Marietta Heights Post Acute
Inspection history, citations, penalties and survey trends for this long-term care facility in Marietta, Ohio.
- Location
- 5001 State Route 60, Marietta, Ohio 45750
- CMS Provider Number
- 365780
- Inspections on file
- 35
- Latest survey
- March 9, 2026
- Citations (last 12 mo.)
- 13
Citation history
Health deficiencies cited at Marietta Heights Post Acute during CMS and state inspections, most recent first.
Surveyors identified extensive failures in food storage, temperature control, dishwashing, and documentation. In the main kitchen, frozen and dry goods were found open, undated, or past disposal dates, and a walk-in refrigerator and temporary outdoor refrigerator were operating above 41°F with inadequate temperature monitoring. In a resident kitchenette, staff failed to consistently record refrigerator and freezer temperatures and kept undated prepared foods. Dishwashing logs showed identical, twice-daily entries with no lunch readings, and direct observation revealed wash and rinse cycles not consistently meeting manufacturer-required temperatures while staff failed to monitor the machine. Meal service temperature logs were incomplete and often recorded uniform values (e.g., all hot foods at 180°F and all cold items at 33°F) that did not match observed temperatures, and potentially temperature-abused milk and juice from a malfunctioning rental refrigerator were later served before being discarded. These practices conflicted with the facility’s own policies on food receiving, storage, preparation, and equipment sanitization.
Surveyors found that essential kitchen equipment, including a walk-in refrigerator and both ovens, was not maintained in safe operating condition, potentially affecting all 38 residents. The walk-in refrigerator had documented temperatures above safe cold-holding levels over multiple days, with missing temperature entries and no documented food temperature checks or discarding of potentially affected food, despite staff awareness that the unit was in the 50s. The Administrator and Maintenance staff reported delayed notification of the refrigerator problem. Additionally, both kitchen ovens were nonfunctional for an extended period, one having suffered internal fire damage and the other experiencing recurrent failures since purchase, with ongoing electrical and equipment issues despite prior repair attempts.
A resident with type I diabetes experienced critically high blood sugar readings and symptoms such as nausea and vomiting, but did not receive scheduled insulin or adequate monitoring. Staff failed to follow physician orders, missed medication administration, and did not respond appropriately to changes in the resident's condition. The resident was later found unresponsive and hospitalized for diabetic ketoacidosis and sepsis, with actual harm resulting from these failures.
A resident with diabetes and cognitive communication deficit was observed eating lunch in his room while three full urinals hung on the footboard of his bed. The resident stated that staff would bring food and medications but did not empty the urinals, which he found undignified during meals. Staff notes indicated the resident had earlier requested privacy, but staff still entered for other tasks without addressing the urinals, resulting in a failure to provide a dignified dining experience.
A resident with multiple chronic conditions was given an incorrect dose of Oxycodone for pain management, and neither the resident nor the primary care physician was notified of the medication error as required by facility policy. The error was discovered during a shift change narcotic count, but there was no documentation of notification to the appropriate parties.
A facility failed to maintain adequate nursing staff levels, resulting in missed blood sugar checks and insulin administration for a resident with type I diabetes. Due to insufficient staffing and communication breakdowns, the resident was not properly monitored, was later found on the floor with severe hyperglycemia and other critical symptoms, and required transfer to the hospital for multiple acute conditions.
Two residents received incorrect medication doses due to failures in following physician orders and medication administration protocols. One resident was repeatedly given a higher dose of Lorazepam than prescribed, while another received an extra dose of Oxycodone without a physician's order. These errors occurred despite facility policies requiring verification of medication orders and proper administration procedures.
The facility did not provide enough nursing staff to meet resident needs, resulting in long call light response times, missed showers, and delays in assistance with activities of daily living. Residents and staff reported that care was compromised, especially on weekends and night shifts, due to inadequate CNA coverage and unfilled call-offs. The issue was ongoing and recognized by both facility staff and the local Ombudsman.
A resident dependent on staff for personal care did not receive scheduled bathing and nail care assistance as required by her care plan. Documentation showed a missed scheduled shower with no record of it being offered or provided, and observations found the resident with dirty fingernails. Staff interviews confirmed the resident's dependency and the lack of documentation for the missed care.
A resident with dysphagia and no teeth was served a hot dog on a bun cut into uneven pieces, which did not meet the prescribed soft, bite-sized texture diet. The LPN was unaware of the resident's dietary requirements until reviewing the tray card, and the dietitian confirmed the meal was inappropriate for the ordered diet. The facility lacked a policy defining soft, bite-sized diets.
A resident with dementia and behavioral disorders was discharged after the closure of a secured unit, with the process planned and coordinated with the family. However, the MDS assessment was inaccurately coded as an unplanned discharge due to a delay in the moving date, despite CMS guidelines indicating the discharge was planned.
A resident with chronic medical and mental health conditions was subjected to verbal and emotional abuse by the Activities Director, who argued with her, raised her voice, and made dismissive gestures during a dispute over the use of the activity room for puzzles. The resident reported feeling humiliated and anxious, and the Ombudsman and DON observed unprofessional conduct by the staff member.
The facility did not provide complete or timely discharge notices to resident representatives and failed to notify the state health department of discharges from the secured unit. Discharge notices were missing required information such as discharge date, location, appeal rights, and advocacy contacts, and were sometimes illegible or not received. Interviews confirmed that the state health department and Ombudsman were not properly notified, and resident representatives reported receiving incomplete documentation and inadequate support during the discharge process.
The facility failed to verify three staff members against the State nurse aide registry before hiring, as required by their policy. This oversight involved a Medical Records employee, a Social Worker, and a Director of Rehabilitation, potentially affecting all 57 residents. The Human Resources representative confirmed the lapse in verification, which contradicts the facility's policy on preventing abuse, neglect, exploitation, and misappropriation.
The facility did not ensure CNAs received the required 12 hours of annual in-service training, as revealed by a review of personnel files and confirmed by HR. The missing documentation for 2024 and 2025 indicates a failure to comply with the facility's policy, which mandates regular training to maintain staff competency in essential care areas.
The facility's kitchen was found to be unsanitary, with issues such as a walk-in freezer lacking a thermometer, expired and undated food items in the reach-in cooler, and black debris in the ice machine. The Registered Dietitian was unaware of these concerns, and the pureed food preparation process was not conducted hygienically. These deficiencies affected the meals served to all 57 residents.
The facility failed to assist residents with ADLs, affecting hygiene. A resident with dementia was observed in the same clothes for days, while another with COPD missed scheduled showers. Two residents with cognitive impairments had long, dirty nails, and a resident needing oral hygiene assistance reported not receiving help. Documentation inconsistencies were noted.
A resident with dementia and depression was not served the correct double portions as ordered, receiving only one piece of pork instead of two, and insufficient gravy. The facility's policy required larger portions, but staff failed to comply due to concerns about food availability for other residents.
The facility failed to provide pureed food at the correct consistency for two residents on pureed diets. One resident with Alzheimer's was served improperly pureed bread and ground pork instead of pureed. Another resident with multiple diagnoses was served ground pancakes and sausage, not of the required smooth consistency, leading to coughing during the meal. Staff confirmed the improper preparation and expressed uncertainty about achieving the correct texture.
A long-term care facility failed to implement an effective infection control program, resulting in multiple deficiencies. A resident on droplet precautions was exposed to a staff member without PPE, and improper hand hygiene was observed during wound care and meal delivery. Additionally, a nephrostomy bag was improperly placed on the floor, highlighting systemic lapses in infection prevention practices.
The facility failed to monitor antibiotic use and ensure infection criteria were met for three residents. One resident received Ceftriaxone for a suspected UTI without proper testing or documentation. Another resident was discharged from the hospital with Cefdinir, but the facility lacked documentation of a urine analysis or culture. A third resident was discharged with Cefdinir and Doxycycline, but the facility did not confirm the need for antibiotics. The facility's antibiotic stewardship policy was not followed.
A persistent sewage-like odor on the 400 hall affected 19 residents, with complaints dating back to February. Despite efforts by maintenance and an outside company to address the issue, the odor remained. Residents expressed discomfort, and staff confirmed the presence of the odor, indicating a potential plumbing issue.
Two residents were not treated with dignity and respect in an LTC facility. A CNA made disrespectful comments about a resident with major depressive disorder, while another resident with Alzheimer's was left in a soiled state after being inadequately assisted with a meal. Staff failed to provide timely care, contrary to the facility's dignity policy.
A facility failed to ensure a resident's code status was consistent between the EMR and the hard chart. The resident was admitted with a DNRCC-A status in the hard chart, but the EMR listed her as a full code. The resident confirmed her desire to be a full code. The DON acknowledged the inconsistency and the potential risk of not providing CPR as desired. Facility policy requires consistency in documenting treatment preferences.
A facility failed to maintain resident privacy during insulin administration, affecting a resident with diabetes and depression. An LPN checked the resident's blood glucose level and administered insulin in the dining room without offering privacy. Interviews confirmed the incident, and the facility's policy on resident rights, which includes privacy, was not followed.
The facility failed to ensure accurate comprehensive assessments for two residents. One resident, with vascular dementia, was inaccurately marked as having no natural teeth despite having dentures. Another resident, with diabetes and dysphagia, was reported to have no issues with dentures, although they were edentulous and had ill-fitting dentures. These inaccuracies were confirmed by the DON.
The facility failed to complete baseline care plans within 48 hours for two residents, impacting their immediate care needs. One resident, with conditions like vascular dementia and hypertension, had an incomplete care plan, confirmed by the DON. Another resident, admitted with rhabdomyolysis and acute kidney failure, also had an unfinished care plan, as verified by the DON.
The facility failed to involve residents and/or their representatives in care plan reviews and revisions, affecting three residents. A resident with severe cognitive impairment had no care conferences since admission, and another resident's care plan inaccurately reflected resolved pressure ulcers. These deficiencies were confirmed by facility staff and family members.
The facility failed to follow physician orders and infection control protocols for a resident's wound care, neglected bowel management for another resident, and did not change a dressing as scheduled for a third resident. These deficiencies highlight lapses in adhering to treatment protocols and infection control measures.
A resident with contractures did not have orthotics applied daily as per their care plan. Despite recommendations from occupational therapy, there was no active physician's order for the orthotic, and staff were unaware of its necessity. Observations confirmed the orthotic was not in use, and the facility lacked documentation to support the recommended restorative nursing program.
A facility failed to follow a urologist's orders for a resident with an indwelling urinary catheter, leading to deficiencies in catheter maintenance and estrogen therapy. The resident's catheter was not changed as scheduled in November and December, and the recommended vaginal estrogen therapy was not administered, despite its importance in reducing UTI risk. Observations showed thick sediment in the catheter tubing, and interviews confirmed the discontinuation of estrogen therapy without documented justification.
The facility failed to monitor and address the nutritional needs of two residents, leading to significant weight loss. One resident experienced a 14.47% weight loss over five months without proper documentation of meal intakes or supplements. Another resident lost 13.9% of their weight in six months, with misunderstandings about diuretic use and no new interventions despite the weight loss. The facility's inadequate monitoring and communication with the physician contributed to the deficiency.
The facility failed to provide timely and appropriate pain management for two residents. One resident with a stage III pressure ulcer experienced severe pain during care without adequate intervention, while another resident reported severe shoulder pain after a Hoyer lift incident, which was not documented or promptly addressed. The facility's pain management policy was not followed, leading to prolonged discomfort for the residents.
A resident with multiple health conditions was served a meal that did not meet the required pureed consistency, as observed by surveyors. The CNA responsible for the meal delivery confirmed the inconsistency and demonstrated a lack of understanding of the proper diet texture, despite having received prior education on diets.
The facility failed to monitor side effects and behaviors for a resident on psychotropic medications, and another resident received antipsychotic medication without an appropriate diagnosis. The DON confirmed these lapses, indicating inadequate medication management.
A resident with diabetes, pressure ulcer, and depression was served a lunch meal with burnt and unappealing meatballs and rubbery green beans. The resident expressed dissatisfaction, and an Activity Director confirmed the meal's condition, offering a substitute which was declined. Dietary staff disagreed on whether the meatballs were burnt, describing them as dark brown from the oven.
A facility failed to provide necessary assistive eating equipment for a resident with dementia, dysphagia, and traumatic brain injury. Despite orders for a divided plate to aid independence, the resident's meal was served in a scooper bowl, contrary to the meal ticket instructions. This was confirmed by the staff member involved.
A resident with end-stage renal disease and hypertension did not have their medical records accurately maintained. The facility failed to follow physician orders for administering amlodipine, as the medication was not held when the heart rate was below the specified threshold. Additionally, the resident's indwelling urinary catheter output was not consistently documented. The DON confirmed these discrepancies and suggested a possible transcription error.
The facility failed to implement fall prevention measures for a resident with a history of falls, as Dycem was not used in the resident's wheelchair as per the care plan. Additionally, another resident's medication was improperly administered in a cookie, leading to accidental ingestion by a family member. These incidents highlight lapses in adherence to care plans and medication protocols.
The facility failed to provide prescribed evening snacks to two residents, one with diabetes and another with dementia, due to an oversight by the dietary department. The snacks were not included on the delivery tray, as confirmed by the Dietary Manager.
The facility administration failed to ensure timely payment of bills, risking service interruptions for all 53 residents. The Administrator, responsible for day-to-day functions, did not manage financial obligations effectively, leading to overdue payments to multiple vendors. The facility's billing ledger was inaccurate, and the Director of Nursing confirmed discrepancies. The Administrator struggled to obtain financial information from previous ownership, complicating the transition process.
A resident with cognitive impairments and a history of wandering managed to exit the facility unsupervised due to a malfunctioning door alarm system. Despite having a wander guard, the system failed to alert staff, allowing the resident to reach the parking lot and attempt to leave. Staff intervention and EMS assistance were required to bring the resident back inside. The incident highlighted a continued non-compliance issue with the facility's alarm system.
The facility failed to maintain a clean and safe environment, affecting 25 residents and two shower rooms. Observations revealed a black substance and musty odor in the 100-hall shower room, and a sewage-like odor in the 400-hall shower room. Missing grout and cracked tiles were also noted, verified by the DON.
The facility failed to implement fall prevention interventions for two residents, leading to multiple falls. One resident, with a history of atrial fibrillation, did not have anti-rollbacks on their wheelchair as planned. Another resident, with a lumbar fracture, was found without non-skid footwear, dycem, anti-rollbacks, and a night light, contrary to their care plan. Staff confirmed these deficiencies.
A facility failed to provide adequate dementia care and supervision in its memory care unit, leading to a resident being assaulted by another resident. The unit was understaffed, with only one STNA present, and staff lacked specialized dementia care training. Observations and interviews revealed a lack of organized activities and insufficient supervision, contrary to the facility's claims of providing specialized care. This deficiency placed all residents at risk for harm.
The facility failed to manage pain effectively for two residents, leading to actual harm. One resident with arthritis and chronic pain did not receive Methadone due to pharmacy issues, resulting in severe pain and hospital transfer. Another resident with a history of fractures missed multiple Oxycodone doses, experiencing withdrawal symptoms. Staff interviews revealed communication lapses and inadequate follow-up on medication availability.
The facility failed to maintain a comfortable temperature on the memory care unit, with the thermostat set below the policy range, affecting several residents. Additionally, two residents' rooms had walls in disrepair, with torn wallpaper and exposed drywall. The Maintenance Supervisor confirmed the issues, noting staff adjustments to the thermostat and improper furniture placement contributed to the problems.
The facility failed to develop comprehensive care plans for four residents, resulting in unaddressed needs. A resident with schizophrenia and dementia had no dental care plan despite dental issues. Another resident with Alzheimer's lacked a personal hygiene care plan. A third resident was prescribed Benadryl without a care plan for its use, and a fourth resident on Aspirin had no plan addressing bleeding risks. The DON confirmed these omissions.
The facility failed to provide scheduled activities for residents in the memory care unit, affecting seven residents with conditions like dementia and Alzheimer's. Observations showed that planned activities were not conducted, and staff interviews revealed confusion about responsibility for activities. A family member noted the lack of activities, and the DON acknowledged staffing limitations. Facility policies emphasize individualized activities, but these were not implemented, highlighting a deficiency in care.
The facility failed to address pharmacy recommendations in a timely manner for several residents, leading to deficiencies in medication management. A resident with depression had delayed review of sertraline recommendations, while another with multiple conditions had mirtazapine recommendations similarly delayed. A third resident was on neomycin without proper documentation or indication, despite a black box warning. Additionally, a resident's Voltaren Gel recommendations were not addressed promptly, highlighting lapses in the facility's adherence to its policies on medication management.
Widespread Failures in Food Storage, Temperature Control, and Dishwashing Practices
Penalty
Summary
The deficiency involves multiple failures in food storage, temperature control, dishwashing, and documentation in the dietary department and a resident kitchenette. Surveyors observed in the main kitchen that several frozen items, including rib-shaped pork patties, breakfast omelets, and precooked hamburger patties, were left open in the walk-in freezer, exposing them to freezer air. In dry storage, several opened pasta products were either past their disposal date, undated, unsealed, or both, including pasta opened in December without a discard date. The walk-in refrigerator had been above 41°F since early in the month and was taken out of use, and a temporary outdoor portable refrigerator showed a temperature of 42°F with a damaged mercury thermometer. In the kitchenette area, staff were not recording refrigerator temperatures consistently, were not recording freezer temperatures at all, and surveyors found undated food items such as a turkey and cheese sandwich and a piece of coconut cream pie. Dishwashing practices and documentation were also deficient. Review of the dishwasher temperature log showed that staff only recorded temperatures twice daily, not for each meal, and that the same wash and rinse temperatures (160°F wash, 190°F rinse) were recorded for every entry without variation, with no lunch temperatures documented. During direct observation of the dishwashing process, the wash cycle initially registered 145°F, below the manufacturer’s minimum effective wash temperature of 150°F, and the staff member operating the dishwasher did not appear to monitor the temperature readings or notice when the machine failed to advance to the rinse cycle until the surveyor intervened. Subsequent cycles showed fluctuating wash and rinse temperatures, with several readings below the manufacturer’s recommended levels before finally reaching 150°F wash and 180°F rinse. The dietary manager confirmed the presence of open and undated food items, the inaccurate and incomplete dishwasher logs, and that the dishwasher temperatures were not reaching sanitary levels during observation. Food service temperature monitoring and documentation for meals were inconsistent and inaccurate. During observation of a lunch tray line, the listed meal included store-bought pasta salad containing mayonnaise and eggs, turkey and cheese croissants, vegetables, cake, and milk. The dietary manager obtained very high temperatures for the hot vegetables (near or above 200°F), but there was no observation of staff taking or logging temperatures for the milk or pasta salad. When the surveyor reviewed the temperature log for that meal, the recorded temperatures for the vegetables and milk (180°F for hot foods and 33°F for milk) did not match the observed readings, and food temperatures were not being recorded consistently across days. Review of the February food temperature logs showed numerous days with missing entries for entire meals, and on several days all hot foods were uniformly recorded as 180°F and all cold items (milk, juice, dessert) as 33°F, suggesting inaccurate or non-specific documentation rather than actual measured temperatures. Refrigeration failures and the handling of potentially temperature-abused milk and juice further contributed to the deficiency. The walk-in refrigerator had been above safe temperatures and taken out of service, leading the facility to use a rented portable refrigerator placed outside. Temperature logs for the portable unit showed it at 50°F on one evening, and interviews revealed conflicting accounts about how long it had been warm and whether food was removed promptly. Staff reported that when the rental refrigerator was found to be “ridiculously warm,” measurements of items inside showed milk and juice at approximately 50°F and potato salad at 42°F. A technician later confirmed the unit was at 50.4°F when he arrived and that milk and juice crates remained in the unit while he repaired it. Despite this, there was no documented testing of milk temperatures after repair, and interviews indicated that milk stored in the rental refrigerator was later served for breakfast and lunch before being discarded the following day, with no additional milk or juice deliveries made specifically to replace discarded product. The administrator and various staff interviews confirmed that the warm milk and juice remained in use through multiple meals before being thrown away, and that documentation on logs (such as the notation that the unit was warm for less than two hours) was based on verbal reports rather than recorded evidence. Facility policies on Food Receiving and Storage and Food Preparation and Service required that refrigerated and frozen foods be covered, labeled, and dated with use-by dates; that dry goods be stored to maintain package integrity; that foods on nursing units be labeled with resident name and use-by date; and that foods requiring refrigeration be kept at or below 41°F. Policies also required use of clean, sanitized, and calibrated thermometers, adherence to manufacturer recommendations for sanitizing equipment, maintenance of proper hot and cold holding temperatures during service, discarding foods held in the temperature danger zone after four hours, and monitoring steam table temperatures throughout meal service. The observed practices in the kitchen, kitchenette, dishwashing area, and with the rental refrigerator did not align with these written policies, leading to the cited deficiency for failure to store and serve food under sanitary conditions.
Failure to Maintain Safe, Functional Kitchen Refrigeration and Ovens
Penalty
Summary
The facility failed to maintain essential kitchen electrical equipment, including a walk-in refrigerator and ovens, in safe operating condition. Surveyors observed that the walk-in refrigerator temperature log showed readings above 41°F beginning on 02/04/26, with temperatures documented at 50°F, 56°F, 54°F, and 58°F on various dates, and missing entries on some days. Staff interviews revealed that when a staff member noticed the walk-in felt warmer than the kitchen and reported temperatures in the 50s, the Dietary Manager instructed staff via text to move perishable items to a reach-in refrigerator but did not direct staff to take food temperatures or discard any items. The Dietary Manager stated she deleted the text messages and could not recall who notified her, and she had no paperwork or identification for any service person who allegedly came to check the unit. The Administrator and Maintenance staff both reported that they were not informed of the refrigerator problem until several days after the first elevated temperature was recorded, and they confirmed there was a multi-day delay between the initial temperature issue and their awareness and response. The facility also lacked a functioning kitchen oven system for an extended period. During observation, neither of the two ovens was operational, and it was reported that both became nonfunctioning between 01/30/26 and 02/05/26. One oven, purchased in June 2025, had experienced an internal fire that welded the heating element to the bottom panel, and the other oven, purchased in March 2025, had ongoing operational problems since October 2025, working only intermittently. Maintenance staff described the second oven as a “lemon” and reported that the manufacturer attributed the failures to incorrect electrical wattage supplied by the facility. An invoice showed both ovens were down and had been repaired on 01/30/26, with additional electrical panel troubleshooting on 02/02/26, but by the time of the survey the kitchen still did not have a working oven. These conditions demonstrated that essential electrical kitchen equipment was not maintained in safe and reliable operating condition, with the potential to affect all 38 residents in the facility.
Failure to Monitor and Treat Diabetes Leads to Resident Harm
Penalty
Summary
A deficiency occurred when the facility failed to comprehensively assess and timely identify an acute change in a resident's condition, resulting in hospitalization for diabetic ketoacidosis (DKA) and sepsis. The resident, who had a history of type I diabetes with diabetic neuropathy and muscle weakness, was admitted with orders for scheduled and sliding scale insulin, as well as regular blood glucose monitoring. On multiple occasions, the resident's blood sugar was recorded as 'hi' (above the glucometer's readable range, typically >600 mg/dL), but there was inadequate monitoring and treatment. The resident did not receive scheduled insulin or blood sugar checks as ordered, and there was a significant lapse in monitoring between the evening and the following day. Documentation revealed that the resident experienced symptoms such as nausea, vomiting, and confusion, which were reported to staff but not adequately addressed. Staff interviews indicated that there was confusion and lack of communication regarding the resident's care, with missed medication administration and insufficient follow-up on abnormal blood sugar readings. Additionally, there was a lack of root cause analysis regarding a fall that occurred during this period, and the potential link between the fall and the resident's elevated blood sugar was not explored. Staffing shortages and unclear delegation of responsibilities contributed to the failure to provide necessary care and monitoring. The resident was eventually found unresponsive on the floor in her room, with critically high blood sugar, low blood pressure, and low oxygen saturation. She was transferred to the hospital, where she was diagnosed with DKA, sepsis, and other acute medical issues. The facility's failure to follow physician orders for insulin administration, monitor blood glucose as required, and respond to changes in the resident's condition resulted in actual harm and hospitalization.
Failure to Ensure Dignified Dining Experience Due to Unattended Full Urinals
Penalty
Summary
A deficiency was identified when a resident with diagnoses including type II diabetes, muscle weakness, and cognitive communication deficit was observed eating lunch in his room while three full urinals were hanging by the handle on the footboard of his bed. The resident reported that staff would enter his room to deliver food, pick up trays, or administer medications, but did not address the full urinals. He expressed that he did not like having full urinals hanging on his bed during meals. The care plan did not note any behavioral concerns related to urinal use, and the resident's cognition was documented as intact, with some decline in care acceptance on certain days. Staff documentation indicated that the resident had requested staff to stay out of his room earlier in the day, which may have contributed to the urinals not being emptied prior to his meal. However, staff still entered the room for other reasons without addressing the urinals. Facility policy states that residents have the right to be treated with respect, kindness, and dignity. The presence of full urinals during mealtime was confirmed by both the resident and the facility administrator, indicating a failure to provide a dignified dining experience.
Failure to Notify Resident and Physician of Medication Error
Penalty
Summary
The facility failed to notify both the resident and the resident's primary care physician of a medication error involving the administration of pain medication. The resident, who had multiple diagnoses including diabetes mellitus, chronic obstructive pulmonary disease, asthma, hypertension, chronic kidney disease, polyneuropathy, severe morbid obesity, osteoarthritis, and obstructive sleep apnea, was prescribed Oxycodone ER 10 mg every 12 hours for moderate to severe pain and Oxycodone 5 mg every 12 hours as needed for pain rated five to ten. On a specific date, the nurse documented administering the scheduled Oxycodone 10 mg dose but did not document administration of the as-needed 5 mg dose. However, controlled drug records indicated that the resident received the 5 mg dose instead of the prescribed 10 mg dose at that time. During a shift change narcotic count, it was discovered that the nurse had administered the incorrect dose of Oxycodone. There was no documented evidence in the medical record that either the resident or the resident's physician was notified of this medication error. Facility policy required prompt notification of the resident, physician, and resident representative of changes in the resident's medical condition or status, but this was not followed in this instance.
Failure to Maintain Adequate Nursing Staff and Monitor Resident with Diabetes
Penalty
Summary
The facility failed to maintain adequate nursing staff levels to meet the needs of all residents, resulting in a deficiency that directly affected one resident and had the potential to impact others. On the day in question, the facility did not have the required number of licensed nurses on duty due to call-offs and scheduling issues. The staffing plan called for at least three LPNs or RNs on dayshift, but only two nurses were present, and attempts to secure additional coverage were unsuccessful. Communication breakdowns occurred between the nightshift nurse, the Director of Nursing, the Administrator, and Human Resources, leading to confusion about who was responsible for medication administration and resident care during the shift change. A resident with type I diabetes and a history of unstable blood glucose levels experienced significant lapses in care. The resident did not receive scheduled blood sugar checks or insulin administration as ordered by the physician. Documentation showed that the resident's blood sugar was not monitored for an extended period, and there was no evidence that insulin was administered when indicated. The resident was later found on the floor in her room, lying in vomit, with critically low blood pressure, irregular pulse, and severe hyperglycemia. Staff were initially unaware of the resident's whereabouts, and it was only after a search that she was located and assessed. The resident was subsequently transferred to the emergency department, where she was diagnosed with diabetic ketoacidosis, high anion gap metabolic acidosis, acute urinary tract infection, non-ST elevated myocardial infarction, and sepsis. The facility's failure to provide adequate staffing and ensure proper monitoring and care for the resident's complex medical needs contributed to the adverse outcome. The deficiency was further evidenced by the lack of a root cause analysis for the resident's fall and the absence of timely interventions in response to her deteriorating condition.
Medication Administration Errors Result in Unnecessary Drug Use
Penalty
Summary
The facility failed to ensure that residents were free from unnecessary medications, as evidenced by medication administration errors affecting two residents. One resident with multiple diagnoses, including anxiety disorder and moderate cognitive deficit, was prescribed Lorazepam 0.25 mg twice daily for anxiety and Lorazepam 0.5 mg as needed. However, the resident was repeatedly administered Lorazepam 0.5 mg instead of the prescribed 0.25 mg dose on multiple occasions, with no evidence that the higher dose was given as an as-needed medication. Documentation showed that staff were signing off on the administration of the incorrect dose, contrary to the physician's orders. Another resident with a history of chronic pain and multiple comorbidities was prescribed Oxycodone 5 mg every six hours for pain and Hydromorphone 2 mg as needed for severe pain. The resident was administered an extra dose of Oxycodone 5 mg without a physician's order, and there was no documentation in the medical record or medication administration record (MAR) to support the administration of this extra dose. The incident was discovered during a narcotic shift count, but the error was not documented in the resident's records. Review of facility policy indicated that medications are to be administered as prescribed, with staff required to verify the right resident, medication, dosage, time, and method before administration. Despite these policies, the facility did not ensure adherence to medication orders, resulting in residents receiving unnecessary or incorrect doses of medication.
Insufficient Staffing Resulting in Delayed Resident Care
Penalty
Summary
The facility failed to provide sufficient nursing staff to meet the needs of all 48 residents, as evidenced by multiple sources including staff schedules, facility assessments, resident council meeting minutes, and interviews with residents and staff. The facility assessment indicated that staffing decisions should be informed by resident needs and contingency plans were in place for unplanned staffing shortages. However, review of staffing schedules revealed instances where only two or three CNAs were available for 48 residents during certain shifts, and staff interviews confirmed that call-offs were not always covered, leading to inadequate staffing levels, particularly on weekends and night shifts. Residents consistently reported long wait times for call light responses, sometimes up to 30-60 minutes, and difficulty receiving assistance with activities of daily living such as bathing, toileting, and scheduled showers. Several residents also noted that they were unable to participate in activities like smoking breaks due to lack of available staff. Resident council meeting minutes documented ongoing concerns about delayed care and insufficient help, especially for tasks requiring two staff members, such as using a mechanical lift. Staff interviews corroborated these concerns, with CNAs and LPNs stating that the workload was unmanageable with the current staffing levels, especially given the high number of residents requiring two-person assistance. Staff reported that routine care such as two-hour checks, showers, and restorative programs were not consistently completed. The staffing coordinator acknowledged the use of agency and temporary staff but confirmed that management did not always come in to cover shifts when call-offs occurred. The local Ombudsman was also aware of the ongoing staffing issues.
Failure to Provide Scheduled Bathing and Nail Care Assistance
Penalty
Summary
A deficiency occurred when a resident who was dependent on staff for personal care did not receive scheduled bathing and nail care assistance as required. The resident, who had diagnoses including rheumatoid arthritis, osteoarthritis, difficulty walking, and diabetes, required partial to moderate assistance with bathing and set up or clean-up assistance for personal hygiene. Her care plan specified that staff should provide showers or bed baths and nail care according to her preferences. Documentation showed her last completed shower and nail care occurred on 08/23/25, with a refusal documented on 08/27/25. There was no documentation that a shower or bath was offered or provided on her next scheduled day, 08/30/25. Observations on 09/02/25 and 09/03/25 found the resident in bed with a dark substance under her fingernails. Interviews with staff confirmed the lack of documentation for the missed scheduled shower and acknowledged the resident was dependent on staff for nail care. The CNA who provided a bed bath on 09/03/25 reported cleaning the resident's dirty fingernails at that time and confirmed the resident could not perform her own nail care. The DON verified the absence of documentation for the missed scheduled shower and confirmed the resident's dependency on staff for these activities.
Failure to Provide Diet Consistent with Resident's Needs
Penalty
Summary
A deficiency was identified when a resident with dysphagia, oropharyngeal phase, and who was edentulous, was not served food in accordance with her prescribed diet. The resident's care plan and physician orders specified a regular diet with soft, bite-sized textures and thin liquids, and the dietary card for the dinner meal reflected these requirements. However, during observation, the resident was served a hot dog on a bun cut into uneven pieces ranging from 0.5 to 1 inch, along with other meal items. The hot dog was not considered soft or appropriately bite-sized for the resident's needs, and there were no condiments provided. The resident was observed eating the hot dog and bun without staff present in the room. Further review and interviews confirmed that the LPN assigned to the resident was unaware of the specific diet order until reviewing the tray card, and acknowledged that the hot dog as served did not meet the soft, bite-sized texture requirement. The registered dietitian also verified that a hot dog is not part of a soft diet and that the pieces served were not bite-sized. Additionally, the facility did not have a policy defining a soft diet with bite-sized texture for review. This failure to provide food in a form designed to meet the resident's individual needs constituted the deficiency.
Inaccurate MDS Assessment Coding for Discharge
Penalty
Summary
The facility failed to complete an accurate comprehensive assessment for a resident with Alzheimer's disease, schizoaffective disorder, and intermittent explosive disorder. The resident was admitted with a high risk for elopement, aggression, and required close supervision in a secured unit. Due to the closure of the secured unit, the resident and family were given a 30-day notice for discharge, as the resident's needs could not be met on the main floor. The discharge was scheduled and anticipated, with the family involved in planning and arranging for the resident's personal items to be moved. Despite the planned nature of the discharge, the Minimum Data Set (MDS) assessment was coded as an unplanned discharge by the RN, based on the discharge occurring a day later than originally scheduled. Interviews with staff confirmed that the delay was due to logistical reasons related to moving the resident's belongings, not due to an acute medical event or an unexpected decision by the resident. The Centers for Medicare and Medicaid Services (CMS) guidelines define an unplanned discharge as one resulting from an acute medical need or an unexpected departure, which did not apply in this case. This misclassification resulted in an inaccurate assessment for the resident.
Failure to Protect Resident from Verbal and Emotional Abuse
Penalty
Summary
A deficiency occurred when a resident with chronic kidney disease, bipolar disorder, and cognitive communication deficit was not protected from verbal and emotional abuse. The resident, who had an intact cognition and no behavioral issues per her MDS assessment, had a long-standing routine of keeping puzzles in the activity room. Facility staff, including the Activities Director (AD), told the resident she could no longer keep her puzzles in the activity room, disrupting her routine. During a meeting involving the resident, the AD, the Ombudsman, and the DON, the AD argued with the resident, raised her voice, and made dismissive gestures, stating she would not be told what to do in her activity room. The Ombudsman and the DON both observed the AD's unprofessional conduct, with the DON noting that the AD's comments and gestures were inappropriate. The resident reported feeling emotionally abused, stating that being yelled at in front of peers made her feel horrible, anxious, and unable to eat or sleep. She also described feeling disrespected and undignified after the Administrator addressed her for cussing at the AD in front of staff and other residents. The Ombudsman corroborated the resident's account, noting that the AD argued with the resident and accused her of lying. Facility policy defines mental and verbal abuse as conduct that causes or has the potential to cause humiliation, intimidation, fear, shame, agitation, or degradation, and requires such allegations to be investigated and reported.
Failure to Provide Complete and Timely Discharge Notices and Notifications
Penalty
Summary
The facility failed to provide complete and timely discharge notices to resident representatives and did not notify the state health department of resident discharges, as required. This deficiency affected five residents who were discharged from the facility's secured memory care unit. Medical record reviews, interviews, and policy reviews revealed that discharge notices were missing critical information, such as the date and location of discharge, and did not include required details about appeal rights or advocacy contacts for residents with mental health disorders. In several cases, discharge notices were not sent with the initial letters, and when they were eventually sent, they were often incomplete or illegible due to poor copying quality. For each resident, documentation showed that representatives were informed of the memory care unit closure, but the written notices lacked essential elements. The discharge notices did not specify how to appeal the discharge, omitted the contact information for agencies responsible for the protection and advocacy of individuals with mental disorders, and failed to include the discharge order. Additionally, there was no evidence that revised notices with updated discharge dates and locations were sent to representatives once those details were determined. Certified mail receipts were inconsistent, and in some cases, there was no confirmation that the representatives received the required documentation. Interviews with the Social Service Designee and the Administrator confirmed that the state health department was not notified of the discharges, and the Ombudsman was not provided with the required discharge notices in a timely manner. The Ombudsman expressed concerns about improper discharges and the lack of appropriate notice, including the absence of information about appeal rights and discharge locations. The deficiency was further substantiated by interviews with resident representatives, who reported receiving incomplete or missing discharge documentation and insufficient assistance during the discharge process.
Failure to Verify Staff Against Nurse Aide Registry
Penalty
Summary
The facility failed to ensure that staff hired did not have findings of abuse, neglect, exploitation, mistreatment of residents, or misappropriation of property entered into the State nurse aide registry. This deficiency was identified through a review of personnel files, interviews, and policy reviews. Specifically, the personnel files for three staff members, including a Medical Records employee, a Social Worker, and a Director of Rehabilitation, showed no evidence of being checked against the Nurse Aide Registry prior to their hire dates. This oversight had the potential to affect all 57 residents in the facility. During an interview, the Human Resources representative confirmed that these staff members, who had the potential to provide direct resident care, were not verified against the nurse aide registry before being hired. The facility's policy, titled 'Abuse, Neglect, Exploitation and Misappropriation Prevention Program,' dated April 2021, mandates that staff with such findings should not be employed. The failure to adhere to this policy indicates a significant oversight in the facility's hiring practices.
Deficiency in CNA In-Service Training Hours
Penalty
Summary
The facility failed to ensure that Certified Nursing Assistants (CNAs) received the required 12 hours of annual in-service training, which is essential for maintaining their skills in caring for residents. This deficiency was identified through a review of personnel files for several CNAs and an Activity Director who occasionally worked as a CNA, revealing no evidence of the required training hours for the years 2024 and 2025. An interview with the Human Resources representative confirmed the lack of documentation for these training hours. The facility's policy, dated 2001, mandates regular in-service education for all staff to ensure they can enhance residents' quality of life and demonstrate competency in various training areas, including communication, resident rights, abuse prevention, infection prevention, and compliance standards. However, the documentation of completed training, which should include details such as the date, time, topic, and hours of training, was missing for the identified staff members.
Sanitation and Food Storage Deficiencies in Facility Kitchen
Penalty
Summary
The facility failed to maintain a clean and sanitary kitchen, which had the potential to affect all 57 residents served meals from the kitchen. Observations revealed several issues, including a walk-in freezer with large icicles and no thermometer, leading to soft ice cream and a lack of cold temperature. The walk-in cooler also lacked thermometers and had milk crates on the floor with black debris under the shelving units. Additionally, the reach-in cooler contained expired and undated food items, with red and black flakes observed in applesauce containers. Further observations in the dry stock room showed dented cans of sliced apples and diced tomatoes, which staff were not supposed to accept. The Registered Dietitian was unaware of the cooler or freezer concerns, expired foods, and dry stock issues, indicating a lack of oversight. During the pureed food preparation process, the staff member did not clean the prep table before use and placed a spatula directly on the table without a barrier, leading to potential contamination. The facility's only ice machine, located in the main dining room, was found with black speckled debris and standing water, despite being recently cleaned and sanitized by a contractor. The Maintenance Director and Director of Nursing verified the presence of black residue, which was not a stain, and took steps to address the issue. The facility's policies on environment, ice, and food storage were reviewed, revealing non-compliance with maintaining clean and sanitary conditions, as well as proper storage of cold and dry foods.
Deficiencies in Resident Hygiene and ADL Assistance
Penalty
Summary
The facility failed to ensure residents were assisted with activities of daily living (ADLs) to maintain appropriate hygiene, affecting five residents. Resident #25, who was admitted with dementia and muscle weakness, was observed wearing the same clothes for consecutive days and had a noticeable body odor. Despite being care planned for supervision with dressing, staff marked him as independent due to his refusal to change clothes, which was confirmed by interviews with staff and the Director of Nursing. Resident #46, diagnosed with COPD and congestive heart failure, required maximum assistance with bathing. However, the facility failed to offer showers on scheduled days, as evidenced by missing documentation and the resident's inability to recall her last shower. The facility's policy required documentation of showers, including refusals, but this was not consistently followed. Residents #27 and #35, both with severe cognitive impairments, were dependent on staff for personal hygiene. Observations revealed long and dirty fingernails, indicating a lack of nail care, which was supposed to be part of their bathing routine. Interviews with CNAs confirmed that nail care was not consistently provided. Additionally, Resident #6, who required assistance with oral hygiene, reported not receiving help with brushing her teeth over a weekend, which was corroborated by missing documentation in her records.
Failure to Provide Double Portions as Ordered
Penalty
Summary
The facility failed to provide double portions as indicated for a resident who required them. During an observation of the lunch tray line, it was noted that a resident with a regular diet order for double portions was not served the correct amount of food. The resident's meal card specified double portions, including two open-faced roast pork sandwiches and four ounces of gravy. However, the resident was served only one piece of pork between two slices of bread and half of the required amount of gravy. The staff member responsible for serving the meal acknowledged that double portions were only provided for the entree, which was incorrectly interpreted as an extra slice of bread rather than additional meat. The resident in question had been admitted with diagnoses including unspecified dementia, aphasia, and depression, and had a diet order for large portions to support weight maintenance. The facility's policy on altered portion sizes specified that double portions should include six to eight ounces of meat, two sandwiches, one cup of vegetables, two slices of bread, and one cup of potatoes. Despite this policy, the staff member did not initially provide the correct portions due to concerns about having enough food for other residents. The issue was only rectified after intervention from a regional dietary staff member, who instructed the server to add another pork patty to the meal.
Improper Pureed Food Consistency for Residents
Penalty
Summary
The facility failed to ensure that pureed food was prepared to the correct consistency for two residents on pureed diets. Resident #35, who was admitted with Alzheimer's disease and was severely impaired for daily decision-making, was ordered a pureed diet. However, during a lunch observation, it was noted that the bread served was not pureed to a smooth consistency, resembling dry bread dressing instead. Additionally, Resident #35 was initially served ground pork instead of the required pureed consistency. Despite attempts to correct the consistency by adding water, the bread remained improperly prepared. Similarly, Resident #45, with diagnoses including atrial fibrillation, dementia, and chronic kidney disease, was also ordered a pureed diet. During breakfast, the resident was served ground pancakes and sausage, which were not of the smooth, pudding-like consistency required for a pureed diet. The food was observed to be the consistency of cooked oatmeal, and the resident consumed the meal quickly, coughing twice during the process. A CNA confirmed the improper consistency and expressed uncertainty about how to achieve the correct pureed texture. The facility's policy on therapeutic diets mandates that all mechanically altered diets must adhere to specific texture modifications as ordered by a physician or dietitian.
Infection Control Deficiencies in LTC Facility
Penalty
Summary
The facility failed to implement an effective infection control program, as evidenced by multiple deficiencies in infection prevention practices. One resident, who was placed on droplet precautions due to suspected Influenza A, was exposed to a staff member who entered the room without donning the required personal protective equipment (PPE). The staff member, unaware of the resident's precautionary status, handled the resident's meal tray and bed linens without gloves, potentially increasing the risk of infection transmission. Another deficiency was observed during wound care for a resident with multiple wounds, including a venous wound on the right lower leg. The registered nurse performing the wound care failed to adhere to proper hand hygiene protocols, opting to wear multiple pairs of gloves simultaneously to avoid frequent handwashing. This practice compromised the sterile field and increased the risk of cross-contamination. Additionally, the nurse used an incorrect treatment for the wound, despite the availability of the correct medication, further highlighting lapses in adherence to treatment protocols. The facility also demonstrated inadequate infection control during meal delivery processes. Staff members delivering meals to residents in their rooms and in the dining room failed to perform hand hygiene between tray deliveries, increasing the risk of foodborne illness. Furthermore, a resident with a nephrostomy bag was observed with the bag lying on the floor, contrary to infection prevention guidelines. These observations indicate a systemic failure in maintaining infection control standards across various aspects of resident care.
Failure to Monitor Antibiotic Use and Ensure Infection Criteria
Penalty
Summary
The facility failed to monitor the use of antibiotics and ensure infection criteria were met for three residents. Resident #7 was administered Ceftriaxone for a suspected urinary tract infection (UTI) without evidence of a urinalysis or urine culture to justify the treatment. The resident had an increased white blood cell count and confusion, but no other testing was conducted to confirm the need for antibiotics. Interviews with registered nurses confirmed the lack of documentation and evaluation to support the antibiotic use, and the resident's treatment was not recorded in the Infection Control Log. Resident #19 was admitted to the hospital with a UTI and discharged with an order for Cefdinir. However, there was no documentation of a urine specimen analysis or culture and sensitivity being completed by the facility or received from the hospital. The Infection Preventionist confirmed that McGeer's criteria paperwork was not filled out, and the facility did not confirm the resident met criteria for antibiotic use. Similarly, Resident #46 was discharged from the hospital with orders for Cefdinir and Doxycycline for a UTI, but the facility did not document a urine analysis or culture and sensitivity. The Infection Preventionist acknowledged the absence of McGeer's criteria documentation and the lack of confirmation that the resident met the criteria for antibiotic use. The facility's antibiotic stewardship policy requires documentation and review of antibiotic use, which was not adhered to in these cases.
Persistent Odor Issue on 400 Hall
Penalty
Summary
The facility failed to maintain a building environment free of offensive odors, specifically on the 400 hall, affecting all 19 residents residing there. Observations made between March 3 and March 10, 2025, noted a persistent sewage-like odor throughout the hall, which was not transient and could not be traced to any specific resident room. Resident council meeting minutes from February 17, 2025, indicated that residents had previously raised concerns about a bad smell in the 400 hall shower room, which was reportedly addressed by the maintenance department on February 18, 2025. However, interviews with residents and staff revealed that the odor persisted, with residents expressing discomfort and reluctance to use the shower facilities due to the smell. The Maintenance Director acknowledged ongoing issues with the odor and mentioned that an outside company was involved in addressing the problem. The company had attempted to resolve the issue by running a camera through the drain lines and applying chemicals to clear a blockage, but the odor remained. The Housekeeper assigned to the 400 hall confirmed the presence of a sewer-like odor emanating from the shower room drain, which extended into the hallway. Despite efforts to clean the area, the odor persisted, indicating a more significant underlying issue with the facility's plumbing system. The Director of Nursing confirmed the ongoing complaints and the need for further action to address the odor problem.
Failure to Ensure Resident Dignity and Respect
Penalty
Summary
The facility failed to ensure residents were treated with respect and dignity, affecting two residents. Resident #18, diagnosed with major depressive disorder, was the subject of disrespectful comments made by CNA #202 in the dining room. CNA #202 referred to Resident #18 as a 'hateful old lady' while speaking with another CNA and dietary staff. This behavior was acknowledged by CNA #202 upon noticing the surveyor's presence, admitting the comment was inappropriate. Resident #42, with diagnoses including schizoaffective disorder bipolar type and Alzheimer's disease, experienced neglect in care. Video footage provided by the resident's family showed CNA #222 placing a lunch tray out of reach and not assisting with feeding, resulting in the resident dropping food on himself. The resident remained in a soiled state until other CNAs were assigned to assist him later. Interviews revealed that staff were aware of the resident's needs but failed to provide timely assistance, leaving him in an undignified condition. The facility's policy on dignity emphasizes treating residents with respect and addressing their needs sensitively. However, the actions and inactions of the staff, as observed and reported, did not align with this policy, leading to the deficiencies noted in the care of Residents #18 and #42.
Inconsistent Code Status Documentation for Resident
Penalty
Summary
The facility failed to ensure consistency in a resident's code status between the electronic medical record (EMR) and the hard chart of the medical record. This discrepancy affected a resident who was admitted with a Do Not Resuscitate Comfort Care-Arrest (DNRCC-A) status, as indicated in the hard chart. However, the EMR listed the resident as a full code, which was inconsistent with the hard chart. The inconsistency was discovered during a review of the resident's records, which included a hospital discharge summary that also identified the resident as a full code. The resident, who was cognitively intact and had no communication issues, confirmed her desire to be a full code when asked by an LPN. The Director of Nursing (DON) acknowledged the inconsistency between the EMR and the hard chart, recognizing the potential risk of not providing CPR as desired by the resident in the event of a cardiac or respiratory arrest. The facility's policy on advanced directives requires that the plan of care for each resident be consistent with their documented treatment preferences. The policy also mandates that the DON or designee notify the attending physician of advanced directives to ensure appropriate orders are documented in the resident's medical record and plan of care.
Failure to Maintain Resident Privacy During Insulin Administration
Penalty
Summary
The facility failed to maintain resident privacy during the administration of insulin, affecting one resident during a meal observation in the dining room. Resident #7, who was admitted with diagnoses including diabetes mellitus and depression, was observed during lunch when an LPN approached her to check her blood glucose level. The LPN announced the resident's blood glucose level aloud and then left to determine the insulin dosage. Upon returning, the LPN administered the insulin injection in the resident's right arm without offering to move to a private area, thus compromising the resident's privacy. Interviews conducted with the Director of Nursing and the LPN confirmed the incident. The Director of Nursing acknowledged that the insulin should not have been administered in the dining room, while the LPN did not initially recognize the issue with administering the injection in a public setting. The facility's policy on Resident Rights, revised in August 2009, emphasizes treating residents with kindness, respect, and dignity, including ensuring their privacy and confidentiality, which was not adhered to in this instance.
Inaccurate Comprehensive Assessments for Residents
Penalty
Summary
The facility failed to ensure comprehensive assessments were accurate for two residents. Resident #16 was admitted with multiple diagnoses, including vascular dementia and cognitive communication deficit. Upon admission, it was noted that the resident had full upper and lower dentures, but the admission Minimum Data Set (MDS) inaccurately marked the dental section as 'no' for no natural teeth or tooth fragments. This error was confirmed by the Director of Nursing (DON). Resident #7, admitted with diabetes mellitus and dysphagia, had a care plan indicating poor-fitting dentures. A dental evaluation confirmed the resident was edentulous and reported ill-fitting dentures. However, the quarterly MDS inaccurately stated there were no broken or loosely fitting dentures. The resident confirmed the lower denture was loose, and the upper denture was missing. This inaccuracy was also verified by the DON.
Failure to Complete Baseline Care Plans Within 48 Hours
Penalty
Summary
The facility failed to complete baseline care plans within 48 hours of admission for two residents, affecting their immediate care needs. Resident #16, admitted with multiple diagnoses including vascular dementia and hypertension, had an incomplete baseline care plan marked as pending, with no evidence of completion or provision to the resident or responsible party. This was confirmed by the Director of Nursing (DON) during an interview. Similarly, Resident #256, admitted with conditions such as rhabdomyolysis and acute kidney failure, had an incomplete baseline care plan that was due but not finished within the required timeframe. The DON also confirmed this deficiency during an interview.
Deficiencies in Care Plan Involvement and Accuracy
Penalty
Summary
The facility failed to ensure that residents and/or their representatives were involved in the review and revision of care plans, affecting three residents. Resident #45, who was admitted with multiple diagnoses including atrial fibrillation and dementia, had no documented care plan conferences since admission, as confirmed by the Director of Nursing. Similarly, Resident #42, with severe cognitive impairment and requiring substantial assistance with daily activities, did not have a care conference completed in February 2025, as verified by the MDS RN and confirmed by the resident's daughter. Additionally, the facility failed to maintain accurate care plans for Resident #7, who was admitted with diabetes mellitus and pressure ulcers. The care plan inaccurately reflected the presence of pressure ulcers on the resident's heels, despite the MDS RN's observation that the skin was intact. This discrepancy was confirmed during an interview with the MDS RN, indicating a failure to update the care plan to reflect the resident's current condition.
Deficiencies in Wound Care and Bowel Management Protocols
Penalty
Summary
The facility failed to adhere to physician orders and infection control protocols in the care of Resident #7, who had multiple wounds requiring specific treatments. The resident had an order to cleanse a venous wound on the right lower leg and apply specific dressings daily. However, during an observation, RN #313 did not follow proper infection control procedures, such as changing gloves and performing hand hygiene between tasks. The RN used multiple pairs of gloves simultaneously and did not change them when leaving and re-entering the room, which posed a risk of cross-contamination. Additionally, the RN used a substitute dressing without confirming the unavailability of the prescribed treatment, despite the ordered treatment being available. Resident #46's bowel management was inadequately addressed, as the facility did not follow the bowel protocol despite the resident not having a bowel movement for several days. The resident had orders for laxatives and enemas to be administered if no bowel movement occurred in three days. However, the facility failed to administer these treatments consistently and did not document the effectiveness of the treatments given. Interviews with staff revealed a lack of adherence to the bowel management protocol, and the DON confirmed that the protocol should have been initiated earlier. Resident #8's wound care was also neglected when the facility did not change the dressing on the resident's left lower leg as scheduled. The resident was unable to attend a wound center appointment due to illness, and the facility staff did not change the dressing, resulting in drainage seeping through the dressing. The DON confirmed that the dressing should have been changed by the facility staff in the absence of the wound center visit. This oversight in wound care management highlights a failure to ensure proper treatment and monitoring of residents' conditions.
Failure to Apply Orthotics for Contracture Management
Penalty
Summary
The facility failed to ensure that a resident with contractures had orthotics applied daily for contracture management as per their plan of care. Resident #35, who was admitted with diagnoses including Alzheimer's disease, dementia, and contractures, was supposed to wear a left hand/wrist orthotic for up to four hours twice daily. However, there was no active physician's order for the orthotic, and the treatment administration record did not reflect its use. Observations confirmed that the orthotic was not applied, and staff interviews revealed a lack of awareness about the resident's need for the orthotic. Resident #35's medical record indicated a care plan for an ADL self-care deficit, with interventions including the use of a left hand/wrist orthotic. Despite recommendations from occupational therapy for contracture management, the orthotic was not being used as prescribed. Staff interviews revealed that the orthotic was found in a drawer, and the nursing staff were unaware of its necessity. The resident's care plan was not being followed, and there was no documentation to support the implementation of the recommended restorative nursing program. The Director of Nursing confirmed that the facility did not have a dedicated restorative aide and that any restorative programs would be documented under the task tab of the EMR. However, there was no evidence that the restorative nursing program recommended by occupational therapy was being followed. The facility's policy on resident mobility and range of motion emphasized the importance of preventing avoidable reductions in ROM, but the lack of adherence to the care plan and recommendations resulted in a deficiency in the resident's care.
Failure to Follow Urologist's Orders for Catheter Care and Estrogen Therapy
Penalty
Summary
The facility failed to provide ordered care and services for a resident with an indwelling urinary catheter, affecting one resident out of four reviewed for urinary catheter or UTI. The resident, who was admitted with multiple diagnoses including diabetes mellitus, neuromuscular disorder of the bladder, and a history of UTIs, was under a care plan that required the catheter to be changed every four weeks and as needed. However, the medical records showed that the catheter was not changed in November or December 2024, despite the urologist's orders. Observations in March 2025 revealed the resident's catheter tubing contained thick yellow sediment, indicating potential issues with catheter maintenance. Additionally, the facility did not follow the urologist's recommendation to continue vaginal estrogen therapy, which was intended to lower the risk of UTIs. The electronic Medication Administration Record from October 2024 to March 2025 showed no evidence of the vaginal estrogen being ordered, despite the urologist's and infectious disease recommendations. Interviews with the DON and a registered nurse confirmed that the primary care physician had discontinued the estrogen therapy without documented justification, and the urologist had reiterated the need for its continuation.
Failure to Monitor Nutritional Status and Weight Loss
Penalty
Summary
The facility failed to adequately monitor and address the nutritional needs of two residents, leading to significant weight loss without proper intervention. Resident #45, who was admitted with multiple diagnoses including dementia and COPD, experienced a 14.47% weight loss over five months. Despite a care plan that required monitoring of food and fluid intake and notifying the Registered Dietician if consumption was poor, there were several days with no documented meal intakes or supplements offered. The Director of Nursing confirmed the lack of documentation and that the resident was not out of the facility on those days. Resident #25, admitted with conditions such as morbid obesity and type II diabetes, also experienced significant weight loss. The resident's weight dropped from 346 pounds to 299.4 pounds over several months, a 13.9% loss in six months, without being on a prescribed weight loss regimen. Despite the weight loss, the dietician and medical staff did not implement new interventions, and there was a misunderstanding regarding the resident's use of diuretics. Interviews revealed that the resident was eating well and desired weight loss, but the rapid weight loss was not adequately addressed by the facility. The facility's failure to monitor and document the nutritional intake and weight changes of these residents, along with the lack of timely intervention and communication with the physician, contributed to the deficiency. The oversight in recognizing the absence of a diuretic and the impact of dental extractions on Resident #25's nutritional status further exemplifies the facility's inadequate response to the residents' nutritional needs.
Inadequate Pain Management for Two Residents
Penalty
Summary
The facility failed to provide timely and appropriate pain management for two residents, Resident #6 and Resident #7, as identified through interviews, observations, and record reviews. Resident #7, who was admitted with diagnoses including diabetes mellitus, a stage III pressure ulcer, and chronic pain, experienced significant pain that was not adequately addressed during care. Despite receiving scheduled pain medications, Resident #7 reported severe leg pain during an interview and was observed to be in distress during a dressing change, with no additional pain relief interventions offered by the staff at that time. Resident #6, admitted with conditions such as cerebral infarction and hemiplegia, also experienced inadequate pain management. The resident reported severe shoulder pain following an incident with a Hoyer lift, which was not documented in the facility's incident log. Despite a high pain rating and complaints of pain affecting daily activities, there was a delay in obtaining an x-ray and providing appropriate pain relief. The resident's pain was not adequately assessed or managed, leading to prolonged discomfort and anxiety. The facility's policy on pain assessment and management, revised in October 2022, outlines procedures for identifying and addressing pain, including the use of both pharmacological and non-pharmacological interventions. However, the facility failed to adhere to these procedures, resulting in inadequate pain management for the residents. The lack of timely assessment and intervention for acute pain episodes contributed to the deficiencies identified in the report.
Inadequate CNA Training on Pureed Diets
Penalty
Summary
The facility failed to ensure that certified nurse aides (CNAs) had the necessary knowledge to identify and serve mechanically altered food, specifically a pureed diet, to a resident. This deficiency was observed in the case of a resident with multiple diagnoses, including atrial fibrillation, dementia with behavioral disturbances, hypertension, cognitive communication deficit, and chronic kidney disease. The resident was ordered to receive a pureed diet, but during an observation, the resident was served a meal that was not of the required pureed consistency. Instead, the meal consisted of ground pancakes and sausage, which were not smooth and pudding-like as required for a pureed diet. During the observation, the resident consumed the meal at a fast rate and coughed twice, indicating potential difficulty with the meal's consistency. The CNA responsible for delivering the meal confirmed that the food was not of the correct consistency and expressed uncertainty about how to achieve the proper pureed texture. Despite having received education on diets, the CNA lacked the competency to ensure the resident received the appropriate meal consistency, leading to the deficiency identified by the surveyors.
Failure to Monitor Psychotropic Medication Use
Penalty
Summary
The facility failed to adequately assess and monitor Resident #40 for side effects and behaviors related to the use of psychotropic medications, leading to the potential for unnecessary medication use. Resident #40, who has diagnoses including unspecified psychosis, dementia, and major depressive disorder, was receiving citalopram and risperdal. However, there was no documented side effect or behavior monitoring in the medical record, medication administration record, or care plan. The Director of Nursing confirmed the absence of such monitoring, indicating a lapse in the facility's responsibility to ensure safe medication management. Additionally, the facility did not ensure that Resident #48 received psychotropic medication with an appropriate diagnosis and documented necessity. Resident #48, diagnosed with Alzheimer's disease and severe cognitive impairment, was prescribed olanzapine as a sleep aid without a suitable diagnosis for its use. The Director of Nursing confirmed the lack of an appropriate diagnosis for the antipsychotic medication, highlighting a failure in the facility's medication management practices.
Failure to Provide Palatable and Attractive Meals
Penalty
Summary
The facility failed to provide meals that were palatable and attractive, affecting a resident with a history of diabetes mellitus, pressure ulcer, and depression. The resident was moderately impaired for daily decision-making. During an observation, the resident's lunch meal included meatballs that were black and burnt on one side, with the burnt portions peeled away and placed on a napkin. The remaining meatball appeared dry and unappealing. Additionally, the resident struggled to cut a green bean in half with her fork, describing them as rubbery, hard, and unseasoned. The resident expressed dissatisfaction with the meal, stating the meatballs were dry and burnt, and the green beans were difficult to chew. An Activity Director verified the condition of the meatballs and offered a substitute meal, which the resident declined. Further observation with the Dietary Manager and Regional Dietary revealed a disagreement on whether the meatballs were burnt, with staff describing them as dark brown from being crisped in the oven. The resident consumed only a portion of the rice and mandarin oranges from the meal tray.
Failure to Provide Assistive Eating Equipment
Penalty
Summary
The facility failed to provide the necessary assistive eating equipment for a resident, which was identified during an observation of the lunch tray line. The resident, who was admitted with diagnoses including unspecified dementia, dysphagia, and traumatic brain injury, was cognitively intact for daily decision making according to a recent assessment. The resident's electronic Physician Orders specified a regular diet with thin liquids consistency and the use of a divided plate to increase independence. However, during the lunch service, a staff member placed the resident's meal, which included a slice of bread, pork patty with gravy, mashed potatoes, and carrots, into a scooper bowl instead of using the required divided plate and scoop plate as indicated on the meal ticket. This oversight was confirmed by the staff member involved.
Failure to Maintain Accurate Medical Records and Follow Physician Orders
Penalty
Summary
The facility failed to maintain comprehensive and accurate medical records for a resident with end-stage renal disease, hypertension, and constipation. The resident was prescribed amlodipine desylate with specific instructions to hold the medication if the systolic blood pressure was less than 90 mmHg or the heart rate was less than 90 beats per minute, and to hold the medication on dialysis days. However, the electronic Medication Administration Record (eMAR) for February and March 2025 showed that these instructions were not consistently followed. Specifically, the medication was not held when the heart rate was below the specified threshold, and there were discrepancies in the dosage administered on certain days. Additionally, the facility failed to document the indwelling urinary catheter output for the resident as required. The eMAR for February 2025 indicated that catheter output was not recorded during several day and night shifts. An interview with the Director of Nursing confirmed that the physician's instructions were not adhered to and that there was a lack of documentation regarding the catheter output. The DON suggested that a transcription error might have occurred, as the resident had other blood pressure medications with different parameters.
Failure to Implement Fall Prevention and Safe Medication Administration
Penalty
Summary
The facility failed to implement fall prevention interventions for Resident #23 as per the care plan. The resident, who had a history of falls and required assistance with mobility, was found on the floor after sliding out of his wheelchair. The care plan included interventions such as anti-tippers, non-slip footwear, and the use of a call light, but did not mention the use of Dycem, a non-slip pad, which was supposed to be added to the resident's wheelchair. Upon observation, it was confirmed that Dycem was not in place, and the resident's physician orders did not include any fall prevention interventions. In a separate incident, the facility failed to ensure that Resident #42's medication was administered safely. The resident, who resided in the memory care unit and had a history of noncompliance with medication, was given medication mixed in a cookie. The medication was left unattended, and the resident's daughter accidentally ingested part of it. The nurse responsible for administering the medication, LPN #400, was distracted and did not ensure the medication was taken by the resident. The facility's policy on administering medications did not provide clear directives on remaining with the resident until the medication was taken or disposing of it if refused. These deficiencies were identified during a survey, highlighting lapses in the facility's adherence to care plans and medication administration protocols. The incidents involved two residents, one with a history of falls and another with cognitive impairments, and resulted in a failure to provide adequate supervision and safety measures as required by the facility's policies.
Failure to Provide Prescribed Evening Snacks
Penalty
Summary
The facility failed to ensure that residents received their prescribed evening snacks, affecting two residents out of thirteen who were ordered an evening/bedtime snack. Resident #3, who was readmitted with diagnoses including diabetes mellitus, mild intellectual disabilities, and cerebral infarction, was supposed to receive vanilla ice cream at bedtime. Resident #28, admitted with non-Alzheimer's dementia and anxiety disorder, was to receive nectar thickened cranberry juice. However, during an observation between 6:50 P.M. and 7:07 P.M., it was noted that their snacks were not included on the snack tray delivered to the residents. The Dietary Manager #500 confirmed that the snacks for Resident #3 and Resident #28 were not on the snack tray due to an oversight, as they were not placed on the tray for distribution. This oversight was verified through a review of the Snack Summary list, which showed that the snacks were not prepared for delivery. The deficiency was identified during an investigation under Master Complaint Number OH00163355 and Complaint Number OH00162745.
Facility Administration Fails to Ensure Timely Payment of Bills
Penalty
Summary
The facility administration failed to ensure timely payment of bills, which could potentially interrupt services for all 53 residents. The Administrator, hired on 07/15/24, was responsible for directing day-to-day functions and ensuring compliance with regulations. However, the facility's financial management was inadequate, as evidenced by overdue payments to multiple vendors, including the local water company, power company, heating and cooling contractor, sprinkler company, sewer company, and door company. These vendors were not informed of the change in ownership effective 12/01/24, and new accounts were not set up, leading to confusion and potential service disruptions. Interviews with various vendor staff revealed significant outstanding debts, with the water bill overdue by almost 20 days and the power company expecting payment by 12/26/24. The heating and cooling contractor had not received payment for invoices dating back to September 2024, and the sprinkler company reported a substantial outstanding balance for the entire corporation. The facility's billing ledger did not accurately reflect these debts, and the Director of Nursing confirmed discrepancies between the ledger and vendor statements. The Administrator struggled to obtain financial information from the previous ownership entities, which hindered the transition process. The Director of Nursing also reported receiving calls from vendors, such as the local grocery store, regarding unpaid bills. This deficiency was investigated under Complaint Number OH00160491, highlighting the facility's failure to manage its financial obligations effectively, potentially affecting the quality of care provided to residents.
Resident Elopement Due to Malfunctioning Alarm System
Penalty
Summary
The facility failed to prevent a resident from exiting the building unsupervised, which was a significant deficiency. The resident, who had a history of cognitive impairments and was at risk for elopement, managed to leave the facility without triggering the door alarm system. The resident's medical records indicated a risk for elopement due to conditions such as dementia, psychosis, and a history of wandering behaviors. Despite having a wander guard device in place, the system did not function as intended, allowing the resident to exit the building. On the day of the incident, the resident was found outside in the parking lot, attempting to get a ride and refusing to return inside. Several staff members, including a CNA and an RN, attempted to persuade the resident to come back inside, but the resident was combative and insistent on leaving. The situation escalated to the point where EMS had to be called to assist in bringing the resident back into the facility. The facility's investigation revealed that the door alarm system did not activate when the resident exited, and staff were only alerted to the situation by a CNA who observed the resident outside. Interviews with staff confirmed that the wander guard system was not functioning properly at the time of the incident. The Maintenance Director later reported that a reset and adjustment of the door sensor were necessary to restore proper function. The deficiency was part of a continued non-compliance issue, as similar problems had been identified in previous surveys. The lack of a functioning alarm system and adequate supervision allowed the resident to elope, posing a significant safety risk.
Facility Fails to Maintain Clean and Safe Environment
Penalty
Summary
The facility failed to maintain a clean and safe environment for its residents, affecting 25 out of 53 residents and two of the three shower rooms. Observations revealed a black substance on the grout of the shower floor and between the floor and wall in the 100-hall shower room, accompanied by a musty, stale, earthy odor similar to mold or mildew. Additionally, a musty, rotten egg-like odor similar to sewage was detected in the 400-hall shower room. Further inspection showed missing grout and cracked tiles in the 100-hall shower room and broken tiles in the 400-hall shower room. These conditions were verified by the Director of Nursing during the observations.
Failure to Implement Fall Prevention Interventions
Penalty
Summary
The facility failed to implement fall prevention interventions as per the care plans for two residents, leading to multiple falls. Resident #35, with a medical history including atrial fibrillation and chronic obstructive pulmonary disease, experienced falls on three occasions within a month. Despite having a care plan that included interventions such as anti-rollbacks for the wheelchair, these were not applied, as observed on 11/24/24. A Certified Nursing Assistant confirmed the absence of the anti-rollbacks on the resident's wheelchair. Similarly, Resident #29, who has a history of lumbar vertebrae fracture and manic episodes, fell four times in the past month. The care plan for this resident included several interventions like non-skid footwear, dycem for the wheelchair, and a night light in the bathroom. However, observations on 11/24/24 revealed that the resident was not wearing non-skid footwear, the dycem and anti-rollbacks were missing from the wheelchair, and the bathroom light was not on. A Registered Nurse verified these deficiencies, indicating a failure to adhere to the planned fall prevention measures.
Inadequate Dementia Care and Supervision in Memory Care Unit
Penalty
Summary
The facility failed to provide comprehensive and individualized treatment and services to residents diagnosed with dementia, resulting in Immediate Jeopardy. This deficiency was highlighted by an incident where a resident was physically assaulted by another resident due to inadequate supervision and intervention by the staff. At the time of the incident, only one staff member was present on the secured memory care unit, who left the area to seek additional help, leaving the residents unsupervised. This lack of supervision and intervention led to the resident being punched in the head multiple times, causing physical and psychosocial harm. The facility's staffing schedules revealed that only one State Tested Nursing Assistant (STNA) was scheduled to be on the memory care unit at all times, which was insufficient to meet the needs of the residents. Interviews with staff members indicated that they did not receive specialized training for dementia care, and there was a lack of organized activities for the residents. The staff expressed concerns about their ability to manage the unit effectively, especially during emergencies or when dealing with aggressive behaviors. The facility's marketing materials and policies claimed that the memory care unit was staffed by specially trained professionals and provided daily social activities and a secure environment. However, observations and interviews revealed that these services were not being implemented as described. The facility's failure to provide adequate staffing, training, and activities placed all residents on the memory care unit at risk for additional harm, serious injury, and death.
Removal Plan
- Resident #46 and Resident #48 were both transported to the hospital for evaluation.
- Resident #48 returned to the facility from the hospital. The Psychiatric Nurse Practitioner (NP) saw Resident #48 in the facility.
- Head-to-toe assessments were completed for the four non-interviewable residents residing on the Memory Care Unit by the Director of Nursing. Assessments included pain assessment, psychosocial assessments and skin inspections. Five family members were interviewed by phone to identify any care concerns. Two residents were interviewed.
- Resident #46 returned to the facility from the hospital. Resident #46 was placed on one-to-one supervision with a plan for the one-to-one to continue until the resident was discharged.
- State tested Nursing Assistant (STNA) staffing was increased to two staff members at all times during the shifts for the secured Memory Care Unit. The increase in staffing was to provide activities for the memory care unit and to provide daily care and supervision/safety for the seven residents on the secured memory care unit. The facility plan indicated as the unit census increased (capacity 17) resident needs for care, activities and supervision would be assessed to determine if an increase in staff was needed.
- Resident #48 was assessed for psychosocial needs and injury by the Licensed Practical Nurse (LPN) and Corporate Licensed Social Worker. Resident #48 would continue monitoring as needed by the Psychiatric NP and nurses for changes in psychosocial status.
- Resident #46 was discharged from the facility to an Inpatient Behavioral Health facility for evaluation, medication review and potential adjustments.
- A root cause analysis of the resident-to-resident altercation was completed by the Clinical Service Manager. The facility root cause analysis identified staff were not properly trained in dementia care and there was a lack of activities for residents on the Memory Care Unit.
- An Ad Hoc Policy review was held with the Administrator, Director of Nursing, Regional Clinical Services Manager, Medical Director, Diet Tech, Medical Records/Accounts Payable, Director of Rehab, Staff Development Coordinator, Unit Manager, Business Office Manager, Maintenance Director, Central Supply/Scheduler, and Activity Coordinator to review facility policies for the Memory Care Unit, Staffing and Dementia care training, activities on the memory care unit, interventions for residents with outburst/behaviors, and the Abuse policy on how to respond to residents with behaviors. The facility identified policies were appropriate but were not implemented daily for the Memory Care unit.
- The Regional Clinical Services Manager educated the Administrator, Director of Nursing, Unit Manager, and Staff Development coordinator, regarding policies and procedures for the Memory Care Unit, Staffing and Dementia care training, activities on the Memory care unit, immediate interventions for residents with outburst/behaviors and the Abuse policy including how to respond to redirect residents with behaviors.
- The Corporate Licensed Social Worker (LSC) reviewed the care plans for all residents on the secured Memory Care Unit to ensure appropriate interventions for behaviors, supervision and activities were in place.
- Staff education was provided for 23 STNAs, two activities staff, nine therapy staff, 11 LPNs, five RNs, six Dietary staff, six Housekeeping staff on the facility Memory Care Unit policies and procedures, Staffing and Dementia care training, activities and immediate interventions for residents with outburst/behaviors by the Staff Development Coordinator. The facility provided a plan for training to continue on hire, annually and as updates to Memory Care training were available and as necessary to maintain the highest level of care, supervision, quality of life and activities for Memory Care residents. Training would be completed.
- Resident referrals for placement on the Memory Care Unit would be screened by the DON and Social Services to determine if residents were appropriate for the unit by reviewing the history of the resident including resident testing that had occurred before acceptance to the Memory Care Unit.
- The facility implemented a plan for the LNHA/Designee to audit staffing on the Memory Care Unit to ensure two staff members were always present on the Memory Care Unit. Audits would be completed five days a week for four weeks.
- The facility implemented a plan for the DON/ Designee to audit resident care plans for appropriate interventions for resident behaviors and for the Memory Care Unit supervision. Audits would be completed on three residents three times a week for four weeks.
- The facility implemented a plan for the LNHA/Designee to audit activities on the Memory Care Unit to ensure activities on the Memory Care Unit based on the Alzheimer's Association recommendations and were being completed. An activity calendar would be hung in the resident lobby on the Memory Care Unit and would be overseen by the Activity director, three times a week for four weeks and calendar was specialized for the Memory Care Unit, three times a week for four weeks.
- The facility identified a Quality Assessment and Performance Improvement meeting would be completed every week with the Medical Director to review audits and any additional changes for QAPI plan/modifications or further education for four weeks then monthly for two.
Failure in Pain Management for Two Residents
Penalty
Summary
The facility failed to provide effective pain management for two residents, resulting in actual harm. Resident #156, who had multiple diagnoses including pyogenic and rheumatoid arthritis, myalgia, and chronic back syndrome, did not receive the ordered Methadone following admission. This led to unrelieved pain that affected his sleep, therapy, and daily activities. Despite having orders for Methadone, Oxycodone, and Lyrica, the Methadone was not administered due to pharmacy delivery issues. The resident's pain was consistently high, and he was eventually transferred to the hospital for intractable back pain. Resident #7, with a history of traumatic fractures and rheumatoid arthritis, was prescribed Oxycodone five times a day. However, the facility failed to ensure the resident received the medication, resulting in missed doses. The resident experienced unrelieved pain and withdrawal symptoms, including irritability, crying, sweating, stomach cramps, and feeling weird. The facility's backup medication storage did not have the correct dose, and the pharmacy failed to deliver the medication on time, leading to the resident missing multiple doses. Interviews with staff revealed a lack of communication and follow-up regarding the unavailability of medications. The DON confirmed that Resident #156 was not receiving Methadone as ordered due to pharmacy issues, and there was no documentation of notifying the NP or physician. Similarly, for Resident #7, the DON acknowledged missed doses of Oxycodone and the absence of pain assessments. The facility's policy on pain assessment and management was not effectively implemented, contributing to the deficiencies in pain management for these residents.
Temperature and Environmental Deficiencies in Memory Care Unit
Penalty
Summary
The facility failed to maintain a comfortable temperature on the memory care unit, affecting seven residents. Observations revealed that the thermostat was consistently set to 68 degrees Fahrenheit, which was below the facility's policy range of 71 to 81 degrees. A resident was observed rubbing his arms and stating he was cold, indicating discomfort due to the low temperature. The Maintenance Supervisor confirmed the inappropriate setting and mentioned that staff had been adjusting the thermostat to their preference, which contributed to the issue. Additionally, the facility did not ensure that the walls in residents' rooms were in good repair, affecting two residents. Observations showed torn wallpaper, exposed drywall with deep gouges, and a looped television cable hanging unsafely. The Maintenance Supervisor and a nurse aide confirmed the disrepair, noting that the damage was exacerbated by residents' actions and the improper placement of furniture. The wallpaper and drywall damage had been present since at least July 2024, indicating a lack of timely maintenance and repair.
Deficiencies in Comprehensive Care Planning
Penalty
Summary
The facility failed to complete comprehensive care plans for four residents, leading to deficiencies in addressing their specific needs. Resident #36, diagnosed with schizophrenia, dementia, and hyperlipidemia, was observed with a broken and discolored front tooth, yet lacked an oral/dental care plan. The Director of Nursing (DON) confirmed the absence of such a plan. Similarly, Resident #48, who required moderate assistance with personal hygiene due to Alzheimer's disease and anxiety disorder, did not have a care plan addressing her personal hygiene needs, as verified by the DON. Resident #26, with diagnoses including bullous pemphigoid and hypertensive heart disease, was prescribed Benadryl for itching without a corresponding care plan for its use, despite multiple administrations over several months. The DON confirmed the lack of a care plan for the medication. Additionally, Resident #6, with adult-onset diabetes mellitus and iron deficiency anemia, was prescribed Aspirin for heart health without a care plan addressing the use of this anti-platelet medication or the associated risk of bleeding and bruising. The DON acknowledged the omission of these critical care plans.
Failure to Provide Scheduled Activities in Memory Care Unit
Penalty
Summary
The facility failed to provide scheduled activities to residents in the secured memory care unit, affecting seven residents with various diagnoses including dementia, Alzheimer's disease, and schizophrenia. Observations on two consecutive days revealed that scheduled activities such as the Daily Chronicle and Sounds of Serenity were not conducted. Instead, a visitor initiated a Bingo game, and country music was played on the television, deviating from the planned activities. Interviews with staff and family members highlighted a lack of clarity and responsibility regarding who should conduct activities in the memory care unit. The Activities Assistant mentioned that while they provide necessary items for activities, they do not directly engage with residents. A family member expressed dissatisfaction, stating that she had to purchase activities for residents herself, as the facility did not provide them. Additionally, a State Tested Nursing Assistant (STNA) was unaware of her role in facilitating activities and expressed concerns about managing multiple responsibilities alone. The Director of Nursing acknowledged the issue of activities not being provided but attributed staffing limitations to corporate decisions. The facility's policies on recreation programs and activities emphasize the importance of individualized, daily activities to meet residents' needs, yet these were not implemented as intended. The lack of a structured memory care program and training for aides further contributed to the deficiency in providing adequate activities for residents.
Delayed Response to Pharmacy Recommendations
Penalty
Summary
The facility failed to ensure timely responses to pharmacy recommendations for several residents, leading to deficiencies in medication management. Resident #26, who had multiple diagnoses including depression, was prescribed sertraline. A pharmacy recommendation regarding this medication was made in February 2024, but the physician did not review it until April 2024. Similarly, Resident #10, with a history of depression among other conditions, was on mirtazapine, and the pharmacy's recommendation was also delayed in being addressed by the physician. Resident #17, who had diagnoses including anxiety disorder and alcohol cirrhosis, was receiving neomycin, an antibiotic, without proper documentation or indication for its continued use. Despite a black box warning for neomycin, indicating potential toxicity, there was no care plan in place for its use, and the resident was unsure why they were taking the medication. The facility's Antibiotic Stewardship Program policy was not effectively implemented, as evidenced by the lack of appropriate assessment and documentation for the antibiotic's use. Resident #6, with diagnoses including diabetes and chronic pain, had pharmacy recommendations regarding the use of Voltaren Gel that were not addressed in a timely manner. Recommendations made in January and February 2024 were only responded to in April 2024. The facility's policy on Consultant Pharmacist Reports required timely communication and response to pharmacy recommendations, which was not adhered to in these cases, leading to deficiencies in medication management for the residents involved.
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A resident with intact cognition receiving Medicare Part A skilled services for metabolic encephalopathy had services discontinued while benefit days remained, but the facility did not issue the required Skilled Nursing Facility Advance Beneficiary Notice (SNF ABN). The Social Services Director later confirmed that no SNF ABN was provided and reported she believed only a Notice of Medicare Non-Coverage (NOMNC) was needed when all skilled services were stopped. This practice conflicted with the facility’s written policy, which required SNF ABNs to be issued when extended care items or services were initiated, reduced, or terminated due to expected non-coverage by Medicare.
Surveyors identified that the facility exceeded the acceptable medication error rate when two residents with type 2 DM received insulin doses that were not administered according to orders or manufacturer instructions. In two separate observations, an LPN administered Novolog and another LPN administered insulin glargine and insulin lispro without priming the insulin pens, and the insulin lispro and Novolog were given after the residents had already consumed a significant portion of their breakfast meals, despite orders for administration before meals. Manufacturer information for both insulin products required priming before each injection to ensure accurate dosing, and facility policy required medications, including insulin, to be administered safely, timely, and in accordance with prescriber orders and specified time frames.
Surveyors found that the facility failed to document tray line food temperatures for multiple meals served from two dining room kitchenettes, despite having a “Trayline Taste & Temperature Log” and a policy requiring food to be stored, prepared, distributed, and served according to professional food safety standards. Review of logs showed repeated missing entries for breakfast, lunch, and dinner services in both the Harrison and McClellan dining areas, and the Senior Director of Culinary Services confirmed that temperatures had not been recorded for those meals, potentially affecting all residents receiving meals from those kitchenettes.
The facility failed to conduct and document required periodic care conferences for two residents, despite multiple comprehensive, quarterly, and significant change MDS assessments and a policy requiring periodic care conferences with resident and/or family participation. One resident with Parkinson’s disease, post-stroke hemiplegia, TIA, DMII, and depression had only two documented care conferences over a year, while another resident with aphasia, cerebrovascular disease, DMII, gait difficulty, coagulation defect, depression, and muscle weakness had no documented care conferences in the past year, aside from a declined invitation to the representative. The UCC confirmed that care conferences were expected to occur quarterly and that no additional documentation existed for either resident.
A resident with Alzheimer's disease and type II DM, who required extensive assistance with ADLs and was receiving scheduled Lantus and sliding-scale Humalog, experienced a severely elevated blood glucose level. The on-call provider was notified and ordered an additional dose of lispro insulin with a directive to recheck the blood glucose after administration. Nursing staff administered the extra insulin but did not document any follow-up blood glucose check, and the DON confirmed that this reevaluation was required by the facility's abnormal blood glucose policy and was not completed or documented.
A resident with Parkinson’s disease, dementia, and hypothyroidism was prescribed levothyroxine once daily along with other medications. A consultant pharmacist’s monthly drug regimen review recommended that levothyroxine be given in the morning on an empty stomach, 30–60 minutes before food, per manufacturer instructions. The medical record contained no documented physician response to this recommendation, and the MAR showed the drug scheduled for morning administration while the resident was observed eating breakfast and receiving the medication at the same time. An LPN confirmed administering levothyroxine during the meal, and the DON verified there was no documentation explaining whether or why the pharmacist’s recommendation was or was not followed, resulting in a failure to act on and document the identified irregularity.
A resident with severe cognitive impairment, multiple comorbidities, documented gait and balance abnormalities, and a high fall risk was care planned and assessed by therapy to require contact guard assistance and use of a gait belt for transfers and ambulation. While being assisted by a CNA from a recliner to the bathroom with a walker, the CNA did not apply a gait belt, even though the resident had a known tendency to lean backward when standing. As the CNA reached to open the bathroom door, the resident lost balance and fell backward, striking the back of the head, and was later found by an LPN without a gait belt in place, contrary to the facility’s gait belt policy and the resident’s assessed needs.
A resident with CKD stage five requiring peritoneal dialysis (PD) was admitted with pre-admission physician orders for three daily PD exchanges and monitoring for peritonitis (fever, abdominal pain, cloudy effluent), but these monitoring orders were not entered into the facility’s physician orders. The care plan referenced PD and general monitoring but did not specifically address peritonitis monitoring. Paper PD flowsheets showed incomplete and inconsistent documentation of exchanges and resident condition, including missing condition/comments for individual treatments and no record of one ordered PD exchange. The PD cycler flowsheet lacked effluent descriptions on multiple days. The PD nurse reported facility staff were expected to monitor effluent and symptoms, and the DON confirmed the absence of specific peritonitis monitoring orders, lack of an order for the PD cycler, and documentation gaps, despite a facility policy requiring ongoing assessment and monitoring for complications before, during, and after dialysis treatments.
A nurse was observed preparing multiple oral medications for a resident with depression, traumatic brain injury, anxiety, and impaired cognition by pushing tablets and capsules from unit-dose cards directly into her ungloved hand and then using her fingers to place them into a medication cup. In a follow-up interview, the RN confirmed this practice and acknowledged that the correct procedure is to dispense medications directly from the card into the cup, contrary to the facility’s medication administration policy requiring adherence to good nursing principles and practices.
A resident with Alzheimer’s disease, diabetes, anxiety, significant ADL dependence, and behavioral symptoms was observed seated in a chair positioned against the nursing station with a locked wheelchair placed directly in front, also against the nursing station, effectively restricting movement. An LPN confirmed both wheelchair wheels were locked and that it should not have been placed there, while a CNA stated she had positioned the wheelchair to prepare for lunch, was unable to complete the transfer, and left it in place, acknowledging this was wrong. This arrangement conflicted with the facility’s restraint policy, which prohibits physical restraints except when alternatives are ineffective for treating a medical symptom and defines restraints as devices adjacent to the body that cannot be easily removed and that restrict freedom of movement or access to the body.
Failure to Issue Required SNF ABN When Discontinuing Medicare Part A Services
Penalty
Summary
The deficiency involves the facility’s failure to issue a Skilled Nursing Facility Advance Beneficiary Notice (SNF ABN) when Medicare Part A services were discontinued for a resident who still had available benefit days. The resident was admitted with a diagnosis of metabolic encephalopathy and had intact cognition per the Minimum Data Set assessment. The facility’s own SNF Beneficiary Notification Review documented that Medicare Part A skilled services began on 02/11/26 and the last covered day was 03/11/26, and that the facility initiated discharge from Medicare Part A services before the resident’s benefit days were exhausted. Despite this, no SNF ABN was provided to the resident or the resident’s representative. During interviews, the Social Services Director stated that the SNF ABN was issued hours prior to the last covered day but, upon reviewing her files, confirmed that no SNF ABN had actually been issued for this resident. She further explained that she believed an SNF ABN was only required if one skilled service remained and that if all skilled services were being discontinued, only the Notice of Medicare Non-Coverage (NOMNC) needed to be issued. The Administrator, however, stated that a resident should always receive both a SNF ABN and a NOMNC when Medicare Part A services are discontinued and benefit days remain. Review of the facility’s written policy dated 03/28/23 showed that the facility was required to issue SNF ABNs for initiation, reduction, or termination of extended care items or services when Medicare payment was not expected, which did not occur in this case.
Plan Of Correction
This Plan of Correction is submitted as required under State and Federal law. This Plan of Correction does not constitute an admission on the part of the Facility that the findings cited are accurate, that the findings constitute a deficiency or that the scope and severity regarding the deficiency cited are correctly applied. Any changes to the Facility's policies and procedures should be inadmissible in any proceeding on that basis. Without admitting or denying the validity or the existence of the alleged noncompliance, the Facility submits this Plan of Correction with the intention that it be inadmissible by any third party in any civil or other action against the facility or any employee, agent, officer, director or shareholder of the Facility. The Facility is utilizing this Plan of Correction as its allegation of substantial compliance as of 05/29/2026 F-0582 Corrective action for resident/s: On 5/14/26 Resident #34 was informed of rights and responsibilities related to Advanced Beneficiary Notice and voiced understanding of information for future reference by administrator. Identification of other residents who may be affected: Any resident receiving skilled services from nursing or therapy services. The Administrator audited all residents who were discharged from skilled services in the past 30 days to ensure they were issued a Notice of Non-Coverage and Advanced Beneficiary Notice on 5/29/26. No non-compliance was noted. Measures for systemic change: On 5/14/2026 Business Office Manager, Director of Rehab, Minimum Data Set nurse, Director of Nursing and Social Services Director were educated on proper procedure of issuing of Notice Of Medicare Non Coverage and Advanced Beneficiary Notice by administrator. All upcoming discharges from skilled services will be reviewed weekly at Utilization Review meeting to ensure notices will be delivered timely. How Corrective Action will be monitored: Administrator or designee to complete audits of all residents being discharged from skilled services to ensure they were issued a Notice of Non-Coverage and Advanced Beneficiary. This audit will be completed weekly x 4 weeks, then monthly x 2 months. Corrective action will be initiated for any noted non-compliance. Audit findings will be reviewed as part of the monthly quality assurance process to determine the need for further monitoring. Date of Compliance 5/29/26
Insulin Administration Errors and Failure to Prime Insulin Pens
Penalty
Summary
The deficiency involves the facility’s failure to maintain a medication error rate below 5%, with surveyors identifying 3 errors out of 28 medication administration opportunities, resulting in a 10.71% error rate. For one resident with type 2 diabetes mellitus and moderate cognitive impairment, the physician’s order directed Novolog insulin 10 units via subcutaneous pen-injector to be given before meals. During an observed medication pass, the LPN administered 10 units of Novolog insulin without priming the pen and did so after the resident had already consumed approximately 50% of the breakfast meal. The LPN later confirmed she did not prime the pen and acknowledged that the insulin was ordered to be administered prior to meals. Manufacturer instructions for the Novolog FlexPen specified that an air shot (priming) must be performed before each injection to ensure proper dosing. Another resident, also diagnosed with type 2 diabetes mellitus and with intact cognition, had orders for insulin glargine 35 units subcutaneously twice daily and insulin lispro 20 units subcutaneously before meals, plus 12 units subcutaneously if blood glucose was between 251 mg/dL and 300 mg/dL. During an observed medication administration, an LPN administered 35 units of insulin glargine and 32 units of insulin lispro without priming the insulin pens and after the resident had consumed approximately 90% of the breakfast meal, despite orders for insulin lispro to be given before meals. The LPN later stated she could not remember if she had primed the pen and acknowledged that the insulin was ordered to be administered prior to meals. Manufacturer information for insulin lispro stated that the pen must be primed before each injection to confirm insulin delivery and remove air, and that failure to prime could result in too much or too little insulin. The DON confirmed the expectation that insulin be administered as ordered, including priming each pen with two units before dialing the prescribed dose, and facility policy required medications, including insulin, to be administered safely, timely, and in accordance with prescriber orders and required time frames.
Plan Of Correction
This Plan of Correction is submitted as required under State and Federal law. This Plan of Correction does not constitute an admission on the part of the Facility that the findings cited are accurate, that the findings constitute a deficiency or that the scope and severity regarding the deficiency cited are correctly applied. Any changes to the Facility's policies and procedures should be inadmissible in any proceeding on that basis. Without admitting or denying the validity or the existence of the alleged noncompliance, the Facility submits this Plan of Correction with the intention that it be inadmissible by any third party in any civil or other action against the facility or any employee, agent, officer, director or shareholder of the Facility. The Facility is utilizing this Plan of Correction as an allegation of substantial compliance as of 5/29/2026. F-0759 Corrective action for resident/s: Residents #21 and #22 were assessed and evaluated by nurse and Director of Nursing 5/14/26. Resident #21 and #22 both denied any adverse effects and none were noted upon assessment by the Director of Nursing on 5/14/2026. Notification made to physician on 5/14/2026. LPN # 2 competency Eval on insulin administration with the Director of Nursing completed 5/14/2026. Identification of other residents who may be affected: Diabetic residents on assignment of LPN #2/station 2 have the potential to be affected and were assessed by the DON/Designee on 5/14/26 and found to be within normal limits. Measures for systemic change: All Nurses were educated by the Director of Nursing on the steps for Insulin administration per competency, diabetes clinical protocol policy, Medication and treatment orders policy, administering medications policy, and Obtaining fingerstick Glucose Level policy On 5/14/2026. How Corrective Action will be monitored: Director of Nursing and Assistant Director of Nursing will complete insulin administration audits on 5 nurses. This audit will be completed weekly x 4 weeks, then monthly x 2 months. Corrective action will be initiated for any noted non-compliance. Audit findings will be reviewed as part of the monthly quality assurance process to determine the need for further monitoring. Date of Compliance: 5/29/2026
Failure to Document Tray Line Food Temperatures in Dining Room Kitchenettes
Penalty
Summary
The deficiency involves the facility’s failure to document tray line food temperatures for meals served from the Harrison and McClellan Dining Room kitchenettes, as required by professional standards for food service safety and the facility’s own policy. Review of the “Trayline Taste & Temperature Log” (revised September 2018) showed missing temperature documentation for multiple meals from the Harrison Dining Room kitchenette, including dinner on 03/30/26 and 03/31/26, lunch and dinner on 04/01/26 and 04/02/26, dinner on 04/07/26, and lunch and dinner on 04/08/26 and 04/10/26. The Senior Director of Culinary Services confirmed during interview that tray line food temperatures were not documented on the log for these meals. Similarly, review of the same log for the McClellan Dining Room kitchenette revealed that tray line food temperatures were not documented for dinner on 04/01/26, breakfast and lunch on 04/02/26, and lunch and dinner on 04/07/26. The Senior Director of Culinary Services also verified these omissions during interview. The facility census at the time was 27 residents, and the governing “Food and Nutrition” policy, approved on 09/07/21, stated that the facility must store, prepare, distribute, and serve food in accordance with professional standards for food service safety.
Plan Of Correction
F812 The facility will continue to ensure food temperatures are completed before meals are served for all residents. To ensure compliance with this standard the following measures have been taken: 1. Immediately 4/15/26 culinary supervisor #224 was re-educated by Dietary Manager to this standard and policy "Food and Nutrition" which includes documentation of food temperatures. 2. All dietary staff have been re-educated to the standard and policy "Food and Nutrition" during the month of April 2026. 3. Audits of food temperature documentation to be completed by Dietary Manager 4 x per week for 4 weeks then weekly for 4 weeks. 4. Administrator to validate audits/compliance and provide additional training as needed. Administrator will present to QAPI committee for ongoing monitoring and further direction.
Failure to Conduct and Document Required Care Conferences
Penalty
Summary
The deficiency involves the facility’s failure to complete and document comprehensive care conferences at required intervals in accordance with care plan regulations and facility policy. For one resident with Parkinson’s disease with dyskinesia, cognitive communication deficit, hemiplegia and hemiparesis following cerebral infarction, transient cerebral ischemic attack, type II diabetes mellitus, and major depressive disorder, the record showed multiple MDS assessments over a one-year period, including annual, quarterly, and significant change assessments. However, only two care conferences were documented during the last 12 months, despite the expectation that care conferences be conducted quarterly with the resident and family when possible. The Unit Care Coordinator confirmed that no additional care conference documentation existed for this resident beyond the notes dated 04/21/25 and 01/02/26. A second resident, with diagnoses including aphasia following cerebrovascular disease, cerebral infarction, type II diabetes mellitus, unsteadiness on feet, difficulty in walking, coagulation defect, depression, and muscle weakness, also had multiple MDS assessments completed over the review period, including quarterly and annual assessments. The record contained a note that a care conference was offered to the resident’s representative, who declined to attend, but there was no documentation of any care conferences for the most recent 12 months. The Unit Care Coordinator confirmed that no other care conference documentation was available for this resident. Facility policy stated that periodic care conferences involving the resident, family, and the interdisciplinary team are part of the care planning process, but the required periodic care conferences and corresponding documentation were not completed for these two residents.
Plan Of Correction
THIS PLAN OF CORRECTION SERVES AS BERKELEY SQUARE'S CREDIBLE ALLEGATION OF SUBSTANTIAL COMPLIANCE AS OF June 1, 2026. Without admitting or denying the validity or existence of the alleged deficiencies, Berkeley Square provides the following Plan of Correction: F657 The facility will continue to document completion of care conferences at the required intervals for all residents, including residents #04 & #15. To ensure compliance with this standard the following measures have be taken: 1. The social service designee and the inter- disciplinary team were re-educated by the administrator to the facility policy "Care Conference" on 4/29/26 and verbalized understanding. 2. Care conferences for resident #04 and resident #15 were conducted on or before 4/29/2026 by the interdisciplinary team. 3. Review of all other residents was conducted by the social service designee to validate and ensure that care conference schedule is up to date with timely care conferences scheduled for them on 4/15/2026. Audits of care conferences to be completed weekly for four weeks and then monthly after that by the social service designee. Documentation of the care conference including any identified concerns in the medical record. Administrator to validate audits/compliance and provide additional training as needed. Administrator will present results of these audits to QAPI committee for ongoing monitoring and further direction.
Failure to Reevaluate Blood Glucose After Treatment for Hyperglycemia
Penalty
Summary
The facility failed to ensure that a resident with diabetes received treatment in accordance with professional standards of practice when nursing staff did not reevaluate the resident's blood glucose after treatment for severe hyperglycemia. The resident, admitted with diagnoses including Alzheimer's disease, type II diabetes mellitus, and depression, had physician orders for Humalog insulin on a sliding scale before meals, Lantus insulin 25 units daily, and lisinopril 5 mg daily. The resident required extensive assistance with activities of daily living, including transfers, toileting hygiene, eating, and bathing. On the evening in question, the resident's blood glucose was documented as 532 mg/dL, and the on-call provider was notified. The provider gave a new order to administer an additional 8 units of lispro (Humalog) and to recheck the blood glucose in 30 minutes. The electronic medication administration record showed that the blood glucose of 532 mg/dL was obtained at 9:00 p.m. and that the additional 8 units of lispro were administered at 9:21 p.m. However, there was no documentation in the resident's chart that the blood glucose was rechecked after the additional insulin was given. In an interview, the DON confirmed there was no evidence of reevaluation and verified that, according to the facility's "Abnormal Blood Glucose Procedure" policy, the resident should have been reevaluated and that the evaluation step should have been included in the progress note documentation.
Plan Of Correction
F684 The facility will continue to ensure all residents, including #03, receive treatment in accordance with professional standards of practice and reevaluated for hyperglycemia. To ensure compliance with this standard the following measures have been taken: 1. The director of nursing assessed resident #03, reviewed documentation and orders and found no ill effects immediately 4/16/26. 2. All licensed nurses were re-educated to facility policy "Blood Glucose Monitoring" by the Director of Nursing/designee in April 2026. 3. Audits of like-residents that require blood sugar checks to be completed by the director of nursing/designee two times a week for 4 weeks and then monthly after that to validate correct follow through when there is abnormally high blood glucose result. The Administrator will bring results of these audits to the QAPI committee for ongoing monitoring and further direction.
Failure to Act on Pharmacist Drug Regimen Recommendation for Thyroid Medication
Penalty
Summary
The deficiency involves the facility’s failure to ensure that pharmacy recommendations from the monthly drug regimen review were acted upon and documented for a resident. The resident was admitted with diagnoses including Parkinson’s disease, dementia, and hypothyroidism, and had current physician orders for levothyroxine 150 mcg once daily, buspirone 50 mg twice daily, and losartan 100 mg once daily. A medication regimen review dated 11/25/2025 included a consultant pharmacist recommendation that levothyroxine be administered consistently in the morning on an empty stomach, at least 30–60 minutes before food, per manufacturer instructions. There was no specific physician response in the medical record to this recommendation, and the facility’s policy stated that consulting pharmacist reviews are sent to nursing and addressed with the primary care provider or consulting specialist for review and follow-up. Review of the resident’s medication administration record for April 2026 showed levothyroxine scheduled for 9:00 a.m. On observation, the resident was seen eating breakfast in the dining area at 8:03 a.m., and an LPN reported administering the levothyroxine 150 mcg to the resident while the resident was in the dining area eating breakfast. The DON confirmed there was no evidence in the resident’s medical record explaining why the consultant pharmacist’s recommendation from 11/25/2025 was or was not acted upon. This lack of documented physician review and action on the pharmacist’s identified irregularity constituted noncompliance with the drug regimen review requirements.
Plan Of Correction
F756 The facility will continue to ensure the pharmacy recommendations from the monthly drug regimen review by a licensed pharmacist are acted upon for all residents, including #08. To ensure compliance with this standard the following measures have been taken: 1. Resident #08 was assessed by the registered nurse and med review completed by 4/28/26. After review of resident's drug regime's, it was discovered that resident #8 had 2 separate medication recommendations on the same form, to be reviewed by two separate practitioners, pharmacy has been instructed and agreed to separate meds on individual forms. 2. Licensed nurses re-educated to facility policy "Drug Regimen Review" by Director of nursing/designee in April 2026 and no later than 5/8/26. Licensed nurses are responsible for ensuring the reviews and recommendations are given to the physician for timely review. 3. Review of all other current residents Drug Regimen orders completed by Director of nursing/designee on 4/16/26 to ensure recommendations were followed up on/reviewed by the physician and address concerns if needed. 4. Audit of drug regime recommendations, pharmacy recommendations, and physician follow up to be completed weekly for four weeks by the Director of nursing/designee. Administrator will present results of these audits to the QAPI committee for ongoing monitoring and further direction.
Failure to Use Required Gait Belt During Ambulation Resulting in Resident Fall
Penalty
Summary
The deficiency involves the facility’s failure to ensure that a required gait belt was used while assisting a high fall‑risk resident with ambulation, resulting in a fall with head injury. The resident had multiple diagnoses including metabolic encephalopathy, hypertension, osteoarthritis, muscle weakness, gait and mobility abnormalities, major depressive disorder, anxiety, and visual hallucinations. Admission and subsequent MDS and fall risk assessments documented that the resident was severely cognitively impaired, required moderate to maximal assistance with transfers and ambulation, could not independently come to a standing position, exhibited loss of balance while standing, used an assistive device, and had decreased muscle coordination. The resident had a history of falls prior to admission and was assessed as being at high, later moderate, risk for falls. The resident’s fall care plan identified her as at risk for falls and included interventions such as providing maximum to moderate assistance with transfers and walking short distances, use of a walker and wheelchair, and following the facility’s fall protocol. Therapy notes and care conference documentation indicated that the resident leaned backwards when standing, required contact guard to minimal assistance for bed mobility and transfers, and needed constant verbal cueing for safe sequencing during toilet transfers. The physical therapist confirmed that the resident was to use a gait belt with staff when ambulating, and the DON verified that therapy had assessed the resident as requiring contact guard assistance and a gait belt for ambulation and transfers. On the day of the incident, a CNA was assisting the resident from her recliner to the bathroom using a walker. The CNA walked beside the resident, providing guidance and support, and reported having a hand on the resident while assisting her. As they approached the bathroom door, the CNA reached for the doorknob to open it, and at that moment the resident began to lose her balance and fell backwards to the floor, striking the back of her head. The nurse who responded found the resident on her back at the foot of the bed with her feet near the bathroom, noted a red raised area on the back of the head, and documented that the resident was not wearing a gait belt and that the gait belt was on the dresser. In the facility’s investigative summary and in interviews, the CNA acknowledged that she did not have a gait belt on the resident while ambulating her, despite the resident’s assessed need for hands‑on assistance and gait belt use per facility policy and the resident’s care and therapy plans.
Failure to Implement PD Orders and Monitor Resident Receiving Peritoneal Dialysis
Penalty
Summary
The deficiency involves the facility’s failure to implement pre-admission physician orders for peritoneal dialysis (PD) and to provide ongoing monitoring for a resident with chronic kidney disease (CKD) stage five who required PD. Pre-admission orders dated 11/14/25 specified three daily PD exchanges at 6:00 A.M., 2:00 P.M., and 10:00 P.M., and directed staff to monitor for signs and symptoms of peritonitis, including fever, abdominal pain, and cloudy effluent. These monitoring orders were not entered into the facility’s physician orders. The resident’s care plan noted the need for PD and included general monitoring interventions (labs, signs of bleeding, bacteremia, septic shock, and significant vital sign changes), but did not specifically address the ordered monitoring for peritonitis. Review of PD documentation showed incomplete and inconsistent charting of treatments and resident condition. The paper peritoneal flowsheet had columns for time of PD and condition/comments, including instructions to call the nurse immediately for cloudy fluid, abdominal pain, or fever. However, the first entry on 11/15/26 at 2:00 P.M. only noted that the PD nurse completed the exchange, and the 10:00 P.M. entry that day had no condition/comment documentation. Subsequent days (11/16/25, 11/17/25, and 11/18/25) contained only one condition/comment entry per day rather than for each exchange, and there was no documentation that the 6:00 A.M. PD on 11/18/25 was completed. The PD cycler flowsheet starting 11/19/25 lacked any description of the effluent on multiple days. The PD nurse from the dialysis company stated facility staff were expected to monitor effluent for cloudiness and assess for abdominal pain and fever, and the DON confirmed there was no electronic physician order for peritonitis monitoring or for use of the PD cycler, that the paper charting did not allow for effluent description or symptom documentation for each treatment, and that PD was not documented at one ordered time. The facility’s dialysis policy required ongoing assessment and monitoring for complications before, during, and after treatments, which was not reflected in the documentation for this resident.
Improper Infection Control During Medication Administration
Penalty
Summary
Surveyors identified a deficiency in infection prevention and control related to medication administration for Resident #29. The resident was admitted on 02/28/14 with diagnoses including depression, traumatic brain injury, and anxiety, and had impaired cognition per a quarterly MDS assessment. During an observation on 03/25/26 at 6:58 A.M., RN #281 prepared the resident’s medications by removing an Amoxicillin-Pot Clavulanate tablet from the medication card and pushing it directly into her ungloved hand, then using her fingers to place the pill into a medication cup. The same process was observed for multiple other medications, including Escitalopram Oxalate, Furosemide, Sennosides, Lyrica, and Vitamin D, each being pushed from the card into the RN’s ungloved hand and then transferred by her fingers into the medication cup before administration to Resident #29. In a subsequent interview at 7:27 A.M. the same day, RN #281 confirmed she had placed each medication into her ungloved hands prior to administration and acknowledged that the proper procedure was to push the pills directly from the card into the medication cup. Review of the facility’s “Medication Administration – General guidelines” policy, revised 10/08/25, stated that medications are to be administered in accordance with good nursing principles and practices. This practice failure was cited as a deficiency under Complaint Number 2681777.
Improper Use of Wheelchair as a Physical Restraint
Penalty
Summary
Surveyors identified a deficiency related to the facility’s failure to ensure a resident was free from physical restraints. Resident #7, admitted with diagnoses including Alzheimer’s disease, diabetes mellitus, and anxiety disorder, was documented on a recent MDS as rarely understood and dependent for ADLs except eating. The resident ambulated independently on the unit without an assistive device and had documented verbal and other behaviors occurring one to three days during the look-back period. The care plan noted the resident had potential to be physically aggressive, chase staff, throw objects, and be combative with care, with interventions such as offering choices, administering medications as ordered, and intervening early when agitation occurred. During an observation and interview, Resident #7 was found sitting in a chair with the right arm of the chair positioned against the nursing station and a wheelchair placed directly in front of him. The left arm of the wheelchair was also against the nursing station, and both wheelchair wheels were locked, creating a barrier that appeared to restrain the resident, who was sleeping with his knees touching the locked wheelchair. An LPN confirmed both wheelchair wheels were locked and that the wheelchair should not have been placed in front of the resident. A CNA reported she had placed the wheelchair there in preparation to get the resident up for lunch, was unable to transfer him, and left the wheelchair in that position, acknowledging it was wrong to keep it there. The facility’s physical restraint policy stated that physical restraints are not used except when alternatives are not appropriate or effective for treating a medical symptom and defined physical restraints as any device attached or adjacent to the body that the individual cannot easily remove and that restricts freedom of movement or access to the body.
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