Luxe Rehabilitation And Care Center
Inspection history, citations, penalties and survey trends for this long-term care facility in Lancaster, Ohio.
- Location
- 957 Becks Knob Road, Lancaster, Ohio 43130
- CMS Provider Number
- 365344
- Inspections on file
- 45
- Latest survey
- December 31, 2025
- Citations (last 12 mo.)
- 7
Citation history
Health deficiencies cited at Luxe Rehabilitation And Care Center during CMS and state inspections, most recent first.
Two residents experienced deficiencies in medical record documentation, including missing entries for wound care treatments and conflicting information about the type, location, and origin of pressure ulcers and MASD. Staff interviews confirmed that treatments were performed but not documented, and that care plans and wound assessments contained errors and contradictions regarding wound status.
Two nurses failed to don required PPE and perform proper hand hygiene while providing tracheostomy and PEG tube care to a resident on enhanced barrier precautions for invasive devices. Despite clear signage and available PPE, both entered the room and performed high-contact care without gowns or masks, and removed gloves without hand hygiene before touching supplies or leaving the room. Facility policy required these infection control measures, but they were not followed during the observed care.
The facility did not pay its food supply vendor on time, resulting in a missed food delivery and the need to alter menus until service resumed after payment. Staff interviews and records showed a significant outstanding balance, and the business office manager could not provide invoices or payment details. This deficiency impacted all residents.
A resident with intact cognition and a history of seizures reported feeling mistreated, but the facility did not conduct a thorough investigation as required. Although a skin check was performed and no injuries were found, there was no evidence that follow-up questions were asked to determine the specifics of the alleged mistreatment, and required interviews were not completed.
A resident with severe cognitive impairment and a history of schizophrenia was transferred to another SNF after a single elopement incident, but the facility failed to document the necessity of the transfer, why the resident's needs could not be met, or involve the legal guardian in the decision. The transfer was made to a facility far from the guardian, with no evidence of attempts to find a closer option or documentation of how the new facility would better meet the resident's needs.
A resident with severe cognitive impairment was transferred to another facility after an elopement incident, but the required written notice, including the reason for transfer, effective date, location, appeal rights, and Ombudsman contact information, was not provided to the resident's legal guardian. Facility staff confirmed that the transfer was facility-initiated and that proper documentation and notification were not completed as required by policy.
The facility did not ensure that required fall prevention interventions were in place for a resident with cognitive impairment and failed to provide adequate supervision and documentation when another resident with severe cognitive impairment eloped from the building. Staff were unaware of the procedures related to exit door security during fire panel alarms, and key safety interventions were not implemented as outlined in care plans and facility policy.
A resident with complex medical needs was found to have soiled bedrail padding and a wheelchair with visible stains and smears. An LPN and the DON confirmed the equipment was dirty and required cleaning, contrary to facility policy requiring a clean and sanitary environment.
A resident's responsible party was not included in the development or review of the resident's baseline care plan, as required. Medical records and staff interviews confirmed that neither the resident nor their POA participated in the initial care planning process, and no documentation or signatures were obtained to show their involvement.
A resident with dementia and a history of falls sustained a laceration after a fall, but the facility failed to promptly notify the correct Power of Attorney (POA) as required by policy, instead informing the resident's daughter. The appropriate representative was not notified until the following day, resulting in non-compliance with notification requirements.
Surveyors observed that the facility's medication error rate was 11.9%, exceeding the acceptable threshold. Errors included an LPN administering a chewable Aspirin tablet whole, another LPN giving a chewable Phenytoin tablet whole, and the same LPN crushing or opening delayed release and extended release medications before administration. These actions did not follow proper medication administration protocols as outlined in facility policy.
An LPN did not perform hand hygiene after checking a resident's blood pressure and before preparing medication for another resident. The LPN also handled dropped medication and removed pills from a medication cup with bare hands, contrary to facility policy prohibiting direct contact with medications to prevent contamination.
The facility failed to conduct federal background checks for new hires who had not lived in the state for five years and did not have a policy in place for such checks. Additionally, a resident reported feeling intimidated and verbally abused by staff, but the facility did not conduct a thorough investigation or report the incident to the state. The alleged perpetrators continued to work during the investigation, contrary to policy.
The facility failed to provide sufficient and adequately trained staff for food and nutrition services, affecting nearly all residents. Meal delivery was inconsistent, with breakfast and supper often served late. The Dietary Manager, also serving as Activity Director, confirmed operational challenges due to only one kitchen being used. Staff interviews revealed inadequate training and short-staffing, while residents reported dissatisfaction with late and cold meals. The Dietician confirmed insufficient staffing and cold test trays, and the Administrator acknowledged multiple resident complaints.
The facility failed to serve meals at regular times and according to resident preferences, affecting 137 residents. Breakfast and supper services were inconsistent, with meals served late and often cold. Staff shortages, equipment issues, and the use of only one kitchen contributed to the delays. Residents frequently complained about the late and cold meals, and the facility had not determined resident meal time preferences.
The facility did not employ a full-time, qualified social worker, affecting 139 residents. The Social Service Director had a degree in business administration, not in social work or a human services field. The last licensed social worker left in December 2024, and interviews confirmed the absence of a licensed social worker during the survey.
The facility failed to schedule activities for memory care residents, affecting all 21 residents in the unit and one outside of it. Observations showed no activities on weekends and delays during scheduled times due to staff being occupied with meal duties. Interviews confirmed activities were often late or not conducted as planned, causing frustration for residents.
A facility failed to provide adequate care for a resident with complex medical conditions, including heart failure and diabetes. The resident's blood pressure and blood sugar levels were not consistently monitored or reported to a physician, and vital signs were carried over from previous days without new measurements. The facility lacked a policy on vital sign monitoring, and the resident's condition was not adequately addressed, leading to a deficiency finding.
The facility failed to ensure safe smoking practices and did not assess residents for safe smoking, as required by their policy. Observations showed residents smoked on non-designated areas and disposed of cigarette butts unsafely. Interviews confirmed the lack of adherence to the smoking policy, which required residents to smoke off property. Additionally, smoking assessments were not conducted for residents with significant medical histories, as confirmed by the DON.
The facility failed to follow prescribed menus and serving sizes, affecting 11 residents. Staff used food packaging to determine serving sizes, leading to inconsistencies. Residents on various diets received incorrect portions, and some did not receive required food items. The dietary manager and dietician were unaware of the lack of printed menus with serving sizes, contributing to the oversight.
The facility failed to ensure meals were palatable and served at appropriate temperatures, affecting several residents. Observations showed that breakfast trays were not fully distributed until 45 minutes after delivery, resulting in cold food. Interviews with residents and staff confirmed frequent complaints about cold meals, and a test tray confirmed food temperatures were below required standards. The facility's policy on food temperatures was not adhered to, and the issue was investigated under specific complaint numbers.
A resident with severely impaired cognition and on a pureed diet due to food pocketing received regular texture pineapple during lunch service, contrary to dietary orders. An LPN confirmed the error and removed the pineapple, but the resident later received another bowl of regular texture pineapple, possibly from another resident. The resident did not eat any food during the observation.
The facility failed to notify representatives of significant changes in two residents' conditions. One resident, with a complex medical history, was not reported to family about declining vital signs before passing away. Another resident's POA was not informed about changes in swallowing ability and diet modification. The facility's policy on notifying representatives was not followed.
A resident with multiple health conditions reported feeling intimidated and verbally abused by staff, which was not reported to the state survey agency as required. The facility's policy mandates immediate notification of abuse allegations, but this was not followed, and the resident was not interviewed about the incident.
A facility failed to thoroughly investigate an abuse allegation involving a resident who felt intimidated and verbally abused by three staff members, including two CNAs and an LPN. The resident reported that the abuse stopped after being moved to a different room. The facility did not document interviews with the resident or other potential witnesses, and the alleged perpetrators continued to work during the investigation. The facility's policy required immediate removal of accused staff, but this was not followed, resulting in a deficiency.
The facility failed to ensure medications were available for two residents as per physician orders. A resident's Vitamin D2 was unavailable during administration, and another resident's Mucinex DM ER and fexofenadine were also not available. The DON and ADON confirmed the unavailability of these medications, which were supposed to be provided by the pharmacy or as stock medications.
A resident with severe cognitive impairment and a history of hypertension was inappropriately administered Midodrine despite blood pressure readings exceeding the physician's parameters. An LPN failed to adequately check the resident's blood pressure before administering the medication and did not recheck it until much later, leading to a deficiency in ensuring the resident's drug regimen was free from unnecessary medications.
A resident with intact cognition was found to have been self-administering Breo Ellipta and Flonase without a physician's order, storing them in an open basket in her room. An LPN discovered the issue during medication administration, and the Assistant DON confirmed the resident should not have had the medications without proper authorization.
A resident admitted with osteomyelitis did not receive timely antibiotic treatment or necessary lab monitoring due to a failure in processing hospital discharge orders. The resident's first doses of IV antibiotics were delayed, and required lab tests were not conducted as scheduled, leading to Vancomycin toxicity and acute kidney injury. The resident was transferred to the hospital for treatment after a critically high Vancomycin level was detected.
The facility's medication error rate was 14.8%, exceeding the acceptable threshold. Two residents were affected: one did not receive a prescribed inhaler due to its unavailability, and another did not receive two medications and had insulin administered without proper priming. LPNs confirmed the errors, which were against facility policy.
The facility failed to obtain vital signs and complete a transfer form for a resident experiencing a change in condition, leading to incomplete documentation during hospital transfer. Additionally, another resident did not have daily weights monitored as required post-surgery, with the order for daily weights being missed upon admission and inconsistently recorded thereafter.
Two residents in an LTC facility suffered harm due to inadequate assessment and intervention for pressure ulcers. One resident developed a Stage III ulcer due to improper boot application and lack of off-loading, while another's heel ulcer deteriorated to unstageable due to insufficient care planning and staff awareness. The facility failed to follow its pressure ulcer prevention policy, affecting the quality of care.
A resident in a manual wheelchair was not properly secured with torso and pelvic seat belts during transport in the facility's bus, leading to a fall and injuries, including a left femoral shaft fracture and a left great toe fracture. Despite the resident's known fall risk and complex medical history, the transport driver failed to secure the resident correctly, and the accompanying STNA was not trained in the new bus's securing procedures.
The facility failed to properly prepare pureed foods, affecting nine residents on pureed diets. Observations showed a staff member inadequately blending hotdogs, buns, and other foods, resulting in incorrect textures. The facility's policy on therapeutic diets was not followed.
The facility's kitchen was found to be unsanitary, with flies, dirty garbage cans, expired food, and improperly stored items. Observations included grime on surfaces, inadequate sanitizer concentration, and flies landing on utensils. Interviews confirmed these issues, and the facility's policies on cleanliness and pest control were not followed.
The facility failed to provide adequate hydration for three residents, as they did not receive the required daily fluid intake and lacked fluids at the bedside. Additionally, a resident experienced significant weight loss due to inconsistent recording of weekly weights. Staff interviews confirmed the residents' inability to request fluids and the need for assistance with intake.
The facility failed to ensure cleanliness and pest control in the kitchen, affecting meal service for nearly all residents. Observations revealed flies and gnats in the pantry, uncovered and dirty garbage cans, and dirty hot-wells with dead flies. Flies were also seen landing on clean utensils used for food preparation. The Dietary Manager confirmed these issues, and the facility's pest control policy was not followed.
The facility failed to maintain resident rooms and mobility devices, affecting four residents. Issues included non-functional lighting, unclean ceilings, damaged walls, and cracked wheelchair armrests. Maintenance reports did not document these issues, indicating a lapse in the repair process.
A resident with multiple health conditions, including dementia and muscle weakness, was unable to maneuver easily in their room due to insufficient space between their bed and dresser. This deficiency was confirmed by an LPN, and the facility did not provide a policy on accommodating physical needs when requested.
A resident with intellectual disabilities and depression reported missing personal items, including a teddy bear, which were not documented or located by the facility. Despite staff awareness, the facility did not follow its procedure for missing items, and no policy was provided when requested.
A resident with intellectual disabilities reported being hit by an aide, but the facility failed to investigate the allegation. Despite the resident's complaint and an LPN's report to management, the incident was dismissed as a misunderstanding, and no formal investigation was conducted, violating the facility's abuse policy.
A facility failed to accurately complete a level one PASARR for a resident, omitting a psychosis disorder from the serious mental illness section requiring a level two review. The resident had severe cognitive impairment and was diagnosed with a psychotic disorder, but this was not indicated in the PASARR completed by the BOM. The omission was confirmed during an interview with the BOM.
A facility failed to accurately complete a PASRR for a resident with multiple diagnoses, including bipolar disorder and epilepsy. The PASRR did not reflect the resident's mental health conditions, as it omitted several diagnoses. The Business Office Manager indicated that the PASRR was based on hospital information, leading to the oversight. Facility policy mandates screening for mental disorders and intellectual disabilities upon admission and with any psychiatric diagnosis changes.
The facility failed to involve a resident in care planning conferences and did not update another resident's nutritional care plan to include a PEG tube for enteral nutrition. One resident was not invited to care planning meetings, and their record lacked evidence of interdisciplinary care conferences. Another resident's care plan was not revised to reflect the use of a PEG tube, despite having orders for enteral nutrition. An RN confirmed the oversight in updating the care plan.
A facility failed to date and time enteral feeding bottles for a resident receiving nightly tube feedings. The resident, with conditions including Parkinson's and severe malnutrition, had a physician's order for Osmolite 1.5 cal via PEG tube. Observations showed bottles left hanging without date or time, confirmed by an LPN, affecting the ability to ensure freshness as bottles are only good for 24 hours after being spiked.
The facility failed to provide appropriate respiratory care for two residents. One resident received oxygen without a physician's order, while another received a higher oxygen flow rate than prescribed. Staff confirmed these discrepancies, which were not in line with the facility's policy requiring verification of physician orders and correct flow rates.
The facility failed to conduct ordered laboratory tests for two residents. One resident did not receive quarterly tests for diabetes and medication levels, while another resident did not have a basic metabolic panel done within the required timeframe after admission. The oversight was confirmed by the DON and an LPN, who acknowledged the missed orders and delayed testing.
A resident with a history of dementia and chronic kidney disease was observed with their indwelling urinary catheter bag on the floor, contrary to facility policy. An LPN verified the observation and instructed an aide to correct it. The resident's care plan was not updated to address this issue until after the incident was noted.
A resident with a complex medical history was administered antibiotics for a UTI without waiting for culture and sensitivity results, contrary to the facility's Antibiotic Stewardship policy. An LPN confirmed the premature administration of antibiotics, highlighting a deficiency in adhering to the facility's guidelines.
A resident with severe cognitive deficit and multiple health issues was repeatedly observed in a hospital gown instead of personal clothing, compromising her dignity. An LPN confirmed this practice was due to the resident's incontinence, despite facility policy emphasizing the importance of dressing residents in their preferred clothing to promote dignity.
Incomplete and Inaccurate Medical Record Documentation for Wound Care
Penalty
Summary
The facility failed to ensure that residents' medical records were complete and accurate, specifically regarding the documentation of wound care and the identification of pressure ulcers. For one resident, review of the treatment administration record (TAR) revealed that a nurse did not document completion of required tracheostomy and PEG tube site care on several night shifts. The nurse later confirmed that the treatments were performed but had not been documented in the electronic TAR, leaving several entries blank for those dates. The Director of Nursing verified that the nurse was responsible for the missing documentation and acknowledged that the medical record was incomplete until the nurse retroactively initialed the TAR. Another resident's medical record contained conflicting and inaccurate information regarding the type, location, and origin date of skin impairments, including a Stage II pressure ulcer and moisture-associated skin dermatitis (MASD). The care plans for this resident contradicted each other, with one indicating a Stage II ulcer and MASD on the left buttock and the other indicating these conditions on the right buttock. Additionally, a wound assessment incorrectly stated that the pressure ulcer was present on admission and listed an incorrect origin date. Progress notes from the wound nurse practitioner also misidentified the locations of the wounds, which was later clarified through an addendum after the discrepancies were discovered. Interviews with facility staff, including the wound nurse and the DON, confirmed that the medical records did not accurately reflect the residents' wound status, locations, and dates of origin. Staff acknowledged ongoing issues with proper documentation and data entry in the electronic medical record system, leading to incomplete and conflicting information in the residents' records.
Failure to Use PPE and Perform Hand Hygiene During Tracheostomy and PEG Tube Care
Penalty
Summary
The facility failed to ensure that appropriate personal protective equipment (PPE) was worn and proper hand hygiene was performed during the care of a resident with a tracheostomy and a percutaneous endoscopic gastrostomy (PEG) tube, who was under enhanced barrier precautions (EBP) due to the presence of medically invasive devices. During an observation, two nurses, an LPN and an RN, entered the resident's room, which was clearly marked for EBP and had PPE available outside the door, but neither donned any PPE before providing tracheostomy and PEG tube care. The resident, who had diagnoses including acute and chronic respiratory failure and required regular tracheostomy and PEG tube care, was observed coughing during the procedure, which included suctioning and removal of the inner cannula. After removing the resident's inner cannula, the LPN removed her gloves without performing hand hygiene and searched through supplies in the room with bare hands. The RN, after removing the old split gauze dressing from the PEG tube site, also removed her gloves without performing hand hygiene before leaving the room to retrieve a needed supply. Both nurses only performed hand hygiene upon the RN's return to the room, prior to resuming care. Interviews with both nurses confirmed their awareness of the EBP requirements and the need for PPE and hand hygiene, but acknowledged that these protocols were not followed during the observed care. Review of facility policies confirmed that EBP required gown and gloves for high-contact care and that hand hygiene was mandated after glove removal and before handling invasive devices or environmental surfaces. The failure to adhere to these protocols was observed and confirmed through staff interviews, record review, and policy review, affecting one resident who required enhanced infection prevention measures due to his medical condition.
Failure to Ensure Timely Payment to Food Vendor Resulting in Disrupted Food Deliveries
Penalty
Summary
The facility failed to administer its operations in a manner that ensured effective and efficient use of resources, specifically regarding compliance with financial obligations necessary for the delivery of care. Review of the facility's open payables log and interviews revealed that the facility did not pay its food supply vendor, resulting in a missed food delivery. Staff confirmed that the food delivery truck did not arrive as scheduled, and the menu had to be altered due to unavailable planned menu items. The food delivery service resumed only after a payment was made, but there was a period during which the facility operated without its regular food supply schedule. Further investigation showed that the business office manager was unable to provide invoices or details on the amounts owed to the food vendor, and the facility's records indicated a significant outstanding balance to the food supplier. The administrator's job description included responsibilities for ensuring compliance with regulations and managing vendor contracts, but there was a lack of evidence that these duties were fulfilled in relation to the food supply payments. This deficiency affected all 133 residents in the facility.
Failure to Thoroughly Investigate Alleged Abuse
Penalty
Summary
The facility failed to conduct a thorough investigation following an allegation of abuse involving Resident #131, who had diagnoses including seizures and other specified brain disorders and was noted to have intact cognition and no behaviors. Upon review of a self-reported incident, it was found that while a questionnaire indicated the resident felt mistreated, there was no documentation of follow-up questions to clarify the nature, timing, or circumstances of the alleged mistreatment. The Director of Nursing confirmed that although a skin check was performed with no findings, no further inquiry was made to determine details of the alleged mistreatment. Facility policy required that residents on the same unit and the resident making the allegation be interviewed, but this was not fully carried out.
Failure to Document and Justify Resident Transfer/Discharge
Penalty
Summary
A deficiency occurred when the facility failed to provide evidence that a transfer from the facility was necessary for a resident's welfare and that the resident's needs could not be met in the facility. The resident involved had diagnoses including schizophrenia, hypertension, benign neoplasm of cranial nerves, and hearing loss, with a legal guardian who was his brother. The resident had severe cognitive impairment and was independent with mobility, with no prior history of elopement until a single incident occurred when the resident exited the facility during a fire alarm. The facility's root cause analysis identified a lack of staff education regarding supervision during fire alarms, as all exit doors became unlocked during such events. Following the elopement incident, the facility initiated a referral to another nursing facility located approximately 170 miles away. Documentation in the medical record was lacking regarding the basis for the transfer, why the resident's needs could not be met at the current facility, or any attempts to address those needs. There was also no documentation explaining how the receiving facility could better meet the resident's needs or was different from the current facility, which also had locked doors. The discharge paperwork did not specify the details of the transfer, and there was no evidence of physician documentation supporting the necessity of the transfer or outlining the specific services the new facility would provide. The resident's guardian was not involved in the selection of the receiving facility and expressed that he did not want the resident to move, citing the distance as a barrier to visitation. The guardian reported feeling that the decision had already been made by the facility and that he was not given a choice. Facility staff interviews confirmed that there was no documentation related to the decision-making process for the transfer, the resident's unmet needs, or efforts to find a facility closer to the guardian. The facility's policy required proper documentation and involvement of the resident or representative, which was not followed in this case.
Failure to Provide Required Transfer Notice and Appeal Rights Prior to Resident Discharge
Penalty
Summary
The facility failed to provide the required written notice to a resident and their legal guardian prior to transferring the resident to another nursing facility. The resident, who had severe cognitive impairment and multiple medical diagnoses, was involved in an elopement incident when he exited the building while the fire alarm was sounding and was subsequently returned by staff. Following this event, a referral was made to transfer the resident to a sister facility located approximately 170 miles away, which was described as having a more secure environment suitable for mental health needs. Documentation in the medical record did not include the required details regarding the transfer, such as the reason for transfer, effective date, location, appeal rights, or Ombudsman contact information. The discharge recap form indicated that notice was given to the resident or representative, but there was no evidence that the guardian received the required written notice or information about appeal rights prior to the transfer. Interviews with facility staff confirmed that the decision to transfer was initiated by the facility, and that the required documentation and notifications were not provided or properly recorded in the medical record. The resident's guardian reported that he was not given a choice in the transfer, was not provided with a discharge notice, and did not receive information on how to appeal or contact the Ombudsman. He also expressed concern about the distance to the new facility and the quality of care there. Facility policy requires written notice at least 30 days in advance of a planned discharge or transfer, including information about appeal rights, but this was not followed in this case.
Failure to Implement Fall and Elopement Prevention Measures
Penalty
Summary
The facility failed to ensure that accident prevention interventions were in place for two residents, resulting in deficiencies related to fall prevention and elopement. For one resident with dementia, muscle weakness, and moderately impaired cognition, the care plan included specific fall prevention interventions such as keeping a urinal at bedside, placing a bedside toilet in the room, and posting a 'please call don't fall' sign. However, during observation, none of these interventions were present in the resident's room, and the DON confirmed that the fall prevention measures were not in place at the time of the survey. Another resident with severe cognitive impairment and a history of schizophrenia eloped from the facility. The resident was found missing during staff rounds, and was later located and returned by a staff nurse who saw him walking outside. The facility's investigation revealed that the resident exited through a door that was unlocked while the fire panel was alarming. Staff interviews indicated a lack of awareness regarding the unlocking of exit doors during fire panel alarms, and there was inconsistent documentation and statements about the timing and awareness of the elopement. The medical record contained minimal documentation about the incident, and a statement from the nurse responsible for the resident was not obtained. The facility's policies required documentation and investigation of missing residents and the implementation of interventions to prevent accidents. However, the failure to implement and maintain required safety interventions for fall prevention, as well as inadequate supervision and documentation related to the elopement, led to non-compliance with accident prevention standards. These deficiencies were identified through observations, record reviews, and staff interviews.
Failure to Maintain Clean and Sanitary Resident Equipment
Penalty
Summary
Staff failed to maintain clean and sanitary resident equipment for a resident with multiple complex medical diagnoses, including metabolic encephalopathy, mood affective disorder, heart transplant, cardiomyopathy, and frontotemporal neurocognitive disease. The resident, who utilized a wheelchair, had previously sustained a skin tear to the left eyelid after hitting his face on a bedrail, leading staff to place white cloth bandage padding on the bedrails as an intervention. During observations, surveyors noted that the white padding on the right side of the bedrail had a visible rust-colored stain, and the wheelchair had white cloth bandage wraps with a large patch of brown substance on the right side of the frame. The wheelchair cushion also had black and brown smears. Interviews with an LPN and the DON confirmed the presence of these stains and that nursing staff were responsible for cleaning resident equipment as needed. Facility policy required maintaining a clean, sanitary, and orderly environment, but this was not followed in this instance.
Failure to Involve Responsible Party in Care Planning
Penalty
Summary
The facility failed to ensure that a resident's responsible party participated in the development and implementation of the resident's person-centered care plan. Medical record review showed that the baseline care plan for a resident with diagnoses including heart disease, acute and chronic respiratory failure, seizures, and COPD was not reviewed with the resident or their Power of Attorney (POA) as required. Staff interviews confirmed that there was no documentation or signature indicating the POA was informed or involved in the initial care planning process, despite the facility's usual practice of obtaining such signatures to demonstrate participation.
Failure to Notify Correct Resident Representative After Fall
Penalty
Summary
A deficiency occurred when the facility failed to notify the appropriate resident representative, specifically the Power of Attorney (POA), following a fall incident involving a resident with dementia, cognitive communication deficit, and schizoaffective disorder. The resident, who was at risk for falls and had interventions in place to mitigate this risk, experienced a fall resulting in a forehead laceration. The incident was documented by nursing staff, and the resident's daughter was notified of the fall, despite the medical record indicating that the resident's wife was the designated POA. The facility's policy required that the resident's physician and responsible party be notified after a fall. However, the correct representative was not informed until the day after the incident, as confirmed by staff interviews and record review. This lapse in timely notification of the POA constituted non-compliance with facility policy and regulatory requirements for notification of changes affecting residents.
Medication Error Rate Exceeds Acceptable Threshold Due to Improper Administration
Penalty
Summary
The facility failed to maintain a medication error rate below 5%, as evidenced by 5 medication errors out of 43 administrations, resulting in an 11.9% error rate. During medication administration observations, one LPN gave a resident an 81 mg chewable Aspirin tablet along with other medications, without ensuring it was chewed as intended. The LPN confirmed that the chewable tablet was not separated and was consumed whole. In another instance, a different LPN administered all medications, including a chewable Phenytoin 150 mg tablet, whole and at the same time, rather than ensuring the chewable tablet was chewed, as confirmed by the LPN. Additionally, the same LPN was observed administering medications to another resident by crushing all ordered medications or opening capsules and mixing them with pudding. The resident's orders included delayed release and extended release medications, which the LPN confirmed were not to be crushed or opened, as this could alter their absorption. Review of the facility's medication administration policy indicated the need to double-check the right medication, dose, route, and time, but the observed practices did not align with these requirements.
Failure to Maintain Infection Control During Medication Administration
Penalty
Summary
During a medication administration observation, an LPN failed to follow infection control protocols for three residents. After checking one resident's blood pressure, the LPN did not perform hand hygiene before preparing medication for the next resident. The LPN was also observed dropping medication onto the medication cart, then picking it up with an ungloved hand and placing it back into the medication cup for administration. Additionally, the LPN used an ungloved hand to remove medication from the cup prior to crushing it for administration. These actions were confirmed during an interview with the LPN, who acknowledged not performing hand hygiene and handling medication without gloves. Review of the facility's policy indicated that pills should never be touched with bare hands to prevent contamination.
Failure to Conduct Background Checks and Investigate Abuse Allegations
Penalty
Summary
The facility failed to complete required federal criminal background checks for new employees who had not lived in the state for the last five years. This oversight was identified through a review of the facility's Bureau of Criminal Investigation log and personnel records, which showed that nine new hires did not have federal background checks completed. Additionally, the facility's new hire application form lacked a section to determine if applicants had lived in the state for the required period, and there was no specific policy in place for conducting federal background checks. Interviews with the Human Resources Director and the Administrator confirmed these deficiencies. The facility also failed to implement its abuse policy effectively in the case of a resident who reported feeling intimidated and verbally abused by staff. The resident, who had a range of complex medical conditions including hepatic failure and major depressive disorder, reported feeling intimidated by three staff members. Despite this, the facility did not conduct a thorough investigation, as evidenced by incomplete documentation and a lack of interviews with other residents or staff. The alleged perpetrators continued to work during the investigation, contrary to the facility's policy of placing staff on administrative leave during such investigations. The facility's policy required immediate removal of staff accused of abuse and notification of the state department of health, neither of which occurred in this case. The Administrator confirmed that the investigation was incomplete and that the incident was not reported to the state as required. The resident confirmed feeling intimidated and that the abuse ceased only after being moved to a different room, away from the staff involved.
Inadequate Staffing and Training in Dietary Services
Penalty
Summary
The facility failed to provide sufficient staff with the necessary competencies and skills to effectively carry out the functions of the food and nutrition services, affecting 137 of 139 residents. Observations revealed that meal delivery was inconsistent, with breakfast trays being delivered late and supper sometimes served as late as 8:00 P.M. The Dietary Manager, who also served as the Activity Director, confirmed that only one kitchen was operational, leading to delays in meal service. The facility lacked specific meal times for each hallway, and the dietary staff were not adequately trained, as evidenced by the absence of training records for new hires on diet types and menu usage. Interviews with staff and residents highlighted the issues with meal service. An LPN noted the lack of a set schedule for meal delivery, while dietary staff reported being short-staffed and untrained, resulting in delays and errors in meal preparation. Residents expressed dissatisfaction with the late and cold meals, with one resident noting that supper was served as late as 8:30 P.M. The Administrator acknowledged multiple resident complaints about late meals and cited issues such as a locked kitchen, a ceiling leak, and a non-functional dishwasher as contributing factors. The Dietician, who visited the facility twice a week, confirmed that test trays often revealed cold food and that the facility did not have enough staff to operate both kitchens. The Dietary Manager admitted feeling overwhelmed by her dual roles and unable to provide adequate support to her staff. The facility's monitoring of meal service times showed consistent delays, and the lack of resident preference determination for meal times further compounded the issue. This deficiency was investigated under Complaint Number OH00161227.
Inconsistent Meal Service Times and Cold Food
Penalty
Summary
The facility failed to ensure meals were served at regular times and in accordance with resident needs and preferences, affecting 137 of 139 residents. Observations revealed that breakfast service was inconsistent, with meal carts arriving late and meals being served over an extended period. The Dietary Manager confirmed that there was no set schedule for meal delivery, and the facility was operating with only one kitchen, causing delays in meal service. Additionally, there were instances where supper was served as late as 8:00 P.M., and residents reported receiving cold food. Staff interviews highlighted several operational challenges contributing to the deficiency. The Dietary Manager, who also served as the Activity Director, acknowledged the lack of specific meal times and insufficient dietary staff to operate both kitchens. Staff shortages and equipment issues, such as a non-functioning dishwasher, further exacerbated the delays. The Administrator noted that resident preferences for meal times had not been determined, and the facility had only recently begun monitoring meal service times. Interviews with residents and staff indicated frequent complaints about late meals and cold food. The Dietician confirmed that test trays often revealed cold hot foods and noted that the facility lacked sufficient staff to operate both kitchens. The deficiency was investigated under Complaint Numbers OH00161464 and OH00161227, with the facility's meal service practices failing to meet the needs and preferences of the residents.
Facility Lacks Qualified Social Worker
Penalty
Summary
The facility failed to employ a full-time, qualified social worker, which is a requirement for facilities with more than 120 beds. This deficiency potentially affected all 139 residents in the facility. The Social Service Director, hired on July 22, 2022, held a bachelor's degree in business administration, not in social work or a human services field as required. The last licensed social worker was employed from September 23, 2024, to December 6, 2024, but was no longer with the facility. Interviews with the Social Service Director and the Administrator confirmed the absence of a licensed social worker at the time of the survey. This deficiency was identified during a complaint investigation.
Failure to Schedule Activities for Memory Care Residents
Penalty
Summary
The facility failed to schedule activities to meet the needs of residents in the memory care unit, affecting all 21 residents in that unit and one resident outside of it. Observations and reviews of the activity calendars from November 2024 to January 2025 revealed that no activities were scheduled for weekends in the memory care unit. On January 15, 2025, no activities were observed in the memory care unit during scheduled times, and staff were occupied with breakfast and morning hygiene routines instead. Similarly, in the non-memory care unit, activities were not occurring as scheduled, with staff assisting with meal duties instead. Interviews with activity assistants and the activities director confirmed that activities were delayed or not conducted as scheduled due to staff being overwhelmed with meal duties and other responsibilities. The activities director admitted to prioritizing activities in other parts of the building due to limited staff and confirmed that activities were often late because of the time taken to serve meals. A resident expressed frustration over activity delays, which sometimes required her to wait in her wheelchair for extended periods, causing discomfort. The deficiency was investigated under Complaint Number OH00161522.
Failure to Provide Adequate Care and Notify Physician of Changes
Penalty
Summary
The facility failed to ensure adequate treatment and care for a resident, Resident #145, who was admitted with multiple complex medical conditions, including systolic heart failure, diabetes, and a gastrostomy tube. Upon admission, the resident had specific physician's orders for insulin administration and blood sugar monitoring, but there were no parameters set for notifying the physician about abnormal blood sugar levels. The resident's blood pressure readings were inconsistently documented, with some readings being carried over from previous days without new measurements being taken. On one occasion, a low blood pressure reading was not followed up with a recheck or physician notification. On 12/17/24, the resident's blood pressure was significantly lower than previous readings, but there was no evidence of physician notification or further action taken. The resident's blood sugar levels were also elevated, reaching 380 mg/dl on 12/19/24, yet the physician was not notified. The resident was receiving morphine for pain, and vital signs were not consistently monitored or documented. The LPN on duty attempted to take the resident's blood pressure but was unable to obtain a reading due to an error with the machine and did not follow up with a manual check or notify the physician. The Director of Nursing confirmed that the facility lacked a policy on vital sign monitoring, although the procedure was to take vital signs every shift for Medicare-skilled residents. The facility's policy on diabetes management required physician orders for glucose monitoring parameters, which were not in place for Resident #145. The deficiency was identified during an investigation of a complaint, highlighting the facility's failure to provide adequate care and notify the physician of significant changes in the resident's condition.
Failure to Ensure Safe Smoking Practices and Assessments
Penalty
Summary
The facility failed to ensure that residents followed safe smoking provisions and did not assess residents for safe smoking prior to smoking while residing in the facility. Observations revealed that used cigarette butts were found in trash cans on the front porches of the buildings, which were not designated smoking areas. The trash cans were lined with plastic bags, making them unsafe for disposing of smoking materials. Interviews with the administrator and a resident confirmed that residents smoked on the front porches and disposed of cigarette butts in the trash cans, contrary to the facility's policy that required residents to sign out and go off property to smoke. The facility's smoking policy, dated November 2024, stated that residents' right to smoke would be respected, and a safe environment would be maintained, with the policy reviewed with residents upon admission and annually. The facility also failed to conduct smoking assessments for residents who smoked, as required by their policy. Residents identified as smokers, including those with significant medical histories such as COPD, heart failure, and chronic respiratory conditions, had not been assessed for safe smoking since their admission. The Director of Nursing confirmed that smoking assessments were not completed upon admission or quarterly thereafter for the residents involved. The facility's smoking policy required that residents be assessed on admission, quarterly, and as needed to determine if they were safe to smoke independently or required supervision and adaptive equipment. This deficiency was investigated under Master Complaint Number OH00161522.
Failure to Follow Prescribed Menus and Serving Sizes
Penalty
Summary
The facility failed to ensure that menus were followed, affecting 11 residents who received nutrition from the kitchen. The surveyor observed that the facility did not provide specific food items or serving sizes for various diets, including mechanical soft, pureed, and finger foods. Staff used the packaging of food items to determine serving sizes, which led to inconsistencies in meal preparation. For instance, residents on regular, mechanical soft, and finger food diets received three ounces of peas and carrots instead of the required four ounces. Additionally, residents on finger food diets did not receive mashed potatoes or a substitute, and a resident on a pureed diet received tomato soup instead of pureed peas and carrots. The dietary manager and dietician were unaware that staff did not have access to menus with serving sizes. The dietician confirmed that the new menu system implemented in December 2024 should have included printed menus with serving sizes for staff use. However, these were not available, leading to reliance on recipes that did not specify the necessary food items or quantities for different diets. The dietary manager, who had recently assumed the role, and the dietician, who visited the facility twice weekly, did not monitor meal tray preparation, contributing to the oversight. Specific residents were affected by these deficiencies. Resident #86, with severe cognitive impairment and on a pureed diet, did not receive the appropriate vegetables as per the menu. Similarly, Resident #25, also with severe cognitive impairment and on a pureed diet, did not receive pureed green beans or a replacement. These deficiencies were part of a broader issue investigated under Master Complaint Number OH00161522 and Complaint Number OH00161227, highlighting the facility's failure to meet the nutritional needs of its residents as per the prescribed menus.
Deficiency in Meal Temperature and Palatability
Penalty
Summary
The facility failed to ensure that meals were palatable, appetizing, and served at appropriate temperatures, affecting six residents who were interviewed about food temperatures and palatability. Observations on a specific date revealed that the breakfast meal cart was delivered to the hallway at 9:10 A.M. but was not fully distributed until 9:55 A.M., resulting in food being served cold. A test tray confirmed that the food was not at the required temperatures, with items like hash browns and scrambled eggs measuring significantly below the standard for hot foods. Interviews with residents and staff confirmed that cold food was a frequent issue, and the facility had received multiple complaints about this problem. The facility's policy requires that hot foods be maintained at or above 135 degrees Fahrenheit and cold foods at or below 41 degrees Fahrenheit. However, the observations and interviews indicated that these standards were not met. The dietician, who visits the facility twice a week, also confirmed that during her test trays, the hot foods were cold. The administrator acknowledged receiving multiple complaints about cold food and late tray delivery. The deficiency was investigated under specific complaint numbers, indicating ongoing issues with meal service in the facility.
Failure to Provide Pureed Diet to Resident
Penalty
Summary
The facility failed to ensure that Resident #86 received food prepared in a form to meet their individual needs, specifically a pureed texture diet. The resident, who had severely impaired cognition and was on a pureed diet due to pocketing food, was observed during lunch service receiving a meal tray that included regular texture pineapple, contrary to the dietary orders. The meal card on the tray clearly indicated the resident was on a pureed texture diet, yet the regular texture pineapple was included and delivered to the resident. During the observation period, the Licensed Practical Nurse (LPN) confirmed the dietary error and removed the pineapple from the resident's tray. However, shortly after, the resident was observed with another bowl of regular texture pineapple, which the LPN attributed to another resident possibly giving it to her. Throughout the observation, Resident #86 did not consume any of her food. This deficiency was investigated under Complaint Numbers OH00161321 and OH00161227.
Failure to Notify Resident Representatives of Significant Changes
Penalty
Summary
The facility failed to notify resident representatives of significant changes in the condition of two residents, leading to a deficiency. For Resident #145, the facility did not inform the family about the resident's declining vital signs and the inability to obtain a blood pressure reading. The resident, who had a complex medical history including heart surgery, a pacemaker, and other serious conditions, expressed a desire for comfort care only. Despite this, the LPN did not contact the family about the resident's low pulse and inability to obtain a blood pressure until after the resident had passed away. The hospice care transition was also mishandled, as the resident was not under the care of any hospice agency at the time of death. For Resident #86, the facility did not notify the resident's power of attorney (POA) about changes in the resident's swallowing ability and subsequent diet modification. The resident, who had severe cognitive impairment and other chronic conditions, was observed pocketing food, prompting a consultation with a speech therapist and a change to a puree diet. However, there was no evidence that the POA was informed of these changes, as confirmed by the Director of Nursing. The facility's policy required notification of significant changes, which was not adhered to in these cases.
Failure to Report Alleged Abuse to State Agency
Penalty
Summary
The facility failed to report an allegation of abuse to the state survey agency, affecting one resident. The resident, who was cognitively intact, had a history of multiple serious health conditions, including hepatic failure, diabetes, and major depressive disorder. She was moved to a different room without documented reasons, and a concern was raised about two aides on her previous hallway regarding lack of respect and proper care. The facility's investigation documents did not show evidence that this incident was reported to the state survey agency, as required by their policy. The resident confirmed feeling intimidated and verbally abused by three staff members, including an LPN and two CNAs, who mocked her for requesting incontinence care. This behavior ceased after her room change, as the staff involved did not work on her new floor. The facility's policy mandates immediate notification to the state department of health within two hours of an abuse allegation, which was not followed in this case. The administrator confirmed the failure to report the incident, and the resident was not interviewed about the incident by facility staff.
Failure to Investigate Abuse Allegation Thoroughly
Penalty
Summary
The facility failed to conduct a thorough investigation of an abuse allegation involving a resident, identified as Resident #8, who was cognitively intact and had a complex medical history including hepatic failure, diabetes, and major depressive disorder. The incident involved allegations of intimidation and verbal abuse by three staff members, including two CNAs and an LPN, which led to the resident feeling intimidated and verbally abused. The resident reported that the abuse ceased after being moved to a different room, where the alleged perpetrators did not work. Despite the resident's claims, the facility did not document interviews with the resident or other potential witnesses, and the alleged perpetrators continued to work during the investigation period. The facility's policy required immediate removal of staff accused of abuse pending investigation, but this was not followed. The Director of Nursing (DON) confirmed that interviews were conducted with the accused staff and the resident, but these were not documented, and there was no record of other staff or residents being interviewed. The facility's failure to adhere to its policy and thoroughly investigate the abuse allegation resulted in a deficiency, as confirmed by the Administrator and DON during interviews. This deficiency was investigated under Complaint Number OH00161464.
Medication Availability Deficiency
Penalty
Summary
The facility failed to provide pharmacy services to ensure medications were available for administration as per physician orders, affecting two residents. Resident #39 had a physician's order for ergocalciferol (Vitamin D2) to be administered once weekly for Vitamin D deficiency. However, during a medication administration observation, the LPN noted that the Vitamin D was not available and was unsure of the reason. The Director of Nursing confirmed that the medication was supposed to come from the pharmacy but was unavailable at the time of administration. Similarly, Resident #71 had physician's orders for Mucinex DM ER and fexofenadine for cough/congestion and seasonal allergies, respectively. During the medication administration observation, the LPN reported that both medications were not available. The Assistant Director of Nursing confirmed that these were stock medications but were not available for administration. This deficiency was investigated under Complaint Number OH00161227.
Inadequate Monitoring of Blood Pressure Leads to Unnecessary Medication Administration
Penalty
Summary
The facility failed to ensure a resident's drug regimen was free from unnecessary medications due to inadequate monitoring of blood pressure. Resident #7, who had severe cognitive impairment and a history of hypertension, syncope, hypotension due to drugs, and dementia, was prescribed Midodrine for hypotension. The physician's order specified that the medication should be withheld if the systolic blood pressure exceeded 140 mmHg or the diastolic exceeded 80 mmHg. On the day of the incident, an LPN prepared and administered Midodrine to Resident #7 without adequately checking the resident's blood pressure. The blood pressure reading on the machine was 160/93 mmHg, which exceeded the parameters for administering the medication. The LPN mistakenly believed the reading was for another resident and proceeded with the administration. Further review revealed that Resident #7's blood pressure was not rechecked after the inappropriate administration of Midodrine until much later in the evening, at which point it was recorded as 107/67 mmHg. The Assistant Director of Nursing confirmed that the medication should not have been given under the circumstances and that the resident's blood pressure should have been rechecked within an hour of administration. This deficiency was identified during a complaint investigation and represents non-compliance with the requirement to ensure residents' drug regimens are free from unnecessary medications.
Improper Medication Storage and Administration
Penalty
Summary
The facility failed to ensure proper storage of medications, affecting one resident observed for medication administration. The resident, who had intact cognition, was admitted with physician's orders for Breo Ellipta inhalation and Flonase nasal spray. These medications were documented as administered daily by nurses, yet there was no physician's order allowing the resident to self-administer them. During an observation, an LPN was unable to find the medications in the medication cart and discovered that the resident had them in her room, stored in an open basket on her bed. Interviews revealed that the resident had been keeping the medications in her room for two years and self-administering them without supervision. The Assistant Director of Nursing confirmed that the resident should not have had the medications in her room without a physician's order to self-administer. This deficiency was identified during a complaint investigation, highlighting a lapse in medication storage and administration protocols.
Failure to Administer Antibiotics and Conduct Lab Tests Timely
Penalty
Summary
The facility failed to provide timely and appropriate antibiotic treatment and laboratory monitoring for Resident #139, who was admitted with a diagnosis of osteomyelitis and required intravenous antibiotics. Upon admission, the resident's discharge instructions from the hospital included orders for IV Cefepime and Vancomycin, along with weekly laboratory tests to monitor the treatment. However, these orders were not included in the resident's admission orders at the facility, and no clarification was sought by the staff at the time of admission. The resident did not receive the first doses of the prescribed antibiotics until two to three days after admission, and the required laboratory tests were not conducted as scheduled. The facility staff failed to perform the necessary lab work on 09/23/24 and 09/30/24, which was crucial for monitoring the resident's Vancomycin levels and preventing toxicity. It was only on 10/01/24 that a critically high Vancomycin trough level was detected, leading to the resident's transfer to the hospital for treatment of Vancomycin toxicity and acute kidney injury. Interviews with facility staff revealed a lack of communication and follow-through regarding the resident's discharge orders and laboratory testing. The Director of Nursing (DON) acknowledged that the facility did not complete the labs prior to 09/30/24 due to a lack of orders, and there was uncertainty about why the orders were not clarified sooner. The failure to administer antibiotics and conduct necessary lab tests in a timely manner resulted in actual harm to the resident, who remained hospitalized due to complications from the oversight.
Medication Error Rate Exceeds Acceptable Threshold
Penalty
Summary
The facility failed to maintain a medication error rate of less than five percent, with the error rate calculated at 14.8%. This deficiency was observed during medication administration for two residents. For Resident #17, who has a history of chronic obstructive pulmonary disease and other respiratory issues, the prescribed Fluticasone Propionate inhaler was not available in the medication cart, and the resident confirmed it was not in her room. The LPN administering the medication confirmed the unavailability of the inhaler, resulting in a missed dose. For Resident #61, who has type two diabetes mellitus and other health conditions, the prescribed Allopurinol and Mucinex medications were also unavailable in the medication cart. Additionally, the LPN failed to prime the Tresiba Flex Pen as recommended before administering the insulin, which could lead to incorrect dosing. The LPN incorrectly believed that priming was not necessary, despite the instruction guide indicating its importance. These errors were confirmed through interviews and a review of the facility's medication administration policy.
Deficiencies in Resident Care and Documentation
Penalty
Summary
The facility failed to complete vital signs and a transfer form for Resident #115 when a change of condition was required. Resident #115, who had a history of chronic gastric ulcer with hemorrhage, was admitted to the facility and experienced a change in condition when he began vomiting black substances. Despite this, the nurse did not obtain vital signs before transferring the resident to the emergency department. The transfer documentation was incomplete, lacking a transfer form that should have included vital signs and other relevant information for continuity of care. Upon arrival at the hospital, the resident was found to be hypotensive and required intravenous fluids. Additionally, the facility failed to order and monitor daily weights for Resident #443 after surgery upon readmission. Resident #443, who had undergone a coronary artery bypass graft, was instructed to have daily weights monitored as per discharge instructions from the hospital. However, the facility did not carry over this order upon the resident's admission, and daily weights were not consistently recorded even after the order was eventually added. The resident himself reported that he had to monitor his weight independently, as the facility staff did not perform daily checks. Interviews with facility staff confirmed these deficiencies. RN #140 acknowledged the absence of a transfer form for Resident #115 and the failure to obtain vital signs during the change in condition. Similarly, RN #140 confirmed that the order for daily weights for Resident #443 was missed upon admission and that weights were not consistently recorded even after the order was added. These lapses in care and documentation highlight significant deficiencies in the facility's handling of resident care and adherence to medical orders.
Failure to Prevent and Manage Pressure Ulcers
Penalty
Summary
The facility failed to accurately assess and implement interventions for pressure ulcers in two residents, leading to actual harm. Resident #38, who required extensive assistance and was incontinent, developed a Stage III pressure ulcer between the fourth and fifth toes of the left foot. The facility did not comprehensively assess the wound or provide appropriate prevention interventions and treatment. Observations revealed that the resident's left foot was not off-loaded, and the pressure ulcer was caused by a boot being applied too tightly. Additionally, the resident's foot was observed dragging on the carpet without a dressing, indicating a lack of comprehensive and individualized interventions. Resident #49, who had paraplegia and other medical conditions, was admitted with a suspected deep tissue injury (SDTI) to the right heel, which deteriorated into an unstageable pressure ulcer. The facility's care plan did not include necessary interventions such as off-loading the heel, despite the resident's known pressure ulcer. Observations showed the resident's heel in direct contact with the mattress, and staff were unaware of the existing wound. The facility's wound nurse confirmed the lack of off-loading and acknowledged the incorrect staging of the pressure ulcer as a SDTI instead of unstageable. The facility's policy on pressure ulcer prevention was not followed, as evidenced by the lack of appropriate support devices and interventions for the residents. The facility failed to provide comprehensive assessments and individualized care plans to prevent the development and worsening of pressure ulcers. This deficiency affected two of the five residents reviewed for pressure ulcers, highlighting a significant lapse in care and assessment procedures.
Resident Injury Due to Improper Securing During Transport
Penalty
Summary
The facility failed to properly secure a resident during transport in the facility's bus, resulting in actual harm. On 05/06/24, a resident in a manual wheelchair was placed in the facility bus for transport. Although the wheelchair was secured with tie-downs and belts, the resident was not secured with the recommended torso and pelvic seat belts. Consequently, the resident slid out of the wheelchair onto the floor of the bus, sustaining a left femoral shaft fracture and a left great toe fracture. The resident involved had a complex medical history, including conditions such as Parkinson's disease, severe morbid obesity, and congestive heart failure, which contributed to their fall risk. The resident's care plan, dated 08/31/19, identified them as at risk for falls due to factors like decreased mobility and muscle weakness. Despite these known risks, the resident was not properly secured during transport, leading to the incident. Interviews and reviews revealed that the transport driver failed to ensure the resident was secured with the necessary belts, despite having received training on the procedure. Additionally, the State tested Nursing Assistant accompanying the resident was not trained in securing residents in the new facility bus. This lack of proper training and adherence to safety protocols directly contributed to the resident's fall and subsequent injuries.
Improper Preparation of Pureed Foods
Penalty
Summary
The facility failed to ensure that pureed foods were prepared to the correct texture, potentially affecting nine residents who were on pureed texture diets. During an observation of food preparation, a staff member was seen preparing pureed hotdogs by blending hotdogs, buns, and beef broth. However, the mixture was not properly blended, as chunks of hotdog and bun were visible, and the staff member required encouragement to scrape the sides of the blender and continue blending until smooth. Even after additional blending and the addition of thickener, the mixture was initially thin and runny. Further observations revealed similar issues with the preparation of other pureed foods. Fiesta blend vegetables and sweet potato fries were also prepared, but both mixtures initially contained chunks and were not smooth. The staff member had to continue blending and adjust the consistency by adding more liquid or thickener to achieve the correct texture. The facility's policy on therapeutic diets, which requires specific texture modifications for mechanically altered diets, was not adhered to during these preparations.
Kitchen Sanitation and Pest Control Deficiencies
Penalty
Summary
The facility failed to maintain the kitchen in a clean and sanitary condition, which had the potential to affect 139 of the 140 residents receiving meals. Observations revealed a large number of flies and gnats in the pantry, uncovered and dirty garbage cans, expired food items, and improperly stored food. The walk-in refrigerator contained expired sour cream, and the pantry had an open bag of spaghetti noodles and a partially filled tub of sugar with a use-by date. Additionally, the standing refrigerator lacked a thermometer, and there was grime and dust on shelves and stainless steel backsplashes. Debris was found under the refrigerator and shelving, and the sanitizer fluid used for cleaning was below the required concentration. Further observations noted dirty water and debris, including dead flies, in the hot-wells, and flies were seen landing on clean utensils in the food prep area. Interviews with the Dietary Manager confirmed these findings, and the Kitchen Consultant described the kitchen as filthy, with a need for deep cleaning and pest control. The facility's policies on dry storage, pest control, and sanitization were reviewed, highlighting the requirement for cleanliness and pest management, which were not adhered to in this instance.
Inadequate Hydration and Nutritional Monitoring
Penalty
Summary
The facility failed to ensure adequate hydration for three residents, as observed through a lack of oral fluids provided between meals. Resident #10, who was totally dependent on care due to severe cognitive impairment and other health issues, did not have the required daily fluid intake documented. Observations confirmed the absence of fluids at the bedside, and staff interviews revealed that the resident could not request fluids and needed assistance with intake. Similar deficiencies were noted for Resident #33, who also had severe cognitive impairment and required assistance with eating. The resident's fluid intake records did not meet the required daily amounts, and observations showed no fluids at the bedside. Resident #41, with severe cognitive impairment and total dependence on care, also did not receive adequate hydration. The intake records showed insufficient fluid consumption, and observations confirmed the absence of fluids at the bedside. Staff interviews indicated that the resident could not ask for fluids and required assistance with intake. The facility's policy required staff to provide fresh water each shift, but this was not consistently followed, as confirmed by staff interviews. Additionally, the facility failed to maintain acceptable nutritional parameters for Resident #130, who experienced significant weight loss. The resident's weekly weights were not consistently recorded as ordered, missing two weeks of data. This oversight was verified by the dietician, who acknowledged the problem with obtaining weekly weights. The deficiency was investigated under a specific complaint number, indicating noncompliance with regulatory standards.
Improper Garbage Disposal and Pest Control in Kitchen
Penalty
Summary
The facility failed to maintain cleanliness and pest control in the kitchen, affecting the majority of its residents who received meals there. Observations made over two days revealed a significant presence of flies and gnats in the pantry, along with uncovered and dirty garbage cans near critical areas such as the back door, walk-in refrigerator, and hand-washing sink. Additionally, hot-wells contained dirty water with debris and dead flies, and flies were observed landing on clean utensils used for food preparation without prior cleaning. Interviews with the Dietary Manager confirmed these findings, and a review of the facility's pest control policy indicated a lack of adherence to the established pest control program, which required frequent treatment and monitoring of the kitchen environment.
Facility Fails to Maintain Resident Rooms and Equipment
Penalty
Summary
The facility failed to maintain residents' rooms and mobility devices in a proper state, affecting four residents out of a sample of 34. Resident #70's room had a non-functional overbed light, with a short chain that was unreachable, preventing the resident from using the light. Despite a follow-up observation, the issue remained unresolved. Resident #105's room had dried substances on the ceiling above the bed, which were not identified or cleaned by the time of the follow-up observation. Maintenance Director #145 acknowledged the need for cleaning but could not determine the nature of the substance. Resident #68's room was observed to be unclean, with debris on the floor and walls in disrepair, including gouges and paint smears. The resident's wheelchair armrest was also damaged, with exposed foam. These issues persisted during a follow-up observation. Similarly, Resident #115's room had dirty walls with gouge marks, and the wheelchair's armrest was cracked, creating a rough surface. Maintenance Director #145 confirmed these findings and noted that the facility's maintenance reports did not document these issues, indicating a lapse in the reporting and repair process.
Insufficient Space for Resident Mobility
Penalty
Summary
The facility failed to provide sufficient space in a resident's room to accommodate their physical needs, specifically affecting a resident with type II diabetes, heart failure, dementia, and muscle weakness. The resident required assistance for activities of daily living due to cognitive impairment and immobility, with interventions including assistive devices. However, observations and interviews revealed that the space between the resident's bed and dresser was approximately two feet, insufficient for the resident to maneuver with a rollator. This lack of space was confirmed by an LPN, and the facility did not provide a policy regarding the accommodation of physical needs when requested.
Failure to Assist Resident in Locating Missing Personal Items
Penalty
Summary
The facility failed to assist a resident in locating missing personal items, specifically three stuffed animals, including a new teddy bear. The resident, who has moderate intellectual disabilities, major depression, and hypertension, reported the missing items to staff. Interviews with State Tested Nursing Assistants (STNAs) revealed that the resident was known to have a teddy bear with her at all times, which went missing about three weeks prior. However, the missing items were not documented in the facility's logs for July and August 2024. The STNAs indicated that the process for handling missing items involves notifying a nurse, who then informs the unit manager, searching for the item, informing the social worker, checking the lost and found, writing a concern, and reviewing the inventory sheet. Despite the resident's report and the STNAs' awareness of the missing teddy bear, the facility did not follow its procedure for missing items, as evidenced by the lack of documentation and action taken to locate the teddy bear. A statement from an STNA noted that the resident had thrown the teddy bear during an anxiety attack, which was reported by the previous shift. The facility's administrator suggested that the teddy bear might not have been missing for as long as reported. Additionally, the facility was unable to provide a policy for handling missing items when requested, indicating a lack of formalized procedures to address such incidents.
Failure to Investigate Allegation of Abuse
Penalty
Summary
The facility failed to investigate an allegation of abuse involving a resident with moderate intellectual disabilities, major depression, and hypertension. The resident reported that an aide hit her on the left arm during the night shift, describing it as a hard, open-handed hit. An LPN confirmed that the resident had complained about the aide tapping her arm and not stopping until she yelled. The LPN reported the incident to the nurse unit manager and human resources. However, the nurse unit manager and HR did not perceive the incident as abuse, attributing it to a misunderstanding or a joking relationship, and no formal investigation was conducted. The Director of Nursing and the Administrator were not aware of any abuse allegations against the resident. The facility's policy requires immediate reporting of all abuse allegations to the administrator and the Ohio Department of Health, but this was not followed. The Administrator acknowledged that all allegations should be investigated, but no investigation was completed because the staff did not believe abuse had occurred. The failure to investigate the allegation of abuse constitutes a deficiency in the facility's compliance with its abuse policy.
Failure to Accurately Complete PASARR for Resident
Penalty
Summary
The facility failed to accurately complete a level one Pre-Admission Screening/Resident Review (PASARR) for a resident, which resulted in the omission of a psychosis disorder from the serious mental illness section that required a level two review. This deficiency affected one resident out of two reviewed for PASARR, with the facility census being 140. The resident in question was admitted with diagnoses including cerebral infarction, major depressive disorder, anxiety disorder, and a psychotic disorder as of March 12, 2024. The Minimum Data Set (MDS) 3.0 assessment indicated severe cognitive impairment with a Brief Interview for Mental Status (BIMS) score of 09 out of 15, and the resident was assessed to have a psychotic disorder. However, the PASARR completed on March 5, 2024, by the Business Office Manager did not list the psychosis disorder under the level one review for serious mental illness. This omission was confirmed during an interview with the Business Office Manager.
Failure to Accurately Complete PASRR for Resident
Penalty
Summary
The facility failed to properly screen a resident for serious mental illness and intellectual disabilities as part of the PASRR process. This deficiency affected one resident who was admitted with diagnoses including dementia, bipolar disorder, major depression, mood disorder, and epilepsy. Upon review, it was found that the PASRR completed did not accurately reflect the resident's mental health diagnoses, as it omitted bipolar disorder, major depression, and mood disorder. Additionally, epilepsy was not listed in the section for intellectual disabilities. An interview with the Business Office Manager revealed that the PASRR was completed using information from the Hospital Exemption, which likely led to the oversight of these diagnoses. The facility's policy requires all new admissions to be screened for mental disorders and intellectual disabilities, and any changes in psychiatric diagnoses necessitate a new PASRR.
Deficiencies in Care Planning and Nutritional Care Plan Updates
Penalty
Summary
The facility failed to develop comprehensive care plans with the resident in attendance and an interdisciplinary team for one resident, and did not revise a nutritional care plan to include gastrostomy tube placement for another resident. Resident #105, who was cognitively intact and dependent on assistance for various activities, reported not being invited to care planning conferences. A review of the resident's medical record confirmed the absence of interdisciplinary care conferences in the past year, which was verified by a social services worker. The facility's policy requires a comprehensive care plan to be developed within seven days of the resident assessment, with the resident and their family encouraged to participate. For Resident #115, the facility did not update the nutritional care plan to reflect the placement of a PEG tube for enteral nutrition. The resident, who had severe protein calorie malnutrition and other chronic health issues, was admitted with a PEG tube for nutritional purposes. Despite having orders for enteral nutrition feedings, the care plan was not revised to include this significant change. An RN confirmed that the care plan had not been updated to reflect the PEG tube placement, indicating a lapse in the management team's responsibility to ensure care plans are revised as needed.
Failure to Date and Time Enteral Feeding Bottles
Penalty
Summary
The facility failed to ensure that enteral tube feeding bottles were dated and timed when they were hung for administration for a resident receiving nightly nocturnal tube feedings. This deficiency was identified during a review of Resident #115, who was admitted with diagnoses including Parkinson's disease, unspecified dementia, Barrett's esophagus, severe protein-calorie malnutrition, and gastrostomy status. The resident had a physician's order to receive Osmolite 1.5 cal at 60 ml/hour for 12 hours via a PEG tube, scheduled to be hung at 6:00 P.M. and disconnected at 6:00 A.M. the following day. Observations on multiple occasions revealed that the enteral feeding bottles were left hanging in the resident's room without a date or time to indicate when they were hung. An interview with an LPN confirmed that the bottles were supposed to be dated and timed by the nurse who initiated the feeding. The LPN acknowledged that the bottles were observed without the required date and time, which is necessary to ensure the bottles are not expired, as they are only good for 24 hours after being spiked. This oversight affected the ability of the night shift nurse to confirm the freshness of the feeding bottles, as they were hung by the prior shift.
Failure to Provide Appropriate Respiratory Care
Penalty
Summary
The facility failed to provide appropriate respiratory care for two residents, leading to deficiencies in their treatment. Resident #54, who had a history of chronic respiratory failure with hypoxia and chronic obstructive pulmonary disease, was observed receiving humidified oxygen at two liters per minute without a physician's order. This was confirmed by two Licensed Practical Nurses (LPNs) who verified that there was no order for oxygen for this resident, despite the ongoing administration. Resident #78, who had diagnoses including chronic obstructive pulmonary disease and was cognitively intact, was observed receiving oxygen at a rate of five liters per minute, contrary to the physician's order of four liters per minute. The resident reported feeling short of breath, and a Registered Nurse (RN) confirmed that he had increased the oxygen flow rate, mistakenly believing there was an order to titrate the oxygen between four and five liters per minute. The RN later verified the correct order and adjusted the flow rate accordingly. The facility's policy on oxygen administration requires staff to verify physician orders and ensure the proper flow rate, which was not adhered to in these cases.
Failure to Conduct Ordered Laboratory Tests
Penalty
Summary
The facility failed to provide or obtain laboratory services as ordered by a physician for two residents. Resident #85, who had multiple diagnoses including type two diabetes mellitus and dementia, did not receive the required quarterly laboratory tests, including hemoglobin A1C, complete blood count, comprehensive metabolic panel, and Depakote level, in June 2024. The physician's order for these tests was in place from March 15, 2024, but the tests were not conducted, as confirmed by the Director of Nursing. Resident #443, who was admitted following a quintuple coronary artery bypass graft and had acute kidney failure, was supposed to have a basic metabolic panel (BMP) done within seven days of admission as per discharge instructions from the hospital. However, the BMP was not ordered until 13 days after admission, and the test was not conducted until 11 days after the resident intervened. An LPN acknowledged that the BMP was missed during the admission process and that the discharge instructions were not followed in a timely manner.
Failure to Maintain Catheter Bag Off the Floor
Penalty
Summary
The facility failed to maintain a resident's indwelling urinary catheter's collection bag off the floor, increasing the risk of infection. The resident, who had a history of unspecified dementia, chronic kidney disease, and urinary tract infections, was observed with the catheter bag on the floor while sitting in a recliner. This observation was verified by an LPN, who then instructed an aide to ensure the bag was not in direct contact with the floor. The aide claimed the resident must have moved it, although there was no documented evidence of the resident being known to move the catheter bag. The resident's care plan included interventions to position the catheter bag below the bladder level and ensure the tubing was not under the resident's leg. However, the care plan was not revised to address the specific issue of the catheter bag being placed on the floor until after the incident was reported. Observations made after the incident showed the resident's catheter bag properly secured and off the floor, with no evidence of the resident handling the bag.
Unjustified Antibiotic Use for Resident
Penalty
Summary
The facility failed to provide justification for the use of antibiotic therapy for a resident, which was identified during a review of medical records, staff interviews, and facility policy. The resident, who had a comprehensive medical history including conditions such as severe sepsis, urinary tract infection, and chronic kidney disease, was administered antibiotics without waiting for the culture and sensitivity results. The resident was initially prescribed Keflex for a UTI, but the antibiotic was changed to Macrobid after the physician's review, indicating a lack of initial justification for the antibiotic choice. The deficiency was further highlighted during an interview with an LPN, who confirmed that the antibiotic was started before the culture and sensitivity results were returned. This action was contrary to the facility's Antibiotic Stewardship policy, which mandates that antibiotics should be prescribed and administered under the guidance of the facility's program. The failure to adhere to this policy resulted in the unjustified use of antibiotics for the resident, affecting the quality of care provided.
Failure to Dress Resident in Personal Clothing
Penalty
Summary
The facility failed to ensure that a resident was dressed in personal clothing daily, which compromised the resident's dignity. The resident, who was admitted with multiple diagnoses including cerebrovascular accident with left-sided hemiplegia, dysphagia, and severe cognitive deficit, was observed multiple times over two days dressed in a hospital gown instead of personal clothing. The resident's care plan included interventions for self-care deficits related to cognitive impairment and generalized weakness, but there were no physician orders indicating the resident could not be dressed in personal clothing. During an interview, an LPN confirmed that the staff did not dress the resident in personal clothing, citing the resident's incontinence as the reason for keeping her in a hospital gown. The facility's policy on dignity emphasized that residents should be cared for in a manner that promotes their well-being and self-esteem, including being encouraged to dress in clothing they prefer. This deficiency was identified during a complaint investigation.
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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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