Mccrea Manor Nsng And Rehab Ctr Llc
Inspection history, citations, penalties and survey trends for this long-term care facility in Alliance, Ohio.
- Location
- 2040 Mccrea Street, Alliance, Ohio 44601
- CMS Provider Number
- 365634
- Inspections on file
- 31
- Latest survey
- March 25, 2026
- Citations (last 12 mo.)
- 15
Citation history
Health deficiencies cited at Mccrea Manor Nsng And Rehab Ctr Llc during CMS and state inspections, most recent first.
A resident with multiple complex conditions, including CHF with CKD stage 3, COPD, diabetes, fractures, and protein-calorie malnutrition, had a physician order for 1L NS IV at 100 cc/hr for dehydration that was not implemented in a timely manner. An LPN documented the order, but the IV was not started until later by an RN, who reported that prior nurses had refused to hang the IV. The DON, Interim DON, and ADON all confirmed that the IV infusion was not initiated within a timely period after the order was received, despite facility policy requiring the nurse who takes the order to execute it or ensure a safe hand-off.
A resident with multiple medical conditions, including COPD and chronic respiratory failure requiring O2 via nasal cannula, was care planned as at risk for injury related to smoking, with interventions requiring supervision during smoking and storage of all smoking items at the nurse station. During observation, surveyors found an open metal box containing a disposable e-cigarette on the resident’s over-bed tray, and the resident and CNAs confirmed the vape was kept in the room despite staff acknowledging it was not permitted. The DON confirmed the resident was not allowed to keep e-cigarette supplies in the room, and review of the facility’s smoking policy showed all smoking materials, including vapes, were required to be stored in locked boxes at the nurse station or designated area.
A resident with anxiety and other medical conditions, care planned for safe medication use, had multiple scheduled doses of clonazepam 0.5 mg PO BID not administered as ordered, with MAR entries coded to see nurses’ notes and incomplete documentation, including one missed dose with no corresponding progress note and no narcotic sign-outs for the omitted doses. Progress notes on some days cited waiting for pharmacy supply or a new prescription. Additionally, clonazepam 1 mg tablets were available while the order was for 0.5 mg BID, and on two occasions RNs documented wasting 0.5 mg of clonazepam with only a single nurse signature and no second witness, contrary to facility policy requiring two licensed nurse witnesses and signatures for controlled substance destruction.
A resident with intact cognition and a history of mental health and medical conditions was served meals on disposable dishware and utensils without clear justification or reassessment, despite facility policy limiting such use to emergencies. Both the resident and staff were unaware of the reason for this intervention, and the Dietary Director confirmed that the practice had not been reviewed for continued appropriateness.
Surveyors identified that staff did not date opened insulin pens for several residents, and undated pens were found in medication carts, including one for a resident no longer at the facility. Nurses acknowledged the lack of dating and proper disposal, which did not comply with manufacturer guidelines or facility policy.
Staff served only two ounces of rice pilaf to residents instead of the required three or four ounces, as specified by the menu and portion control guidelines. This error was confirmed during tray line observation and affected a large number of residents, with one resident excluded due to a no food by mouth order.
Surveyors found that the facility did not maintain a clean and sanitary environment, with dirty floors, trash, and personal care items left on the floor, discolored and stained flooring, and over-bed tables in disrepair. Staff and residents confirmed these issues, and the Administrator acknowledged that all staff are responsible for cleaning up spills and trash.
A resident with multiple medical and psychiatric diagnoses, who was assessed as cognitively intact, had his preference for sponge baths and right to refuse showers disregarded when staff contacted his POA to obtain permission to proceed with a shower against his wishes. Despite the resident's ability to make his own care decisions, staff deferred to the POA and completed the shower, failing to honor the resident's rights.
Surveyors found that ordered medications were not available for administration to three residents, including cases where an LPN could not provide Clopidogrel, and other residents missed doses of medications such as Losartan, Amlodipine, and Phenobarbital due to pharmacy delivery delays. The DON, new to the facility, was aware of pharmacy issues but could not explain the specific incidents.
Staff failed to administer medications as ordered and in accordance with manufacturer guidance, resulting in a 12.9% medication error rate. Two residents received incorrect medications: one was given a multivitamin with minerals instead of the ordered multivitamin and did not receive a prescribed medication due to unavailability, while another received a multivitamin with minerals instead of the ordered type and was administered insulin from a Kwik-pen without a recorded open date, contrary to manufacturer instructions.
A resident received a lunch meal where the fish was served at 111°F, below the facility's required temperature of 135°F, resulting in the food being cold and unpalatable. Observations revealed confusion on the tray line and delays in serving, contributing to the deficiency.
Two residents with complex medical conditions had incomplete documentation in their MARs, with several scheduled medications not recorded as administered or offered. An agency RN was observed giving medications but failed to sign off, and the DON could not provide additional details for missing entries.
A resident with dementia in a secured memory care unit exhibited aggressive behaviors, and the facility failed to provide appropriate care. Despite having a care plan, staff struggled to manage the resident's behaviors, and prescribed medications were not administered. An interdisciplinary team meeting with the resident's family was not coordinated, and there were allegations of physical abuse by staff. The facility's dementia care policy was not followed, leading to a deficiency.
The facility failed to maintain a clean and sanitary kitchen, affecting nearly all residents receiving food. Observations revealed dirty floors, food-splattered equipment, and improperly labeled or dated food items in storage. The Dietary Manager confirmed these findings, which were contrary to the facility's Food Safety and Sanitation policy.
The facility failed to provide scheduled activities for residents in the memory care unit, affecting 15 out of 16 residents. Observations showed that during activity times, residents were left without structured engagement, with staff either on breaks or unaware of their responsibilities. The Activity Assistant assumed activities were conducted, but they were not, and the DON was unaware of communication regarding completed activities. The activity calendar showed limited scheduling, and despite training, activities were not implemented.
Several residents in the LTC facility did not receive wound and skin care treatments as ordered, leading to deficiencies in care. A resident with diabetes did not have their foot ulcer dressings changed regularly, and an offloading shoe was not provided. Another resident with blisters on the leg did not receive proper assessments or dressings, and ACE wraps were not applied. Additionally, a resident at risk for skin tears was not wearing prescribed protective gear, and another resident's PEG tube dressing was not in place. Staff interviews confirmed a lack of awareness and adherence to treatment orders.
The facility failed to update and individualize care plans for residents regarding smoking status and interventions, affecting several residents. One resident was allowed to keep smoking materials in his room against policy, while another had smoking materials without proper supervision. Additionally, a resident with impaired cognition was observed smoking without a required apron, and another resident at risk for falls was not wearing nonskid socks as per their care plan.
A facility failed to maintain contact isolation for a resident with an active HSV outbreak, as ordered by a physician. The resident's door signage inaccurately indicated enhanced barrier precautions instead of contact isolation, which required staff to wear PPE when entering the room. This error was confirmed by the DON and affected 12 other residents on the same unit.
A facility failed to set a resident's oxygen flow rate according to the physician's order. The resident, with multiple diagnoses including COPD and asthma, was supposed to receive oxygen at two liters per minute via nasal cannula. However, observations showed the flow rate was set at three liters per minute. Interviews with an LPN and the DON confirmed the discrepancy.
A resident's room was found to be in disrepair, with four holes in the drywall and a damaged electrical outlet recessed into the wall. The Maintenance Director confirmed these issues during an inspection.
The facility failed to provide proper pressure ulcer wound care for two residents. One resident did not receive the prescribed treatment for a sacrum wound, and the nurse did not follow hand hygiene protocols. Another resident's Stage 4 sacral ulcer was found without the required dressing, and a nurse aide did not report this to the nurse. The facility's wound care policy was not adhered to, resulting in deficiencies.
Failure to Timely Implement Physician Order for IV Fluids
Penalty
Summary
The deficiency involves the facility’s failure to ensure timely implementation of a physician’s order for IV fluids for one resident. The resident had multiple significant diagnoses, including age-related osteoporosis, hypertensive heart and chronic kidney disease with heart failure stage 3, COPD, type 2 diabetes mellitus, multiple right-sided rib fractures, fractures of the right ulna styloid process and shaft of the right radius, and protein-calorie malnutrition. A handwritten physician order dated 02/17/26 directed that 1 liter of normal saline be administered intravenously at 100 cc/hr. This order was signed by an LPN on 02/18/26. The MAR/TAR for 02/18/26 showed an order for 0.9% normal saline IV, 1 liter every 24 hours for dehydration, to run at 100 ml/hr starting at 6:30 p.m., and documentation indicated that an RN initiated a peripheral IV in the left antecubital space at that time with normal saline running at 100 ml/hr. Interviews revealed that the IV order was not carried out in a timely manner after it was received. The RN who started the IV stated that two nurses before her had refused to hang the IV and that she was told by the DON that they had to hang it, while the DON denied instructing any nurse to start the IV or having knowledge of nurses refusing to do so. The DON confirmed that the IV infusion order was not initiated timely on 02/18/26 and stated that the RN had all day to start the IV and administer the fluids per the physician’s order. The LPN who signed the order reported she might have taken the IV order and believed the dayshift nurse was to start the IV. The Interim DON confirmed that timely IV administration would be within a few hours of receiving the order and that this did not occur. The ADON also confirmed the IV infusion order was not initiated timely and denied knowledge of instructing a nurse to start the IV or of any refusals. The facility’s Physician Orders policy stated that the nurse who takes the physician order is responsible for executing it or providing a safe hand-off to the next nurse, which did not occur as required in this case.
Unsecured E-Cigarette Supplies Kept in Resident Room
Penalty
Summary
The facility failed to ensure smoking supplies were locked and secured as required by facility policy and the resident’s care plan. One resident, admitted with diagnoses including hemiplegia and hemiparesis following cerebral infarction, acute and chronic respiratory failure with hypoxia, epilepsy, COPD, alcohol abuse, cannabis use, and tobacco use, had a quarterly MDS indicating intact cognition. The resident’s care plan, dated 02/13/26, identified risk for injury related to smoking, cigarettes, and electronic devices, with interventions specifying that the resident was to be supervised at all times while smoking, wear a smoking apron, and have all smoking items kept at the nurse station. During observation on 03/18/26 at 10:49 A.M., the resident was seen in bed with oxygen via nasal cannula, and an open red metal box containing a disposable e-cigarette (vape) was on the over-bed tray next to the bed. The resident confirmed that he kept the vape in his room in the red box. Two CNAs separately confirmed that the resident had his e-cigarette vape in his room, and one CNA stated he was not permitted to have it there. The DON also confirmed the resident was not permitted to keep e-cigarette supplies in his room. Review of the facility’s “Lionstone Smoking” policy, revised 10/15/24, showed that no smoking materials are permitted with the resident or in their room and that all smoking materials, including vapes, must be kept in lock boxes at the nurse station or designated area. This constituted non-compliance with the requirement to keep smoking materials secured.
Failure to Administer and Reconcile Clonazepam per Orders and Controlled Substance Policy
Penalty
Summary
The deficiency involves the facility’s failure to administer and reconcile a controlled medication, clonazepam, according to physician orders and facility policy for one resident. The resident was admitted with diagnoses including encephalopathy, low back pain, cervical spinal stenosis, and anxiety, and had a care plan identifying increased risk of adverse reactions related to opiate use, with interventions to administer medications as ordered and monitor for side effects. The admission MDS showed intact cognition. Physician orders for February directed clonazepam 0.5 mg PO BID for anxiety. Review of the MAR/TAR showed that multiple scheduled doses (one morning dose on the first day of the month, both morning and evening doses on the second day, and both morning and evening doses on the sixteenth day) were marked with a code indicating “Other/See Nurses Notes,” and the narcotic sign-out sheet showed no corresponding sign-outs for these doses. Progress notes lacked any entry for the missed dose on the first day, while notes on the second and sixteenth days documented that clonazepam was not administered due to awaiting medication from the pharmacy or a new prescription. The Interim DON confirmed that five doses were missed, contrary to the facility’s medication administration policy requiring medications to be given safely, timely, and as prescribed. The deficiency also includes improper handling and documentation of controlled substance wasting for the same resident’s clonazepam. The narcotic sign-out sheet showed clonazepam 1 mg available with an order for 0.5 mg BID, and entries on two consecutive days documented that RNs each wasted 0.5 mg of clonazepam but signed the waste with only a single signature and no second witness, despite facility policy requiring all controlled substance destruction to be witnessed by at least two nurses with both signatures recorded. The Interim DON confirmed that only one signature appeared for each waste event. One RN stated she always had a witness and speculated the other nurse may have walked away without signing, while the other RN reported she had not been aware at the time that two nurse witnesses and signatures were required. The facility’s controlled substance policy specified adherence to state and federal laws and required two licensed nurse witnesses and a record for each drug destruction, which was not followed in these instances.
Failure to Provide Appropriate Dishware and Silverware to Promote Resident Dignity
Penalty
Summary
The facility failed to ensure that a resident was provided with appropriate dishware and silverware to promote dignity during meals. Record review showed that the resident, who had diagnoses including major depressive disorder, essential hypertension, and generalized anxiety disorder, was cognitively intact and had been receiving disposable dishware and utensils. The use of disposables was originally implemented due to the resident discarding smokeless tobacco into mugs and bowls, but there was no evidence of reassessment to determine if this intervention was still necessary. The resident's care plan indicated a risk for malnutrition, and the use of disposables was discontinued at a later date, but during the period reviewed, the resident continued to receive paper plates and plastic utensils without clear justification. Interviews with the resident and staff confirmed that the resident was unaware of the reason for receiving disposable dishware, and staff could not provide an explanation. The Dietary Director acknowledged that the intervention had been in place since the previous year and that no reassessment had occurred to determine if regular dishware and silverware should be reinstated. Facility policy stated that disposables should only be used in emergency situations, yet multiple residents, including the one reviewed, were receiving them outside of such circumstances.
Failure to Date and Dispose of Opened Insulin Pens
Penalty
Summary
Surveyors found that the facility failed to ensure opened insulin pens were properly dated for use and disposal, as required by professional standards and manufacturer guidelines. During medication administration, a registered nurse used an insulin Lispro Kwik-pen for a resident without an open date recorded on the pen, despite being aware of the requirement. Manufacturer information specifies that insulin pens should not be used for more than 28 days after opening, but the pen in use did not have documentation of when it was first opened. Further observations revealed additional undated, opened insulin pens for three other residents in two medication carts. One LPN confirmed the presence of an undated insulin pen for a resident who was no longer at the facility, indicating a lack of proper medication disposal. The facility's own policy requires medications to be stored in their original, labeled containers and for expired or discontinued medications to be removed and disposed of appropriately. These findings demonstrate a failure to comply with medication labeling and storage requirements.
Failure to Serve Correct Portion Sizes of Rice Pilaf
Penalty
Summary
The facility failed to ensure that appropriate portion sizes of rice pilaf were served to residents, as required by the facility's menu and portion control guidelines. According to the menu spreadsheet, residents were to receive four ounces of rice pilaf, except for those on carbohydrate-controlled diets who were to receive three ounces. However, during an observation of the tray line, it was found that only two ounces of rice pilaf were being served. This discrepancy was confirmed by a staff member at the time of observation and upon review of the spreadsheet. The incorrect portion sizes affected 33 residents and had the potential to affect 69 out of 70 residents, with one resident on a no food by mouth order. The facility's policy emphasized the importance of portion control to ensure nutritional adequacy, but the established procedures were not followed during meal service.
Failure to Maintain Clean and Sanitary Resident Environment
Penalty
Summary
Surveyors observed multiple instances where the facility failed to maintain a clean and sanitary environment in resident rooms and common areas. Specific findings included dirty floors, personal care items and trash such as a used toothette, disposable glove, plastic bottle, crayon, hairbrush, paper, and plastic bag found on the floors or under beds. There was also a white substance on the floor, and a build-up of dirt around toilet bolts in bathrooms. Over-bed tables were found in disrepair, with stripping pulled away or taped, and some flooring was discolored or stained, indicating a lack of thorough cleaning. These conditions were observed in the rooms of twelve residents during medication administration and routine checks. Staff interviews confirmed the environmental concerns, with a CNA/med tech and an RN acknowledging the cleanliness issues and disrepair, and the RN stating she was unaware of the facility's cleaning schedule. The Administrator verified the observations and agreed that staff should address spills and trash regardless of their roles. Residents also reported dissatisfaction with the cleanliness of their rooms and bathrooms, noting discolored and dirty floors. The deficiency was identified during investigations related to two specific complaint numbers.
Failure to Honor Resident's Right to Refuse Care
Penalty
Summary
The facility failed to honor a resident's right to make choices regarding personal care, specifically related to bathing preferences. The resident, who had chronic kidney disorder, bipolar disorder, major depressive disorder, generalized muscle weakness, and required assistance with activities of daily living, was assessed as cognitively intact and able to make his own decisions. The care plan indicated that staff should assist with bathing according to the resident's preferences, and a preference evaluation showed the resident preferred sponge baths and valued having his brother involved in care discussions. Despite this, nursing documentation revealed that when the resident refused a shower, staff contacted his Power of Attorney (POA) to obtain permission to proceed with the shower against the resident's wishes, citing concerns about soiled linens and hygiene. The POA ultimately gave permission for the shower, and staff proceeded to bathe the resident. Further review and interviews confirmed that the resident had not been deemed incompetent and did not have a guardianship assigned, meaning his right to make decisions about his care remained intact. The Administrator and DON acknowledged that the POA's authority did not override the resident's choices as long as he was capable of making his own decisions. The incident demonstrates that the facility did not respect the resident's expressed preferences and right to refuse care, as required by regulations, and instead deferred to the POA despite the resident's cognitive ability to make his own choices.
Failure to Ensure Availability of Ordered Medications
Penalty
Summary
The facility failed to ensure that ordered medications were available for administration to residents, as observed and documented in three separate cases. In one instance, an LPN was unable to administer Clopidogrel to a resident because the medication was not available at the time of the medication pass. Another resident, with multiple diagnoses including type two diabetes mellitus with a foot ulcer, COPD, and protein-calorie malnutrition, had several medications, including Losartan Potassium and Amlodipine, not administered due to waiting on pharmacy delivery, as noted in the electronic Medication Administration Record (MAR). Additionally, a resident with epilepsy did not receive Phenobarbital on multiple occasions because the medication was not available, with MAR notes indicating the physician was aware and the facility was awaiting pharmacy delivery. The Director of Nursing, who had only recently started at the facility, was unable to provide explanations for the unavailability of these medications but acknowledged being aware of ongoing pharmacy-related issues.
Medication Administration Errors and Policy Non-Compliance
Penalty
Summary
The facility failed to administer medications as ordered and in accordance with manufacturer guidance, resulting in a medication error rate of 12.9% (four errors out of 31 opportunities). For one resident, a physician order required Clopidogrel bisulfate 75 mg to be given once daily in the morning, and a separate order specified a multivitamin without minerals. On the day of observation, the LPN preparing medications reported that Clopidogrel was unavailable and instead prepared and administered a multivitamin with minerals, contrary to the physician's order. This resulted in two medication errors for this resident. For another resident, physician orders included a daily multivitamin and insulin Lispro with specific dosing instructions based on blood glucose levels. The RN prepared and administered a multivitamin with minerals instead of the ordered multivitamin, and administered 24 units of insulin Lispro using a Kwik-pen that did not have an open date recorded, despite manufacturer instructions that the pen should not be used more than 28 days after opening. The RN was made aware of the missing open date but proceeded with administration, resulting in two additional medication errors. The facility's policy required verification of the right drug, dose, route, rate, time, and resident prior to administration, which was not followed in these instances.
Failure to Serve Food at Safe and Palatable Temperature
Penalty
Summary
The facility failed to ensure that food was served at a palatable and safe temperature, as required by its own Food Temperature Guidelines. During observation of the lunch tray line, it was noted that there was confusion regarding which carts had been served, and meals were being held in a warmer while waiting for residents to decide on their dining location. A test tray prepared directly from the steam table showed the fish was served at 111 degrees Fahrenheit, which was below the facility's standard of greater than 135 degrees at point of service. The fish was reported to taste cool, and a resident later stated that the fish served for lunch was cold and unappetizing.
Incomplete Medication Administration Documentation
Penalty
Summary
The facility failed to ensure that medical records were complete and accurately reflected the administration of medications for two residents. For one resident with multiple diagnoses including type 2 diabetes, foot ulcer, and morbid obesity, the March 2025 Medication Administration Record (MAR) lacked documentation of morning medications being administered on a specific date. The ordered medications included several critical prescriptions such as mag ox, fluoxetine, buspirone, pantoprazole, metformin, meloxicam, losartan, iron-vitamins, aspirin, and amlodipine. The Director of Nursing (DON) confirmed that an agency RN was scheduled and observed administering medications but did not sign off on the MAR before leaving her shift. For another resident with complex conditions such as multiple sclerosis, schizoaffective disorder, narcolepsy, and chronic pain syndrome, the February 2025 MAR showed no documentation of several scheduled medications being offered or administered on multiple occasions. These included riboflavin, vitamin D, Zyrtec, guaifenesin, Keppra, modafinil, senna S, baclofen, sucralfate, and simvastatin. The DON was unable to provide further details regarding the lack of documentation for these medication administrations.
Inadequate Dementia Care and Medication Management
Penalty
Summary
The facility failed to provide appropriate dementia care for a resident diagnosed with Alzheimer's disease and dementia with mood disturbances. The resident, who resided in a secured memory care unit, exhibited resistive-to-care behaviors, including verbal and physical aggression towards staff and other residents. Despite having a care plan in place that included interventions such as approaching the resident in a calm manner and providing a quiet environment, the staff struggled to manage the resident's behaviors effectively. The resident's care plan was not adequately followed, as evidenced by multiple incidents where the resident became aggressive and required multiple staff members to manage. The resident's medication regimen was adjusted by a psychiatry nurse practitioner, including a gradual dose reduction of Seroquel, an antipsychotic medication. However, the as-needed Ativan prescribed for agitation and anxiety was not administered during February and March, despite the resident's ongoing aggressive behaviors. The facility's failure to utilize the prescribed medication and coordinate an interdisciplinary team meeting with the resident's wife to discuss behavior management contributed to the deficiency. Additionally, there was an allegation of physical and verbal abuse involving the resident, where staff members were accused of holding the resident down and covering his mouth. Interviews with staff revealed that the resident often became violent during care, and staff resorted to physical interventions to manage his behaviors. The facility's policy on dementia and behavioral health guidelines emphasized non-restraint interventions, which were not adhered to, further highlighting the deficiency in providing appropriate dementia care.
Kitchen Sanitation Deficiency
Penalty
Summary
The facility failed to maintain the kitchen in a clean and sanitary condition, as observed during an initial tour with the Dietary Manager. The kitchen floor was found to be dirty with food splatter, pieces of paper, and dried food debris, particularly underneath equipment. The microwave had food splatter on all sides and burnt food on the bottom. Additionally, the grill had food residue, and the grill pan contained french fries and food pieces. The prep table under the grill was also covered in food debris. The Dietary Manager confirmed that the grill was not in use due to a lack of power. Further inspection of the walk-in refrigerator revealed an undated and unlabeled food container on the floor, along with containers of soup, black olives, and sliced tomatoes that were neither labeled nor dated. The walk-in freezer contained an open bag of pepper steak and a bag of breaded patties, both of which were not labeled or dated. The Dietary Manager verified these findings. The facility's undated Food Safety and Sanitation Review policy included a checklist for ensuring cleanliness and sanitation, which was not adhered to, as evidenced by the observations. The policy required all food to be covered, labeled, and dated, and all equipment to be cleaned after use or on a daily basis.
Failure to Provide Activities in Memory Care Unit
Penalty
Summary
The facility failed to provide adequate activities for residents in the memory care unit, affecting 15 out of 16 residents. Observations revealed that during scheduled activity times, residents were left without structured activities. For instance, at 3:02 P.M., the television was merely playing music, and an STNA was observed taking a break instead of engaging residents in activities. Another STNA confirmed the absence of activities while managing resident care. The Director of Nursing acknowledged that one STNA was supposed to conduct activities while another attended to residents not participating, but agency staff were not informed of their responsibilities. The Activity Assistant admitted to assuming that staff would play movies and engage residents with daily chronicles, but these activities were not actually conducted. The DON was unaware of how STNAs communicated completed activities to the activity department. A review of the activity calendar showed only two scheduled activities per day, with no evening activities. Despite an in-service training instructing STNAs to conduct activities at specific times, these were not implemented, leading to a lack of engagement for the memory care residents.
Deficiencies in Wound and Skin Care Management
Penalty
Summary
The facility failed to implement wound-related treatments as ordered for several residents, leading to deficiencies in care. Resident #9, who had a history of diabetes and multiple ulcers, did not receive proper wound care as per physician orders. The resident's left foot ulcer was not dressed as frequently as required, and the offloading shoe prescribed to aid in healing was not provided. Observations revealed that the resident's dressings were not changed regularly, and interviews with staff confirmed a lack of awareness and follow-through on the prescribed treatments. Resident #18, with a history of respiratory failure and cognitive impairment, also experienced deficiencies in skin care. The resident had orders for skin assessments and specific dressings for blisters on the right lower leg, but these were not consistently documented or applied. Observations showed that the resident's blisters were not properly treated, and the ACE wraps ordered for the resident's legs were not applied as required. Interviews with staff revealed a lack of knowledge about the resident's condition and the necessary treatments, leading to inadequate care. Resident #34 and Resident #45 also experienced deficiencies in care. Resident #34, who was at risk for skin tears, was not wearing the prescribed TED hose and geri sleeves, which were intended to protect against skin damage. Similarly, Resident #45 did not have the PEG tube dressing in place as ordered, which is crucial for preventing infection and irritation. These oversights were confirmed through observations and staff interviews, highlighting a pattern of non-compliance with physician orders and facility policies.
Deficiencies in Smoking Policies and Fall Risk Management
Penalty
Summary
The facility failed to ensure that resident comprehensive care plans were updated and individualized, particularly concerning the residents' smoking status and interventions. This deficiency affected four residents who were reviewed for smoking. For instance, Resident #9 was permitted to smoke independently but kept smoking materials in his room, contrary to the facility's policy. The care plan did not specify smoking times or whether Resident #9 was safe for unsupervised smoking. Interviews with staff revealed a lack of awareness about the resident's care plan allowing storage of smoking materials in his room. Similarly, Resident #13 had moderate cognitive impairment and was found to have smoking materials in his room, which was against the facility's policy. The care plan did not include interventions related to his ability to roll his own cigarettes or specify his supervision needs. Staff interviews indicated uncertainty about whether Resident #13 was considered an independent smoker and a lack of knowledge about any care plan interventions regarding the storage of smoking materials in his room. Additionally, Resident #31, who had severely impaired cognition, was observed smoking without a smoking apron, which was a care plan intervention to prevent accidental injury. The facility also failed to ensure Resident #53, who was at risk for falls, was wearing nonskid socks as per his care plan. This oversight was confirmed by a staff member during an observation. The facility's policy on falls and fall risk management emphasized resident-centered approaches, which were not implemented in this case.
Failure to Maintain Contact Isolation for Resident with HSV
Penalty
Summary
The facility failed to maintain contact isolation as ordered for a resident with an active herpes simplex virus (HSV) outbreak. The resident was admitted with diagnoses including hemiplegia, hemiparesis, bipolar disorder, and polyneuropathy, and exhibited intact cognition. Despite a physician's order for contact isolation dated 08/30/24, the signage on the resident's door indicated enhanced barrier precautions instead. This discrepancy was confirmed by the Director of Nursing (DON), who acknowledged that the signage was inaccurate. Contact precautions required staff to don personal protective equipment (PPE) when entering the resident's room, whereas enhanced barrier precautions required PPE only during direct care. This oversight affected 12 other residents residing on the same unit.
Oxygen Flow Rate Not Set as Ordered
Penalty
Summary
The facility failed to ensure that a resident's oxygen flow rate was set according to the physician's order, affecting one resident who was reviewed for respiratory care. Resident #34, who was admitted with diagnoses including chronic obstructive pulmonary disease, asthma, dementia, diabetes mellitus, congestive heart failure, and atrial fibrillation, was receiving oxygen therapy. The resident's medical record indicated an order for oxygen at two liters per minute via nasal cannula. However, observations on two occasions revealed that the oxygen flow rate was set at three liters per minute. Interviews with an LPN and the Director of Nursing confirmed that the oxygen flow rate was not set as ordered by the physician.
Room Maintenance Deficiency
Penalty
Summary
The facility failed to maintain a resident's room in good repair, affecting one of the 22 residents reviewed for environmental concerns. During an observation, it was noted that the resident's room had four holes in the drywall behind the recliner and a damaged electrical outlet that was recessed into the wall. The Maintenance Director confirmed these deficiencies during an interview.
Failure to Implement Pressure Ulcer Wound Care as Ordered
Penalty
Summary
The facility failed to ensure proper pressure ulcer wound care for two residents, leading to deficiencies in their treatment. Resident #4, who had diagnoses including acute respiratory failure, multiple sclerosis, and chronic pain syndrome, was readmitted with orders to treat pressure ulcers on the sacrum and right buttock. However, the prescribed treatment for the sacrum wound was not implemented for several days, and during an observation, the wound care was not performed according to the physician's orders. The nurse did not follow proper hand hygiene protocols between treating different wounds, and the correct dressing was not applied to the sacrum wound. Resident #19, diagnosed with dementia, hypothyroidism, and major depressive disorder, had a Stage 4 sacral pressure ulcer that required specific dressing. During an observation, it was found that the dressing was not in place as ordered. A nurse aide confirmed that the resident did not have a dressing during incontinence care earlier in the day and failed to report this to the nurse. The facility's wound care policy outlines specific steps for wound care, which were not followed in these cases, leading to the identified deficiencies.
Latest citations in Ohio
A resident with intact cognition receiving Medicare Part A skilled services for metabolic encephalopathy had services discontinued while benefit days remained, but the facility did not issue the required Skilled Nursing Facility Advance Beneficiary Notice (SNF ABN). The Social Services Director later confirmed that no SNF ABN was provided and reported she believed only a Notice of Medicare Non-Coverage (NOMNC) was needed when all skilled services were stopped. This practice conflicted with the facility’s written policy, which required SNF ABNs to be issued when extended care items or services were initiated, reduced, or terminated due to expected non-coverage by Medicare.
Surveyors identified that the facility exceeded the acceptable medication error rate when two residents with type 2 DM received insulin doses that were not administered according to orders or manufacturer instructions. In two separate observations, an LPN administered Novolog and another LPN administered insulin glargine and insulin lispro without priming the insulin pens, and the insulin lispro and Novolog were given after the residents had already consumed a significant portion of their breakfast meals, despite orders for administration before meals. Manufacturer information for both insulin products required priming before each injection to ensure accurate dosing, and facility policy required medications, including insulin, to be administered safely, timely, and in accordance with prescriber orders and specified time frames.
Surveyors found that the facility failed to document tray line food temperatures for multiple meals served from two dining room kitchenettes, despite having a “Trayline Taste & Temperature Log” and a policy requiring food to be stored, prepared, distributed, and served according to professional food safety standards. Review of logs showed repeated missing entries for breakfast, lunch, and dinner services in both the Harrison and McClellan dining areas, and the Senior Director of Culinary Services confirmed that temperatures had not been recorded for those meals, potentially affecting all residents receiving meals from those kitchenettes.
The facility failed to conduct and document required periodic care conferences for two residents, despite multiple comprehensive, quarterly, and significant change MDS assessments and a policy requiring periodic care conferences with resident and/or family participation. One resident with Parkinson’s disease, post-stroke hemiplegia, TIA, DMII, and depression had only two documented care conferences over a year, while another resident with aphasia, cerebrovascular disease, DMII, gait difficulty, coagulation defect, depression, and muscle weakness had no documented care conferences in the past year, aside from a declined invitation to the representative. The UCC confirmed that care conferences were expected to occur quarterly and that no additional documentation existed for either resident.
A resident with Alzheimer's disease and type II DM, who required extensive assistance with ADLs and was receiving scheduled Lantus and sliding-scale Humalog, experienced a severely elevated blood glucose level. The on-call provider was notified and ordered an additional dose of lispro insulin with a directive to recheck the blood glucose after administration. Nursing staff administered the extra insulin but did not document any follow-up blood glucose check, and the DON confirmed that this reevaluation was required by the facility's abnormal blood glucose policy and was not completed or documented.
A resident with Parkinson’s disease, dementia, and hypothyroidism was prescribed levothyroxine once daily along with other medications. A consultant pharmacist’s monthly drug regimen review recommended that levothyroxine be given in the morning on an empty stomach, 30–60 minutes before food, per manufacturer instructions. The medical record contained no documented physician response to this recommendation, and the MAR showed the drug scheduled for morning administration while the resident was observed eating breakfast and receiving the medication at the same time. An LPN confirmed administering levothyroxine during the meal, and the DON verified there was no documentation explaining whether or why the pharmacist’s recommendation was or was not followed, resulting in a failure to act on and document the identified irregularity.
A resident with severe cognitive impairment, multiple comorbidities, documented gait and balance abnormalities, and a high fall risk was care planned and assessed by therapy to require contact guard assistance and use of a gait belt for transfers and ambulation. While being assisted by a CNA from a recliner to the bathroom with a walker, the CNA did not apply a gait belt, even though the resident had a known tendency to lean backward when standing. As the CNA reached to open the bathroom door, the resident lost balance and fell backward, striking the back of the head, and was later found by an LPN without a gait belt in place, contrary to the facility’s gait belt policy and the resident’s assessed needs.
A resident with CKD stage five requiring peritoneal dialysis (PD) was admitted with pre-admission physician orders for three daily PD exchanges and monitoring for peritonitis (fever, abdominal pain, cloudy effluent), but these monitoring orders were not entered into the facility’s physician orders. The care plan referenced PD and general monitoring but did not specifically address peritonitis monitoring. Paper PD flowsheets showed incomplete and inconsistent documentation of exchanges and resident condition, including missing condition/comments for individual treatments and no record of one ordered PD exchange. The PD cycler flowsheet lacked effluent descriptions on multiple days. The PD nurse reported facility staff were expected to monitor effluent and symptoms, and the DON confirmed the absence of specific peritonitis monitoring orders, lack of an order for the PD cycler, and documentation gaps, despite a facility policy requiring ongoing assessment and monitoring for complications before, during, and after dialysis treatments.
A nurse was observed preparing multiple oral medications for a resident with depression, traumatic brain injury, anxiety, and impaired cognition by pushing tablets and capsules from unit-dose cards directly into her ungloved hand and then using her fingers to place them into a medication cup. In a follow-up interview, the RN confirmed this practice and acknowledged that the correct procedure is to dispense medications directly from the card into the cup, contrary to the facility’s medication administration policy requiring adherence to good nursing principles and practices.
A resident with Alzheimer’s disease, diabetes, anxiety, significant ADL dependence, and behavioral symptoms was observed seated in a chair positioned against the nursing station with a locked wheelchair placed directly in front, also against the nursing station, effectively restricting movement. An LPN confirmed both wheelchair wheels were locked and that it should not have been placed there, while a CNA stated she had positioned the wheelchair to prepare for lunch, was unable to complete the transfer, and left it in place, acknowledging this was wrong. This arrangement conflicted with the facility’s restraint policy, which prohibits physical restraints except when alternatives are ineffective for treating a medical symptom and defines restraints as devices adjacent to the body that cannot be easily removed and that restrict freedom of movement or access to the body.
Failure to Issue Required SNF ABN When Discontinuing Medicare Part A Services
Penalty
Summary
The deficiency involves the facility’s failure to issue a Skilled Nursing Facility Advance Beneficiary Notice (SNF ABN) when Medicare Part A services were discontinued for a resident who still had available benefit days. The resident was admitted with a diagnosis of metabolic encephalopathy and had intact cognition per the Minimum Data Set assessment. The facility’s own SNF Beneficiary Notification Review documented that Medicare Part A skilled services began on 02/11/26 and the last covered day was 03/11/26, and that the facility initiated discharge from Medicare Part A services before the resident’s benefit days were exhausted. Despite this, no SNF ABN was provided to the resident or the resident’s representative. During interviews, the Social Services Director stated that the SNF ABN was issued hours prior to the last covered day but, upon reviewing her files, confirmed that no SNF ABN had actually been issued for this resident. She further explained that she believed an SNF ABN was only required if one skilled service remained and that if all skilled services were being discontinued, only the Notice of Medicare Non-Coverage (NOMNC) needed to be issued. The Administrator, however, stated that a resident should always receive both a SNF ABN and a NOMNC when Medicare Part A services are discontinued and benefit days remain. Review of the facility’s written policy dated 03/28/23 showed that the facility was required to issue SNF ABNs for initiation, reduction, or termination of extended care items or services when Medicare payment was not expected, which did not occur in this case.
Plan Of Correction
This Plan of Correction is submitted as required under State and Federal law. This Plan of Correction does not constitute an admission on the part of the Facility that the findings cited are accurate, that the findings constitute a deficiency or that the scope and severity regarding the deficiency cited are correctly applied. Any changes to the Facility's policies and procedures should be inadmissible in any proceeding on that basis. Without admitting or denying the validity or the existence of the alleged noncompliance, the Facility submits this Plan of Correction with the intention that it be inadmissible by any third party in any civil or other action against the facility or any employee, agent, officer, director or shareholder of the Facility. The Facility is utilizing this Plan of Correction as its allegation of substantial compliance as of 05/29/2026 F-0582 Corrective action for resident/s: On 5/14/26 Resident #34 was informed of rights and responsibilities related to Advanced Beneficiary Notice and voiced understanding of information for future reference by administrator. Identification of other residents who may be affected: Any resident receiving skilled services from nursing or therapy services. The Administrator audited all residents who were discharged from skilled services in the past 30 days to ensure they were issued a Notice of Non-Coverage and Advanced Beneficiary Notice on 5/29/26. No non-compliance was noted. Measures for systemic change: On 5/14/2026 Business Office Manager, Director of Rehab, Minimum Data Set nurse, Director of Nursing and Social Services Director were educated on proper procedure of issuing of Notice Of Medicare Non Coverage and Advanced Beneficiary Notice by administrator. All upcoming discharges from skilled services will be reviewed weekly at Utilization Review meeting to ensure notices will be delivered timely. How Corrective Action will be monitored: Administrator or designee to complete audits of all residents being discharged from skilled services to ensure they were issued a Notice of Non-Coverage and Advanced Beneficiary. This audit will be completed weekly x 4 weeks, then monthly x 2 months. Corrective action will be initiated for any noted non-compliance. Audit findings will be reviewed as part of the monthly quality assurance process to determine the need for further monitoring. Date of Compliance 5/29/26
Insulin Administration Errors and Failure to Prime Insulin Pens
Penalty
Summary
The deficiency involves the facility’s failure to maintain a medication error rate below 5%, with surveyors identifying 3 errors out of 28 medication administration opportunities, resulting in a 10.71% error rate. For one resident with type 2 diabetes mellitus and moderate cognitive impairment, the physician’s order directed Novolog insulin 10 units via subcutaneous pen-injector to be given before meals. During an observed medication pass, the LPN administered 10 units of Novolog insulin without priming the pen and did so after the resident had already consumed approximately 50% of the breakfast meal. The LPN later confirmed she did not prime the pen and acknowledged that the insulin was ordered to be administered prior to meals. Manufacturer instructions for the Novolog FlexPen specified that an air shot (priming) must be performed before each injection to ensure proper dosing. Another resident, also diagnosed with type 2 diabetes mellitus and with intact cognition, had orders for insulin glargine 35 units subcutaneously twice daily and insulin lispro 20 units subcutaneously before meals, plus 12 units subcutaneously if blood glucose was between 251 mg/dL and 300 mg/dL. During an observed medication administration, an LPN administered 35 units of insulin glargine and 32 units of insulin lispro without priming the insulin pens and after the resident had consumed approximately 90% of the breakfast meal, despite orders for insulin lispro to be given before meals. The LPN later stated she could not remember if she had primed the pen and acknowledged that the insulin was ordered to be administered prior to meals. Manufacturer information for insulin lispro stated that the pen must be primed before each injection to confirm insulin delivery and remove air, and that failure to prime could result in too much or too little insulin. The DON confirmed the expectation that insulin be administered as ordered, including priming each pen with two units before dialing the prescribed dose, and facility policy required medications, including insulin, to be administered safely, timely, and in accordance with prescriber orders and required time frames.
Plan Of Correction
This Plan of Correction is submitted as required under State and Federal law. This Plan of Correction does not constitute an admission on the part of the Facility that the findings cited are accurate, that the findings constitute a deficiency or that the scope and severity regarding the deficiency cited are correctly applied. Any changes to the Facility's policies and procedures should be inadmissible in any proceeding on that basis. Without admitting or denying the validity or the existence of the alleged noncompliance, the Facility submits this Plan of Correction with the intention that it be inadmissible by any third party in any civil or other action against the facility or any employee, agent, officer, director or shareholder of the Facility. The Facility is utilizing this Plan of Correction as an allegation of substantial compliance as of 5/29/2026. F-0759 Corrective action for resident/s: Residents #21 and #22 were assessed and evaluated by nurse and Director of Nursing 5/14/26. Resident #21 and #22 both denied any adverse effects and none were noted upon assessment by the Director of Nursing on 5/14/2026. Notification made to physician on 5/14/2026. LPN # 2 competency Eval on insulin administration with the Director of Nursing completed 5/14/2026. Identification of other residents who may be affected: Diabetic residents on assignment of LPN #2/station 2 have the potential to be affected and were assessed by the DON/Designee on 5/14/26 and found to be within normal limits. Measures for systemic change: All Nurses were educated by the Director of Nursing on the steps for Insulin administration per competency, diabetes clinical protocol policy, Medication and treatment orders policy, administering medications policy, and Obtaining fingerstick Glucose Level policy On 5/14/2026. How Corrective Action will be monitored: Director of Nursing and Assistant Director of Nursing will complete insulin administration audits on 5 nurses. This audit will be completed weekly x 4 weeks, then monthly x 2 months. Corrective action will be initiated for any noted non-compliance. Audit findings will be reviewed as part of the monthly quality assurance process to determine the need for further monitoring. Date of Compliance: 5/29/2026
Failure to Document Tray Line Food Temperatures in Dining Room Kitchenettes
Penalty
Summary
The deficiency involves the facility’s failure to document tray line food temperatures for meals served from the Harrison and McClellan Dining Room kitchenettes, as required by professional standards for food service safety and the facility’s own policy. Review of the “Trayline Taste & Temperature Log” (revised September 2018) showed missing temperature documentation for multiple meals from the Harrison Dining Room kitchenette, including dinner on 03/30/26 and 03/31/26, lunch and dinner on 04/01/26 and 04/02/26, dinner on 04/07/26, and lunch and dinner on 04/08/26 and 04/10/26. The Senior Director of Culinary Services confirmed during interview that tray line food temperatures were not documented on the log for these meals. Similarly, review of the same log for the McClellan Dining Room kitchenette revealed that tray line food temperatures were not documented for dinner on 04/01/26, breakfast and lunch on 04/02/26, and lunch and dinner on 04/07/26. The Senior Director of Culinary Services also verified these omissions during interview. The facility census at the time was 27 residents, and the governing “Food and Nutrition” policy, approved on 09/07/21, stated that the facility must store, prepare, distribute, and serve food in accordance with professional standards for food service safety.
Plan Of Correction
F812 The facility will continue to ensure food temperatures are completed before meals are served for all residents. To ensure compliance with this standard the following measures have been taken: 1. Immediately 4/15/26 culinary supervisor #224 was re-educated by Dietary Manager to this standard and policy "Food and Nutrition" which includes documentation of food temperatures. 2. All dietary staff have been re-educated to the standard and policy "Food and Nutrition" during the month of April 2026. 3. Audits of food temperature documentation to be completed by Dietary Manager 4 x per week for 4 weeks then weekly for 4 weeks. 4. Administrator to validate audits/compliance and provide additional training as needed. Administrator will present to QAPI committee for ongoing monitoring and further direction.
Failure to Conduct and Document Required Care Conferences
Penalty
Summary
The deficiency involves the facility’s failure to complete and document comprehensive care conferences at required intervals in accordance with care plan regulations and facility policy. For one resident with Parkinson’s disease with dyskinesia, cognitive communication deficit, hemiplegia and hemiparesis following cerebral infarction, transient cerebral ischemic attack, type II diabetes mellitus, and major depressive disorder, the record showed multiple MDS assessments over a one-year period, including annual, quarterly, and significant change assessments. However, only two care conferences were documented during the last 12 months, despite the expectation that care conferences be conducted quarterly with the resident and family when possible. The Unit Care Coordinator confirmed that no additional care conference documentation existed for this resident beyond the notes dated 04/21/25 and 01/02/26. A second resident, with diagnoses including aphasia following cerebrovascular disease, cerebral infarction, type II diabetes mellitus, unsteadiness on feet, difficulty in walking, coagulation defect, depression, and muscle weakness, also had multiple MDS assessments completed over the review period, including quarterly and annual assessments. The record contained a note that a care conference was offered to the resident’s representative, who declined to attend, but there was no documentation of any care conferences for the most recent 12 months. The Unit Care Coordinator confirmed that no other care conference documentation was available for this resident. Facility policy stated that periodic care conferences involving the resident, family, and the interdisciplinary team are part of the care planning process, but the required periodic care conferences and corresponding documentation were not completed for these two residents.
Plan Of Correction
THIS PLAN OF CORRECTION SERVES AS BERKELEY SQUARE'S CREDIBLE ALLEGATION OF SUBSTANTIAL COMPLIANCE AS OF June 1, 2026. Without admitting or denying the validity or existence of the alleged deficiencies, Berkeley Square provides the following Plan of Correction: F657 The facility will continue to document completion of care conferences at the required intervals for all residents, including residents #04 & #15. To ensure compliance with this standard the following measures have be taken: 1. The social service designee and the inter- disciplinary team were re-educated by the administrator to the facility policy "Care Conference" on 4/29/26 and verbalized understanding. 2. Care conferences for resident #04 and resident #15 were conducted on or before 4/29/2026 by the interdisciplinary team. 3. Review of all other residents was conducted by the social service designee to validate and ensure that care conference schedule is up to date with timely care conferences scheduled for them on 4/15/2026. Audits of care conferences to be completed weekly for four weeks and then monthly after that by the social service designee. Documentation of the care conference including any identified concerns in the medical record. Administrator to validate audits/compliance and provide additional training as needed. Administrator will present results of these audits to QAPI committee for ongoing monitoring and further direction.
Failure to Reevaluate Blood Glucose After Treatment for Hyperglycemia
Penalty
Summary
The facility failed to ensure that a resident with diabetes received treatment in accordance with professional standards of practice when nursing staff did not reevaluate the resident's blood glucose after treatment for severe hyperglycemia. The resident, admitted with diagnoses including Alzheimer's disease, type II diabetes mellitus, and depression, had physician orders for Humalog insulin on a sliding scale before meals, Lantus insulin 25 units daily, and lisinopril 5 mg daily. The resident required extensive assistance with activities of daily living, including transfers, toileting hygiene, eating, and bathing. On the evening in question, the resident's blood glucose was documented as 532 mg/dL, and the on-call provider was notified. The provider gave a new order to administer an additional 8 units of lispro (Humalog) and to recheck the blood glucose in 30 minutes. The electronic medication administration record showed that the blood glucose of 532 mg/dL was obtained at 9:00 p.m. and that the additional 8 units of lispro were administered at 9:21 p.m. However, there was no documentation in the resident's chart that the blood glucose was rechecked after the additional insulin was given. In an interview, the DON confirmed there was no evidence of reevaluation and verified that, according to the facility's "Abnormal Blood Glucose Procedure" policy, the resident should have been reevaluated and that the evaluation step should have been included in the progress note documentation.
Plan Of Correction
F684 The facility will continue to ensure all residents, including #03, receive treatment in accordance with professional standards of practice and reevaluated for hyperglycemia. To ensure compliance with this standard the following measures have been taken: 1. The director of nursing assessed resident #03, reviewed documentation and orders and found no ill effects immediately 4/16/26. 2. All licensed nurses were re-educated to facility policy "Blood Glucose Monitoring" by the Director of Nursing/designee in April 2026. 3. Audits of like-residents that require blood sugar checks to be completed by the director of nursing/designee two times a week for 4 weeks and then monthly after that to validate correct follow through when there is abnormally high blood glucose result. The Administrator will bring results of these audits to the QAPI committee for ongoing monitoring and further direction.
Failure to Act on Pharmacist Drug Regimen Recommendation for Thyroid Medication
Penalty
Summary
The deficiency involves the facility’s failure to ensure that pharmacy recommendations from the monthly drug regimen review were acted upon and documented for a resident. The resident was admitted with diagnoses including Parkinson’s disease, dementia, and hypothyroidism, and had current physician orders for levothyroxine 150 mcg once daily, buspirone 50 mg twice daily, and losartan 100 mg once daily. A medication regimen review dated 11/25/2025 included a consultant pharmacist recommendation that levothyroxine be administered consistently in the morning on an empty stomach, at least 30–60 minutes before food, per manufacturer instructions. There was no specific physician response in the medical record to this recommendation, and the facility’s policy stated that consulting pharmacist reviews are sent to nursing and addressed with the primary care provider or consulting specialist for review and follow-up. Review of the resident’s medication administration record for April 2026 showed levothyroxine scheduled for 9:00 a.m. On observation, the resident was seen eating breakfast in the dining area at 8:03 a.m., and an LPN reported administering the levothyroxine 150 mcg to the resident while the resident was in the dining area eating breakfast. The DON confirmed there was no evidence in the resident’s medical record explaining why the consultant pharmacist’s recommendation from 11/25/2025 was or was not acted upon. This lack of documented physician review and action on the pharmacist’s identified irregularity constituted noncompliance with the drug regimen review requirements.
Plan Of Correction
F756 The facility will continue to ensure the pharmacy recommendations from the monthly drug regimen review by a licensed pharmacist are acted upon for all residents, including #08. To ensure compliance with this standard the following measures have been taken: 1. Resident #08 was assessed by the registered nurse and med review completed by 4/28/26. After review of resident's drug regime's, it was discovered that resident #8 had 2 separate medication recommendations on the same form, to be reviewed by two separate practitioners, pharmacy has been instructed and agreed to separate meds on individual forms. 2. Licensed nurses re-educated to facility policy "Drug Regimen Review" by Director of nursing/designee in April 2026 and no later than 5/8/26. Licensed nurses are responsible for ensuring the reviews and recommendations are given to the physician for timely review. 3. Review of all other current residents Drug Regimen orders completed by Director of nursing/designee on 4/16/26 to ensure recommendations were followed up on/reviewed by the physician and address concerns if needed. 4. Audit of drug regime recommendations, pharmacy recommendations, and physician follow up to be completed weekly for four weeks by the Director of nursing/designee. Administrator will present results of these audits to the QAPI committee for ongoing monitoring and further direction.
Failure to Use Required Gait Belt During Ambulation Resulting in Resident Fall
Penalty
Summary
The deficiency involves the facility’s failure to ensure that a required gait belt was used while assisting a high fall‑risk resident with ambulation, resulting in a fall with head injury. The resident had multiple diagnoses including metabolic encephalopathy, hypertension, osteoarthritis, muscle weakness, gait and mobility abnormalities, major depressive disorder, anxiety, and visual hallucinations. Admission and subsequent MDS and fall risk assessments documented that the resident was severely cognitively impaired, required moderate to maximal assistance with transfers and ambulation, could not independently come to a standing position, exhibited loss of balance while standing, used an assistive device, and had decreased muscle coordination. The resident had a history of falls prior to admission and was assessed as being at high, later moderate, risk for falls. The resident’s fall care plan identified her as at risk for falls and included interventions such as providing maximum to moderate assistance with transfers and walking short distances, use of a walker and wheelchair, and following the facility’s fall protocol. Therapy notes and care conference documentation indicated that the resident leaned backwards when standing, required contact guard to minimal assistance for bed mobility and transfers, and needed constant verbal cueing for safe sequencing during toilet transfers. The physical therapist confirmed that the resident was to use a gait belt with staff when ambulating, and the DON verified that therapy had assessed the resident as requiring contact guard assistance and a gait belt for ambulation and transfers. On the day of the incident, a CNA was assisting the resident from her recliner to the bathroom using a walker. The CNA walked beside the resident, providing guidance and support, and reported having a hand on the resident while assisting her. As they approached the bathroom door, the CNA reached for the doorknob to open it, and at that moment the resident began to lose her balance and fell backwards to the floor, striking the back of her head. The nurse who responded found the resident on her back at the foot of the bed with her feet near the bathroom, noted a red raised area on the back of the head, and documented that the resident was not wearing a gait belt and that the gait belt was on the dresser. In the facility’s investigative summary and in interviews, the CNA acknowledged that she did not have a gait belt on the resident while ambulating her, despite the resident’s assessed need for hands‑on assistance and gait belt use per facility policy and the resident’s care and therapy plans.
Failure to Implement PD Orders and Monitor Resident Receiving Peritoneal Dialysis
Penalty
Summary
The deficiency involves the facility’s failure to implement pre-admission physician orders for peritoneal dialysis (PD) and to provide ongoing monitoring for a resident with chronic kidney disease (CKD) stage five who required PD. Pre-admission orders dated 11/14/25 specified three daily PD exchanges at 6:00 A.M., 2:00 P.M., and 10:00 P.M., and directed staff to monitor for signs and symptoms of peritonitis, including fever, abdominal pain, and cloudy effluent. These monitoring orders were not entered into the facility’s physician orders. The resident’s care plan noted the need for PD and included general monitoring interventions (labs, signs of bleeding, bacteremia, septic shock, and significant vital sign changes), but did not specifically address the ordered monitoring for peritonitis. Review of PD documentation showed incomplete and inconsistent charting of treatments and resident condition. The paper peritoneal flowsheet had columns for time of PD and condition/comments, including instructions to call the nurse immediately for cloudy fluid, abdominal pain, or fever. However, the first entry on 11/15/26 at 2:00 P.M. only noted that the PD nurse completed the exchange, and the 10:00 P.M. entry that day had no condition/comment documentation. Subsequent days (11/16/25, 11/17/25, and 11/18/25) contained only one condition/comment entry per day rather than for each exchange, and there was no documentation that the 6:00 A.M. PD on 11/18/25 was completed. The PD cycler flowsheet starting 11/19/25 lacked any description of the effluent on multiple days. The PD nurse from the dialysis company stated facility staff were expected to monitor effluent for cloudiness and assess for abdominal pain and fever, and the DON confirmed there was no electronic physician order for peritonitis monitoring or for use of the PD cycler, that the paper charting did not allow for effluent description or symptom documentation for each treatment, and that PD was not documented at one ordered time. The facility’s dialysis policy required ongoing assessment and monitoring for complications before, during, and after treatments, which was not reflected in the documentation for this resident.
Improper Infection Control During Medication Administration
Penalty
Summary
Surveyors identified a deficiency in infection prevention and control related to medication administration for Resident #29. The resident was admitted on 02/28/14 with diagnoses including depression, traumatic brain injury, and anxiety, and had impaired cognition per a quarterly MDS assessment. During an observation on 03/25/26 at 6:58 A.M., RN #281 prepared the resident’s medications by removing an Amoxicillin-Pot Clavulanate tablet from the medication card and pushing it directly into her ungloved hand, then using her fingers to place the pill into a medication cup. The same process was observed for multiple other medications, including Escitalopram Oxalate, Furosemide, Sennosides, Lyrica, and Vitamin D, each being pushed from the card into the RN’s ungloved hand and then transferred by her fingers into the medication cup before administration to Resident #29. In a subsequent interview at 7:27 A.M. the same day, RN #281 confirmed she had placed each medication into her ungloved hands prior to administration and acknowledged that the proper procedure was to push the pills directly from the card into the medication cup. Review of the facility’s “Medication Administration – General guidelines” policy, revised 10/08/25, stated that medications are to be administered in accordance with good nursing principles and practices. This practice failure was cited as a deficiency under Complaint Number 2681777.
Improper Use of Wheelchair as a Physical Restraint
Penalty
Summary
Surveyors identified a deficiency related to the facility’s failure to ensure a resident was free from physical restraints. Resident #7, admitted with diagnoses including Alzheimer’s disease, diabetes mellitus, and anxiety disorder, was documented on a recent MDS as rarely understood and dependent for ADLs except eating. The resident ambulated independently on the unit without an assistive device and had documented verbal and other behaviors occurring one to three days during the look-back period. The care plan noted the resident had potential to be physically aggressive, chase staff, throw objects, and be combative with care, with interventions such as offering choices, administering medications as ordered, and intervening early when agitation occurred. During an observation and interview, Resident #7 was found sitting in a chair with the right arm of the chair positioned against the nursing station and a wheelchair placed directly in front of him. The left arm of the wheelchair was also against the nursing station, and both wheelchair wheels were locked, creating a barrier that appeared to restrain the resident, who was sleeping with his knees touching the locked wheelchair. An LPN confirmed both wheelchair wheels were locked and that the wheelchair should not have been placed in front of the resident. A CNA reported she had placed the wheelchair there in preparation to get the resident up for lunch, was unable to transfer him, and left the wheelchair in that position, acknowledging it was wrong to keep it there. The facility’s physical restraint policy stated that physical restraints are not used except when alternatives are not appropriate or effective for treating a medical symptom and defined physical restraints as any device attached or adjacent to the body that the individual cannot easily remove and that restricts freedom of movement or access to the body.
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