Madison Health Care
Inspection history, citations, penalties and survey trends for this long-term care facility in Madison, Ohio.
- Location
- 7600 S Ridge Rd, Madison, Ohio 44057
- CMS Provider Number
- 365306
- Inspections on file
- 24
- Latest survey
- March 13, 2025
- Citations (last 12 mo.)
- 0
Citation history
Health deficiencies cited at Madison Health Care during CMS and state inspections, most recent first.
The facility did not maintain its dumpster area in a clean and sanitary manner, potentially affecting all 102 residents. An observation revealed that two lids on one of the dumpsters were not closed, with the top lid open and cardboard boxes hanging out of the side door. This was confirmed by the Dietary Manager.
The facility failed to maintain a safe and sanitary environment, with cobwebs and insects in resident rooms, rotting windowsills, and unclean bathrooms. The housekeeping department was understaffed, leading to incomplete cleaning tasks. Additionally, the main dining room had an active ceiling leak, and the parking lot was poorly lit due to a broken light pole. These issues persisted for months without resolution.
The facility failed to provide individual designated closet space for residents, affecting several individuals. A resident with bipolar disorder and schizophrenia reported that his roommate wore his clothes due to the lack of dividers in the shared closet. Another resident with major depression and anxiety confirmed wearing his roommate's clothing because he could not identify his own. A third resident with adjustment disorder and psychosis found the closet too small and lacking dividers. The facility's policy required private closet space, but this was not followed, as verified by the Administrator and Unit Manager/LPN.
A resident with a history of self-harm and dementia was admitted to a facility and later complained of hip pain, revealing a fracture. Despite the injury's unknown origin, the facility failed to report it to the Ohio Department of Health or conduct a thorough investigation, assuming it was due to osteopenia. Interviews with staff revealed a lack of awareness and action, and the facility did not follow its policy on abuse, neglect, and exploitation.
A resident with a history of self-harm and dementia was admitted to the facility and later complained of hip pain, revealing a fracture. Despite the resident's history, the facility failed to investigate the cause of the injury or report it to the state agency, violating their abuse policy. Interviews with staff showed a lack of awareness and action, and the injury was assumed to be due to osteoporosis without proper investigation.
A resident with wrist fractures wore a brace/splint continuously without a physician's order or documented guidelines for its use. Despite the resident's refusal to remove the splint, staff were unaware of any orders regarding its duration, and there was no documentation of monitoring for skin integrity or circulation. The facility's policy required care plan interventions to be documented, but there was no mention of ensuring a physician's order for the splint.
A facility failed to implement fall prevention measures for a resident with severe cognitive impairment and a history of falls. The resident was found without necessary interventions such as a reachable call light, a wheelchair at the bedside, and non-skid socks. Staff were unable to locate the resident's wheelchair, which was found in the shower room, indicating a lapse in following the facility's fall prevention policy.
A facility failed to provide appropriate respiratory care for a resident by not using a high flow nasal cannula as required and not documenting oxygen saturation levels. Additionally, two residents lacked proper signage indicating oxygen use on their room doors, contrary to facility policy. These deficiencies affected three residents directly and had the potential to impact 22 more residents using oxygen.
A resident with a PEG tube was administered multiple medications mixed together without a physician's order, contrary to facility policy. An LPN crushed and combined medications before administering them, which was confirmed by the DON as inappropriate practice. The facility lacked specific policies on administering medications through a PEG tube.
A resident was inappropriately placed on a secured memory care unit despite being cognitively intact and competent to make her own decisions. The facility failed to provide sufficient evidence to justify her placement, as there were no documented behaviors such as aggression or wandering. The resident expressed a desire to leave the secured unit, but the facility did not re-evaluate her need for such placement after she was deemed competent.
A resident with a history of diabetes and cognitive impairments had an open area on the left buttock and thigh that was not identified or treated in a timely manner. Despite being dependent on staff for personal hygiene, the care plan interventions to inspect and report skin conditions were not followed. The wound was discovered during an observation, but there was no prior documentation or treatment orders. The facility's policy required therapeutic treatment with a physician's order, which was not adhered to, resulting in a deficiency.
A resident with intellectual disabilities and epilepsy experienced frequent falls due to noncompliance with safety interventions, such as using non-skid footwear and the call light for assistance. Despite being located near the nurses' station for closer supervision, the resident often removed footwear and refused assistance, leading to multiple falls and injuries. Staff acknowledged the challenges in implementing effective fall prevention strategies.
A resident with a history of traumatic brain injury and cognitive impairments eloped from the facility without staff knowledge. The resident, who was at risk for elopement, was last seen by staff at 9:00 P.M. and later found outside by a passerby. The staff initiated elopement procedures and located the resident at a nearby house, returning them to the facility without injuries. The incident was considered an unauthorized leave of absence.
A resident with COPD and schizophrenia died due to neglect in a facility. Despite requesting a bronchodilator, there was no follow-up assessment or documentation of medication administration. The resident was found deceased the next day, with rigor mortis indicating a prolonged period without care. Staff interviews revealed failures in communication and monitoring, contributing to the neglect.
A resident with multiple diagnoses, including schizophrenia and cognitive impairment, did not receive their prescribed morning medications due to an LPN's decision to let the resident sleep. The medications were not administered within the ordered time frame, and the omission was confirmed through interviews and record reviews. This significant medication error was identified during a complaint investigation.
Improper Disposal of Garbage and Refuse
Penalty
Summary
The facility failed to maintain its dumpster area in a clean and sanitary manner, which had the potential to affect all 102 residents residing in the facility. During an observation of the dumpster area, it was noted that two lids on one of the two dumpsters were not closed. Specifically, the top lid was open, and the side door was open with cardboard boxes hanging out. This condition was verified through an interview with the Dietary Manager at the time of the observation.
Facility Fails to Maintain Safe and Sanitary Environment
Penalty
Summary
The facility failed to maintain a safe, sanitary, and comfortable environment for its residents, staff, and the public. Observations during a survey revealed multiple deficiencies in the cleanliness and maintenance of resident rooms and common areas. Cobwebs with insects were found in several residents' rooms, and windowsills were observed to be rotting and moist, indicating water damage. Bathrooms shared by residents had accumulations of dark substances around toilets and sticky floors with strong odors, suggesting inadequate cleaning. Additionally, light fixtures were found to contain numerous dead insects, and some rooms had holes in the walls covered with tape. The facility was also found to be understaffed in the housekeeping department, with a lack of a housekeeping supervisor for nearly three months. Interviews with staff confirmed that the facility was operating with fewer housekeepers than required, leading to incomplete cleaning tasks, including deep cleaning of residents' rooms. The housekeeping staffing schedule showed multiple days with only one or two housekeepers on duty, and documentation revealed that some rooms had not been deep cleaned for over two months. Furthermore, the main dining room had an active ceiling leak, with water dripping into a bucket, and the parking lot was poorly lit due to a broken light pole. The facility had been aware of these issues for several months but had not completed necessary repairs. Interviews with maintenance staff and administrators confirmed the ongoing nature of these problems and the lack of progress in addressing them. The facility's policy on maintaining a safe and sanitary environment was not being followed, contributing to the deficiencies observed during the survey.
Deficiency in Providing Designated Closet Space for Residents
Penalty
Summary
The facility failed to provide individual designated closet space for residents, affecting three residents directly and potentially impacting three additional residents. The deficiency was identified through record review, observation, and interviews. Resident #17, diagnosed with bipolar disorder, paranoid personality disorder, and schizophrenia, expressed dissatisfaction with his roommate wearing his clothes due to the lack of dividers in the shared closet. The closet was shared by three residents, and clothing was hung randomly without any indication of ownership, leading to confusion and mix-ups. Resident #18, with major depression, anxiety disorder, schizoaffective disorder, and bipolar disorder, confirmed that he sometimes wore his roommate's clothing as he could not identify his own due to the absence of dividers. Similarly, Resident #81, diagnosed with adjustment disorder, major depression, and psychosis, reported that the closet was too small and lacked dividers, making it difficult to store his clothes. The facility's policy required providing each resident with a private closet space, but this was not adhered to, as verified by the Administrator and Unit Manager/LPN during their interview.
Failure to Report and Investigate Injury of Unknown Origin
Penalty
Summary
The facility failed to report an injury of unknown origin to the state agency for a resident, which is a violation of their policy on abuse, neglect, and exploitation. The resident, who had a history of self-harm and dementia, was admitted to the facility and later complained of right hip pain. An x-ray revealed a mildly displaced fracture of the right femoral neck, which was later determined to be a nondisplaced superior ramus fracture. Despite the resident's history and the nature of the injury, the facility did not report the incident to the Ohio Department of Health (ODH) or conduct a thorough investigation. Interviews with facility staff, including the LPN, DON, and Administrator, revealed a lack of awareness and action regarding the resident's injury. The LPN was unaware of any falls or investigations, and the DON, who was not employed at the time, had no knowledge of the incident. The Administrator, who was the abuse coordinator, did not report the injury to ODH, assuming it was pathological due to the resident's osteopenia. However, there was no clinical verification of this assumption, and no investigation was conducted to rule out other causes such as self-injury or abuse. The facility's failure to investigate and report the injury was further highlighted by the absence of documentation in the incident log and the lack of a self-reported incident (SRI). The previous DON and attending physician also confirmed that no investigation was conducted to determine the cause of the fracture. The facility's policy required them to investigate and report such incidents, but this was not implemented, leading to non-compliance with state regulations.
Failure to Investigate Injury of Unknown Origin
Penalty
Summary
The facility failed to thoroughly investigate injuries of unknown origin for a resident, which affected the quality of care provided. The resident, who had a history of self-harm and dementia, was admitted to the facility and later complained of right hip pain. An x-ray revealed a mildly displaced fracture of the right femoral neck, which was later determined to be a nondisplaced superior ramus fracture. Despite the resident's history of self-injurious behavior, the facility did not conduct an investigation to determine the cause of the fracture or report it to the state agency as required by their abuse policy. Interviews with facility staff, including the LPN, DON, and Administrator, revealed a lack of awareness and action regarding the resident's injury. The LPN was unaware of any falls or investigations, and the DON, who was not employed at the time, could not provide information on the incident. The Administrator confirmed that no investigation was conducted to rule out an unwitnessed fall, self-injurious behavior, or abuse. The facility's failure to investigate and report the injury was a violation of their policy on abuse, neglect, and exploitation. The facility's documentation and interviews indicated that the injury was assumed to be a result of osteoporosis, without proper investigation. The attending physician noted that the fracture could have occurred from various causes, but no specific reason was determined due to the lack of investigation. The facility's incident log did not document any incidents related to the resident, further highlighting the deficiency in addressing the injury of unknown origin.
Lack of Physician's Order for Resident's Brace/Splint
Penalty
Summary
The facility failed to ensure that a resident, identified as Resident #71, had a physician's order for the application and maintenance of a brace/splint on his left hand. Resident #71 was admitted with multiple wrist fractures and had refused occupational therapy but agreed to wear a splint. Despite this, there were no documented orders regarding the duration or guidelines for wearing the splint. The resident had impaired cognition and was independent with dressing but required setup help for personal hygiene. Nursing notes indicated that the resident continued to wear the splint since admission and refused to remove it, but there was no further documentation regarding the brace/splint in the care plan or physician's orders. Interviews with staff, including a CNA and a Unit Manager, confirmed that the resident wore the brace/splint continuously and refused to allow staff to remove it. The staff were unaware of any orders regarding the brace/splint, including its duration of use, and there was no documentation of monitoring for skin integrity or circulation under the brace. The facility's policy on the prevention of decline in range of motion required care plan interventions to be documented, but there was no mention of ensuring a physician's order for the splint. This oversight had the potential to affect other residents identified as using a brace/splint.
Failure to Implement Fall Prevention Measures for High-Risk Resident
Penalty
Summary
The facility failed to ensure that preventative measures were in place for a resident identified as a fall risk, leading to a deficiency in care. The resident, who had a history of repeated falls and severe cognitive impairment, was observed without necessary fall prevention interventions. These interventions included having the call light within reach, the wheelchair at the bedside with brakes locked, and wearing non-skid socks. On multiple occasions, the resident was found in bed yelling for help with the call light out of reach, the wheelchair missing, and non-skid socks not in place. Staff interviews confirmed the resident's high fall risk and the absence of required interventions. The facility's policy on fall prevention and management was not implemented effectively, as evidenced by the resident's unmet needs and the staff's inability to locate the resident's wheelchair, which was found in the shower room. Despite having a care plan and physician orders detailing specific interventions to prevent falls, these measures were not consistently applied, resulting in the resident being left unattended and at risk for falls. The facility's failure to adhere to its own policy and the prescribed interventions contributed to the deficiency identified during the survey.
Failure in Oxygen Administration and Signage
Penalty
Summary
The facility failed to provide appropriate respiratory care for Resident #89, who was admitted with diagnoses including dementia, acute respiratory failure with hypoxia, and was receiving hospice care. The resident had a physician's order for oxygen to be administered at two to ten liters per minute per nasal cannula to maintain pulse oximetry, but there were no parameters for titration or specific oxygenation levels to be maintained. Observations revealed that the resident's nasal cannula was not positioned correctly, and the oxygen delivery system was not a high flow nasal cannula as required for higher flow rates. The facility's records showed a lack of documentation regarding the resident's oxygen saturation levels and the effectiveness of the oxygen therapy. Additionally, the facility did not ensure proper signage indicating oxygen use for Residents #7 and #81. Resident #7, with diagnoses including morbid obesity and respiratory failure, had an order for continuous oxygen but lacked signage on the room door indicating oxygen was in use. Similarly, Resident #81, with chronic obstructive pulmonary disease and chronic respiratory failure, also had an order for continuous oxygen but no signage on the room door. Observations confirmed the absence of required oxygen warning signs, which was verified by the facility's Administrator and Unit Manager. The facility's policy on oxygen administration required documentation of the resident's condition and response to oxygen therapy, as well as the placement of oxygen warning signs on the doors of rooms where oxygen was in use. The failure to adhere to these policies affected three residents directly and had the potential to impact an additional 22 residents identified by the facility as using oxygen. The facility census was 102 at the time of the survey.
Medication Administration Error via PEG Tube
Penalty
Summary
The facility failed to ensure that a resident was free from significant medication errors. Resident #95, who had diagnoses including chronic obstructive pulmonary disease, dysphagia, hypertension, and acute respiratory failure with hypoxia, was receiving nutrition and medications through a PEG tube. The resident's care plan indicated that medications should be administered per physician order, but there was no order to crush and mix all medications together. During an observation, an LPN was seen administering multiple medications by crushing them together and mixing them with liquid supplements before administering them through the resident's PEG tube. This was done without a physician's order to cocktail the medications. Interviews with the LPN and the Director of Nursing confirmed that there was no order to mix the medications, and the facility lacked a policy regarding the administration of medications through a PEG tube. The facility's existing policies on medication administration and feeding tubes did not address the practice of cocktailing medications. The Director of Nursing acknowledged that medications should not be crushed and mixed together due to potential interactions, and that each medication should be administered separately with flushing in between to prevent interactions.
Inappropriate Secured Unit Placement for Competent Resident
Penalty
Summary
The facility failed to ensure that a resident, identified as Resident #103, resided in the least restrictive environment and was free from involuntary seclusion. Resident #103 was placed on a secured memory care unit despite being cognitively intact and competent to make her own decisions. The resident's medical records and progress notes did not provide sufficient evidence to justify her placement on the secured unit, as there were no documented behaviors such as yelling, screaming, verbal aggression, wandering, or medication non-compliance that would necessitate such a restrictive environment. Resident #103 had a history of schizoaffective disorder, bipolar type, and mild dementia with other behavioral disturbances. Despite these diagnoses, the resident was deemed competent and capable of making her own decisions, as confirmed by a statement of expert evaluation. The resident expressed her desire to leave the secured unit and was aware of her rights to make decisions regarding her care. However, the facility did not re-evaluate her need for secured unit placement after she was determined competent, and there was no documentation supporting the necessity of her continued confinement. Interviews with facility staff, including the Administrator and Social Worker Assistant, revealed that Resident #103's placement on the secured unit was initially influenced by her family's request and her past behaviors. However, staff acknowledged that there was no current evidence of behaviors that would justify her placement on the secured unit. The facility's policy required a diagnosis of dementia or other health conditions that would benefit from increased supervision, but Resident #103 did not exhibit behaviors that posed a risk to herself or others, nor did she have a history of elopement or exit-seeking behaviors.
Failure to Implement Care Plan for Resident's Wound
Penalty
Summary
The facility failed to implement care planned interventions for a resident with an open area on the left buttock and posterior thigh. The resident, who was cognitively intact, had a history of type two diabetes mellitus, depression, bipolar disorder, schizoaffective disorder, and an acquired absence of the left upper limb below the elbow. The resident was dependent on staff for personal hygiene and was frequently incontinent. Despite these needs, the care plan interventions to inspect the skin condition daily and report any impaired areas were not followed, leading to the oversight of the resident's wound. During an observation, a Licensed Practical Nurse (LPN) and a Certified Nursing Assistant (CNA) discovered an open area on the resident's left buttock and thigh, which was covered with a foam dressing and barrier cream. The wound was approximately one and a half inches by a half inch, with surrounding tissue that was dark red and purple. The LPN and CNA confirmed that the wound was present during previous incontinence care, but there was no documentation or treatment orders for the wound prior to this observation. The facility's policy required therapeutic treatment for wounds to be implemented by a nurse with a physician's order, and wounds were to be evaluated and monitored regularly. However, the resident's wound was not assessed or treated according to these guidelines. The deficiency was identified during a complaint investigation, highlighting a failure to provide timely and appropriate care for the resident's skin integrity issues.
Inadequate Fall Prevention for High-Risk Resident
Penalty
Summary
The facility failed to ensure effective fall interventions for Resident #10, who was at high risk for falls due to moderate intellectual disabilities, major depressive disorder, epilepsy, and unsteadiness on feet. Despite being provided with a helmet and encouraged to use non-skid footwear, Resident #10 was noncompliant with these safety measures and frequently attempted self-ambulation and transfers without assistance. The resident's care plan included reminders to use the call light for assistance, but these interventions were not consistently effective, as Resident #10 often refused to comply and experienced multiple falls, some resulting in injuries and fractures. Observations revealed that Resident #10 was often seen without a shoe or non-skid sock on his left foot, despite the facility's policy to encourage the use of non-slip footwear. Staff interviews indicated that Resident #10 was impulsive and valued his independence, which contributed to his noncompliance with safety interventions. The resident's room was located near the nurses' station to allow for closer supervision, but the call light was not always tied to the light cord as intended, further compromising the effectiveness of the fall prevention measures. The facility's incident log documented numerous witnessed and unwitnessed falls over the course of a year, highlighting the ongoing issue of inadequate fall prevention for Resident #10. Staff members, including CNAs and the DON, acknowledged the resident's high fall risk and the challenges in implementing effective interventions. Despite efforts to review and adjust the resident's care plan, the facility struggled to find successful strategies to prevent falls, resulting in a deficiency under Complaint Number OH00159658.
Resident Elopement Due to Inadequate Supervision
Penalty
Summary
The facility failed to ensure appropriate supervision to prevent a resident from leaving the facility unattended without staff knowledge. This incident involved a resident with a history of traumatic brain injury, cognitive communication deficit, impulse disorder, and falls. The resident was at risk for elopement and had previously expressed a desire to leave the facility. On the day of the incident, the resident had pulled out their nasogastric tube and was scheduled to be transported to the hospital for replacement. However, the resident was last seen by staff at 9:00 P.M. and was later found outside the facility by a passerby. The passerby alerted the staff after observing the resident in a gown and wheelchair on the road in front of the facility. The staff initiated elopement procedures and called emergency services. The police were already en route to a nearby house where the resident had been reported by a homeowner. The staff located the resident at the residence and returned them to the facility without any noted injuries. The resident was then transported to the hospital for the scheduled procedure and placed on 1:1 supervision upon return. Interviews with the facility's Administrator and RN revealed that the resident was considered alert and oriented, although their mentation fluctuated due to their brain injury. The facility considered the event an unauthorized leave of absence. The RN on duty at the time of the incident had informed the resident of the upcoming hospital transport and denied their request to go outside to smoke. The resident's elopement was discovered when a woman entered the facility to report seeing the resident outside, prompting the staff to initiate a head count and elopement procedures.
Neglect Leads to Resident's Death Due to Inadequate Monitoring and Care
Penalty
Summary
The facility failed to provide necessary goods and services to prevent neglect, resulting in the death of a resident. The resident, who had a full code status, exhibited behaviors and requested a bronchodilator without further assessment or monitoring. Despite the resident's request for medication, there was no documented evidence of its administration or any follow-up assessment to determine its effectiveness. The resident was found deceased the following day, with rigor mortis indicating he had been dead for some time. The resident had a history of chronic obstructive pulmonary disease (COPD), schizophrenia, and other medical conditions. He had recently been readmitted from a psychiatric hospital stay for psychosis. Despite his complex medical history and recent behavioral issues, the facility staff failed to monitor his condition adequately. The resident's care plan included specific interventions for his COPD and behavioral issues, but these were not followed, leading to a lack of necessary care and monitoring. Interviews with staff revealed multiple failures in communication and care. The LPN on duty did not assess the resident's respiratory status or document the administration of the requested medication. The morning shift nurse assumed the resident was sleeping and did not attempt to administer medications or assess his condition. The resident was left unattended for several hours, during which time he passed away without receiving the necessary care and attention.
Removal Plan
- LPN #410 was educated on the medication administration policy.
- Education was provided to nine nurses in the center by the DON regarding Abuse/Neglect policy, Resident Care policy, Medication Administration policy, Notification of Change policy, Medical Emergency Response policy and Stop Watch protocol.
- Education was provided to 16 STNAs in the center by the DON regarding Abuse/Neglect, Resident Care policy, Medical Emergency Response policy and Stop and Watch policy.
- The Administrator, Regional Director of Clinical Services #459, and Regional Director of Operations #458 provided education to 20 nurses over the phone regarding Abuse/Neglect, Resident Care policy, Medication Administration policy, Notification of Change policy, Medical Emergency Response Policy and Stop and Watch protocol. All staff who were not contacted were removed from the schedule until education was provided.
- The administrator, Regional Director of Clinical Services #459, and Regional Director of Operations #458 provided education to 42 STNAs over the phone regarding Abuse/Neglect, Resident Care policy, Emergency Response policy and Stop and Watch protocol. All staff that could not be contacted were removed from the schedule until education could be provided.
- The facility conducted comprehensive assessment utilizing the Monthly Long Term Care Assessment (UDA) on all residents. This was completed by the DON, unit managers, or mobile DON.
- Medication Administration Records were reviewed by Regional Director of Clinical Services #459 in the facility regarding any medication that was not administered. Follow up completed as indicated.
- Medication Administration Records were reviewed by Regional Director of Clinical Services #459 for all residents in the facility regarding refusal of medication. Follow up completed as indicated.
- An Ad hoc Quality Assessment and Performance Improvement meeting was held. Staff in attendance at the meeting included the Administrator, the DON, Regional Director of Clinical Services #459, and Regional Director of Operations #458. The Medical Director was notified of the Immediate Jeopardy concern.
- The DON/Unit Manager/Designee completed observations with non-interviewable residents for concerns related to potential neglect. Any concerns would be addressed as indicated.
- The DON and Unit Managers met with interviewable residents regarding any resident concerns related to potential neglect. Any concerns were addressed as indicated.
- The facility implemented a plan to conduct ongoing monitoring/audits regarding completed medication administration documentation to ensure all residents received medication as ordered. A QAPI meeting would be held to determine if extension of medication administration documentation audits were indicated.
- The facility implemented a plan to conduct ongoing monitoring of progress note reviews for all residents in the facility for change in condition. Follow-up would be completed as indicated for change in condition. A QAPI meeting would be held to determine if extension of progress note review was indicated.
- The facility implemented a plan for ongoing monitoring/audits regarding comprehensive assessments for five residents utilizing the UDA for any change in condition. A QAPI meeting would be held to determine if extension of the comprehensive assessments was indicated.
Significant Medication Error Due to Missed Administration
Penalty
Summary
The facility failed to ensure that medications were administered per physician orders, resulting in a significant medication error for Resident #105. This resident, who had multiple diagnoses including schizophrenia and cognitive impairment, did not receive their prescribed morning medications on 05/25/24. The medications included Famotidine, Paliperidone Palmitate, Polyethylene Glycol, Carbamazepine, Klonopin, and Benztropine Mesylate, which were to be administered between 7:00 A.M. and 11:00 A.M. The failure occurred when LPN #339, upon finding the resident sleeping, decided not to administer the medications and did not return to attempt administration until after a Code Blue was called for the unresponsive resident at 12:30 P.M. Interviews and record reviews confirmed that the medications were not administered as ordered, and the MAR reflected this omission. The facility's policy required medications to be administered within the ordered time frames and for attempts to be made three times before notifying a physician if a resident does not take the medication. The deficiency was identified during a complaint investigation, highlighting a lapse in following the facility's medication administration policy.
Latest citations in Ohio
A resident with intact cognition receiving Medicare Part A skilled services for metabolic encephalopathy had services discontinued while benefit days remained, but the facility did not issue the required Skilled Nursing Facility Advance Beneficiary Notice (SNF ABN). The Social Services Director later confirmed that no SNF ABN was provided and reported she believed only a Notice of Medicare Non-Coverage (NOMNC) was needed when all skilled services were stopped. This practice conflicted with the facility’s written policy, which required SNF ABNs to be issued when extended care items or services were initiated, reduced, or terminated due to expected non-coverage by Medicare.
Surveyors identified that the facility exceeded the acceptable medication error rate when two residents with type 2 DM received insulin doses that were not administered according to orders or manufacturer instructions. In two separate observations, an LPN administered Novolog and another LPN administered insulin glargine and insulin lispro without priming the insulin pens, and the insulin lispro and Novolog were given after the residents had already consumed a significant portion of their breakfast meals, despite orders for administration before meals. Manufacturer information for both insulin products required priming before each injection to ensure accurate dosing, and facility policy required medications, including insulin, to be administered safely, timely, and in accordance with prescriber orders and specified time frames.
Surveyors found that the facility failed to document tray line food temperatures for multiple meals served from two dining room kitchenettes, despite having a “Trayline Taste & Temperature Log” and a policy requiring food to be stored, prepared, distributed, and served according to professional food safety standards. Review of logs showed repeated missing entries for breakfast, lunch, and dinner services in both the Harrison and McClellan dining areas, and the Senior Director of Culinary Services confirmed that temperatures had not been recorded for those meals, potentially affecting all residents receiving meals from those kitchenettes.
The facility failed to conduct and document required periodic care conferences for two residents, despite multiple comprehensive, quarterly, and significant change MDS assessments and a policy requiring periodic care conferences with resident and/or family participation. One resident with Parkinson’s disease, post-stroke hemiplegia, TIA, DMII, and depression had only two documented care conferences over a year, while another resident with aphasia, cerebrovascular disease, DMII, gait difficulty, coagulation defect, depression, and muscle weakness had no documented care conferences in the past year, aside from a declined invitation to the representative. The UCC confirmed that care conferences were expected to occur quarterly and that no additional documentation existed for either resident.
A resident with Alzheimer's disease and type II DM, who required extensive assistance with ADLs and was receiving scheduled Lantus and sliding-scale Humalog, experienced a severely elevated blood glucose level. The on-call provider was notified and ordered an additional dose of lispro insulin with a directive to recheck the blood glucose after administration. Nursing staff administered the extra insulin but did not document any follow-up blood glucose check, and the DON confirmed that this reevaluation was required by the facility's abnormal blood glucose policy and was not completed or documented.
A resident with Parkinson’s disease, dementia, and hypothyroidism was prescribed levothyroxine once daily along with other medications. A consultant pharmacist’s monthly drug regimen review recommended that levothyroxine be given in the morning on an empty stomach, 30–60 minutes before food, per manufacturer instructions. The medical record contained no documented physician response to this recommendation, and the MAR showed the drug scheduled for morning administration while the resident was observed eating breakfast and receiving the medication at the same time. An LPN confirmed administering levothyroxine during the meal, and the DON verified there was no documentation explaining whether or why the pharmacist’s recommendation was or was not followed, resulting in a failure to act on and document the identified irregularity.
A resident with severe cognitive impairment, multiple comorbidities, documented gait and balance abnormalities, and a high fall risk was care planned and assessed by therapy to require contact guard assistance and use of a gait belt for transfers and ambulation. While being assisted by a CNA from a recliner to the bathroom with a walker, the CNA did not apply a gait belt, even though the resident had a known tendency to lean backward when standing. As the CNA reached to open the bathroom door, the resident lost balance and fell backward, striking the back of the head, and was later found by an LPN without a gait belt in place, contrary to the facility’s gait belt policy and the resident’s assessed needs.
A resident with metabolic encephalopathy, muscle weakness, and a history of CVA experienced a fall in his room that was not documented in the medical record until the following morning as a late entry. Two RNs acknowledged that the fall was not recorded at the time it occurred and stated that fall incidents should be documented as soon as possible after the event, resulting in a deficiency for failure to maintain timely, professionally standard medical records.
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.
A resident with cirrhosis, ascites, mood disorder, and alcohol-induced major neurocognitive disorder, and with moderately impaired cognition, was observed sitting on a shower chair in a gown with buttocks exposed and visible from the hallway through an open room door. A CNA left the room quickly after hearing another resident yell and forgot to close the door or pull the privacy curtain, and an RN confirmed the exposure, demonstrating a failure to maintain the resident’s dignity and privacy.
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.
Untimely Documentation of Resident Fall Incident in Medical Record
Penalty
Summary
The deficiency involves the facility’s failure to document a resident’s fall incident in the medical record in a timely manner, in accordance with accepted professional standards. The resident was admitted with diagnoses including metabolic encephalopathy, muscle weakness, and cerebrovascular accident. According to the medical record, a progress note was entered as a late entry on 02/20/26 at 8:21 A.M., stating that the resident had suffered a fall in his room on 02/19/26 at 8:00 P.M. There was no evidence of any documentation of the fall incident entered in the medical record at the time of, or shortly after, the fall on 02/19/26 at 8:00 P.M. During an interview on 03/30/26 at 12:05 P.M., two RNs confirmed that the fall incident was not documented until the following morning and stated that fall incidents should be entered in the medical record as soon as possible following the event. This lack of timely documentation of the fall incident constituted non-compliance with requirements to safeguard resident-identifiable information and maintain medical records in accordance with professional standards.
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.
Resident Left Exposed and Visible From Hallway Due to Failure to Maintain Privacy
Penalty
Summary
The facility failed to ensure resident dignity and privacy when a cognitively impaired resident was left exposed and visible from the hallway. The resident, who had diagnoses including cirrhosis with ascites, mood disorder, and alcohol-induced major neurocognitive disorder, had a BIMS score of eight, indicating moderately impaired cognition. During an observation, the resident was seen sitting on a shower chair in a gown with buttocks exposed, and this exposure was visible from the open room door in the hallway. A Certified Resident Care Associate and a Registered Nurse confirmed that the resident’s buttocks were visible from the hallway. The Certified Resident Care Associate reported that she had left the resident’s room quickly after hearing a resident in an adjacent room yell and, in her haste, forgot to close the door or pull the privacy curtain, resulting in the resident’s exposed state being visible to others. This incident involved one resident out of three reviewed for dignity, in a facility with a census of 52 residents, and was identified through record review, observation, and staff interviews.
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