Lost Creek Rehabilitation And Nursing Center
Inspection history, citations, penalties and survey trends for this long-term care facility in Lima, Ohio.
- Location
- 804 South Mumaugh Road, Lima, Ohio 45804
- CMS Provider Number
- 365600
- Inspections on file
- 24
- Latest survey
- June 9, 2025
- Citations (last 12 mo.)
- 0
Citation history
Health deficiencies cited at Lost Creek Rehabilitation And Nursing Center during CMS and state inspections, most recent first.
A resident with multiple risk factors for skin breakdown developed a stage four pressure ulcer on the right calf due to inadequate monitoring and lack of daily skin assessments under a knee brace. Despite care plan interventions and physician orders, staff did not consistently remove the brace or inspect the skin, leading to a deep tissue injury that progressed to a severe wound requiring surgical debridement.
The facility did not ensure that two CNAs completed the federally required 12 hours of annual in-service training, as confirmed by missing documentation in their education files. This deficiency was identified during a review of employee records and verified by the staff responsible for medical records, potentially impacting all residents.
The facility did not consistently hold quarterly care conferences with the required interdisciplinary team, residents, and their families or representatives. Several residents and families reported not being invited or involved, and documentation was lacking for invitations and participation. Staff confirmed that care conferences were sometimes held without nurses or aides and that proper notice was not always given, resulting in noncompliance with care planning requirements.
Surveyors found that two residents, both care planned as fall risks, did not have their call lights within reach as required by facility policy. One resident with severe cognitive impairment had the call light hooked to a privacy curtain out of reach, while another resident with Parkinson's and muscle weakness had the call light on the bed and inaccessible while needing assistance. The activity director confirmed the call lights were not accessible in both cases.
A resident with multiple diagnoses and intact cognition had conflicting advance directive information in their records, with the physician order indicating full code while the hard chart and care plan documented DNR CCA status. The DON confirmed the inconsistency between the physician order and the hard chart, contrary to facility policy requiring clear documentation of advance directives.
The facility did not provide required discharge and transfer notifications or summaries to two residents, their representatives, or the Ombudsman following hospital transfers, as confirmed by staff interviews and record review.
A resident with multiple psychiatric diagnoses and prescribed psychotropic medications was admitted, but the PASARR only listed mood and anxiety disorders, omitting other diagnoses and all psychotropic medications. The Managed Care Coordinator confirmed these omissions, and the facility's policy requiring accurate PASARR coordination was not followed.
A resident admitted with multiple complex conditions, including an active infection requiring IV antibiotics, a PICC line, and a wearable cardioverter defibrillator, did not have these care needs addressed in the baseline care plan. The DON confirmed these omissions, which were present from admission and not reflected in the care planning.
Surveyors identified that the facility did not ensure residents had the mental capacity to sign arbitration agreements and failed to explain these agreements in a way residents could understand. One resident with severe cognitive impairment signed an agreement without involvement of a power of attorney, while two cognitively intact residents either did not recall signing or misunderstood the agreement. Staff interviews revealed inconsistent explanation practices and lack of verification of resident understanding.
Surveyors observed that two residents did not receive care in accordance with infection control protocols. An LPN failed to perform hand hygiene before donning gloves and did not change gloves or sanitize hands at appropriate times during feeding tube care. An RN, while providing wound care, did not sanitize scissors taken from a student's pocket before use and did not change gloves or wash hands before handling wound dressings. These lapses in hand hygiene, glove use, and equipment cleaning were confirmed by staff interviews.
Survey results were not clearly posted or easily accessible, as the binder containing them was not easily identifiable and lacked proper signage in the lobby. This affected all residents, as required postings and notifications were not in place.
The facility did not maintain proper emergency lighting documentation, failing to record the duration of monthly tests and omitting the required annual 90-minute test, potentially affecting 39 residents. Additionally, the facility did not ensure that cooking facilities met NFPA fire protection and ventilation standards, as observed during the survey and confirmed by staff interviews.
Surveyors found that a movable natural gas stove in the kitchen lacked required chock devices to ensure proper alignment with fire suppression nozzles and did not have a chain or restraint to prevent overextension of the gas line. These deficiencies were confirmed by maintenance staff and were not in compliance with NFPA standards, potentially affecting all residents.
Surveyors found that the designated smoking area in the courtyard gazebo lacked metal containers with self-closing covers for emptying ashtrays, as required by NFPA 101. This deficiency was confirmed by maintenance staff and had the potential to affect staff and 39 residents.
Surveyors found a corridor door held open by an unapproved chain and magnet, which interfered with the door's latching mechanism and did not meet NFPA requirements for smoke resistance and positive latching, potentially affecting 13 residents.
Surveyors found multiple penetrations in smoke barriers sealed with non-fire-rated materials and one unsealed pipe, compromising the required fire and smoke resistance in several corridors and the attic. Maintenance leadership confirmed uncertainty about the materials used, and these deficiencies had the potential to affect all 39 residents.
Two residents suffered falls and fractures due to inadequate supervision and failure to follow safety protocols during transfers. One resident fell during a mechanical lift transfer conducted by a single staff member, contrary to the facility's policy requiring two staff members. Another resident fell out of bed when left unattended after the bed was elevated for care, resulting in bilateral femur fractures. These incidents highlight a failure to adhere to safety protocols and care plans, leading to significant harm.
Failure to Monitor and Prevent Pressure Ulcer from Medical Device
Penalty
Summary
A resident with multiple medical conditions, including a recent femur fracture, peripheral vascular disease, and muscle weakness, was admitted and required the use of a knee brace. Physician orders and the care plan indicated the need for skin assessments, monitoring for redness or open areas, and interventions to prevent skin breakdown, especially given the resident's risk factors. Despite these orders, there was no documented evidence that the facility staff consistently removed the brace and checked the skin under and around the device on a daily basis. The resident developed a skin tear on the right calf, which was initially treated with Steristrips and kerlix. Over the following days, the area worsened, becoming open and bleeding, and was later found to be a deep tissue injury that progressed to a stage four pressure ulcer. The wound was attributed to pressure from the knee brace, specifically where the dial of the brace contacted the skin. The wound ultimately required two surgical debridements and ongoing wound care. Interviews with the DON and ADON confirmed that the wound was caused by the brace and that additional padding could have been used to prevent pressure, but this was not done. Review of the facility's documentation and staff interviews revealed a lack of consistent monitoring and documentation regarding removal of the brace and assessment of the skin beneath it. The facility failed to follow best practices for prevention of medical device-related pressure injuries, such as daily inspection of the skin under devices and appropriate cushioning. This failure resulted in actual harm to the resident, who developed a severe pressure injury requiring extensive medical intervention.
Plan Of Correction
F 0686 Lost Creek Nursing and Rehabilitation Center wishes to have this plan of correction submitted as our written allegation of compliance. Preparation and/or execution of this plan of correction does not constitute an admission to nor agreement with, either the existence of, or the scope and severity of, any of the cited deficiencies or conclusions set forth in the statements of deficiencies. This plan is prepared and/or executed to ensure continuing compliance with regulatory requirements. Our alleged date of compliance is 6/27/25. F 0686 Treatment/Services to Prevent/Heal Pressure Ulcer: Resident #9 skin check was completed on 6/23/25 by the Director of Nursing, and no new skin areas of concern were noted. The wound is now improving, currently classified as stage IV, with wound doctor visits weekly. An initial audit was conducted on all residents with braces/splints on 6/23/25 by the Director of Nursing and Assistant Director of Nursing, and no skin issues or areas of concern were noted. An audit was conducted to ensure daily skin checks were listed as a treatment on the TAR by the Director of Nursing on 6/23/25. All clinical staff were educated on the importance of removing any and all braces and/or splints with daily skin checks and performing complete skin checks with hygiene and bathing on 6/23/25 by the Director of Nursing. Education also included daily documentation of braces and/or splints removal and skin checks daily in a progress note and/or TAR. The Director of Nursing will conduct an audit 3 times per week for 4 weeks to observe all residents with splints and/or braces to ensure daily skin checks are being completed. The Director of Nursing will observe brace removal and review nursing documentation (progress notes and/or the TAR) to ensure it is being completed daily. Any unusual findings will be forwarded to the QAPI committee for prompt resolution. The Director of Nursing will monitor this area for compliance on an ongoing basis.
Failure to Provide Required Annual In-Service Training for CNAs
Penalty
Summary
The facility failed to ensure that Certified Nursing Assistants (CNAs) received the required 12 hours of in-service training annually, as mandated by federal regulations. During a review of employee files, it was found that two CNAs did not complete the annual in-service training hours. Specifically, the education files for these CNAs did not contain documentation showing completion of the required training for the relevant years. An interview with the staff member responsible for medical records confirmed that there was no documentation available to verify that the two CNAs had completed the 12-hour in-service requirement for the specified years. This deficiency was identified through a review of three CNA files, with two found to be non-compliant, potentially affecting all residents in the facility, which had a census of 39 at the time.
Plan Of Correction
Tag: F 0947 All nurse aides (#510 and #519) identified during the survey who had not completed the required 12 hours of in-service training for calendar year 2025 were immediately scheduled for and have now completed the missing training, including dementia care and abuse prevention modules. A facility-wide audit of all nurse aide training records for the past 12 months was conducted to identify any additional staff who were out of compliance with the annual in-service requirements. Any additional deficiencies found have been corrected as of 6/25/25. The administrator provided training to the HR director on 6/16/25 regarding requirements of CNAs to complete 12 CEUs annually. HR or designee will audit monthly for the next 3 months. Results of the audit will be provided to the QAPI committee for review and recommendation.
Failure to Hold Timely, Inclusive Interdisciplinary Care Conferences
Penalty
Summary
The facility failed to ensure that quarterly care conferences were held in a timely manner and that the required interdisciplinary team (IDT), residents, and their families or representatives were included in the process. Multiple residents with varying diagnoses, including cognitive impairment, mental health disorders, and chronic medical conditions, were affected. Documentation revealed that care conferences were either not held at the required intervals, not attended by the full IDT, or did not include the resident and/or their representative, as required by regulation and facility policy. For several residents, care conferences were documented as occurring, but interviews with the residents and their families indicated they were not aware of or did not recall being invited to or participating in these meetings. In some cases, there was no documentation that residents or their families were invited, and no input or concerns from them were recorded. For one resident, no care conferences had been held since admission, and both the resident and their spouse confirmed they had never participated in such a meeting. Staff interviews confirmed that care conferences were sometimes held without the required nursing or aide staff, and that invitations to residents and families were not consistently documented or provided with adequate notice. The facility's policy required a seven-day advance notice for care conferences, with documentation of the date, time, method of contact, and input from the resident or representative if they could not attend. However, staff acknowledged that this process was not consistently followed, and that care conferences were often scheduled based on staff availability rather than resident or family participation. As a result, the facility did not meet regulatory requirements for timely, inclusive, and interdisciplinary care planning.
Plan Of Correction
Tag: F 0657 Care conferences were held with residents / sponsors for the following residents #10, #16, #35, #5, and #6 on or before 6/25/25. Social services or designee will review all current resident records by 6/25/25 to ensure that quarterly care conferences have been completed timely. If a care conference did not occur, one will be held by 6/25/25. The administrator provided education to the social services designee on 6/17/25 regarding the timely completion of quarterly care conferences, quarterly completion, and the requirement for IDT, resident, and sponsor involvement. The administrator or designee will audit 3 resident charts for the completion of timely care conferences weekly for 4 weeks to ensure timely completion and involvement of the resident, sponsor, and IDT. Results of the audit will be reviewed by the QAPI committee for further recommendations.
Failure to Ensure Call Lights Within Reach for Residents at Risk for Falls
Penalty
Summary
Surveyors identified that the facility failed to ensure call lights were within reach for two residents, both of whom were care planned as being at risk for falls. For one resident with severe cognitive impairment and multiple diagnoses including dementia with agitation and paranoid schizophrenia, the call light was observed hooked to the privacy curtain and out of reach while the resident was lying in bed. The activity director confirmed that the resident uses the call light and verified it was not accessible at the time of observation. The resident's care plan specifically required that the call light be within reach and that the resident be encouraged to use it for assistance. For another resident, who was cognitively intact and had diagnoses including Parkinson's disease, muscle weakness, and difficulty walking, the call light was found lying on the bed and out of reach while the resident was sitting in a chair and expressing a need to use the bathroom. The activity director again confirmed the call light was not accessible. Facility policy required that call lights be within easy reach of residents when in bed or confined to a chair, but this was not followed in these instances.
Inconsistent Advance Directive Documentation
Penalty
Summary
The facility failed to ensure that both the hard chart and the electronic medical record contained consistent and correct advance directive information for a resident. Specifically, the physician orders indicated the resident was a full code, while the hard chart documented the resident as Do Not Resuscitate Comfort Care Arrest (DNR CCA), and the care plan also reflected DNR CCA status. The Director of Nursing confirmed this discrepancy during an interview, verifying that the physician order was for full code, but the hard chart had a DNR CCA form signed by the physician. The resident involved was admitted with diagnoses including Parkinson's disease, muscle weakness, hypertension, other specified forms of tremor, and thrombocytopenia. The resident was assessed as cognitively intact, with a BIMS score of 15. Facility policy required that information about whether a resident has executed an advance directive be displayed prominently in the medical record, but this was not consistently done in this case, resulting in conflicting documentation regarding the resident's code status.
Failure to Provide Required Discharge and Transfer Notifications
Penalty
Summary
The facility failed to provide required discharge and transfer notifications to residents, their representatives, and the Ombudsman for two residents. In the first case, a resident with diagnoses including diabetes type two, paraplegia, chronic obstructive pulmonary disease, pain, and schizoid personality disorder was admitted to the facility and later transferred to the hospital following a change in condition and declining vital signs. Documentation showed the resident was transferred via emergency squad, but there was no evidence of a transfer summary or notification sent to the hospital, the resident, the resident's representative, or the Ombudsman during the relevant period. In the second case, another resident with a history of complications post femur fracture surgery, depression, and myeloma was admitted and subsequently discharged to the hospital after a syncopal episode and possible urinary tract infection. The transfer occurred after the resident was seen by an outside physician. Review of the medical records revealed no documentation of discharge or transfer notification to the resident, the resident's representative, or the Ombudsman. Interviews with facility staff, including a Managed Care Provider and the Administrator, confirmed that the required notifications and summaries were not completed or documented for either resident. The findings indicate that the facility did not meet regulatory requirements for communication and documentation during resident transfers and discharges.
Plan Of Correction
Tag: F 0628 Facility has provided resident #28 and #42 with transfer notices, as well as updated transfer log and sent to ombudsman. Administrator reviewed all transfer/discharges from 5/1/25 through 5/30/25 for corresponding notice of transfer/discharge. Administrator or designee will review discharged patients for the last 30 days to ensure they received a transfer/discharge notice. If they did not receive a notice, they will be issued one, this will occur on or before 6/25/25. Administrator provided education to social service designee on transfer/discharge notice requirements on 6/17/25. Administrator or designee will audit 3 discharge residents weekly x4 weeks to ensure proper notice of transfer/discharge. Results of audits will be reviewed by the QAPI committee for further recommendations.
Failure to Accurately Complete PASARR for Resident with Psychiatric Diagnoses
Penalty
Summary
The facility failed to ensure that the Preadmission Screening and Resident Review (PASARR) was completed accurately for a resident with multiple psychiatric diagnoses. The resident was admitted with a history of bipolar disorder, schizoaffective disorder, visual and auditory hallucinations, cognitive communication deficit, inadequate social skills, anxiety, and adult antisocial behavior. Despite these diagnoses and the use of several psychotropic medications, the PASARR completed for the resident only listed mood disorders and panic or other severe anxiety disorders, omitting other relevant diagnoses and all psychotropic medications. A review of the resident's Minimum Data Set (MDS) indicated the resident was cognitively intact, and current physician orders included multiple psychotropic medications for the management of their psychiatric conditions. During an interview, the Managed Care Coordinator confirmed that the PASARR did not include any psychotropic medications or additional diagnoses beyond mood disorder and panic or other severe anxiety disorders. The facility's policy requires coordination with the PASARR program to ensure accurate assessment and care planning for individuals with mental disorders, intellectual disabilities, or related conditions, but this was not followed in this case.
Plan Of Correction
Tag: F 0644 The facility will ensure the PASARR is completed accurately. PASARR for resident #10 has been updated by social service designee to include all diagnoses and antipsychotic medications. Social services or designee will complete a whole house audit to determine if PASARR is accurate by 6/25/25. Administrator will provide social service designee with education regarding PASARR process on 6/17/25. Administrator or designee will audit 3 PASARRs weekly for 4 weeks. Audit results will be reviewed by the QAPI committee for further recommendations.
Failure to Include Critical Admission Care Needs in Baseline Care Plan
Penalty
Summary
The facility failed to implement a baseline care plan that included all care concerns present at the time of admission for one resident. The resident was admitted with multiple significant diagnoses, including chronic obstructive pulmonary disease with exacerbation, chronic ischemic heart disease, bacteremia, heart failure, chronic kidney disease stage four, atrial fibrillation, and obstructive sleep apnea. Upon admission, the resident had active physician orders for intravenous antibiotics (ampicillin sodium and ceftriaxone) to treat an implantable cardioverter-defibrillator (ICD) infection, required the use of a wearable cardioverter defibrillator (life vest) with specific battery and placement checks, and had a peripherally inserted central catheter (PICC) line with associated care instructions. A review of the baseline care plan dated the day of admission revealed that it did not address the PICC line, life vest, infection, or the administration of antibiotics, all of which were present and required care from the time of admission. The Director of Nursing confirmed in an interview that these care needs were present on admission and should have been included in the baseline care plan, but were not.
Plan Of Correction
F-0655 Baseline Care Plan Resident #96 Baseline care plan did not include instructions to provide effective and person-centered care on 6/10/25 by the Director of Nursing. An initial audit was conducted on all new residents on 6/10/25 by the Director of Nursing and all Baseline Care Plans were completed. All clinical staff were educated on 6/10/25 on baseline care plans needing to be completed on admission by the Director of Nursing. The Director of Nursing or Designee will conduct an audit on all new Residents for 4 weeks to ensure Baseline Care Plans reflect all minimum healthcare information needed to provide effective person-centered care. Any unusual findings will be forwarded to the QAPI committee for prompt resolution. The Director of Nursing will monitor this area for compliance on an ongoing basis.
Failure to Ensure Capacity and Understanding in Arbitration Agreements
Penalty
Summary
Surveyors found that the facility failed to ensure residents had the mental capacity to sign arbitration agreements and did not adequately explain these agreements in a manner or language the residents could understand. In one case, a resident with a BIMS score indicating severe cognitive impairment signed an arbitration agreement, despite the expectation that a power of attorney should have been involved. Interviews confirmed that the resident did not recall signing the agreement or understand its purpose. Another resident, who was cognitively intact according to their BIMS score, signed an arbitration agreement but could not recall if the agreement was explained or if they had signed it. This resident also did not understand what an arbitration agreement was. A third resident, also cognitively intact, misunderstood the arbitration process, believing it involved a judge and a court, and was unsure if they had signed such an agreement upon admission. Staff interviews revealed inconsistent practices in explaining arbitration agreements. The administrator stated that residents were told they did not have to sign if they did not understand, but typically had residents read the agreement themselves rather than providing a thorough explanation. The previous admissions director described explaining the voluntary nature of the agreement and the option to seek legal counsel, but would only involve a responsible party if the resident did not understand. The regional director confirmed that a resident with severe cognitive impairment should not have signed the agreement without the power of attorney.
Plan Of Correction
Tag: F 0847 Administrator or designee will review and explain the arbitration agreement to residents and/or sponsors of #9, #25, and #31 by 6/20/25. The administrator or designee will review the arbitration agreement log with identified residents to ensure choice and understanding by 6/20/25. RDO provided education to administrator on arbitration requirements on 6/5/25. Three new admissions will be audited weekly x4 weeks to ensure understanding and choice in regards to signing arbitration agreements. Results of audit will be provided to QAPI committee for review and recommendations.
Infection Control Deficiencies in Hand Hygiene, Glove Use, and Equipment Cleansing
Penalty
Summary
Surveyors identified deficiencies in the facility's infection prevention and control practices during care provided to two residents. For one resident with impaired cognition and a feeding tube, an LPN prepared for tube feeding care by donning a gown and gloves but failed to sanitize hands before applying gloves. Throughout the procedure, the LPN did not change gloves or perform hand hygiene at appropriate intervals, including after handling potentially contaminated items and before applying a new bandage. The LPN only changed gloves once, without hand hygiene between glove changes, and later confirmed that protocol required more frequent handwashing and glove changes, which were not followed. For another resident with multiple medical conditions and a wound on the right upper lateral calf, an RN performed wound care with a nursing student present. The RN followed some hand hygiene steps, such as washing hands and changing gloves at certain points, but failed to sanitize or change gloves after touching the box of dressings and before placing the dressing into the wound bed. Additionally, scissors used to cut the dressing were taken from the student nurse's pocket and were not sanitized before use. The RN acknowledged these lapses during an interview, confirming that the scissors were not cleaned and that gloves were not changed or hands washed before handling the wound dressing. These observations demonstrate that the facility did not consistently ensure proper hand hygiene, glove use, and equipment cleansing during resident care, as required by infection prevention and control protocols. The lapses were directly observed by surveyors and confirmed by staff interviews, affecting two residents reviewed for infection control practices.
Plan Of Correction
F 0880 Lost Creek Nursing and Rehabilitation Center wishes to have this plan of correction submitted as our written allegation of compliance. Preparation and/or execution of this plan of correction does not constitute an admission to nor agreement with, either the existence of, or the scope and severity of, any of the cited deficiencies or conclusions set forth in the statements of deficiencies. This plan is prepared and/or executed to ensure continuing compliance with regulatory requirements. Our alleged date of compliance is 6/27/25. F 0880 Infection Prevention & Control Resident #23 & #9 dressing changes were monitored by the Director of Nursing on 6/12/25, and all infection control standards were followed. An initial audit was conducted on all residents with wounds on 6/13/25 by the Director of Nursing and all infection control standards were met. All clinical staff were educated on infection prevention and control on 6/11/25 by the Director of Nursing, including handwashing and EBP precautions. The Director of Nursing or Designee will conduct an audit with staff 3x a week x 4 weeks to watch dressing changes. Any unusual findings will be forwarded to the QAPI committee for prompt resolution. The Director of Nursing will monitor this area for compliance on an ongoing basis.
Survey Results Not Clearly Posted or Accessible
Penalty
Summary
The facility failed to ensure that the results of the most recent survey were visibly posted and easily accessible to residents, family members, and legal representatives. During an observation in the front lobby, surveyors noted that three black letter holders were present on the wall between the business office and admissions office, containing a binder with a small label indicating 'survey results.' However, the binder was not easily identifiable as containing survey results unless someone was in close proximity to it, and there was no signage observed to indicate where the binder was located. An interview with the Administrator confirmed that there was no signage in the lobby or common area to direct individuals to the location of the survey results. This lack of visible posting and signage had the potential to affect all residents in the facility, as it did not comply with the requirement to make survey results readily accessible and to post notice of their availability in prominent and accessible areas. The facility census at the time was 39 residents. No specific residents or medical histories were mentioned in relation to this deficiency.
Plan Of Correction
Tag: F 0577 Facility will ensure there is a visible posting on where to locate the survey results. Posting was placed on 6/10/25 in a prominent location adjacent to the business office. No other required postings were identified as missing. Licensed administrator was educated on requirements of F0577 by RDO on 6/05/25. Administrator or designee will audit one time a week x4 weeks to ensure signage is in place. Audit results will be reported to QAPI committee for review and recommendations. F 0578 Lost Creek Nursing and Rehabilitation Center wishes to have this plan of correction submitted as our written allegation of compliance. Preparation and/or execution of this plan of correction does not constitute admission to nor agreement with, either the existence of, or the scope and severity of, any of the cited deficiencies or conclusions set forth in the statements of deficiencies. This plan is prepared and/or executed to ensure continuing compliance with regulatory requirements. Our alleged date of compliance is 6/27/25. F 0578 Request/Refuse/Dscntnue Tmnt; Formite Adv Dir Resident #27 code status was checked on 6/10/25 at 0900 by the Director of Nursing, and code status matched in hard chart and PCC. An initial audit was conducted on all residents on 6/11/25 by the Director of Nursing and all resident code status hard chart and electronic chart matched. All clinical staff were educated on checking code status on admission and with any code status change to ensure accuracy from hard chart to electronic chart on 6/11/25 by the Director of Nursing. The Director of Nursing or Designee will conduct an audit on all Residents initially and 2x weekly for any changes. Director of Nursing will also audit new admits and any return from hospital day of return or following day for any changes. Any unusual findings will be forwarded to the QAPI committee for prompt resolution. The Director of Nursing will monitor this area for compliance on an ongoing basis.
Deficiencies in Emergency Lighting and Cooking Facility Safety Standards
Penalty
Summary
The facility failed to maintain emergency lighting in accordance with NFPA 101-2012 requirements. A review of the life safety documentation revealed that while twenty-three emergency lights were listed as "OK" on the emergency lighting log, the records did not indicate the duration of the monthly tests. Additionally, the section of the log designated for the required annual 90-minute test was not utilized. During an interview, the Regional Maintenance Director confirmed that the maintenance director was likely unaware of the specific testing requirements. This deficiency had the potential to affect 39 residents. The report also notes a failure to maintain cooking facilities in compliance with NFPA 101-2012 and related standards. The facility did not meet the requirements for protecting cooking equipment as outlined in the relevant NFPA codes. The observations and staff interviews indicated that the necessary fire protection and ventilation controls for cooking operations were not properly maintained, as required by the standards cited.
Plan Of Correction
Tag: K 0291 On 6/20/25, all 23 emergency lights were tested and found to be functional. All emergency lights will be appropriately tested and documented by the maintenance director or designee monthly. The administrator provided the maintenance director with education regarding emergency lighting requirements on 6/16/25. The maintenance director or designee will submit the emergency lighting log to the QAPI committee for review and recommendation for the next 3 months.
Failure to Maintain Safe Cooking Equipment Positioning and Restraints
Penalty
Summary
During a facility tour, surveyors observed a natural gas six-burner/griddle stove on wheels in the kitchen that was not equipped with chock devices to ensure proper alignment with the fire suppression system nozzles when the appliance was moved for cleaning or service. The absence of these chock devices meant that the required protection by the suppression system could not be guaranteed if the stove was not returned to its designated position after being moved. Additionally, the movable stove was not provided with a chain or restraint to prevent overextension of the gas line, as required by relevant NFPA standards. This lack of a restraining device could allow the gas line to be stretched or damaged during movement, which is not in compliance with the manufacturer's installation instructions and applicable codes. These deficiencies were confirmed through interviews with the Regional Maintenance Director and the Maintenance Director at the time of observation. The findings indicated that the facility failed to maintain its cooking facilities in accordance with multiple sections of NFPA 101, NFPA 54, NFPA 96, and NFPA 17A, potentially affecting all 39 residents in the facility.
Plan Of Correction
Tag: K 0324 The natural gas 6 burner griddle stove has been equipped with both chock devices and restraint to prevent over extension of gas line as of 6/20/25. There are no other natural gas moveable stoves in the facility. The administrator provided education to maintenance director on 6/16/25 regarding requirements NFPA 101 cooking facilities. The maintenance director or designee will audit the natural gas 6 burner griddle stove to ensure proper equipment and restraint weekly for the next 4 weeks. Results of the audit will be submitted to the QAPI committee for review and recommendations.
Missing Self-Closing Metal Containers in Smoking Area
Penalty
Summary
During a facility tour, surveyors observed that the designated smoking area in the courtyard gazebo did not have metal containers with self-closing cover devices available for emptying ashtrays. This observation was confirmed in interviews with the Regional Maintenance Director and the Maintenance Director at the time of the survey. The absence of these containers is a violation of NFPA 101-2012 Edition, Section 19.7.4, which requires that such containers be readily available in all areas where smoking is permitted. The deficiency was identified as having the potential to affect an undetermined number of staff and 39 residents in the event of an emergency. The report does not mention any specific incidents involving residents or staff at the time of the observation, nor does it provide details about the medical history or condition of any individuals involved. The finding is based solely on the lack of required fire safety equipment in the designated smoking area.
Plan Of Correction
Tag: K 0741 On or before 6/20/25, the designated smoking areas were equipped with self-closing cover metal devices. There are no other smoking areas on the property. The administrator provided the maintenance director with education regarding NFPA 101 smoking regulations. The maintenance director or designee will audit smoking areas for appropriate self-closing devices 3 times a week for 4 weeks. Results of the audit will be submitted to the QAPI committee for review and recommendations.
Noncompliant Corridor Door Hold-Open Device
Penalty
Summary
The facility failed to ensure that all corridor doors were able to resist the passage of smoke and were provided with a suitable means for keeping the doors closed, as required by NFPA 101-2012 and NFPA 80-2010 standards. During a facility tour, surveyors observed a 20-minute fire-rated double-corridor door being held open by an unapproved chain with a magnet attached. This setup was not compliant with regulations, as the magnet on the chain could interfere with the door's latching mechanism and was not an approved device for holding the door open. The magnet, when the door closed, would swing on its chain and potentially interfere with the door's ability to latch properly. This deficiency was confirmed through interviews with the Regional Maintenance Director and the Maintenance Director, who acknowledged the findings at the time of observation. The improper use of the chain and magnet did not meet the requirement for corridor doors to have positive latching hardware and to resist the passage of smoke. The report specifies that this deficiency had the potential to affect 13 out of 39 residents in the facility. No additional details about the specific residents or their medical conditions were provided in the report. The deficiency was limited to the improper securing of a fire-rated corridor door, which did not comply with the required fire and smoke protection standards.
Plan Of Correction
Tag: K 0363 Chain and magnet on double corridor door modified to keep from impeding closure on 6/20/25. No other fire rated or smoke barrier doors found to be impeded from closing appropriately. Administrator educated maintenance director on NFPA 101 corridor doors on 6/16/25. Maintenance director or designee will audit all corridor doors weekly x 4 weeks. Audit results will be submitted to the QAPI committee for review and recommendations.
Failure to Maintain Smoke Barrier Integrity per NFPA 101
Penalty
Summary
The facility failed to maintain fire and smoke barriers in accordance with NFPA 101-2012 Edition, Section 19.3.7.3 and Section 8.5.6.2. During a facility tour, surveyors observed multiple penetrations in smoke barriers that were improperly sealed with non-fire-rated, rubber-like materials. These penetrations included aluminum conduits and black pipes located in the interstitial spaces between the ceiling and drop ceiling above several 20-minute fire-rated double corridors leading into various halls, including the 100, 200, 300, and 400 Halls, as well as the Service Hall. Additionally, one 3-inch black pipe was found completely unsealed in the attic space above a fire-rated double corridor leading into the attic. The materials used to seal the other penetrations were not fire-rated and did not meet the requirements for restricting the transfer of smoke as specified by the referenced NFPA standards. The Regional Maintenance Director confirmed at the time of discovery that he was unsure of the type of material used to seal the pipes. These deficiencies were identified during direct observation and staff interviews, and the findings were confirmed by facility maintenance leadership. The report notes that these failures had the potential to affect all 39 residents in the facility, as the integrity of the smoke barriers was compromised by the use of improper sealing materials and the presence of unsealed penetrations.
Plan Of Correction
Tag: K 0372 Both the pipe and conduits between the ceiling and drop ceiling above the fire-rated double corridor leading into 100 hall, 200 hall, 300 hall, 400 hall, service hallway, and into the attic space were repaired with fire-rated caulk on or before 6/20/25. There was no other conduit or pipes found to have penetrations not properly sealed. Administrator educated maintenance director on NFPA 101 subdivision of building spaces - smoke barrier construction on 6/16/25. Maintenance director or designee will audit pipes and conduits for penetration monthly x 3 months. Audits will be submitted to the QAPI committee for review and recommendations. K 0372
Failure to Ensure Resident Safety During Transfers
Penalty
Summary
The facility failed to ensure adequate supervision and safety measures during resident transfers, resulting in falls and injuries. Resident #10, who required extensive assistance for transfers due to conditions such as obesity and chronic obstructive pulmonary disease, fell during a mechanical lift transfer conducted by a single staff member. The resident was supposed to be assisted by two staff members as per facility policy, but this was not adhered to, leading to a fall that resulted in a fractured left femur requiring surgery. The investigation revealed that the nurse aide involved was following the manufacturer's guidelines rather than the facility's policy, which mandates two staff members for such transfers. Resident #2, who had impaired cognition and was dependent on assistance for activities of daily living, fell out of bed when left unattended after the bed was elevated for incontinence care. The nurse aide had raised the bed to waist level and left the room to retrieve a lift, during which time the resident attempted to reach for items on the bedside table and fell, sustaining fractures to both femurs. The care plan for Resident #2 included keeping the bed in a low position and ensuring personal items were within reach, but these interventions were not followed at the time of the incident. Both incidents highlight a failure to adhere to established safety protocols and care plans, resulting in significant harm to the residents involved. The facility's policy required two staff members for mechanical lift transfers, which was not followed in the case of Resident #10. Similarly, the care plan interventions for Resident #2 were not implemented, leading to the resident's fall. These deficiencies were identified during the investigation of multiple complaints, indicating a pattern of non-compliance with safety and supervision standards.
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A resident with intact cognition receiving Medicare Part A skilled services for metabolic encephalopathy had services discontinued while benefit days remained, but the facility did not issue the required Skilled Nursing Facility Advance Beneficiary Notice (SNF ABN). The Social Services Director later confirmed that no SNF ABN was provided and reported she believed only a Notice of Medicare Non-Coverage (NOMNC) was needed when all skilled services were stopped. This practice conflicted with the facility’s written policy, which required SNF ABNs to be issued when extended care items or services were initiated, reduced, or terminated due to expected non-coverage by Medicare.
Surveyors identified that the facility exceeded the acceptable medication error rate when two residents with type 2 DM received insulin doses that were not administered according to orders or manufacturer instructions. In two separate observations, an LPN administered Novolog and another LPN administered insulin glargine and insulin lispro without priming the insulin pens, and the insulin lispro and Novolog were given after the residents had already consumed a significant portion of their breakfast meals, despite orders for administration before meals. Manufacturer information for both insulin products required priming before each injection to ensure accurate dosing, and facility policy required medications, including insulin, to be administered safely, timely, and in accordance with prescriber orders and specified time frames.
Surveyors found that the facility failed to document tray line food temperatures for multiple meals served from two dining room kitchenettes, despite having a “Trayline Taste & Temperature Log” and a policy requiring food to be stored, prepared, distributed, and served according to professional food safety standards. Review of logs showed repeated missing entries for breakfast, lunch, and dinner services in both the Harrison and McClellan dining areas, and the Senior Director of Culinary Services confirmed that temperatures had not been recorded for those meals, potentially affecting all residents receiving meals from those kitchenettes.
The facility failed to conduct and document required periodic care conferences for two residents, despite multiple comprehensive, quarterly, and significant change MDS assessments and a policy requiring periodic care conferences with resident and/or family participation. One resident with Parkinson’s disease, post-stroke hemiplegia, TIA, DMII, and depression had only two documented care conferences over a year, while another resident with aphasia, cerebrovascular disease, DMII, gait difficulty, coagulation defect, depression, and muscle weakness had no documented care conferences in the past year, aside from a declined invitation to the representative. The UCC confirmed that care conferences were expected to occur quarterly and that no additional documentation existed for either resident.
A resident with Alzheimer's disease and type II DM, who required extensive assistance with ADLs and was receiving scheduled Lantus and sliding-scale Humalog, experienced a severely elevated blood glucose level. The on-call provider was notified and ordered an additional dose of lispro insulin with a directive to recheck the blood glucose after administration. Nursing staff administered the extra insulin but did not document any follow-up blood glucose check, and the DON confirmed that this reevaluation was required by the facility's abnormal blood glucose policy and was not completed or documented.
A resident with Parkinson’s disease, dementia, and hypothyroidism was prescribed levothyroxine once daily along with other medications. A consultant pharmacist’s monthly drug regimen review recommended that levothyroxine be given in the morning on an empty stomach, 30–60 minutes before food, per manufacturer instructions. The medical record contained no documented physician response to this recommendation, and the MAR showed the drug scheduled for morning administration while the resident was observed eating breakfast and receiving the medication at the same time. An LPN confirmed administering levothyroxine during the meal, and the DON verified there was no documentation explaining whether or why the pharmacist’s recommendation was or was not followed, resulting in a failure to act on and document the identified irregularity.
A resident with severe cognitive impairment, multiple comorbidities, documented gait and balance abnormalities, and a high fall risk was care planned and assessed by therapy to require contact guard assistance and use of a gait belt for transfers and ambulation. While being assisted by a CNA from a recliner to the bathroom with a walker, the CNA did not apply a gait belt, even though the resident had a known tendency to lean backward when standing. As the CNA reached to open the bathroom door, the resident lost balance and fell backward, striking the back of the head, and was later found by an LPN without a gait belt in place, contrary to the facility’s gait belt policy and the resident’s assessed needs.
A resident with CKD stage five requiring peritoneal dialysis (PD) was admitted with pre-admission physician orders for three daily PD exchanges and monitoring for peritonitis (fever, abdominal pain, cloudy effluent), but these monitoring orders were not entered into the facility’s physician orders. The care plan referenced PD and general monitoring but did not specifically address peritonitis monitoring. Paper PD flowsheets showed incomplete and inconsistent documentation of exchanges and resident condition, including missing condition/comments for individual treatments and no record of one ordered PD exchange. The PD cycler flowsheet lacked effluent descriptions on multiple days. The PD nurse reported facility staff were expected to monitor effluent and symptoms, and the DON confirmed the absence of specific peritonitis monitoring orders, lack of an order for the PD cycler, and documentation gaps, despite a facility policy requiring ongoing assessment and monitoring for complications before, during, and after dialysis treatments.
A nurse was observed preparing multiple oral medications for a resident with depression, traumatic brain injury, anxiety, and impaired cognition by pushing tablets and capsules from unit-dose cards directly into her ungloved hand and then using her fingers to place them into a medication cup. In a follow-up interview, the RN confirmed this practice and acknowledged that the correct procedure is to dispense medications directly from the card into the cup, contrary to the facility’s medication administration policy requiring adherence to good nursing principles and practices.
A resident with Alzheimer’s disease, diabetes, anxiety, significant ADL dependence, and behavioral symptoms was observed seated in a chair positioned against the nursing station with a locked wheelchair placed directly in front, also against the nursing station, effectively restricting movement. An LPN confirmed both wheelchair wheels were locked and that it should not have been placed there, while a CNA stated she had positioned the wheelchair to prepare for lunch, was unable to complete the transfer, and left it in place, acknowledging this was wrong. This arrangement conflicted with the facility’s restraint policy, which prohibits physical restraints except when alternatives are ineffective for treating a medical symptom and defines restraints as devices adjacent to the body that cannot be easily removed and that restrict freedom of movement or access to the body.
Failure to Issue Required SNF ABN When Discontinuing Medicare Part A Services
Penalty
Summary
The deficiency involves the facility’s failure to issue a Skilled Nursing Facility Advance Beneficiary Notice (SNF ABN) when Medicare Part A services were discontinued for a resident who still had available benefit days. The resident was admitted with a diagnosis of metabolic encephalopathy and had intact cognition per the Minimum Data Set assessment. The facility’s own SNF Beneficiary Notification Review documented that Medicare Part A skilled services began on 02/11/26 and the last covered day was 03/11/26, and that the facility initiated discharge from Medicare Part A services before the resident’s benefit days were exhausted. Despite this, no SNF ABN was provided to the resident or the resident’s representative. During interviews, the Social Services Director stated that the SNF ABN was issued hours prior to the last covered day but, upon reviewing her files, confirmed that no SNF ABN had actually been issued for this resident. She further explained that she believed an SNF ABN was only required if one skilled service remained and that if all skilled services were being discontinued, only the Notice of Medicare Non-Coverage (NOMNC) needed to be issued. The Administrator, however, stated that a resident should always receive both a SNF ABN and a NOMNC when Medicare Part A services are discontinued and benefit days remain. Review of the facility’s written policy dated 03/28/23 showed that the facility was required to issue SNF ABNs for initiation, reduction, or termination of extended care items or services when Medicare payment was not expected, which did not occur in this case.
Plan Of Correction
This Plan of Correction is submitted as required under State and Federal law. This Plan of Correction does not constitute an admission on the part of the Facility that the findings cited are accurate, that the findings constitute a deficiency or that the scope and severity regarding the deficiency cited are correctly applied. Any changes to the Facility's policies and procedures should be inadmissible in any proceeding on that basis. Without admitting or denying the validity or the existence of the alleged noncompliance, the Facility submits this Plan of Correction with the intention that it be inadmissible by any third party in any civil or other action against the facility or any employee, agent, officer, director or shareholder of the Facility. The Facility is utilizing this Plan of Correction as its allegation of substantial compliance as of 05/29/2026 F-0582 Corrective action for resident/s: On 5/14/26 Resident #34 was informed of rights and responsibilities related to Advanced Beneficiary Notice and voiced understanding of information for future reference by administrator. Identification of other residents who may be affected: Any resident receiving skilled services from nursing or therapy services. The Administrator audited all residents who were discharged from skilled services in the past 30 days to ensure they were issued a Notice of Non-Coverage and Advanced Beneficiary Notice on 5/29/26. No non-compliance was noted. Measures for systemic change: On 5/14/2026 Business Office Manager, Director of Rehab, Minimum Data Set nurse, Director of Nursing and Social Services Director were educated on proper procedure of issuing of Notice Of Medicare Non Coverage and Advanced Beneficiary Notice by administrator. All upcoming discharges from skilled services will be reviewed weekly at Utilization Review meeting to ensure notices will be delivered timely. How Corrective Action will be monitored: Administrator or designee to complete audits of all residents being discharged from skilled services to ensure they were issued a Notice of Non-Coverage and Advanced Beneficiary. This audit will be completed weekly x 4 weeks, then monthly x 2 months. Corrective action will be initiated for any noted non-compliance. Audit findings will be reviewed as part of the monthly quality assurance process to determine the need for further monitoring. Date of Compliance 5/29/26
Insulin Administration Errors and Failure to Prime Insulin Pens
Penalty
Summary
The deficiency involves the facility’s failure to maintain a medication error rate below 5%, with surveyors identifying 3 errors out of 28 medication administration opportunities, resulting in a 10.71% error rate. For one resident with type 2 diabetes mellitus and moderate cognitive impairment, the physician’s order directed Novolog insulin 10 units via subcutaneous pen-injector to be given before meals. During an observed medication pass, the LPN administered 10 units of Novolog insulin without priming the pen and did so after the resident had already consumed approximately 50% of the breakfast meal. The LPN later confirmed she did not prime the pen and acknowledged that the insulin was ordered to be administered prior to meals. Manufacturer instructions for the Novolog FlexPen specified that an air shot (priming) must be performed before each injection to ensure proper dosing. Another resident, also diagnosed with type 2 diabetes mellitus and with intact cognition, had orders for insulin glargine 35 units subcutaneously twice daily and insulin lispro 20 units subcutaneously before meals, plus 12 units subcutaneously if blood glucose was between 251 mg/dL and 300 mg/dL. During an observed medication administration, an LPN administered 35 units of insulin glargine and 32 units of insulin lispro without priming the insulin pens and after the resident had consumed approximately 90% of the breakfast meal, despite orders for insulin lispro to be given before meals. The LPN later stated she could not remember if she had primed the pen and acknowledged that the insulin was ordered to be administered prior to meals. Manufacturer information for insulin lispro stated that the pen must be primed before each injection to confirm insulin delivery and remove air, and that failure to prime could result in too much or too little insulin. The DON confirmed the expectation that insulin be administered as ordered, including priming each pen with two units before dialing the prescribed dose, and facility policy required medications, including insulin, to be administered safely, timely, and in accordance with prescriber orders and required time frames.
Plan Of Correction
This Plan of Correction is submitted as required under State and Federal law. This Plan of Correction does not constitute an admission on the part of the Facility that the findings cited are accurate, that the findings constitute a deficiency or that the scope and severity regarding the deficiency cited are correctly applied. Any changes to the Facility's policies and procedures should be inadmissible in any proceeding on that basis. Without admitting or denying the validity or the existence of the alleged noncompliance, the Facility submits this Plan of Correction with the intention that it be inadmissible by any third party in any civil or other action against the facility or any employee, agent, officer, director or shareholder of the Facility. The Facility is utilizing this Plan of Correction as an allegation of substantial compliance as of 5/29/2026. F-0759 Corrective action for resident/s: Residents #21 and #22 were assessed and evaluated by nurse and Director of Nursing 5/14/26. Resident #21 and #22 both denied any adverse effects and none were noted upon assessment by the Director of Nursing on 5/14/2026. Notification made to physician on 5/14/2026. LPN # 2 competency Eval on insulin administration with the Director of Nursing completed 5/14/2026. Identification of other residents who may be affected: Diabetic residents on assignment of LPN #2/station 2 have the potential to be affected and were assessed by the DON/Designee on 5/14/26 and found to be within normal limits. Measures for systemic change: All Nurses were educated by the Director of Nursing on the steps for Insulin administration per competency, diabetes clinical protocol policy, Medication and treatment orders policy, administering medications policy, and Obtaining fingerstick Glucose Level policy On 5/14/2026. How Corrective Action will be monitored: Director of Nursing and Assistant Director of Nursing will complete insulin administration audits on 5 nurses. This audit will be completed weekly x 4 weeks, then monthly x 2 months. Corrective action will be initiated for any noted non-compliance. Audit findings will be reviewed as part of the monthly quality assurance process to determine the need for further monitoring. Date of Compliance: 5/29/2026
Failure to Document Tray Line Food Temperatures in Dining Room Kitchenettes
Penalty
Summary
The deficiency involves the facility’s failure to document tray line food temperatures for meals served from the Harrison and McClellan Dining Room kitchenettes, as required by professional standards for food service safety and the facility’s own policy. Review of the “Trayline Taste & Temperature Log” (revised September 2018) showed missing temperature documentation for multiple meals from the Harrison Dining Room kitchenette, including dinner on 03/30/26 and 03/31/26, lunch and dinner on 04/01/26 and 04/02/26, dinner on 04/07/26, and lunch and dinner on 04/08/26 and 04/10/26. The Senior Director of Culinary Services confirmed during interview that tray line food temperatures were not documented on the log for these meals. Similarly, review of the same log for the McClellan Dining Room kitchenette revealed that tray line food temperatures were not documented for dinner on 04/01/26, breakfast and lunch on 04/02/26, and lunch and dinner on 04/07/26. The Senior Director of Culinary Services also verified these omissions during interview. The facility census at the time was 27 residents, and the governing “Food and Nutrition” policy, approved on 09/07/21, stated that the facility must store, prepare, distribute, and serve food in accordance with professional standards for food service safety.
Plan Of Correction
F812 The facility will continue to ensure food temperatures are completed before meals are served for all residents. To ensure compliance with this standard the following measures have been taken: 1. Immediately 4/15/26 culinary supervisor #224 was re-educated by Dietary Manager to this standard and policy "Food and Nutrition" which includes documentation of food temperatures. 2. All dietary staff have been re-educated to the standard and policy "Food and Nutrition" during the month of April 2026. 3. Audits of food temperature documentation to be completed by Dietary Manager 4 x per week for 4 weeks then weekly for 4 weeks. 4. Administrator to validate audits/compliance and provide additional training as needed. Administrator will present to QAPI committee for ongoing monitoring and further direction.
Failure to Conduct and Document Required Care Conferences
Penalty
Summary
The deficiency involves the facility’s failure to complete and document comprehensive care conferences at required intervals in accordance with care plan regulations and facility policy. For one resident with Parkinson’s disease with dyskinesia, cognitive communication deficit, hemiplegia and hemiparesis following cerebral infarction, transient cerebral ischemic attack, type II diabetes mellitus, and major depressive disorder, the record showed multiple MDS assessments over a one-year period, including annual, quarterly, and significant change assessments. However, only two care conferences were documented during the last 12 months, despite the expectation that care conferences be conducted quarterly with the resident and family when possible. The Unit Care Coordinator confirmed that no additional care conference documentation existed for this resident beyond the notes dated 04/21/25 and 01/02/26. A second resident, with diagnoses including aphasia following cerebrovascular disease, cerebral infarction, type II diabetes mellitus, unsteadiness on feet, difficulty in walking, coagulation defect, depression, and muscle weakness, also had multiple MDS assessments completed over the review period, including quarterly and annual assessments. The record contained a note that a care conference was offered to the resident’s representative, who declined to attend, but there was no documentation of any care conferences for the most recent 12 months. The Unit Care Coordinator confirmed that no other care conference documentation was available for this resident. Facility policy stated that periodic care conferences involving the resident, family, and the interdisciplinary team are part of the care planning process, but the required periodic care conferences and corresponding documentation were not completed for these two residents.
Plan Of Correction
THIS PLAN OF CORRECTION SERVES AS BERKELEY SQUARE'S CREDIBLE ALLEGATION OF SUBSTANTIAL COMPLIANCE AS OF June 1, 2026. Without admitting or denying the validity or existence of the alleged deficiencies, Berkeley Square provides the following Plan of Correction: F657 The facility will continue to document completion of care conferences at the required intervals for all residents, including residents #04 & #15. To ensure compliance with this standard the following measures have be taken: 1. The social service designee and the inter- disciplinary team were re-educated by the administrator to the facility policy "Care Conference" on 4/29/26 and verbalized understanding. 2. Care conferences for resident #04 and resident #15 were conducted on or before 4/29/2026 by the interdisciplinary team. 3. Review of all other residents was conducted by the social service designee to validate and ensure that care conference schedule is up to date with timely care conferences scheduled for them on 4/15/2026. Audits of care conferences to be completed weekly for four weeks and then monthly after that by the social service designee. Documentation of the care conference including any identified concerns in the medical record. Administrator to validate audits/compliance and provide additional training as needed. Administrator will present results of these audits to QAPI committee for ongoing monitoring and further direction.
Failure to Reevaluate Blood Glucose After Treatment for Hyperglycemia
Penalty
Summary
The facility failed to ensure that a resident with diabetes received treatment in accordance with professional standards of practice when nursing staff did not reevaluate the resident's blood glucose after treatment for severe hyperglycemia. The resident, admitted with diagnoses including Alzheimer's disease, type II diabetes mellitus, and depression, had physician orders for Humalog insulin on a sliding scale before meals, Lantus insulin 25 units daily, and lisinopril 5 mg daily. The resident required extensive assistance with activities of daily living, including transfers, toileting hygiene, eating, and bathing. On the evening in question, the resident's blood glucose was documented as 532 mg/dL, and the on-call provider was notified. The provider gave a new order to administer an additional 8 units of lispro (Humalog) and to recheck the blood glucose in 30 minutes. The electronic medication administration record showed that the blood glucose of 532 mg/dL was obtained at 9:00 p.m. and that the additional 8 units of lispro were administered at 9:21 p.m. However, there was no documentation in the resident's chart that the blood glucose was rechecked after the additional insulin was given. In an interview, the DON confirmed there was no evidence of reevaluation and verified that, according to the facility's "Abnormal Blood Glucose Procedure" policy, the resident should have been reevaluated and that the evaluation step should have been included in the progress note documentation.
Plan Of Correction
F684 The facility will continue to ensure all residents, including #03, receive treatment in accordance with professional standards of practice and reevaluated for hyperglycemia. To ensure compliance with this standard the following measures have been taken: 1. The director of nursing assessed resident #03, reviewed documentation and orders and found no ill effects immediately 4/16/26. 2. All licensed nurses were re-educated to facility policy "Blood Glucose Monitoring" by the Director of Nursing/designee in April 2026. 3. Audits of like-residents that require blood sugar checks to be completed by the director of nursing/designee two times a week for 4 weeks and then monthly after that to validate correct follow through when there is abnormally high blood glucose result. The Administrator will bring results of these audits to the QAPI committee for ongoing monitoring and further direction.
Failure to Act on Pharmacist Drug Regimen Recommendation for Thyroid Medication
Penalty
Summary
The deficiency involves the facility’s failure to ensure that pharmacy recommendations from the monthly drug regimen review were acted upon and documented for a resident. The resident was admitted with diagnoses including Parkinson’s disease, dementia, and hypothyroidism, and had current physician orders for levothyroxine 150 mcg once daily, buspirone 50 mg twice daily, and losartan 100 mg once daily. A medication regimen review dated 11/25/2025 included a consultant pharmacist recommendation that levothyroxine be administered consistently in the morning on an empty stomach, at least 30–60 minutes before food, per manufacturer instructions. There was no specific physician response in the medical record to this recommendation, and the facility’s policy stated that consulting pharmacist reviews are sent to nursing and addressed with the primary care provider or consulting specialist for review and follow-up. Review of the resident’s medication administration record for April 2026 showed levothyroxine scheduled for 9:00 a.m. On observation, the resident was seen eating breakfast in the dining area at 8:03 a.m., and an LPN reported administering the levothyroxine 150 mcg to the resident while the resident was in the dining area eating breakfast. The DON confirmed there was no evidence in the resident’s medical record explaining why the consultant pharmacist’s recommendation from 11/25/2025 was or was not acted upon. This lack of documented physician review and action on the pharmacist’s identified irregularity constituted noncompliance with the drug regimen review requirements.
Plan Of Correction
F756 The facility will continue to ensure the pharmacy recommendations from the monthly drug regimen review by a licensed pharmacist are acted upon for all residents, including #08. To ensure compliance with this standard the following measures have been taken: 1. Resident #08 was assessed by the registered nurse and med review completed by 4/28/26. After review of resident's drug regime's, it was discovered that resident #8 had 2 separate medication recommendations on the same form, to be reviewed by two separate practitioners, pharmacy has been instructed and agreed to separate meds on individual forms. 2. Licensed nurses re-educated to facility policy "Drug Regimen Review" by Director of nursing/designee in April 2026 and no later than 5/8/26. Licensed nurses are responsible for ensuring the reviews and recommendations are given to the physician for timely review. 3. Review of all other current residents Drug Regimen orders completed by Director of nursing/designee on 4/16/26 to ensure recommendations were followed up on/reviewed by the physician and address concerns if needed. 4. Audit of drug regime recommendations, pharmacy recommendations, and physician follow up to be completed weekly for four weeks by the Director of nursing/designee. Administrator will present results of these audits to the QAPI committee for ongoing monitoring and further direction.
Failure to Use Required Gait Belt During Ambulation Resulting in Resident Fall
Penalty
Summary
The deficiency involves the facility’s failure to ensure that a required gait belt was used while assisting a high fall‑risk resident with ambulation, resulting in a fall with head injury. The resident had multiple diagnoses including metabolic encephalopathy, hypertension, osteoarthritis, muscle weakness, gait and mobility abnormalities, major depressive disorder, anxiety, and visual hallucinations. Admission and subsequent MDS and fall risk assessments documented that the resident was severely cognitively impaired, required moderate to maximal assistance with transfers and ambulation, could not independently come to a standing position, exhibited loss of balance while standing, used an assistive device, and had decreased muscle coordination. The resident had a history of falls prior to admission and was assessed as being at high, later moderate, risk for falls. The resident’s fall care plan identified her as at risk for falls and included interventions such as providing maximum to moderate assistance with transfers and walking short distances, use of a walker and wheelchair, and following the facility’s fall protocol. Therapy notes and care conference documentation indicated that the resident leaned backwards when standing, required contact guard to minimal assistance for bed mobility and transfers, and needed constant verbal cueing for safe sequencing during toilet transfers. The physical therapist confirmed that the resident was to use a gait belt with staff when ambulating, and the DON verified that therapy had assessed the resident as requiring contact guard assistance and a gait belt for ambulation and transfers. On the day of the incident, a CNA was assisting the resident from her recliner to the bathroom using a walker. The CNA walked beside the resident, providing guidance and support, and reported having a hand on the resident while assisting her. As they approached the bathroom door, the CNA reached for the doorknob to open it, and at that moment the resident began to lose her balance and fell backwards to the floor, striking the back of her head. The nurse who responded found the resident on her back at the foot of the bed with her feet near the bathroom, noted a red raised area on the back of the head, and documented that the resident was not wearing a gait belt and that the gait belt was on the dresser. In the facility’s investigative summary and in interviews, the CNA acknowledged that she did not have a gait belt on the resident while ambulating her, despite the resident’s assessed need for hands‑on assistance and gait belt use per facility policy and the resident’s care and therapy plans.
Failure to Implement PD Orders and Monitor Resident Receiving Peritoneal Dialysis
Penalty
Summary
The deficiency involves the facility’s failure to implement pre-admission physician orders for peritoneal dialysis (PD) and to provide ongoing monitoring for a resident with chronic kidney disease (CKD) stage five who required PD. Pre-admission orders dated 11/14/25 specified three daily PD exchanges at 6:00 A.M., 2:00 P.M., and 10:00 P.M., and directed staff to monitor for signs and symptoms of peritonitis, including fever, abdominal pain, and cloudy effluent. These monitoring orders were not entered into the facility’s physician orders. The resident’s care plan noted the need for PD and included general monitoring interventions (labs, signs of bleeding, bacteremia, septic shock, and significant vital sign changes), but did not specifically address the ordered monitoring for peritonitis. Review of PD documentation showed incomplete and inconsistent charting of treatments and resident condition. The paper peritoneal flowsheet had columns for time of PD and condition/comments, including instructions to call the nurse immediately for cloudy fluid, abdominal pain, or fever. However, the first entry on 11/15/26 at 2:00 P.M. only noted that the PD nurse completed the exchange, and the 10:00 P.M. entry that day had no condition/comment documentation. Subsequent days (11/16/25, 11/17/25, and 11/18/25) contained only one condition/comment entry per day rather than for each exchange, and there was no documentation that the 6:00 A.M. PD on 11/18/25 was completed. The PD cycler flowsheet starting 11/19/25 lacked any description of the effluent on multiple days. The PD nurse from the dialysis company stated facility staff were expected to monitor effluent for cloudiness and assess for abdominal pain and fever, and the DON confirmed there was no electronic physician order for peritonitis monitoring or for use of the PD cycler, that the paper charting did not allow for effluent description or symptom documentation for each treatment, and that PD was not documented at one ordered time. The facility’s dialysis policy required ongoing assessment and monitoring for complications before, during, and after treatments, which was not reflected in the documentation for this resident.
Improper Infection Control During Medication Administration
Penalty
Summary
Surveyors identified a deficiency in infection prevention and control related to medication administration for Resident #29. The resident was admitted on 02/28/14 with diagnoses including depression, traumatic brain injury, and anxiety, and had impaired cognition per a quarterly MDS assessment. During an observation on 03/25/26 at 6:58 A.M., RN #281 prepared the resident’s medications by removing an Amoxicillin-Pot Clavulanate tablet from the medication card and pushing it directly into her ungloved hand, then using her fingers to place the pill into a medication cup. The same process was observed for multiple other medications, including Escitalopram Oxalate, Furosemide, Sennosides, Lyrica, and Vitamin D, each being pushed from the card into the RN’s ungloved hand and then transferred by her fingers into the medication cup before administration to Resident #29. In a subsequent interview at 7:27 A.M. the same day, RN #281 confirmed she had placed each medication into her ungloved hands prior to administration and acknowledged that the proper procedure was to push the pills directly from the card into the medication cup. Review of the facility’s “Medication Administration – General guidelines” policy, revised 10/08/25, stated that medications are to be administered in accordance with good nursing principles and practices. This practice failure was cited as a deficiency under Complaint Number 2681777.
Improper Use of Wheelchair as a Physical Restraint
Penalty
Summary
Surveyors identified a deficiency related to the facility’s failure to ensure a resident was free from physical restraints. Resident #7, admitted with diagnoses including Alzheimer’s disease, diabetes mellitus, and anxiety disorder, was documented on a recent MDS as rarely understood and dependent for ADLs except eating. The resident ambulated independently on the unit without an assistive device and had documented verbal and other behaviors occurring one to three days during the look-back period. The care plan noted the resident had potential to be physically aggressive, chase staff, throw objects, and be combative with care, with interventions such as offering choices, administering medications as ordered, and intervening early when agitation occurred. During an observation and interview, Resident #7 was found sitting in a chair with the right arm of the chair positioned against the nursing station and a wheelchair placed directly in front of him. The left arm of the wheelchair was also against the nursing station, and both wheelchair wheels were locked, creating a barrier that appeared to restrain the resident, who was sleeping with his knees touching the locked wheelchair. An LPN confirmed both wheelchair wheels were locked and that the wheelchair should not have been placed in front of the resident. A CNA reported she had placed the wheelchair there in preparation to get the resident up for lunch, was unable to transfer him, and left the wheelchair in that position, acknowledging it was wrong to keep it there. The facility’s physical restraint policy stated that physical restraints are not used except when alternatives are not appropriate or effective for treating a medical symptom and defined physical restraints as any device attached or adjacent to the body that the individual cannot easily remove and that restricts freedom of movement or access to the body.
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