Majora Lane Ctr For Rehab & Nsg Care Inc
Inspection history, citations, penalties and survey trends for this long-term care facility in Millersburg, Ohio.
- Location
- 105 Majora Lane, Millersburg, Ohio 44654
- CMS Provider Number
- 365632
- Inspections on file
- 23
- Latest survey
- January 8, 2026
- Citations (last 12 mo.)
- 17
Citation history
Health deficiencies cited at Majora Lane Ctr For Rehab & Nsg Care Inc during CMS and state inspections, most recent first.
Two residents on a secured unit did not receive meaningful or preferred activities despite documented preferences and care plan directives. One cognitively intact resident with dementia and depression had care plan goals to participate in music, religious services, socialization, and other leisure pursuits, yet records showed minimal participation beyond some food events and bingo, and observations found the resident in common areas without structured or independent activities. Another resident, who was legally blind with communication and mobility deficits, had documented preferences for music and news, but activity logs showed almost no provision of these, and observations over several days found the resident in a recliner or in bed with no music or TV playing. Staff interviews confirmed there was no dedicated activity staff on the secured unit, activity staff did not routinely go there, only a few residents were occasionally brought off the unit for activities, and there were no daily, structured activities despite a policy requiring accommodation of resident activity preferences.
A resident with visual impairment, cognitive communication deficit, and mobility difficulties was repeatedly observed in a common-area recliner positioned at an angle, with legs and head hanging off the chair and against a handrail, without a blanket, entertainment, or fluids within reach. Staff at the nearby nurses’ station and the ADON did not reposition the resident or offer a pillow, and the resident was not offered ice cream or cake during an activity. Even after being assisted into a wheelchair at the resident’s request, no drink was made available. The ADON confirmed the resident had been left in this undignified position without food or fluids within reach, explaining the resident was placed in the area so staff could keep the resident in sight.
A resident with a history of stroke, contractures, and vascular dementia had physician orders and a care plan requiring a left-hand palm protector or hand roll splint to be applied daily and nightly with skin checks and hand hygiene. The Treatment Administration Record indicated these interventions were consistently completed, but repeated observations over several days showed the resident without any palm protector or splint in the affected hand while in bed, in a wheelchair, and during activities. An RN confirmed the device was not in place and had been missing from the room for several days, resulting in a failure to provide ordered ROM support for the resident’s contracture.
A resident with hypertension, hallucinations, weakness, and cognitive communication deficit was assessed as initially at moderate, then high risk for falls. After the resident was found on the floor beside the bed following a fall without injury, the fall care plan was revised to include a perimeter mattress to define the bed edges. During a subsequent survey observation, the bed was found to have only a regular flat mattress without perimeter sides, and the ADON confirmed the perimeter mattress was not in place despite the care plan and facility policy requiring fall interventions based on identified risk factors.
Staff failed to use appropriate dementia‑focused, person‑centered approaches with two residents who had dementia and documented behavioral symptoms. In one case, a resident with a history of aggression resisted a scheduled shower; despite a care plan directing staff to stop care when the resident became combative and to return later, staff proceeded with the shower while reporting being hit and having hair pulled, and an LPN delayed responding to repeated requests for help while the resident was reportedly aggressive. In the second case, a resident with dementia and a care plan for verbal aggression and disruptive behaviors became frustrated with a staff member’s child who was running around during smoke time and struck the child; afterward, an LPN who was the child’s parent, and not the resident’s nurse, confronted the resident and told the resident she could be charged with assault, taken to jail, and was “lucky” the LPN was staff, rather than using calm, dementia‑appropriate communication as outlined in facility training and care plans.
Surveyors found that the facility failed to maintain accurate and complete medical records for three residents. For a resident with lower-extremity skin issues, Aquaphor ordered three times daily was documented on the MAR as given even though no ointment was visible and the RN admitted signing before administration. For another resident on a bowel and bladder incontinence program, bladder program service records contained numerous blanks where two-hourly incontinence checks and toileting assistance should have been documented, and a CNA confirmed that aides sometimes forget to sign the log. For a third resident with severe cognitive impairment, malnutrition, and ongoing weight loss, meal intake records were frequently incomplete, with some days missing meals or all documentation, and both the dietician consultant and DON confirmed that intake documentation was not consistently recorded.
Surveyors found that staff failed to follow required transmission-based precautions for two residents. One resident on enhanced barrier precautions for chronic wounds and a urinary catheter was transferred via mechanical lift by two CNAs who did not wear required gowns and gloves, despite posted signage and available PPE. Another resident on airborne precautions for Covid had appropriate signage and PPE at the door, but there was no hand sanitizer immediately available at the room exit, no disinfectant wipes or designated area to clean reusable eye protection, and no used eyewear present, conditions that were confirmed by the ADON.
Surveyors identified that multiple residents in a secured unit were exposed to unsanitary conditions, including a broken and soiled toilet seat riser used daily by two residents, persistent foul odors, and a malfunctioning toilet in the only shower room. Staff and maintenance confirmed the ongoing issues, which included grime, rust, and mold in resident bathrooms, in violation of the facility's environmental services policy.
Staff did not promptly inform a resident, the resident's doctor, and a family member about situations such as injury, decline, or room changes that affected the resident, as required by regulation.
A resident was subjected to physical restraints without a documented medical need, in violation of requirements that ensure restraints are only used for medical treatment.
A resident who was dependent on staff for personal care and incontinent of bowel and bladder was not provided timely incontinence care. Staff confirmed that the resident was only changed in the morning and not checked or changed again until the evening, despite care plan requirements and standard practices. When care was finally provided, the resident's brief was saturated and her skin was red and sore.
Surveyors found that appropriate care was not consistently provided to residents who were continent or incontinent of bowel and bladder, including improper catheter care and insufficient measures to prevent UTIs.
The facility did not adequately protect resident-identifiable information or maintain medical records according to professional standards, as observed by surveyors.
The facility failed to ensure proper food storage and preparation, with expired moldy bread found in dry storage and improper cleaning of a food processor used for pureed meals. A staff member also compromised food hygiene by using a spoon for taste testing and then placing it back into the food. These actions affected the quality and safety of meals served to residents.
A resident's room contained an unsecured oxygen tank, despite the discontinuation of the oxygen order. Facility staff confirmed that oxygen tanks should be stored in a locked room, upright, and in a storage rack when not in use. The facility's policy requires tanks to be secured, yet the tank was improperly stored, indicating a lapse in safety protocol adherence.
A facility failed to implement Enhanced Barrier Precautions during wound care for a resident with a Stage III pressure ulcer. Despite a care plan and signage requiring the use of gowns and gloves, an LPN and the ADON only used gloves during the procedure. They later acknowledged forgetting to don gowns, contrary to the facility's policy aimed at preventing infection transmission.
A resident with severe cognitive impairment and incontinence was found to have redness and excoriation on the buttocks, which was not documented or treated promptly. Despite the care plan's interventions, the prescribed extra protection cream was not applied until the day after the condition was noted. Observations showed the resident in pain during care, and staff interviews revealed communication and documentation lapses, leading to non-compliance with the facility's wound care policy.
A resident with a history of a right humerus fracture and other conditions experienced inadequate pain management due to the facility's failure to document and reassess pain levels. Despite receiving pain medications, the resident's pain was not properly evaluated, and follow-up assessments were not conducted. The facility's electronic system and staff practices contributed to the deficiency, as confirmed by the DON.
Failure to Provide Meaningful and Preferred Activities on Secured Unit
Penalty
Summary
The deficiency involves the facility’s failure to provide meaningful and preferred activities for residents on the secured unit, specifically for Resident #9 and Resident #11, despite identified preferences and care plan interventions. Resident #9, admitted with dementia, major depressive disorder, anxiety, and other medical conditions, had a BIMS score indicating intact cognition and a care plan stating the resident felt it was important to listen to music, be around animals, watch TV, play bingo, socialize, go outside in good weather, and attend religious services. The care plan directed staff to invite, encourage, and assist the resident to activities of interest and to provide supplies for independent leisure activities. Activity calendars showed that music, religious services, food activities, and bingo were regularly scheduled, but participation records for December showed Resident #9 did not attend any music or religious activities, only some food and bingo events, and observations during survey showed the resident in common areas without involvement in any structured or independent activity. Interviews with staff confirmed that the secured unit did not have an assigned activity person and that activity staff did not go to the secured unit to conduct activities. The Activity Coordinator stated that only three or four residents who could sit for 15 to 30 minutes were brought off the secured unit for activities, and verified that residents on the secured unit did not participate in certain scheduled activities such as bread day, although bread was passed to them. The Program Director for the secured unit stated that “Social Circle” on the activity log could mean puzzles, crafts, coloring, or other various activities, and that movies and watching TV were considered the same activity. The Program Director further stated that music was played during meals and the TV was on the rest of the time, and that these were considered daily activities for Resident #9, along with talking and interaction in common areas. However, the Program Director also verified there were no daily, structured activities on the secured unit and that nursing staff only did activities when able. For Resident #11, who was legally blind with a cognitive communication deficit, difficulty walking, and high blood pressure, the activity care plan documented that it was important to him to listen to music, keep up with the news, participate in group activities, go outside, attend religious services, and have snacks between meals. Review of daily activity logs over several weeks showed that the only documented music exposure occurred when musical entertainment performed at the facility, and there was only one entry for crafts, with no entries indicating that the resident listened to music or kept up with the news as preferred. Multiple observations over several days found Resident #11 lying or sitting in a recliner in a common area near the front desk and main entrance, or resting in bed, without music or TV playing. The Activity Coordinator confirmed that the resident had been seated in the common area for the past two days with no music or news playing, despite these being documented as important activity choices for him. The facility’s policy on Resident Activity Preferences stated that the facility would accommodate resident activity preferences through the comprehensive assessment and care planning process, which was not followed in these cases.
Failure to Provide Dignified Seating and Access to Fluids
Penalty
Summary
The deficiency involves the facility’s failure to reasonably accommodate a resident’s needs and preferences for appropriate and dignified seating and access to fluids. The resident had been admitted with diagnoses including legal blindness, cognitive communication deficit, difficulty walking, and high blood pressure, and had a physician’s order for a regular texture diet with thin liquids. On multiple observations, the resident was found lying or seated in a recliner in a common area near the front desk and main entrance, positioned at an angle with both legs hanging off the side of the footrest and the head hanging off or leaning against a handrail. The resident was not covered with a blanket, had no music or TV for engagement, and had no fluids within reach despite the diet order for thin liquids. Over several observation times, staff seated at the nearby nurses’ desk did not reposition the resident, offer a pillow, or otherwise adjust the resident’s seating to a more appropriate or dignified position, even as visitors walked past. When the ADON stopped to talk with the resident, the resident was still not repositioned. During an activity where ice cream and cake were being passed, the resident was not offered either item while seated in the common area recliner, and there continued to be no water cup available. Later, when the resident requested to be transferred from the recliner to a wheelchair, staff assisted with the transfer, but the resident still had no drink available within reach. In an interview, the ADON confirmed the resident had been lying in the recliner at an angle, was not repositioned, and had no food or fluids within reach, and stated the resident was brought to the common area so staff could keep the resident within their sight.
Failure to Implement Ordered Palm Protector for Contracture Management
Penalty
Summary
The deficiency involves the facility’s failure to provide ordered range of motion support for a resident with a left-hand contracture. The resident was admitted with multiple diagnoses including stroke, contractures, vascular dementia, hypertension, depression, and anxiety, and required staff assistance with ADLs while having intact cognition. Physician orders directed that a left-hand palm protector be applied each morning and removed at bedtime with skin integrity checks each shift, and that the resident tolerate a hand roll splint or palm protector nightly, with the left hand thoroughly washed and dried before and after use. The resident’s ADL functional status care plan also specified use of a palm protector to the left hand for contracture management. The Treatment Administration Record for the review period showed these orders as completed as written. However, multiple observations over several days showed the resident without a palm protector or hand roll splint in the left hand while in bed, in a wheelchair, and participating in activities. On each observed occasion, no palm protector was visible despite the active orders and documented completion on the TAR. In an interview, an RN confirmed that the resident did not have a palm protector in place and reported that the device could not be found in the room and had been missing for several days. This discrepancy between physician orders, care plan, documented implementation, and actual practice led to the cited deficiency for failure to maintain range of motion for a resident with contracture.
Failure to Implement Care-Planned Fall Intervention for High-Risk Resident
Penalty
Summary
The deficiency involves the facility’s failure to implement a care-planned fall intervention for a resident identified as being at risk for falls. The resident was admitted with diagnoses including high blood pressure, hallucinations, weakness, and cognitive communication deficit. A Falls Risk Observation completed at admission showed a moderate fall risk with a score of eight, and a subsequent Falls Risk Observation increased the resident’s status to high risk with a score of 14. A Safety Event report documented that the resident experienced a fall without injury when found lying on the floor beside the bed in the early morning hours, with the only intervention in place at the time being the bed in the lowest position. Following this fall, the resident’s fall care plan was revised to include a perimeter mattress to help define the edges of the bed. However, during a later observation, surveyors noted that the resident’s bed had a regular flat mattress with no perimeter sides in place. In an interview, the ADON confirmed that the resident did not have a perimeter mattress and instead had a regular flat mattress, and stated that the resident had moved into the current room sometime in October. Review of the facility’s Fall Investigation policy showed that the interdisciplinary team is required to review current interventions and implement additional fall interventions based on residents’ risk factors, but the perimeter mattress intervention that had been added to the care plan was not in place for this resident.
Failure to Provide Appropriate Dementia‑Focused Care and Responses to Behavioral Incidents
Penalty
Summary
The deficiency involves the facility’s failure to ensure staff had the skills and used appropriate approaches to provide person‑centered dementia care to two residents with dementia and behavioral symptoms. For one resident with dementia, depression, anxiety, psychosis, and documented physical and verbal aggression, the care plan specified that staff should offer alternatives when care was refused, allow the resident to make choices, maintain a calm environment, approach slowly and calmly, and stop care if the resident became combative, ensuring safety and returning later. Progress notes documented that this resident was confused, resistive, and combative at times, with increased restlessness, anxiety, and verbal aggression. On the night in question, staff reported the resident initially agreed to a shower but then became combative in the shower room, pulling a staff member’s hair and exhibiting aggressive behaviors. According to staff statements and the self‑reported incident, a resident assistant and a trainee CNA reported that the resident was combative during the shower and that they were being hit, bitten, and having hair pulled. The RA sought guidance from an RN, who advised using two aides and suggested one aide watch or hold the resident’s hands as a distraction so the resident would not grab, hit, or pull hair. The RA and CNA reported feeling that they were being forced to complete the shower despite the resident’s resistance. The LPN on duty acknowledged knowing that the resident did not want to be showered and that staff had asked her for help multiple times while they were agitated and reporting aggression. The LPN did not immediately enter the shower room, continued other tasks, and only later went in, at which time she found the resident agitated but not aggressive and used a redirection strategy (offering to take the resident back to her “baby”) to complete drying and dressing. Another CNA later provided care without issues. The LPN verified that if a resident became combative or agitated, staff should stop what they were doing, and also verified she did not immediately assess the situation in the shower room to ensure the resident’s safety. The second component of the deficiency concerns the facility’s failure to ensure staff approached a resident with dementia appropriately after a behavioral incident. This resident had dementia without behavioral disturbance listed among diagnoses but had a care plan for verbal aggression, hallucinations, false accusations, yelling, argumentativeness, insulting comments, and threatening statements, with interventions including removing the resident from overstimulating situations and moving the resident to a quiet, calm environment when behaviors escalated. During an evening smoke break, a staff member’s seven‑year‑old child was outside in the courtyard running around while residents smoked. Multiple statements indicated that the resident became frustrated with the child’s behavior and struck or punched the child in the stomach. The child went inside crying and reported being hit, and a red mark was observed on the child’s abdomen. After the incident, the LPN who was the child’s mother, and who was not the resident’s nurse and had not witnessed the event, confronted the resident near the nurse’s station. The LPN asked if the resident had hit her child; when the resident confirmed, the LPN told the resident that many children come into the facility and that the resident did not have the right to hit children. The LPN further told the resident that she could be charged with assault, could be taken to jail, and that the resident was “lucky” she was a staff member because someone else might press charges. Other staff and resident statements corroborated that the LPN told the resident she was lucky she was there or in there, that she could be leaving in a police car, and that it was not acceptable to hit other people’s children. The LPN acknowledged she was upset, spoke sternly, and believed she was educating the resident about not hitting children, despite knowing the resident had dementia and that the facility was the resident’s home. The facility assessment and training materials indicated that staff were to receive dementia management, person‑centered care, and communication training, but the events described show that staff responses to these residents’ dementia‑related behaviors did not align with the planned dementia‑care approaches.
Failure to Maintain Accurate Medication, Toileting, and Nutritional Intake Records
Penalty
Summary
The deficiency involves the facility’s failure to maintain accurate and complete medical records for multiple residents. For one resident with morbid obesity, depression, chronic venous stasis, lymphedema, anemia, and pulmonary hypertension, the nurse practitioner ordered Aquaphor to be applied to both lower extremities three times daily. The MAR showed scheduled administration times in the morning, afternoon, and evening. On one review date, the morning Aquaphor dose had not been signed as given, and later that same day the MAR reflected that the afternoon dose had been signed out by an RN. However, direct observation shortly afterward revealed no visible Aquaphor on the resident’s lower legs, and the resident reported that no one had applied it all day. The administrator confirmed there was no Aquaphor visible despite the MAR being signed for that time frame, and the RN acknowledged she had signed for administration before actually applying the medication. Another resident, admitted with heart failure, stroke with right-sided paralysis, cognitive and language deficits, morbid obesity, depression, and bowel and bladder incontinence, had an MDS showing a severely impaired BIMS score and participation in a bladder and bowel incontinence program. The care plan called for a routine bowel and bladder program with staff checking and offering toileting assistance every two hours. Review of the Bladder Program Service Delivery Records for several months showed numerous blanks where staff were to document incontinence checks and toileting assistance, including multiple specific dates in one month with no entries at all. A CNA interview confirmed that CNAs are expected to perform and document two-hourly checks and toileting, that the documentation is kept in a logbook at the nurses’ desk, and that aides, including the interviewed CNA, sometimes forget to sign the logs. A third resident with Alzheimer’s disease, schizoaffective disorder, bipolar disorder, severe protein-calorie malnutrition, anxiety, paranoid schizophrenia, cerebral palsy, and major depressive disorder had a care plan identifying risk for altered nutrition and preferences for sweets, pop, milk, ice cream, pudding, and yogurt, with variable oral intake and acceptance of supplements. The MDS showed severe cognitive impairment and interventions including supplements and menu alternatives. Weight records showed ongoing weight loss, and dietician notes documented significant percentage weight loss over 90 and 180 days, low BMI, variable intake from 1% to 100%, and use of multiple nutritional supplements. Review of meal intake documentation revealed missing entries, including days where only dinner was documented and days with no meal intake documentation at all. The regional dietician consultant and the DON both verified that meal intake documentation for this resident was incomplete or missing in the electronic record.
Failure to Maintain Transmission-Based and Enhanced Barrier Precautions
Penalty
Summary
The deficiency involves the facility’s failure to maintain required transmission-based precautions for residents on enhanced barrier and airborne precautions. One resident with a history of stroke, contractures, vascular dementia, hypertension, depression, and anxiety had physician orders for enhanced barrier precautions related to chronic wounds and an indwelling urinary catheter. The resident’s care plan required use of gowns and gloves during high-contact care activities, with signage and PPE supplies available at the room. Surveyors observed two CNAs transferring this resident from bed to wheelchair using a mechanical lift without wearing gowns or gloves, despite the posted enhanced barrier precautions sign and PPE being available. One CNA acknowledged that gowns and gloves should have been worn during the transfer. Another resident, admitted with diagnoses including Covid, intracranial hemorrhage, and fall with injuries at home, had physician orders for airborne transmission-based precautions, including remaining in the room with all services brought to the room. Signage at the room instructed all persons entering to clean hands when entering and before leaving, and to wear gown, gloves, mask, and eye protection, with HCP additionally required to use an N95 mask. Surveyors observed that, although PPE was available at the door, there was no hand sanitizer immediately available upon exiting the room, the nearest dispenser being down the hallway. There were also no disinfectant wipes or designated area to clean and disinfect used eyewear, and no used eyewear was present in the room or PPE storage. The ADON confirmed the absence of hand sanitizer at exit, the lack of disinfectant wipes and cleaning area for eyewear, and the lack of used eyewear in the PPE storage, despite facility policy requiring appropriate use of transmission-based precautions.
Failure to Maintain Clean and Homelike Environment in Secured Unit
Penalty
Summary
Surveyors found that the facility failed to maintain a clean and homelike environment in the secured unit, affecting all 17 residents living there. Observations revealed that a shared bathroom used by two residents had a plastic toilet seat riser that was broken, smeared with stool, and stained with dried urine, emitting a foul odor. Despite being used daily by both residents, the seat remained uncleaned and in disrepair over multiple days. One of the residents using the seat was moderately cognitively impaired and required extensive assistance with mobility and toileting, while the other was frequently incontinent and needed assistance with hygiene and transfers. Staff confirmed the condition of the toilet seat and that both residents used it, even though only one had an order or care plan for its use. Further observations in the secured unit's only shower room revealed that the toilet was not consistently flushing for approximately two weeks, despite repeated notifications to maintenance. The floor around the toilet was dirty with significant dirt and grime buildup, and the caulking in the shower stall was discolored with black/grey mold. Maintenance staff confirmed the presence of rust and grime around the toilet and acknowledged recent cleaning and repairs for mold in the shower area. The facility's policy required maintaining a clean and sanitary environment, but these conditions were not met, as verified by staff and maintenance interviews.
Failure to Immediately Notify Resident, Physician, and Family of Significant Events
Penalty
Summary
Facility staff failed to immediately notify the resident, the resident's physician, and a family member about situations that affected the resident, such as injury, decline, or changes in room assignment. This lack of timely communication was observed and documented by surveyors during the review of facility practices and records. The deficiency centers on the facility's failure to ensure that all required parties were promptly informed when significant events impacting the resident occurred, as required by regulation.
Use of Physical Restraints Without Medical Necessity
Penalty
Summary
A deficiency was identified regarding the use of physical restraints on residents. The report notes that residents were not consistently free from the use of physical restraints, except when required for medical treatment. This indicates that physical restraints were used in situations where they were not medically necessary, contrary to regulatory requirements.
Failure to Provide Timely Incontinence Care
Penalty
Summary
A deficiency was identified when a resident with a history of urinary tract infections, hemiplegia, hemiparesis, and muscle weakness, who was dependent on staff for personal care and incontinent of bowel and bladder, was not provided timely incontinence care. The resident's care plan required staff to check and provide incontinence care as needed, and staff interviews confirmed that residents should be checked and changed every two hours and as needed. However, observation and interviews revealed that the resident was only changed in the morning before being transferred to a wheelchair and was not checked or changed again until the evening. During the day, the resident remained in her wheelchair without being offered incontinence care, and staff confirmed that she was not checked or changed after the initial morning care. When incontinence care was finally provided in the evening, the resident's brief was found to be saturated, bulging, and foul-smelling, and her buttocks were red. The resident reported feeling sore and confirmed that this was the first time she had been changed since the morning.
Deficient Bowel/Bladder and Catheter Care Leading to UTI Risk
Penalty
Summary
The report identifies a deficiency related to the provision of care for residents who are continent or incontinent of bowel and bladder, as well as the management of catheter care and the prevention of urinary tract infections (UTIs). Surveyors found that appropriate care was not consistently provided to residents in these areas. Specific failures included inadequate attention to the needs of residents with continence or incontinence issues, improper catheter care, and insufficient measures to prevent UTIs. These lapses were observed during the survey and were directly related to the care processes for residents requiring assistance with bowel and bladder management, catheter maintenance, and infection prevention.
Failure to Safeguard Resident Information and Maintain Medical Records
Penalty
Summary
The facility failed to safeguard resident-identifiable information and/or did not maintain medical records for each resident in accordance with accepted professional standards. This deficiency was identified through surveyor observation or review, indicating that the required protocols for protecting confidential resident information and proper record-keeping were not consistently followed. No additional details regarding specific residents, staff actions, or the circumstances leading to the deficiency are provided in the report.
Deficiencies in Food Storage and Preparation
Penalty
Summary
The facility failed to ensure proper food storage and preparation practices in the kitchen, affecting the quality and safety of meals served to residents. During an observation, six loaves of expired wheat bread with visible mold were found in the dry storage area. The Dietary Coordinator confirmed the findings and removed the bread, acknowledging that all residents, except for two who were NPO, could have potentially received the moldy bread. The facility's policy on dry storage and supplies emphasized the importance of storing non-perishable food to optimize safety and quality, which was not adhered to in this instance. Additionally, the facility did not maintain cleanliness standards for the Robo-coupe food processor used to prepare pureed meals for two residents. The processor was observed to be wet and not properly cleaned before use, with visible food remnants from previous use. Furthermore, a staff member was seen using a plastic spoon to taste test a pureed mixture and then placing the same spoon back into the food, compromising its hygiene. The Dietary Coordinator and the staff member confirmed these observations, which violated the facility's policy requiring clean equipment for preparing pureed diets.
Improper Storage of Oxygen Tank in Resident's Room
Penalty
Summary
The facility failed to prevent a potential accident hazard by not properly storing a compressed gas cylinder (oxygen tank) in a resident's room. The resident, who had been admitted with diagnoses including pneumonia, major depressive disorder, chronic kidney disease, diabetes, and osteoarthritis, had a physician's order for continuous oxygen at two liters per minute via nasal cannula. This order was discontinued, yet an unsecured oxygen tank was observed leaning against the wall of the closet in the resident's room. Interviews with facility staff, including a housekeeper and a registered nurse, confirmed that oxygen tanks should not be stored in resident rooms without being in a storage cart and should be kept in a locked room, upright, and in a storage rack when not in use. The facility's policy on oxygen storage also mandates that tanks be stored in a well-ventilated, protected area and secured by a chain, strap, or on a cart. Despite a staff in-service on the proper handling of compressed gas cylinders, the oxygen tank was improperly stored, indicating a lapse in adherence to safety protocols.
Failure to Implement Enhanced Barrier Precautions During Wound Care
Penalty
Summary
The facility failed to implement Enhanced Barrier Precautions (EBP) during wound care for a resident with a Stage III pressure ulcer on the left buttock. The resident, who was admitted with diagnoses including Alzheimer's Disease and acute respiratory failure with hypoxia, had a physician's order and care plan requiring EBP due to the chronic wound. The care plan specified that EBP supplies should be available in the resident's room, with signage to alert caregivers, and that personal protective equipment (PPE) such as gowns and gloves should be used during high-contact care activities. During an observation, it was noted that a sign outside the resident's room instructed staff to wear gowns and gloves for high-contact care, including wound care. However, when an LPN and the Assistant Director of Nursing (ADON) entered the room to perform wound care, they only applied gloves and did not don gowns as required. Both staff members later confirmed in an interview that they had forgotten to apply gowns, despite the signage and availability of PPE in the room. The facility's policy on Enhanced Barrier Precautions, updated earlier in the year, mandates the use of gowns and gloves during high-contact care to prevent the transmission of communicable diseases and infections.
Failure to Document and Treat Resident's Skin Condition Timely
Penalty
Summary
The facility failed to ensure timely documentation and treatment of a resident's skin condition, specifically redness and excoriation on the buttocks. The resident, who had severe cognitive impairment and required extensive assistance with personal care, was found to have redness and painful areas on the buttocks during a skin assessment. Despite the presence of redness, the condition was not documented in the progress notes, and the prescribed treatment was not applied promptly. The resident's care plan indicated a risk for skin breakdown due to incontinence, and interventions included applying moisture barrier cream after each incontinent episode. However, the facility's records did not show evidence of the application of the prescribed extra protection cream until the day after the condition was noted. Observations by surveyors revealed that the resident cried out in pain during incontinence care, and the redness and excoriation were visibly apparent. Interviews with staff, including the Director of Nursing and nursing assistants, revealed a lack of communication and documentation regarding the resident's skin condition. The facility's policy required nurses to assess and document skin issues, but the process was not followed, leading to a delay in treatment. The deficiency was identified during an investigation of a complaint, highlighting non-compliance with the facility's wound care policy.
Inadequate Pain Management Documentation and Follow-Up
Penalty
Summary
The facility failed to ensure accurate documentation and timely treatment of pain for a resident with a history of a right humerus fracture, major depressive disorder, and a leg laceration. The resident's care plan included interventions for pain management, such as assessing pain, encouraging the resident to rate their pain, and medicating per physician orders. However, on a specific day, the resident's pain was not properly documented or managed, as evidenced by missing pain level assessments and inadequate follow-up on the effectiveness of administered pain medications. On the day in question, the resident was observed to be in pain, with a grimace and reluctance to get out of bed due to discomfort. Despite receiving pain medications, including acetaminophen and oxycodone-acetaminophen, there was no documentation of the resident's pain level on a scale of one to ten. Interviews with staff revealed that the electronic system required a follow-up pain assessment, but this was not completed, and the resident's pain level was not reassessed after medication administration. The Director of Nursing confirmed that the resident's pain management orders were not correctly set up in the electronic system, leading to a lack of appropriate follow-up. The facility's policy on pain assessment and management emphasized the importance of evaluating both verbal and non-verbal signs of pain and ensuring effective pain management. However, the failure to document and reassess the resident's pain level resulted in inadequate pain management for the resident.
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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