Majestic Care Of Middletown Llc
Inspection history, citations, penalties and survey trends for this long-term care facility in Middletown, Ohio.
- Location
- 6898 Hamilton Middletown Road, Middletown, Ohio 45044
- CMS Provider Number
- 365209
- Inspections on file
- 46
- Latest survey
- June 5, 2025
- Citations (last 12 mo.)
- 0
Citation history
Health deficiencies cited at Majestic Care Of Middletown Llc during CMS and state inspections, most recent first.
Surveyors found that food storage areas, including the kitchen refrigerator and dry storage, were dirty and not maintained according to professional standards, with uncovered and unlabeled food items and debris present. Additionally, a resident's refrigerator contained spilled juice and dead bugs. These conditions were confirmed by dietary and nursing staff and did not comply with facility policies for cleanliness and food safety.
Surveyors found that the facility did not have a Legionella prevention program in place and failed to ensure staff followed proper glove use and hand hygiene during incontinence care for a resident under Enhanced Barrier Precautions. A CNA provided catheter and incontinence care, then touched multiple surfaces and the resident's wheelchair without changing gloves or performing hand hygiene, in violation of facility policy.
Surveyors found that several resident rooms had damaged, discolored, and missing ceiling tiles above beds, compromising the required safe, clean, and homelike environment. The Maintenance Director confirmed these conditions during the inspection.
Surveyors found that two residents with significant cognitive and physical impairments had long, jagged, and dirty fingernails, indicating a failure by staff to provide necessary nail care. One resident was unable to communicate due to cognitive impairment, while the other expressed a desire for nail care to be completed by nursing staff. The DON confirmed the need for nail care during the survey.
A resident with multiple diagnoses was prescribed both an opioid and a benzodiazepine, prompting the pharmacy to recommend PRN Narcan for overdose risk. Although the recommendation was accepted with a verbal physician order, PRN Narcan was not actually ordered until nearly two months later, as confirmed by the DON. This delay represented a failure to act promptly on pharmacy recommendations.
Insulin pen-injectors for three residents were found in a medication cart without being dated when removed from refrigerated storage, as required by facility policy and professional standards. An LPN, the DON, and the consulting pharmacist all confirmed that insulin vials and pens must be dated upon removal from refrigeration, but this was not done for Lantus, Glargine, and Tresiba pens. The deficiency was identified during a survey of the medication cart.
A resident with a colostomy experienced inadequate care, resulting in frequent leaks and a rash due to improper appliance fitting and untimely pouch changes. Staff interviews and observations confirmed the issues, with the DON and Wound Nurse acknowledging the rash caused by gastric juices. The facility's policy on monitoring and addressing pouching problems was not adequately followed.
The facility failed to provide a reasonably accessible and weather-protected outdoor smoking area for residents. A resident, who was cognitively intact and required assistance with daily activities, struggled to open the manual door to the smoking area while using a wheelchair. The door lacked an automatic opener, and no communication devices were available for assistance requests. Additionally, the smoking area lacked weather protection as the canopy was removed for colder months, affecting multiple residents.
A facility failed to notify a resident's representative of a significant change in condition, including increased confusion and hallucinations, as well as new medical orders. The resident's condition worsened, leading to a hospital transfer, with the family only being informed shortly before the transfer. The ADON confirmed the notification should have occurred earlier, as per facility policy.
A facility failed to conduct required care conferences for a resident with multiple diagnoses, including heart failure and dementia. Despite the need for quarterly conferences and alignment with MDS assessments, only one care conference was held over a significant period. The DON confirmed the lack of adherence to the facility's policy, which mandates routine scheduling of care conferences. This deficiency was identified during a complaint investigation.
A resident with chronic respiratory failure and hypertension received Midodrine despite blood pressure readings exceeding prescribed parameters. The facility's failure to adhere to physician orders resulted in significant medication errors, as confirmed by the DON. This non-compliance was identified during a complaint investigation.
An LPN at an LTC facility failed to follow infection control policy by administering a pill that was dropped on the floor to a resident with a history of COVID-19 and other conditions. The DON confirmed the medication should have been destroyed and replaced.
The facility failed to perform timely incontinence care and did not follow physician orders for four residents, resulting in them remaining in heavily soiled briefs for extended periods. Staff interviews confirmed that incontinence care was not performed as required, with some staff admitting to completing rounds every four hours instead of the mandated two hours.
The facility failed to notify the physician of significant weight loss for a resident and did not inform the nurse practitioner of wound treatment refusals for another resident, despite clear directives in the care plans and physician orders.
The facility failed to provide two residents with meals that were palatable and served at appropriate temperatures. Both residents reported that the food was cold and unappetizing, which was confirmed by a sample food test tray showing significantly low temperatures for the food items. The facility's policy on providing a nourishing and well-balanced diet was not adhered to.
A facility experienced significant coordination and communication failures in managing hemodialysis treatments for residents with end-stage renal disease (ESRD). One resident missed four consecutive dialysis sessions, leading to cardiopulmonary arrest and death. The facility staff were unaware of the missed appointments, failed to arrange transportation, and did not notify the physician. Additionally, three other residents faced risks due to similar communication lapses, including missed appointments and inadequate documentation. These events highlight systemic issues in ensuring continuity of dialysis care.
The facility failed to notify a resident's physician when a diabetic medication was unavailable due to a national shortage. The resident missed three doses, and there was no documentation of physician notification. This issue was confirmed by the DON and RNC and represents continued non-compliance from a previous survey.
A facility failed to prevent physical abuse when a resident, who was cognitively intact and had multiple diagnoses, was involved in a verbal and physical altercation with an RN. The RN allegedly used profane language and attempted to force the resident into her room, resulting in the resident's foot being injured. The incident was reported to local police, and the RN was suspended and resigned.
Deficient Food Storage and Sanitation Practices
Penalty
Summary
Surveyors observed multiple deficiencies in the facility's food storage and sanitation practices. In the kitchen refrigerator, food storage shelves were found to be dirty and covered in debris, with spots of a blackish green substance present. Several milk cartons were stored in a plastic tub containing water, but no ice, which is not in accordance with proper food storage practices. In the dry storage area, a large plastic container of dry cereal was left uncovered on a roll cart, and the surrounding area, including the floor, was dirty and covered in debris. Several plastic bowls containing dry cereal were also found on the cart without labels or dates. The Dietary Manager confirmed these observations during the survey. Additionally, a resident's personal refrigerator was found to have spilled cranberry juice at the bottom, along with multiple dead, black bugs in the spilled liquid. This was verified by a Certified Nursing Assistant at the time of observation. Review of facility policies indicated that food storage areas should be neat, clean, and organized, with all foods stored in covered, labeled, and dated containers to prevent cross-contamination, and that all food preparation and service areas should be maintained in a clean and sanitary condition. The observed conditions did not meet these standards.
Plan Of Correction
Facility Name: Majestic Care of Middletown Survey Date: 06/02/2025 Plan of Correction Tag: F0812 - Failure to store, prepare, distribute, and serve food under sanitary conditions. All residents potentially affected by the deficient practice were assessed by DNS/designees on 06/06/2025. No residents exhibited signs or symptoms of foodborne illness. The affected food storage and preparation areas were immediately cleaned and sanitized by the Regional Dietary Manager on 06/03/2025. All improperly stored food items were discarded. A facility-wide audit of all food storage, preparation, and service areas was conducted by the ED on 06/03/2025. No additional concerns were identified. Staff were interviewed and observed to ensure compliance with sanitary food handling practices. All dietary staff were educated on proper food handling, storage, and sanitation procedures per CMS and Ohio Department of Health guidelines by the Executive Director on 06/06/2025. The DON or designee will audit the resident refrigerators weekly to ensure that they are clean and there is no expired food. The dietary manager, Executive Director/designee will conduct random weekly audits of food storage and preparation areas. The Dietary Manager or Executive Director will complete weekly sanitation audits for 4 weeks. Results will be reviewed during the facility's Quality Assurance and Performance Improvement (QAPI) meetings. The DON or designee will audit the resident refrigerators three times a week for 4 weeks to ensure they are clean and contain no expired food. Any issues identified will be addressed immediately with appropriate corrective action. The facility alleges compliance date: July 10, 2025.
Failure to Implement Legionella Prevention and Proper Infection Control During Incontinence Care
Penalty
Summary
The facility failed to establish and implement a Legionella prevention program as part of its infection prevention and control program. Review of the facility's water management documentation showed no evidence of an active Legionella prevention plan, no designated team members responsible for managing such a plan, and no documentation of control measures to prevent Legionella. During interviews, both the Maintenance Supervisor and the Administrator confirmed the absence of an implemented Legionella prevention plan and related control measures, despite the facility's policy outlining the need for a comprehensive water management program. Additionally, the facility did not ensure proper infection control practices during incontinence care for a resident under Enhanced Barrier Precautions. Observation revealed that a CNA provided catheter and incontinence care to a resident, then touched multiple surfaces and the resident's wheelchair without changing gloves or performing hand hygiene. The CNA also left the resident's room without washing or sanitizing hands, contrary to posted signage and facility policy requiring hand hygiene before leaving the room. The CNA later confirmed not changing gloves or sanitizing hands during and after care. The resident involved had a history of intracerebral hemorrhage, hemiplegia, morbid obesity, encephalopathy, and depression, and was always incontinent of bowel and bladder, requiring significant assistance with activities of daily living. Facility policies on Enhanced Barrier Precautions and hand hygiene were reviewed and found to require proper glove use and handwashing, which were not followed during the observed care event.
Plan Of Correction
F0880: Water Management Program Facility Name: Majestic Care of Middletown Survey Date: June 5, 2025 Tag Number: F0880 Deficiency: The facility failed to implement a Legionella prevention plan, designate responsible personnel, or document control measures. The facility completed a review of all water management plan engineering protocols, which were all in place as of 6/20/25 by the maintenance director. The infection control prevention team completed a review of all current residents with no findings related to the cited practice on 6/6/25. As a precaution, the ED and Maintenance Director conducted an immediate risk assessment and flushed all water outlets to reduce potential exposure. All members of the Water Management Program (WMP) will complete CDC Legionella Training by July 10. A Water Management Team has been established, including the Administrator, Maintenance Director, Infection Preventionist, and Environmental Services. The facility has developed and adopted a comprehensive Water Management Program (WMP) in accordance with CDC Toolkit and ASHRAE Standard 188. The WMP includes: a detailed building water system diagram, hazard analysis identifying areas at risk for Legionella growth, control measures such as temperature monitoring, flushing protocols, and disinfectant levels, monitoring procedures and corrective actions for deviations, and documentation and communication protocols. The WMP will be reviewed quarterly by the Water Management Team. Monthly logs will be maintained for all control measures by the Maintenance Director. The facility will conduct annual validation of the WMP, and Legionella testing if indicated. Findings will be reported to the QAPI Committee for oversight. Date of Compliance: July 10, 2025
Failure to Maintain Safe and Homelike Resident Room Conditions
Penalty
Summary
Surveyors observed that the facility failed to maintain a safe, clean, comfortable, and homelike environment for its residents, as required by federal regulations. During an inspection of resident rooms, it was found that three residents' rooms had significant issues with ceiling tiles. Specifically, one room had a damaged, brown and black discolored ceiling tile above the bed, another room had three damaged and discolored ceiling tiles, one broken ceiling tile with a portion missing, and one entire ceiling tile missing, while a third room had three damaged, brown and black discolored ceiling tiles above the bed. These deficiencies were confirmed during an interview with the Maintenance Director, who acknowledged the conditions of the rooms. The observations directly indicate that the facility did not provide the necessary housekeeping and maintenance services to ensure a sanitary, orderly, and comfortable interior, as well as failing to maintain the physical environment in a manner that supports resident safety and comfort.
Plan Of Correction
Tag Number: F584 Deficiency: The facility failed to provide a homelike environment by having ceiling tiles that had brown stains on them. Residents #54, #81, and #116 were affected by this deficient practice, with no negative outcomes. Ceiling tiles for the affected residents were changed by maintenance staff on 6/6/2025. A facility-wide audit was conducted to identify any ceiling tiles with stains on them on 6/21/25 through 6/23/25 and replaced by the Maintenance staff. The ED/designee provided education to the Maintenance supervisor and staff on ceiling tiles and cluttered rooms on 6/9/25. Weekly rounds by the Maintenance supervisor/designee to ensure that ceiling tiles are in good condition will be conducted for 4 weeks, and then twice monthly for 2 months. Results will be reviewed by the QAPI Committee and used to guide continuous improvement. Date of Compliance: July 10th F 0584
Failure to Provide Nail Care for Dependent Residents
Penalty
Summary
Surveyors identified a deficiency in the provision of activities of daily living (ADL) care, specifically related to nail care for dependent residents. Two residents with significant cognitive and physical impairments were observed to have long, jagged fingernails with unknown material underneath. One resident, with diagnoses including Alzheimer's dementia, Parkinson's disease, and diabetes, was noted to be dependent on staff for most ADLs and unable to communicate due to cognitive impairment. The other resident, with diabetes, rhabdomyolysis, and metabolic encephalopathy, required moderate assistance with ADLs and expressed a desire for nursing staff to provide nail care. During observations, both residents were found in clean, seasonally appropriate clothing, but their fingernails were visibly unkempt and dirty. The Director of Nursing confirmed the condition of the residents' nails, verifying that they were long, jagged, and in need of care. The failure to provide necessary nail care services was documented through direct observation, record review, and interviews, affecting two of three residents reviewed for care and services.
Plan Of Correction
Facility Name: Majestic Care of Middletown F0677 ADL Care for Dependent Residents State: Ohio Residents #32 and #100 identified during the survey were immediately assessed by the DNS/designee on 6/2/2025, revealing no negative outcomes related to the cited deficient practice. Both residents immediately received nail care by DNS/designee. A facility-wide audit was conducted by DNS/designee on 6/18/2025 - 6/20/2025 to identify residents who need ADL/nail care to ensure nails are clean and trimmed to the resident's preference. Residents' care plans were updated based on their personal preferences. Any discrepancies were corrected immediately by DNS/designee, and appropriate interventions were implemented. All nursing/CNA staff received in-service training on ADL care per policy requirements, with emphasis on nail care. The DON educated staff on 6/18/2025. The DNS/designee will audit 5 random residents weekly for 4 weeks, then once weekly for 2 months. All findings will be reported to the QA committee for review. The committee meets monthly and as needed. Completion Date: July 10, 2025
Failure to Timely Implement Pharmacy Recommendation for PRN Narcan
Penalty
Summary
The facility failed to follow through on a pharmacy recommendation regarding medication safety for a resident with multiple diagnoses, including chronic pain syndrome, anxiety, and a tracheostomy. The resident was prescribed both an opioid (Oxycodone) and a benzodiazepine (Clonazepam), a combination that increases the risk of life-threatening overdose. On 04/08/25, the pharmacy recommended that PRN Narcan (a narcotic reversal medication) be available for this resident, and this recommendation was documented as accepted with a verbal order from the physician. Despite the acceptance of the pharmacy's recommendation, a review of physician orders showed that PRN Narcan was not actually ordered for the resident until 06/04/25, nearly two months later. The Director of Nursing confirmed that the order for PRN Narcan was not placed in a timely manner and was only completed after pharmacy recommendations were specifically requested. This delay in implementing the pharmacy's recommendation constituted a failure to act promptly on identified drug regimen irregularities as required by regulation.
Plan Of Correction
F0756 - Drug Regimen Review The resident #135 during the survey had their medication regimen reviewed by the Nurse Practitioner on 6/4/24 in house who addressed the recommendation. PRN order implemented on 6/4/2024. A retrospective audit of all residents' monthly drug regimen reviews over the past 60 days was conducted on 6/25/25 by the consultant pharmacist. Any missed or undocumented irregularities were addressed, and physicians were notified to ensure appropriate follow-up and documentation on 7/2/25. Nursing leadership will be educated by RNC on ensuring timely follow-up to pharmacy recommendations by 6/18/2025. The DON or designee will audit 100% of pharmacist recommendations weekly for 4 weeks then monthly for 2 months. All findings will be reported to the QA committee for review, which meets monthly and as needed. Compliance date: July 10, 2025
Failure to Date Insulin Pens Upon Removal from Refrigeration
Penalty
Summary
Surveyors observed that insulin pen-injectors for three residents were not properly labeled with the date they were removed from refrigerated storage and placed in the medication cart for administration. Specifically, Lantus, Glargine, and Tresiba insulin pens were found in the Aspen medication cart without the required dating. This was confirmed during an observation with an LPN, who verified that none of the pens had been dated when removed from stock. The Director of Nursing and the consulting pharmacist both confirmed that facility policy and professional standards require insulin vials and pen-injectors to be dated when removed from refrigeration for use. A review of the facility's medication storage policy indicated that certain medications, including multiple dose injectable vials, require an expiration date shorter than the manufacturer’s date once opened, to ensure medication purity and potency. The failure to date the insulin pens upon removal from refrigeration affected three of the 26 residents with medications stored in the Aspen medication cart, out of a total facility census of 148.
Plan Of Correction
Plan of Correction for F0761 - Label/Store Drugs and Biologicals During the observation of the Aspen Med Cart, it was found that resident's #23, #29, and #128 insulin pen injectors were not dated when removed from the refrigerator and placed in the cart. Correction was made by the staff member at the time of observation. A full house audit of all medication carts was conducted by DNS/designee on 6/4/2025. Any expired, improperly labeled, or unsecured medications were discarded or corrected. Staff were educated by DNS/designee on 6/4/2025 on the facility medication storage policy to reinforce labeling standards, including expiration dates, and the proper way to store insulin and date. The DNS/designee will conduct weekly audits on medication carts for 4 weeks, then 2 times a month for 2 months. All findings will be reviewed by the QAA committee, which meets monthly and as needed. Compliance date of July 10, 2025.
Inadequate Colostomy Care Leading to Rash and Leakage
Penalty
Summary
The facility failed to provide appropriate and adequate colostomy care for Resident #10, who had a colostomy due to malignant carcinoid of the stomach and other health issues. The resident's medical records indicated a need for specific colostomy care, including cleaning the colostomy with soap and water, applying skin prep, and changing the pouch when it was one-third to one-half full. However, interviews and observations revealed that the colostomy pouch was not always replaced timely, leading to leaks and a rash on the resident's abdomen. Interviews with staff, including an LPN and a CNA, confirmed that the colostomy pouch often leaked, and the resident frequently needed cleaning upon their arrival. The LPN expressed concerns about the night shift not emptying the pouch timely, and the CNA acknowledged the rash was not a new finding. Observations showed the colostomy appliance was not fitting properly, with the hole in the wafer cut too big, and paste was used unnecessarily, which contributed to the leakage and skin irritation. The Director of Nursing and the Wound Nurse confirmed the presence of a rash caused by gastric juices contacting the skin, and the DON noted the improper fit of the appliance due to the stoma's position. Despite the ongoing issue with the rash and leaking, there was a lack of documentation regarding the rash's recurrence. The facility's policy required monitoring the skin for breakdown and making appropriate referrals for ongoing pouching problems, which was not adequately followed, leading to the deficiency.
Inaccessible and Unprotected Smoking Area for Residents
Penalty
Summary
The facility failed to ensure that the outdoor smoking area was reasonably accessible and protected from the weather for its residents. This deficiency was identified through observations, interviews, and record reviews. Specifically, Resident #110, who was cognitively intact and required assistance with various activities of daily living, was observed having difficulty opening the manual door to the smoking area while maneuvering a manual wheelchair. The door lacked an automatic opener, and there were no communication devices available for residents to request assistance when needed. Interviews with other residents confirmed that the door was heavy and challenging to pass through. Additionally, the smoking area, which was an enclosed courtyard, lacked adequate protection from the weather as the canopy had been removed for the colder months. The facility's policy on providing a safe and functional environment was not adhered to, as there was no area to protect residents from the weather. The deficiency was noted to have the potential to affect 26 unsupervised residents who smoke, out of a total of 33 residents who smoke, within a facility census of 134.
Failure to Notify Resident's Representative of Change in Condition
Penalty
Summary
The facility failed to notify a resident's representative of a change in health care status, affecting one resident out of three reviewed for change in condition. The resident, who had diagnoses including acute diastolic heart failure, vascular dementia, and anxiety, exhibited behaviors such as refusing care and medications. Despite a significant change in condition, including increased confusion and hallucinations, there was no documentation that the resident's representative was notified of these changes or the new medical orders. The resident's condition further deteriorated, with oxygen saturation levels dropping significantly, prompting the initiation of oxygen therapy and a subsequent transfer to the hospital. The family was only notified of the change in condition shortly before the transfer. The Assistant Director of Nursing confirmed that the family should have been notified earlier, as per the facility's policy, which mandates notifying the physician and resident/representative when a significant change occurs. This deficiency was investigated under a specific complaint number.
Failure to Conduct Required Care Conferences
Penalty
Summary
The facility failed to ensure that care conferences were conducted as required for Resident #137, who was admitted on 12/20/22 and discharged on 11/03/24. The resident had multiple diagnoses, including acute diastolic heart failure, venous insufficiency, vascular dementia, and anxiety. The Minimum Data Set (MDS) assessment indicated impaired cognition, requiring supervision for eating and total staff dependence for bed mobility, transfers, and toileting. The care plan noted behaviors such as refusing care and interventions included encouraging family involvement and maintaining a safe environment. However, a review of progress notes from 02/21/24 to 12/31/24 revealed only one care conference was held on 02/21/24, despite the requirement for quarterly conferences and alignment with MDS assessments. The Director of Nursing confirmed the absence of additional care conferences for Resident #137 since 02/21/24, which was a deviation from the facility's policy. The policy, dated 12/12/23, stipulated that care conferences should be scheduled soon after admission, routinely, and with any change in condition, with advance notice provided to the resident and their representative. This deficiency was identified during a complaint investigation, highlighting the facility's failure to adhere to its care conference policy, affecting the quality of care provided to the resident.
Failure to Follow Medication Administration Parameters
Penalty
Summary
The facility failed to adhere to physician orders for medication administration, resulting in significant medication errors for a resident. The resident, who was admitted with diagnoses including chronic respiratory failure, hypotension, and hypertension, had an order for Midodrine to be administered with specific blood pressure parameters. The order specified that the medication should be held if the systolic blood pressure exceeded 120. However, the medication administration record for December 2024 showed that Midodrine was administered on multiple occasions when the resident's systolic blood pressure was above the prescribed threshold. The Director of Nursing confirmed that the medication was administered despite the blood pressure readings being outside the ordered parameters. The facility's policy on medication administration required obtaining and recording vital signs and holding medications if vital signs were outside the physician's prescribed parameters. This deficiency was identified during an investigation under Complaint Numbers OH00160511 and OH00161077, indicating non-compliance with the facility's medication administration policy.
Infection Control Breach During Medication Administration
Penalty
Summary
The facility failed to implement its infection control policy during medication administration, affecting one resident. During an observation, an LPN was seen dropping a pill on the floor, picking it up, and then handing it to the resident, who subsequently ingested it. This action was contrary to the facility's policy, which mandates that medications be administered in a manner that prevents contamination or infection. The resident involved had a medical history that included COVID-19, an infection following a surgical procedure, type two diabetes mellitus, depression, and hypertension. The resident was cognitively intact and required staff assistance for certain daily tasks. The Director of Nursing confirmed that the medication should not have been administered after being dropped and should have been destroyed, with a replacement offered to the resident.
Failure to Perform Timely Incontinence Care and Follow Physician Orders
Penalty
Summary
The facility failed to perform timely and adequate incontinence care and did not follow physician orders for the use of incontinence products for four residents. Resident #14, who was cognitively intact and required substantial assistance with toileting, was found with a heavily soiled incontinence brief. Resident #43, who was dependent on staff for toileting, also had a heavily soiled brief. Resident #116, who had memory problems and was dependent on staff for all care, was similarly found with a heavily soiled brief. Resident #108, who had severe cognitive impairment and required substantial assistance for toileting, was found with a heavily soiled brief despite having a physician order not to wear briefs while in bed. Staff interviews confirmed that incontinence care was not performed as required, with some staff admitting to completing rounds every four hours instead of the mandated two hours. Observations and staff interviews revealed that incontinence care was not performed in a timely manner, leading to residents remaining in wet and bulging briefs for extended periods. Specifically, STNA #342 admitted to not changing or completing peri-care for Resident #108 during her shift, and LPN #340 confirmed that Resident #108 was wearing a brief against physician orders. Additionally, LPN #355 and STNA #321 confirmed that Residents #14, #43, and #116 had not received incontinence care since the start of the shift. The facility's perineal care policy aimed to provide cleanliness, comfort, and prevent infections, but these standards were not met, resulting in non-compliance with care protocols and physician orders.
Failure to Notify Physician of Significant Changes
Penalty
Summary
The facility failed to notify the physician or nurse practitioner of significant weight changes and wound treatment refusals for two residents. Resident #26 experienced an 18.39% weight loss over approximately six months, dropping from 223.0 lbs. to 182.0 lbs. Despite the care plan's directive to notify the physician of significant weight changes, there was no documentation in the progress notes indicating that the physician was informed. This was confirmed by the Regional Nurse Consultant during an interview. Resident #108, who had severe cognitive impairment and a stage four pressure ulcer, refused wound treatments on two occasions due to pain. The physician's order required the nurse practitioner to be personally notified of every treatment refusal. However, there was no documentation in the progress notes indicating that the nurse practitioner was informed of the refusals. This was confirmed by both an LPN and the Unit Manager during interviews. The facility's change in condition policy also mandates physician notification prior to the end of the shift, which was not adhered to in these cases.
Failure to Provide Palatable and Appropriately Tempered Meals
Penalty
Summary
The facility failed to provide residents with meals that were palatable and served at appropriate temperatures. Resident #69, who has diagnoses including acquired clubfoot, hemiplegia, hemiparesis, and mild protein-calorie malnutrition, reported that the food was not favorable and was usually cold when it should be hot. This was confirmed during an interview on 05/23/24. Resident #113, with diagnoses of heart failure and chronic obstructive pulmonary disease, also reported that the food was cold and unappetizing. Both residents were cognitively intact and able to communicate their dissatisfaction with the meal temperatures and quality. On 05/28/24, a sample food test tray revealed that the temperatures of the food items were significantly below the appropriate levels for serving. The barbequed meat was 121.0°F, baked beans were 110°F, spinach was 60.2°F, fruit was 60.3°F, and milk was 43.3°F. The Account Manager Healthcare Services (AMHS) #401 confirmed that these temperatures were not appropriate for serving. Both residents confirmed that they did not eat much of their lunch due to the cold temperatures, and Resident #113 mentioned that he always received his food tray last, resulting in consistently cold meals. The facility's undated food and nutrition services policy states that each resident should be provided with a nourishing, palatable, well-balanced diet that meets their daily nutritional and special dietary needs, considering their preferences, which was not adhered to in these instances.
Coordination and Communication Failures in Hemodialysis Care
Penalty
Summary
The facility failed to ensure that a resident with end-stage renal disease (ESRD), identified as Resident #06, received scheduled hemodialysis treatments as ordered by the physician. This failure resulted in Immediate Jeopardy and potential serious harm, as Resident #06 went four days without dialysis due to communication and coordination failures within the facility. The resident ultimately suffered cardiopulmonary arrest and passed away in the facility. The facility's staff were unaware of the resident's missed appointments, failed to coordinate transportation to the dialysis center, and did not notify the physician of the missed treatments, leading to the tragic outcome. Additionally, the facility did not maintain proper communication with the dialysis center for three other residents (#07, #08, #139) receiving hemodialysis, placing them at risk for more than minimal harm. The deficiency extended to issues such as missed appointments, lack of documentation in the communication binder for dialysis, and failure to ensure continuity of care for residents requiring dialysis services. The report highlighted instances where staff were unaware of residents' dialysis schedules, missed appointments, and lacked essential communication with the dialysis center, indicating systemic failures in coordinating and monitoring dialysis care for residents. The investigation revealed specific events that contributed to the deficiency, including missed dialysis appointments, lack of physician notification, communication breakdowns between staff and the dialysis center, and inadequate documentation of dialysis treatments. The report detailed the circumstances surrounding Resident #06's missed appointments, the lack of transportation coordination, and the subsequent failure to provide necessary dialysis treatments. These events underscored critical lapses in communication, coordination, and oversight within the facility's dialysis care services, leading to severe consequences for the residents involved.
Failure to Notify Physician of Medication Unavailability
Penalty
Summary
The facility failed to ensure the physician was notified when medications were not available due to a national shortage, affecting one resident. Resident #65, who has type II diabetes, was admitted on an unspecified date and had a physician's order for Mounjaro subcutaneous pen-injector to be administered once a week for four weeks. The medication was not administered on three occasions due to the shortage, specifically on 03/15/24, 03/22/24, and 03/29/24. There was no documentation indicating that Resident #65's physician was informed about the unavailability of the medication. This deficiency was confirmed by the Director of Nursing and the Regional Nurse Consultant during an interview on 04/17/24. The issue represents continued non-compliance from a previous survey dated 02/14/24.
Failure to Prevent Physical Abuse
Penalty
Summary
The facility failed to prevent physical abuse involving a resident who was cognitively intact and had multiple diagnoses, including depressive mood disorder, anxiety disorder, and respiratory failure. The incident occurred when the resident was at the nurse's station and was asked by a registered nurse (RN) to move due to HIPAA concerns. The resident resisted and a verbal altercation ensued, during which the RN allegedly used profane language and attempted to force the resident into her room, resulting in the resident's foot being injured against the door frame. The resident responded by throwing water at the RN, who then left the room. The RN denied using profane language but confirmed the altercation and the resident's resistance. Interviews with staff and the resident confirmed the sequence of events, with the resident and a State Tested Nursing Assistant (STNA) reporting that the RN tried to pull the resident into her room against her will. The resident's care plan included interventions for managing her behavior, such as postponing care if the resident became combative, which the RN did not follow. The incident was reported to local police, and the RN was suspended and subsequently resigned. The facility's policy on abuse prevention defines abuse as the willful infliction of injury, intimidation, or punishment causing physical harm, pain, or mental anguish. The policy emphasizes that residents have the right to be free from abuse and that any instances of abuse must be reported and addressed. The deficiency was confirmed by the Director of Nursing (DON) and the Regional Nurse Consultant (RNC), who acknowledged that the RN did not follow the resident's care plan interventions during the incident.
Latest citations in Ohio
A resident with intact cognition receiving Medicare Part A skilled services for metabolic encephalopathy had services discontinued while benefit days remained, but the facility did not issue the required Skilled Nursing Facility Advance Beneficiary Notice (SNF ABN). The Social Services Director later confirmed that no SNF ABN was provided and reported she believed only a Notice of Medicare Non-Coverage (NOMNC) was needed when all skilled services were stopped. This practice conflicted with the facility’s written policy, which required SNF ABNs to be issued when extended care items or services were initiated, reduced, or terminated due to expected non-coverage by Medicare.
Surveyors identified that the facility exceeded the acceptable medication error rate when two residents with type 2 DM received insulin doses that were not administered according to orders or manufacturer instructions. In two separate observations, an LPN administered Novolog and another LPN administered insulin glargine and insulin lispro without priming the insulin pens, and the insulin lispro and Novolog were given after the residents had already consumed a significant portion of their breakfast meals, despite orders for administration before meals. Manufacturer information for both insulin products required priming before each injection to ensure accurate dosing, and facility policy required medications, including insulin, to be administered safely, timely, and in accordance with prescriber orders and specified time frames.
Surveyors found that the facility failed to document tray line food temperatures for multiple meals served from two dining room kitchenettes, despite having a “Trayline Taste & Temperature Log” and a policy requiring food to be stored, prepared, distributed, and served according to professional food safety standards. Review of logs showed repeated missing entries for breakfast, lunch, and dinner services in both the Harrison and McClellan dining areas, and the Senior Director of Culinary Services confirmed that temperatures had not been recorded for those meals, potentially affecting all residents receiving meals from those kitchenettes.
The facility failed to conduct and document required periodic care conferences for two residents, despite multiple comprehensive, quarterly, and significant change MDS assessments and a policy requiring periodic care conferences with resident and/or family participation. One resident with Parkinson’s disease, post-stroke hemiplegia, TIA, DMII, and depression had only two documented care conferences over a year, while another resident with aphasia, cerebrovascular disease, DMII, gait difficulty, coagulation defect, depression, and muscle weakness had no documented care conferences in the past year, aside from a declined invitation to the representative. The UCC confirmed that care conferences were expected to occur quarterly and that no additional documentation existed for either resident.
A resident with Alzheimer's disease and type II DM, who required extensive assistance with ADLs and was receiving scheduled Lantus and sliding-scale Humalog, experienced a severely elevated blood glucose level. The on-call provider was notified and ordered an additional dose of lispro insulin with a directive to recheck the blood glucose after administration. Nursing staff administered the extra insulin but did not document any follow-up blood glucose check, and the DON confirmed that this reevaluation was required by the facility's abnormal blood glucose policy and was not completed or documented.
A resident with Parkinson’s disease, dementia, and hypothyroidism was prescribed levothyroxine once daily along with other medications. A consultant pharmacist’s monthly drug regimen review recommended that levothyroxine be given in the morning on an empty stomach, 30–60 minutes before food, per manufacturer instructions. The medical record contained no documented physician response to this recommendation, and the MAR showed the drug scheduled for morning administration while the resident was observed eating breakfast and receiving the medication at the same time. An LPN confirmed administering levothyroxine during the meal, and the DON verified there was no documentation explaining whether or why the pharmacist’s recommendation was or was not followed, resulting in a failure to act on and document the identified irregularity.
A resident with severe cognitive impairment, multiple comorbidities, documented gait and balance abnormalities, and a high fall risk was care planned and assessed by therapy to require contact guard assistance and use of a gait belt for transfers and ambulation. While being assisted by a CNA from a recliner to the bathroom with a walker, the CNA did not apply a gait belt, even though the resident had a known tendency to lean backward when standing. As the CNA reached to open the bathroom door, the resident lost balance and fell backward, striking the back of the head, and was later found by an LPN without a gait belt in place, contrary to the facility’s gait belt policy and the resident’s assessed needs.
A resident with CKD stage five requiring peritoneal dialysis (PD) was admitted with pre-admission physician orders for three daily PD exchanges and monitoring for peritonitis (fever, abdominal pain, cloudy effluent), but these monitoring orders were not entered into the facility’s physician orders. The care plan referenced PD and general monitoring but did not specifically address peritonitis monitoring. Paper PD flowsheets showed incomplete and inconsistent documentation of exchanges and resident condition, including missing condition/comments for individual treatments and no record of one ordered PD exchange. The PD cycler flowsheet lacked effluent descriptions on multiple days. The PD nurse reported facility staff were expected to monitor effluent and symptoms, and the DON confirmed the absence of specific peritonitis monitoring orders, lack of an order for the PD cycler, and documentation gaps, despite a facility policy requiring ongoing assessment and monitoring for complications before, during, and after dialysis treatments.
A nurse was observed preparing multiple oral medications for a resident with depression, traumatic brain injury, anxiety, and impaired cognition by pushing tablets and capsules from unit-dose cards directly into her ungloved hand and then using her fingers to place them into a medication cup. In a follow-up interview, the RN confirmed this practice and acknowledged that the correct procedure is to dispense medications directly from the card into the cup, contrary to the facility’s medication administration policy requiring adherence to good nursing principles and practices.
A resident with Alzheimer’s disease, diabetes, anxiety, significant ADL dependence, and behavioral symptoms was observed seated in a chair positioned against the nursing station with a locked wheelchair placed directly in front, also against the nursing station, effectively restricting movement. An LPN confirmed both wheelchair wheels were locked and that it should not have been placed there, while a CNA stated she had positioned the wheelchair to prepare for lunch, was unable to complete the transfer, and left it in place, acknowledging this was wrong. This arrangement conflicted with the facility’s restraint policy, which prohibits physical restraints except when alternatives are ineffective for treating a medical symptom and defines restraints as devices adjacent to the body that cannot be easily removed and that restrict freedom of movement or access to the body.
Failure to Issue Required SNF ABN When Discontinuing Medicare Part A Services
Penalty
Summary
The deficiency involves the facility’s failure to issue a Skilled Nursing Facility Advance Beneficiary Notice (SNF ABN) when Medicare Part A services were discontinued for a resident who still had available benefit days. The resident was admitted with a diagnosis of metabolic encephalopathy and had intact cognition per the Minimum Data Set assessment. The facility’s own SNF Beneficiary Notification Review documented that Medicare Part A skilled services began on 02/11/26 and the last covered day was 03/11/26, and that the facility initiated discharge from Medicare Part A services before the resident’s benefit days were exhausted. Despite this, no SNF ABN was provided to the resident or the resident’s representative. During interviews, the Social Services Director stated that the SNF ABN was issued hours prior to the last covered day but, upon reviewing her files, confirmed that no SNF ABN had actually been issued for this resident. She further explained that she believed an SNF ABN was only required if one skilled service remained and that if all skilled services were being discontinued, only the Notice of Medicare Non-Coverage (NOMNC) needed to be issued. The Administrator, however, stated that a resident should always receive both a SNF ABN and a NOMNC when Medicare Part A services are discontinued and benefit days remain. Review of the facility’s written policy dated 03/28/23 showed that the facility was required to issue SNF ABNs for initiation, reduction, or termination of extended care items or services when Medicare payment was not expected, which did not occur in this case.
Plan Of Correction
This Plan of Correction is submitted as required under State and Federal law. This Plan of Correction does not constitute an admission on the part of the Facility that the findings cited are accurate, that the findings constitute a deficiency or that the scope and severity regarding the deficiency cited are correctly applied. Any changes to the Facility's policies and procedures should be inadmissible in any proceeding on that basis. Without admitting or denying the validity or the existence of the alleged noncompliance, the Facility submits this Plan of Correction with the intention that it be inadmissible by any third party in any civil or other action against the facility or any employee, agent, officer, director or shareholder of the Facility. The Facility is utilizing this Plan of Correction as its allegation of substantial compliance as of 05/29/2026 F-0582 Corrective action for resident/s: On 5/14/26 Resident #34 was informed of rights and responsibilities related to Advanced Beneficiary Notice and voiced understanding of information for future reference by administrator. Identification of other residents who may be affected: Any resident receiving skilled services from nursing or therapy services. The Administrator audited all residents who were discharged from skilled services in the past 30 days to ensure they were issued a Notice of Non-Coverage and Advanced Beneficiary Notice on 5/29/26. No non-compliance was noted. Measures for systemic change: On 5/14/2026 Business Office Manager, Director of Rehab, Minimum Data Set nurse, Director of Nursing and Social Services Director were educated on proper procedure of issuing of Notice Of Medicare Non Coverage and Advanced Beneficiary Notice by administrator. All upcoming discharges from skilled services will be reviewed weekly at Utilization Review meeting to ensure notices will be delivered timely. How Corrective Action will be monitored: Administrator or designee to complete audits of all residents being discharged from skilled services to ensure they were issued a Notice of Non-Coverage and Advanced Beneficiary. This audit will be completed weekly x 4 weeks, then monthly x 2 months. Corrective action will be initiated for any noted non-compliance. Audit findings will be reviewed as part of the monthly quality assurance process to determine the need for further monitoring. Date of Compliance 5/29/26
Insulin Administration Errors and Failure to Prime Insulin Pens
Penalty
Summary
The deficiency involves the facility’s failure to maintain a medication error rate below 5%, with surveyors identifying 3 errors out of 28 medication administration opportunities, resulting in a 10.71% error rate. For one resident with type 2 diabetes mellitus and moderate cognitive impairment, the physician’s order directed Novolog insulin 10 units via subcutaneous pen-injector to be given before meals. During an observed medication pass, the LPN administered 10 units of Novolog insulin without priming the pen and did so after the resident had already consumed approximately 50% of the breakfast meal. The LPN later confirmed she did not prime the pen and acknowledged that the insulin was ordered to be administered prior to meals. Manufacturer instructions for the Novolog FlexPen specified that an air shot (priming) must be performed before each injection to ensure proper dosing. Another resident, also diagnosed with type 2 diabetes mellitus and with intact cognition, had orders for insulin glargine 35 units subcutaneously twice daily and insulin lispro 20 units subcutaneously before meals, plus 12 units subcutaneously if blood glucose was between 251 mg/dL and 300 mg/dL. During an observed medication administration, an LPN administered 35 units of insulin glargine and 32 units of insulin lispro without priming the insulin pens and after the resident had consumed approximately 90% of the breakfast meal, despite orders for insulin lispro to be given before meals. The LPN later stated she could not remember if she had primed the pen and acknowledged that the insulin was ordered to be administered prior to meals. Manufacturer information for insulin lispro stated that the pen must be primed before each injection to confirm insulin delivery and remove air, and that failure to prime could result in too much or too little insulin. The DON confirmed the expectation that insulin be administered as ordered, including priming each pen with two units before dialing the prescribed dose, and facility policy required medications, including insulin, to be administered safely, timely, and in accordance with prescriber orders and required time frames.
Plan Of Correction
This Plan of Correction is submitted as required under State and Federal law. This Plan of Correction does not constitute an admission on the part of the Facility that the findings cited are accurate, that the findings constitute a deficiency or that the scope and severity regarding the deficiency cited are correctly applied. Any changes to the Facility's policies and procedures should be inadmissible in any proceeding on that basis. Without admitting or denying the validity or the existence of the alleged noncompliance, the Facility submits this Plan of Correction with the intention that it be inadmissible by any third party in any civil or other action against the facility or any employee, agent, officer, director or shareholder of the Facility. The Facility is utilizing this Plan of Correction as an allegation of substantial compliance as of 5/29/2026. F-0759 Corrective action for resident/s: Residents #21 and #22 were assessed and evaluated by nurse and Director of Nursing 5/14/26. Resident #21 and #22 both denied any adverse effects and none were noted upon assessment by the Director of Nursing on 5/14/2026. Notification made to physician on 5/14/2026. LPN # 2 competency Eval on insulin administration with the Director of Nursing completed 5/14/2026. Identification of other residents who may be affected: Diabetic residents on assignment of LPN #2/station 2 have the potential to be affected and were assessed by the DON/Designee on 5/14/26 and found to be within normal limits. Measures for systemic change: All Nurses were educated by the Director of Nursing on the steps for Insulin administration per competency, diabetes clinical protocol policy, Medication and treatment orders policy, administering medications policy, and Obtaining fingerstick Glucose Level policy On 5/14/2026. How Corrective Action will be monitored: Director of Nursing and Assistant Director of Nursing will complete insulin administration audits on 5 nurses. This audit will be completed weekly x 4 weeks, then monthly x 2 months. Corrective action will be initiated for any noted non-compliance. Audit findings will be reviewed as part of the monthly quality assurance process to determine the need for further monitoring. Date of Compliance: 5/29/2026
Failure to Document Tray Line Food Temperatures in Dining Room Kitchenettes
Penalty
Summary
The deficiency involves the facility’s failure to document tray line food temperatures for meals served from the Harrison and McClellan Dining Room kitchenettes, as required by professional standards for food service safety and the facility’s own policy. Review of the “Trayline Taste & Temperature Log” (revised September 2018) showed missing temperature documentation for multiple meals from the Harrison Dining Room kitchenette, including dinner on 03/30/26 and 03/31/26, lunch and dinner on 04/01/26 and 04/02/26, dinner on 04/07/26, and lunch and dinner on 04/08/26 and 04/10/26. The Senior Director of Culinary Services confirmed during interview that tray line food temperatures were not documented on the log for these meals. Similarly, review of the same log for the McClellan Dining Room kitchenette revealed that tray line food temperatures were not documented for dinner on 04/01/26, breakfast and lunch on 04/02/26, and lunch and dinner on 04/07/26. The Senior Director of Culinary Services also verified these omissions during interview. The facility census at the time was 27 residents, and the governing “Food and Nutrition” policy, approved on 09/07/21, stated that the facility must store, prepare, distribute, and serve food in accordance with professional standards for food service safety.
Plan Of Correction
F812 The facility will continue to ensure food temperatures are completed before meals are served for all residents. To ensure compliance with this standard the following measures have been taken: 1. Immediately 4/15/26 culinary supervisor #224 was re-educated by Dietary Manager to this standard and policy "Food and Nutrition" which includes documentation of food temperatures. 2. All dietary staff have been re-educated to the standard and policy "Food and Nutrition" during the month of April 2026. 3. Audits of food temperature documentation to be completed by Dietary Manager 4 x per week for 4 weeks then weekly for 4 weeks. 4. Administrator to validate audits/compliance and provide additional training as needed. Administrator will present to QAPI committee for ongoing monitoring and further direction.
Failure to Conduct and Document Required Care Conferences
Penalty
Summary
The deficiency involves the facility’s failure to complete and document comprehensive care conferences at required intervals in accordance with care plan regulations and facility policy. For one resident with Parkinson’s disease with dyskinesia, cognitive communication deficit, hemiplegia and hemiparesis following cerebral infarction, transient cerebral ischemic attack, type II diabetes mellitus, and major depressive disorder, the record showed multiple MDS assessments over a one-year period, including annual, quarterly, and significant change assessments. However, only two care conferences were documented during the last 12 months, despite the expectation that care conferences be conducted quarterly with the resident and family when possible. The Unit Care Coordinator confirmed that no additional care conference documentation existed for this resident beyond the notes dated 04/21/25 and 01/02/26. A second resident, with diagnoses including aphasia following cerebrovascular disease, cerebral infarction, type II diabetes mellitus, unsteadiness on feet, difficulty in walking, coagulation defect, depression, and muscle weakness, also had multiple MDS assessments completed over the review period, including quarterly and annual assessments. The record contained a note that a care conference was offered to the resident’s representative, who declined to attend, but there was no documentation of any care conferences for the most recent 12 months. The Unit Care Coordinator confirmed that no other care conference documentation was available for this resident. Facility policy stated that periodic care conferences involving the resident, family, and the interdisciplinary team are part of the care planning process, but the required periodic care conferences and corresponding documentation were not completed for these two residents.
Plan Of Correction
THIS PLAN OF CORRECTION SERVES AS BERKELEY SQUARE'S CREDIBLE ALLEGATION OF SUBSTANTIAL COMPLIANCE AS OF June 1, 2026. Without admitting or denying the validity or existence of the alleged deficiencies, Berkeley Square provides the following Plan of Correction: F657 The facility will continue to document completion of care conferences at the required intervals for all residents, including residents #04 & #15. To ensure compliance with this standard the following measures have be taken: 1. The social service designee and the inter- disciplinary team were re-educated by the administrator to the facility policy "Care Conference" on 4/29/26 and verbalized understanding. 2. Care conferences for resident #04 and resident #15 were conducted on or before 4/29/2026 by the interdisciplinary team. 3. Review of all other residents was conducted by the social service designee to validate and ensure that care conference schedule is up to date with timely care conferences scheduled for them on 4/15/2026. Audits of care conferences to be completed weekly for four weeks and then monthly after that by the social service designee. Documentation of the care conference including any identified concerns in the medical record. Administrator to validate audits/compliance and provide additional training as needed. Administrator will present results of these audits to QAPI committee for ongoing monitoring and further direction.
Failure to Reevaluate Blood Glucose After Treatment for Hyperglycemia
Penalty
Summary
The facility failed to ensure that a resident with diabetes received treatment in accordance with professional standards of practice when nursing staff did not reevaluate the resident's blood glucose after treatment for severe hyperglycemia. The resident, admitted with diagnoses including Alzheimer's disease, type II diabetes mellitus, and depression, had physician orders for Humalog insulin on a sliding scale before meals, Lantus insulin 25 units daily, and lisinopril 5 mg daily. The resident required extensive assistance with activities of daily living, including transfers, toileting hygiene, eating, and bathing. On the evening in question, the resident's blood glucose was documented as 532 mg/dL, and the on-call provider was notified. The provider gave a new order to administer an additional 8 units of lispro (Humalog) and to recheck the blood glucose in 30 minutes. The electronic medication administration record showed that the blood glucose of 532 mg/dL was obtained at 9:00 p.m. and that the additional 8 units of lispro were administered at 9:21 p.m. However, there was no documentation in the resident's chart that the blood glucose was rechecked after the additional insulin was given. In an interview, the DON confirmed there was no evidence of reevaluation and verified that, according to the facility's "Abnormal Blood Glucose Procedure" policy, the resident should have been reevaluated and that the evaluation step should have been included in the progress note documentation.
Plan Of Correction
F684 The facility will continue to ensure all residents, including #03, receive treatment in accordance with professional standards of practice and reevaluated for hyperglycemia. To ensure compliance with this standard the following measures have been taken: 1. The director of nursing assessed resident #03, reviewed documentation and orders and found no ill effects immediately 4/16/26. 2. All licensed nurses were re-educated to facility policy "Blood Glucose Monitoring" by the Director of Nursing/designee in April 2026. 3. Audits of like-residents that require blood sugar checks to be completed by the director of nursing/designee two times a week for 4 weeks and then monthly after that to validate correct follow through when there is abnormally high blood glucose result. The Administrator will bring results of these audits to the QAPI committee for ongoing monitoring and further direction.
Failure to Act on Pharmacist Drug Regimen Recommendation for Thyroid Medication
Penalty
Summary
The deficiency involves the facility’s failure to ensure that pharmacy recommendations from the monthly drug regimen review were acted upon and documented for a resident. The resident was admitted with diagnoses including Parkinson’s disease, dementia, and hypothyroidism, and had current physician orders for levothyroxine 150 mcg once daily, buspirone 50 mg twice daily, and losartan 100 mg once daily. A medication regimen review dated 11/25/2025 included a consultant pharmacist recommendation that levothyroxine be administered consistently in the morning on an empty stomach, at least 30–60 minutes before food, per manufacturer instructions. There was no specific physician response in the medical record to this recommendation, and the facility’s policy stated that consulting pharmacist reviews are sent to nursing and addressed with the primary care provider or consulting specialist for review and follow-up. Review of the resident’s medication administration record for April 2026 showed levothyroxine scheduled for 9:00 a.m. On observation, the resident was seen eating breakfast in the dining area at 8:03 a.m., and an LPN reported administering the levothyroxine 150 mcg to the resident while the resident was in the dining area eating breakfast. The DON confirmed there was no evidence in the resident’s medical record explaining why the consultant pharmacist’s recommendation from 11/25/2025 was or was not acted upon. This lack of documented physician review and action on the pharmacist’s identified irregularity constituted noncompliance with the drug regimen review requirements.
Plan Of Correction
F756 The facility will continue to ensure the pharmacy recommendations from the monthly drug regimen review by a licensed pharmacist are acted upon for all residents, including #08. To ensure compliance with this standard the following measures have been taken: 1. Resident #08 was assessed by the registered nurse and med review completed by 4/28/26. After review of resident's drug regime's, it was discovered that resident #8 had 2 separate medication recommendations on the same form, to be reviewed by two separate practitioners, pharmacy has been instructed and agreed to separate meds on individual forms. 2. Licensed nurses re-educated to facility policy "Drug Regimen Review" by Director of nursing/designee in April 2026 and no later than 5/8/26. Licensed nurses are responsible for ensuring the reviews and recommendations are given to the physician for timely review. 3. Review of all other current residents Drug Regimen orders completed by Director of nursing/designee on 4/16/26 to ensure recommendations were followed up on/reviewed by the physician and address concerns if needed. 4. Audit of drug regime recommendations, pharmacy recommendations, and physician follow up to be completed weekly for four weeks by the Director of nursing/designee. Administrator will present results of these audits to the QAPI committee for ongoing monitoring and further direction.
Failure to Use Required Gait Belt During Ambulation Resulting in Resident Fall
Penalty
Summary
The deficiency involves the facility’s failure to ensure that a required gait belt was used while assisting a high fall‑risk resident with ambulation, resulting in a fall with head injury. The resident had multiple diagnoses including metabolic encephalopathy, hypertension, osteoarthritis, muscle weakness, gait and mobility abnormalities, major depressive disorder, anxiety, and visual hallucinations. Admission and subsequent MDS and fall risk assessments documented that the resident was severely cognitively impaired, required moderate to maximal assistance with transfers and ambulation, could not independently come to a standing position, exhibited loss of balance while standing, used an assistive device, and had decreased muscle coordination. The resident had a history of falls prior to admission and was assessed as being at high, later moderate, risk for falls. The resident’s fall care plan identified her as at risk for falls and included interventions such as providing maximum to moderate assistance with transfers and walking short distances, use of a walker and wheelchair, and following the facility’s fall protocol. Therapy notes and care conference documentation indicated that the resident leaned backwards when standing, required contact guard to minimal assistance for bed mobility and transfers, and needed constant verbal cueing for safe sequencing during toilet transfers. The physical therapist confirmed that the resident was to use a gait belt with staff when ambulating, and the DON verified that therapy had assessed the resident as requiring contact guard assistance and a gait belt for ambulation and transfers. On the day of the incident, a CNA was assisting the resident from her recliner to the bathroom using a walker. The CNA walked beside the resident, providing guidance and support, and reported having a hand on the resident while assisting her. As they approached the bathroom door, the CNA reached for the doorknob to open it, and at that moment the resident began to lose her balance and fell backwards to the floor, striking the back of her head. The nurse who responded found the resident on her back at the foot of the bed with her feet near the bathroom, noted a red raised area on the back of the head, and documented that the resident was not wearing a gait belt and that the gait belt was on the dresser. In the facility’s investigative summary and in interviews, the CNA acknowledged that she did not have a gait belt on the resident while ambulating her, despite the resident’s assessed need for hands‑on assistance and gait belt use per facility policy and the resident’s care and therapy plans.
Failure to Implement PD Orders and Monitor Resident Receiving Peritoneal Dialysis
Penalty
Summary
The deficiency involves the facility’s failure to implement pre-admission physician orders for peritoneal dialysis (PD) and to provide ongoing monitoring for a resident with chronic kidney disease (CKD) stage five who required PD. Pre-admission orders dated 11/14/25 specified three daily PD exchanges at 6:00 A.M., 2:00 P.M., and 10:00 P.M., and directed staff to monitor for signs and symptoms of peritonitis, including fever, abdominal pain, and cloudy effluent. These monitoring orders were not entered into the facility’s physician orders. The resident’s care plan noted the need for PD and included general monitoring interventions (labs, signs of bleeding, bacteremia, septic shock, and significant vital sign changes), but did not specifically address the ordered monitoring for peritonitis. Review of PD documentation showed incomplete and inconsistent charting of treatments and resident condition. The paper peritoneal flowsheet had columns for time of PD and condition/comments, including instructions to call the nurse immediately for cloudy fluid, abdominal pain, or fever. However, the first entry on 11/15/26 at 2:00 P.M. only noted that the PD nurse completed the exchange, and the 10:00 P.M. entry that day had no condition/comment documentation. Subsequent days (11/16/25, 11/17/25, and 11/18/25) contained only one condition/comment entry per day rather than for each exchange, and there was no documentation that the 6:00 A.M. PD on 11/18/25 was completed. The PD cycler flowsheet starting 11/19/25 lacked any description of the effluent on multiple days. The PD nurse from the dialysis company stated facility staff were expected to monitor effluent for cloudiness and assess for abdominal pain and fever, and the DON confirmed there was no electronic physician order for peritonitis monitoring or for use of the PD cycler, that the paper charting did not allow for effluent description or symptom documentation for each treatment, and that PD was not documented at one ordered time. The facility’s dialysis policy required ongoing assessment and monitoring for complications before, during, and after treatments, which was not reflected in the documentation for this resident.
Improper Infection Control During Medication Administration
Penalty
Summary
Surveyors identified a deficiency in infection prevention and control related to medication administration for Resident #29. The resident was admitted on 02/28/14 with diagnoses including depression, traumatic brain injury, and anxiety, and had impaired cognition per a quarterly MDS assessment. During an observation on 03/25/26 at 6:58 A.M., RN #281 prepared the resident’s medications by removing an Amoxicillin-Pot Clavulanate tablet from the medication card and pushing it directly into her ungloved hand, then using her fingers to place the pill into a medication cup. The same process was observed for multiple other medications, including Escitalopram Oxalate, Furosemide, Sennosides, Lyrica, and Vitamin D, each being pushed from the card into the RN’s ungloved hand and then transferred by her fingers into the medication cup before administration to Resident #29. In a subsequent interview at 7:27 A.M. the same day, RN #281 confirmed she had placed each medication into her ungloved hands prior to administration and acknowledged that the proper procedure was to push the pills directly from the card into the medication cup. Review of the facility’s “Medication Administration – General guidelines” policy, revised 10/08/25, stated that medications are to be administered in accordance with good nursing principles and practices. This practice failure was cited as a deficiency under Complaint Number 2681777.
Improper Use of Wheelchair as a Physical Restraint
Penalty
Summary
Surveyors identified a deficiency related to the facility’s failure to ensure a resident was free from physical restraints. Resident #7, admitted with diagnoses including Alzheimer’s disease, diabetes mellitus, and anxiety disorder, was documented on a recent MDS as rarely understood and dependent for ADLs except eating. The resident ambulated independently on the unit without an assistive device and had documented verbal and other behaviors occurring one to three days during the look-back period. The care plan noted the resident had potential to be physically aggressive, chase staff, throw objects, and be combative with care, with interventions such as offering choices, administering medications as ordered, and intervening early when agitation occurred. During an observation and interview, Resident #7 was found sitting in a chair with the right arm of the chair positioned against the nursing station and a wheelchair placed directly in front of him. The left arm of the wheelchair was also against the nursing station, and both wheelchair wheels were locked, creating a barrier that appeared to restrain the resident, who was sleeping with his knees touching the locked wheelchair. An LPN confirmed both wheelchair wheels were locked and that the wheelchair should not have been placed in front of the resident. A CNA reported she had placed the wheelchair there in preparation to get the resident up for lunch, was unable to transfer him, and left the wheelchair in that position, acknowledging it was wrong to keep it there. The facility’s physical restraint policy stated that physical restraints are not used except when alternatives are not appropriate or effective for treating a medical symptom and defined physical restraints as any device attached or adjacent to the body that the individual cannot easily remove and that restricts freedom of movement or access to the body.
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