Medina Center For Rehabilitation And Nursing
Inspection history, citations, penalties and survey trends for this long-term care facility in Medina, Ohio.
- Location
- 555 Springbrook Dr, Medina, Ohio 44256
- CMS Provider Number
- 365667
- Inspections on file
- 30
- Latest survey
- August 14, 2025
- Citations (last 12 mo.)
- 1
Citation history
Health deficiencies cited at Medina Center For Rehabilitation And Nursing during CMS and state inspections, most recent first.
Two residents on the secured dementia unit were not provided with activities to meet their interests and psychosocial needs, with no organized or individual activities observed on the unit. Staff and family interviews confirmed that activity staff rarely visited the memory care unit, and only a few residents occasionally attended activities outside the unit. The activity assistant did not conduct activities in memory care, and the dedicated staff member for the unit was only present every other weekend.
Two residents experienced significant medication errors when anti-convulsant and pain medications were not administered as ordered due to failures in the medication reordering process, lack of follow-up, and poor communication among nursing staff. One resident suffered severe seizures and required intensive hospital care, while another experienced unmanaged pain after not receiving a Fentanyl patch. Staff interviews revealed confusion and inconsistent practices regarding medication reordering, especially during technical issues with fax machines.
The facility did not provide meals that were palatable or served at safe, appetizing temperatures. Multiple residents reported that the food was bland, dry, and not hot enough, and observations confirmed that food items were served below required temperatures and were unappealing in appearance and taste. The Dietary Manager acknowledged ongoing complaints and cited limited seasoning options and poor quality of delivered ingredients as contributing factors.
Two residents experienced deficiencies in their living environment, including cold water during bathing, heavily soiled carpeting, dust buildup, and unsanitary bathroom conditions. Staff interviews confirmed that cleaning equipment was lacking, water temperatures were below recommended levels, and maintenance issues such as non-functioning lights were not promptly addressed. These failures resulted in a living environment that did not meet facility policies for cleanliness, comfort, and safety.
Staff did not provide caffeinated coffee or tea to residents, offering only decaffeinated options based on a previous DON's directive, despite residents' stated preferences and no medical reason for restriction. The Medical Director was unaware of any prohibition, and several residents, including the Resident Council President, expressed dissatisfaction with the lack of caffeinated beverages, which was not in line with facility policy to honor resident preferences.
A broken water mixing valve in the west shower room was not promptly repaired, resulting in a resident dependent on staff for bathing receiving cold showers and reporting discomfort. Maintenance logs and staff interviews confirmed the water temperature was below recommended levels, and residents were not promptly provided with an alternative bathing option, affecting multiple individuals.
A resident with diabetes and mental health diagnoses, who was cognitively intact, was not treated with respect and dignity when an LPN failed to follow physician orders for medication administration after meals and responded dismissively to the resident's request. The resident was told to find the nurse later if he did not take his medications immediately, and another LPN stated she did not have time to check every chart, then left abruptly and slammed the door. The resident reported feeling disrespected, and the facility's policy requiring respect and dignity for all residents was not followed.
A resident with significant care needs was left unattended despite repeated calls for help, found lying on a deflated mattress in soiled linens, without required heel protectors, and with unaddressed wounds. Staff did not respond to the resident's needs or follow care plans and physician orders, resulting in neglect.
Multiple residents with cognitive and physical impairments did not receive timely or adequate staff assistance with personal hygiene and grooming, including shaving and oral care. Observations revealed unaddressed facial hair, dry skin, and significant oral debris, with staff confirming that care was not consistently provided due to time limitations, contrary to facility policy.
A resident with bilateral hand contractures and multiple comorbidities did not receive individualized care planning or consistent wound treatment as ordered by the physician. Staff failed to apply and document required dressings to the resident's hands, and no interventions were in place to prevent skin impairment, despite the resident's dependence on staff for all ADLs.
Staff failed to follow infection control protocols, including hand hygiene and PPE use, during medication administration and wound care for three residents. The DON did not wash hands or use sanitizer before or after preparing and administering oral and topical medications to two residents. An RN provided wound care to a resident on transmission-based precautions without wearing an isolation gown and did not perform hand hygiene after handling soiled dressings. These actions were not in accordance with facility policy or CDC guidance.
A resident was injured during transport due to improper wheelchair securement by an inadequately trained bus driver, resulting in a fracture. Another resident was at risk of harm from cigarette ashes due to the lack of non-flammable protective covers and inadequate smoking safety policies. These incidents highlight deficiencies in training and safety protocols at the facility.
The facility did not address resident concerns about staffing and food quality, as documented in resident council and food committee meetings. Residents reported issues with night shift staff being unkind, slow call light responses, and inconsistent care, including missed medications. Food was often cold and unappetizing. Interviews with residents and staff confirmed these issues, and a test tray verified inadequate food temperatures. The facility provided no evidence of follow-up on these concerns.
The facility's kitchen was found to be unsanitary, with issues such as expired food, rust, and debris. The walk-in freezer had ice buildup, and the dementia unit kitchen had food splatter and debris. These deficiencies were confirmed by staff, indicating a failure to maintain cleanliness and adhere to professional standards.
The facility failed to maintain a clean and sanitary garbage disposal area, affecting all 73 residents. One dumpster lacked a lid, and trash, including latex gloves and a cardboard box, was scattered around and behind the dumpster. The Dietary Manager confirmed these observations.
The facility failed to designate a certified infection preventionist responsible for the infection control and prevention program, affecting a resident and potentially all 73 residents. Despite the ADON completing the necessary training, a part-time qualified infection control preventionist was not present as required, and the infection preventionist was absent from several QAPI meetings. The facility's policy requires adaptable infection prevention programs, but these guidelines were not followed.
The facility was found to have inadequate staffing levels, particularly during weekends and night shifts, leading to missed medications and delayed call light responses. Residents, family members, and staff reported concerns about insufficient staffing, with documentation in resident council meeting minutes and grievance logs. The facility's quality assurance reports indicated ongoing staffing challenges.
The facility did not ensure the presence of an RN for at least eight hours a day, seven days a week, as required. On a specific day, only four hours of RN coverage were documented, confirmed by a scheduler interview. This deficiency had the potential to affect all 73 residents.
The facility failed to provide palatable and properly tempered food, as evidenced by resident complaints and test tray evaluations. Residents reported cold, bland, and unappetizing meals, with specific grievances about the lack of hot plates and poor food quality. Observations confirmed meals were served at inadequate temperatures, verified by the Dietary Manager.
The facility failed to maintain an effective infection prevention and control program, as evidenced by the handling of a scabies exposure incident involving two residents. A resident exposed to scabies was not treated, and skin checks were incomplete. Another resident's wound and catheter care lacked proper aseptic technique. The facility's policies on infection control were not followed, leading to deficiencies in care.
A resident with dementia and diabetes was found to have two large holes in the wall of their room, along with debris such as dust and food wrappers. The resident reported the holes had been present since moving in. These conditions were confirmed by a housekeeper and the President of Operations.
A facility failed to secure protected health information, leaving a laptop open with a resident's medical chart visible in a public hallway. The Regional Administrator confirmed the breach, and an LPN admitted to mistakenly leaving the laptop on. Facility policy requires compliance with HIPAA Privacy Standards.
A facility failed to update a care plan for a resident who experienced a significant change in condition due to a fracture of the right humerus. Despite the resident's return with a brace, there was no documentation in the medical record or MDS assessments indicating the change, and the care plan did not reflect the injury. The facility's policy requires care plans to include measurable objectives and timetables, which was not followed.
A resident with dementia and anxiety disorder, requiring supervision for oral hygiene, did not receive routine oral care as per their care plan. Observations showed the resident's teeth covered with debris and sharing a toothbrush with another resident. Interviews revealed no documentation of oral care in the past 30 days, and staff were unaware of the resident's needs. The facility's policy required appropriate care for residents unable to perform ADLs independently.
A facility failed to provide a functional call light system for a resident, as confirmed by both the resident and a CNA. The resident reported long delays in response times, and the call light outside her room did not illuminate to alert staff, indicating a deficiency in the system.
A resident sustained injuries, including a fractured humerus, after falling from her wheelchair during transport in a facility bus. The bus driver, lacking proper training, had positioned the resident's wheelchair sideways, contrary to safety protocols. The facility failed to ensure that bus drivers received adequate training on securing wheelchairs and residents, contributing to the incident.
A facility failed to arrange transportation for a resident with multiple sclerosis and other conditions, resulting in a missed wound care appointment. The resident was cognitively intact and dependent on staff for daily activities. Interviews confirmed the facility's responsibility for transportation, and the resident had not refused to attend appointments.
The facility failed to secure medications properly, affecting two residents. One resident with multiple diagnoses had medications left unattended on their bedside table, which they confirmed they had not taken. The responsible LPN admitted to the oversight. Another resident with Wernicke's encephalopathy was found with morning medications left on their bedside, which they had not taken. The LPN confirmed leaving the medications and recording them as administered without witnessing ingestion. The facility's policy on medication storage was not followed.
The facility's assessment was incomplete, lacking input from direct care staff such as RNs, LPNs, and CNAs, and did not include a plan for staff recruitment and retention. This deficiency was confirmed by a Regional Administrator, affecting all 73 residents.
The facility failed to change oxygen tubing as ordered for two residents with respiratory conditions. One resident with COPD had tubing dated nearly two months old, while another with COPD and heart failure had tubing dated several weeks old. Observations confirmed the tubing was not changed weekly as required by physician orders and facility policy.
The facility failed to provide therapeutic diets as ordered for two residents with cognitive deficits. One resident, with a mechanical soft diet order, was served inappropriate foods like whole bacon strips. Another resident, with dysphasia, received a meal including whole cherries and an uncut grilled cheese, contrary to their dietary needs. Both residents were unable to be interviewed due to impaired cognition.
The facility failed to ensure crash carts contained the appropriate supplies, affecting all residents. An LPN revealed the memory care unit lacked a crash cart, and another LPN observed missing essential items like an oxygen tank and checklist. A Regional Risk RN confirmed the need for full oxygen tanks and checklists on crash carts.
A resident with a suprapubic catheter experienced decreased urinary output and increased pain due to a malfunctioning catheter. Despite documentation of these issues, the facility failed to provide adequate follow-up or interventions. The resident's appointments with a urologist were repeatedly canceled due to transportation issues, and there was a lack of communication and documentation regarding the resident's condition. The facility's failure to address the malfunctioning catheter placed the resident at increased risk of complications.
The facility failed to implement its abuse prevention policy by hiring an MDSC with a felony conviction and restrictions on her LPN license, and by not completing a BCI background check for an SSD. Additionally, a reference check for the HR Director was delayed by five months. These actions violated the facility's policy against employing individuals with criminal histories.
The facility failed to provide sufficient dietary staff, resulting in a 54-minute delay in lunch service for all 60 residents. The Dietary Manager, acting as the cook, confirmed the delay was due to staffing issues, as dietary staff who worked weekends had Mondays off. The scheduled dietary aide did not arrive, and the Activities Director had to assist in the kitchen.
The facility failed to serve food in a palatable and attractive manner, affecting all residents. Chili con carne was served on a plate, causing it to mix with other food items, due to inadequate bowls for maintaining temperature. The Dietary Manager acknowledged the issue, and a Registered Dietitian confirmed the chili should have been served in an insulated bowl.
The facility failed to maintain dishwasher water temperatures at the manufacturer's minimum during the wash cycle, potentially affecting all 60 residents. Observations and logs revealed the dishwasher did not reach the required 155 degrees Fahrenheit due to plumbing issues, with multiple days showing temperatures below the minimum. The issue was identified during a complaint investigation.
The facility failed to secure smoking devices for a resident requiring supervision, as multiple vaporizing nicotine pens were found in his room, contrary to policy. Additionally, the facility did not conduct thorough fall investigations for several residents, lacking details such as witness statements and timely assessments. The VPO confirmed significant issues with the investigations, indicating noncompliance with safety protocols.
The facility failed to provide complete pureed diets to residents requiring such dietary modifications. Six residents with specific orders for pureed food texture did not receive all menu items, as observed during a lunch service. The Dietary Manager admitted to forgetting to prepare a required component, and the Registered Dietitian confirmed the deficiency.
The facility failed to provide necessary adaptive eating equipment to nine residents, despite their care plans indicating the need for such aids due to conditions like dementia and muscle weakness. Observations showed residents without required items like sippy cups and nosey cups during meals. Staff interviews revealed a lack of awareness and insufficient equipment supply, leading to a rotation system where residents received the necessary aids only at certain meals.
The facility failed to maintain accurate medical records for five residents, including incorrect allergy documentation, missing records of abuse allegations, and lack of evidence for required checks. Interviews confirmed these documentation deficiencies.
The facility failed to provide annual behavioral health and dementia education to its staff, affecting 32 residents with dementia. Personnel records and staff interviews revealed no evidence of training since 2021, despite the facility having a dementia unit. This deficiency was discovered during a complaint survey.
A facility failed to notify a physician of sexual abuse allegations involving a resident with Wernicke's Encephalopathy and PTSD. The resident was involved in two separate incidents as the alleged perpetrator, but there was no evidence of physician notification in the medical records. The facility's policy requires such notifications, but this was not followed, as confirmed by the President of Operations during a complaint investigation.
A facility failed to maintain a homelike environment by placing a loud alarm on a resident's door, disturbing three residents. A resident with anxiety had an alarm to alert staff when he left his room, but its volume caused significant disturbance. Two other residents, located across the hall, reported being frequently woken up by the alarm, which went off day and night.
The facility failed to protect residents from abuse, involving a resident who was found inappropriately touching two other residents. Despite allegations and witness accounts, the facility's investigations were inadequate, lacking proper documentation and follow-up. The facility did not implement necessary interventions or perform required checks, contributing to repeated incidents of inappropriate behavior.
A resident's hospice-provided incontinence briefs were misappropriated by staff due to a shortage of supplies in the facility. Staff interviews confirmed that the briefs were taken to use for other residents because the facility's supply closets were often empty, and overstocked supplies were locked away. The facility's policy on preventing misappropriation was not followed, affecting the resident and potentially others receiving hospice services.
A facility failed to ensure residents were free from physical restraints, as seen in the case of a resident with cognitive intactness and mobility issues. After an unsubstantiated allegation of sexual abuse, one-on-one supervision was replaced with a door alarm to alert staff when the resident left the room. The alarm caused distress and embarrassment to the resident, and there was no consistent supervision provided. The facility's policy defines such alarms as inappropriate restraints, leading to a deficiency finding.
The facility failed to document and investigate abuse allegations involving three residents. In one case, a cognitively intact resident was involved in an alleged sexual abuse incident, but the investigation lacked proper documentation and review. In another case, a resident reported non-consensual touching, corroborated by a staff witness, yet the facility deemed the allegation unsubstantiated. The third case involved a resident with a hip fracture, where the investigation was delayed and incomplete, lacking proper documentation.
The facility failed to update care plans for two residents after new interventions were implemented following falls. One resident, severely cognitively impaired and at high risk for falls, had new interventions like bed bolsters not reflected in their care plan. Another resident, rarely understood and at moderate fall risk, had a new intervention for a well-lit room omitted from their care plan. This oversight highlights a lapse in maintaining current care plans.
A resident with Alzheimer's and muscle weakness, dependent on staff for all ADLs, did not receive routine showers as scheduled. Despite being scheduled for showers twice weekly, the resident only received eight showers over three months. Observations and interviews confirmed the resident's unkempt appearance and lack of documentation for the scheduled showers, indicating non-compliance with facility policy.
Failure to Provide Activities for Memory Care Residents
Penalty
Summary
The facility failed to provide activities that met the interests and psychosocial needs of residents on the secured dementia (memory care) unit, specifically affecting two residents and potentially impacting twelve additional residents. Observations during the survey revealed that no organized or individual activities were available for any residents on the memory care unit, despite the activity calendar indicating scheduled group activities for that day. Interviews with family, staff, and residents confirmed that activity staff rarely visited the memory care unit, and only a few residents occasionally attended activities outside the unit. The activity assistant reported that she did not conduct activities in memory care and that there was no separate activity calendar for the unit. Residents and staff expressed concerns about the lack of stimulation and engagement for those residing in memory care. One resident reported that while his care needs were met, there was nothing to do on the unit. Staff interviews corroborated that activities had not been held in the memory care unit for a significant period, and only a small number of residents were taken off the unit to participate in activities elsewhere. The dedicated activity staff member for memory care was only present every other weekend, further limiting opportunities for engagement.
Significant Medication Errors Due to Reordering Failures and Communication Breakdowns
Penalty
Summary
The facility failed to ensure that residents were free from significant medication errors, resulting in actual harm to one resident and potential harm to another. One resident with a history of traumatic brain injury and epilepsy did not receive the physician-ordered anti-convulsant medication Vimpat for three consecutive doses due to a breakdown in the medication reordering process. The medication was not available because the required prescription was not received by the pharmacy, as the facility's fax machines were not functioning and staff did not follow up to confirm receipt or notify the physician of the missed doses. This resident subsequently experienced severe clonic tonic seizures, required emergency medical intervention, intubation, and transfer to a neuro ICU for ongoing care. Another resident with a diagnosis of stable burst fracture and paraplegia did not receive a scheduled Fentanyl transdermal patch for pain management. The medication was not administered because the facility failed to send the required prescription to the pharmacy, despite the pharmacy indicating that prior authorization was not the cause of the delay. The resident reported significant pain as a result of not receiving the medication. Staff interviews confirmed a lack of understanding and inconsistent practices regarding the reordering of narcotic medications, contributing to the missed doses. Documentation revealed that staff did not consistently document or communicate missed medication doses to physicians, and there was confusion among both facility and agency nurses about the correct procedures for reordering medications, especially when technical issues such as fax machine failures occurred. The facility's policies required medications to be administered safely and as prescribed, but these were not followed, leading to significant medication errors affecting at least two residents.
Removal Plan
- The facility pharmacy was contacted and delivered Resident #63's Vimpat to the facility.
- An Ad Hoc Quality Assurance Performance Improvement (QAPI) meeting was held to discuss the root cause analysis of Resident #63 not receiving Vimpat, staff education, and ongoing medication audits. The Administrator, DON, ADON, Social Services, Minimum Data Set Nurse, and Medical Director were in attendance.
- Regional Director of Clinical Services educated the DON, ADON, and Unit Manager on re-ordering resident medications.
- The DON and ADON completed a whole house audit to ensure all in-house residents had all ordered medications available.
- The Administrator/designee educated the nurses who were currently working on re-ordering of medications and the procedure if the fax machine was not functioning properly. All remaining nurses would be educated prior to the beginning of their next shift. Nursing leadership would add education to the nursing agencies the facility utilized to educate their staff on the facility's procedure of re-ordering medications and what to do if the fax machine was not working. Education would also be added to orientation for all new hire nurses. The facility also had a plan in place to hire a unit manager for night shift supervision.
- The Administrator checked the facility fax machines and all three were in working order.
- The DON/designee would audit all resident medications three times weekly for four weeks then two times weekly for two weeks, then one time for two weeks to ensure all in-house residents have all ordered medications available. Any concerns identified would be reviewed in Ad Hoc QAPI by the interdisciplinary team.
- Nursing leadership would ensure all resident medications would be re-ordered when no less than five days remaining of the medication. Nursing leadership would be responsible for providing any prior authorization requests to the physician and/or nurse practitioner and following up to ensure the prior authorization request was returned to pharmacy timely.
- Staff would contact the Administrator or nursing leadership to inform them if the fax machine is not working. If a prescription was needed, the physician and/or nurse practitioner would be contacted by staff or nursing leadership to request the prescription. Staff/nursing leadership would follow up with pharmacy to ensure the physician order was received.
Failure to Provide Palatable and Properly Tempered Meals
Penalty
Summary
The facility failed to ensure that meals provided to residents were palatable, attractive, and served at safe and appetizing temperatures. Observations during meal service revealed that food items, including chicken, mashed potatoes, and baked beans, were served at temperatures below the facility's required standard of 135 degrees Fahrenheit for hot foods. The chicken was noted to be dry, small in portion size, and unappetizing, while the mashed potatoes had a strong garlic flavor and the baked beans were watery and lacked flavor. Milk was also served at an inappropriate temperature. Multiple residents reported that the food was bland, dry, and not hot enough, and the Dietary Manager confirmed receiving several complaints about the quality and temperature of the food. Further review of resident council minutes indicated ongoing concerns about the quality of meals, specifically mentioning watery mixed vegetables. The Dietary Manager stated that limited seasoning options and reliance on frozen food items contributed to the poor quality and lack of variety in meals. Additionally, some fresh vegetables delivered to the facility were often spoiled and had to be discarded. The facility's own policies require that residents receive nourishing, palatable, well-balanced meals prepared and served at appropriate temperatures, but these standards were not met, as evidenced by direct observation, resident feedback, and staff interviews.
Failure to Maintain Cleanliness, Adequate Lighting, and Safe Water Temperatures
Penalty
Summary
Surveyors identified deficiencies related to the facility's failure to provide a safe, clean, and comfortable environment for residents, specifically regarding water temperature for bathing and the cleanliness and maintenance of resident rooms. One resident, who was cognitively intact and dependent on staff for bathing, reported that the water in the west shower room was cold and described her bathing experience as miserable. Observations confirmed that the carpeting in her room was heavily soiled with embedded dirt and stains, and there was visible dust and missing floor molding. Housekeeping staff stated that the facility did not provide a carpet scrubber and that requests for deep cleaning equipment were not addressed by management. Maintenance records showed that water temperatures in the west shower room were below recommended levels, and staff confirmed that residents had complained about cold showers. Another resident, also cognitively intact, was observed in a room with carpeting embedded with black dirt and grime, multiple large spills, and a bathroom in unsanitary condition, including a non-functioning light, dirty sink and faucets, and a toilet and bathtub with visible grime and waste. The resident stated that staff did not offer to clean his room, and interviews with housekeeping and administrative staff revealed that while the resident sometimes refused housekeeping, he would often allow cleaning if approached by an administrator. The maintenance supervisor was unaware of the bathroom light issue, and the new administrator had not previously entered the resident's room. Facility policy reviews indicated requirements for routine cleaning, adequate lighting, and maintaining a homelike environment, but these standards were not met in the cases observed. The deficiencies affected two residents directly and had the potential to impact additional residents who used the same shower facilities. The findings were substantiated through observations, interviews, and record reviews, confirming non-compliance with resident rights to a safe, clean, and comfortable environment.
Failure to Provide Drinks Consistent with Resident Preferences
Penalty
Summary
The facility failed to honor residents' drink preferences by not providing caffeinated coffee or tea, despite residents' requests and the absence of medical contraindications. Interviews with dietary staff revealed that residents were only offered decaffeinated beverages, based on a previous directive from the former DON, and staff believed caffeinated drinks were not allowed due to their stimulant properties. The Medical Director was unaware of any restriction on caffeinated coffee and confirmed there was no known medical reason to prohibit it. Residents expressed dissatisfaction, stating they preferred regular coffee and were told it was not available due to budget constraints or concerns about medication interactions. The facility's policy requires that residents be provided with drinks consistent with their needs and preferences, but this was not followed. The deficiency had the potential to affect all residents except for two who were NPO. The Resident Council President and other residents confirmed that they were recently informed of the restriction on caffeinated beverages, and many disliked the decaffeinated alternatives. The facility census at the time was 70.
Failure to Timely Repair Shower Room Water Temperature
Penalty
Summary
The facility failed to promptly repair a broken water mixing valve in the west shower room, resulting in residents being provided with water at an uncomfortably low temperature during showers and baths. Record review showed that one resident, who was cognitively intact but dependent on staff for bathing due to a history of CVA with hemiparesis, reported that the water felt cold and described the experience as miserable. Maintenance logs indicated that the water temperature in the west shower room was recorded at 87.6°F, which is below the recommended range, and staff interviews confirmed that residents had complained about cold showers. The issue was identified during routine water temperature checks, but there was a delay in providing an alternative showering location for affected residents. Further interviews with staff revealed that the water temperature issue persisted, with CNAs noting that the water remained cool even after attempts to let it run. The facility's policy requires a safe, clean, and comfortable environment for residents, but there was no evidence that residents were promptly offered another option for bathing once the problem was identified. This deficiency affected one resident directly and had the potential to impact 19 additional residents who used the west shower room, as documented in the facility census and care records.
Failure to Honor Resident's Right to Dignity and Respect During Medication Administration
Penalty
Summary
A resident with diagnoses including type 2 diabetes mellitus with diabetic neuropathy, major depressive disorder, and generalized anxiety disorder, who was cognitively intact, experienced a lack of respect and dignity from nursing staff. Physician orders specified that several morning medications were to be administered after breakfast, but the Medication Administration Record showed these medications were scheduled and offered at 7:00 A.M. On one occasion, the resident refused the medications at that time, stating he takes them after eating, as per his orders. The LPN responded that if the resident did not take the medications then, he would have to find the nurse later, and did not accommodate the resident’s preference or physician’s order. When the resident pointed out his medication schedule, another LPN responded dismissively, stating she did not have time to check every chart, and then left the room abruptly, slamming the door. The resident reported these interactions to the Administrator and the Assistant Director of Nursing (ADON), expressing that he felt disrespected. The ADON confirmed the resident’s account, noting that the LPN involved was an agency nurse who had previously been placed on a do-not-return list due to attitude concerns, but was brought back by the new Director of Nursing (DON). The Regional Director of Operations also spoke with the resident, who stated he did not feel abused but did not feel respected. The facility’s policy affirms every resident’s right to be treated with respect and dignity, which was not upheld in this instance.
Failure to Prevent Neglect and Provide Basic Care
Penalty
Summary
A deficiency occurred when staff failed to ensure a resident was free from neglect, as evidenced by multiple observations and record reviews. The resident, who had diagnoses including cerebral infarction, COPD, and GERD, was care planned for interventions such as keeping the head of the bed elevated, use of a low air loss mattress, peri care after incontinence, and heel protectors. The resident was dependent on staff for most activities of daily living, including bed mobility, hygiene, and toileting, and was always incontinent of bowel and bladder. On the day of the incident, the resident was observed repeatedly calling for help, with the call light activated but not making a sound. Staff were present in the hallway but did not respond to the resident's calls. Upon entering the room, the resident was found lying on a mostly deflated mattress with his head and shoulders lower than his body, wearing only a t-shirt and brief, with no pants, blanket, or sheet. The bed linens, bed pad, and dressing on the resident's contracted foot were saturated with urine, and a strong odor was present. The resident's hair was unkempt, facial hair untrimmed, skin dry and flaky, and fingernails long and dirty. Heel protectors were not in place as ordered. Staff confirmed the resident had been in this condition since the start of the shift, and that wounds on the sacral area and gluteal fold were present and had not been treated or assessed by a nurse, despite being reported. Further review revealed that the resident developed new, non-blanchable wounds on the sacrum and left gluteal fold, which were not covered by any current treatment orders. Facility policies required staff to provide necessary services for hygiene and to prevent neglect, defined as failure to provide goods and services necessary to avoid physical harm or emotional distress. The observed inaction and lack of response to the resident's needs, as well as failure to follow care plans and physician orders, led to the finding of neglect.
Failure to Provide Timely and Adequate ADL Assistance for Hygiene and Grooming
Penalty
Summary
The facility failed to provide timely, adequate, and necessary staff assistance with activities of daily living (ADLs), specifically in the areas of personal hygiene and grooming, for multiple residents. One resident with Parkinson's disease, who was cognitively intact but required substantial staff assistance, was observed on two occasions with dry, flaky skin and long, unkempt facial hair. The resident reported that staff only shaved him once every week to two weeks, despite his preference to be clean-shaven, and staff confirmed they had not provided facial care or shaving as part of morning care. Facility policy required that residents unable to perform ADLs independently receive necessary services to maintain grooming and hygiene. Another resident with dementia and muscle weakness, who was severely cognitively impaired and required staff assistance for oral hygiene, was observed with a thick yellow build-up and food between her teeth. Staff confirmed that oral care had not been provided before or after breakfast. A third resident, dependent on staff for all ADL care due to Alzheimer's disease and muscle weakness, was also observed with significant yellow build-up between the teeth, and the assigned CNA admitted that oral care was not always provided due to time constraints. These findings were consistent with the facility's policy, which mandates support for residents' ADLs, including personal and oral hygiene.
Failure to Implement Care Plan and Wound Treatment for Resident with Hand Contractures
Penalty
Summary
The facility failed to develop and implement a comprehensive and individualized plan of care for a resident with bilateral hand contractures, resulting in a lack of interventions to prevent skin impairment. The resident, who had diagnoses including Alzheimer's disease, muscle weakness, and bone disorders, was dependent on staff for all activities of daily living and was rarely or never understood. The care plan identified a risk for infection and discomfort due to the contractures but did not include any specific interventions. Physician orders were in place for daily wound care and dressings for both palms, but the Treatment Administration Record showed that these treatments were not completed on several dates. Observations confirmed that the resident's hands were contracted, with long and uneven nails, and no dressings were present on either hand during multiple checks. Staff interviews revealed that the resident had not worn palm guards or any protective dressings for an extended period, and attempts to open the contracted fingers were unsuccessful. The Assistant Director of Nursing confirmed that the resident was supposed to have her hands wrapped to prevent the nails from causing wounds, but this had not been done for several weeks. There was no documentation indicating that dressings had been removed and re-applied as needed, contrary to physician orders and facility policy.
Failure to Follow Infection Control Practices During Medication Administration and Wound Care
Penalty
Summary
Staff failed to maintain proper infection control practices, specifically regarding hand hygiene and the use of personal protective equipment (PPE), during medication administration and wound care for three residents. The Director of Nursing (DON) was observed preparing and administering both oral and topical medications to two residents without washing hands or using hand sanitizer before or after the process, and confirmed during an interview that hand hygiene was not performed during these activities. Facility policy required hand hygiene before and after resident contact, after touching contaminated surfaces, and before moving between clean and soiled body sites, but these protocols were not followed. For one resident with multiple sclerosis, the DON prepared and administered 13 oral pills and a topical lidocaine patch without performing hand hygiene at any point before, during, or after the medication administration. The DON then proceeded to prepare medications for another resident without hand hygiene in between. Similarly, for another resident with multiple sclerosis, the DON prepared and administered oral medications without hand hygiene before or after the process, and then prepared a topical medication for the previous resident, again without hand hygiene. A third resident, who had multiple wounds and was on transmission-based precautions due to infection, received wound care from a registered nurse (RN) who did not wear an isolation gown as required and did not perform hand hygiene after removing a heavily soiled dressing and before applying a clean one. The RN confirmed the resident was on transmission-based precautions and acknowledged not using the appropriate PPE. Facility policies and CDC guidance required the use of gowns and hand hygiene in these situations, but these were not adhered to during the observed care.
Deficiencies in Resident Safety During Transport and Smoking
Penalty
Summary
The facility failed to ensure the safety of Resident #24 during transportation to an outside appointment, resulting in actual harm. Resident #24, who was dependent on staff and used an electric wheelchair, was not properly secured in the facility bus by Bus Driver #118. The resident was positioned facing sideways, which was against the training guidelines that required residents to face forward. During the transport, the bus driver had to stop abruptly, causing Resident #24 to be propelled out of her wheelchair and sustain a right humerus fracture. The facility's investigation revealed that the bus driver had not received adequate training on securing residents in wheelchairs, and there was no evidence of a thorough investigation or audit of the bus's safety equipment following the incident. Additionally, the facility failed to provide a non-flammable protective cover for Resident #30, who was known to drop cigarette ashes while smoking. This oversight placed the resident at risk for more than minimal harm. Observations revealed that Resident #30 had numerous burn holes in his blanket and clothing due to falling ashes. Despite the facility's policy requiring supervision during smoking, there was no policy addressing the use of smoking aprons or protective covers for residents who needed them. Staff supervising the smoking area were unaware of the location of smoking aprons or which residents required them, further indicating a lack of proper safety measures. The report highlights deficiencies in the facility's training and safety protocols, particularly concerning the transportation of residents and smoking safety. The lack of proper training for bus drivers and the absence of a comprehensive smoking safety policy contributed to the incidents involving Resident #24 and Resident #30. These deficiencies demonstrate a failure to provide necessary goods and services to prevent physical harm to residents, as outlined in the facility's policies on abuse and neglect.
Facility Fails to Address Resident Concerns on Staffing and Food Quality
Penalty
Summary
The facility failed to address and respond to concerns raised by residents during resident council and food committee meetings. These concerns included issues with staffing, such as night shift staff being unkind, slow response to call lights, and inconsistency in care, including missed medications and residents being dressed in soiled clothing. Additionally, residents expressed dissatisfaction with the quality and temperature of the food served, noting that meals were often cold and unappetizing. Despite these repeated concerns being documented over several months, the facility did not provide evidence of any investigation or follow-up actions taken to address these issues. Interviews with residents and staff further corroborated the concerns raised in the meetings. Residents reported long wait times for call lights to be answered, insufficient staffing levels, particularly during night shifts, and poor food quality. Staff members also acknowledged the lack of productivity and completion of duties by night shift workers. A test tray conducted during the survey confirmed the residents' complaints about the food, with the meal being served at inadequate temperatures and lacking in taste. The facility's Regional Administrator confirmed that there was no evidence of follow-up on the concerns raised by residents.
Kitchen Sanitation Deficiencies
Penalty
Summary
The facility failed to maintain the kitchen in a clean and sanitary manner, which had the potential to affect all 73 residents. During a kitchen tour, several deficiencies were observed, including an expired bottle of vanilla, rust, food debris, and crumbs on the shelf under the tray line, and rust on the ice machine door hinge. The dry storage area floor had significant crumbs and food debris, and the air vent next to the food preparation area was rusted with a thick layer of grime. Additionally, a large brown stain and crack were noted on the ceiling above the three-compartment sink, and the refrigerator door seal was falling off. The walk-in freezer had an ice cream tub wedged under a pipe, with water dripping onto it, forming a large ice chunk, and large ice chunks were observed on the floor. These findings were confirmed by a staff member who had worked at the facility for eight years and stated that the walk-in freezer had always been in that condition. Further observations in the dementia unit kitchen revealed splatter and food debris on kitchen cabinets, and the microwave was soiled with food debris. A resident's slippers were found in the kitchen next to the trash can, with a broom and dustpan placed on top of them. These findings were confirmed by the Dietary Manager and Dietician present during the observation. The report highlights the facility's failure to adhere to professional standards for food storage, preparation, and cleanliness, potentially impacting the health and safety of all residents.
Improper Garbage Disposal
Penalty
Summary
The facility failed to maintain its garbage disposal area in a clean and sanitary condition, which had the potential to affect all 73 residents. During an observation, one of the two outside dumpsters was found without a lid, and there were multiple latex gloves, a large cardboard box, and other miscellaneous trash on the ground around the dumpster. Additional trash and debris were observed to have blown into the grass and woods behind the dumpster. An interview with the Dietary Manager confirmed the observation that the dumpster did not have a cover and verified the presence of trash around the dumpster.
Failure to Designate a Certified Infection Preventionist
Penalty
Summary
The facility failed to designate a certified infection preventionist responsible for the infection control and prevention program, which affected one resident of four sampled and had the potential to affect all 73 residents in the facility. The Assistant Director of Nursing completed the Nursing Home Infection Preventionist Training Course, but the facility staffing records during the annual survey revealed that a part-time qualified infection control preventionist was not present in the building as required. This absence was confirmed by the VP of Clinical Operations, who stated that no additional documentation of a qualified infection control preventionist working part-time at the facility was available from the date of the last annual survey until the training course was completed. Additionally, the quarterly Quality Assurance and Performance Improvement (QAPI) committee meeting documentation showed that an Infection Preventionist was not in attendance at several meetings. This was confirmed by the Regional Administrator, who acknowledged that the infection preventionist was not documented at the QAPI committee meetings as required. The facility's policy on infection prevention and control, revised in December 2023, outlines the need for infection prevention and control programs to fulfill essential functions and be adaptable to the facility's specific environment and resident needs, yet the facility failed to adhere to these guidelines.
Inadequate Staffing Levels
Penalty
Summary
The facility failed to provide adequate staffing to meet the needs of its residents, as evidenced by multiple interviews and reviews of records. Residents expressed concerns about insufficient staffing, particularly during weekends and night shifts, which led to missed medications and delayed response times to call lights, sometimes up to four hours. Family members and staff also reported issues with staffing levels, noting that night shifts were particularly understaffed and less productive compared to day shifts. The resident council meeting minutes and grievance logs further documented ongoing concerns about staffing ratios and quality of care, with no noted resolutions. The facility's quality assurance performance improvement reports highlighted goals to hire more staff, reduce turnover, and improve customer service, indicating ongoing staffing challenges. Despite a policy stating that the facility provides sufficient and competent nursing staff, the evidence from interviews and documentation suggests that the facility did not adhere to its policy or state-imposed minimum staffing requirements. This deficiency was investigated under Complaint Numbers OH00161426 and OH00161390.
Failure to Maintain Required RN Coverage
Penalty
Summary
The facility failed to ensure the presence of a Registered Nurse (RN) for at least eight hours a day, seven days a week, as required by regulations. This deficiency was identified through a review of the staffing schedule and posted nursing staff information for December 21, 2024, which showed only four total hours of RN coverage on that day. An interview with the scheduler confirmed the lack of required RN hours. This deficiency had the potential to affect all 73 residents in the facility and was investigated under Complaint Numbers OH00161426 and OH00161390.
Facility Fails to Provide Palatable and Properly Tempered Food
Penalty
Summary
The facility failed to provide palatable food to its residents, as evidenced by multiple complaints and observations. Residents expressed concerns about cold food and coffee, lack of hot plates, and overall food palatability during food committee meetings from July 2024 to February 2025. Grievance logs revealed specific complaints from residents about cold meals and dissatisfaction with the quality of the food. Interviews with several residents confirmed these issues, with reports of bland, cold, and unappetizing meals. Observations during test tray evaluations further supported these complaints. On two separate occasions, meals were found to be served at inadequate temperatures, with the BBQ pork sandwich and baked beans being lukewarm and unappetizing, and the pasta and brussels sprouts also not meeting appropriate temperature standards. The Dietary Manager verified these findings during the test tray evaluations. This deficiency was investigated under Complaint Number OH00161426, indicating non-compliance with the requirement to provide palatable and appropriately tempered food to residents.
Infection Control Deficiencies in Resident Care
Penalty
Summary
The facility failed to maintain an effective infection prevention and control program, as evidenced by the handling of a scabies exposure incident involving two residents. Resident #32 was exposed to scabies at an outside adult day program, and the facility was notified by the program and the resident's guardian. Despite this, the Director of Nursing (DON) decided not to treat the resident for scabies, opting instead for skin checks twice daily, which were not fully completed. The exposure was not reported to the infection control designee, staff, or the resident's roommate, and no further investigation or infection surveillance was conducted. Resident #33's care also demonstrated lapses in infection control practices. During wound care, the Assistant Director of Nursing (ADON) placed wound supplies directly on the resident's side table without disinfecting it or creating a barrier, violating aseptic technique. Additionally, during urinary catheter care, the ADON failed to wipe the drain with an antiseptic wipe after draining the urine, as required by protocol. These actions were confirmed by the ADON following the observations. The facility's policies on scabies identification, treatment, and environmental cleaning, as well as wound care and urinary catheter care, were not adhered to, leading to deficiencies in infection prevention and control. The facility's infection prevention and control program was found lacking in coordination, oversight, and adherence to established procedures, as evidenced by the handling of these two residents' care.
Facility Fails to Maintain Safe and Sanitary Environment
Penalty
Summary
The facility failed to maintain a safe and sanitary environment for a resident, which was identified during a survey. A resident with diagnoses including unspecified dementia and type two diabetes mellitus, who had intact cognition, was found to have two large holes in the wall of their room, measuring approximately six inches in width by seven inches in length, located behind the headboard. Additionally, there was miscellaneous debris, including dust, food wrappers, and crumbs, present in the room. The resident reported that the holes had been there since moving in. These observations were verified by a housekeeper and the President of Operations, who acknowledged the condition of the room.
Failure to Secure Protected Health Information
Penalty
Summary
The facility failed to secure protected health information, compromising resident privacy. During an observation, a laptop on the west medication cart outside the nursing station was left open, displaying a resident's medical chart with private information visible to the public. This occurred in a busy hallway with visitors, residents, and staff present. The Regional Administrator confirmed the visibility of the protected health information and closed the laptop. An LPN later returned to the cart, acknowledging that she thought she had turned off the laptop before leaving. The facility's policy mandates that protected health information be used and disclosed in accordance with HIPAA Privacy Standards.
Failure to Update Care Plan for Resident's Fracture
Penalty
Summary
The facility failed to develop a comprehensive care plan for a resident who experienced a significant change in condition following an injury. The resident, who had diagnoses including chronic obstructive pulmonary disease, muscle wasting and atrophy, major depressive disorder, and lack of coordination, suffered a fracture of the right humerus. Despite the resident's return to the facility with a brace on the right arm, there was no documentation in the medical record or the Minimum Data Set (MDS) assessments indicating a significant change in condition. Additionally, the care plan did not reflect the fracture, and nurse progress notes from the period following the injury lacked documentation of this significant change. The facility's policy requires care plans to include measurable objectives and timetables to address residents' needs, which was not adhered to in this case.
Failure to Provide Routine Oral Care for Resident
Penalty
Summary
The facility failed to provide routine oral care for a resident who required assistance, affecting one resident out of five reviewed for activities of daily living. The resident, diagnosed with unspecified dementia and anxiety disorder, had impaired cognition and required supervision for oral hygiene. The plan of care did not include specific interventions for assisting the resident with oral hygiene. During an observation, the resident's bottom teeth were found covered with white food debris, and it was noted that the resident shared a toothbrush with another resident. Interviews revealed that the resident had not been seen by dental services, and there was no documentation of oral hygiene being completed in the last 30 days. A CNA was unaware of the resident's needs and typically provided oral care after breakfast. The ADON confirmed the lack of documentation and the shared toothbrush situation. The Social Services Designee mentioned the resident often refused care, but there was no documentation to support refusals of dental care in the previous year. The facility's policy stated that appropriate care and services should be provided for residents unable to perform ADLs independently, in accordance with the plan of care.
Non-Functional Call Light System
Penalty
Summary
The facility failed to ensure that a functional call light system was available for residents, specifically affecting one resident out of a sample of 25. During an observation and interview, the resident reported that it could take hours for her call light to be answered. When the resident pressed her call light, the visual indicator outside her room did not illuminate, failing to alert staff that she required assistance. A Certified Nursing Assistant confirmed that the call light outside the resident's door was not working, indicating a deficiency in the facility's call light system.
Inadequate Bus Driver Training Leads to Resident Injury
Penalty
Summary
The facility failed to ensure that staff approved to drive the facility bus were appropriately trained on safety mechanisms, which led to an incident involving a resident. Resident #24, who had intact cognition and required maximum assistance for activities of daily living, was being transported in an electric wheelchair. During the transport, the bus driver, BD #118, had to abruptly stop the vehicle to avoid a collision, causing Resident #24 to fall out of her wheelchair and sustain injuries, including a fracture to her right humerus. The investigation revealed that BD #118 had not received adequate training on securing wheelchairs and residents safely in the facility bus. The training materials provided by the facility emphasized the importance of securing wheelchairs facing the front of the vehicle, but BD #118 had positioned Resident #24 facing sideways due to the wheelchair's size and the resident's leg brace. This improper securement contributed to the resident's fall and subsequent injuries. Further review of personnel files indicated that neither BD #118 nor BD #119, another bus driver, had received the necessary training related to resident safety when transporting residents. The facility's Risk Management policy required annual review and acknowledgment by bus drivers, but BD #118 did not review the policy in 2024, and BD #119 had not reviewed it before assuming the bus driver role. The lack of formal training and oversight in ensuring compliance with safety protocols directly contributed to the incident involving Resident #24.
Failure to Arrange Transportation for Medical Appointment
Penalty
Summary
The facility failed to arrange transportation for a resident to attend an outside medical appointment, resulting in a missed appointment. The resident, who was admitted with diagnoses including multiple sclerosis, neuromuscular dysfunction of the bladder, and morbid obesity, was cognitively intact and dependent on one staff member for activities of daily living. The resident had a scheduled appointment with a plastic surgeon for wound care services, which was not attended due to the facility's failure to arrange transportation. Interviews with the Director of Nursing (DON) and Assistant Director of Nursing (ADON) confirmed that the resident did not attend the appointment and no other wound care appointments were scheduled. The DON was unaware of the reason for the missed appointment until contacting the outside provider, who confirmed the resident was marked as a no-show. The facility acknowledged it was their responsibility to arrange transportation, and the resident had not refused to attend any appointments. This deficiency was investigated under specific complaint numbers.
Medication Security Lapse in Facility
Penalty
Summary
The facility failed to ensure medications were properly secured, affecting two residents. Resident #11, who has multiple diagnoses including chronic obstructive pulmonary disease and dementia, was observed with medications left unattended on their bedside table. The resident confirmed they had not taken the medications, and the Unit Manager verified this observation. The medications included divalproex, duloxetine, levetiracetam, and several others. The LPN responsible admitted to leaving the medications at the bedside, acknowledging it was a mistake. Resident #52, diagnosed with Wernicke's encephalopathy and other conditions, was found with a cup of morning medications left on their bedside table, which they had not taken. The resident stated that medications are sometimes left at their bedside by nursing staff, and they take them at their discretion. The LPN confirmed leaving the medications and recording them as administered without witnessing the resident ingest them. The facility's policy requires staff to maintain medication storage in a safe manner, which was not adhered to in these instances.
Incomplete Facility Assessment Lacks Staff Input
Penalty
Summary
The facility failed to ensure that its facility-wide assessment included all required information, which had the potential to affect all 73 residents residing in the facility. The assessment, dated on an unspecified date, lacked evidence of direct input from direct care staff, including Registered Nurses (RNs), Licensed Practical Nurses (LPNs), and Certified Nursing Assistants (CNAs). Additionally, the assessment did not include a plan to maximize recruitment and retention of direct care staff. This deficiency was confirmed during an interview with the Regional Administrator (RA) #206, who verified that the assessment was incomplete.
Failure to Change Oxygen Tubing as Ordered
Penalty
Summary
The facility failed to ensure that oxygen tubing was changed as ordered for two residents, both of whom were observed to have outdated oxygen tubing. Resident #21, diagnosed with chronic obstructive pulmonary disease (COPD) and impaired cognition, had a physician's order to change oxygen tubing every Sunday on the night shift. However, during an observation, it was noted that the oxygen tubing was dated from nearly two months prior, on 09/25/24. This observation was confirmed by the Director of Nursing, who acknowledged that the tubing should be changed weekly and as needed. Similarly, Resident #40, who had diagnoses including COPD and congestive heart failure, was also found to have outdated oxygen tubing. The resident's care plan included oxygen therapy, and the physician's orders specified that the tubing should be changed weekly. During an observation, the tubing was found to be dated 10/31/24, which was confirmed by an LPN. The facility's policy on oxygen administration, which was undated, also required weekly changes of the tubing. This deficiency was identified during a complaint investigation.
Failure to Provide Therapeutic Diets as Ordered
Penalty
Summary
The facility failed to provide therapeutic diets as ordered by the physician for two residents, Resident #25 and Resident #39, who were observed for therapeutic diets. Resident #25, diagnosed with dementia and cognitive deficits, had a physician's order for a mechanical soft diet with ground meats. However, during an observation, Resident #25 was served scrambled eggs, a blueberry muffin, and whole bacon strips, which did not comply with the ordered diet. The meal ticket indicated a mechanical soft diet with chopped meats, and this discrepancy was confirmed by an LPN. Due to impaired cognition, Resident #25 was unable to be interviewed. Similarly, Resident #39, who had dysphasia and cognitive deficits, was also not provided with the correct diet. The care plan and physician orders specified a mechanical soft diet with ground meats. During an observation, Resident #39 was served a sloppy joe sandwich, diced potatoes, a whole grilled cheese sandwich, and a fruit cocktail with whole cherries, which did not align with the dietary requirements. A speech therapist confirmed the diet order and noted that the grilled cheese should have been cut in half and whole cherries should not have been served. Resident #39 was also unable to be interviewed due to impaired cognition.
Crash Cart Deficiency in LTC Facility
Penalty
Summary
The facility failed to ensure that crash carts contained the appropriate supplies, which had the potential to affect all residents residing in the facility with a census of 66. During an interview, an LPN revealed that the memory care unit did not have a crash cart, and she was unaware if the crash cart located outside the unit had the appropriate equipment. An observation of the crash cart with another LPN revealed the absence of a checklist of equipment, an empty oxygen tank, and missing essential items such as a non-rebreather mask and a blood pressure cuff. Further observation on a later date with a different LPN confirmed the absence of an oxygen tank and a checklist of required supplies on the crash cart. The LPN acknowledged that there should have been an oxygen tank on the cart but was unsure of all the equipment needed. A Regional Risk Registered Nurse confirmed that crash carts should have full oxygen tanks and a checklist of the required equipment. This deficiency was investigated under Complaint Number OH00159305.
Failure to Monitor and Follow-Up on Malfunctioning Suprapubic Catheter
Penalty
Summary
The facility failed to provide adequate monitoring, appropriate treatment, and follow-up for a non-functioning suprapubic catheter for a resident with multiple sclerosis and neuromuscular dysfunction of the bladder. The resident experienced decreased urinary output, urinary retention, and increased pain and discomfort due to the malfunctioning catheter. Despite documentation of these issues, there was no evidence of adequate follow-up or interventions from the facility staff. The resident's care plan required regular catheter changes and monitoring for signs of urinary tract infections, but these interventions were not effectively implemented. Nursing progress notes indicated multiple instances where the catheter was not draining, and attempts to irrigate it were unsuccessful. Despite these issues, the facility did not ensure timely follow-up with a urologist, and the resident's appointments were repeatedly canceled or rescheduled due to transportation issues. Interviews with facility staff revealed a lack of communication and documentation regarding the resident's condition and the malfunctioning catheter. The facility's policy required reporting of unusual findings to a physician or supervisor, but this was not consistently done. The resident continued to experience pain and discomfort, and there was no evidence of bladder assessments or proper intake and output monitoring. The facility's failure to address the malfunctioning catheter placed the resident at increased risk of complications, including infection and potential surgery.
Failure to Implement Abuse Prevention Policy in Hiring Practices
Penalty
Summary
The facility failed to implement its abuse prevention policy related to pre-employment background checks, potentially affecting all 60 residents. The personnel file for the Minimum Data Set Coordinator (MDSC) revealed a hire date of October 3, 2023, and disclosed a felony conviction for conspiracy to commit mail fraud. The Ohio Board of Nursing's website confirmed the MDSC's LPN license had board action taken against it due to the felony conviction, with permanent restrictions on her nursing license. Despite these restrictions, the MDSC was hired by the previous Administrator, who was aware of her conviction. Interviews with the Human Resources Director and the Regional Director of Operations confirmed that the facility's policy was not followed, as the facility should not have hired anyone with a criminal history. Additionally, the personnel file for the Social Services Director (SSD) showed no evidence of a completed BCI background check, and the SSD was placed on administrative leave pending the results. The Human Resources Director's file revealed that a reference check was not completed until five months after hire. The facility's policy, dated December 2016, stated that background checks would be conducted and that the facility would not knowingly employ anyone found guilty of abuse, neglect, exploitation, misappropriation of property, or mistreatment by a court of law. These deficiencies were investigated under Complaint Number OH00157492.
Staffing Shortages Delay Meal Service
Penalty
Summary
The facility failed to provide sufficient dietary staff to ensure timely meal service for all 60 residents. Observations and interviews revealed that lunch service, scheduled to begin at 11:30 A.M., was delayed by 54 minutes, starting instead at 12:24 P.M. This delay was attributed to staffing issues, as confirmed by the Dietary Manager (DM), who was also acting as the cook. The DM noted that the kitchen typically ran late on Mondays due to staff shortages, as dietary staff who worked over the weekend had Mondays off. On the day of observation, the dietary staff schedule showed that the DM was the only scheduled cook for the entire day, with only one dietary aide scheduled from 7:00 A.M. to 2:30 P.M., and another aide scheduled from 12:30 P.M. to 8:30 P.M. However, the aide scheduled to arrive at 12:30 P.M. did not show up for their shift, further exacerbating the staffing shortage. The Activities Director also assisted in the kitchen due to the lack of staff. This deficiency was investigated under Complaint Number OH00157492.
Improper Food Presentation and Temperature Maintenance
Penalty
Summary
The facility failed to serve food in a manner that was palatable and attractive, affecting all 60 residents. During an observation of the lunch tray line, it was noted that chili con carne was served on a plate rather than in a bowl, causing it to run into other food items like rice and corn. This presentation was verified by the Dietary Manager (DM), who acknowledged that the bowls available did not keep soups hot, leading to the decision to use a plate with a warmer and domed lid. The DM admitted that the presentation was not appealing and could cause issues for residents. A Registered Dietitian (RD) later confirmed that the chili should have been served in an insulated bowl, not on a plate.
Dishwasher Temperature Deficiency
Penalty
Summary
The facility failed to maintain the dishwasher water temperatures at the manufacturer's specified minimum during the wash cycle, which had the potential to affect all 60 residents. Observations on September 30, 2024, revealed that the dishwasher did not reach the required minimum temperature of 155 degrees Fahrenheit after being run for three consecutive cycles. This was confirmed by a Dietary Aide, who noted that the machine typically required multiple runs to reach the appropriate temperature due to plumbing issues in the building. The Dietary Manager also acknowledged the plumbing problem affecting the hot water flow to the dishwasher. A review of the dishwasher temperature logs for September 2024 showed that the wash cycle temperature was below the required minimum on 19 days at breakfast, four days at lunch, and five days at dinner. The Registered Dietitian, responsible for conducting monthly audits of the dishwasher temperature logs, admitted to not noticing the recorded temperatures were below the required minimum. This deficiency was identified during a complaint investigation.
Deficiencies in Smoking Device Security and Fall Investigations
Penalty
Summary
The facility failed to ensure that smoking devices were secured, affecting a resident who was cognitively intact and required supervision while smoking. Despite the care plan indicating that smoking items should be kept at the nurses' station, the resident was observed with multiple vaporizing nicotine pens in his room. The LPN was unaware of any residents using such devices, indicating a lack of adherence to the facility's smoking policy, which mandates that all smoking paraphernalia be locked at the nurses' station. Additionally, the facility did not conduct thorough fall investigations for several residents, all of whom had varying degrees of cognitive impairment and were at risk for falls. For instance, one resident was found on the floor with injuries, but the investigation lacked details such as the presence of fall prevention measures, witness statements, and timely vital sign checks. Another resident was found on the floor with a head injury, yet the investigation did not document whether fall prevention interventions were in place or if neuro checks were conducted promptly. The facility's failure to conduct comprehensive fall investigations was confirmed by the VPO, who acknowledged significant issues with the investigations, including missing witness statements and untimely assessments. The facility's policy on managing fall risks was not adequately followed, as evidenced by the lack of identified interventions and incomplete documentation of fall incidents. This deficiency was investigated under a specific complaint number, highlighting the facility's noncompliance with safety protocols.
Failure to Provide Complete Pureed Diets
Penalty
Summary
The facility failed to provide all pureed food items as identified on the menu for residents requiring a pureed diet. This deficiency affected six residents who had specific dietary orders for pureed food texture. The facility's census at the time was 60 residents. The issue was identified through observation, medical record review, and staff interviews, revealing that the facility did not adhere to the prescribed dietary requirements for these residents. Resident #6, diagnosed with dementia, hypertension, and type two diabetes mellitus, had a care plan that included a consistent carbohydrate diet with pureed texture. Similarly, Resident #16, with Alzheimer's disease and dysphagia, was ordered a regular diet with pureed texture and nectar thick liquids. Resident #23, with dementia and hypertension, was also on a regular diet with pureed texture. Resident #35, diagnosed with Alzheimer's disease and type two diabetes mellitus, required a consistent carbohydrate diet with pureed texture. Resident #37, with dementia and dysphagia, was on a dysphagia pureed level one diet with honey thickened liquids. Lastly, Resident #44, with dementia and chronic kidney disease, was on a regular diet with pureed texture and nectar thick liquids. On the day of the deficiency, the production sheet for the lunch meal indicated that puree trays should include pureed chili con carne, seasoned cream of rice, pureed carrots, and pureed chocolate cake. However, during the lunch tray line observation, residents received pureed creamed corn, pureed chili con carne, and pudding, but not the pureed rice as indicated. The Dietary Manager confirmed the omission, stating that he forgot to prepare the pureed rice. The Registered Dietitian later confirmed that it was unacceptable for residents with puree food texture orders to miss a starch component in their meal.
Failure to Provide Adaptive Eating Equipment
Penalty
Summary
The facility failed to provide adaptive eating equipment and utensils to nine residents who required them during meals. These residents had various diagnoses, including dementia, Alzheimer's disease, multiple sclerosis, and other conditions that necessitated the use of adaptive equipment such as sippy cups, nosey cups, and built-up utensils to assist with their nutritional intake. Observations revealed that these residents were not provided with the necessary equipment during meal times, despite care plans and diet instruction sheets indicating their need for such aids. For instance, Resident #41, who had dementia and abnormal weight loss, was observed without a sippy cup, which was recommended to help her drink fluids independently. Similarly, Resident #37, who required a nosey cup due to coordination issues, was not provided with one during meals. Staff interviews revealed a lack of awareness and understanding of the residents' needs, with some staff members being agency workers unfamiliar with the specific requirements of the residents they were assisting. The facility's Director of Rehabilitation and Dietary Manager confirmed the shortage of adaptive equipment, stating that the facility had insufficient supplies, such as only one nosey cup and no sippy cups available. This lack of equipment had been ongoing for several months, leading to a rotation system where residents would receive the necessary equipment only at certain meals. The deficiency was identified during a complaint investigation, highlighting the facility's failure to ensure the availability and use of adaptive equipment as recommended for the residents' independence and nutritional well-being.
Deficiency in Accurate Medical Record Documentation
Penalty
Summary
The facility failed to maintain complete and accurate medical records for five residents, as identified during a review of medical records, self-reported incidents, and staff interviews. Resident #39's medical record inaccurately documented allergies to chicken and turkey as preferences rather than true allergies, without explanation. Resident #49's medical record contained discrepancies in documentation dates for a skin grid assessment and a progress note related to a self-reported incident, which were confirmed to be inaccurately documented by the Minimum Data Set Coordinator. Resident #42's medical record lacked documentation of incidents involving allegations of sexual and physical abuse, as well as evidence of required 15-minute and 30-minute checks following these incidents. Additionally, Resident #25's medical record did not contain documentation related to an allegation of sexual abuse, and Resident #55's record lacked documentation of an alleged physical abuse incident. Interviews with the Vice President of Operations confirmed the absence of necessary documentation in the medical records of these residents. The facility's failure to document these incidents and interventions in the residents' medical records represents a deficiency in maintaining accurate and complete medical records, as required by professional standards.
Failure to Provide Behavioral Health/Dementia Training
Penalty
Summary
The facility failed to provide annual behavioral health and dementia education to its staff, as required by regulations and the facility's own assessment. This deficiency was identified during a review of personnel records and staff interviews. Specifically, the personnel record of a State Tested Nursing Assistant (STNA) revealed no evidence of completed behavioral health or dementia education for the years 2023 and 2024. An interview with the STNA confirmed that she had not received any such training since 2021. Additionally, the Regional Director of Operations verified that there was no evidence of any staff receiving behavioral health or dementia training since 2021, despite the facility having a dedicated dementia/behavior unit where residents with dementia resided. This deficiency had the potential to affect 32 residents diagnosed with dementia, as identified by the facility, out of a total census of 60 residents. The lack of training was discovered incidentally during the course of a complaint survey.
Failure to Notify Physician of Sexual Abuse Allegations
Penalty
Summary
The facility failed to notify the physician of allegations of sexual abuse involving a resident. Specifically, Resident #42, who was cognitively intact and had diagnoses including Wernicke's Encephalopathy and post-traumatic stress disorder, was involved in two separate allegations of sexual abuse against female residents. Despite these serious allegations, there was no evidence in Resident #42's medical record that the physician was notified of either incident. The facility's policy, titled 'Abuse and Neglect - Clinical Protocol,' requires that the nurse assess the individual, document related findings, and report these findings to the physician. The policy also states that the physician and staff should help identify risk factors for abuse within the facility. However, an interview with the President of Operations confirmed that the facility had no evidence of physician notification for the allegations involving Resident #42. This deficiency was identified during a complaint investigation.
Facility Fails to Maintain Homelike Environment Due to Loud Alarm
Penalty
Summary
The facility failed to ensure a comfortable, homelike environment free from loud noises, affecting three residents. Resident #42, who was cognitively intact and had a history of anxiety, had a loud alarm placed on his door to alert staff when he left his room. This alarm was described as very loud by both the resident and his daughter. The alarm was intended to monitor Resident #42's movements, as he frequently left his room, but it caused significant disturbance due to its volume. Residents #28 and #17, both cognitively intact and with adequate hearing, were also affected by the noise from the alarm on Resident #42's door. Their rooms were located across the hall from Resident #42, and they reported being disturbed by the alarm, which went off frequently, including during the night. Resident #28 stated that the alarm woke him up all the time, while Resident #17 mentioned that it announced every time Resident #42 went in and out of his room, disrupting her rest.
Failure to Protect Residents from Abuse
Penalty
Summary
The facility failed to protect residents from abuse, specifically involving two residents who were cognitively intact. Resident #42 was involved in multiple incidents with Resident #25 and Resident #55, where inappropriate sexual behavior was alleged. On one occasion, Resident #42 was found barricaded in a room with Resident #25, and there was an allegation of a sexual gesture, although the facility's investigation did not find evidence of sexual assault. However, the investigation lacked a witness statement or an interview with Resident #25. In another incident, Resident #42 was found in Resident #55's room with his hand in her pants. Despite Resident #55 initially stating she was okay, she later confirmed she did not consent to the touching. The facility's investigation deemed the allegation unsubstantiated due to conflicting statements, but there were witness accounts from staff that supported the claim of inappropriate behavior. The facility did not implement new care plan interventions after the initial incident and failed to perform the required 30-minute checks on Resident #42. The facility's policy defined sexual abuse as non-consensual sexual contact, yet the facility did not take adequate steps to prevent further incidents after the initial allegations. The facility's failure to monitor Resident #42 effectively and to implement preventive measures after the first incident contributed to the recurrence of inappropriate behavior. The lack of documentation and follow-up on the allegations further highlights the deficiency in protecting residents from abuse.
Misappropriation of Resident's Belongings Due to Supply Shortage
Penalty
Summary
The facility failed to protect a resident from the misappropriation of personal belongings, specifically incontinence briefs provided by hospice services. Resident #57, who was severely cognitively impaired and dependent on staff for personal hygiene, had their hospice-provided incontinence briefs taken by staff to use for other residents due to a shortage of supplies. Interviews with staff, including State Tested Nursing Assistants (STNAs) and a Hospice Aid, confirmed that the briefs were frequently taken from Resident #57 because the facility's supply closets were often empty, and the overstocked supplies were locked in a garage. The Administrator and Central Supply staff were aware of the supply shortages, but the issue persisted, leading to the misappropriation of Resident #57's belongings. The facility's policy on abuse prevention, which includes protection against misappropriation of resident property, was not adhered to, resulting in a deficiency. The report indicates that this issue had the potential to affect other residents receiving hospice services, highlighting a systemic problem with supply management within the facility.
Inappropriate Use of Door Alarm as Physical Restraint
Penalty
Summary
The facility failed to ensure that residents were free from the use of physical restraints, as evidenced by the case of Resident #42. This resident, who was cognitively intact and used a walker/wheelchair for mobility, had a care plan that included interventions for mood and behavior issues. After an unsubstantiated allegation of sexual abuse, the facility initially provided one-on-one staff supervision for the resident. However, this supervision was discontinued, and an alarm was placed on the resident's door to alert staff when the resident left the room. Observations revealed that the alarm was loud and caused embarrassment and distress to Resident #42, who expressed dislike for the device. The alarm was intended to notify staff to provide one-on-one supervision when the resident left his room, but there was no evidence that this supervision was consistently provided. Interviews with staff and the resident's family confirmed that the alarm was distressing and that the resident felt humiliated by its use. The facility's policy on unauthorized physical restraints defines such restraints as any device that restricts a resident's freedom of movement and cannot be easily removed by the resident. The use of the alarm on Resident #42's door was deemed an inappropriate restraint, as it inhibited the resident's freedom of movement and was not accompanied by ongoing re-evaluation of its necessity. This deficiency was investigated under specific complaint numbers, indicating non-compliance with regulatory standards.
Failure to Document and Investigate Abuse Allegations
Penalty
Summary
The facility failed to accurately document and thoroughly investigate allegations of abuse involving three residents. In the first case, Resident #25, who was cognitively intact, was involved in an alleged sexual abuse incident with Resident #42. The facility's investigation lacked a statement from Resident #25, and the Administrator admitted to not documenting the interview with the resident. The investigation was closed without proper review, and the Administrator relied on the previous Director of Nursing's conclusion that there was no evidence of abuse, despite not having seen the investigation notes. In the second case, Resident #55, also cognitively intact, was involved in an alleged physical abuse incident with Resident #42. Despite Resident #55 stating multiple times that she did not consent to being touched and a staff witness corroborating the incident, the facility deemed the allegation unsubstantiated due to conflicting responses from the residents involved. The Administrator confirmed that Resident #55 did not give consent, yet the facility concluded the incident was hearsay. The third case involved Resident #49, who suffered a left hip fracture. The facility's investigation into the incident was delayed, with key documents such as the skin grid assessment and progress notes not being completed until months after the injury. The investigation lacked proper documentation, including undated and unsigned summaries and timelines, making it difficult to validate the findings. The facility concluded that the injury was due to osteopenia, but the investigation process was flawed and incomplete.
Failure to Update Care Plans with New Interventions
Penalty
Summary
The facility failed to ensure care plans were updated when new interventions were implemented for two residents. Resident #22, who was severely cognitively impaired and at high risk for falls, had a fall on 09/24/24. Despite the implementation of new interventions, such as placing bolsters on the bed and positioning the bed against the wall, these changes were not reflected in the resident's care plan. The resident had a history of falls and required significant assistance with daily activities, highlighting the importance of accurate and up-to-date care planning. Similarly, Resident #38, who was rarely understood and at moderate risk for falls, experienced a fall on 09/23/24. A new intervention to ensure a well-lit room was implemented following the fall, but this was not updated in the resident's care plan. The resident's care plan initially included interventions for fall risk due to confusion and incontinence, but the failure to update the care plan with the new intervention indicates a lapse in maintaining comprehensive and current care plans for residents.
Failure to Provide Routine Showers for Dependent Resident
Penalty
Summary
The facility failed to provide routine showers for a resident who was dependent on staff for all activities of daily living, including bathing. The resident, diagnosed with Alzheimer's disease, cognitive communication deficit, and muscle weakness, was scheduled to receive showers twice weekly. However, a review of the shower/bath sheets revealed that the resident received only eight showers out of the 26 scheduled over a three-month period. Observations and interviews confirmed that the resident's hair appeared oily and unkempt, and the resident's husband reported that he frequently had to request showers for the resident. Interviews with staff, including a State Tested Nursing Assistant (STNA) and a Licensed Practical Nurse (LPN), revealed that showers were not consistently provided, even when instructed. The Regional Clinical Director confirmed that there was no documentation of the resident receiving the scheduled showers, as evidenced by the lack of entries on the Medication Administration Record (MAR) and shower/bath sheets. The facility's policy required appropriate support and assistance with hygiene for residents unable to perform activities of daily living independently, which was not adhered to in this case.
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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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