Merit House Llc
Inspection history, citations, penalties and survey trends for this long-term care facility in Toledo, Ohio.
- Location
- 4645 Lewis Ave, Toledo, Ohio 43612
- CMS Provider Number
- 365279
- Inspections on file
- 22
- Latest survey
- January 28, 2026
- Citations (last 12 mo.)
- 4
Citation history
Health deficiencies cited at Merit House Llc during CMS and state inspections, most recent first.
A CNA who had completed a training program but was not yet listed on the state nurse aide registry was observed providing morning care, including dressing and wheelchair positioning, to a resident. Personnel and state registry checks showed no proof of active certification, and staffing records confirmed the CNA had been scheduled and worked in the CNA role beyond the allowable grace period for non-registered aides. The CNA reported she was working as a CNA and providing resident care, and the Administrator acknowledged she had failed her first registry exam and should not have been working in a CNA capacity without passing the required competency test, contrary to facility policy requiring valid certification for such positions.
A resident with multiple fractures and a care plan goal for adequate pain control had PRN orders for acetaminophen for mild to moderate pain and Roxicodone for severe pain defined as 8–10 on a 1–10 scale. Nursing staff repeatedly administered PRN Roxicodone when the resident’s documented pain scores were below the ordered threshold, including doses given for pain levels of 7 and once for a pain level of 0, instead of using the ordered acetaminophen for lower pain levels. An LPN and an RN confirmed that the narcotic was given outside the prescribed parameters, contrary to the facility’s medication administration policy requiring medications to be given as ordered.
A resident with a right humerus fracture, lumbar fractures, and other comorbidities had a physician-ordered orthopedic follow-up appointment requiring accompaniment by medically trained staff. On the morning of the appointment, the resident was observed dressed, with arm in a sling and appointment papers in hand, waiting in the doorway and later still in the room, reporting that no one came to take him to the visit and that the appointment was missed. Review of records and appointment paperwork confirmed the scheduled follow-up and staff accompaniment requirement, and an RN acknowledged the resident was not transported due to miscommunication with the physician’s office.
A medication cart was found unattended and unlocked in a hallway, and an LPN confirmed it should have been secured when not attended. Facility policy requires medications to be stored in locked compartments, but this was not followed, potentially affecting all residents.
The facility failed to provide opportunities and assistance for voting to three cognitively intact residents, despite their expressed importance of voting. An Activity Coordinator confirmed the lack of assistance, and an external individual with credentials was denied entry to help residents vote. The facility's policy mandates arrangements for residents to exercise their voting rights.
The facility failed to provide a dignified dining experience by serving meals on disposable dishware, affecting 79 residents. Observations and staff interviews confirmed the use of Styrofoam bowls and carryout containers for meals, which contradicted the facility's dignity policy. A resident expressed discomfort with this practice.
The facility did not follow its established menu cycle and failed to maintain a substitution log, affecting 79 residents. Meals served on specific days did not match the planned menu, and staff admitted to creating their own menus due to defrosted meat. The Dietary Manager and Technician confirmed the discrepancies and the absence of a substitution log, violating facility policy.
A facility failed to ensure timely cleaning and disinfection of soiled bedpans, affecting a resident who was frequently incontinent and staff-dependent for toileting. A soiled bedpan with a pink substance was observed uncovered on the bathroom floor, confirmed by an RN. The facility's infection control policy was not followed.
A resident with a suspected deep tissue injury on the right heel did not receive dressing changes as ordered by the physician. Despite documentation indicating compliance, interviews and observations revealed the dressing had not been changed since its initial application. The facility's wound care policy was not adhered to, leading to non-compliance with physician orders.
A resident with COPD and other conditions was receiving oxygen therapy without a physician order since admission. Despite being cognitively intact and having a history of oxygen use at home, the facility failed to secure the necessary order, as confirmed by staff and hospital referral records. This oversight was discovered during a complaint investigation.
A resident with COPD did not receive prescribed medications, Zithromax and prednisone, due to facility staff not utilizing the fully stocked emergency medication box (E-box). The MAR indicated non-administration, and interviews revealed a lack of communication and adherence to facility policy, which required medications to be administered per prescriber orders.
A resident in the facility did not receive several prescribed medications as ordered, despite the medications being available in the facility. The resident, who was independent in most ADLs and had multiple diagnoses, was affected by this deficiency. The facility's policy required medications to be administered as per prescribers' orders, but this was not adhered to, leading to continued non-compliance.
A facility failed to maintain a pest-free environment, leading to a bed bug infestation affecting a resident with mild intellectual disabilities, congestive heart failure, and diabetes mellitus. Staff observed bug bites on the resident's extremities, and an exterminator found dead bed bugs in the resident's room. The room and its contents were treated, and the DON confirmed the resident suffered from bed bug bites.
The facility failed to investigate allegations of verbal abuse involving three cognitively impaired residents who were dependent on staff. Despite reports of a State tested Nurse Aide threatening residents, there was no documentation or evidence of an investigation. The facility policy required immediate reporting and removal of the accused staff member, but the accused continued working until the surveyor's inquiry.
The facility failed to maintain a safe environment, leading to a small outdoor fire near resident rooms. A nurse noticed smoke, and staff found a smoking flowerpot under a chair with a burn hole. Numerous cigarette butts were found in the potting soil, suggesting the fire started from a cigarette. The facility's safety policy emphasized accident prevention, indicating a lapse in adherence.
A resident with a surgically absent right breast requested a prosthetic bra, as documented in physician notes. Despite the facility's awareness, there was no follow-up on the request, leaving the resident without the necessary item to maintain a dignified appearance. The resident expressed feelings of shame, and a social worker confirmed the oversight.
The facility failed to provide a call light within reach for a resident with diabetes and gangrene, who required assistance for transfers. The resident reported not having a working call light for weeks, confirmed by the DON. Additionally, another resident with pulmonary disease and heart failure did not have siderails as ordered by a physician, confirmed by an LPN and the resident's family.
A resident with a history of severe malnutrition and other health issues experienced a significant weight loss of 13.5 pounds, which was not reported to the physician or dietitian as required by the facility's policy. The resident's care plan included interventions for weight changes, but the facility failed to notify the necessary medical personnel in a timely manner.
A resident's restroom sink was found to contain a brown liquid that was not draining, persisting over several days despite being reported by staff. The resident, who is moderately cognitively impaired, reported the issue had been ongoing for four days. Multiple staff members confirmed the condition of the sink, which was eventually resolved.
The facility failed to report an allegation of verbal abuse involving three residents to the state agency in a timely manner. Despite being cognitively impaired and dependent on staff, the residents' medical records lacked documentation of the abuse allegations. Interviews revealed that a STNA reported the threats to management, but the facility did not report the incident to the state agency as required by their policy.
A resident with a surgical incision was admitted without proper orders for incision care, leading to a delay in treatment. The hospital recommended washing the incision twice daily, but the facility did not initiate this care until several days later. The ADON confirmed the oversight in obtaining necessary orders upon admission.
A resident with severe cognitive impairment and multiple health issues did not receive necessary grooming services, resulting in long, dirty nails and facial hair. Despite the facility's policy requiring assistance with ADLs, the resident's grooming needs were neglected, as confirmed by staff observations.
The facility failed to provide timely vision services to two residents. One resident, admitted with dementia and atrial fibrillation, requested eye care but was not seen by a vision provider despite multiple requests. Another resident, with cerebral infarction and congestive heart failure, requested an optometrist visit but was not evaluated until months later. The facility did not adhere to its policy of assisting residents in obtaining needed services.
A resident with severe protein-calorie malnutrition did not consistently receive a prescribed dietary supplement, a magic cup, with meals as ordered by the physician. Despite being cognitively intact and aware of the prescription, the resident reported irregularities in receiving the supplement. Observations and staff interviews confirmed the resident did not receive the supplement with several meals, including breakfast and lunch, as required.
A facility failed to administer medications as per physician orders, resulting in a five percent medication error rate. A resident with multiple diagnoses, including breast cancer and diabetes, did not receive prescribed fluticasone and simethicone. An LPN confirmed the medications were unavailable for administration.
A facility failed to use proper PPE for a COVID-19 positive resident. An STNA was observed exiting the resident's room wearing only a surgical mask, without an N95 respirator or eye protection, as required by the facility's policy. Interviews confirmed the absence of necessary PPE on the isolation cart, indicating non-compliance with infection control protocols.
The facility failed to educate and offer COVID-19 vaccinations to two residents, despite their cognitive ability to understand the information. One resident had no documentation of vaccination education or administration, while another had only received one vaccination with no further offers. Interviews confirmed the lack of adherence to the facility's policy on providing recommended vaccines.
A resident with chronic hepatic failure did not receive prescribed doses of lactulose due to medication unavailability and storage issues. An LPN reported a delay in pharmacy delivery, while the DON later revealed the medication was available but not located by the nurse. The facility's policy on timely medication administration was not followed.
The facility did not complete required performance reviews for two STNAs, affecting their compliance with annual and 90-day evaluations. This oversight was confirmed by an administrator and had the potential to impact all residents in the facility.
Uncertified CNA Allowed to Provide Direct Resident Care Beyond Permitted Timeframe
Penalty
Summary
The deficiency involves the facility’s failure to ensure that a nurse aide had obtained proper placement on the state nurse aide registry before working as a CNA. Observation showed that Certified Nursing Assistant (CNA) #101 was providing morning care to a resident, including dressing and positioning the resident in a wheelchair. Review of CNA #101’s personnel file showed a hire date of 08/22/25 and completion of a Nurse Aide Training and Competency Evaluation Program on 06/13/25, but there was no proof of state registry in the file. A check of the State of Ohio State Tested Nursing Assistant website also did not show evidence of registry for this individual. Further review of the staffing schedule confirmed that CNA #101 was scheduled and worked in the role of CNA on 01/27/26 and 01/28/26. During an interview, CNA #101 stated she was employed as a CNA and was caring for residents on the day of observation. In an interview, the Administrator confirmed that CNA #101 had been employed longer than four months since completion of her CNA program, had failed her first registry test, and was scheduled to retake it. The Administrator acknowledged that CNA #101 should not have been working as a CNA providing resident care without having passed the registry examination. The facility’s policy stated that positions requiring certification or licensing must maintain valid credentials, and failure to do so could result in termination and reporting to the licensing board.
Narcotic Pain Medication Administered Outside Ordered Parameters
Penalty
Summary
The deficiency involves the facility’s failure to administer narcotic pain medication according to the physician’s ordered parameters for a resident with multiple fractures and other comorbidities. The resident was admitted with diagnoses including nondisplaced right humerus fracture, lumbar vertebral fractures, morbid obesity, fall, anxiety disorder, and alcohol use. The baseline care plan identified the resident as alert and aware, with goals for physical and occupational therapy and adequate pain control. Physician orders included PRN acetaminophen 500 mg every six hours for mild to moderate pain and PRN Roxicodone (oxycodone HCl) 5 mg every six hours for severe pain, defined as a pain level of 8–10 on a 1–10 scale. Record review showed that staff administered the PRN Roxicodone outside the ordered parameters on multiple occasions. Under the first Roxicodone order, the resident received the narcotic for pain scores of 7 on several dates and once for a documented pain level of 0, even though the order specified use only for severe pain (8–10). After the order was refilled, the resident again received Roxicodone for a pain level of 7, which was below the ordered threshold. In total, there were eight administrations under the first order and one under the second order when the resident’s pain level was below 8. Staff interviews with an LPN and an RN confirmed that the PRN narcotic was given outside the ordered parameters and that acetaminophen, ordered for mild to moderate pain, should have been used when pain levels were below 8. The facility’s medication administration policy required medications to be administered safely, timely, and as prescribed.
Failure to Transport Resident to Scheduled Orthopedic Appointment
Penalty
Summary
The deficiency involves the facility’s failure to ensure a resident was transported to an outside orthopedic appointment as scheduled. The resident was admitted with multiple significant diagnoses, including a nondisplaced right humerus fracture, lumbar fractures at L1 and L2, morbid obesity, anxiety disorder, alcohol use, and a traumatic subdural hematoma from prior falls. The baseline care plan indicated the resident was alert and aware, non-weight bearing on the affected extremity, and was to receive physical and occupational therapy with the goal of discharge home, with social services coordinating services to achieve discharge goals. Physician orders documented an orthopedic follow-up appointment scheduled for 8:50 A.M. on 01/27/26, with instructions that staff accompaniment was required and that the accompanying staff needed to be medically trained. On the morning of the scheduled appointment, surveyor observation found the resident standing in the doorway with his right arm in a sling, wearing shoes and holding appointment papers, looking up and down the hallway shortly before the appointment time. In an interview, the resident stated he had been admitted about a week earlier, was supposed to have a follow-up with his orthopedic doctor that day, that his arm and sling were bothering him, and that no one had come to get him for the appointment. A later observation the same morning showed the resident still in his room with his arm in a sling, shoes on, and the appointment paperwork on the bedside table; he reported that no one ever came to get him and that he missed the appointment. Review of the appointment paperwork confirmed the scheduled orthopedic follow-up and the requirement for medically trained staff accompaniment. An RN interview verified the resident had not been transported to the appointment and attributed the missed appointment to miscommunication with the doctor’s office.
Unattended and Unlocked Medication Cart
Penalty
Summary
A medication cart was observed unattended and unlocked in the hallway outside a resident room. An LPN confirmed that the cart was left unattended and unlocked, and acknowledged that it should have been locked when not attended by staff. Review of the facility's policy on medication storage indicated that medications are to be stored in locked compartments. This failure to secure the medication cart had the potential to affect all 81 residents in the facility.
Failure to Assist Residents with Voting
Penalty
Summary
The facility failed to ensure that residents were provided opportunities and assistance with voting, affecting three residents who were cognitively intact and expressed the importance of voting to them. Resident #4, diagnosed with Parkinson's disease, Resident #7, with diabetes mellitus, hypertension, and a cerebral vascular accident, and Resident #47, with diabetes mellitus, hypertension, heart failure, and chronic obstructive pulmonary disease, all reported that the facility did not assist or offer opportunities for them to vote in recent elections. Interviews with these residents confirmed their cognitive ability to participate in voting, yet they were not supported in exercising this right. The Activity Coordinator (AC) #500 confirmed that residents were not assisted or offered the opportunity to vote, stating a lack of awareness of the facility's policy regarding voting assistance. Additionally, AC #510 recounted an incident where an individual with credentials from the board of elections was denied entrance by the previous facility Administrator, preventing residents from receiving external voting assistance. The facility's policy, dated October 2019, clearly states that residents have the right to exercise their civil rights, including voting, and arrangements must be made to facilitate this. This deficiency was investigated under Complaint Number OH00161624.
Deficiency in Dignified Dining Experience Due to Disposable Dishware
Penalty
Summary
The facility failed to maintain a dignified dining experience for its residents by serving meals on disposable dishware, which affected 79 out of 81 residents who received meals from the kitchen. Observations on December 26, 2024, revealed that desserts were served in Styrofoam bowls, and dinner meals were served in disposable carryout containers. Interviews with Certified Nursing Assistants (CNAs) confirmed the use of disposable dishware, and one CNA stated that the decision was made to avoid dirtying regular dishes. A resident expressed discomfort with meals being served on disposable dishware instead of regular plates. The facility's policy on dignity, revised in February 2021, emphasizes caring for residents in a manner that promotes their well-being and self-esteem. However, the practice of serving meals on disposable dishware was inconsistent with this policy. The facility identified two residents who were NPO (nothing by mouth) and did not receive meals from the kitchen, but the deficiency primarily affected the other residents who were served meals. This issue was investigated under Complaint Number OH00160314.
Failure to Follow Menu and Maintain Substitution Log
Penalty
Summary
The facility failed to adhere to its established menu cycle and did not maintain a substitution log, affecting 79 of 81 residents who received meals from the kitchen. On 12/26/24, the breakfast served did not match the planned menu, which was supposed to include cereal, scrambled eggs, bacon, wheat toast, and beverages. Instead, residents received french toast, sausage links, and hot cereal. The staff member responsible for the meal was unable to confirm the portion sizes used. Similarly, on 12/31/24, the lunch menu was not followed. The planned meal of maple mustard glazed pork tenderloin and accompanying sides was replaced with spaghetti, green beans, and ice cream. The staff member admitted to creating her own menu due to the need to use defrosted meat. Interviews with the Dietary Manager and Dietary Technician confirmed that the meals served did not align with the planned menu and that the facility did not maintain a substitution log as required by their policy. The facility's policy mandates that all menu changes be recorded and retained according to state regulations. The lack of adherence to the menu and absence of a substitution log were identified as deficiencies during the investigation of Complaint Number OH00160314.
Failure to Timely Clean and Disinfect Soiled Bedpans
Penalty
Summary
The facility failed to ensure timely cleaning and disinfection of soiled bedpans, affecting one resident reviewed for bedpan use. Resident #22, who was admitted with diagnoses including spinal stenosis, congestive heart failure, atrial fibrillation, and hypertension with heart disease, was frequently incontinent and dependent on staff for toileting. Observations on December 26, 2024, revealed a soiled bedpan with a pink substance on the bottom, left uncovered on the bathroom floor of Resident #22. This was confirmed by a registered nurse during an interview. The facility's infection control policy, revised in October 2018, was intended to maintain a safe and sanitary environment to prevent disease transmission, but was not adhered to in this instance.
Failure to Follow Physician Orders for Wound Care
Penalty
Summary
The facility failed to complete dressing changes according to physician orders for a resident with a suspected deep tissue injury on the right heel. The resident, who was cognitively intact and had no unhealed pressure or vascular ulcers upon admission, developed an intact purple area on the right heel. A physician order was obtained to apply skin prep, cover with an ABD pad, and wrap with kerlix twice daily and as needed. However, the dressing change was not completed as ordered, and the dressing was observed to be dated several days prior, indicating it had not been changed. Interviews with the resident and nursing staff confirmed that the dressing had not been changed since the initial application, despite documentation in the Treatment Administration Record indicating otherwise. The wound care RN confirmed the original physician order for twice daily dressing changes and acknowledged the discrepancy in the treatment record. The facility's policy on wound care, which aims to promote healing, was not followed, resulting in non-compliance with the physician's orders.
Failure to Obtain Physician Order for Oxygen Therapy
Penalty
Summary
The facility failed to obtain a physician order for the administration of oxygen therapy for a resident, identified as Resident #30, who was one of three residents reviewed for oxygen therapy. Resident #30 was admitted with diagnoses including status post cardiac arrest, respiratory arrest, chronic obstructive pulmonary disease (COPD), and congestive heart failure. The admission Minimum Data Set (MDS) assessment indicated that the resident was cognitively intact and received oxygen therapy. However, a review of the physician orders for December 2024 revealed no order for oxygen therapy, despite the resident receiving it since admission. An observation on December 30, 2024, confirmed that Resident #30 was wearing oxygen via nasal cannula at two liters per minute. During an interview, the resident stated that she had been on oxygen therapy since her admission and had also used it at home prior to admission. A registered nurse confirmed the absence of a physician order for the oxygen therapy, acknowledging that it was an oversight, as the hospital referral records indicated the need for such an order. The facility's policy on oxygen administration required verification of a physician order, which was not adhered to in this case. The deficiency was identified during a complaint investigation.
Failure to Administer Medications as Ordered
Penalty
Summary
The facility failed to administer medications per physician order for a resident with chronic obstructive pulmonary disease (COPD), emphysema, and anxiety. The resident was ordered Zithromax and prednisone for an acute exacerbation of COPD. However, the Medication Administration Record (MAR) indicated that these medications were not administered as ordered on a specific date. The nursing progress notes revealed that the Zithromax was not given due to awaiting pharmacy, and the prednisone was not administered because the medication was on order. Interviews with facility staff, including an LPN and the Director of Nursing (DON), revealed that the facility had an emergency medication box (E-box) that contained common medications for immediate use. Despite this, the medications were not administered. The pharmacy Processing Manager confirmed that the E-box was fully stocked with the required medications and that no requests for these medications were submitted to the pharmacy during the relevant period. The facility's policy required medications to be administered per prescriber orders, but this was not followed, leading to the deficiency.
Medication Administration Deficiency
Penalty
Summary
The facility failed to ensure medications were administered as ordered for a resident, affecting one of three residents reviewed for medications. The resident, who had an intact cognitive function and was independent in most activities of daily living, was admitted with diagnoses including cellulitis, diabetes mellitus, ulcerative colitis, and schizophrenia. Upon admission, the resident's medications were reviewed and confirmed with the physician. However, the medication administration record revealed multiple instances where medications were not administered as ordered, including atorvastatin, Seroquel, Fluticasone-Salmeterol, mesalamine, warfarin, doxycycline, and memantine. The nursing progress notes indicated that several medications were not available at the time they were supposed to be administered, despite the Director of Nursing confirming that the medications were in the facility. The facility's policy on administering medications stated that medications should be administered in accordance with prescribers' orders, including any required time frame. This deficiency was investigated under a complaint and represented continued non-compliance from a previous survey.
Failure to Maintain Pest-Free Environment
Penalty
Summary
The facility failed to maintain a pest-free environment, resulting in a bed bug infestation that affected a resident. The resident, who had mild intellectual disabilities, congestive heart failure, and diabetes mellitus, was admitted to the facility and had an intact cognition with a risk for skin impairment. On two separate occasions, staff noted small bug bites on the resident's legs and arms during showers. An exterminator service record indicated that a significant number of dead bed bugs were found in the resident's room, specifically on the mattress. The room and its contents, including the mattress, chair, dresser drawers, armoire, and perimeter baseboards, were treated for bed bugs. The Director of Nursing confirmed the resident suffered from bed bug bites due to the infestation. The facility's policy on preventing and managing bed bug infestations was reviewed, revealing that staff were expected to employ infection control strategies to manage such infestations.
Failure to Investigate and Protect Residents from Verbal Abuse
Penalty
Summary
The facility failed to thoroughly investigate an allegation of verbal abuse and did not protect residents from potential abuse. This deficiency affected three residents who were cognitively impaired and dependent on staff for most activities of daily living. Despite the allegations being reported to management, there was no evidence in the medical records of any investigation or documentation regarding the abuse allegations for these residents. The facility's Self-Reported Incidents (SRIs) also did not contain any reports related to the verbal abuse allegations. Interviews with staff revealed that a State tested Nurse Aide (STNA) had threatened to hit two residents, and this was reported to the Director of Nursing (DON). However, the DON could not provide any investigative documentation, and the facility was unable to produce any evidence of an investigation. The facility policy required immediate reporting and documentation of such incidents, as well as the removal of the accused staff member pending investigation. Despite this, the accused STNA continued to work at the facility until being sent home after the surveyor's inquiry.
Facility Fails to Maintain Safe Environment, Resulting in Outdoor Fire
Penalty
Summary
The facility failed to maintain a safe environment, resulting in a small outdoor fire that had the potential to affect 11 residents with rooms near the incident site. The incident occurred when a nurse noticed smoke outside the 200 Hall lounge exit door. Upon investigation, a small flowerpot under a chair was found smoking, and staff had already attempted to extinguish it with dirt and water. The chair had a burn hole, and there was black soot staining on the wall behind it. Numerous cigarette butts were found in the potting soil, suggesting that the fire may have started when a cigarette was put out in the flower planter. The Director of Maintenance confirmed the burn hole, soot, and cigarette butts during an observation. An LPN also confirmed the fire in the flowerpot and stated that no staff or residents were present in the courtyard at the time. The facility's policy on safety and supervision, last revised in 2017, emphasized making the environment as free from accident hazards as possible, highlighting a lapse in adherence to this policy. This deficiency was investigated under a specific complaint number, indicating noncompliance with safety standards.
Failure to Provide Prosthetic Bra for Resident
Penalty
Summary
The facility failed to ensure that a resident received the necessary services to maintain a dignified appearance, specifically regarding the provision of a prosthetic bra. The resident, who was admitted with multiple diagnoses including chronic obstructive pulmonary disease, chronic kidney disease, heart failure, gout, hypertension, and type II diabetes mellitus, had a moderate cognitive impairment and was dependent on staff for dressing and personal hygiene. The medical record indicated that the resident had a surgically absent right breast and had requested a prosthetic bra, as noted in physician progress notes on multiple occasions. Despite the resident's request and the facility's awareness of the need for a prosthetic bra, there was no evidence in the medical record that the request was followed up on. The resident expressed feelings of shame about going out without an appropriate bra, and an observation confirmed the absence of a prosthetic bra. An interview with a licensed social worker verified that the request had not been addressed, highlighting a failure in the facility's responsibility to honor the resident's right to a dignified existence.
Failure to Provide Call Light and Siderails as Ordered
Penalty
Summary
The facility failed to ensure that a call light was within reach for Resident #128, who was admitted with diagnoses including type two diabetes mellitus, hypothyroidism, depressive disorder, and gangrene of the right leg. The resident, who had intact cognition and required substantial assistance for toileting and transfers, was observed without a call light within reach. The call light was found on the floor, detached from the wall. During an interview, the resident mentioned not having a working call light for a couple of weeks, which was confirmed by the Director of Nursing. Additionally, the facility did not comply with physician orders for Resident #182, who was admitted with chronic destructive pulmonary disease, asthma, and heart failure. The resident, who was cognitively intact and required moderate assistance for bed mobility, had an active physician order for top bilateral siderails to aid in bed mobility and promote independence. However, an observation revealed that the resident's bed did not have any siderails, as confirmed by an Agency Licensed Practical Nurse. The resident's family member also reported that siderails were supposed to be in place since admission, but they were not provided.
Failure to Notify Physician of Significant Weight Loss
Penalty
Summary
The facility failed to notify the physician of a significant weight loss experienced by a resident, which is a deficiency in their care protocol. The resident, who was cognitively intact, had a history of severe protein-calorie malnutrition, nutritional deficiency, heart disease, heart failure, weakness, anxiety, depression, and bipolar disorder. The resident's care plan, revised on August 15, 2024, indicated a risk for decline in nutrition and hydration status due to these diagnoses and weight loss. The plan included interventions such as providing supplements and reporting significant weight changes to the physician. Despite these interventions, the resident experienced a weight loss of 13.5 pounds between August 31, 2024, and September 1, 2024, which was not reported to the physician or dietitian. The facility's policy required that any weight change of five percent or more should be verified and reported immediately. However, an interview with the Director of Nursing and the Assistant Director of Nursing confirmed that there was no evidence of notification to the physician or dietitian about the weight loss until September 18, 2024.
Failure to Maintain a Clean and Homelike Environment
Penalty
Summary
The facility failed to provide a clean, comfortable, and homelike environment for a resident, as evidenced by the condition of the restroom sink in the resident's room. The sink was observed to contain a brown liquid that filled to approximately four inches from the top and was not draining. This condition persisted over several days, as confirmed by multiple observations and interviews with the resident and staff members, including a medication aide and housekeeping aides. The resident, who was moderately cognitively impaired with a BIMS score of eight, reported that the sink had been in this condition for approximately four days. Despite the issue being noticed by a housekeeper the week prior and reported to a nurse, the problem remained unaddressed until it was finally resolved. The resident's medical history includes cerebral infarction, hyperlipidemia, type two diabetes, bipolar disorder, nutritional deficiency, hypertension, seborrheic dermatitis, unspecified intellectual disabilities, personal history of COVID-19, and tinea unguium.
Failure to Timely Report Alleged Verbal Abuse
Penalty
Summary
The facility failed to report an allegation of verbal abuse to the state agency in a timely manner, affecting three residents. Resident #9, who was cognitively impaired and required substantial assistance for daily activities, had no evidence of abuse allegations in their medical record. Similarly, Resident #42, also cognitively impaired and dependent on staff, showed no documentation of abuse allegations. Resident #54, who was cognitively impaired, receiving hospice services, and dependent on staff, also had no record of abuse allegations. Despite these residents' vulnerabilities, the facility did not document or report the alleged verbal abuse. Interviews revealed that a State tested Nurse Aide (STNA) reported that another STNA had threatened to hit Residents #42 and #54, and this was communicated to management. The Director of Nursing (DON) confirmed that an investigation was conducted and documentation was provided to the previous Administrator. However, the current Administrator could not locate any investigative documentation and acknowledged that the allegation should have been reported to the state agency but was not. The facility's Self-Reported Incidents (SRIs) lacked any reports of the verbal abuse allegation, and the facility's policy required immediate reporting of such incidents to the state agency, which was not adhered to in this case.
Failure to Obtain Admission Orders for Surgical Incision Care
Penalty
Summary
The facility failed to ensure that admission orders were obtained for a resident with a surgical incision, which led to a deficiency in providing appropriate care and treatment. Resident #178, who was admitted with a surgical incision on the neck, did not have any orders in place to wash the incision as recommended by the hospital from which they were discharged. The hospital record indicated that the incision should be washed twice daily with soap and water, but this was not initiated until several days after the resident's admission. Upon observation, it was noted that the resident had clear tape covering the incision, and the resident reported that no treatments had been performed on it by the facility. The physician orders for the month did not include any instructions for incision care until an order was finally placed to wash the incision every shift. The Assistant Director of Nursing confirmed that there should have been an order in place upon admission to cleanse the surgical incision, which was not done, resulting in a lapse in care.
Failure to Provide Grooming Services
Penalty
Summary
The facility failed to provide necessary grooming services for a resident, identified as Resident #20, who was unable to perform activities of daily living independently. Resident #20, who was admitted with multiple diagnoses including polyosteoarthritis, acute respiratory failure, and severe cognitive impairment, required substantial or maximal assistance with personal hygiene as per the most recent Minimum Data Set (MDS) assessment. Despite this, observations revealed that the resident had long and dirty nails and multiple long, coarse hairs on her chin, which she expressed dissatisfaction with during an interview. The facility's policy on Activities of Daily Living (ADLs) mandates that residents who cannot independently perform ADLs should receive necessary services to maintain good grooming and personal hygiene. However, the facility did not adhere to this policy for Resident #20, as confirmed by a State tested Nursing Assistant (STNA) who verified the resident's unkempt nails and facial hair. This oversight affected the resident's grooming needs, contrary to the facility's stated policy and the resident's care plan.
Failure to Provide Timely Vision Services
Penalty
Summary
The facility failed to assist two residents in gaining timely access to vision services. Resident #32, who was admitted with diagnoses including dementia and atrial fibrillation, had requested eye care services on 06/13/24. Despite this request, there was no documentation indicating that the resident had seen a vision provider. The resident expressed to staff multiple times the need to see an eye doctor, but was not added to the list for the vision provider's visit on 09/16/24. The facility's policy, which mandates assisting residents in obtaining needed services, was not adhered to in this case. Similarly, Resident #46, who was admitted with multiple diagnoses including cerebral infarction and congestive heart failure, requested to see an optometrist on 03/08/24. Although the optometrist visited the facility on 04/03/24, Resident #46 was not evaluated at that time. The resident, who was cognitively intact, expressed a desire to see an eye doctor but was not provided the opportunity until 09/16/24. The facility's failure to ensure timely access to vision services for these residents constitutes a deficiency in care.
Failure to Administer Dietary Supplements as Ordered
Penalty
Summary
The facility failed to ensure that dietary supplements were administered according to the physician's order for a resident diagnosed with severe protein-calorie malnutrition and other health conditions. The resident, who was cognitively intact, was prescribed a magic cup supplement three times per day with meals. However, the resident reported inconsistencies in receiving the supplement, describing it as a 'throw of the coin' whether they received it with meals. Observations and interviews confirmed the resident did not receive the magic cup with several meals, including breakfast and lunch on multiple occasions. A Licensed Practical Nurse and a State-tested Nurse Aide verified that the resident was supposed to receive the supplement with breakfast, but it was not provided. This deficiency affected the resident's nutritional care plan, which aimed to prevent a decline in their nutrition and hydration status.
Medication Administration Deficiency
Penalty
Summary
The facility failed to ensure medications were administered in accordance with physician orders, resulting in a medication error rate of five percent. During an observation, it was noted that 37 medications were administered, with two errors occurring, affecting one of the two residents reviewed for medication administration. Specifically, Resident #17, who had diagnoses including malignant neoplasm of the breast, type two diabetes mellitus, chronic obstructive pulmonary disease, and chronic kidney disease, was not administered fluticasone propionate and simethicone as ordered by the physician. The Medication Administration Record (MAR) confirmed that these medications were not given on the specified date. An interview with LPN #419 revealed that the medications were unavailable for administration at the time.
Failure to Use Proper PPE for COVID-19 Positive Resident
Penalty
Summary
The facility failed to utilize proper Personal Protective Equipment (PPE) for a resident who tested positive for COVID-19. During an observation, it was noted that a COVID-19 isolation cart was present outside the room of the resident, who had a range of medical conditions including Alzheimer's disease, COPD, and type two diabetes. The door to the resident's room was open, and a State tested Nursing Assistant (STNA) was observed doffing her gown and gloves inside the room and exiting while wearing only a surgical mask. At no point did the STNA wear an N95 respirator or eye protection, which are required for entering the room of a COVID-19 positive resident. Interviews with the STNA and the Director of Nursing (DON) confirmed that N95 masks and face shields were not present on the isolation cart, contrary to the facility's policy. The facility's policy, updated earlier in the year, mandates that staff entering the room of a resident with a suspected or confirmed SARS-CoV-2 infection must use an N95 mask, gown, gloves, and eye protection. The STNA admitted to changing her mask after leaving the room and not using the required PPE, highlighting a lapse in adherence to the infection prevention and control program.
Failure to Educate and Offer COVID-19 Vaccination
Penalty
Summary
The facility failed to ensure that residents were educated on and received the COVID-19 vaccination, affecting two residents out of five reviewed. Resident #32, who was cognitively intact with a BIMS score of 13, had no documentation in their medical record regarding education, administration, or refusal of the COVID-19 vaccination. Similarly, Resident #46, also cognitively intact with a BIMS score of 15, had only received one COVID-19 vaccination in May 2021, with no further documentation of education or offers for additional vaccinations upon admission or thereafter. Interviews with RN #484 confirmed the lack of documentation and education regarding COVID-19 vaccinations for both residents. The facility had received information about the availability of COVID-19 vaccinations but had not yet begun offering them to residents. The facility's policy, revised in February 2024, stated that recommended vaccines should be provided to residents and staff, with information encouraging vaccination shared with families and visitors. However, the facility had not adhered to this policy, as confirmed by the administrator.
Failure to Administer Medications as Prescribed
Penalty
Summary
The facility failed to ensure medications were administered per physician orders for a resident with multiple diagnoses, including chronic hepatic failure. The resident was prescribed lactulose oral solution to be administered three times a day. However, the Medication Administration Record (MAR) indicated that the resident did not receive two doses on one day and one dose on the following day. The medication was reportedly unavailable on these occasions, as noted in the administration records. Interviews with staff revealed discrepancies in the availability of the medication. An LPN stated that the medication was not available upon the resident's arrival due to a delay in pharmacy delivery. However, the Director of Nursing later indicated that the medication was indeed available but was not found by the nurse because it was stored in a side drawer of the medication cart. The facility's policy on administering medications, which mandates timely and prescribed administration, was not adhered to in this instance.
Failure to Conduct Timely Performance Reviews for STNAs
Penalty
Summary
The facility failed to conduct performance reviews for every nurse aide at least once every 12 months, affecting two State tested Nursing Assistants (STNAs) out of four reviewed. Specifically, STNA #402, hired on 08/24/23, did not have a 90-day or annual employee evaluation in her file. Similarly, STNA #475, hired on 03/28/24, lacked a 90-day employee evaluation in her file. This deficiency was confirmed during an interview with Administrator #2, who verified the absence of the required evaluations for both STNAs. This oversight had the potential to impact all residents residing in the facility, which had a census of 85.
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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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