Mayfair Village Nursing Care C
Inspection history, citations, penalties and survey trends for this long-term care facility in Columbus, Ohio.
- Location
- 3000 Bethel Rd, Columbus, Ohio 43230
- CMS Provider Number
- 365410
- Inspections on file
- 42
- Latest survey
- December 1, 2025
- Citations (last 12 mo.)
- 6
Citation history
Health deficiencies cited at Mayfair Village Nursing Care C during CMS and state inspections, most recent first.
A medication error rate above five percent was identified when a resident with severe cognitive impairment was administered extended-release and electrolyte tablets in crushed form, despite clear 'do not crush' labeling. An LPN crushed and administered these medications in pudding, and a pharmacist later confirmed this was inappropriate. The facility's policies require adherence to proper medication administration procedures, which were not followed in this instance.
A resident with severe cognitive impairment and multiple chronic conditions was administered Metoprolol Succinate ER and Potassium CL ER tablets in crushed form, despite both being labeled 'do not crush.' An LPN crushed these medications and mixed them with pudding for administration, contrary to facility policy and manufacturer instructions. The error was confirmed by staff interviews and pharmacist consultation.
Surveyors found that medications and biologicals were not properly labeled or stored. An LPN was observed with opened but undated bottles of Thiamine B1, Famotidine, and MiraLAX, and several expired medications were found in the medication storage room. The ADON confirmed the presence of expired items, which were not separated as required by facility policy.
Two residents dependent on staff for bathing and shaving did not receive assistance according to their preferences or scheduled needs. One resident, with multiple medical and mental health conditions, received infrequent bed and sponge baths and was not shaved as desired, while another resident with severe cognitive impairment received only minimal bathing. The DON confirmed concerns with the completion of scheduled bathing and shaving for both residents.
A resident with severe cognitive impairment and a history of falls was not thoroughly assessed for range of motion after a fall, and the physician was not notified promptly. Staff documented a head-to-toe assessment and provided pain medication, but delayed physician notification and omitted a full assessment, as confirmed by the DON and a CNP.
A resident with cognitive impairment and a recent hip fracture experienced multiple falls and reported ongoing pain, but did not receive prescribed pain medication in a timely manner. Staff failed to administer pain relief as ordered, and stronger medication was only provided after further assessment revealed a new fracture. Facility policy for pain assessment and management was not followed.
A resident with a history of acute medical conditions and drug use was admitted to a facility without proper physician orders or supervision, leading to neglect. The resident did not receive necessary medications and experienced a rapid decline, resulting in death. The facility also failed to provide timely post-mortem care, leaving the body in the facility for over 11 hours. This incident resulted in Immediate Jeopardy due to significant lapses in care and communication.
A facility failed to update a resident's care plan to include interventions for aggressive behaviors and racial expletives as indicated in a self-reported incident. The resident, with multiple diagnoses and moderate cognitive impairment, had their silverware changed to plastic, but this was not reflected in the care plan. The DON confirmed the oversight, and nursing staff were unaware of the intervention.
The facility failed to provide comprehensive tracheostomy care for two residents, as there were no physician orders or documentation of care in their medical records. One resident, with chronic respiratory failure and tracheostomy, was dependent on staff for daily activities and always incontinent. Another resident, with hemiplegia and tracheostomy, required assistance with daily activities and was occasionally incontinent. The DON confirmed the lack of documentation for tracheostomy care.
An LPN left a medication cart unattended, with several medications on top, posing a security risk for seven cognitively impaired and independently mobile residents. The facility's medication policy did not address leaving medications unlocked and unattended.
A facility failed to maintain proper infection control during tracheostomy care for a resident with multiple health conditions, including chronic respiratory failure and a tracheostomy. An LPN did not wash hands between glove changes during the procedure, contrary to the facility's hand hygiene policy. The resident's medical record lacked physician's orders and documentation for tracheostomy care.
A facility failed to protect a resident's medical privacy by posting a sign with private medical information in a hallway. The sign, visible to other residents, included details about the resident's medical instructions and surgery. Staff confirmed this was against protocol and had been displayed since the morning shift.
The facility failed to maintain the dignity of two residents with indwelling urinary catheters by not covering the catheter drainage bags, as required by physician orders. Observations revealed that the drainage bags were visible from the doorway and hallway, and an LPN confirmed this oversight.
A medication administration error occurred when a resident was given Zyprexa 10 mg intended for another resident. The medication, initially refused by one resident, was not returned to the pharmacy and was later administered to another resident experiencing escalated behaviors. This error was confirmed by the RN Unit Manager.
A facility failed to document the justification for administering an antipsychotic medication to a resident with impaired cognition and schizoaffective disorder. The medication was given for reported increased agitation, but there were no progress notes or documentation to support the need for the medication. The DON confirmed the lack of documentation, which is required by the facility's policy.
The facility failed to have a carbon monoxide detector in the main kitchen where a gas stove was present, potentially affecting all 90 residents. An observation revealed the absence of the detector, and the Food Service Director confirmed it was missing and was unaware of how long it had been absent.
A resident with quadriplegia and other conditions was found with a lighter and cigarettes at his bedside while receiving oxygen therapy, contrary to facility policy. A nurse confirmed the presence of these items and confiscated them, as the resident was not allowed to store smoking materials at his bedside.
The facility failed to protect the privacy of two residents' medical records. A resident's electronic medical record was left open and unattended on a medication cart, visible to passersby. Similarly, another resident's treatment record was left open on a treatment cart, visible to several individuals. The facility's policy on safeguarding electronic health information was not followed.
A facility failed to complete required PASRR documentation for a resident with multiple diagnoses, including mood and anxiety disorders. The resident was cognitively intact, but the first PASRR document was completed months after admission and inaccurately indicated it was for an expiring respite stay. The DON confirmed this was the only PASRR document and that the resident had not been discharged or received respite services.
A facility failed to create a comprehensive care plan for a resident with PTSD, despite her history of sexual assault and identified triggers. The resident, with an intact cognitive status, reported that people entering her room was a trigger, yet no trauma-informed care plan was developed. This deficiency was confirmed through interviews and a review of the facility's policy, which mandates a multi-pronged approach to trauma care.
The facility failed to conduct quarterly care conferences for three residents, as required by their policy. Interviews confirmed that residents were not invited to participate, and the DON verified the lack of evidence for quarterly interdisciplinary care conferences. The facility's policy mandates comprehensive care plans be developed and reviewed by an interdisciplinary team, including the resident and their representative, to ensure person-centered care.
A facility failed to monitor and document skin abnormalities for a resident on anticoagulant therapy, leading to unreported bruising and a scratch. Despite orders to monitor for bleeding signs, the MAR inaccurately showed no adverse reactions. Observations confirmed bruising and a scratch, which were not documented, violating facility policies requiring daily anticoagulation management and weekly wound assessments.
A facility failed to assess a resident for PTSD, missing a history of sexual assault in their trauma-informed care plan. Despite the resident's intact cognitive status and a policy requiring comprehensive trauma assessments, the facility did not identify PTSD triggers or develop a care plan. The resident reported feeling safe but was triggered by room entries, a detail not captured in the assessment.
Medication Error Rate Exceeds Five Percent Due to Improper Administration
Penalty
Summary
The facility failed to maintain a medication error rate of five percent or less during observed medication administration, resulting in an error rate of 7.69%. During medication pass observations for six residents, two errors were identified out of 26 observations. One resident with multiple diagnoses, including severe cognitive impairment, was administered Metoprolol Succinate ER 100 mg and Potassium CL ER 20 mEq, both labeled 'do not crush,' in crushed form along with Eliquis. These medications were crushed and given in pudding by an LPN, despite clear labeling and facility policy instructions. The LPN confirmed the medications were crushed and administered, and a pharmacist later verified that these medications should not be crushed. The facility's medication administration policy requires staff to adhere to the 10 rights of medication administration, including verifying the correct form of the drug. The facility's policy on medication-related errors also outlines steps for notification and monitoring if a medication error occurs. The deficiency was identified through direct observation, record review, and staff interviews.
Crushing of Extended-Release and Labeled 'Do Not Crush' Medications
Penalty
Summary
A deficiency occurred when a resident with multiple complex medical diagnoses, including dementia, chronic kidney disease, atrial fibrillation, and hypertension, was administered medications in a manner inconsistent with physician orders and manufacturer instructions. During a medication pass, an LPN crushed and administered Metoprolol Succinate ER 100 mg and Potassium CL ER 20 mEq tablets, both of which were clearly labeled 'do not crush,' along with Eliquis, by mixing them into pudding for the resident. The resident's Medication Administration Record (MAR) specified the use of these medications for hypertension and hypokalemia, with additional instructions to hold Metoprolol if systolic blood pressure was below 110. The resident was noted to have severely impaired cognitive skills and was rarely or never understood, as documented in the Minimum Data Set (MDS). The error was confirmed through direct observation, staff interview, and consultation with a pharmacist, who verified that both Metoprolol Succinate ER and Potassium CL ER tablets should not be crushed. Facility policy required staff to adhere to the '10 rights' of medication administration, including verifying the correct form of the drug, and to consult pharmacy or prescriber if there was any doubt. The facility's policy on medication-related errors also required notification of pharmacy and physician if a medication error occurred. The failure to follow these protocols resulted in the resident receiving medications in a form that was not intended, constituting a significant medication error.
Failure to Properly Label and Store Medications and Biologicals
Penalty
Summary
Surveyors observed that medications and biologicals in the facility were not properly labeled or stored according to accepted professional standards. During medication administration, an LPN was found with several facility stock bottles, including Thiamine B1, Famotidine, and MiraLAX, that had been opened but were not labeled with the date they were opened. Other stock medication bottles in the medication cart had open dates written on the lids, but these specific bottles did not. The LPN confirmed the lack of labeling and was seen labeling the bottles during the observation. Further inspection of the medication storage room revealed several unopened but expired items, including Fiber Powder Psyllium husk, Vitamin A, B2 Riboflavin, nasal moisturizing spray, and nasal decongestant, all with past expiration dates. The ADON confirmed that these medications were expired. Facility policy requires that expired, contaminated, or deteriorated medications be stored separately until destroyed or returned, but these expired items were not separated as required.
Failure to Provide Assistance with Bathing and Shaving
Penalty
Summary
The facility failed to provide adequate assistance with bathing and shaving for residents who were unable to perform these activities independently. One resident, admitted with multiple diagnoses including schizoaffective disorder, dementia, and severe protein-calorie deficiency, was documented as requiring supervision for bathing and expressed a preference for showers over bed baths. Over a 30-day period, this resident received only two bed baths and one sponge bath, and refused bathing once with occupational therapy. The resident was observed with a short beard and stated a dislike for facial hair, expressing a desire to be shaved. Both the resident and a family member confirmed a preference for showers, and the family member reported having to take the resident home to provide a shower due to infrequent bathing at the facility. The DON confirmed that bathing and shaving were not being provided according to the resident's preferences and schedule. Another resident, with severe cognitive impairment and dependent on staff for bathing, received only a sponge bath and one shower in the past 30 days. The DON acknowledged concerns with the completion of scheduled bathing for this resident as well. These findings were based on record reviews, resident and family interviews, and staff interviews, and were investigated under a specific complaint number.
Failure to Assess and Notify Physician After Resident Fall
Penalty
Summary
A deficiency occurred when staff failed to thoroughly assess a resident after a fall and did not notify the physician in a timely manner. The resident, who had a history of cognitive communication deficit, dementia, depression, anxiety, and a previous femur fracture, was found on the floor by his roommate after a fall. The resident was unable to explain what happened, had severely impaired cognition, and complained of left hip pain. Although a head-to-toe assessment was documented with no visible injuries, the resident was unable to stand, and staff assisted him back to bed and provided pain medication. The facility's fall investigation revealed that the resident's range of motion was not assessed following the fall, and the physician was not notified until several hours later. Interviews with the DON and a CNP confirmed that the range of motion assessment was omitted and that the physician notification was delayed, both of which should have occurred immediately after the incident. This deficiency was identified during a review of falls and related care for residents at risk.
Failure to Provide Timely and Appropriate Pain Management
Penalty
Summary
The facility failed to ensure timely and appropriate pain management for a resident with a history of cognitive impairment, dementia, depression, anxiety, and a recent left femur fracture. The resident experienced multiple falls, including one unwitnessed fall where he was found on the floor, unable to stand, and complaining of left hip pain. Despite a care plan identifying the resident as at risk for pain and discomfort, and physician orders for acetaminophen suppositories for pain, staff did not administer pain medication as ordered following the fall and during subsequent reports of pain. After the fall, the resident was given acetaminophen 325 mg, which was ordered only for fever, not for pain, and not the prescribed acetaminophen suppository for pain. The resident continued to report pain and had difficulty with activities of daily living, but no pain medication was administered from the day after the fall until two days later, despite ongoing complaints. It was only after further assessment and review of hospital records, which revealed a new hip fracture, that a stronger pain medication (oxycodone) was ordered and administered. Interviews with facility staff confirmed that pain management interventions were not implemented as per the care plan and physician orders. The CNP was unaware that acetaminophen had not been used for pain, and the DON verified that nursing staff did not attempt to give the prescribed pain medication during the period when the resident was experiencing pain. Facility policy required timely assessment and management of acute pain, but this was not followed in the resident's case.
Neglect in Resident Admission and Care Leads to Immediate Jeopardy
Penalty
Summary
The facility failed to ensure that a resident, who had been hospitalized prior to admission, received adequate, timely, and appropriate treatment and continuity of care. Upon admission, the staff did not obtain physician orders for medications or treatments, nor did they contact the physician or medical director regarding the resident's admission. This resulted in the resident not receiving necessary medications, including blood pressure medication, blood thinners, and insulin, which were critical given the resident's medical history of acute respiratory failure, cardiomyopathy, and polysubstance abuse. The resident, who had a history of illegal drug use, was not adequately assessed or provided with comprehensive and individualized interventions to maintain safety. Despite the resident's known comorbidities and recent hospitalization for acute conditions, the facility did not implement appropriate supervision or care plans to address these issues. The resident's condition deteriorated rapidly, leading to a call for emergency medical services and subsequent cardiopulmonary resuscitation, but the resident was pronounced deceased shortly after. Following the resident's death, the facility failed to provide timely and appropriate post-mortem care. The resident's body remained in the facility for over 11 hours before being transported to the morgue, as staff were unsure of the procedures to follow. This incident highlighted significant lapses in the facility's admission process, communication with medical professionals, and post-mortem care procedures, resulting in a situation of neglect and Immediate Jeopardy.
Removal Plan
- Education was provided to the facility's 32 nurses on the facility's admission policies, notification of the physician on admission, and physician orders, including medications.
- One-on-one education was provided to RN #15 and RN #35 as they were responsible for Resident #82's care during admission.
- The initial Self-Reported Incident (SRI) was submitted by the Administrator based on the allegation of neglect.
- The admitting nurse for Resident #82, RN #35, was suspended pending the outcome of the investigation.
- A whole house audit of 23 residents admitted was conducted to ensure physician orders were consistent with hospital discharge orders and physicians were notified of admission.
- All new admissions and re-admissions will be audited to ensure physician notification and physician orders are included.
- Education was provided to all 32 licensed nurses to communicate with facility leadership regarding changes that may occur to a resident's admission to the facility or with the hospital discharge plan, to seek further instruction and guidance; that residents with a history of drug abuse have a care plan with appropriate interventions in place; administration of an opioid reversal agent in suspected opioid overdose; the policy for postmortem care and pronouncement of death to include timely notification for release of a deceased resident and notification of the police and/or coroner as necessary.
- A whole house audit for residents with a drug abuse history diagnosis was completed to ensure interventions were in place and care plans reflected updated interventions as needed.
- Audits of care plans will be completed to ensure care plans for all residents with a history of drug abuse are appropriate.
- Audits of residents who have expired in the facility were reviewed to ensure they were provided with timely and appropriate postmortem care with notifications of the coroner and police as appropriate.
- Audits will be completed to ensure compliance.
- An Ad Hoc Quality Assurance and Performance Improvement Plan meeting was held to discuss the removal plan and root cause analysis (RCA).
- The Medical Director was notified of and approved the QAPI plan.
- All audits will be conducted and results will be discussed at the monthly QAPI meeting.
Failure to Update Care Plan for Aggressive Behaviors
Penalty
Summary
The facility failed to ensure that care plans were comprehensive and addressed problems as identified in a self-reported incident (SRI) involving a resident. The resident, who was admitted with diagnoses including idiopathic aseptic necrosis of the left femur, unsteadiness on feet, history of falling, type II diabetes mellitus, and memory deficit following a cerebral infarction, was moderately cognitively impaired. The SRI indicated that the facility had changed the resident's silverware to plastic and updated the care plan for aggressive behaviors and racial expletives. However, a review of the care plan revealed that these interventions were not reflected in the care plan. Interviews with the Director of Nursing (DON) confirmed that the aggressive behaviors should have been addressed in the care plan as indicated in the SRI. The DON also verified that the care plan was not updated for aggressive behaviors and racial expletives, and nursing staff were not aware of the intervention added in the SRI. The facility's policy on care planning emphasized the importance of updating care plans to promote continuity of care and communication among staff, but this was not adhered to in this case.
Failure to Document Tracheostomy Care for Two Residents
Penalty
Summary
The facility failed to provide comprehensive tracheostomy care for two residents, Resident #65 and Resident #66, as evidenced by the absence of physician orders and documentation of tracheostomy care in their medical records. Resident #65, who was admitted with diagnoses including chronic respiratory failure and tracheostomy, was found to have no documented plan of care or evidence of tracheostomy care being completed. Her quarterly MDS assessment indicated she was dependent on staff for various activities and was always incontinent of bowel and bladder. Similarly, Resident #66, admitted with conditions such as hemiplegia, dysphagia, and tracheostomy, also lacked physician orders and documentation for tracheostomy care. Her admission MDS assessment showed she required assistance with daily activities and was occasionally incontinent of urine and always incontinent of bowel. An interview with the Director of Nursing confirmed the absence of documentation for tracheostomy/stoma care, highlighting a deficiency in the facility's care practices.
Unattended Medication Cart Poses Security Risk
Penalty
Summary
The facility failed to ensure medications were secured to prevent unauthorized access, which had the potential to affect seven residents identified as cognitively impaired and independently mobile. During an observation of medication administration, an LPN left the medication cart unattended while preparing medication for a resident. Several medications, including hydroxide HCL, Potassium Chloride ER, Spironalactone, toresmide, Venlafaxine HCL, and a bottle of Miralax, were left on top of the cart, unattended and out of the LPN's sight. The LPN confirmed leaving the medications unattended. The facility's Administration of Medications policy did not reference leaving medications unlocked and unattended.
Infection Control Deficiency in Tracheostomy Care
Penalty
Summary
The facility failed to maintain proper infection control guidelines during tracheostomy care for Resident #65. The resident, who was admitted with diagnoses including chronic respiratory failure, cerebral aneurysm, liver transplant, tracheostomy, dysphagia, and Hepatitis C, was dependent on staff for various activities of daily living. A review of the medical record revealed no physician's orders for tracheostomy care, no documented plan of care, and no evidence that tracheostomy care had been completed as part of the treatment record. During an observation of tracheostomy care, an LPN was noted to have washed her hands and donned gloves initially, but failed to wash her hands between all glove changes throughout the procedure. This was confirmed during an interview with the LPN. The facility's hand hygiene policy, revised in 2024, requires hand hygiene to be performed even if gloves are used, particularly after removing personal protective equipment. This deficiency was investigated under Complaint Number OH00163322.
Privacy Breach of Resident's Medical Information
Penalty
Summary
The facility failed to protect the privacy of medical information for a resident, affecting one of three residents reviewed for privacy. During a medication administration, a piece of paper with private medical information for a resident was observed on the wall in the hallway next to the resident's room. The sign included details about the resident's medical instructions and upcoming surgery. Another resident was seen reading the sign and inquiring about the surgery, indicating that the information was visible to others. Staff confirmed that it was not protocol to display such information publicly and that the sign had been posted since the morning shift began.
Failure to Maintain Resident Dignity with Catheter Use
Penalty
Summary
The facility failed to uphold the dignity of residents with indwelling urinary catheters by not covering the catheter drainage bags, as required by physician orders. Resident #5, who was cognitively intact and required assistance with activities of daily living, had a suprapubic catheter with an order for a dignity bag to cover the drainage bag. However, during an observation, the catheter drainage bag was found hanging from the bed frame, visible from the doorway and hallway, with urine clearly visible. Similarly, Resident #27, who also required assistance with activities of daily living, had an indwelling urinary catheter with an order for a dignity bag to cover the drainage bag at all times. An observation revealed that the drainage bag was uncovered and visible from the doorway and hallway. An LPN confirmed that the catheter drainage bags for both residents were uncovered and in view, which constituted a failure to maintain resident dignity as per the facility's obligations.
Medication Administration Error
Penalty
Summary
The facility failed to maintain professional standards of quality when a medication intended for one resident was administered to another. Resident #74, who had diagnoses including dementia, type two diabetes mellitus, bipolar disorder, and schizoaffective disorder, refused a one-time order for the antipsychotic medication Zyprexa 10 mg via intramuscular injection on 08/07/24. This medication was supposed to be returned to the pharmacy but was instead placed in a box for return and remained in the medication storage room. On 08/12/24, Resident #33, who had diagnoses including epilepsy, high blood pressure, schizoaffective disorder, and traumatic brain injury, was experiencing escalated behaviors. A one-time order for Zyprexa 10 mg via IM injection was received for Resident #33. However, due to the medication not being returned to the pharmacy, Resident #33 was administered the Zyprexa 10 mg that was originally ordered for Resident #74. This incident was confirmed by RN UM #101, who acknowledged that the medication intended for Resident #74 was used for Resident #33.
Failure to Document Justification for Antipsychotic Medication Administration
Penalty
Summary
The facility failed to prevent the administration of an unnecessary antipsychotic medication to a resident, identified as Resident #33, who was admitted with diagnoses including epilepsy, high blood pressure, schizoaffective disorder, and traumatic brain injury. The resident was assessed with impaired cognition, impaired decision-making, and physical behaviors towards others. On a specific date, a one-time order for the antipsychotic medication Zyprexa 10 mg was given via intramuscular injection due to reported increased agitation and behaviors. However, there was no documentation or progress notes in the resident's medical record to support the occurrence of these behaviors that warranted the administration of the medication. The Director of Nursing confirmed the absence of documentation related to the resident's reported escalating behaviors on the date the medication was administered. The facility's policy on nursing documentation requires that nursing documentation be consistent with professional standards of practice and state laws. The deficiency was identified during an investigation under specific complaint numbers, indicating non-compliance with the facility's documentation policy and the requirement to document resident behaviors and interventions attempted before administering PRN medication.
Absence of Carbon Monoxide Detector in Kitchen
Penalty
Summary
The facility failed to have a carbon monoxide detector in the main kitchen where a gas stove was present, which had the potential to affect all 90 residents residing in the facility. During an observation, it was noted that there was no carbon monoxide detector in the designated spot in the kitchen area. An interview with the Food Service Director confirmed the absence of the detector and revealed that she was unaware of how long it had not been in place.
Failure to Maintain Safe Smoking Practices
Penalty
Summary
The facility failed to maintain smoking products safely, affecting a resident with quadriplegia, chronic obstructive pulmonary disease, and other conditions. The resident, who had intact cognition as per the Minimum Data Set 3.0 assessment, was observed with a lighter and a package of cigarettes at his bedside while receiving oxygen therapy at two liters per minute. This was confirmed by a Registered Nurse, who then confiscated the smoking materials and handed them to the Executive Director. The facility's policy on oxygen administration, which requires oxygen to be kept away from combustible materials, was not adhered to, as the resident was not permitted to store smoking materials at his bedside.
Failure to Protect Residents' Medical Record Privacy
Penalty
Summary
The facility failed to protect the privacy of two residents' medical records during an annual survey. Resident #18's electronic medical record was left open and unattended on a medication cart, making it visible to passersby. This occurred from 4:04 P.M. to 4:14 P.M. on 08/05/24, and was confirmed by both the RN Unit Care Coordinator and the LPN Unit Nurse, who admitted to leaving the record unattended. Similarly, Resident #12's electronic medical treatment record was left open and unattended on a treatment cart from 1:25 P.M. to 1:29 P.M. on 08/07/24. During this time, several individuals, including residents, staff, and visitors, passed by the visible record. The record remained viewable until it defaulted to a screen saver, and was later secured by the Executive Director and the RN Assistant Director of Nursing. The LPN Unit Nurse confirmed leaving the record unattended while performing treatments. The facility's policy on safeguarding electronic health information, which requires users to log off when leaving their workstation, was not followed.
Incomplete PASRR Documentation for a Resident
Penalty
Summary
The facility failed to ensure that all Pre-Admission Screening and Resident Review (PASRR) documents were completed as required for a resident. This deficiency affected one resident who was admitted with multiple diagnoses, including mood disorder, major depressive disorder, and anxiety disorder, among others. The resident was cognitively intact according to the Minimum Data Set (MDS) assessment. However, the first PASRR document for this resident was not completed until several months after admission, and it inaccurately indicated that it was for an expiring respite stay, which was not the case. The Director of Nursing confirmed that this was the only PASRR document available for the resident and that the resident had not been discharged or received respite services since admission.
Failure to Develop PTSD Care Plan for Resident
Penalty
Summary
The facility failed to develop and implement a comprehensive care plan for a resident diagnosed with Post Traumatic Stress Disorder (PTSD). The resident, who was admitted with multiple diagnoses including PTSD, was assessed with an intact cognitive status and had a history of sexual assault. Despite this, the facility did not create a trauma-informed care plan that identified PTSD triggers or outlined how to monitor behaviors related to the resident's PTSD. The absence of such a care plan was confirmed during interviews with the resident and the Licensed Practical Nurse (LPN) MDS Nurse. The facility's policy on trauma-informed care requires a multi-pronged approach to identify residents with PTSD or a history of trauma, including assessing for trauma indicators upon admission and during changes in condition. However, the social services assessment for trauma-informed care did not include the resident's history of sexual assault, and no care plan was developed to address potential triggers. The resident expressed that people entering her room was a trigger, which was not addressed in her care plan, highlighting the facility's failure to adhere to its own policy and adequately support the resident's needs.
Failure to Conduct Quarterly Care Conferences
Penalty
Summary
The facility failed to conduct quarterly care conferences for three residents, as required by their policy. Resident #4, who has diagnoses including Parkinson's disease and cognitive communication deficit, was not invited to attend quarterly care conferences. The medical record showed only one interdisciplinary care conference was held in the past year. Similarly, Resident #65, with conditions such as type one diabetes mellitus and acute kidney failure, was also not invited to quarterly care conferences, with only one conference documented in the past year. Resident #40, who has acute and chronic respiratory failure among other diagnoses, was not invited to quarterly care conferences either, with only one conference held in the past year. Interviews with the residents confirmed they were not invited to participate in these conferences, and the Director of Nursing verified the lack of evidence for quarterly interdisciplinary care conferences for these residents. The facility's policy requires that comprehensive care plans be developed and reviewed by an interdisciplinary team, including the resident and their representative, to ensure person-centered care. However, the facility did not adhere to this policy, resulting in the deficiency.
Failure to Monitor and Document Skin Abnormalities
Penalty
Summary
The facility failed to properly monitor and document skin abnormalities for a resident who was at risk due to anticoagulant therapy. The resident, who was cognitively intact and at risk for pressure ulcers, was on anticoagulant therapy for atrial fibrillation, which increased the risk of bleeding. Despite physician orders and care plans requiring monitoring for signs of bleeding, including bruising, the facility's documentation did not reflect the presence of significant bruising observed on the resident's arms. The Medication Administration Record (MAR) inaccurately indicated no signs of adverse reactions, such as bruising, from the anticoagulant use. Observations revealed dark, scattered bruising on the resident's arms and a large scratch on the elbow, which were not documented in the medical records. Interviews with nursing staff confirmed the presence of these skin abnormalities and the lack of documentation or routine monitoring. The facility's policies required daily anticoagulation management and documentation, as well as weekly wound assessments, which were not adhered to in this case. This deficiency in monitoring and documentation of skin conditions and potential adverse reactions to medication was identified during the survey.
Failure to Assess PTSD in Resident
Penalty
Summary
The facility failed to effectively assess a resident for Post Traumatic Stress Disorder (PTSD) as part of their trauma-informed care approach. The resident, who had a history of PTSD and sexual assault, was admitted with multiple diagnoses including bipolar disorder and homelessness. Despite having a cognitive status indicating intact mental capacity, the facility's assessment on 03/13/24 did not acknowledge the resident's history of sexual assault, which was later confirmed in medical progress notes. This oversight resulted in the absence of a trauma-informed care plan that identified PTSD triggers and monitored behaviors related to the resident's past trauma. Interviews and medical record reviews revealed that the resident felt safe in the facility but was triggered by people entering her room, a detail not captured in the initial assessment. The facility's policy required a comprehensive approach to identifying trauma indicators and developing individualized care plans, which was not followed in this case. The LPN MDS Nurse confirmed the omission of the resident's sexual assault history in the trauma assessment, highlighting a gap in the facility's adherence to its own policies for trauma-informed care.
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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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