Majestic Care Of Whitehall
Inspection history, citations, penalties and survey trends for this long-term care facility in Whitehall, Ohio.
- Location
- 4805 Langley Avenue, Whitehall, Ohio 43213
- CMS Provider Number
- 366201
- Inspections on file
- 45
- Latest survey
- January 2, 2025
- Citations (last 12 mo.)
- 0
Citation history
Health deficiencies cited at Majestic Care Of Whitehall during CMS and state inspections, most recent first.
A facility failed to arrange necessary physician appointments for a resident with multiple health conditions, including COPD and congestive heart failure. Despite a physician's order for consultations with urology and gastroenterology, the facility did not secure these appointments after discovering the specialists did not accept the resident's payment sources. The DON confirmed the lack of follow-up to arrange the required consultations.
The facility failed to maintain a safe environment by not replacing transition strips in doorways after changing flooring, resulting in unleveled surfaces affecting several residents. The DON confirmed the flooring change but did not explain the missing strips.
A resident with severe cognitive deficits and multiple medical conditions was observed wearing mismatched non-skid socks, compromising their dignity. Despite being notified, the issue persisted, indicating a failure to adhere to the facility's policy on treating residents with respect and dignity.
A facility failed to notify a resident's physician of blood pressure readings exceeding ordered parameters. The resident, with a complex medical history including hypertension, had multiple elevated readings without physician notification or follow-up documentation. The DON confirmed the oversight, which violated the facility's policy on reporting changes in resident condition.
A resident with a complex medical history had sutures that were not removed within the physician-ordered timeframe of five to seven days, instead being removed on day 10. This delay was confirmed by the DON and represents a deficiency in following prescribed care protocols.
An LPN failed to follow proper infection control practices by not changing gloves or performing hand hygiene between administering nasal spray and eye drops to a resident. This action violated the facility's hand hygiene policy, which aims to prevent the spread of infection.
The facility failed to maintain a safe and clean environment, with issues including a deteriorating nightstand, food debris, and stained curtains in one room, and a frequently clogged sink in another. Despite maintenance efforts, the sink issue persisted, with staff unaware of the problem until informed by surveyors. These deficiencies were part of ongoing non-compliance.
The facility failed to provide necessary assistance for activities of daily living, affecting residents' nutrition and hygiene. A resident with cerebral infarction and dysphagia was left without meal assistance, resulting in an untouched tray. Another resident with end-stage renal disease had dirty fingernails, confirmed by an LPN, and a third resident, dependent on staff for hygiene, had long, dirty nails despite no evidence of non-compliance. This issue was part of ongoing non-compliance.
A resident with paranoid schizophrenia was not provided with necessary vision services despite a physician's order. The resident expressed the need for new glasses, but due to the absence of a social worker and lack of follow-up by an LPN, the resident was not scheduled to see an eye doctor. This deficiency was noted during a complaint investigation.
A resident with multiple health conditions experienced several falls due to the facility's failure to provide physician-ordered assistance devices, such as non-skid strips, despite being at risk for falls. The resident's intermittent confusion and impulsivity contributed to the incidents, and staff cited a room change as the reason for the absence of safety measures.
A facility failed to maintain proper infection control during incontinence care for a resident. An STNA changed gloves multiple times without washing hands, despite the presence of bowel movement, violating the facility's hand hygiene policy. The resident required assistance for toileting and personal hygiene, and the deficiency was noted during a complaint investigation.
A resident with a gastrostomy tube did not receive enteral feeding according to the physician's orders. The resident was supposed to receive Glucerna 1.5 calorie feeding from 6:00 P.M. to 6:00 A.M., but observations showed it was administered during the day. Interviews with an LPN and the DON confirmed the feeding schedule was not followed, leading to a deficiency finding.
The facility failed to monitor two residents on beta blockers for blood pressure control. One resident received Metoprolol despite low pulse rates, and another on Carvedilol lacked monitoring orders and had elevated blood pressures without physician notification. The facility lacked clear protocols for monitoring and communication, as confirmed by staff interviews.
The facility's medication error rate was 10%, affecting two residents. An LPN failed to administer Folic Acid to a resident due to unavailability and mistakenly gave Guaifenesin instead of Docusate Sodium to another resident, as the bottles looked similar. The latter resident did not have an order for Guaifenesin.
A facility failed to maintain an accurate water management program to prevent Legionella, affecting a resident who tested positive for Legionella antigen. The facility's policy required hot water boilers to be set above 140°F, but temperatures recorded in resident rooms were below 120°F. Interviews revealed that water temperatures were only recorded in resident rooms, not in hot water tanks, leading to potential Legionella growth.
A resident with a history of substance abuse experienced multiple overdoses in the facility due to inadequate supervision and ineffective interventions. Despite a care plan addressing his behaviors, the resident was found unresponsive on two occasions with drug paraphernalia, requiring Narcan and hospitalization. Staff interviews confirmed the lack of measures to prevent the resident from acquiring drugs during unsupervised outings.
A resident with right side hemiplegia from a stroke was not provided with a functioning electric wheelchair in a timely manner. The resident's electric wheelchair was found not charging, and the battery had died due to improper charging by night shift staff. The Therapy Director obtained a quote for a battery replacement, but the expense was not approved by the former Administrator. The DON was unaware of the charging issue, and the current Administrator was not informed of the need for battery approval.
A resident with severe cognitive impairment eloped from a secured unit and was found in the parking lot. The incident was not reported to the DON until the next day, and the resident's physician and responsible party were notified more than 24 hours later, violating facility policy.
A facility failed to prevent the elopement of two residents with cognitive impairments due to inadequate supervision. Despite an exit door alarm sounding, staff did not respond promptly, leading to a delay in discovering one resident missing. The investigation revealed that staff failed to conduct a timely search or head count, and the incident was not reported immediately as required by facility policy.
A resident with cirrhosis of the liver, emotional distress, and generalized pain did not receive timely physician services, as required by facility policy. The resident was not examined by their physician or any other qualified medical professional for 86 days, despite having concerns about kidney function, x-rays, and pain issues. This deficiency was confirmed through interviews and medical record reviews.
The facility failed to document TB test results for newly hired staff, including two STNAs and an RN, as required by their infection prevention policy. The second step TB test results were missing for the STNAs, and the RN's test results were not recorded. This oversight had the potential to impact all 126 residents.
The facility failed to maintain sanitary conditions in common area refrigerators, affecting residents except those in the memory care unit. A resident reported the 200 Hall refrigerator was full, unclean, and infested with flies and gnats. Observations confirmed unsanitary conditions, including undated and moldy food items. Staff were unsure who was responsible for maintenance, and temperature logs were missing. The facility's policy requires cleanliness and temperature tracking, which were not adhered to.
The facility failed to remove two expired vials of Tubersol from circulation, potentially affecting 66 new residents. Observations revealed opened vials without 'open as of' dates in medication storage rooms. LPNs confirmed the vials were expired and needed disposal. Manufacturer guidelines and facility policy required such vials to be discarded after 30 days or past expiration.
The facility failed to maintain effective pest control, affecting three residents and potentially impacting all residents except those in the memory care unit. A resident reported flies and gnats in a refrigerator, confirmed by the Administrator. Another resident's room had multiple flies and gnats, with food in the bed and empty containers nearby. A third resident's room also had flies, some landing on her meal tray. The facility's pest control company conducts monthly treatments, but the presence of pests indicates a failure to maintain a pest-free environment.
The facility failed to notify residents when their fund accounts reached $200 less than the SSI resource limit, affecting three residents with Medicaid. The Business Office Manager was unaware of the requirement, leading to delayed notifications, contrary to the facility's policy.
A facility failed to assess and document a resident's transfer to the hospital for pain evaluation. Despite a physician's order, there were no progress notes or Interact assessments completed. The resident, with a history of Parkinson's and diabetes, was transferred without documented reasons, contrary to facility expectations.
The facility failed to provide personalized smoking care plans for two residents, one with chronic respiratory issues and another with end-stage renal disease. Despite being assessed as smokers, neither resident had a care plan addressing smoking-related privileges or restrictions, contrary to the facility's policy. Observations and interviews confirmed the deficiency, highlighting a lapse in policy adherence.
A resident with multiple health issues, including Alzheimer's and malnutrition, did not receive adequate assistance with eating, despite being dependent on staff for ADLs. Observations showed the resident's food was left uneaten without staff intervention, and interviews confirmed inconsistent assistance. Facility policy required necessary services for residents unable to perform ADLs, which was not followed.
A resident with dementia and diabetes did not receive proper foot care, as her care plan required. Despite being dependent on staff for hygiene, her toenails were long, thick, and jagged, with no documentation of foot condition in weekly assessments. Staff interviews revealed she was not on the podiatry list for six months, contrary to facility policy requiring regular nail care and physician notification for abnormalities.
A resident with COPD and respiratory failure was observed using an oxygen tank without a physician's order for oxygen administration, except for nighttime use for sleep apnea. The resident managed the oxygen himself, and the DON confirmed the need for supplemental oxygen to maintain appropriate saturation levels. The facility's policy required physician orders for oxygen administration.
A resident with dementia fell while attempting to transfer into a locked wheelchair, resulting in swollen shins and a fracture. Despite complaints of pain and visible distress, the facility staff failed to adequately document or address her pain, with no follow-up on a recorded pain level of five. Non-verbal pain assessments were not completed, and the facility's pain management policy was not followed. The resident was later transferred to the hospital, where additional injuries were identified.
The facility failed to conduct PTSD assessments and document triggers for residents with PTSD, affecting their care plans. A resident receiving antipsychotic and antidepressant medications, another on antipsychotic, antidepressant, and opioid medications, and a third with a care plan lacking trigger identification were all impacted. Interviews confirmed the absence of necessary assessments and documentation, highlighting a deficiency in providing trauma-informed care.
The facility failed to ensure proper medication administration parameters for four residents, leading to unnecessary medication use. A resident received pain medications without specific parameters, while two others were given heart medications without required monitoring of vital signs. The DON and LPNs confirmed these deficiencies.
A facility failed to justify and monitor the use of Azithromycin for a resident with chronic respiratory conditions. Despite the facility's antibiotic stewardship policy, there was no evidence of monitoring the antibiotic's effectiveness or justification for its use. Interviews with the DON and RNC confirmed the lack of monitoring, and the resident's antibiotic usage was not documented in the infection control logs.
A resident with multiple sclerosis and reduced mobility had inconsistent and inaccurate pressure ulcer assessments, with discrepancies in staging and measurements. The facility's wound care policy was not followed, as confirmed by the DON, who noted delays in documentation and incorrect staging of wounds.
The facility failed to evaluate and supervise residents for safe smoking, affecting two residents. One resident with COPD and supplemental oxygen was found with marijuana paraphernalia in the smoking area, contrary to policy. Another resident, a smoker with end-stage renal disease, lacked a safe smoking evaluation and care plan, and smoked unsupervised outside posted times. The facility's policy requires supervision for all smokers, which was not followed.
The facility did not complete reference checks for newly hired staff, including RNs, STNAs, the business office manager, and the social services director, before employment. This oversight was confirmed by the HR representative, despite being a required part of the hiring process. The facility's policy on abuse prevention mentioned background checks but did not specifically address reference checks, potentially affecting the care and safety of all 126 residents.
The facility failed to provide evidence of completed performance reviews for two STNAs, potentially affecting all 126 residents. STNA #441 and STNA #578 lacked annual evaluations, as confirmed by HR staff, indicating a lapse in maintaining up-to-date performance reviews.
Failure to Arrange Physician Appointments as Ordered
Penalty
Summary
The facility failed to arrange physician appointments as ordered for a resident, identified as Resident #16, who was admitted with multiple diagnoses including Chronic Obstructive Pulmonary Disease, morbid obesity, cirrhosis of the liver, congestive heart failure, anxiety, and hypertension. The resident, who had intact cognition and required assistance with daily activities, had a physician's order dated 11/27/24 for consultations with Central Ohio Urology and Ohio Gastroenterology for evaluation and treatment of a staghorn calculus and gastric/esophageal thickening, respectively. However, progress notes from 12/17/24 indicated that the facility contacted both specialties, but they did not accept the resident's payment sources. There was no further documentation of attempts to secure these appointments. The Director of Nursing confirmed on 01/02/25 that no follow-up had been made since 12/17/24 to arrange the necessary consultations.
Missing Transition Strips Create Unleveled Surfaces
Penalty
Summary
The facility failed to maintain a safe and functional environment due to missing transition strips in the doorways of resident rooms, leading to an unleveled surface between the resident room floors and the hallway. This deficiency was observed during a survey on November 4, 2024, affecting eight residents residing on a specific hallway. The issue arose after the facility removed carpet and replaced it with a different type of flooring, but did not replace the transition strips. An interview with the Director of Nursing confirmed the removal of the carpet and installation of new flooring, but no explanation was provided for the absence of the transition strips.
Resident Dignity Compromised by Mismatched Socks
Penalty
Summary
The facility failed to ensure that a resident was treated with respect and dignity, as evidenced by the mismatched non-skid socks worn by the resident. The resident, who had a severe cognitive deficit and multiple medical conditions including early onset Alzheimer's disease, severe dementia, and secondary Parkinsonism, was observed wandering behind the memory care unit nurse's station with mismatched socks. Initially, the resident was seen wearing a yellow non-skid sock on the right foot and a white low cut sock on the left foot. Upon notification, an LPN took the resident to his room to change his socks. However, shortly after, the resident was observed again with mismatched socks, this time with a yellow non-skid sock on the right foot and a navy blue non-skid sock on the left foot. The LPN verified that the resident was not being treated in a dignified manner due to the mismatched socks. The facility's policy on dignity emphasizes the importance of treating each resident with respect and dignity, recognizing their individuality, and maintaining or enhancing their quality of life. This incident was investigated under a specific complaint number, indicating non-compliance with the facility's policy.
Failure to Notify Physician of Elevated Blood Pressure
Penalty
Summary
The facility failed to notify Resident #133's physician of blood pressure readings that exceeded the physician-ordered parameters. Resident #133, who has a complex medical history including end-stage renal disease, hypertension, and other chronic conditions, was admitted with a care plan that required notifying the physician if blood pressure readings exceeded 150/90. Despite this, the resident's blood pressure readings on multiple occasions were above this threshold, specifically on 10/27/24, 10/28/24, 10/29/24, and 11/03/24, without any documented notification to the physician or a follow-up progress note. The Director of Nursing confirmed that the physician was not notified of these elevated blood pressure readings, and no follow-up progress note was documented in the resident's medical record. The facility's policy mandates prompt identification, response, and reporting of changes in resident condition to the physician or other designated medical personnel, which was not adhered to in this case. This oversight affected one of the nine sampled residents in a facility with a census of 118.
Failure to Remove Sutures as Ordered
Penalty
Summary
The facility failed to adhere to physician orders regarding the removal of sutures for a resident, leading to a deficiency in care. The resident, who had a complex medical history including end stage renal disease, chronic obstructive pulmonary disease, and other significant conditions, was admitted with a laceration above the left eye that required sutures. The care plan specified that these sutures should be removed within five to seven days, as per the physician's directive. However, the medical record review revealed that the sutures were not removed until day 10, which was confirmed by the Director of Nursing during an interview. The resident's plan of care included several interventions to monitor and manage the laceration, such as observing for signs of infection, providing pain medication as needed, and keeping the area clean and dry. Despite these measures, the delay in suture removal indicates a lapse in following the prescribed treatment timeline. This oversight affected the resident's care and was identified during a survey, highlighting a deficiency in the facility's adherence to physician orders and care protocols.
Infection Control Breach During Medication Administration
Penalty
Summary
The facility failed to maintain appropriate infection control practices during the administration of eye drops, affecting one resident. During an observation of medication administration, an LPN donned gloves at the medication cart, gathered medications including a nasal spray and eye drops, and entered the resident's room. The LPN assisted the resident with oral medications, wiped the tip of the nasal spray applicator with a tissue, and administered the nasal spray. Without changing gloves or performing hand hygiene, the LPN then administered eye drops to the resident. This action was in violation of the facility's hand hygiene policy, which requires proper hand hygiene procedures to prevent the spread of infection.
Facility Fails to Maintain Safe and Clean Environment
Penalty
Summary
The facility failed to maintain a safe, clean, and comfortable environment for its residents, as evidenced by observations and interviews. In one room, a nightstand was missing a drawer, had a deteriorating finish, and there was food debris on the floor. The walls had exposed drywall patches, and the privacy curtain was stained. These conditions were observed multiple times over several days and were confirmed by the Director of Nursing. In another room, the bathroom sink was frequently clogged with standing, dirty water, preventing residents from washing their hands. Despite maintenance efforts to unclog the sink, it continued to become blocked, with maintenance staff unaware of the issue until informed by surveyors. Interviews with the Maintenance Director and an LPN confirmed the recurring problem, with conflicting accounts regarding the cause of the clogging. This deficiency was part of a continued non-compliance issue from a previous survey.
Deficiency in Providing Necessary ADL Assistance
Penalty
Summary
The facility failed to provide necessary services for residents who were unable to perform activities of daily living, affecting their nutrition and personal hygiene. Resident #24, with diagnoses including cerebral infarction and dysphagia, required substantial assistance with eating and personal hygiene. Observations revealed the resident in a soiled hospital gown with dirty fingernails, and no staff assistance was provided during meal delivery, resulting in an untouched lunch tray. The Director of Nursing confirmed the lack of assistance and the resident's need for a new meal and hygiene care. Resident #30, diagnosed with end-stage renal disease and diabetes, required assistance with personal hygiene. Observations showed the resident with dirty fingernails, which were confirmed by an LPN to have a substance resembling bowel movement. Despite the resident's ability to feed herself, her nails remained unclean until a later observation. Resident #9, who was dependent on staff for personal hygiene and frequently incontinent, was observed with long, dirty nails. Staff indicated the resident refused nail care, but there was no evidence of non-compliance in her care plan. This deficiency was part of a continued non-compliance issue from a previous survey.
Failure to Provide Vision Services
Penalty
Summary
The facility failed to ensure that a resident received proper treatment and assistive devices to maintain vision. Resident #55, who was admitted with a diagnosis of paranoid schizophrenia, was noted to wear corrective lenses according to a Minimum Data Set assessment. Despite having a physician's order from August 2022 to be seen by an optometrist, there was no evidence that the resident had been seen by any physician for vision-related issues since admission. During an interview, the resident expressed the need for new glasses, stating that he was unable to see with his current ones. A Licensed Practical Nurse acknowledged awareness of the resident's request for new glasses and mentioned that the social worker was supposed to arrange an appointment with the eye doctor about a month prior. However, the facility no longer had a social worker, and the nurse had not followed up to ensure the resident was on the list to see the eye doctor or to confirm the eye doctor's visit schedule. This deficiency was identified during an investigation under Complaint Number OH00157451.
Failure to Provide Fall Prevention Measures
Penalty
Summary
The facility failed to ensure that a resident received physician-ordered assistance devices to prevent falls, affecting one of three residents reviewed for falls. The resident, who had diagnoses including cerebral infarction, diabetes, end-stage renal disease, and schizophrenia, was admitted to the facility and required substantial assistance with transfers. Despite this, the resident experienced multiple falls, some resulting in injuries, due to a lack of appropriate interventions and assistance devices. The resident was noted to have intermittent periods of confusion and impulsivity, which contributed to the falls. The facility's inaction included failing to implement non-skid strips beside the resident's bed, despite a physician's order and a care plan intervention. Observations confirmed the absence of these strips, and staff interviews revealed that a room change was cited as the reason for their absence. The deficiency was part of a continued non-compliance issue, as similar deficiencies were noted in previous surveys. The report highlights the facility's failure to provide adequate supervision and safety measures for the resident, leading to repeated falls and hospitalizations.
Infection Control Deficiency in Incontinence Care
Penalty
Summary
The facility failed to maintain proper infection control techniques during incontinence care for a resident. The resident, who was frequently incontinent of urine and always incontinent of bowel, was observed receiving care from a State tested Nurses Aide (STNA). The STNA used hand sanitizer, prepared water, and donned gloves before providing care. However, during the process, the STNA changed gloves multiple times without washing hands in between, despite the presence of bowel movement on the washcloths. This action was contrary to the facility's Hand Hygiene policy, which requires hand hygiene to be performed before donning gloves and immediately after removing them. The incident involved a resident who was readmitted to the facility with intact cognition and required assistance for toileting and personal hygiene. The deficiency was identified during an observation of incontinence care, where the STNA failed to adhere to the hand hygiene protocol. The STNA confirmed in an interview that she did not wash her hands between glove changes. This deficiency was documented as part of a complaint investigation under Complaint Number OH00157991.
Improper Enteral Feeding Schedule for Resident
Penalty
Summary
The facility failed to ensure that a resident with a gastrostomy tube received the appropriate enteral feeding as ordered by the physician. The resident, who had a history of cerebral infarction, diabetes, dysphagia, protein-calorie malnutrition, and malignant neoplasm of the prostate, was supposed to receive Glucerna 1.5 calorie enteral feeding at 100 cc's per hour from 6:00 P.M. to 6:00 A.M. only. However, observations revealed that the feeding was administered outside of these hours, with a new bottle being hung at 8:00 A.M., contrary to the physician's orders. Interviews with the nursing staff confirmed the deviation from the prescribed feeding schedule. A Licensed Practical Nurse acknowledged that the enteral feeding was hung by the night shift nurse at 8:00 A.M., and the Director of Nursing confirmed that the feeding should not have been running during the day. The enteral feeding was intended to be administered at night to ensure the resident had more appetite during the day. This incident was part of a complaint investigation and was identified as a deficiency in the facility's compliance with the resident's care plan.
Failure to Monitor Blood Pressure in Residents on Beta Blockers
Penalty
Summary
The facility failed to adequately monitor residents receiving medications for blood pressure control, affecting two residents. Resident #71, who had severe cognitive impairment and was on Metoprolol Succinate ER for hypertension, had parameters to hold the medication if the systolic blood pressure was less than 100 or pulse was less than 60. Despite the physician discontinuing these parameters, the medication was administered on multiple occasions when the resident's apical pulse was below 60, without any nursing judgment to hold the medication. This oversight was confirmed by the Director of Nursing. Resident #140, with diagnoses including end-stage renal disease and hypertension, was on Carvedilol for blood pressure control but lacked physician orders for monitoring blood pressure or pulse. The resident's care plan indicated a risk for impaired cardiac output, yet there were no parameters for notifying the physician of abnormal blood pressures. The resident had bilateral non-functioning fistulas, complicating blood pressure monitoring, and there was no clear guidance on which limb to use. Elevated blood pressures were documented on dialysis communication sheets, but there was no evidence of physician notification or timely follow-up, as confirmed by the Director of Nursing. Interviews with the Nurse Practitioner and a Nephrologist revealed a lack of awareness and communication regarding the residents' blood pressure management. The Nurse Practitioner was unaware of the documented blood pressures and emphasized the need for regular monitoring. The Nephrologist, not directly involved in the resident's care, stated that elevated blood pressures should prompt physician notification and medication administration by the facility. The Director of Nursing confirmed the absence of a policy for managing abnormal vital signs without physician-ordered parameters, highlighting a systemic issue in monitoring and communication.
Medication Error Rate Exceeds Acceptable Threshold
Penalty
Summary
The facility failed to maintain a medication error rate below five percent, with an observed error rate of 10 percent. This deficiency affected two residents during medication administration. For Resident #8, a prescribed dose of Folic Acid was unavailable for administration at the scheduled time, and the LPN was unaware of the reason for its unavailability. For Resident #52, the LPN mistakenly administered Guaifenesin instead of the prescribed Docusate Sodium due to the similar appearance of the medication bottles. The resident did not have a physician's order for Guaifenesin, highlighting a significant medication administration error.
Failure to Maintain Water Management Program for Legionella Prevention
Penalty
Summary
The facility failed to maintain a complete and accurate water management program to prevent the spread of Legionella, which affected one resident and had the potential to affect all 129 residents. The deficiency was identified during a review of the facility's policy, hospital records, water temperature logs, and interviews with staff and the local health department. The facility's water management program, based on CDC and ASHRAE recommendations, was not properly implemented, as it did not include parameters for safe water storage, and the hot water temperatures in the tanks were not monitored to ensure compliance with the policy. Resident #9, who was admitted with chronic kidney disease stage IV, was found to have a positive Legionella antigen urine result after being sent to the emergency room due to lethargy, hypoxemia, and not following commands. The resident was diagnosed with acute respiratory failure and severe sepsis, with pneumonia confirmed on a chest x-ray. The facility's water management plan required hot water boilers to be set to 140 degrees Fahrenheit or higher, but the recorded temperatures in resident rooms were below 120 degrees Fahrenheit, indicating a failure to maintain the necessary water temperatures to control Legionella growth. Interviews with the Maintenance Director and the Administrator revealed that water temperatures were only being recorded in resident rooms, not in the hot water tanks, as required by the facility's policy. The Maintenance Director stated that his electronic form instructed him to only record temperatures in residents' rooms, and the Administrator confirmed that the facility's water management plan did not include parameters for safe water storage. This oversight led to the potential spread of Legionella, as evidenced by the positive test result for Resident #9.
Inadequate Supervision Leads to Resident Overdoses
Penalty
Summary
The facility failed to provide adequate supervision and a safe environment for a resident with a history of psychoactive substance abuse, leading to recurrent overdosing incidents. The resident, who was cognitively impaired and independently mobile via an electric wheelchair, was admitted with a diagnosis of psychoactive substance abuse and was receiving medications for opioid dependence. Despite having a care plan that included various interventions to manage his behaviors and substance use, the resident experienced multiple overdoses within the facility. On two separate occasions, the resident was found unresponsive due to suspected opioid overdoses, with drug paraphernalia discovered in his possession. The first incident involved the resident being found in a restroom with a crack pipe and required administration of Narcan and hospitalization. The second incident occurred in the resident's room, where he was found with a glass pipe containing residue, again necessitating Narcan administration and hospital transfer. Both incidents were linked to the resident's unsupervised outings, during which he likely obtained drugs. Interviews with facility staff, including LPNs and the DON, confirmed that there were no effective interventions in place to prevent the resident from acquiring substances during his unsupervised leaves of absence. The facility's policy prohibited the use of illegal drugs, but it was not effectively enforced, as evidenced by the repeated overdoses and the resident's ability to bring substances into the facility. The deficiency was noted as a continuation of non-compliance from previous surveys.
Failure to Provide Timely Electric Wheelchair Maintenance
Penalty
Summary
The facility failed to provide a resident with an operating electric wheelchair in a timely manner, affecting one of the three residents reviewed for accommodation of needs. The resident, who was admitted with right side hemiplegia from a stroke, had intact cognition and required two staff for lift transfers to his wheelchair. During an interview and observation, it was revealed that the resident's electric wheelchair was not working, and he expressed a preference for using it over a standard wheelchair. The electric wheelchair was found in the resident's bathroom, not charging, while the resident was in bed. The Therapy Director disclosed that the wheelchair's battery had died because the night shift staff were not properly charging it. A quote for a battery replacement was obtained, but the expense was not approved by the former Administrator. The Director of Nursing was unaware of the issue with the night shift staff not charging the battery, and the current Administrator was not informed of the need for approval to order the battery. The facility's policy on Accommodation of Needs, dated February 2023, states that staff will make reasonable accommodations to promote residents' independent functioning, dignity, and well-being. This deficiency was investigated under Complaint Number OH00155945.
Delayed Notification of Elopement Incident
Penalty
Summary
The facility failed to timely notify the responsible party and physician of an elopement incident involving a resident with severe cognitive impairment. The resident, who was admitted with diagnoses including dementia, psychosis, and anxiety, was found to have exited the secured unit and entered the parking lot. This incident was not reported to the Director of Nursing until the following day, and the resident's physician and responsible party were notified more than 24 hours after the event. The facility's policies require that the physician and responsible party be notified within 24 hours of an incident involving a resident. However, in this case, the notification was delayed, which constitutes a deficiency. The incident was discovered during an investigation of a separate elopement incident involving another resident, highlighting a lapse in communication and adherence to established protocols.
Failure to Prevent Resident Elopement Due to Inadequate Supervision
Penalty
Summary
The facility failed to provide adequate supervision to prevent a resident with altered mental status and exit-seeking behaviors from leaving the facility unsupervised. Resident #6, who had diagnoses of Alzheimer's dementia and anxiety, was admitted to the facility and resided on a secured unit. Despite being assessed as having severely impaired cognition and being ambulatory, Resident #6 managed to elope from the secured unit. The incident occurred when the exit door alarm sounded, but the staff did not respond promptly. Another resident, Resident #4, was found outside in the parking lot by an STNA, who did not immediately report the finding to other staff members. It was only after a head count was initiated by an LPN returning from break that Resident #6 was discovered missing. The investigation revealed that the staff did not observe either resident leaving the secured unit, and there was no video footage available. The root cause identified was the failure of the STNAs to respond to the door alarm in a timely manner, conduct a thorough search, or perform a timely head count. Interviews with the DON and CRN confirmed these findings, and it was noted that the staff did not report the elopement of Resident #4 until the following day. The facility's policy on elopement and wandering emphasized the need for adequate supervision and immediate alerting of personnel if a resident was found missing, which was not adhered to in this case.
Failure to Provide Timely Physician Services
Penalty
Summary
The facility failed to provide timely physician services to a resident, identified as Resident #115, who was admitted with diagnoses including cirrhosis of the liver, emotional distress, and generalized pain. The resident's most recent Minimum Data Set (MDS) assessment indicated intact cognition. The resident had not been examined by their physician, Physician #70, or any other qualified medical professional such as a physician assistant, nurse practitioner, or clinical nurse specialist from May 7, 2024, to July 22, 2024, a period of 86 days. This lack of timely medical attention was confirmed through interviews with the resident, the Corporate Registered Nurse, and Physician #70. The facility's policy required that a physician or a legally approved delegate review the resident's total program of care, including medications and treatment, at least every 60 days after the first 90 days post-admission. However, this policy was not adhered to in the case of Resident #115, as verified by the Corporate Registered Nurse and Physician #70. The resident expressed concerns about his kidney function, x-rays completed in May 2024, and ongoing pain issues that he wished to discuss with his physician, highlighting the impact of the missed visits. This deficiency was investigated under Complaint Number OH00156040.
Incomplete TB Test Documentation for New Hires
Penalty
Summary
The facility failed to properly administer and document tuberculin (TB) tests for newly hired staff, which is a requirement for infection prevention and control. The personnel files of three staff members, including two State tested Nursing Aides (STNAs) and one Registered Nurse (RN), were reviewed and found to have incomplete TB test documentation. STNA #644's file showed that the second step of the TB skin test was administered but not recorded on the Employee Immunization Record. Similarly, STNA #589's second step TB test results were not documented. Additionally, RN #575's initial TB test was not signed by the administering nurse, and the results of both the initial and second step tests were not recorded. Interviews with Human Resource personnel confirmed the lack of documentation for the TB test results in the staff members' files. The facility's policy on Infection Prevention and Control, dated January 2024, mandates TB testing for direct care staff upon hire. The failure to document these tests as required by the facility's policy had the potential to affect all 126 residents residing in the facility.
Unsanitary Conditions in Common Area Refrigerators
Penalty
Summary
The facility failed to maintain a safe and sanitary environment for residents using the common area refrigerators, as evidenced by interviews, observations, and policy review. A resident reported that the refrigerator in the 200 Hall activities area was full, unclean, and infested with flies and gnats. Observations confirmed the presence of a spilled drink, undated food items with mold-like substances, and unsanitary conditions in both the refrigerator and freezer. Staff interviews revealed uncertainty about who was responsible for maintaining the refrigerator, with both an Activities Assistant and an LPN expressing a lack of knowledge regarding its upkeep. Further observations of the 100 Hall refrigerator revealed similar issues, including the absence of a temperature log and undated food items. An LPN confirmed the lack of temperature logs for the past year, attributing it to residents removing them. The facility's policy, revised in December 2014, mandates that refrigerators and freezers be kept clean and that monthly tracking sheets be posted to record temperatures. However, these procedures were not followed, leading to unsanitary conditions that could potentially affect all residents except those in the memory care unit.
Expired Tubersol Vials Not Removed from Circulation
Penalty
Summary
The facility failed to remove two expired vials of Tubersol, a tuberculin solution, from circulation, which had the potential to affect 66 residents who were new admissions in the last six months. During an observation, a partially used multiple dose vial of TB solution with lot number 68154 and an expired date was found in the refrigerator of the 300-hallway medication storage room. The vial lacked an 'open as of' date and instructions for administration. An LPN confirmed the vial's presence and acknowledged it needed to be removed and disposed of due to the uncertainty of when it was opened and if it had been in use for more than 30 days. Another observation revealed a second opened and expired vial of TB solution with lot number 57798 in the memory unit medication storage room refrigerator. This vial was also without an 'open as of' date. An LPN confirmed the vial was expired and stated it would be removed and disposed of. The manufacturer's guidelines indicated that a vial of Tubersol should be discarded after 30 days of use and not used past its expiration date. The facility's policy required outdated or deteriorated drugs to be returned to the pharmacy or destroyed.
Failure to Maintain Effective Pest Control
Penalty
Summary
The facility failed to maintain effective pest control, affecting three residents and potentially impacting all residents except those in the memory care unit. Resident #113 reported flies and gnats in the refrigerator in the activities area on the 200 Hall, which was confirmed by an observation and interview with the Administrator. Additionally, Resident #7's room was observed to have multiple flies and gnats, with food in the bed and a large box of empty food and drink containers beside the bed. Resident #96's room also had multiple flies, some landing on her meal tray, and she stated that flies were always present in her room. The facility's pest control company conducts monthly preventative treatments and additional treatments as needed, targeting flies and small fruit flies or gnats. A review of the pest control invoices indicated that treatment was completed for all drains and areas under and behind equipment to control small flies, with light fruit fly activity noted in the kitchen and dishwasher areas. The facility's Pest Control Policy, dated February 2021, states the facility's commitment to maintaining a pest-free environment, yet the presence of pests in resident areas indicates a failure to uphold this policy.
Failure to Notify Residents of Fund Thresholds
Penalty
Summary
The facility failed to notify residents or their representatives when the resident funds account reached $200 less than the Supplemental Security Income (SSI) resource limit for one person. This deficiency affected three residents who were reviewed for resident funds. All three residents had Medicaid as a payor source. The review of the Resident Fund accounts revealed that the balances for these residents exceeded the notification threshold for an extended period before they received a spend down notification. Specifically, Resident #14's account balance was above the threshold from April 29, 2024, to June 13, 2024, but the notification was not sent until June 3, 2024. Similarly, Resident #55's account balance was above the threshold from April 3, 2024, to May 20, 2024, with the notification also delayed until June 3, 2024. Resident #87's account balance was above the threshold from December 1, 2023, to June 13, 2024, with the notification sent on June 3, 2024. An interview with the Business Office Manager confirmed that the manager was unaware of the requirement to issue spend down notices before June 3, 2024. The facility's policy on Resident Personal Funds for 2023 states that residents receiving Medicaid benefits must be notified when their account balance reaches $200 less than the SSI resource limit. Failure to comply with this policy could result in residents losing eligibility for Medicaid or SSI if their account balance, combined with other nonexempt resources, reaches the SSI resource limit. The facility's oversight in providing timely notifications represents a significant lapse in adhering to its own policies and federal requirements.
Failure to Document and Assess Resident Transfer
Penalty
Summary
The facility failed to properly assess, document, and complete the transfer of a resident to the hospital for evaluation and treatment. This deficiency involved a resident with a medical history that included Parkinson's disease, atrial fibrillation, type two diabetes mellitus, and chronic pain syndrome. The resident, who had intact cognition and was able to communicate needs, was discharged to the hospital without a documented reason. The baseline care plan indicated the resident required assistance with discharge planning. On the day of the transfer, the resident's pain level was recorded as three out of ten, and a physician's order was issued to send the resident to the emergency room for evaluation and treatment for pain. However, the medical record lacked entries regarding the resident's health status, assessment of condition, or any family request for the transfer. An interview with the Director of Nursing confirmed that no progress notes or Interact assessments were completed prior to the transfer, which was against the facility's expectations for floor nurses to assess the resident, complete necessary documentation, notify the physician and family, and document the health status and reason for transfer.
Lack of Smoking Care Plans for Residents
Penalty
Summary
The facility failed to ensure that residents who smoked had a personalized smoking care plan, affecting two residents. Resident #94, who has chronic obstructive pulmonary disease, acute and chronic respiratory failure, cognitive impairment, and long-term use of opiate analgesics, was observed smoking marijuana in the facility's courtyard with oxygen tubing on the armrest of his wheelchair. Despite being educated on safe smoking practices and the facility's smoking policy, Resident #94 did not have a smoking care plan in place. The resident claimed that he had been smoking marijuana since he was 15 and continued to do so at the facility, indicating a lack of clarity in the initial smoking assessment conducted by the nursing staff. Resident #113, diagnosed with end-stage renal disease, dependence on renal dialysis, and chronic obstructive pulmonary disease, was assessed as a smoker but also lacked a smoking care plan. The facility's smoking policy, revised in July 2017, mandates that any smoking-related privileges, restrictions, and concerns should be noted on the care plan and communicated to all personnel caring for the resident. Interviews with the Administrator and the Director of Nursing confirmed the absence of a smoking care plan for Resident #113, highlighting a deficiency in the facility's adherence to its own policies.
Failure to Assist Resident with Eating
Penalty
Summary
The facility failed to provide adequate assistance with eating to a resident who required staff support for activities of daily living (ADLs). The resident, who had multiple diagnoses including polyneuropathy, diabetes mellitus type two, chronic kidney disease, and Alzheimer's disease, was identified as being at nutritional risk and dependent on staff for eating. Observations revealed that the resident's food tray was placed in front of them without staff assistance, and the resident did not consume the food. Staff interactions were limited to verbal encouragement without physical assistance, and the resident's uneaten food was removed without further intervention. Interviews with staff, including a State Tested Nursing Aide (STNA), Licensed Practical Nurse (LPN), and the Director of Nursing (DON), confirmed that the resident was not consistently assisted with meals. The MDS Coordinator acknowledged that the resident was dependent on staff for eating and should have been assisted by staff sitting with them for every meal. The facility's policy stated that residents unable to carry out ADLs should receive necessary services to maintain good nutrition, which was not adhered to in this case.
Failure to Provide Adequate Foot Care for Diabetic Resident
Penalty
Summary
The facility failed to provide appropriate foot care for a resident, identified as Resident #99, who was admitted with diagnoses including dementia, type II diabetes mellitus, and Alzheimer's disease. The resident was severely cognitively impaired and dependent on staff for personal hygiene. Her care plan indicated a need for routine and as-needed podiatry care due to her diabetes, with weekly skin inspections focusing on her feet. However, weekly skin assessments did not document the condition of her feet or toenails. A hospice nurse noted a nail abnormality on 05/28/24, describing the resident's toenails as thick and overgrown. Observations on 06/10/24 and 06/11/24 confirmed that Resident #99's toenails were long, thick, and jagged, with significant overgrowth on both great toenails. Interviews with facility staff revealed that the resident's toenails had not been addressed, and she was not on the podiatry list for the past six months. The facility's policy required staff to report unusual nail conditions to a physician and ensure routine nail care, especially for residents with diabetes. Despite these guidelines, the resident's toenails were neglected, and necessary referrals were not made.
Lack of Physician Orders for Oxygen Administration
Penalty
Summary
The facility failed to ensure that a resident had physician orders for oxygen administration, affecting one resident reviewed for respiratory care. The resident, who had diagnoses of chronic obstructive pulmonary disease (COPD) and acute and chronic respiratory failure, was observed sitting in the facility's courtyard with an oxygen tank attached to his wheelchair, but without the oxygen tubing in use. The resident confirmed that he regularly used oxygen and managed it himself. However, a review of the resident's medical records showed no routine or as-needed physician orders for oxygen administration, except for an order to apply two liters of oxygen at night for sleep apnea. The Director of Nursing confirmed the resident required supplemental oxygen to maintain appropriate oxygen saturation levels and acknowledged the absence of a current physician order for supplemental oxygen use. The facility's policy stated that oxygen should be administered under a physician's orders, except in emergencies.
Failure to Assess and Manage Pain After Resident Fall
Penalty
Summary
The facility failed to properly assess and manage the pain of a resident who fell and sustained a major injury. The resident, who had a history of restlessness, agitation, and dementia, fell while attempting to transfer herself into a locked wheelchair, resulting in swollen shins and a fracture. Despite the resident's complaints of pain and visible signs of distress, such as screaming when moved, the facility staff did not adequately document or address her pain. The resident was given Tylenol without a documented pain scale, and there was no follow-up on the pain level of five that was recorded. Additionally, non-pharmacological interventions were not attempted, and the physician was not notified of the resident's pain. Interviews with facility staff revealed that non-verbal pain assessments were not completed, and the facility's policy on pain management was not followed. The resident was eventually transferred to the hospital, where further injuries were identified, including a non-displaced proximal tibia fracture. The Regional Nurse Consultant confirmed that the facility staff should have conducted non-verbal pain assessments and addressed the resident's pain, especially given her cognitive impairments and inability to communicate effectively.
Failure to Provide Trauma-Informed Care for Residents with PTSD
Penalty
Summary
The facility failed to ensure that residents diagnosed with PTSD received appropriate assessments and documentation of triggers related to their condition. This deficiency affected three residents, each with a diagnosis of PTSD, who were reviewed for emotional needs and behaviors. Resident #33, who had intact cognition and was receiving antipsychotic and antidepressant medications, did not have a PTSD assessment completed, and no triggers were identified in their care plan. Similarly, Resident #92, who also had intact cognition and was on antipsychotic, antidepressant, and opioid medications, lacked a PTSD assessment and documentation of triggers in their care plan. Resident #104, with intact cognition and a diagnosis of PTSD, had a care plan addressing the cause of PTSD but did not include potential triggers or interventions to prevent re-traumatization. Interviews with Social Services Worker #656 confirmed the absence of PTSD assessments and identification of triggers for these residents. The lack of assessments and documentation of triggers for residents with PTSD represents a failure to provide trauma-informed care, which is essential for addressing the emotional and behavioral needs of these individuals.
Failure to Ensure Proper Medication Administration Parameters
Penalty
Summary
The facility failed to ensure that residents were free from unnecessary medication use, affecting four residents. Resident #10, who was cognitively intact, was administered Oxycodone and acetaminophen without parameters for as-needed pain medications. The medication administration records showed that Oxycodone was given 24 times, with 13 doses administered at a pain level of five or below, which was confirmed by the Director of Nursing (DON) and Licensed Practical Nurses (LPNs) as inappropriate without specific parameters. Resident #67, with severe cognitive impairment, was administered Metoprolol Succinate despite physician orders to hold the medication if the pulse was less than 60. The medication was given nine times when the resident's pulse was below the specified threshold. The DON and an LPN confirmed that the medication should not have been administered under these conditions, as it violated the physician's orders. Residents #83 and #91, both with severely impaired cognition, were administered medications without proper monitoring of blood pressure and heart rate, despite physician orders requiring such checks. Resident #83 was given hydralazine without documented blood pressure or heart rate monitoring, and Resident #91 received metoprolol without the necessary checks. Interviews with LPNs and the DON confirmed the lack of documentation and monitoring, which was against the facility's policy of administering medications as prescribed.
Inadequate Monitoring and Justification of Antibiotic Use
Penalty
Summary
The facility failed to provide adequate justification and monitoring for the use of an antibiotic, Azithromycin, prescribed to Resident #38. The resident, who was cognitively intact, was admitted with diagnoses including chronic obstructive pulmonary disease and acute and chronic respiratory failure. The physician's orders indicated that Azithromycin was to be administered prophylactically three times a week. However, there was no evidence in the medical records or infection control logs to justify the use of the antibiotic or to monitor its effectiveness. Interviews with the Director of Nursing and the Regional Nurse Consultant confirmed that there was no monitoring or testing conducted to determine the necessity or effectiveness of the antibiotic for Resident #38. The facility's antibiotic stewardship policy required complete antibiotic orders and monitoring as part of the stewardship program, but these protocols were not followed. The facility's infection control logs did not include the resident's antibiotic usage, indicating a lapse in the implementation of the antibiotic stewardship program.
Inaccurate Pressure Ulcer Assessments
Penalty
Summary
The facility failed to complete accurate pressure ulcer assessments for a resident with multiple sclerosis, reduced mobility, and contractures. The resident had two stage three and two stage four pressure ulcers, all of which were facility-acquired. The care plan included interventions such as using an air mattress, assessing and documenting skin condition, and notifying the medical director of any worsening conditions. However, the assessments were inconsistent and inaccurate, with discrepancies in the staging and measurements of the pressure ulcers. The Director of Nursing confirmed that the wound assessments were not accurate or consistent, as wounds cannot change stages in the manner documented. Additionally, there was a delay in documenting a pressure wound on the resident's right ischium, which was first observed on one date but not documented until a week later. The facility's wound care policy required documentation of wound care, changes in condition, and assessment data, but these were not adhered to in this case.
Failure to Ensure Safe Smoking Practices and Supervision
Penalty
Summary
The facility failed to ensure residents were evaluated for safe smoking and provided adequate supervision and monitoring of residents who smoke. This deficiency affected two residents, both of whom were not properly assessed or supervised for their smoking habits. Resident #94, who has chronic obstructive pulmonary disease and uses supplemental oxygen, was observed with marijuana paraphernalia and a lighter in the smoking area, despite the facility's policy prohibiting oxygen use in smoking areas. The resident was not initially identified as a smoker, and there was no smoking care plan in place for him. Resident #113, who has end-stage renal disease and chronic obstructive pulmonary disease, was identified as a smoker but did not have a completed safe smoking evaluation or a smoking care plan. The resident was listed as an unsupervised smoker and reported smoking outside of the facility's posted smoking times without supervision. The facility's policy requires all residents to be supervised during smoking, but this was not adhered to, as confirmed by interviews with the Administrator and the Director of Nursing. The facility's smoking policy, revised in July 2017, mandates that all residents be supervised during smoking and that any smoking-related privileges, restrictions, and concerns be noted on the care plan. However, the facility failed to implement these policies effectively, leading to unsupervised smoking by residents who were not properly assessed for safety. This deficiency was investigated under Master Complaint Number OH00154655.
Failure to Complete Reference Checks for New Hires
Penalty
Summary
The facility failed to ensure that reference checks were completed for newly hired staff prior to employment, which had the potential to affect all 126 residents residing at the facility. Personnel file reviews revealed that several staff members, including registered nurses, state-tested nursing assistants, the business office manager, and the social services director, did not have reference checks completed before being hired. An interview with the human resources representative confirmed that reference checks were a required part of the new hire process and should be available in each employee's personal file. However, it was confirmed that the necessary reference checks were not conducted for the identified staff members. The facility's undated policy on the Abuse Prevention Program indicated that employee background checks are conducted per state and federal regulations, but it did not specifically address the requirement for reference checks. This oversight in the hiring process could potentially impact the quality of care and safety of the residents.
Failure to Complete Nurse Aide Performance Reviews
Penalty
Summary
The facility failed to provide evidence of the completion of nurse aide performance reviews, affecting two State tested Nursing Assistants (STNAs) out of four personnel files reviewed. This deficiency had the potential to impact all 126 residents residing in the facility. Specifically, the personnel file of STNA #441, who was initially hired on 10/26/11 and rehired on 04/26/19, lacked an annual performance evaluation. Similarly, STNA #578, hired on 05/05/23, had a 90-day evaluation completed but no annual evaluation was available for review. An interview with Human Resources staff confirmed the absence of these evaluations, indicating a failure in maintaining up-to-date performance reviews for the STNAs. This oversight in documentation and evaluation processes could potentially affect the quality of care provided to the residents.
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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