually revealed abnormalities, necessitating a biopsy.
A resident was served nectar thick liquids instead of the physician-ordered regular diet with thin liquids due to a failure to update the meal ticket system. The facility lacked a dietary manager at the time, leading to the oversight. Interviews revealed a misunderstanding of the resident's diet requirements, and the facility's tray identification policy was not followed.
A resident with impaired cognition and a history of manipulating bed controls fell from her bed, which was in the highest position, resulting in severe injuries and subsequent death. The facility failed to update the care plan and implement adequate interventions to prevent the fall.
The facility failed to address resident grievances regarding call light response times, with residents reporting delays of 30 to 45 minutes or more. Observations confirmed that call lights were not answered promptly, and staff were seen seated at the nurses' station while call lights remained on.
The facility failed to ensure adequate staffing, resulting in delayed call light responses and unmet resident needs. Interviews and observations confirmed that residents often waited 30 to 45 minutes, and sometimes over an hour, for assistance. Staff reported that management was aware of the issue but stated that corporate would not allow additional staff.
The facility failed to address staff concerns about an LPN taking extended breaks and sleeping during shifts, which led to a resident falling and being transported to the hospital. Despite multiple reports from staff, the Administrator did not take action until the LPN was eventually terminated for insubordination, with no specific incidents documented in the personnel file.
The facility failed to ensure that residents or their representatives participated in the care planning process. Two residents with impaired cognition and requiring assistance with daily activities were affected. Care conferences were either not documented or not rescheduled, and family members reported not being invited or informed. The social worker responsible for care conferences had left the facility, and the administrator was unable to provide information on ensuring participation in care planning.
A resident reported verbal abuse by an aide who made derogatory comments about the resident's weight after a request for ice and soda. The facility's investigation was inconclusive due to a lack of a statement from the aide and previous communication issues.
A resident with Alzheimer's and dementia had bruises on their arms that were not reported to the State Agency as required. The bruises were first noted by staff and observed by the resident's daughter, but the facility failed to document and report the injury in a timely manner, contrary to its policy.
The facility failed to thoroughly investigate allegations of verbal abuse and an injury of unknown origin, affecting two residents. One resident reported being called an inappropriate name by an aide, and another resident was found with unexplained bruises. The facility did not obtain necessary statements or document the incidents properly, leading to non-compliance with their abuse policy.
The facility failed to implement care plans for two residents with skin impairments, leading to unaddressed injuries and lack of proper documentation and communication. One resident was found with a soiled bandage on his hand, and another had unexplained bruising on the arms. Staff were unaware of the injuries' origins, and the care plans' interventions were not followed.
A facility failed to ensure medications were stored in locked compartments and only accessible to authorized personnel. A resident was found with a medication cup containing pills on his bedside table, and an RN admitted he should have stayed while the medications were consumed. The RN received a written warning for this incident.
The facility failed to ensure accurate documentation on a MAR for a resident with dementia and other conditions. An RN documented medications as administered on specific dates, but it was later confirmed that he had not administered the medications himself, only observed another nurse doing so.
A resident reported being roughly handled and having a urine-soaked sheet thrown at her by an STNA. Despite the complaint and a report from the resident's cousin, the DON and Administrator did not initiate an investigation or report the incident to ODH as required by the facility's policy. The STNA was suspended, but no formal investigation was started.
A resident reported that an STNA took an hour and 45 minutes to respond to her call light, pushed her hard into the bedrail, and threw a urine-soaked sheet at her. The incident was reported to the DON, but no investigation was initiated, contrary to facility policy.
A resident with multiple diagnoses was unnecessarily transferred to a hospital for an elevated WBC count and possible sepsis without proper testing or documentation. The resident was returned to the facility with no new orders after a few hours in the ER. The DON confirmed that the transfer was not justified and the resident's needs could have been met within the facility.
The facility failed to provide proper ostomy and drainage tube care for a resident with multiple medical conditions, including an ileostomy. There were no physician's orders or documentation of care from 03/19/24 to 03/24/24, as confirmed by the DON.
A facility failed to provide effective pain management for a resident with serious health conditions, leading to delayed and insufficient pain relief. The resident experienced fluctuating pain levels, and the prescribed hydromorphone was unavailable due to a backorder. Alternative pain management was delayed, causing distress to the family and hospice staff. The resident eventually received morphine but expired shortly after.
The facility failed to accurately document the application of a wound vac for a resident with multiple diagnoses, leading to a deficiency in maintaining accurate medical records. Despite staff confirming the wound vac was applied earlier, it was not documented until several days later.
Failure to Report Missing Fentanyl Patches as Misappropriation
Penalty
Summary
The deficiency involves the facility’s failure to timely report an allegation of misappropriation of controlled substances to all required entities after two Fentanyl transdermal patches ordered for a resident went missing. The resident had diagnoses including hemiplegia and malignant neoplasms of the bladder and prostate and had impaired cognition, and had an active order for Fentanyl 50 mcg/hr patches for chronic pain. The investigation report showed that the former DON was notified by a night-shift LPN that two Fentanyl patches were missing. Interviews established that one LPN received a pharmacy delivery containing two Fentanyl patches, counted them, and signed the delivery slip, then handed the bag with the narcotics to another LPN. The receiving LPN stated she did not receive the two Fentanyl patches and was unaware she was supposed to have them. Another nurse confirmed the two Fentanyl patches were never found and stated they should have been reported as misappropriated. Further interviews revealed that the former DON acknowledged there were two missing Fentanyl patches for the resident and confirmed they should have been reported to the state agency via a Self-Reported Incident for misappropriation and to the police, but stated she was instructed by corporate and the Administrator not to report the incident, based on the rationale that the facility could not misappropriate its own property. The Regional RN did not know why an SRI was not completed and deferred to the Administrator. The pharmacist confirmed he was not notified of any missing narcotics, including the Fentanyl patches, and stated he should have been notified. Facility policies on abuse, neglect, exploitation, misappropriation of resident property, and controlled substances required immediate reporting of such allegations to the Administrator/designee, the state health department, and law enforcement when a crime is suspected, as well as consultation with pharmacy and the Administrator for controlled substance discrepancies. These required notifications and reporting steps were not carried out for the missing Fentanyl patches.
Incomplete Investigation of Missing Fentanyl Patches and Failure to Report Misappropriation
Penalty
Summary
The deficiency involves the facility’s failure to conduct a thorough investigation into two missing Fentanyl transdermal patches prescribed for chronic pain for Resident #73, who had diagnoses including hemiplegia and malignant neoplasms of the bladder and prostate, and impaired cognition per the MDS. Physician orders directed application of a 50 mcg/hr Fentanyl patch every 72 hours. On the date of the incident, the former DON was notified by the night nurse of two missing Fentanyl patches, but the investigation documentation lacked basic elements such as the time of notification and complete staff statements. The investigation file contained only four statements from selected nursing staff and did not include a statement from the night LPN who initially reported the missing patches or from the LPN who oriented with the nurse that signed for the patches. The statement attributed to the LPN who received the pharmacy delivery was only present as an unsigned email from the Administrator. Only three staff members were drug tested two days after the incident, while other involved nurses, including the RN who counted narcotics with a day-shift LPN and the orienting LPN, were not tested. The former DON documented that the investigation was inconclusive and suggested the patches were likely disposed of when bags were thrown away, without supporting documentation. Multiple interviews confirmed that the two Fentanyl patches were never found and that the incident was not reported to the state survey agency via a Self-Reported Incident, to law enforcement, or to the pharmacy, despite facility policies requiring investigation and reporting of alleged misappropriation and controlled substance discrepancies. The pharmacist confirmed he was not notified of any missing narcotics and stated he should have been. The facility’s Abuse, Neglect, Exploitation & Misappropriation of Resident Property policy and Controlled Substances policy require immediate reporting of such allegations to the Administrator, ODH, and law enforcement when a crime is suspected, as well as consultation with pharmacy and documentation of the investigation. These policy requirements were not followed in this case, resulting in a deficient, incomplete investigation of the missing Fentanyl patches for Resident #73.
Failure to Implement Post‑Surgical Wound Care and Anticoagulant Therapy
Penalty
Summary
The deficiency involves the facility’s failure to obtain and implement physician orders for post‑surgical wound care and monitoring, and to provide ordered anticoagulant therapy for post‑operative residents. One resident admitted after a right hip fracture repair had no physician orders for a surgical wound dressing or monitoring on admission or for the first several days of the stay. Physician orders for a dry dressing change to the right hip were not entered until four days after admission, and the treatment was not first implemented until the following day. The resident reported that the surgical wound was seeping, that when the facility removed the bandage it was not replaced for two days, and that after a shower when the dressing came off it was not reapplied; the resident also stated that the doctor and nurses did not look at the wound. A facility RN and a regional RN both confirmed there were no surgical wound orders until four days after admission and that the admitting nurse should have clarified with the physician and obtained post‑surgical hip fracture orders, at least to monitor the site. A second resident admitted with a displaced intertrochanteric fracture of the right femur likewise had no physician orders for surgical wound dressing changes or for monitoring the surgical site on admission. Review of the MARs and TARs for this resident showed no orders for surgical wound dressings or wound site monitoring throughout the month. Both an RN and the regional RN confirmed there were no surgical wound orders and that the admitting nurse should have clarified with the physician and obtained post‑surgical hip fracture orders to monitor the site. A third resident admitted with a recent pacemaker placement had no admission orders for care of the pacemaker surgical site. Physician orders for surgical wound care for this resident were not entered until the day after admission, and only after surveyor intervention. The regional RN and another RN confirmed there were no surgical wound care orders until that time and that the admitting nurse should have clarified with the physician and obtained post‑surgical wound orders to at least monitor the site. The deficiency also includes failure to ensure post‑operative anticoagulant therapy to prevent blood clots was in place and provided as ordered for two residents admitted after hip surgery. One resident’s hospital records showed an order for Enoxaparin 40 mg SQ every 24 hours and a postoperative plan specifying six weeks of chemical DVT prophylaxis with Lovenox after hip surgery. On admission to the facility, there were no physician orders for any anticoagulant, and the medical record contained no evidence of preventive measures being taken to prevent blood clots post‑surgery. The resident stated that blood thinners were never given from the first day of admission. The regional RN and another RN confirmed there were no anticoagulant orders, that the hospital should have been called by the admitting nurse for clarification, and that after post‑operative hip surgery an anticoagulant is prescribed unless contraindicated. Another resident admitted with a right hip fracture and right foot fracture had hospital documentation indicating VTE prophylaxis with an anticoagulant after hip surgery was appropriate and critical for up to 35 days post‑surgery, and hospital referral records showed an order for Enoxaparin 40 mg SQ every 24 hours. Review of the facility physician orders revealed no anticoagulant medications for this resident, and the medical record contained no evidence of preventive measures to prevent blood clots post‑surgery. The regional RN confirmed there were no anticoagulant orders and that the hospital should have been called by the admitting nurse for clarification, and another RN confirmed the resident should have been on Lovenox at the facility and that the admitting nurse should have contacted the hospital regarding clarification of the anticoagulant. These failures occurred despite facility policies on wound care, anticoagulation, and medication administration that required verification of physician orders, identification of anticoagulated individuals including those with recent joint replacement surgery, and safe, timely administration of medications as prescribed.
Unsanitary Kitchen Conditions and Improper Food Storage/Labeling
Penalty
Summary
Surveyors identified a deficiency related to unsanitary food service and improper food storage and dating practices that affected all residents who received meals from the kitchen, except three residents who did not eat meals prepared there. During an initial kitchen tour with a staff member, surveyors observed food debris and pieces of cardboard on the floor in the food preparation room, including an uncooked raw biscuit that had been stepped on and smashed on the floor. The steel preparation table had a large amount of food debris on the lower shelf, and the wall behind the food preparation table and sink had pieces of food debris and dried brown and white liquids splashed on it. Two trays of bowls filled with dried cereal were found on a cart without any dates indicating when the cereal had been poured or prepared. Further observations in the refrigerator revealed a large round plastic container with an unknown red liquid that was not dated or identified, a square container of cherry tomatoes with no date, and a large five-pound bag of salad mix that was open to air and undated as to when it was opened. In the freezer, surveyors found a large plastic container of an unknown type of soup with no date indicating when it was made or placed in the freezer. Two three-tiered black plastic carts in the area had food debris and a dark brown liquid spilled on them, and the wall behind the steamer was dirty with dried liquid splashes running down it. The floor behind the steamer had a large buildup of black dirt. In a subsequent interview, the staff member who accompanied the surveyors verified all of these concerns. Review of facility policies on food storage and cleaning/sanitizing dietary areas showed that the observed conditions did not align with the written requirements for labeling, dating, and maintaining kitchen areas and equipment in a sanitary manner.
Failure to Honor Resident Representative’s Requests and Concerns Regarding Change in Condition
Penalty
Summary
The deficiency involves the facility’s failure to timely address and act upon the concerns and rights of a resident’s representative, despite documentation that this representative held Health Care Power of Attorney (HCPOA). The resident was admitted with multiple serious diagnoses, including cerebral infarction, COPD, chronic bronchitis, acute respiratory failure, atherosclerotic heart disease, hypertension, congestive heart failure, ischemic cardiomyopathy, and vision loss. On admission, the face sheet listed a specific family member as the emergency contact, and HCPOA paperwork dated and notarized on 08/11/25 named this same family member as HCPOA; this paperwork was later submitted to the facility. The resident had a DNR-CC-A order and was documented as having intact cognition on the admission MDS, with later documentation of moderately impaired cognition. On 09/15/25, the resident’s vital signs were within normal limits, but the resident complained of being more tired than usual. That same day, the family member called the facility stating the resident “must go to the hospital,” reporting that the resident was slurring his speech and not acting right, and that he had not been calling as frequently as usual. The LPN explained to the family that the facility could perform a workup in-house, and the physician was notified and ordered a CBC, CMP, urinalysis, urine culture, and chest x-ray for complaints of shortness of breath. A chest x-ray performed on 09/15/25 showed linear opacities in the left lower zone, pulmonary congestion, and elevation of the left hemidiaphragm, with a recommendation for a follow-up HRCT lung scan. A progress note on 09/16/25 documented these x-ray findings and stated that the family member and physician were aware. However, the physician later reported he was not aware that the family had requested the resident be sent to the hospital because he was acting differently, and stated that this information must not have been communicated to him. The family member reported having repeatedly requested that the resident be sent to the hospital and stated that the resident himself had expressed a desire to go to the hospital. She also stated she had completed MPOA paperwork at the hospital and had emailed the facility’s Social Worker several times about this paperwork, later finding and sending the HCPOA documents to both Social Services and the DON on 09/17/25. The DON acknowledged that the facility did not initially have the MPOA paperwork and stated she did not feel the resident needed to be sent out on 09/15/25 because his vital signs were stable and she did not know the person on the phone, despite the family member being listed as emergency contact. The DON further stated she assessed the resident but did not document her assessment in the progress notes and could not recall whether she or the LPN had spoken to the physician on 09/15/25. The LPN confirmed that the family member had requested a hospital transfer and that he initially planned to send the resident out but did not, and he could not recall why the plan changed. He also confirmed that he communicates with the physician via his personal cell phone and could not find any record of a call or text to the physician on that date. Social Service staff reported multiple conversations and email exchanges with the family member about the resident’s condition and the MPOA paperwork, including the family member’s ongoing requests that the resident be sent to the hospital and complaints that the resident said he could not breathe at night and was not receiving aerosol treatments. The Social Service Designee stated she contacted the hospital to obtain MPOA paperwork but never received it with the admission documents, and she did not document her conversations with the family member in the medical record. The DON later confirmed that the resident had PRN albuterol aerosols ordered but none were administered for shortness of breath, and that the resident refused lab work. On 09/21/25, the resident was found with right-sided facial droop, aphasia, and decreased mental status; 911 was activated, and the resident was sent to the hospital for stroke-like symptoms, where he later died. The surveyors concluded that the facility failed to ensure the concerns and requests of the resident’s family representative were addressed timely and that the representative was able to exercise the resident’s rights, affecting one resident reviewed for change in condition. This deficiency was investigated under Complaint Number 2631680 and was based on record review and multiple staff and family interviews. The findings included lack of timely recognition and response to the family member’s repeated concerns and requests for hospital transfer, incomplete or missing documentation of assessments and communications, failure to promptly verify and act upon HCPOA documentation submitted by the family, and failure to consistently document or communicate the family’s reports of the resident’s change in condition to the physician. The DON and LPN both acknowledged gaps in documentation and uncertainty about who contacted the physician, while the physician stated he was not informed of the family’s concerns about the resident acting differently. These actions and inactions led to the determination that the facility did not ensure the resident’s representative could effectively exercise the resident’s rights.
Failure to Notify Resident Representative of New Psychotropic Medication
Penalty
Summary
The deficiency involves the facility’s failure to notify the resident representative when a psychotropic medication was initiated for a resident. The resident, who had intact cognition per the admission MDS, had multiple diagnoses including cerebral infarction, COPD, chronic bronchitis, acute respiratory failure, atherosclerotic heart disease, hypertension, congestive heart failure, ischemic cardiomyopathy, and vision loss, and had been sent to the emergency room during the stay. Health Care Power of Attorney (HCPOA) paperwork, dated and notarized on 08/11/25, identified a family member as the HCPOA, and this information was submitted to the facility. On 09/19/25, a physician ordered Remeron 7.5 mg at bedtime for decreased appetite, but there was no documentation that the resident’s representative was notified of this new psychotropic medication. During interview, the HCPOA stated she was never informed that the resident was started on Remeron and believed that if he had decreased appetite, which she was never told about, it was likely related to pneumonia or a change in condition. The DON confirmed there was no documentation of the rationale for starting Remeron or of notification to the representative. The LPN who obtained the order reported she had observed the resident eating less than 50% of meals over a couple of days, did not want him to lose weight, and therefore called the physician for the Remeron order instead of consulting the dietitian, who was not present that day. She stated she had tried protein shakes from her medication cart, which the resident did not like, and that no other supplements were ordered. The LPN reported she was sure she had informed the emergency contacts about the Remeron but acknowledged she failed to chart this, and there was no documented evidence of notification in the record.
Failure to Notify Resident Representative of New Psychotropic Medication Order
Penalty
Summary
The deficiency involves the facility’s failure to notify a resident’s health care power of attorney (HCPOA) when a new psychotropic medication was ordered. The resident, who had intact cognition, was admitted with multiple diagnoses including cerebral infarction, COPD, chronic bronchitis, acute respiratory failure, atherosclerotic heart disease, hypertension, congestive heart failure, ischemic cardiomyopathy, and vision loss, and had been sent to the emergency room on a prior date. HCPOA paperwork naming a family member as the resident’s representative had been completed and submitted to the facility. On a documented date, the physician ordered Remeron 7.5 mg at bedtime for decreased appetite, but there was no documentation that the resident’s representative was notified of this new psychotropic medication order. During interview, the HCPOA stated she was never informed that Remeron had been started and believed the medication would have been used to sedate the resident rather than for appetite, noting she had not been told of any appetite issues and believed any decreased intake would likely be related to pneumonia or a change in condition. The DON confirmed there was no documentation of the rationale for starting Remeron or of notification to the representative. The LPN who obtained the order reported she had observed the resident eating less than 50% of meals over a couple of days, did not want him to lose weight, and therefore called the physician for the Remeron order instead of consulting the dietitian, who was not present that day. The LPN stated she had attempted to offer protein shakes from her cart, which the resident did not like, and that she believed she had informed the resident’s emergency contacts about the Remeron but acknowledged she failed to chart any such notification. This lack of documented notification to the resident’s representative regarding initiation of a psychotropic medication constituted the cited deficiency.
Failure to Ensure Ordered Fall-Prevention Footwear for High-Risk Resident
Penalty
Summary
The deficiency involves the facility’s failure to ensure that a high fall‑risk resident consistently had ordered fall interventions, specifically gripper/non‑skid socks, in place. The resident had multiple significant diagnoses, including cerebral infarction, COPD, chronic bronchitis, acute respiratory failure, atherosclerotic heart disease, hypertension, congestive heart failure, ischemic cardiomyopathy, and vision loss. A Morse Falls assessment identified the resident as high risk for falls, and the care plan documented fall‑risk related to deconditioning and gait/balance problems, with interventions such as keeping the call light and frequently used items within reach, ensuring appropriate footwear, use of gripper socks when not wearing proper fitting shoes, therapy evaluation, and a toileting plan before and after meals and at bedtime. The admission MDS showed intact cognition and no prior falls at admission. Progress notes and fall scene investigations documented multiple falls where the resident was not wearing appropriate footwear as care planned. On one occasion, the resident stood from bed wearing only socks, reached toward the nightstand, stepped forward, and lost balance, leading to a fall; he was then educated on proper footwear and call light use. A subsequent fall occurred when the resident again was not wearing gripper socks but only regular socks, and the interdisciplinary team identified the need for gripper socks when not in proper shoes and for frequently used items to be closer. Another fall occurred when the resident was found on the floor outside the bathroom after walking back from the bathroom in socks, with a bruise to the left thigh noted; the fall scene report indicated he had been given a laxative and was wearing socks at the time. Although physician orders were written for gripper/non‑skid socks to be worn when not in proper fitting shoes and to check each shift for proper placement, and later for non‑skid socks while out of bed, the DON confirmed the resident did not have gripper socks on as ordered when he fell and that there was no documentation that he removed or changed them himself. The facility’s fall assessment policy was in place, but the ordered and care‑planned fall interventions were not consistently implemented for this resident.
High Medication Error Rate Due to Improper PEG Tube Medication Administration
Penalty
Summary
The facility failed to maintain a medication error rate below 5%, with surveyors identifying 9 medication errors out of 25 opportunities, resulting in a 36% error rate. The deficiency involved one resident who had been admitted with diagnoses including lupus, acute respiratory failure, moderate protein-calorie malnutrition, gastrostomy status, and dysphagia. Physician orders for this resident in January 2026 included multiple medications scheduled for 9:00 A.M.: acidophilus 500 million units daily, Bactrim DS 800/160 mg daily, prednisone 10 mg daily, Protonix 40 mg DR daily, zinc sulfate 220 mg daily, Mucinex 600 mg twice daily, senna plus 8.6/50 mg twice daily, baclofen 10 mg three times daily, and oxycodone 10 mg three times daily. The orders specified that medications were to be administered via PEG tube, but there was no order for the medications to be mixed together and given as a cocktail. During observation, an LPN prepared the resident’s 9:00 A.M. medications by crushing one capsule of acidophilus and tablets of Bactrim DS, prednisone, Protonix, zinc sulfate, Mucinex, senna plus, baclofen, and oxycodone, then combining all the crushed medications into a single medication cup. The LPN mixed the powdered medications together and prepared to administer them via the resident’s PEG tube. At that time, the LPN verified that the resident was to receive all medications via PEG tube but acknowledged there was no order to cocktail the medications and administer them all at once. Review of the facility’s policy, “Administering Medication through an Enteral Tube,” dated 03/2015, showed that medications were not to be mixed together prior to administration through an enteral tube unless there was a physician’s order with a rationale, and that each medication should be administered separately unless otherwise ordered. The observed practice was inconsistent with both the physician’s orders and the facility’s policy, contributing to the identified medication error rate.
Failure to Act on Recommended Follow-Up HRCT After Abnormal Chest X-Ray
Penalty
Summary
The deficiency involves the facility’s failure to ensure that a recommended radiologic follow-up study was scheduled and addressed in a timely manner for one resident who experienced a change in condition. The resident, admitted with multiple significant diagnoses including cerebral infarction, COPD, chronic bronchitis, acute respiratory failure, atherosclerotic heart disease, hypertension, congestive heart failure, ischemic cardiomyopathy, and vision loss, complained of increased fatigue while resting in bed. The family requested hospital transfer, but nursing staff explained that the resident could be worked up at the facility, and the family agreed. The physician was notified and ordered a CBC, CMP, urinalysis, urine culture, and a chest x-ray for complaints of shortness of breath. The chest x-ray was completed and the results, dated 09/15/25, showed suboptimal evaluation due to rotation, linear opacities in the left lower zone possibly representing fibro-atelectatic changes, prominence of both pulmonary hila with attenuation of broncho-vascular markings representing congestion, and elevation of the left dome of the diaphragm. The radiology report recommended a follow-up high-resolution CT (HRCT) lung scan. A progress note the following day documented the chest x-ray findings and indicated that the resident’s family and physician were aware of the results. However, during interview, the DON stated she did not recall speaking with the physician about the HRCT recommendation and verified there was no evidence in the record that the HRCT lung scan had been ordered or scheduled. The physician, when interviewed, did not remember what had occurred with this resident, stated that upon re-review of the chest x-ray he did not see anything acute that needed to be addressed, and acknowledged that the HRCT was a recommendation but did not believe it was necessary at that time. The resident’s family member reported not being aware of the recommendation for a CT scan of the lungs. The surveyors determined that the facility failed to ensure that the recommended radiologic follow-up study was acted upon in a timely manner for this resident, resulting in the cited deficiency under the complaint investigation.
Failure to Assess and Maintain Resident's Fingernail Hygiene
Penalty
Summary
The facility failed to ensure that a resident's fingernails were properly assessed and treated in a timely manner, as required by the resident's care plan and facility policy. The resident, who was admitted with end stage renal disease, a right humerus fracture, and lack of coordination, was dependent on staff for personal hygiene and other activities of daily living. The care plan specified that staff should check, trim, and clean the resident's nails on bath days and report any changes to the nurse. However, weekly skin assessments did not address the resident's fingernails, and observations revealed that the resident's fingernails were yellowed, thickened, and had debris underneath. Interviews with the resident and staff confirmed that the fingernails had not been addressed or noticed during routine care and wound assessments. The LPN Unit Manager and Wound Nurse both acknowledged the condition of the resident's fingernails when it was brought to their attention, and the Wound Nurse confirmed she had not previously noticed the issue during weekly assessments. The facility's policy on nail care emphasized the importance of cleaning, trimming, and monitoring for changes, but these procedures were not followed for this resident.
Failure to Provide Trauma-Informed Care for Resident with PTSD
Penalty
Summary
The facility failed to provide trauma-informed care that considered a resident's history and preferences, specifically for a resident diagnosed with PTSD, anxiety disorder, and depression. The medical record review showed that trauma-related assessments were either marked as not applicable or left blank, and there was no documentation in the social services progress notes addressing the resident's PTSD, its impact on daily living, or any identified triggers and interventions to prevent re-traumatization. The care plan did not include a problem or interventions specific to PTSD, and the only mention of a past traumatic event lacked details about the event, triggers, or person-centered interventions. Interviews with the resident revealed a history of physical abuse leading to PTSD, with specific emotional triggers such as being coerced, having anything wrapped around her, or feeling physically restricted. The resident reported ongoing night terrors while at the facility. Interviews with CNAs indicated a lack of awareness or understanding of the resident's PTSD diagnosis, triggers, or appropriate interventions, with some staff unaware of the diagnosis and others unable to identify or confirm trauma-related interventions. This demonstrates a failure to ensure staff were informed and prepared to provide trauma-informed care tailored to the resident's needs.
Medication Administration Errors Exceed Acceptable Rate
Penalty
Summary
The facility failed to ensure medications were administered as ordered, resulting in a medication error rate of 6.45%, which exceeds the acceptable threshold. Specifically, one resident with type two diabetes, morbid obesity, and chronic obstructive pulmonary disease was observed receiving six units of Humalog insulin via a KwikPen without the required two-unit air shot being dialed up prior to administration. The nurse administering the medication confirmed that this step was omitted, which is contrary to the manufacturer's instructions for use of the Humalog KwikPen. Additionally, another resident with diagnoses including anxiety disorder, schizophrenia, and depression was administered an incorrect dose of Vitamin E. The nurse provided a Vitamin E capsule of 180 mg (400 IU) instead of the prescribed 100 units. The nurse confirmed the error during an interview. In total, two medication errors were observed out of 31 medications administered, and the facility's policy requires medications to be administered safely, timely, and as prescribed.
Failure to Timely Investigate and Report Injury of Unknown Origin
Penalty
Summary
A deficiency occurred when the facility failed to conduct a timely investigation and self-report an incident following the discovery of an injury of unknown origin for a resident with severe cognitive impairment and multiple complex medical conditions, including Alzheimer's dementia, Trisomy 21, and epilepsy. The resident, who was nonverbal and required significant assistance with activities of daily living, was first observed with a bruise above the left eye during a routine skin evaluation. Despite the resident's inability to explain the injury and no staff witnessing an incident, the injury was not immediately classified or investigated as an injury of unknown origin. Subsequent documentation showed that the resident developed additional injuries, including bilateral periorbital bruising and a swollen, painful left hand, which prompted further medical evaluation and imaging. The facility did not initiate a self-reported incident (SRI) or a formal investigation until multiple injuries were observed several days later. Staff interviews confirmed that the initial injury was reported internally but not escalated or reported to external authorities as required by facility policy and state regulations for injuries of unknown source. The facility's policy mandates immediate reporting and investigation of all injuries of unknown origin, especially when the resident cannot explain the injury and no witnesses are present. However, the investigation and reporting process was delayed until additional injuries were identified, and there was no evidence that an investigation was started after the first injury was noted. This lapse had the potential to affect all residents in the facility, as timely identification and investigation of such incidents are critical for resident safety and regulatory compliance.
Failure to Prevent Resident-to-Resident Abuse
Penalty
Summary
The facility failed to protect residents from incidents of resident-to-resident abuse, resulting in Immediate Jeopardy and actual harm. Resident #15, who had a history of wandering and aggression when others entered his space, physically assaulted Resident #38. Resident #38, who was severely cognitively impaired and had a history of wandering, entered Resident #15's room and laid on his bed. Resident #15 responded by dragging Resident #38 out of the bed and throwing her into the hallway, causing her to fall and sustain a closed compression fracture of the L5 vertebra. This injury left Resident #38 unable to ambulate independently and confined to a wheelchair. Another incident involved Resident #15 physically assaulting Resident #23 in the dining room. Resident #23, who was also severely cognitively impaired, reached into Resident #15's space to obtain a spoon, prompting Resident #15 to stab Resident #23's hand with a fork, causing puncture wounds. The facility failed to develop and implement a comprehensive and individualized plan of care to address Resident #15's aggressive behaviors and ensure the safety of other residents, particularly those who were cognitively impaired and independently mobile. The facility's inaction in addressing Resident #15's known aggressive tendencies and the lack of appropriate interventions to prevent resident-to-resident abuse contributed to these incidents. The facility did not adequately assess, care plan, or monitor residents with behaviors that might lead to conflict, such as those with a history of aggression or those who wander into other residents' spaces. This deficiency was investigated under Complaint Number OH00162589.
Removal Plan
- Registered Nurse (RN) #301 observed Resident #38 laying on the floor outside of Resident #15's room and called Emergency (911), and Resident #38 was transported to Hospital #339.
- Resident #15 stabbed Resident #23 with a fork. Resident #23 and Resident #15 were immediately separated.
- Resident #23 was taken to the nurse for first aid. The nurse cleaned the puncture wound with normal saline and applied clean dry dressing for his hand.
- Resident #15 was seen by Psychiatric-Mental Health Nurse Practitioner (PMHNP) #338 with new orders received to increase Zoloft to 50 milligrams (mg) daily for anxiety and agitation. Start hydralazine 25 mg by mouth twice daily for anxiety/agitation for 14 days.
- An action plan was developed due to the facility failing to appropriately manage residents' behavior/change in condition. The DON initiated education to licensed nursing staff on behavioral management and appropriate management of interventions.
- The DON reviewed all nursing progress notes to ensure that all behaviors/change of condition were documented in the facility's electronic medical record with appropriate interventions.
- The facility implemented a plan for the DON to conduct an audit reviewing nursing progress noted to monitor for any change in condition or any behaviors that did not have an intervention in place and ensure that the physician was notified.
- The facility implemented a plan for skin assessments to be completed on all nonverbal residents by the Wound Nurse.
- Resident #15 was placed on 1:1 supervision to ensure the resident's safety and to protect other residents with diagnosis with dementia to prevent them from entering Resident #15's personal space by the Administrator.
- Resident #15 would continue to be followed by psychiatric services.
- The Unit Manager placed a stop sign on Resident #15's door to deter other residents from entering the room.
- A whole house audit was completed identifying six residents, Resident #7, #9, #19, #23, #38, and #40 with a dementia diagnosis and were also self-ambulatory to identify the potential risk of these residents entering Resident #15's personal space.
- These findings led the facility to implement 1:1 supervision for Resident #15.
- A whole house audit was completed of all residents' records to determine if any residents had aggressive or violent behaviors.
- RDCS #328 educated the staff present in the facility on interventions implemented for Resident #15 which included: 1:1 supervision until Resident #15 was discharged, placing a stop sign on Resident #15's room door and that Resident #15 would eat at a separate table in the dining room for meals.
- RDCS #328 informed Resident #15's family/responsible party the resident had been placed on 1:1 supervision, a stop sign was placed on Resident #15's door and he would be eating at separate table for meals.
- An Ad Hoc Quality Assurance Performance Improvement (QAPI) meeting was held to discuss interventions for Resident #15 to ensure resident's safety and to protect other residents (including those with a diagnosis of dementia) to prevent them from entering Resident #15's personal space.
- All facility staff were educated by DON/Designee on the facility policy and procedure for abuse (including resident-to-resident abuse) and immediate action to take.
- The facility would monitor/audit/document aggressive and violent behavior to ensure appropriate interventions are implemented timely.
- All staff were also educated that Resident #15 was to be on 1:1 supervision until Resident #15 was discharged, a stop sign was placed on Resident #15's room door and Resident #15 would eat at a separate table at meals.
- The facility implemented a plan for the Administrator/Designee to audit resident behaviors by reviewing clinical documentation and implementation of interventions to ensure the safety of others.
- The facility implemented a plan for the Administrator/Designee to interview three staff members to identify any observations of physically abusive behaviors.
- If behaviors were identified, the facility would put appropriate resident centered interventions in place.
- The facility implemented a plan for the Administrator/Designee to audit that Resident #15's interventions of 1:1 supervision, eating at separate table for meals, and stop sign were in place at Resident #15's room door.
- The facility implemented a plan that all findings would be submitted to the QAPI Committee for review and recommendations.
Failure to Initiate CPR for Full Code Resident
Penalty
Summary
The facility failed to initiate Cardiopulmonary Resuscitation (CPR) or call 911 for a resident who was found unresponsive and without vital signs, despite having advance directives indicating Full Code status. The resident, who was receiving hospice services, was found by an LPN and later confirmed by an RN to have no pulse or blood pressure. Both nurses failed to check the resident's code status and did not perform CPR or contact emergency services, leading to the resident's death. The resident had been admitted with diagnoses including chronic obstructive pulmonary disease (COPD), esophageal obstruction, and cerebrovascular disease. The care plan indicated the resident's advance directives were for Full Code status, meaning full life-saving measures should be taken in the event of cardiac or respiratory arrest. Despite this, the staff assumed the resident was a Do Not Resuscitate (DNR) due to receiving hospice services, which was incorrect. Interviews with facility staff revealed a misunderstanding regarding the resident's code status, as they assumed hospice care implied DNR status. The facility's policy required verification of code status and initiation of CPR in such situations, but these procedures were not followed. The lack of documentation regarding the resident's condition and the failure to notify the primary physician immediately were also noted as deficiencies.
Removal Plan
- Education on CPR/code status was completed by the DON for all licensed nurses to include residents receiving hospice services have the right to determine their own code status, which may include Full Code status.
- A whole house audit of residents was completed by RDCS #328 verifying code status, care plans and signed DNR forms.
- The crash cart was audited by the DON to ensure all supplies were in stock and available.
- RDCS #328 verified all licensed nursing staff had valid CPR certifications.
- All nursing staff present when Resident #60 expired were interviewed by the Administrator, DON, and RDCS #328 regarding details of the event and nursing staff statements were obtained.
- An Ad Hoc Quality Assurance Performance Improvement (QAPI) meeting was completed to discuss CPR and Code Status for all residents.
- All department managers were educated by RDCS #328 and RDO #330 on the differences in code status and resident code status location.
- All staff were educated on CPR, code status and the location of code status.
- Resident #60's physician was notified Resident #60 did not receive CPR per her code status.
- An Ad Hoc QAPI meeting was held to discuss the differences in code status and resident code status location, as well as to review the State agency findings and develop an abatement to address the specifics of the Immediate Jeopardy template.
- LPN #313 was terminated from services related to not following policy and procedure regarding advanced directives.
- RN #301 received one-on-one education provided by RDCS #328 regarding failing to confirm Resident #60's code status.
- The facility implemented a plan for the DON/Designee to conduct code drills on alternating shifts.
- Administrator/Designee would audit all deaths that occur in the facility to ensure the resident's advanced directives were facilitated per preference.
- All findings would be submitted to the QAPI Committee for review and recommendations.
Failure to Notify Family and Physician of Resident Deaths
Penalty
Summary
The facility failed to notify the family and physician of two residents in a timely manner upon their deaths. Resident #60, who had diagnoses including chronic obstructive pulmonary disease and cerebrovascular disease, was found without vital signs at 8:30 A.M. on 03/01/25. Despite being a Full Code and under hospice care, there was no documentation of immediate notification to the resident's primary physician or family. The hospice provider was informed, and they indicated they would notify the family and funeral home, but the facility did not document these notifications. Similarly, Resident #61, diagnosed with vascular dementia and cerebrovascular disease, was found without vital signs on 11/02/24. The hospice nurse called the time of death at 6:15 A.M., but there was no evidence that the facility notified the resident's physician or family in a timely manner. The facility's policy requires the nurse supervisor or charge nurse to inform the family of a resident's death, which was not adhered to in these cases. This deficiency was identified during a complaint investigation.
Inadequate Investigation of Resident-to-Resident Abuse
Penalty
Summary
The facility failed to thoroughly investigate an allegation of resident-to-resident physical abuse involving two residents. Resident #15, who was severely cognitively impaired with diagnoses including Alzheimer's disease and anxiety disorder, was observed pushing another resident, Resident #38, in the hallway, resulting in Resident #38 falling to the ground. Resident #38, also severely cognitively impaired with diagnoses including Parkinson's disease and dementia, was found lying on the floor outside Resident #15's room, complaining of head and neck pain. Emergency services were called, and Resident #38 was transported to the hospital, where a closed compression fracture of the L5 vertebra was diagnosed. The facility's investigation into the incident was inadequate. It did not include interviews with all potential witnesses, such as Resident #15's roommate, Resident #6, who was cognitively intact and witnessed the incident. Additionally, the facility did not obtain a signed witness statement from CNA #329, who also witnessed the incident. The facility concluded that the evidence was inconclusive and did not suspect abuse, despite the available witness accounts. Interviews with staff revealed that the Director of Nursing (DON) and the Administrator did not fully investigate the incident. The DON did not interview Resident #6, who had a clear view of the incident, and the Administrator altered the witness statement provided by CNA #329. The facility's policy required interviews with all witnesses and obtaining statements from them, which was not followed in this case.
Failure to Implement CPR and Accurately Record Time of Death
Penalty
Summary
The facility failed to ensure that staff were competent and compliant with implementing cardiopulmonary resuscitation (CPR) according to physician orders, affecting two residents. Resident #60, who was admitted with diagnoses including chronic obstructive pulmonary disease (COPD) and cerebrovascular disease, was documented as a Full Code, meaning CPR should have been initiated upon the absence of vital signs. However, due to the resident receiving hospice services, the nursing staff incorrectly assumed a Do Not Resuscitate (DNR) status and did not perform CPR. The time of death was inaccurately recorded by the hospice nurse instead of being called by a physician, as required. Resident #61, who had vascular dementia and cerebrovascular disease, was documented as DNRCC (Do Not Resuscitate Comfort Care). Upon the absence of vital signs, the hospice nurse called the time of death instead of the facility staff notifying the primary physician to do so. This was against the facility's policy, which requires a physician to pronounce the time of death. Interviews with facility staff, including the Director of Nursing and the Regional Director of Clinical Services, confirmed the errors in handling the code status and the process of pronouncing death. The facility's policies on CPR and death documentation were not followed, leading to these deficiencies.
Failure to Provide Scheduled ADL Assistance
Penalty
Summary
The facility failed to provide adequate care and assistance for Resident #16, who was dependent on staff for activities of daily living (ADL). Resident #16, diagnosed with left side hemiplegia, cerebral infarction, anxiety disorder, depression, and paralytic gait, had a self-care deficit related to weakness and required moderate assistance for bathing and personal hygiene. The care plan indicated that Resident #16 needed assistance with grooming and hygiene, including shaving, nail trimming, and showers twice a week. However, observations and interviews revealed that Resident #16 was not consistently receiving these services. The resident reported not receiving showers on scheduled days and not being shaved or having his fingernails trimmed. On one occasion, a State tested Nursing Assistant admitted to not providing a shower to Resident #16 due to time constraints, as she had 12 showers to complete and prioritized another resident with a doctor's appointment. The Licensed Practical Nurse confirmed that Resident #16's nails were long and that he needed to be shaved, but was unaware that the resident had not received a shower. The facility's policies on nail care, shaving, and showering were reviewed, highlighting the importance of cleanliness and skin care, but these were not adhered to in Resident #16's case. This deficiency was investigated under Complaint Number OH00155220.
Failure to Administer Prescribed Medication in a Timely Manner
Penalty
Summary
The facility failed to ensure timely procurement and administration of medication for a resident after admission. The resident, who was admitted with multiple diagnoses including insomnia, had a physician's order for zolpidem tartrate to be administered at bedtime. Despite this order being in place, the medication was not obtained from the pharmacy in a timely manner. The facility's records indicated that they were waiting for the pharmacy to deliver the medication, and later, for a prescription from the physician, which was not communicated during the physician's visit. The resident did not receive any doses of the prescribed medication from the time of admission until the medication was finally delivered, which was a period of over ten days. The Director of Nursing was unaware of the issue until a review of the resident's medications was conducted. This deficiency was identified during a complaint investigation and was noted as a continuation of non-compliance from a previous survey.
Medication Error Rate Exceeds Acceptable Limit
Penalty
Summary
The facility failed to maintain a medication error rate of less than five percent, resulting in a rate of 6.5 percent. This deficiency was identified during an observation of medication administration involving Resident #1, who was admitted with diagnoses including asthma, depression, arthritis, falls, prediabetes, shortness of breath, palpitations, and anxiety disorder. The review of the medical record showed that Resident #1 had an order for duloxetine 60 mg in the morning for depression but did not have an order for Zoloft 50 mg. During the medication administration, LPN #250 was observed placing only one 30 mg tablet of duloxetine in the medication cup instead of the prescribed two tablets. Additionally, LPN #250 mistakenly included a Zoloft 50 mg tablet intended for another resident, Resident #2, who shared the same room. The surveyor intervened before the medication was administered, prompting LPN #250 to verify the orders and acknowledge the errors. The facility's policy requires checking the medication label three times to ensure the correct resident, medication, dosage, time, and method of administration, which was not adhered to in this instance.
Failure in Hand Hygiene During Medication Administration
Penalty
Summary
The facility failed to ensure proper hand hygiene during medication administration, affecting one resident out of three observed. On the morning of July 9, 2024, an LPN administered medications, including eye drops, an inhaler, and a nasal spray, to a resident and then proceeded to set up and administer medications to another resident without performing hand hygiene. The LPN did not wash her hands after administering medication to the first resident, before administering medication to the second resident, or after removing gloves used during insulin administration. This was confirmed during an interview with the LPN, who acknowledged the lapse in hand hygiene. The facility's policy on hand hygiene, dated August 2015, emphasizes the importance of hand hygiene as the primary means to prevent the spread of infections. It requires the use of an alcohol hand rub or soap and water before preparing or handling medication, after contact with objects in the resident's vicinity, and after removing gloves. The deficiency was identified during an investigation under Complaint Number OH00154417.
Non-compliance in Kitchen Sanitation and Pest Control
Penalty
Summary
The facility failed to maintain a clean and sanitary kitchen environment, which had the potential to affect 51 residents who received meals from the kitchen. Observations on June 13, 2024, revealed that various areas in the kitchen, including stainless-steel tables, a three-drawer plastic container, and flour and sugar containers, were dirty with food debris, dirt, and spills. The facility's cleaning schedule required daily cleaning of storage shelves and utility carts after each meal, but these standards were not met. The facility policy titled 'Sanitization' emphasized maintaining a clean and sanitary food service area, but the observed conditions did not align with this policy. Additionally, the facility had issues with pest control, specifically cockroaches, in the kitchen. Pest control invoices indicated extra services were required for cockroach treatment, and observations confirmed the presence of cockroach traps throughout the kitchen. Interviews with the Dietary Manager revealed sightings of both dead and live cockroaches in various areas of the kitchen, including the steam table, above the dishwasher, and by the freezer. The facility's pest control policy outlined a monthly spraying regimen to eliminate pests, but the presence of cockroaches indicated non-compliance with this policy. This deficiency was investigated under Complaint Number OH00154280.
Resident Dignity and Respect Violation
Penalty
Summary
The facility failed to ensure that a resident was treated with dignity and respect during care by a staff member. The incident involved a resident with multiple diagnoses, including dementia and Alzheimer's disease, who was admitted to the facility. The resident had severely impaired cognition and no behaviors as per the quarterly Minimum Data Set assessment. On the morning of the incident, a State Tested Nurse Aide (STNA) attempted to assist the resident in changing her wet clothing. The resident was uncooperative and began to cry, which led to the STNA making inappropriate comments. The resident's family member alleged that the STNA was rude and verbally abusive while trying to change the resident's clothing. The family member recorded the interaction on her phone, claiming the STNA made derogatory remarks about the resident's family. The audio recording was played to the Administrator and Interim Director of Nursing, who noted that the STNA's tone and content were inappropriate. The family member confronted the STNA later in the day, but the STNA did not engage in the confrontation. The STNA admitted to making inappropriate comments and acknowledged that her behavior was not respectful. She stated that she was unaware of being recorded and would not have made such comments if she had known. The facility's policy on dignity and respect requires staff to treat residents with dignity and respect at all times, which was not adhered to in this case. The STNA was terminated following the incident.
Failure to Timely Schedule Ultrasound for Resident
Penalty
Summary
The facility failed to ensure that an ultrasound was scheduled in a timely manner for a resident who was experiencing breast pain. The resident, who had a complex medical history including diabetes, Parkinson's disease, and dementia, was admitted to the facility and had a mammogram scheduled as per the Nurse Practitioner's progress note. The mammogram results indicated the presence of nodules in both breasts, necessitating further evaluation through an ultrasound. However, there was no documented evidence of the facility attempting to arrange the ultrasound or notifying the resident's family about the need for further evaluation from early March to late May. The deficiency was identified when the Interim Director of Nursing was informed by the resident's family member about the mammogram results, prompting the scheduling of the ultrasound. The ultrasound, which was eventually conducted, revealed abnormalities in both breasts, leading to the need for a biopsy. The delay in scheduling the ultrasound and the lack of communication with the resident's family contributed to the deficiency, which was investigated under a specific complaint number.
Failure to Provide Correct Physician-Ordered Diet
Penalty
Summary
The facility failed to ensure that a resident received the correct physician-ordered diet, which was a regular diet with thin liquids. Instead, the resident was served nectar thick liquids, contrary to the physician's order. This discrepancy was discovered during an observation of meal service, where the resident was given nectar thick water and cranberry juice. The error was attributed to a failure to update the meal ticket system after the resident's diet order was changed on 06/06/24. The facility did not have a dietary manager at the time, which contributed to the oversight. Interviews with the Dietary Manager and the Regional Culinary Director revealed that there was a misunderstanding regarding the resident's diet requirements. The list of resident diets incorrectly indicated that there were no residents on thickened liquids, despite the resident receiving them. The facility's policy on tray identification, which requires appropriate identification to ensure correct diets are served, was not followed. This deficiency was investigated under Complaint Number OH00154280.
Failure to Prevent Fall Resulting in Resident's Death
Penalty
Summary
The facility failed to provide adequate intervention and update the care plan for a resident with impaired cognition who had a known history of using the bed remote control to raise her bed to the highest position without the ability to lower it. This deficiency led to an incident where the resident was found on the floor with severe injuries after falling from the bed, which was in the highest position. The resident was subsequently transferred to the hospital and passed away due to hypovolemic shock and bilateral femur fractures caused by the fall. The resident's care plan, dated several months prior to the incident, indicated that the bed should be kept in the lowest position and required two staff members to assist with bed mobility. Despite these interventions, the resident was able to access the bed remote control and raise the bed. Multiple staff members, including LPNs and STNAs, confirmed that the resident had a history of manipulating the bed controls and was unable to lower the bed once it was raised. On the night of the incident, the resident was last seen with the bed in the lowest position, but was later found on the floor with the bed in the highest position. Interviews with staff and the resident's daughter revealed that the resident required assistance for bed mobility and was not capable of getting out of bed on her own. The facility's Director of Nursing confirmed that the care plan was updated only after the fall to include keeping the bed remote control out of the resident's reach. There was no evidence that comprehensive and individualized interventions were implemented prior to the fall to address the resident's safety and fall risk, leading to the tragic outcome.
Failure to Address Resident Grievances on Call Light Response Times
Penalty
Summary
The facility failed to address resident grievances regarding call light response times, which had the potential to affect all residents. Resident council minutes from February and March 2024 revealed complaints about long call light response times and aides being on their phones while call lights were not being answered. Interviews with residents indicated that call light response times were often 30 to 45 minutes or even over an hour, and these concerns had been reported to the Administrator without resolution. Observations confirmed that call lights were not answered promptly, with specific instances where call lights remained on for extended periods while staff were seated at the nurses' station. Further interviews with staff revealed that call lights were not answered timely when residents required the assistance of two staff members. The Administrator stated that she kept a concern log and addressed concerns as they were brought to her attention. However, observations on multiple occasions showed that call lights were left unanswered for significant periods, indicating a systemic issue with call light response times. This deficiency was investigated under Complaint Number OH00153514.
Inadequate Staffing Leading to Delayed Call Light Responses
Penalty
Summary
The facility failed to ensure adequate staffing to meet resident needs, affecting multiple residents and potentially all residents in the facility. Interviews with residents revealed that it usually took 30 to 45 minutes for staff to respond to call lights, with some residents reporting wait times of over an hour. Staff interviews confirmed that there were occasions when only two to three aides were available for the entire building, making it difficult to provide timely care, including getting residents out of bed and serving breakfast. Staff also indicated that management was aware of the staffing concerns but stated that corporate would not allow additional staff. Observations confirmed that call lights were not answered promptly, with specific instances where call lights remained on for nearly 20 minutes. Resident council minutes from February and March 2024 also documented complaints about long call light response times. The deficiency was investigated under Complaint Numbers OH00152859 and OH00153514.
Failure to Address Staff Conduct Concerns
Penalty
Summary
The facility failed to address staff concerns related to the conduct of an LPN, which had the potential to affect all residents. Multiple staff members reported that the LPN frequently took extended breaks, slept during shifts, and was absent from the facility for several hours. These concerns were communicated to the Administrator on several occasions, but no action was taken. On one occasion, a resident fell and had to be transported to the hospital while the LPN was outside in the parking lot. Despite these reports, the Administrator denied being informed of the LPN's extended absences and sleeping during shifts. The LPN was eventually terminated for insubordination, but the personnel file lacked specific incidents of poor work performance or disciplinary actions prior to the termination. Interviews with various staff members corroborated the claims that the LPN had a history of leaving the facility for long periods and sleeping during shifts. The Administrator's review of the LPN's personnel file revealed a termination letter citing insubordination and poor work performance, but no specific incidents were documented. The Administrator admitted to not being able to provide specific examples of the LPN's poor work performance, indicating a lack of proper documentation and follow-up on reported issues. This deficiency was investigated under Complaint Number OH00153045.
Failure to Ensure Resident and Family Participation in Care Planning
Penalty
Summary
The facility failed to ensure that residents or their representatives participated in the care planning process. This deficiency affected two residents. Resident #26, who had diagnoses including difficulty walking, amputation, and diabetes, had impaired cognition and required moderate assistance with daily activities. Despite a care conference being held on 10/12/23, there was no further documentation of care conferences in the medical record. Resident #26's daughter reported not being invited to any care conferences and expressed concerns about her mother being on an anticoagulant and experiencing bloody emesis. The social worker responsible for care conferences had left the facility, and the administrator confirmed the lack of documented care conferences after 10/12/23 and was unable to provide information on ensuring resident and family participation in care planning. Resident #37, diagnosed with Alzheimer's disease, dementia, and altered mental status, also had impaired cognition and required moderate assistance with daily activities. A progress note indicated a care conference was held on 02/29/24 without family presence. Resident #37's daughter stated that a care conference scheduled for February 2024 was canceled and not rescheduled after she inquired about placing a camera in the resident's room. The administrator was unaware of why the family was not present for the care conference and confirmed the sudden departure of the social worker. The administrator could not provide information regarding care conferences.
Failure to Prevent Verbal Abuse
Penalty
Summary
The facility failed to ensure verbal abuse did not occur, affecting one resident. Resident #5, who had intact cognition and required moderate assistance with daily activities, reported an incident where an aide called her an inappropriate name. The resident had requested ice and a soda, to which the aide responded with eye-rolling, sighing, and eventually slamming a cup on the bedside table while making derogatory comments about the resident's weight. The aide then left the building. The facility's investigation included a written statement from the resident and an observation from an LPN, but the allegation was unsubstantiated due to the lack of a statement from the aide and the administrator's previous experience with the aide not answering calls. The facility's policy on abuse, neglect, exploitation, and misappropriation of resident property defined abuse as the willful infliction of mental anguish, including verbal abuse. Despite this, the facility did not substantiate the allegation, citing insufficient evidence. The administrator admitted to not interviewing the aide involved due to past communication issues. The facility's policy also emphasized the importance of sufficient staff deployment and supervision to meet residents' needs and identify inappropriate behaviors, which was not adequately followed in this case.
Failure to Report Injury of Unknown Origin
Penalty
Summary
The facility failed to report an injury of unknown origin to the State Agency as required, affecting one resident with Alzheimer's disease, dementia, and altered mental status. The resident had impaired cognition and required moderate assistance with daily activities. Bruising was first noted on the resident's upper arms on a shower sheet, but there was no description of the bruising. The resident's daughter observed the bruises and expressed concerns that they appeared as though someone had grabbed the resident by the arms. The daughter had not been informed of the bruises and noticed them to be yellow and healing. Observations confirmed the presence of scattered yellow and darker bruises on the resident's arms, but the resident was unable to explain how they occurred. Staff interviews revealed that the bruises had been observed approximately two weeks prior and reported to an LPN, who then informed the Administrator. However, the Administrator and DON were not made aware of the bruises until later, and there was no documentation of the bruises prior to the resident's fall on a specific date. The facility's policy on abuse, neglect, exploitation, and misappropriation of resident property required reporting suspicious bruising to the state agency immediately, but no later than two hours after an allegation is made. Despite this policy, the bruises were not reported in a timely manner. The Administrator and DON were informed of the bruises days after they were first observed, and there was a lack of documentation and investigation into the cause of the bruises. The deficiency was investigated under specific complaint numbers, highlighting the facility's failure to adhere to its own policies and state regulations regarding the reporting of potential abuse or neglect.
Failure to Investigate Abuse and Injury Reports
Penalty
Summary
The facility failed to thoroughly investigate an allegation of verbal abuse and an injury of unknown origin, affecting two residents. Resident #5, who had morbid obesity and muscle weakness, reported that an aide called her an inappropriate name after she requested ice and a soda. The aide, identified as STNA #266, admitted to snapping at Resident #5 and calling her a derogatory name. Despite this admission and corroborating statements from other staff, the facility unsubstantiated the allegation without obtaining a statement from STNA #266, citing past difficulties in contacting her. The facility's abuse policy required statements from direct witnesses and a review of employment records, which were not fully adhered to in this case. Resident #37, who had Alzheimer's disease, dementia, and altered mental status, was found to have bruising on her upper arms. The bruises were first observed by a staff member and reported to an LPN, who then informed the Administrator. The Administrator and the Director of Nursing (DON) were made aware of the bruises but did not document or investigate them promptly. Resident #37's daughter also reported the bruises and provided photographic evidence, which showed the bruises were present before a documented fall. The facility's documentation did not include a description of the bruises, and there was a lack of timely investigation into their cause. The facility's failure to investigate these incidents thoroughly and in a timely manner represents non-compliance with their abuse policy and procedures. The lack of proper documentation and follow-up on the reported bruises and verbal abuse allegations highlights significant gaps in the facility's handling of abuse and injury reports. This deficiency was investigated under Complaint Numbers OH00152859 and OH00153683.
Failure to Implement Care Plans for Skin Impairment
Penalty
Summary
The facility failed to ensure care plans were implemented as written, affecting two residents reviewed for skin impairment. Resident #29, diagnosed with dementia and other conditions, was found with a soiled bandage on his right hand, and neither the nurse aides nor the LPNs were aware of the injury's origin. The resident's daughter had observed blood on the pillowcase and a bandage on the resident's hand, but there was no documentation of the injury in the medical records, and the care plan's intervention to observe and report skin issues was not followed. Resident #37, diagnosed with Alzheimer's disease and dementia, was found with bruising on the upper arms, which was not properly documented or communicated. The resident's daughter observed the bruises and provided photographs, but the facility staff, including STNAs and LPNs, were unaware of how the bruises occurred. The bruises were reported to the Administrator and DON, but there was no documentation of the bruises prior to the fall on 04/24/24, and the care plan's intervention to observe and report skin issues was not followed. The deficiency represents non-compliance with the facility's obligation to implement care plans as written, leading to unaddressed skin impairments and lack of proper documentation and communication regarding the residents' conditions. This non-compliance was investigated under Complaint Numbers OH00152859 and OH00153683.
Medication Storage and Labeling Deficiency
Penalty
Summary
The facility failed to ensure medications were stored in locked compartments, labeled, and only accessible to authorized personnel. This deficiency was observed when a resident was found sleeping with a medication cup containing approximately 8-10 pills on his bedside table. A Registered Nurse (RN) confirmed the presence of the medication and admitted that he thought the resident would take the medications upon waking. The RN acknowledged that he should have remained in the room while the medications were consumed. A review of the RN's personnel file revealed a written warning for leaving medication at a resident's bedside.
Inaccurate MAR Documentation by RN
Penalty
Summary
The facility failed to ensure accurate documentation on a Medication Administration Record (MAR) for one resident. Resident #29, who had diagnoses including dementia, altered mental status, and difficulty walking, was dependent on staff for toileting, bathing, and personal hygiene. The MAR for April and May 2024 showed that RN #246 documented medications as being administered on specific dates. However, upon review and interview, it was confirmed that RN #246 had signed off on medications that he had not administered himself but had observed another nurse administering. This inaccurate documentation was confirmed by the Administrator after speaking with RN #246.
Failure to Report Allegation of Mistreatment
Penalty
Summary
The facility failed to report an allegation of mistreatment involving a resident to the Ohio Department of Health (ODH). Resident #49, who had multiple diagnoses including muscle disorders, cirrhosis, and altered mental status, reported that a State tested Nursing Assistant (STNA) was rough with her and threw a urine-soaked sheet at her face. Despite the resident's complaint and a report from her cousin, the Director of Nursing (DON) and the Administrator did not initiate an investigation or report the incident to ODH as required by the facility's policy. The STNA was suspended pending the investigation, but no formal investigation was started, and the incident was not documented in the resident's progress notes. Interviews with the resident, the DON, and the Administrator revealed discrepancies in the accounts of the incident. The resident claimed she was roughly handled and had a urine-soaked sheet thrown at her, while the STNA denied the allegations, stating the resident was lying to get her in trouble. The facility's policy mandates immediate reporting of such allegations to the Administrator and ODH within 24 hours, which was not followed in this case. The failure to report and investigate the incident represents noncompliance with the facility's abuse, neglect, and mistreatment policy.
Failure to Investigate Allegation of Mistreatment
Penalty
Summary
The facility failed to thoroughly investigate an allegation of mistreatment involving a resident. Resident #49, who had intact cognition and required partial to moderate assistance, reported that a State tested Nursing Assistant (STNA) took an hour and 45 minutes to respond to her call light. The resident had taken a laxative and needed assistance. When the STNA arrived, she pushed the resident hard into the bedrail, causing her to hit her face, and later threw a urine-soaked sheet at her. The resident reported the incident to the Director of Nursing (DON) and requested that the STNA not return to her room. The DON did not open an investigation, believing it was unnecessary, and the STNA was suspended pending the investigation. The Administrator was informed of the incident by the resident's cousin, who reported that the STNA had thrown a wet sheet at the resident and turned her too hard. Despite this, no Self-Reported Incident was opened, and no investigation was initiated. The facility's policy mandates that all allegations of abuse, neglect, exploitation, or mistreatment be investigated and reported to the Ohio Department of Health within 24 hours. The failure to follow this policy was confirmed through interviews with the Administrator, DON, and the STNA involved. Additionally, a patrolman was observed at the facility to take a statement from the resident regarding the incident.
Unnecessary Hospital Transfer Due to Lack of Proper Documentation
Penalty
Summary
The facility failed to ensure that a resident was not unnecessarily transferred to a hospital. Resident #60, who had multiple diagnoses including encephalopathy, diabetes, acute kidney disease, and respiratory failure, was sent to the hospital emergency room for an elevated white blood cell (WBC) count and possible sepsis. However, there were no test or laboratory results in the medical record to confirm an elevated WBC count, nor was there any documentation of a change in the resident's status that would warrant a hospital transfer. Additionally, there was no record of the resident or their representative requesting the transfer. The emergency room report indicated that the resident had mild leukocytosis and a leaking wound vac, but no clinical signs of infection were present, and the resident was returned to the facility with no new orders after a few hours in the ER. An interview with the Director of Nursing (DON) revealed that the Licensed Practical Nurse (LPN) had called her about issues with the resident's wound vac. The DON suggested that the resident could possibly have an elevated WBC count, leading the LPN to indicate this on the hospital transfer form without proper testing or documentation. The DON confirmed that there was no accurate physician notification or proper testing to justify the hospital transfer, and the resident's needs could have been met within the facility. This deficiency was investigated under Complaint number OH00152345.
Failure to Provide Ostomy and Drainage Tube Care
Penalty
Summary
The facility failed to ensure proper ostomy and drainage tube care for a resident with multiple medical conditions, including an ileostomy. The resident was admitted with diagnoses such as encephalopathy, diabetes, acute kidney disease, and respiratory failure, among others. Despite the resident's need for ostomy care, there were no physician's orders for such care from 03/19/24 to 03/24/24. Additionally, the Treatment Administration Record and Medication Administration Record showed no documentation of ileostomy care during this period. An interview with the Director of Nursing confirmed that no ostomy or drainage tube care was documented for the resident throughout their stay. The deficiency was identified during an investigation under Complaint numbers OH00152437 and OH00152345.
Failure to Ensure Effective Pain Management
Penalty
Summary
The facility failed to ensure an effective pain management program for a resident with multiple serious health conditions, including cerebrovascular disease, ischemic cardiomyopathy, and dementia. The resident was admitted with orders for hospice services and hydromorphone for pain and air hunger. However, the hydromorphone was on backorder, and the facility did not have an estimated delivery time. Despite the resident experiencing varying levels of pain, the facility did not administer the prescribed hydromorphone, and alternative pain management was delayed and insufficiently communicated to the family and hospice staff. The resident's pain levels fluctuated, reaching as high as seven out of ten, but the facility did not have the prescribed hydromorphone available. The facility eventually received an order for Hydrocodone-Acetaminophen, but the resident's pain persisted. The family and hospice staff expressed concerns about the resident's comfort and the lack of timely pain medication. The facility nurse explained the need for a physician's script and pharmacy authorization to administer morphine, which further delayed pain relief. The facility's emergency medication kit was found to contain hydromorphone tablets, but it was unclear if they were available at the time of the resident's need. The Director of Nursing and pharmacy staff could not confirm whether the hydromorphone had been used for another resident or if it was unavailable due to a backorder. The resident ultimately received morphine, but the delay in pain management and communication breakdowns contributed to the family's distress and dissatisfaction with the care provided. The resident expired shortly after the issues with pain management were addressed.
Failure to Document Wound Vac Application
Penalty
Summary
The facility did not ensure the accurate documentation of the application of a negative pressure wound therapy machine (wound vac) for a resident. Resident #60, who had multiple diagnoses including encephalopathy, diabetes, and chronic obstructive pulmonary disease, was admitted with an abdominal wound requiring wound vac treatment. The hospital discharge orders specified that the wound vac should be applied on Monday, Wednesday, and Friday. However, the Treatment Administration Record (TAR) showed no documentation of the wound vac being applied until several days after admission, despite staff interviews indicating it was applied earlier. The Wound Nurse Practitioner (NP) noted that the wound vac had not arrived by 03/20/24 and recommended saline wet to dry dressings until it did. However, the Licensed Practical Nurse (LPN) and the Director of Nursing (DON) later confirmed that the wound vac was available and applied either on 03/20/24 or 03/21/24, but this was not documented until 03/22/24. This lack of documentation led to a deficiency in maintaining accurate medical records for Resident #60, as required by professional standards.
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.
Trusted data from CMS and state health departments
Every citation, penalty and Plan of Correction is sourced from public CMS records (latest release May 27, 2026) and official state health department websites — never guesswork.
Trusted by long-term care providers and associations.
