Mapleview Country Villa
Inspection history, citations, penalties and survey trends for this long-term care facility in Chardon, Ohio.
- Location
- 775 South Street, Chardon, Ohio 44024
- CMS Provider Number
- 366433
- Inspections on file
- 20
- Latest survey
- February 26, 2026
- Citations (last 12 mo.)
- 1
Citation history
Health deficiencies cited at Mapleview Country Villa during CMS and state inspections, most recent first.
A cognitively intact but fully ADL-dependent resident with multiple serious diagnoses, including cancer, severe protein-calorie malnutrition, seizures, and DM2, was observed on multiple occasions to have long, dirty fingernails. The resident reported that nail care occurred only when requested and was not part of routine bathing or hygiene. A CNA confirmed that nail care was typically done on shower days, but this resident received only bed baths, and the CNA was unsure when the last bed bath or nail care occurred. This practice did not align with the facility’s ADL care policy, which required staff to assist dependent residents with personal hygiene, including nail care.
A resident with severe cognitive impairment and diabetes was administered insulin outside of physician-ordered parameters, resulting in severe hypoglycemia and hospitalization. An LPN gave short-acting insulin despite a BG level below the hold threshold, and the resident's insulin was not administered with all meals as ordered over several months. The facility failed to ensure medication was given according to prescriber instructions.
A deficiency occurred when the facility did not provide enough nursing staff to meet resident needs across three units, resulting in periods where no staff were present on one unit. Residents experienced long waits for incontinence care, repositioning, and assistance with meals, with some left in soiled briefs for hours and others missing scheduled activities. Staff interviews and observations confirmed that nurses and CNAs were unable to keep up with care demands, and incident logs showed an increase in resident falls during this period.
A resident with multiple chronic conditions repeatedly requested assistance and a cup of tea, but staff failed to respond promptly or provide the requested beverage for nearly three hours. The resident was also unable to eat breakfast in the dining room as preferred due to delays in assistance, resulting in unmet needs and a lack of respect for the resident's dignity and choices.
Two residents with significant medical conditions were found without call lights within reach, resulting in unmet care needs and distress. One resident was left calling for help with the call light behind the bed, while another had to physically get up to access the call light, which was on the floor. Staff confirmed the call lights were not accessible, and facility policy required call lights to be within reach.
A resident with advanced cognitive and physical impairments was not assisted with eating and drinking as required. Staff failed to position the resident upright, make food and drink accessible, or provide encouragement and hands-on assistance during meals. Documentation of meal intake and assistance was inconsistent, and staff interviews revealed a lack of awareness and adherence to the resident's care plan and nutritional needs.
Surveyors identified that two residents received oxygen therapy without required signage indicating oxygen use at their room entrances, as mandated by facility policy. Additionally, one resident was administered oxygen without an active physician order. These deficiencies were confirmed by nursing staff and through review of medical records and facility policy.
A resident with dementia, anxiety, and depression disclosed a history of childhood sexual abuse and experienced flashbacks and delusions, but staff did not assess for trauma or document triggers and interventions in the care plan or Kardex. Social services and psych providers were not notified or involved in trauma assessment after the resident's disclosure, and staff were unaware of the resident's trauma history or care needs related to trauma. The facility's policy lacked procedures for trauma assessment and care planning.
The facility did not post required signage for a resident on droplet isolation due to parvovirus and failed to ensure staff were aware of the type of transmission-based precautions in place. Additionally, an LPN used a blood pressure cuff on two residents without sanitizing it between uses, despite the residents' immunocompromised and chronic health conditions. Facility policies lacked clear instructions on signage and communication of TBP requirements.
A resident's medications, including uncapped eye drops and nasal spray, were improperly left at the bedside by an LPN, leading to missed and late doses. The resident, with multiple diagnoses, did not self-administer the medications, and facility policies were not followed, resulting in non-compliance with medication administration procedures.
A resident's medications, including eye drops, nasal spray, and pain relief gel, were improperly left uncapped and accessible on a soiled bedside table without an order for self-administration. The LPN admitted to forgetting to return the medications to the cart, and the ADON confirmed that medications should not be left at the bedside. Facility policies require medications to be stored in a cart unless there is a written order for bedside storage.
The facility failed to maintain a sanitary kitchen and ensure food items were not expired, potentially affecting all residents receiving food. Observations revealed expired milk and sandwiches, inadequate dish machine rinse temperatures, and insufficient sanitizer levels. Staff confirmed these issues, and policies were not followed regarding food storage and expiration.
A facility failed to implement a comprehensive care plan for a resident with a cardiac pacemaker. The care plan required monitoring for pacemaker failure symptoms and vital signs, but there were no monitoring orders in place, and assessments were not completed on several days. An LPN confirmed the lack of documentation and assessments, indicating a failure to adhere to the care plan.
A resident with a complex medical history was discharged from an LTC facility with an incomplete discharge summary. The summary inaccurately stated that no care was provided during the resident's two-day stay, despite the resident's significant medical needs. Interviews revealed that the RN responsible for the summary misunderstood the documentation requirements, leading to the omission of essential medical information.
Failure to Provide Adequate Nail Care for Dependent Resident
Penalty
Summary
The deficiency involves the facility’s failure to provide adequate nail care as part of activities of daily living (ADL) assistance for a dependent resident. The resident was admitted with multiple significant diagnoses, including severe protein-calorie malnutrition, basal cell carcinoma of the scalp and neck, secondary malignant neoplasm of the bone, convulsions, type 2 diabetes mellitus, anxiety disorder, and absence of the right eye. Her MDS showed intact cognition with a BIMS score of 14, but she required maximum assistance with upper body dressing and was dependent on staff for lower body dressing, toileting, showering, personal hygiene, and mobility. Her care plan identified an ADL self-care, mobility, and functional performance deficit related to cancer, diabetes, and seizures, and documented that she was dependent on staff for personal hygiene tasks. During an interview and observation, surveyors noted that the resident’s fingernails were long and dirty. The resident reported that staff only cleaned and trimmed her fingernails when she specifically asked and that she was unsure when they were last cleaned; she also stated that nail care was not included as part of her routine bathing or hygiene. A subsequent observation again found long and dirty fingernails, which was confirmed by both the resident and a CNA. The CNA stated that fingernails were cleaned on shower days but that this resident received only bed baths, and the CNA was unsure when the resident last had a bed bath or when her nails were last cleaned. The facility’s ADL Care policy, reviewed on 01/06/25, stated that staff were expected to assist dependent residents with maintenance of personal hygiene, including nail care, indicating that this expected care was not being consistently provided.
Significant Insulin Administration Error Resulting in Resident Harm
Penalty
Summary
A significant medication error occurred when a resident with severe cognitive impairment and multiple comorbidities, including diabetes mellitus type 2, was not administered insulin according to physician orders. The resident's order specified that ten units of Novolog insulin should be given with meals and held if the blood glucose (BG) level was less than 110 mg/dL. Despite this, the insulin was administered at a BG level of 97 mg/dL, which was below the hold threshold. This error resulted in the resident being found unresponsive with a BG of 37 mg/dL, displaying symptoms such as flushing, drooling, sweating, and moaning, and requiring emergency intervention and hospitalization for hypoglycemia. Further review revealed that the resident's insulin was only administered at lunch and dinner, not with all meals as ordered, from the time the order was written. This discrepancy was not identified during routine audits or after the resident's return from the hospital, despite the discharge order specifying insulin with meals three times daily. The error in administration times persisted for several months and was confirmed by staff interviews and review of medication administration records. The facility's policy required medications to be administered in accordance with prescriber orders, but this was not followed in the case of the resident's insulin regimen. The incident was documented in the facility's incident logs and medical records, and staff interviews confirmed the failure to adhere to the prescribed insulin parameters and schedule.
Failure to Provide Adequate Staffing Results in Unmet Resident Needs
Penalty
Summary
The facility failed to provide adequate nursing staff to meet the needs of residents in the Rosewood residential area, which included three units. On multiple occasions, there was only one nurse covering all three units during the night shift, with only one nursing assistant assigned to each of the front and middle units, and no nursing assistant assigned to the back unit. This resulted in periods where no staff were present on the back unit, leaving residents without timely assistance for incontinence care, repositioning, or other needs. Observations documented strong odors of urine, unanswered call lights, and residents waiting extended periods for help, including one resident who had to get up from a recliner and walk around the bed to access the call light, and another resident who was left in a soiled brief for several hours, resulting in skin irritation. Staff interviews confirmed the lack of adequate coverage, with the nurse on duty having to perform both nursing and nursing assistant duties for the back unit, and nursing assistants reporting difficulty completing care due to being alone and unable to leave their assigned units. Residents and their private aides also reported frequent delays in receiving assistance, with some residents not being able to get up for breakfast or to the dining room as scheduled, and others missing meals or not receiving requested beverages. The lack of staff also led to situations where mechanical lifts and two-person assist tasks were either delayed or performed with only one staff member, contrary to care requirements. Review of facility records showed that the majority of residents in these units required moderate to total assistance with activities of daily living, incontinence care, and mechanical lifts. Incident logs indicated a rising trend in resident falls over recent months. Staffing data revealed that while the facility met the minimum required direct care hours, actual staff assignments left units inadequately covered, especially on weekends and night shifts. Facility policies required regular incontinence care and call light accessibility, but these were not consistently followed due to insufficient staffing.
Failure to Honor Resident's Dignity and Preferences for Timely Assistance
Penalty
Summary
A deficiency was identified when a resident with diagnoses including diabetes mellitus type 2, congestive heart failure, dementia, and peripheral vascular disease was not treated with dignity and respect. The resident was observed repeatedly calling for help from their room early in the morning, but a CNA who was present on the unit did not respond or inquire about the resident's needs. Shortly after, an LPN entered the unit, acknowledged the resident's request for tea, but stated that she needed to get report first and would provide the tea later. The resident was left without water or tea at the bedside, and no bedside table was within reach. Over the course of several hours, the resident continued to wait for the requested tea, and multiple observations confirmed that the request was not fulfilled. The resident also expressed a desire to eat breakfast in the dining room, but remained in bed due to the need for a second staff member to assist with the transfer. By the time assistance was available, breakfast service in the dining room had ended, and the resident was required to eat in their room. The resident continued to express disappointment about not receiving tea and not being able to eat in the dining room as preferred. Eventually, the resident was transferred to a wheelchair and received a breakfast tray in their room, but the tray contained coffee instead of the requested tea. The LPN acknowledged not checking to ensure the resident received tea and only provided it nearly three hours after the initial request. Throughout this period, the resident's repeated requests for assistance and specific preferences were not promptly addressed, resulting in a failure to honor the resident's right to dignity, respect, and self-determination.
Failure to Maintain Call Lights Within Reach for Two Residents
Penalty
Summary
The facility failed to maintain call lights within reach for two residents, resulting in unmet needs and distress. One resident with Parkinson's disease, diabetes, dementia, and an overactive bladder was found lying in bed without a sheet or blanket, calling out for help. The call light was observed on the floor behind the headboard, out of the resident's reach. The resident reported feeling wet and unable to find the call light, expressing frustration and alleging that staff hid the call light due to frequent use. Both the RN and CNA assigned to the unit confirmed the call light was not in reach but denied intentionally placing it out of reach. Another resident with chronic atrial fibrillation, sick sinus syndrome, and a cognitive communication deficit was found in a recliner with a strong odor of urine in the room. The call light was on the floor, out of reach, and the resident described having to get up and walk around the bed to access it. The resident expressed difficulty in keeping the call light nearby and requested assistance. Multiple observations confirmed the call light remained unanswered for an extended period, and staff verified the call light was not accessible. Facility policy required call lights to be within reach and for staff to be attentive to resident needs.
Failure to Assist Cognitively Impaired Resident with Eating and Drinking
Penalty
Summary
A deficiency was identified when a resident with Alzheimer's disease, diabetes, hypertension, right hip fracture, and anxiety disorder was not provided with necessary assistance during mealtimes. The resident, who was dependent on staff for eating and drinking due to impaired cognition and physical limitations, was observed sitting in a reclined Broda chair with her meal tray placed out of reach. Staff failed to position her upright, uncover her food, unwrap her silverware, or provide a straw for her milk. No encouragement or assistance was offered, and the tray was removed without any attempt to help the resident eat or drink. Documentation in the electronic medical record showed inconsistent and incomplete entries regarding the resident's meal intake and assistance provided. On several occasions, there was no documentation of meal intake or refusals, and the resident's intake varied from refusing to eat to consuming up to 75 percent of meals. The care plan and nutritional assessment indicated that the resident was unable to make her needs known and required substantial to maximum assistance with eating, yet these interventions were not consistently implemented by staff. Interviews with staff revealed a lack of understanding and follow-through regarding the resident's needs. One CNA, new to the facility, stated she was told the resident did not eat breakfast and therefore did not attempt to assist her. The LPN assigned to the unit was unaware of any specific instructions regarding the resident's eating habits. Both the dietitian and RN/unit manager confirmed that the resident was dependent on staff for eating and drinking and should have been properly assisted, including being positioned upright and having her food and drink made accessible.
Failure to Ensure Proper Oxygen Signage and Physician Orders
Penalty
Summary
Surveyors found that the facility failed to ensure proper respiratory care for residents requiring oxygen therapy. Specifically, two residents were observed receiving oxygen without the required signage indicating oxygen use at the entry to their rooms, as mandated by facility policy. One resident with diagnoses including emphysema, COPD with acute exacerbation, and respiratory failure was observed using oxygen at two liters per minute via nasal cannula, but there was no sign posted to indicate oxygen was in use. This was confirmed by an LPN, and the facility's policy required such signage. Another resident was observed twice receiving oxygen via nasal cannula from a concentrator, also without any oxygen safety sign displayed in the room or on the doorway, which was confirmed by an RN. Additionally, review of the medical record for the second resident revealed that there was no active physician order for oxygen administration, despite the resident receiving oxygen. This was verified by an LPN. The facility's policy required checking for a physician's order for oxygen administration and posting an oxygen in use sign. The lack of signage and absence of a physician order for oxygen administration were identified as deficiencies during the survey.
Failure to Provide Trauma-Informed Care and Assess for Trauma After Resident Disclosure
Penalty
Summary
The facility failed to provide trauma-informed care in accordance with professional standards of practice for a resident with a history of trauma and mental health diagnoses. The resident, admitted with dementia, COPD, anxiety disorder, mood disorder, and depression, reported a history of childhood sexual abuse and experienced flashbacks, hallucinations, and delusions related to this trauma. Despite these disclosures, there was no evidence that the facility's social services or psychiatric providers assessed the resident for trauma following her statements, nor were any trauma-related triggers or interventions documented in her care plan or Kardex. The deficiency was identified after the resident alleged rough treatment by a CNA, which she later recanted, attributing her statements to confusion and flashbacks from past trauma. Multiple assessments and progress notes failed to document any follow-up or trauma assessment after the incident, and staff interviews revealed a lack of awareness regarding the resident's trauma history, triggers, or appropriate interventions. The facility's policy on trauma-informed care did not include procedures for assessing residents for trauma or ensuring that triggers were identified and addressed in the plan of care. Interviews with facility staff, including the administrator, social service designee, CNA, and psychiatric nurse practitioner, confirmed that the resident's trauma history was not communicated or incorporated into her care planning. The lack of documentation and communication resulted in the resident's trauma history and related care needs being unaddressed, despite her ongoing symptoms and requests for therapy related to her flashbacks.
Failure to Implement Proper Infection Control Signage and Equipment Cleaning
Penalty
Summary
The facility failed to ensure proper implementation of infection prevention and control protocols for residents on transmission-based precautions (TBP) and during the use of shared medical equipment. For one resident admitted with a history of parvovirus infection, the care plan and physician orders specified strict droplet isolation, including the use of personal protective equipment (PPE), signage on the door, and in-room care. However, observations revealed that there was no signage on the resident's door indicating TBP status or the type of precautions required. Interviews with staff members, including a CNA and LPN, confirmed uncertainty about the resident's isolation status and the absence of appropriate signage. The infection control designee also verified that the admitting nurse should have placed the correct signage and communicated the TBP type and reason during shift reports. Facility policies reviewed did not address requirements for signage or staff/visitor awareness of TBP type. Additionally, the facility did not ensure that medical equipment, specifically a vital signs monitor and blood pressure cuff, was properly sanitized between use with different residents. An LPN was observed using the same blood pressure cuff on two residents without cleaning it before or after use, despite the availability of sanitizing wipes. The residents involved had significant medical histories, including immunocompromised status and chronic illnesses, increasing their vulnerability to infection. The LPN acknowledged the failure to sanitize the equipment during an interview. These deficiencies were identified through medical record review, direct observation, staff interviews, and policy review. The findings affected one resident on TBP and two residents observed for infection control practices with shared equipment, out of a facility census of 88. The facility's policies lacked specific guidance on signage and communication of TBP requirements, contributing to the observed lapses in infection prevention and control.
Medication Administration Deficiency
Penalty
Summary
The facility failed to properly complete medication administration for a resident, identified as Resident #16, by leaving uncapped eye drops and nasal spray with pain relief gel at the resident's bedside. This occurred after the nurse prepared the medications but left them on a soiled bedside table within the resident's reach, intending to return later to administer them. The resident, who was eating breakfast at the time, did not self-administer the medications and reported that the nurse often left medications at the bedside and sometimes administered them late or not at all. Resident #16's medical record indicated several diagnoses, including spinal stenosis, restless legs syndrome, generalized anxiety disorder, GERD, radiculopathy, and chronic pain. The resident had physician orders for various medications, including artificial tears, nasal spray, and Voltaren gel, none of which were ordered for self-administration or bedside storage. The medication administration record showed instances where medications were either omitted or administered late, including omeprazole, gabapentin, hydroxyzine, and tramadol. Interviews with facility staff, including an LPN and the Assistant Director of Nursing, confirmed the improper handling and administration of medications. Facility policies reviewed indicated that medications should not be left at the bedside unless there is a written order for self-administration, and medication caps should be replaced immediately after administration to prevent infection. The deficiency was investigated under a specific complaint number, highlighting non-compliance with medication administration procedures.
Improper Medication Storage and Administration
Penalty
Summary
The facility failed to properly store medications by leaving eye drops, nasal spray, and pain relief gel at the bedside of Resident #16, who did not have an order for self-medication administration. The resident, diagnosed with conditions such as spinal stenosis and chronic pain, was observed with these medications on a soiled bedside table within reach. The resident reported that the nurse left the medications there because they were eating breakfast and would return later to administer them. However, the nurse did not return in a timely manner, and the medications remained uncapped and accessible. Licensed Practical Nurse (LPN) #245 confirmed that the medications were left uncapped on the bedside table, explaining that the caps were kept in the medication cart drawer. The LPN admitted to forgetting to return the medications to the cart after the resident was busy eating. The Assistant Director of Nursing (ADON) verified that medications should not be left at the bedside and that caps should be replaced immediately after administration to prevent infection. The facility's policies on medication administration and storage were reviewed, indicating that medications should be stored in a medication cart unless there is a written order for bedside storage, which was not present for Resident #16.
Deficiencies in Kitchen Sanitation and Food Storage
Penalty
Summary
The facility failed to maintain a clean and sanitary kitchen environment and ensure that food items were not expired, which could potentially affect all residents receiving food from the kitchen. During an initial kitchen tour, it was observed that the dairy walk-in cooler contained six expired milk pints intended for resident use. Additionally, the hot water temperature of the dish machine rinse cycle was recorded at 172 degrees Fahrenheit, below the recommended 180 degrees Fahrenheit necessary to ensure dishes were safe for use. In the dry food storage area, six packages of bread were found without dates indicating when they were opened or their expiration dates. Furthermore, a test strip of the three-sink sanitizer station showed the sanitizer level at 100 parts per million, below the recommended 200 parts per million needed to effectively kill viruses or bacteria. These observations were confirmed by the Food Service Manager. In another observation, the facility's front lobby refrigerator contained several expired sandwiches intended for resident consumption. These included a barbeque sandwich, a chicken and cheese sandwich, a cheese sandwich, and another sandwich, all past their expiration dates. An interview with a Registered Nurse revealed that staff were instructed to discard food after three days from the date on the food label. The Administrator confirmed that resident food was mixed with staff food in the refrigerator and that the sandwiches exceeded the three-day limit. The facility's policy on food brought in from the community stated that all cooked or prepared food for residents should be dated when accepted for storage and discarded after 72 hours or three days.
Failure to Implement Pacemaker Care Plan
Penalty
Summary
The facility failed to implement the interventions of the comprehensive care plan for a resident with a cardiac pacemaker. The resident, who had intact cognition and required supervision with activities of daily living, was admitted with diagnoses including cardiac pacemaker, syncope collapse, and atrioventricular block. The care plan included monitoring for signs and symptoms of pacemaker failure, such as dizziness, fainting, heart palpitations, prolonged hiccups, and chest pain, as well as monitoring oxygen saturation and signs of elevated blood pressure. However, the physician orders for May 2023 did not include monitoring orders for the new pacemaker. Additionally, the skilled nursing assessments and vital signs documentation were incomplete for several days in May 2024. Specifically, there were no skilled nursing assessments or documentation of blood pressure, oxygen saturation, and temperatures on multiple dates. An interview with the unit manager confirmed that these assessments and vital signs were not completed on the specified dates, indicating a failure to adhere to the care plan and monitor the resident's condition adequately.
Incomplete Discharge Summary for Resident
Penalty
Summary
The facility failed to thoroughly complete a discharge recapitulation of stay for a resident, affecting one of three residents reviewed for discharge. The resident, who had a complex medical history including chronic obstructive pulmonary disease, myocardial infarction, and other serious conditions, was admitted and discharged within a two-day period. Despite the resident's significant medical needs, the discharge summary inaccurately indicated that no care was provided during the stay. Interviews with the facility's Administrator and Director of Nursing confirmed the deficiency. The Director of Nursing acknowledged that the Registered Nurse responsible for completing the discharge summary did not understand the requirement to document the care and treatments provided during the resident's stay. As a result, the discharge summary lacked essential information about the resident's diagnoses, course of illness, treatments, and other pertinent medical details, which should have been included according to the facility's discharge summary protocol.
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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