Majestic Care Of Columbus Llc
Inspection history, citations, penalties and survey trends for this long-term care facility in Columbus, Ohio.
- Location
- 44 S Souder Ave, Columbus, Ohio 43222
- CMS Provider Number
- 365754
- Inspections on file
- 52
- Latest survey
- December 9, 2025
- Citations (last 12 mo.)
- 6
Citation history
Health deficiencies cited at Majestic Care Of Columbus Llc during CMS and state inspections, most recent first.
The facility did not notify two residents, one with cognitive impairment and one cognitively intact, when their personal fund balances were within $200 of the SSI resource limit for multiple months. Documentation and interviews confirmed that required notifications to the residents or their representatives were not made.
A resident with a suprapubic catheter did not receive appropriate care and services during routine catheter care, as staff failed to maintain proper technique and dignity. The resident was left fully exposed during the procedure, and the catheter was not properly secured, resulting in tension on the tubing. Staff interviews confirmed that correct practices for securing the catheter and maintaining resident coverage were not followed.
A resident with multiple medical conditions and at risk for skin breakdown did not consistently have ordered heel protectors in place, as required for wound prevention. Despite documentation in the medical record indicating the devices were used, observations showed the resident was often without them, and staff interviews revealed documentation was completed without verification. No refusals were documented, contrary to facility policy.
Surveyors found that two residents with chronic pain did not receive safe, appropriate pain management due to administration of PRN pain medication without proper pain assessment, lack of documentation of nonpharmacological interventions, and failure to evaluate and document the effectiveness of pain medications after administration, contrary to facility policy and care plans.
Staff failed to implement proper infection control practices during suprapubic catheter care for a resident with multiple medical conditions. A CNA, assisted by nursing staff, placed soiled washcloths back into clean soapy water and reused the contaminated water for cleansing the catheter site, contrary to facility protocols. Interviews confirmed that this practice occurred and was not in line with infection prevention standards.
A resident with dementia and a history of falls experienced two unwitnessed falls in one day, resulting in head trauma and hospitalization. Despite existing interventions, the facility failed to implement timely and effective measures to prevent further falls. Neurological checks revealed a change in the resident's condition, but no additional assessments or fall interventions were made. The facility's policy required monitoring and revising interventions, which was not adequately done.
The facility failed to maintain safe and sanitary food storage, affecting all residents. Observations showed expired and undated food items in the kitchen, including expired milk served to a resident. Interviews confirmed the facility's policy was not followed, as food should be dated and expired items discarded.
A resident experienced delays in accessing their personal funds due to the facility's failure to maintain adequate cash reserves in the fund box. Despite a policy allowing for daily cash withdrawals of up to $50, the resident was initially only able to withdraw $10 and had to wait over 48 hours to receive the remaining $20. Staff interviews confirmed that the facility often ran low on cash, requiring trips to the bank to replenish funds.
The facility failed to ensure arbitration agreements were explained in a language residents or their representatives could understand and did not include all required components. This affected several residents, with interviews revealing a lack of understanding and communication regarding the arbitration process. The facility was reviewing the agreements at a corporate level after survey concerns were identified.
A resident with cognitive impairment and a history of eating quickly was not supervised during meals as required by her care plan, leading to a choking incident. Despite needing supervision, she was observed eating alone, and staff confirmed the lack of oversight. The resident expressed dissatisfaction with her prescribed diet, which sometimes led her to skip meals.
The facility failed to timely identify and treat UTIs for two residents, leading to significant delays in care. One resident experienced a 50-day delay in receiving appropriate antibiotics due to contaminated urine samples and lack of follow-up. Another resident's UTI was not treated after a contaminated urinalysis, with no further action taken. These deficiencies highlight issues in managing UTIs, including inadequate communication with the laboratory and delays in obtaining and acting on test results.
The facility failed to ensure physicians provided rationales for declining pharmacy-recommended gradual dose reductions for two residents. One resident with severe cognitive deficits and multiple diagnoses was on Hydroxyzine, and another with moderate cognitive deficits was on Zoloft. In both cases, the physician declined the pharmacist's recommendations without providing a rationale, as confirmed by the DON.
The facility failed to properly store and label medications, specifically a multi-dose vial of tuberculin skin testing solution, which was found undated and unlabeled in the medication refrigerator. An LPN confirmed the vial was delivered from the pharmacy and should have been labeled according to the facility's policy, which requires opened stock medications to expire 30 days after opening. This affected two residents on the third floor.
The facility failed to justify antibiotic use for two residents, leading to deficiencies in antibiotic stewardship. A resident with multiple diagnoses was placed on Cipro before culture results showed resistance, necessitating a change to Keflex. Another resident with urinary issues experienced delays in obtaining accurate culture results, leading to premature antibiotic prescriptions. The facility's policy on antibiotic stewardship was not followed, resulting in inappropriate antibiotic use.
The facility failed to maintain an adequate emergency water supply, potentially affecting all 74 residents. The emergency water policy lacked details on storage and distribution, and the current supply was insufficient. During an observation, staff struggled to locate the emergency water, which was found to be only 93 gallons, far below the estimated need for three days or a week.
A resident with cognitive intactness and multiple diagnoses was not informed of her discharge plan until shortly before the scheduled transfer, leading to confusion and distress. The facility packed her belongings without her knowledge and attempted to transfer her without adequately informing her of the details. The resident refused to get on the transport bus, resulting in police involvement. The facility's actions led to the resident being left without a clear understanding of her discharge plan, violating the policy for a safe and orderly transfer.
The facility failed to maintain water heater temperatures at the required 140 degrees Fahrenheit, as outlined in its legionella prevention policy. From February to July 2024, water heater tanks #1 and #2 consistently recorded temperatures between 110-112 degrees Fahrenheit. Interviews and observations confirmed the facility's non-compliance with its water management program, which is based on CDC and ASHRAE guidelines, potentially affecting all residents.
The facility failed to update PASRR assessments accurately and timely for several residents, missing diagnoses such as Alzheimer's, dementia, and mood disorders. The Social Services Director did not adhere to the policy requiring prompt referral for Level II reviews upon changes in residents' mental health conditions.
The facility failed to maintain a clean and safe environment for residents, with issues such as persistent urine odor, dried blood stains, and damaged infrastructure in resident rooms. Despite some residents refusing housekeeping services, the facility did not address these issues promptly, leading to unsanitary and unsafe conditions.
A facility failed to complete a PASRR for a resident who remained over 30 days. The resident had multiple diagnoses and was initially exempted from PASRR due to no mental disorder diagnosis. However, the facility did not complete the required screening after the exemption expired. Staff interviews confirmed the oversight, and no documentation was found to show compliance with the facility's policy on PASRR completion.
A resident with multiple medical conditions developed a pressure wound that was not managed properly by the facility. The wound care nurse practitioner's treatment orders were delayed, and there were discrepancies in physician documentation. The resident's wound worsened over time, with assessments showing changes in size and depth, and the facility failed to consistently follow recommended treatment protocols.
A resident with a complex medical history experienced inadequate pain management due to the facility's failure to administer prescribed medications consistently and assess their effectiveness. Despite reporting moderate to severe pain, the resident did not receive appropriate pain relief, leading to hospitalization for severe abdominal pain and other complications. Interviews confirmed the facility's lack of regular monitoring and assessment of the resident's pain levels.
A resident with cognitive impairment and a history of incontinence was inappropriately prescribed Macrobid for a UTI without a confirmed diagnosis. Hospital records showed no UTI, and symptoms were due to hypoglycemia and orthostatic hypotension. The DON confirmed the lack of evidence for the UTI diagnosis, indicating a failure in the facility's antibiotic stewardship program.
Failure to Notify Residents of Personal Fund Balances Near SSI Resource Limit
Penalty
Summary
The facility failed to notify residents who received Medicaid benefits when their personal fund balances reached within $200 of the Social Security Income (SSI) resource limit, as required. For one resident with significant cognitive impairment and multiple complex medical diagnoses, records showed that their account balance was within $200 of the SSI resource limit for five consecutive months. There was no documented evidence that the resident or their representative was notified of this status during that period. The resident's care plan noted communication problems and cognitive deficits, further emphasizing the importance of proper notification. A second resident, who was cognitively intact and had a history of multiple chronic conditions, also had personal funds within $200 of the SSI resource limit for three months. Again, there was no documentation that the resident or their representative was notified. The Business Office Manager confirmed in an interview that notifications were not sent to either resident or their representatives during the relevant months.
Failure to Maintain Dignity and Proper Technique During Suprapubic Catheter Care
Penalty
Summary
During routine suprapubic catheter care for a resident with a history of obstructive and reflux uropathy, major depressive disorder, insomnia, chronic pain syndrome, and prior cerebrovascular events, staff failed to follow proper technique and maintain the resident's dignity. The care plan and physician orders required cleansing the suprapubic site every shift with soap and water, covering with split gauze, and maintaining infection control practices. However, observation revealed that the resident was left fully exposed throughout the procedure, with the brief around the knees, and was not covered to maintain dignity. The resident was positioned flat in a Trendelenburg position, and the catheter care was performed by a CNA, assisted by the ADON and an RN. During the procedure, the CNA cleansed the catheter insertion site using a washcloth dipped in soapy water, holding the catheter approximately three inches below the insertion point, which caused tension on the catheter tubing. The same process was repeated with rinse water. Interviews with the ADON, CNA, and RN confirmed that the catheter was not properly secured at the insertion point, resulting in tugging on the tubing, and that the resident should have been kept covered except during the actual peri-care. The staff acknowledged that proper technique and dignity were not maintained during the catheter care.
Failure to Ensure Use of Ordered Pressure Reducing Devices
Penalty
Summary
The facility failed to ensure that pressure reducing devices were in place as ordered for a resident at risk for skin breakdown. The resident, who had multiple diagnoses including cerebral atherosclerosis, dementia, and moderate protein calorie malnutrition, was cognitively intact and had no active wounds. Physician orders required the use of bilateral heel protectors when in bed for wound prevention. The care plan noted the resident sometimes refused preventative boots and floating heels, but there was no documentation of refusal in the behavior logs for the period reviewed. The Treatment Administration Record (TAR) indicated the boots were in place as ordered, but direct observations on multiple occasions showed the resident either had only one boot on, had no boots on, or was not offloading his heels as required. Interviews with staff revealed that Certified Nursing Aides did not document refusals and would report them to a nurse, who was responsible for documentation. However, the nurse confirmed that documentation was completed without verifying whether the boots were actually in use, and that no refusals were documented in the behavior logs. The facility's wound management policy required timely recognition and intervention for impaired skin integrity, but the lack of accurate documentation and failure to ensure the use of ordered pressure reducing devices constituted a deficiency in care.
Failure to Provide and Document Safe, Appropriate Pain Management
Penalty
Summary
Surveyors identified deficiencies in the facility's pain management practices for multiple residents with chronic pain and complex medical histories. For one resident with diagnoses including bipolar disorder, emphysema, spinal stenosis, and chronic pain, the medical record showed that as-needed (PRN) pain medication was administered even when the resident reported a pain level of zero. Documentation was incomplete, with missing descriptions of pain and lack of evidence that nonpharmacological interventions were attempted prior to medication administration, as required by the care plan and facility policy. The Director of Nursing confirmed that PRN pain medications should not be given for a pain level of zero and that documentation of nonpharmacological interventions and pain descriptions was expected with each administration. Another resident with chronic pain syndrome, diabetes with polyneuropathy, and other comorbidities was receiving scheduled and PRN pain medications. The care plan required evaluation of the effectiveness of pain interventions and documentation of resident satisfaction and impact on function. However, the Medication Administration Record showed that while pain levels were recorded at the time of medication administration, there was no follow-up documentation evaluating the effectiveness of the pain medication. Interviews with staff confirmed that effectiveness was not routinely assessed after administration, and there was no established pain goal for the resident. Facility policy required documentation of the reasons for administration and the effectiveness of pain medications in the medical record, as well as monitoring and physician notification as needed. The survey found that these requirements were not consistently met for the residents reviewed, resulting in a failure to provide safe, appropriate, and well-documented pain management services.
Failure to Follow Infection Control Practices During Catheter Care
Penalty
Summary
During routine suprapubic catheter care for a resident with a history of obstructive and reflux uropathy, major depressive disorder, insomnia, chronic pain syndrome, and prior cerebrovascular events, staff failed to follow proper infection control practices. The resident, who was cognitively intact and dependent on staff for toileting, had physician orders and care plan interventions specifying catheter site cleansing every shift with soap and water, use of split gauze, and documentation of output. During the observed procedure, a CNA, assisted by the ADON and an RN, placed soiled washcloths back into containers of clean soapy water and reused the contaminated water for further cleansing of the catheter site. The resident was also left exposed during the procedure, and a blanket with visible hairs was used to cover the resident afterward. Interviews with the ADON, CNA, and RN confirmed that soiled washcloths should not have been placed back into clean water basins, and that this practice contaminated the water used for catheter care. The CNA acknowledged the error but was unsure if it occurred during the observed procedure, while the RN confirmed witnessing the contamination. These actions were inconsistent with established infection control protocols and the facility's own policies for catheter care.
Failure to Implement Effective Fall Management Program
Penalty
Summary
The facility failed to implement a comprehensive and individualized fall management program for a resident with a history of falls and multiple medical conditions, including dementia and epilepsy. The resident experienced two unwitnessed falls on the same day, resulting in head trauma and hospitalization. The first fall occurred when the resident attempted to change a colostomy bag without assistance, despite being known to resist help with such tasks. Although interventions like Dycem, skid strips, and bilateral falls mats were in place, the facility did not implement timely and effective measures to prevent further falls. After the first fall, the facility added a sign in the resident's room to remind them to call for assistance, but there was no evidence that 15-minute checks, which were supposed to be conducted, were completed. Neurological checks were performed post-fall, revealing a change in the resident's level of consciousness from fully conscious to lethargic. However, there were no additional assessments or changes to the resident's fall interventions in response to this change in condition. The second fall occurred later that day, with the resident found beside the bed with a head injury. Despite the resident's lethargy and confusion noted earlier, no new fall risk or safety interventions were implemented before this fall. The facility's Director of Nursing confirmed that the neurological checks were not documented in the electronic medical record and that there were no additional progress notes or assessments following the change in the resident's condition. The facility's policy required that interventions be monitored for effectiveness and revised as needed, but this was not adequately done in this case.
Deficiency in Food Storage and Expiration Management
Penalty
Summary
The facility failed to ensure the safe and sanitary storage of food and drink items in the kitchen, which had the potential to affect all 74 residents. Observations revealed that a resident consumed chocolate milk from a breakfast tray that was past its use-by date. In the facility kitchen, several food items in the freezer and refrigerator were found to be unlabeled, undated, and in some cases, open to air. This included fish, green beans, chicken fingers, chocolate chip cookie dough, mustard, Worcestershire sauce, an unknown brown juice, cinnamon apples, and baby carrots. Additionally, a significant number of chocolate milk containers in the walk-in refrigerator were expired and had been served during breakfast service. Interviews with the Kitchen Manager and Regional Kitchen Manager confirmed that all food should be dated when opened and marked with a use-by date, and expired food should not be served. The Regional Kitchen Manager also confirmed that expired milk had been served and that yogurt with an expired use-by date was found on trays for lunch service. The facility's policy on cold foods stated that food should be stored in wrapped or covered containers, labeled, and dated, which was not adhered to in these instances.
Failure to Provide Timely Access to Resident Funds
Penalty
Summary
The facility failed to ensure that residents' personal funds were available in a timely manner, affecting one resident directly and potentially impacting 68 others. A resident reported difficulty accessing $30 from their personal fund account, being told they could only receive $10 initially and would need to return for the remaining $20. Despite repeated requests, the resident did not receive the additional $20 until over 48 hours later. Observations and interviews with staff confirmed that the facility's fund box was inadequately stocked, with only $38 available at one point, despite a policy to maintain $1,000 for resident withdrawals. Further investigation revealed that the facility's fund box was frequently understocked, leading to delays in fulfilling residents' requests for their funds. Staff interviews indicated that the facility sometimes ran low on cash after residents withdrew money at the beginning of the month, and staff had to go to the bank to replenish the fund box. The Business Office Manager acknowledged the delay in providing the requested funds to the resident and confirmed that the facility's policy allowed for cash withdrawals of up to $50 per day, which was not adhered to in this instance.
Failure to Explain Arbitration Agreements
Penalty
Summary
The facility failed to ensure that arbitration agreements were thoroughly explained to residents or their representatives in a language they could understand. Additionally, the facility did not include all required components and information in the arbitration agreements. This deficiency affected three residents and had the potential to affect 23 additional residents who were admitted to the facility since a specified date. During interviews, it was revealed that the facility did not have arbitration agreements in place, and the admissions staff confirmed that the facility no longer provided these agreements for resident review. However, it was acknowledged that any agreements already made or signed would still be honored. The review of the arbitration agreement showed that it lacked language stating that the agreement was not required and not a condition of admission. Interviews with the Administrator and admissions staff revealed a lack of understanding and communication regarding the arbitration process at the facility. The Administrator acknowledged that the arbitration agreement documents should be thoroughly explained and confirmed that specific language should be included in the agreement as per regulation. The facility was in the process of reviewing the arbitration agreements at a corporate level, but it had not been prioritized until the survey identified concerns. Interviews with the affected residents revealed that they were not familiar with the arbitration agreement and could not recall if they had been provided or signed one upon admission.
Failure to Supervise Resident During Meals
Penalty
Summary
The facility failed to provide necessary supervision to a resident, identified as Resident #13, during meals, as outlined in the resident's care plan. Resident #13, who has a complex medical history including cognitive impairment, epilepsy, and vascular dementia, was noted to require supervision while eating due to a tendency to eat quickly, which increased the risk of choking. Despite this requirement, the resident was observed eating unsupervised in her room, which led to an incident where she choked on her food, became unresponsive, and required emergency medical intervention, including the Heimlich maneuver and CPR, before being transported to the hospital. Interviews and observations revealed that the resident often ate unsupervised, both in her room and in the dining room, contrary to the care plan's directive for supervision. The resident expressed dissatisfaction with the mechanical soft diet prescribed after the choking incident, which she stated led her to sometimes skip meals. Staff interviews confirmed the lack of supervision during meals, and the facility's policy on meal supervision and assistance was not adhered to, resulting in the failure to ensure the resident's safety during meal times.
Failure to Timely Identify and Treat UTIs in Residents
Penalty
Summary
The facility failed to timely identify and treat urinary tract infections (UTIs) for two residents, leading to significant delays in appropriate care. Resident #72, who was cognitively intact and had a Foley catheter, experienced a series of issues with urine samples being contaminated or not processed in a timely manner. Despite initial signs of a UTI, including cloudy urine and blood in the urine, there was a lack of follow-up and communication with the laboratory, resulting in a 50-day delay before appropriate antibiotics were administered. The Interim Director of Nursing acknowledged the delays and attributed them to laboratory issues, but confirmed that the facility did not contact the laboratory during these delays. Resident #59, who had a moderate cognitive deficit and was incontinent of bowel and bladder, was admitted with a prescription for Keflex for infection management. However, upon readmission, the antibiotic was stopped, and a urinalysis was ordered. The urinalysis results indicated probable contamination, but no further action was taken to treat the UTI. The Interim Director of Nursing verified the lack of treatment and follow-up for the contaminated urinalysis. Both cases highlight a failure in the facility's processes for managing UTIs, including inadequate communication with the laboratory and delays in obtaining and acting on test results. These deficiencies affected the timely treatment of UTIs for the residents, potentially impacting their health and well-being.
Failure to Provide Rationale for Declining Pharmacy Recommendations
Penalty
Summary
The facility failed to ensure that the physician provided a rationale for declining pharmacy-recommended gradual dose reductions (GDR) for two residents. Resident #31, who has a severe cognitive deficit and multiple diagnoses including Alzheimer's disease, anxiety disorder, and bipolar disorder, was receiving several medications including Hydroxyzine for anxiety. The pharmacist recommended a GDR for Hydroxyzine, but the physician declined without providing a rationale, only indicating that past reduction attempts led to problematic behavior and care challenges. This lack of rationale was confirmed by the Director of Nursing during an interview. Similarly, Resident #59, with a moderate cognitive deficit and diagnoses such as major depressive disorder and vascular dementia, was receiving Zoloft for depression. The pharmacist recommended a GDR for Zoloft, but the physician again declined without providing a rationale. This was also verified by the Director of Nursing. These actions affected two out of five residents reviewed for unnecessary medications, indicating a failure in the facility's process to ensure appropriate medication management and documentation.
Improper Storage and Labeling of Medications
Penalty
Summary
The facility failed to ensure proper storage and labeling of medications, specifically multi-use vials, in accordance with professional principles. During an observation, an LPN identified an opened multi-dose vial of tuberculin skin testing solution in the medication refrigerator on the third floor, which was undated and lacked labeling indicating when it was first accessed or when it would expire. The manufacturer's expiration date was January 2026, but the facility's policy required that opened stock medications expire 30 days after opening. The LPN confirmed that the vial was delivered from the pharmacy on October 22, 2024, and acknowledged the lack of proper labeling. The facility's policy, last revised in April 2019, stated that medications requiring refrigeration should be stored securely and that discontinued or outdated medications should be returned to the pharmacy or destroyed. This deficiency affected two residents admitted to the third floor after November 14, 2024, in a facility with a census of 74.
Inadequate Antibiotic Justification for Two Residents
Penalty
Summary
The facility failed to provide adequate justification for the use of antibiotics for two residents, leading to deficiencies in antibiotic stewardship. Resident #73 was initially admitted with multiple diagnoses, including diabetes, chronic kidney disease, and anxiety disorder. The resident complained of dysuria, and a urinalysis was ordered. Despite abnormal urinalysis results indicating a potential infection, the resident was placed on Cipro before culture and sensitivity (C&S) results were available. The C&S results later revealed resistance to Cipro, necessitating a change to Keflex. The lack of timely follow-up and inappropriate initial antibiotic choice contributed to the deficiency. Resident #72, with a history of chronic obstructive pulmonary disease and urinary issues, experienced similar issues with antibiotic management. The resident's urinary catheter was leaking, and a urinalysis was ordered. However, delays in obtaining and processing the urine samples led to contaminated results. Despite ongoing symptoms, the resident was initially prescribed Levaquin before C&S results were available. Once the results were received, the antibiotic was changed to Macrobid, and later Bactrim was also prescribed. The delay in obtaining accurate C&S results and the premature prescription of antibiotics without proper justification were key factors in the deficiency. The facility's policy on antibiotic stewardship, last revised in 2016, outlines the need for antibiotics to be prescribed under the guidance of the stewardship program. However, the incidents with Residents #73 and #72 demonstrate a failure to adhere to this policy, as antibiotics were prescribed without adequate justification and before obtaining necessary C&S results. This lack of adherence to the policy and the resulting inappropriate antibiotic use highlight the deficiency in the facility's management of antibiotic prescriptions.
Inadequate Emergency Water Supply
Penalty
Summary
The facility failed to ensure an adequate emergency water supply was maintained, which had the potential to affect all 74 residents. The emergency water supply policy lacked provisions for storing potable and non-potable water, methods for distributing water, and details on estimating the needed volume of water. During an interview, the Administrator indicated that the emergency water plan was in the survey readiness binder, which included steps for short-term water shut-offs. However, the contract with the emergency water supplier, WC #1050, stated that water would be provided within 24 to 48 hours, with exceptions if the supplier was also affected by the outage or if fulfilling the contract would endanger their personnel or violate regulations. An observation with the Kitchen Manager revealed that emergency water was not stored in the kitchen, and staff had difficulty locating it. After a search, 93 gallons of water were found in a supply closet, which was less than the 150 gallons typically stored. The Kitchen Manager admitted that the supply was insufficient and could not provide evidence of a recent order for more water. The facility's policy estimated water needs for three days to be between 169.65 to 286.95 gallons, and for a week, between 395.85 to 669.55 gallons, indicating a significant shortfall in the current supply.
Failure to Ensure Orderly Discharge for Resident
Penalty
Summary
The facility failed to ensure an orderly discharge for Resident #79, who was cognitively intact and had been residing in the facility with diagnoses including diabetes, anxiety, delusion disorder, and paranoid schizophrenia. The resident was given a 30-day discharge notice due to safety concerns, which she refused to sign. Despite an appeal hearing that upheld the facility's right to discharge her, the resident was not informed of the final discharge plan until shortly before the scheduled transfer, leading to confusion and distress. The facility made multiple referrals to other skilled nursing facilities, but Resident #79 was not accepted due to behavioral and income issues. On the day of discharge, the facility packed her belongings without her knowledge and attempted to transfer her to another facility without adequately informing her of the details. The resident refused to get on the transport bus as she was not told where she was going, resulting in the police being called to escort her off the property. The facility's actions led to Resident #79 being left without a clear understanding of her discharge plan, and her whereabouts were unknown for a period of time. The facility's policy required a safe and orderly transfer, which was not adhered to, as evidenced by the lack of communication and involvement of the resident in the discharge process. The resident eventually arrived at the new facility the following day without any new injuries.
Failure to Maintain Required Water Temperatures for Legionella Prevention
Penalty
Summary
The facility failed to adhere to its legionella prevention procedures, as outlined in its policy, which had the potential to affect all residents. The facility's legionella compliance log revealed that the temperatures of water heater tanks #1 and #2 were consistently below the required range from February to July 2024. Specifically, the temperatures were recorded between 110-112 degrees Fahrenheit, whereas the policy required them to be set at 140 degrees Fahrenheit with mixing valves to reduce the temperature upon arrival at residents' rooms. Interviews with the Director of Maintenance, the Administrator, and other staff confirmed that the facility was not following the proper legionella procedures. The legionella binder and policy indicated that hot water boilers should be maintained at or above 140 degrees Fahrenheit to prevent the growth of legionella bacteria. However, observations during the survey confirmed that the water temperatures at the tanks were still below the required levels, at 113 and 112 degrees Fahrenheit, respectively. The facility's water management program, based on CDC and ASHRAE recommendations, emphasized the importance of maintaining water temperatures above 140 degrees Fahrenheit to eradicate legionella bacteria. The program also highlighted that legionella thrives in water temperatures between 77 and 120 degrees Fahrenheit. Despite this, the facility failed to maintain the necessary water temperatures, as confirmed by the review of the water management plan and interviews with staff, including the Director of Nursing and the Regional Nurse.
Failure to Update PASRR Assessments
Penalty
Summary
The facility failed to ensure that Pre Admission Screening and Resident Review (PASRR) assessments were completed accurately and in a timely manner upon a change in condition for four residents. Resident #31's PASRR was not updated to include all mental disorders such as unspecified psychosis, Alzheimer's, dementia, and psychotic disorder, despite these diagnoses being present in the medical record. Similarly, Resident #69's PASRR did not reflect the diagnosis of dementia with mood disturbance, which was confirmed by the Social Services Director (SSD) during an interview. Resident #74's PASRR was not updated to include a current diagnosis of major depressive disorder, and Resident #11's PASRR did not reflect mental health diagnoses such as depression, bipolar disorder, and insomnia, which were added after the initial screening. The facility's policy required the Social Services Director to track each resident's PASRR screening status and refer any resident with a newly evident or possible serious mental disorder to the appropriate state authority for a Level II review. However, this policy was not followed, leading to the deficiencies identified in the report.
Facility Fails to Maintain Clean and Safe Environment
Penalty
Summary
The facility failed to maintain a clean and sanitary environment in resident rooms, as evidenced by the conditions observed in the rooms of Residents #29 and #55. Resident #29's room had a persistent stench of urine, a sticky bathroom floor, and a non-functional bathroom light. Despite the resident's cognitive intactness and occasional refusal of housekeeping services, the facility did not address these issues promptly. Housekeeping documentation showed multiple refusals of service by the resident, but the broken light was reported several times without repair. Resident #55's room had visible dried blood stains on the linens and floor, which were not addressed for at least a week. The resident was unaware of the blood's origin and expressed a desire for the room to be cleaned. Staff, including a State-tested Nursing Aide, were unaware of the blood until it was pointed out, and the Housekeeping Manager confirmed the oversight. Despite the resident not declining standard cleaning services, the blood remained unaddressed until the surveyor's observation. Additionally, the facility failed to maintain a safe and homelike environment for several residents, as observed in the shared rooms of Residents #5, #17, #20, #22, #30, #41, #65, and #69. These rooms had missing vanity drawers, damaged drywall, and unsecured sinks, which were not repaired despite being evident. The Housekeeping Manager acknowledged these issues and took photographs to report to the Maintenance team. The facility's policy on maintaining a safe and comfortable environment was not adhered to, as evidenced by these deficiencies.
Failure to Complete PASRR for Resident After 30 Days
Penalty
Summary
The facility failed to ensure a Pre Admission Screening and Resident Review (PASRR) was completed for a resident who remained in the facility for over 30 days. The resident, identified as Resident #76, was admitted with diagnoses including chronic obstructive pulmonary disease, pulmonary embolism, diverticulosis, hydrocele, nutritional anemia, and dysuria. Initially, a hospital exemption indicated no diagnosis of mental disorders, but the facility did not complete the required PASRR after the exemption expired and the resident stayed beyond 30 days. Interviews with facility staff, including a Regional Nurse, Social Services Assistant, and Social Services Director, confirmed the oversight. The facility relied on a consulting company to conduct PASRR audits and inform staff of necessary updates, but there was no documentation or evidence of a completed PASRR for Resident #76. The facility's policy required coordination of assessments with preadmission screening and resident review, maintaining a record in the resident's medical record, and completing a state level one screening process for residents staying over 30 days, which was not adhered to in this case.
Failure to Implement Timely Wound Care Treatment
Penalty
Summary
The facility failed to accurately assess and manage a skin impairment for a resident, leading to a deficiency in care. The resident, who had multiple medical diagnoses including quadriplegia and neuromuscular dysfunction, developed a new pressure wound on the left outer thigh. The initial assessment by an LPN noted the wound's measurements and ordered a treatment, but there was no clear documentation on how the wound was acquired. The wound care nurse practitioner was not informed of the wound until four days after its discovery, and the initial treatment orders were not implemented in a timely manner. Throughout the course of treatment, there were multiple instances where the facility did not implement the wound care nurse practitioner's treatment orders within the expected timeframe. For example, a treatment order from early May was not implemented until 11 days later, and another order from mid-June was delayed by 10 days. Additionally, there were discrepancies in the documentation of physician orders, with the facility continuing to use the name and electronic signature of a physician who no longer managed the resident's care. The resident's wound was assessed multiple times, showing changes in size and depth, and at times, the presence of necrotic tissue and biofilm. Despite these assessments, the facility failed to consistently follow the recommended treatment protocols, contributing to the worsening of the wound. Interviews with staff confirmed the delays in implementing treatment orders and the inaccuracies in physician documentation, highlighting a significant lapse in the facility's wound management practices.
Inadequate Pain Management for Resident
Penalty
Summary
The facility failed to adequately monitor and treat a resident's increased pain level, which was identified as a deficiency during a survey. The resident, who had a complex medical history including surgical aftercare, irritable bowel syndrome, and chronic pain, was not provided with appropriate pain management. Despite having orders for various pain medications, including Oxycodone, Acetaminophen, and Ibuprofen, the facility did not administer these medications consistently according to the resident's reported pain levels. The resident experienced fluctuating pain levels, often reporting moderate to severe pain, yet the facility did not administer the prescribed medications as needed. For instance, Ibuprofen was not given for a pain level of seven on multiple occasions, and Acetaminophen was not administered for lower pain levels. Additionally, the effectiveness of the pain medications was not accurately assessed or documented, leading to inadequate pain management for the resident. The resident's condition deteriorated, resulting in hospitalization due to severe abdominal pain and other complications. Interviews with the resident and the Director of Nursing Services confirmed that the facility did not monitor the resident's pain levels regularly or assess the effectiveness of the pain medications administered. This lack of proper pain management and monitoring contributed to the resident's worsening condition and subsequent hospitalization.
Inappropriate Antibiotic Prescription Due to Lack of UTI Diagnosis
Penalty
Summary
The facility failed to adhere to its antibiotic stewardship program, resulting in the inappropriate ordering of antibiotics for a resident. The resident, who was moderately cognitively impaired and required assistance with toileting, was admitted with several diagnoses, including toxic encephalopathy and hypertensive heart disease. The resident's care plan included monitoring for signs of a urinary tract infection (UTI) due to episodes of incontinence. Despite this, the resident was prescribed Macrobid for a UTI without a confirmed diagnosis. Hospital records indicated no UTI diagnosis, and the resident's symptoms were attributed to hypoglycemia and orthostatic hypotension. The medical record review revealed no evidence supporting the prescription of Macrobid, as there was no increase in incontinence, frequency, or urgency beyond the resident's baseline. The hospital workup showed unremarkable results, and the resident's change in mental status was not linked to a UTI. The Director of Nursing Services confirmed the absence of evidence for the UTI diagnosis during the hospital stay, highlighting a failure in the facility's antibiotic stewardship program to ensure antibiotics were ordered appropriately.
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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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