Momentous Health At Sidney
Inspection history, citations, penalties and survey trends for this long-term care facility in Sidney, Ohio.
- Location
- 510 Buckeye Ave, Sidney, Ohio 45365
- CMS Provider Number
- 366033
- Inspections on file
- 19
- Latest survey
- March 12, 2026
- Citations (last 12 mo.)
- 2
Citation history
Health deficiencies cited at Momentous Health At Sidney during CMS and state inspections, most recent first.
The facility failed to provide ordered speech therapy services for two residents with dysphagia and post‑cerebral infarction speech and swallowing deficits. Both had physician orders to continue existing speech therapy plans of care under a new provider, with one to receive therapy twice weekly and the other three times weekly over a defined certification period, targeting improved swallow function, diet tolerance without aspiration signs, and better communication and speech intelligibility. Medical records for each resident showed only a single 23‑minute speech therapy session during that entire period. A therapy regional manager confirmed that services under the new contractor started after the prior contractor was terminated, that these two residents received speech therapy only once, and that available telehealth speech therapy was not utilized.
The facility did not ensure coffee was available to all residents as listed on the menu and failed to post menus for resident review. Several residents reported not receiving coffee with breakfast, and staff confirmed that menus were not displayed, requiring residents to ask about daily meal options.
Staff did not consistently don required protective gowns while providing high-contact care to a resident on Enhanced Barrier Precautions for wounds, despite facility policy and posted instructions. Multiple staff, including nurses and CNAs, were observed on several occasions wearing gloves but not gowns during direct care activities.
Staff did not perform required hand hygiene between handling food trays and making direct contact with multiple residents during meal service. An Activities Director delivered meals, touched food and residents without washing or sanitizing hands or using gloves, as confirmed by staff interviews and facility policy review.
A resident with multiple chronic conditions, who was cognitively intact and required assistance with daily living, was not provided shaving care as requested during bathing. Despite the resident's request and facility policy requiring assistance with shaving based on resident preference, staff did not perform the shaving, resulting in the resident having long hair on her legs and underarms and feeling dissatisfied with her appearance.
A resident with multiple chronic conditions alleged that an LPN acted abusively by taking away her meal and requiring her to eat in her room, causing her distress. A CNA witnessed the incident and reported it to the DON, but the allegation was not documented or reported to the state agency as required by facility policy. The Administrator confirmed the failure to report.
A resident with multiple chronic conditions reported that an LPN took her meal away in a manner she felt was abusive, and a CNA who overheard the incident described the LPN's tone as rude and disrespectful. Although the CNA reported the incident to the DON, the Administrator was unaware and no investigation was conducted, in violation of the facility's abuse prevention policy.
A resident with multiple chronic conditions who required assistance for toileting was not changed for over eight hours, resulting in her being found heavily soiled with urine and a wet pad. Staff confirmed the lapse in care, and the resident expressed that she was not changed as frequently as needed, contrary to facility policy.
A resident with CHF, hypertension, and diabetes was not provided the ordered amount of fluids, consistently receiving less than the prescribed 2,000 ml per day over an extended period. The care plan called for assistance and supervision with fluid intake, but the resident frequently reported thirst and did not always receive fluids when requested. Staff and dietary review confirmed the resident was under the fluid restriction amount, and required documentation and reporting of intake variations were not adequately performed.
The facility failed to maintain kitchen sanitation and proper food storage, affecting 38 residents. Observations revealed debris on the ice maker, a brownish-red substance inside the ice machine, and significant ice build-up in a freezer, preventing movement of the inner basket. Food items were not dated or labeled, and the produce cooler contained a rotten tomato. The Dietary Manager confirmed these issues, which violated facility policies requiring sanitary maintenance and proper labeling of food.
The facility did not ensure the Medical Director or their designee attended a required quarterly QAPI meeting, as revealed by attendance logs and confirmed by the DON. The absence was noted for a meeting intended to monitor and revise the QA/QI program, which is crucial for maintaining quality care standards.
The facility failed to maintain a licensed nursing home administrator (LNHA) with a valid license, affecting all 39 residents. Administrator #280's license expired, and there was a period without a licensed LNHA until Administrator #285 temporarily filled the role. This lapse was identified through BELTSS verification and staff interviews.
The facility failed to complete quarterly MDS assessments within the required timeframes for three residents. One resident with dementia had an assessment due on a specific date but completed later, requiring substantial assistance with daily activities. Another resident with schizoaffective disorder and diabetes had a delayed assessment, needing assistance with daily tasks. A third resident with vascular diseases also experienced a delay, despite being cognitively intact. The MDS Nurse confirmed these delays, violating CMS guidelines.
A facility failed to transmit MDS assessments for a resident with chronic conditions to CMS as required. The resident's assessments, including an annual, a significant change, and two quarterly MDS assessments, were not sent. An MDS Nurse confirmed the oversight, which is against the CMS RAI 3.0 User Manual requirements for Medicare/Medicaid-certified facilities.
A resident with peripheral vascular disease and venous insufficiency did not receive prescribed TED hose or ACE wraps, as observed over two days. Despite physician orders, the resident's lower extremities were not properly covered, confirmed by an LPN. The facility lacked a policy to ensure adherence to physician orders, leading to a deficiency in care.
The facility failed to obtain ordered laboratory tests for three residents, affecting their care. A resident with multiple diagnoses did not receive a lipid panel as ordered. Another resident with cognitive impairment had no documentation of required tests being completed. A third resident with heart disease and diabetes had missing lab results. The issue arose from a change in laboratory providers, and the facility lacked a policy for obtaining lab values.
A facility failed to maintain proper infection control practices during wound care for a resident with multiple medical conditions. An LPN did not perform hand hygiene after removing soiled dressings and before applying new gloves, despite the facility's policy emphasizing the importance of hand hygiene in preventing infections.
A facility failed to ensure proper infection control when a staff member touched a resident's genitalia without gloves during care. The resident, who required full assistance, reported the incident, which was confirmed by video surveillance. The facility's policy requires gloves to be worn during such interactions.
Failure to Provide Ordered Speech Therapy Services
Penalty
Summary
The deficiency involves the facility’s failure to provide ordered speech therapy services for two residents requiring specialized rehabilitative care. One resident, admitted with diagnoses including dysphagia, dementia, and rheumatoid arthritis, had an MDS indicating severe cognitive impairment and a need for supervisory support with eating, positioning, and transferring, while remaining independently mobile in a manual wheelchair. Physician orders directed continuation of the resident’s existing speech therapy plan of care under a new provider effective 02/01/26, with a treatment plan calling for speech therapy twice weekly for four weeks during the certification period 02/01/26–02/28/26. The short-term goals included tolerating a mechanical soft diet without signs or symptoms of aspiration and performing oral-motor strength exercises to improve swallow function. Record review showed only one 23‑minute speech therapy session on 02/20/26, with no other speech therapy visits documented during the certification period. The second resident, admitted with a history of cerebral infarction, dysphagia following cerebral infarction, and other speech and language deficits following cerebral infarction, had an MDS showing moderately impaired cognition, a need for supervisory support with eating, and dependence on staff for positioning and transferring, while also being independently mobile in a manual wheelchair. Physician orders similarly required continuation of this resident’s speech therapy plan of care under a new provider effective 02/01/26, with a plan of treatment specifying speech therapy three times weekly for four weeks during the same certification period. Short-term goals included improving communication and speech intelligibility and tolerating a regular texture diet without signs or symptoms of aspiration. Documentation revealed only one 23‑minute speech therapy session on 02/20/26, with no additional visits recorded. In an interview, the Therapy Regional Manager stated that rehabilitative therapy services began on 02/02/26 after termination of the previous therapy contractor, confirmed that both residents received speech therapy only on 02/20/26, and acknowledged that although telehealth speech therapy was available, it was not used.
Failure to Provide Coffee and Post Menus for Resident Review
Penalty
Summary
The facility failed to ensure that coffee was available to residents as indicated on the facility's weekly menu, and did not make menus available for resident review. Observations revealed that coffee, which was supposed to be offered daily with breakfast, was not provided to all residents on the morning in question due to insufficient supply. Interviews with residents confirmed that some were not offered coffee and had to drink hot chocolate instead. The Dietary Manager acknowledged that only one pot of coffee was available and that additional coffee had to be purchased after breakfast. The Dietary Manager was unaware that some residents did not receive coffee as requested. Additionally, the facility did not have weekly or daily menus posted or displayed in the dining or common areas for residents to review. Both staff and residents confirmed that menus were not accessible, and residents had to ask staff or kitchen personnel about the meals being served each day. The weekly menu, created by a contracted food service company, did not specify which vegetables or desserts would be served, only listing them as alternates or assorted options. This deficiency had the potential to affect all residents receiving meals from the kitchen.
Failure to Follow Enhanced Barrier Precautions During Resident Care
Penalty
Summary
Staff failed to follow proper infection control practices for a resident who was under Enhanced Barrier Precautions (EBP) due to wounds. The resident, who had quadriplegia, a history of pressure ulcers, an indwelling urinary catheter, and incontinence of stool, required staff to don both gowns and gloves before providing high-contact care, as indicated by signage in the room and facility policy. Multiple video recordings over several days showed various staff members, including nurses and CNAs, providing direct care to the resident while wearing gloves but not donning the required protective gowns. These observations were verified by the facility's Administrator and DON during a review of the footage. The facility's policy on Transmission Based Precautions clearly stated that both gowns and gloves were required for high-contact care activities such as hygiene, linen changes, and wound care. The failure to adhere to these procedures was identified through medical record review, direct observation, staff interviews, and review of facility investigation materials.
Failure to Perform Hand Hygiene During Meal Service
Penalty
Summary
Staff failed to perform proper hand hygiene during meal service, as observed when the Activities Director delivered breakfast trays to six residents without washing or sanitizing hands between rooms or after touching potentially contaminated surfaces. The Activities Director also handled food items, such as buttering and applying jelly to toast with bare hands, and touched residents directly without using gloves. These actions were observed during a single meal service and involved multiple instances of moving between residents and handling both food and residents without appropriate hand hygiene. Interviews with the Activities Director, a CNA, the Director of Operations, and the Administrator confirmed that staff should have washed or sanitized their hands between residents and used gloves when directly handling food. Facility policy review indicated that all staff are required to comply with CDC hand hygiene guidelines, including performing hand hygiene before direct contact with residents. The deficiency was identified during a complaint investigation and affected six residents out of those reviewed for handwashing.
Failure to Provide Requested Shaving Care Compromises Resident Dignity
Penalty
Summary
A deficiency was identified when a resident, who was cognitively intact and required assistance with activities of daily living, was not provided shaving care as requested. The resident had a history of chronic medical conditions including COPD, diabetes, CVA, seizure disorder, anxiety, depression, bipolar disorder, and asthma. During an observation of incontinence care, it was noted that the resident had long hair under her arms and on her legs. The resident reported that she had asked to have her legs and underarms shaved during her last shower, but this was not done by the assigned CNA. Staff interviews confirmed that the CNA responsible for the resident's last shower did not perform shaving, stating that shaving was only done if time permitted and that she would not ask the resident about shaving even if hair was observed. This was despite the facility's policy, which required assistance with shaving to be provided as needed according to resident preference. Documentation on the shower sheet also indicated that shaving was not completed. The failure to provide requested shaving care resulted in the resident experiencing a lack of dignity and respect for her personal preferences.
Failure to Report Resident Abuse Allegation to State Agency
Penalty
Summary
The facility failed to ensure that an allegation of abuse made by a resident was reported to the state agency as required. A cognitively intact resident with multiple medical diagnoses, including COPD, diabetes, CVA, seizure disorder, anxiety, depression, bipolar disorder, and asthma, reported that after winning a meal through a facility lottery, an LPN took her meal away in the dining room and directed her to eat in her room. The resident described the LPN's actions as abusive, particularly the act of snatching the meal, and stated that this caused her significant distress. A CNA who witnessed the interaction described the LPN's tone as rude and disrespectful, though did not see the meal being physically taken away. The CNA later reported the incident to the DON, who stated she would look into it and clarified that residents could eat any meal in the dining room. Despite the resident's allegation and the CNA's report to the DON, the incident was not documented in the progress notes, nor was it reported to the state agency as required by facility policy. The Administrator confirmed during interview that she was unaware of the allegation and acknowledged that it should have been reported. Facility policy mandates immediate reporting of all allegations of abuse to the Administrator and the state agency within 24 hours, but this procedure was not followed in this case.
Failure to Investigate Alleged Abuse
Penalty
Summary
The facility failed to ensure an investigation was completed following an allegation of abuse involving a resident with multiple medical conditions, including COPD, diabetes, CVA, seizure disorder, anxiety, depression, bipolar disorder, and asthma. The resident, who was cognitively intact and required varying levels of assistance for daily activities, reported that after winning a meal through a facility lottery, an LPN took her meal away in the dining room and directed her to eat in her room. The resident described the LPN's actions as upsetting and abusive, particularly the manner in which the meal was taken from her. A CNA who overheard the interaction described the LPN's tone as rude and disrespectful, and later reported the incident to the DON, who stated she would look into it. Despite the report made to the DON, the Administrator confirmed that she was unaware of the allegation and that no investigation had been conducted. Review of the facility's abuse prevention policy indicated that all allegations of abuse should be immediately reported to the Administrator and the state, and that an investigation should be completed within five working days. The lack of investigation and failure to follow reporting protocols constituted a deficiency in responding appropriately to alleged violations.
Failure to Provide Timely Incontinence Care
Penalty
Summary
Staff failed to provide timely incontinence care for a resident with multiple medical diagnoses, including COPD, diabetes, CVA, seizure disorder, anxiety, depression, bipolar disorder, and asthma. The resident was cognitively intact and required partial to moderate assistance for toileting, bed mobility, and transfers, and was frequently incontinent of bladder and always incontinent of bowel. According to the care plan, staff were to assist with cleansing and changing after each incontinence episode. Documentation showed the last check and change occurred at 2:54 A.M. From 9:32 A.M. to 11:26 A.M., no staff entered the resident's room to provide care. At 11:26 A.M., the resident was observed to be heavily soiled with urine, with a wet pad and noticeable odor. A CNA confirmed the resident had not been changed since 2:54 A.M. and acknowledged that care should have been provided every two hours. The resident also stated she would like to be changed every two hours, but this did not occur that morning. Facility policy required assistance with toileting and maintaining hygiene when residents could not do so independently.
Failure to Follow Fluid Restriction Order for Resident with CHF
Penalty
Summary
A deficiency occurred when the facility failed to ensure that a fluid restriction order for a resident with congestive heart failure, hypertension, and diabetes was properly followed. The physician's order specified a 2,000 ml fluid restriction in a 24-hour period, with specific allocations for dietary and nursing departments, and required documentation of intake every shift. Medical record review showed that the resident was consistently provided with less than the ordered amount of fluids, being shorted 1,000 ml for 25 days and 700 ml for 44 days. The care plan identified a risk for fluid imbalance and included interventions for assistance and supervision with fluid intake, but these were not effectively implemented. Interviews revealed that the resident frequently expressed thirst and sometimes did not receive fluids when requested. Staff confirmed that the resident regularly asked for water and that requests were reported to nursing, but fluids were only provided if the resident was not over the fluid limit. The registered dietician verified that the resident had been under the fluid restriction amount on all reviewed days. Facility policy required nursing to evaluate and document fluid intake for residents at risk for nutritional problems and to report variations, but this was not adequately done, resulting in the deficiency.
Kitchen Sanitation and Food Storage Deficiencies
Penalty
Summary
The facility failed to maintain the kitchen in a clean and sanitary manner, as observed during a survey. The ice maker had debris on the outside and a brownish-red substance inside the ice dispensing chute. Additionally, a small chest freezer designated for residents' private foods had a significant ice build-up, preventing the inner basket from being moved. The freezer contained various food items, including breakfast sandwiches and tater tots, which were not dated or labeled with resident names. The produce cooler also had ice build-up and contained tomatoes, one of which was visibly rotten, and others with soft indents. The Dietary Manager confirmed these observations, acknowledging the debris on the ice maker, the substance inside the ice machine, the ice build-up in the freezer, and the lack of proper labeling on food items. The facility's policies require foods brought in from outside to be dated and labeled with the resident's name and mandate that all kitchen areas and equipment be maintained in a sanitary manner, free of debris. The policy also requires supervisors to inspect freezers monthly for excess condensation and ensure they are clean and sanitized regularly.
Medical Director's Absence from QAPI Meeting
Penalty
Summary
The facility failed to ensure that the Medical Director or their designee attended the quarterly Quality Assurance and Performance Improvement (QAPI) meetings as required. This deficiency was identified through a review of the facility's QAPI attendance logs, staff interviews, and policy review. Specifically, the Medical Director or their designee did not attend the quarterly meeting held on April 23, 2024. The Director of Nursing (DON) confirmed the absence of documentation to verify the attendance of the Medical Director or their designee at this meeting. The facility's policy, dated May 1, 2024, mandates that the QAPI committee, which includes the Medical Director/Physician among other key staff members, meets at least quarterly to monitor and revise the Quality Assurance/Quality Improvement (QA/QI) program. This program is essential for maintaining standards of quality care and improving service delivery and resident outcomes.
Failure to Maintain Licensed Nursing Home Administrator
Penalty
Summary
The facility failed to ensure that a licensed nursing home administrator (LNHA) with a valid license was providing supervision and leadership. This deficiency was identified through a review of the online verification system of the Board of Executives of Long-Term Services and Supports (BELTSS), the Administrator job description, and staff interviews. It was confirmed that Administrator #280, who had been serving as the LNHA of record, had an expired license during a specific period. This lapse in licensure had the potential to affect all 39 residents residing in the facility. Administrator #280 confirmed that she was notified by a BELTSS representative about the expiration of her LNHA license. During the period when her license was expired, Administrator #285, employed by the facility corporation, served as the LNHA. However, there was a gap when no licensed LNHA was serving, which was from the expiration of Administrator #280's license until it was renewed. The facility's job description for the Administrator role clearly stated the requirement for a current state license as a Nursing Home Administrator, which was not met during this period.
Failure to Complete MDS Assessments Timely
Penalty
Summary
The facility failed to ensure that quarterly Minimum Data Set (MDS) assessments were completed within the required timeframes for three residents. Resident #26, who has medical diagnoses including dementia and Alzheimer's disease, had an MDS assessment with an Assessment Reference Date (ARD) of 09/07/24, but it was not completed until 09/24/24. This resident was noted to have moderate cognitive impairment and required substantial assistance with daily activities. Similarly, Resident #2, with diagnoses such as schizoaffective disorder and type II diabetes mellitus, had an ARD of 08/23/24, but the assessment was completed on 09/09/24. Resident #9, diagnosed with peripheral vascular diseases, had an ARD of 08/25/24, with the assessment completed on 09/24/24. Both residents were cognitively intact but required varying levels of assistance with daily activities. The MDS Nurse confirmed these assessments were not completed within the 14-day timeframe as required by the CMS Long-Term Care Facility Resident Assessment Instrument (RAI) 3.0 User Manual.
Failure to Transmit MDS Assessments to CMS
Penalty
Summary
The facility failed to ensure that Minimum Data Set (MDS) assessments were transmitted to the Centers for Medicare and Medicaid Services (CMS) as required. This deficiency affected one resident, identified as Resident #94, out of 12 residents reviewed for MDS assessments. The facility's census at the time was 39. Resident #94 had been admitted with medical diagnoses including chronic obstructive pulmonary disease, diabetes mellitus, anemia, hypertension, and moderate protein calorie malnutrition. The medical record review revealed that there was no documentation to support the timely transmission of MDS assessments for this resident, specifically for an annual MDS assessment, a significant change MDS assessment, and two quarterly MDS assessments. An interview with MDS Nurse #255 confirmed that the MDS assessments for Resident #94, dated 12/16/23, 02/07/24, 05/01/24, and 07/30/24, were not transmitted to CMS. According to the CMS Long-Term Care Facility RAI 3.0 User Manual, all Medicare and/or Medicaid-certified nursing homes must transmit required MDS data records to the CMS Internet Quality Improvement Evaluation System (iQIES). The manual specifies that the required MDS records include comprehensive, quarterly, and PPS assessments mandated under the Omnibus Budget Reconciliation Act (OBRA) and Skilled Nursing Facility Prospective Payment System (SNF PPS).
Failure to Follow Physician Orders for Compression Garments
Penalty
Summary
The facility failed to adhere to physician orders for a resident with peripheral vascular disease and venous insufficiency, leading to a deficiency in treatment for skin conditions. The resident, who was cognitively intact and required varying levels of assistance with daily activities, had a care plan indicating the need for compression garments to prevent skin integrity impairment. The physician's order specified the application of black thrombo-embolic deterrent (TED) hose or all cotton elastic (ACE) wraps to the resident's lower extremities every morning, to be removed every evening. Observations on two consecutive days revealed that the resident was not wearing the prescribed TED hose or ACE wraps, with only a Tubigrip dressing on one leg and the other leg uncovered. Interviews with an LPN confirmed the absence of the required compression garments on both days, despite the existing physician order. Additionally, the facility administrator acknowledged the lack of a policy to ensure compliance with physician orders, contributing to the deficiency in care.
Failure to Obtain Ordered Laboratory Tests
Penalty
Summary
The facility failed to obtain laboratory testing as ordered by the physician for three residents, affecting their care. Resident #28, who was cognitively intact and had multiple diagnoses including chronic obstructive pulmonary disease and heart failure, had a physician order for a complete metabolic panel (CMP), lipid panel, and complete blood count (CBC) with differential to be obtained every six months. However, the last blood work results were from February 2024 and did not include a lipid panel. Resident #26, with moderate cognitive impairment and diagnoses such as dementia and Alzheimer's disease, had orders for a serum magnesium test annually and a CMP, hemoglobin A1c (HbA1c), and lipid panel every six months. There was no documentation that these tests were completed as ordered. Resident #11, who was moderately cognitively impaired and had conditions like atherosclerotic heart disease and type two diabetes mellitus, had orders for a CMP, CBC with differential, thyroid stimulating hormone (TSH), and thyroxine (T4) to be obtained every six months. However, there was no documentation of these tests being completed in April 2024. The Director of Nursing (DON) revealed that the issue arose when the facility switched laboratory providers, and the new provider could not access the laboratory orders from the electronic medical records, leading to missed tests. The facility did not have a policy on obtaining laboratory values as ordered, contributing to the oversight.
Inadequate Hand Hygiene During Wound Care
Penalty
Summary
The facility failed to appropriately perform hand hygiene during dressing changes for a resident, which compromised infection control practices. The resident, who was cognitively intact and dependent on staff for various activities, had multiple medical conditions including quadriplegia and neuromuscular dysfunction of the bladder. The resident had specific physician orders for wound care, including cleansing and dressing changes for the suprapubic catheter site and wounds on the sacrum and ischium. During an observation, an LPN and an STNA performed wound care on the resident. Although they initially washed their hands and wore gloves, the LPN did not perform hand hygiene after removing soiled dressings and before applying new gloves for each wound site. This was confirmed in an interview with the LPN. The facility's handwashing policy emphasized the importance of hand hygiene before and after handling dressings and gloves, which was not adhered to during the procedure.
Failure to Use Gloves During Resident Care
Penalty
Summary
The facility failed to ensure proper infection prevention and control practices during resident care, specifically in the use of gloves. A resident, who was cognitively intact and required full assistance for personal hygiene and transfers, reported that a female staff member touched his genitalia with ungloved hands while providing care. This incident was corroborated by video surveillance, which showed the staff member touching the resident's genital area without gloves and subsequently apologizing for the oversight. The facility's policy on Peri Care, dated 05/01/22, mandates that staff perform hand hygiene and apply gloves prior to resident contact. The incident involved a State tested Nurse Aide (STNA) who was identified by the Administrator and the Director of Nursing during a review of the video surveillance. This deficiency was investigated under Complaint Number OH00155648.
Latest citations in Ohio
A resident with intact cognition receiving Medicare Part A skilled services for metabolic encephalopathy had services discontinued while benefit days remained, but the facility did not issue the required Skilled Nursing Facility Advance Beneficiary Notice (SNF ABN). The Social Services Director later confirmed that no SNF ABN was provided and reported she believed only a Notice of Medicare Non-Coverage (NOMNC) was needed when all skilled services were stopped. This practice conflicted with the facility’s written policy, which required SNF ABNs to be issued when extended care items or services were initiated, reduced, or terminated due to expected non-coverage by Medicare.
Surveyors identified that the facility exceeded the acceptable medication error rate when two residents with type 2 DM received insulin doses that were not administered according to orders or manufacturer instructions. In two separate observations, an LPN administered Novolog and another LPN administered insulin glargine and insulin lispro without priming the insulin pens, and the insulin lispro and Novolog were given after the residents had already consumed a significant portion of their breakfast meals, despite orders for administration before meals. Manufacturer information for both insulin products required priming before each injection to ensure accurate dosing, and facility policy required medications, including insulin, to be administered safely, timely, and in accordance with prescriber orders and specified time frames.
Surveyors found that the facility failed to document tray line food temperatures for multiple meals served from two dining room kitchenettes, despite having a “Trayline Taste & Temperature Log” and a policy requiring food to be stored, prepared, distributed, and served according to professional food safety standards. Review of logs showed repeated missing entries for breakfast, lunch, and dinner services in both the Harrison and McClellan dining areas, and the Senior Director of Culinary Services confirmed that temperatures had not been recorded for those meals, potentially affecting all residents receiving meals from those kitchenettes.
The facility failed to conduct and document required periodic care conferences for two residents, despite multiple comprehensive, quarterly, and significant change MDS assessments and a policy requiring periodic care conferences with resident and/or family participation. One resident with Parkinson’s disease, post-stroke hemiplegia, TIA, DMII, and depression had only two documented care conferences over a year, while another resident with aphasia, cerebrovascular disease, DMII, gait difficulty, coagulation defect, depression, and muscle weakness had no documented care conferences in the past year, aside from a declined invitation to the representative. The UCC confirmed that care conferences were expected to occur quarterly and that no additional documentation existed for either resident.
A resident with Alzheimer's disease and type II DM, who required extensive assistance with ADLs and was receiving scheduled Lantus and sliding-scale Humalog, experienced a severely elevated blood glucose level. The on-call provider was notified and ordered an additional dose of lispro insulin with a directive to recheck the blood glucose after administration. Nursing staff administered the extra insulin but did not document any follow-up blood glucose check, and the DON confirmed that this reevaluation was required by the facility's abnormal blood glucose policy and was not completed or documented.
A resident with Parkinson’s disease, dementia, and hypothyroidism was prescribed levothyroxine once daily along with other medications. A consultant pharmacist’s monthly drug regimen review recommended that levothyroxine be given in the morning on an empty stomach, 30–60 minutes before food, per manufacturer instructions. The medical record contained no documented physician response to this recommendation, and the MAR showed the drug scheduled for morning administration while the resident was observed eating breakfast and receiving the medication at the same time. An LPN confirmed administering levothyroxine during the meal, and the DON verified there was no documentation explaining whether or why the pharmacist’s recommendation was or was not followed, resulting in a failure to act on and document the identified irregularity.
A resident with severe cognitive impairment, multiple comorbidities, documented gait and balance abnormalities, and a high fall risk was care planned and assessed by therapy to require contact guard assistance and use of a gait belt for transfers and ambulation. While being assisted by a CNA from a recliner to the bathroom with a walker, the CNA did not apply a gait belt, even though the resident had a known tendency to lean backward when standing. As the CNA reached to open the bathroom door, the resident lost balance and fell backward, striking the back of the head, and was later found by an LPN without a gait belt in place, contrary to the facility’s gait belt policy and the resident’s assessed needs.
A resident with CKD stage five requiring peritoneal dialysis (PD) was admitted with pre-admission physician orders for three daily PD exchanges and monitoring for peritonitis (fever, abdominal pain, cloudy effluent), but these monitoring orders were not entered into the facility’s physician orders. The care plan referenced PD and general monitoring but did not specifically address peritonitis monitoring. Paper PD flowsheets showed incomplete and inconsistent documentation of exchanges and resident condition, including missing condition/comments for individual treatments and no record of one ordered PD exchange. The PD cycler flowsheet lacked effluent descriptions on multiple days. The PD nurse reported facility staff were expected to monitor effluent and symptoms, and the DON confirmed the absence of specific peritonitis monitoring orders, lack of an order for the PD cycler, and documentation gaps, despite a facility policy requiring ongoing assessment and monitoring for complications before, during, and after dialysis treatments.
A nurse was observed preparing multiple oral medications for a resident with depression, traumatic brain injury, anxiety, and impaired cognition by pushing tablets and capsules from unit-dose cards directly into her ungloved hand and then using her fingers to place them into a medication cup. In a follow-up interview, the RN confirmed this practice and acknowledged that the correct procedure is to dispense medications directly from the card into the cup, contrary to the facility’s medication administration policy requiring adherence to good nursing principles and practices.
A resident with Alzheimer’s disease, diabetes, anxiety, significant ADL dependence, and behavioral symptoms was observed seated in a chair positioned against the nursing station with a locked wheelchair placed directly in front, also against the nursing station, effectively restricting movement. An LPN confirmed both wheelchair wheels were locked and that it should not have been placed there, while a CNA stated she had positioned the wheelchair to prepare for lunch, was unable to complete the transfer, and left it in place, acknowledging this was wrong. This arrangement conflicted with the facility’s restraint policy, which prohibits physical restraints except when alternatives are ineffective for treating a medical symptom and defines restraints as devices adjacent to the body that cannot be easily removed and that restrict freedom of movement or access to the body.
Failure to Issue Required SNF ABN When Discontinuing Medicare Part A Services
Penalty
Summary
The deficiency involves the facility’s failure to issue a Skilled Nursing Facility Advance Beneficiary Notice (SNF ABN) when Medicare Part A services were discontinued for a resident who still had available benefit days. The resident was admitted with a diagnosis of metabolic encephalopathy and had intact cognition per the Minimum Data Set assessment. The facility’s own SNF Beneficiary Notification Review documented that Medicare Part A skilled services began on 02/11/26 and the last covered day was 03/11/26, and that the facility initiated discharge from Medicare Part A services before the resident’s benefit days were exhausted. Despite this, no SNF ABN was provided to the resident or the resident’s representative. During interviews, the Social Services Director stated that the SNF ABN was issued hours prior to the last covered day but, upon reviewing her files, confirmed that no SNF ABN had actually been issued for this resident. She further explained that she believed an SNF ABN was only required if one skilled service remained and that if all skilled services were being discontinued, only the Notice of Medicare Non-Coverage (NOMNC) needed to be issued. The Administrator, however, stated that a resident should always receive both a SNF ABN and a NOMNC when Medicare Part A services are discontinued and benefit days remain. Review of the facility’s written policy dated 03/28/23 showed that the facility was required to issue SNF ABNs for initiation, reduction, or termination of extended care items or services when Medicare payment was not expected, which did not occur in this case.
Plan Of Correction
This Plan of Correction is submitted as required under State and Federal law. This Plan of Correction does not constitute an admission on the part of the Facility that the findings cited are accurate, that the findings constitute a deficiency or that the scope and severity regarding the deficiency cited are correctly applied. Any changes to the Facility's policies and procedures should be inadmissible in any proceeding on that basis. Without admitting or denying the validity or the existence of the alleged noncompliance, the Facility submits this Plan of Correction with the intention that it be inadmissible by any third party in any civil or other action against the facility or any employee, agent, officer, director or shareholder of the Facility. The Facility is utilizing this Plan of Correction as its allegation of substantial compliance as of 05/29/2026 F-0582 Corrective action for resident/s: On 5/14/26 Resident #34 was informed of rights and responsibilities related to Advanced Beneficiary Notice and voiced understanding of information for future reference by administrator. Identification of other residents who may be affected: Any resident receiving skilled services from nursing or therapy services. The Administrator audited all residents who were discharged from skilled services in the past 30 days to ensure they were issued a Notice of Non-Coverage and Advanced Beneficiary Notice on 5/29/26. No non-compliance was noted. Measures for systemic change: On 5/14/2026 Business Office Manager, Director of Rehab, Minimum Data Set nurse, Director of Nursing and Social Services Director were educated on proper procedure of issuing of Notice Of Medicare Non Coverage and Advanced Beneficiary Notice by administrator. All upcoming discharges from skilled services will be reviewed weekly at Utilization Review meeting to ensure notices will be delivered timely. How Corrective Action will be monitored: Administrator or designee to complete audits of all residents being discharged from skilled services to ensure they were issued a Notice of Non-Coverage and Advanced Beneficiary. This audit will be completed weekly x 4 weeks, then monthly x 2 months. Corrective action will be initiated for any noted non-compliance. Audit findings will be reviewed as part of the monthly quality assurance process to determine the need for further monitoring. Date of Compliance 5/29/26
Insulin Administration Errors and Failure to Prime Insulin Pens
Penalty
Summary
The deficiency involves the facility’s failure to maintain a medication error rate below 5%, with surveyors identifying 3 errors out of 28 medication administration opportunities, resulting in a 10.71% error rate. For one resident with type 2 diabetes mellitus and moderate cognitive impairment, the physician’s order directed Novolog insulin 10 units via subcutaneous pen-injector to be given before meals. During an observed medication pass, the LPN administered 10 units of Novolog insulin without priming the pen and did so after the resident had already consumed approximately 50% of the breakfast meal. The LPN later confirmed she did not prime the pen and acknowledged that the insulin was ordered to be administered prior to meals. Manufacturer instructions for the Novolog FlexPen specified that an air shot (priming) must be performed before each injection to ensure proper dosing. Another resident, also diagnosed with type 2 diabetes mellitus and with intact cognition, had orders for insulin glargine 35 units subcutaneously twice daily and insulin lispro 20 units subcutaneously before meals, plus 12 units subcutaneously if blood glucose was between 251 mg/dL and 300 mg/dL. During an observed medication administration, an LPN administered 35 units of insulin glargine and 32 units of insulin lispro without priming the insulin pens and after the resident had consumed approximately 90% of the breakfast meal, despite orders for insulin lispro to be given before meals. The LPN later stated she could not remember if she had primed the pen and acknowledged that the insulin was ordered to be administered prior to meals. Manufacturer information for insulin lispro stated that the pen must be primed before each injection to confirm insulin delivery and remove air, and that failure to prime could result in too much or too little insulin. The DON confirmed the expectation that insulin be administered as ordered, including priming each pen with two units before dialing the prescribed dose, and facility policy required medications, including insulin, to be administered safely, timely, and in accordance with prescriber orders and required time frames.
Plan Of Correction
This Plan of Correction is submitted as required under State and Federal law. This Plan of Correction does not constitute an admission on the part of the Facility that the findings cited are accurate, that the findings constitute a deficiency or that the scope and severity regarding the deficiency cited are correctly applied. Any changes to the Facility's policies and procedures should be inadmissible in any proceeding on that basis. Without admitting or denying the validity or the existence of the alleged noncompliance, the Facility submits this Plan of Correction with the intention that it be inadmissible by any third party in any civil or other action against the facility or any employee, agent, officer, director or shareholder of the Facility. The Facility is utilizing this Plan of Correction as an allegation of substantial compliance as of 5/29/2026. F-0759 Corrective action for resident/s: Residents #21 and #22 were assessed and evaluated by nurse and Director of Nursing 5/14/26. Resident #21 and #22 both denied any adverse effects and none were noted upon assessment by the Director of Nursing on 5/14/2026. Notification made to physician on 5/14/2026. LPN # 2 competency Eval on insulin administration with the Director of Nursing completed 5/14/2026. Identification of other residents who may be affected: Diabetic residents on assignment of LPN #2/station 2 have the potential to be affected and were assessed by the DON/Designee on 5/14/26 and found to be within normal limits. Measures for systemic change: All Nurses were educated by the Director of Nursing on the steps for Insulin administration per competency, diabetes clinical protocol policy, Medication and treatment orders policy, administering medications policy, and Obtaining fingerstick Glucose Level policy On 5/14/2026. How Corrective Action will be monitored: Director of Nursing and Assistant Director of Nursing will complete insulin administration audits on 5 nurses. This audit will be completed weekly x 4 weeks, then monthly x 2 months. Corrective action will be initiated for any noted non-compliance. Audit findings will be reviewed as part of the monthly quality assurance process to determine the need for further monitoring. Date of Compliance: 5/29/2026
Failure to Document Tray Line Food Temperatures in Dining Room Kitchenettes
Penalty
Summary
The deficiency involves the facility’s failure to document tray line food temperatures for meals served from the Harrison and McClellan Dining Room kitchenettes, as required by professional standards for food service safety and the facility’s own policy. Review of the “Trayline Taste & Temperature Log” (revised September 2018) showed missing temperature documentation for multiple meals from the Harrison Dining Room kitchenette, including dinner on 03/30/26 and 03/31/26, lunch and dinner on 04/01/26 and 04/02/26, dinner on 04/07/26, and lunch and dinner on 04/08/26 and 04/10/26. The Senior Director of Culinary Services confirmed during interview that tray line food temperatures were not documented on the log for these meals. Similarly, review of the same log for the McClellan Dining Room kitchenette revealed that tray line food temperatures were not documented for dinner on 04/01/26, breakfast and lunch on 04/02/26, and lunch and dinner on 04/07/26. The Senior Director of Culinary Services also verified these omissions during interview. The facility census at the time was 27 residents, and the governing “Food and Nutrition” policy, approved on 09/07/21, stated that the facility must store, prepare, distribute, and serve food in accordance with professional standards for food service safety.
Plan Of Correction
F812 The facility will continue to ensure food temperatures are completed before meals are served for all residents. To ensure compliance with this standard the following measures have been taken: 1. Immediately 4/15/26 culinary supervisor #224 was re-educated by Dietary Manager to this standard and policy "Food and Nutrition" which includes documentation of food temperatures. 2. All dietary staff have been re-educated to the standard and policy "Food and Nutrition" during the month of April 2026. 3. Audits of food temperature documentation to be completed by Dietary Manager 4 x per week for 4 weeks then weekly for 4 weeks. 4. Administrator to validate audits/compliance and provide additional training as needed. Administrator will present to QAPI committee for ongoing monitoring and further direction.
Failure to Conduct and Document Required Care Conferences
Penalty
Summary
The deficiency involves the facility’s failure to complete and document comprehensive care conferences at required intervals in accordance with care plan regulations and facility policy. For one resident with Parkinson’s disease with dyskinesia, cognitive communication deficit, hemiplegia and hemiparesis following cerebral infarction, transient cerebral ischemic attack, type II diabetes mellitus, and major depressive disorder, the record showed multiple MDS assessments over a one-year period, including annual, quarterly, and significant change assessments. However, only two care conferences were documented during the last 12 months, despite the expectation that care conferences be conducted quarterly with the resident and family when possible. The Unit Care Coordinator confirmed that no additional care conference documentation existed for this resident beyond the notes dated 04/21/25 and 01/02/26. A second resident, with diagnoses including aphasia following cerebrovascular disease, cerebral infarction, type II diabetes mellitus, unsteadiness on feet, difficulty in walking, coagulation defect, depression, and muscle weakness, also had multiple MDS assessments completed over the review period, including quarterly and annual assessments. The record contained a note that a care conference was offered to the resident’s representative, who declined to attend, but there was no documentation of any care conferences for the most recent 12 months. The Unit Care Coordinator confirmed that no other care conference documentation was available for this resident. Facility policy stated that periodic care conferences involving the resident, family, and the interdisciplinary team are part of the care planning process, but the required periodic care conferences and corresponding documentation were not completed for these two residents.
Plan Of Correction
THIS PLAN OF CORRECTION SERVES AS BERKELEY SQUARE'S CREDIBLE ALLEGATION OF SUBSTANTIAL COMPLIANCE AS OF June 1, 2026. Without admitting or denying the validity or existence of the alleged deficiencies, Berkeley Square provides the following Plan of Correction: F657 The facility will continue to document completion of care conferences at the required intervals for all residents, including residents #04 & #15. To ensure compliance with this standard the following measures have be taken: 1. The social service designee and the inter- disciplinary team were re-educated by the administrator to the facility policy "Care Conference" on 4/29/26 and verbalized understanding. 2. Care conferences for resident #04 and resident #15 were conducted on or before 4/29/2026 by the interdisciplinary team. 3. Review of all other residents was conducted by the social service designee to validate and ensure that care conference schedule is up to date with timely care conferences scheduled for them on 4/15/2026. Audits of care conferences to be completed weekly for four weeks and then monthly after that by the social service designee. Documentation of the care conference including any identified concerns in the medical record. Administrator to validate audits/compliance and provide additional training as needed. Administrator will present results of these audits to QAPI committee for ongoing monitoring and further direction.
Failure to Reevaluate Blood Glucose After Treatment for Hyperglycemia
Penalty
Summary
The facility failed to ensure that a resident with diabetes received treatment in accordance with professional standards of practice when nursing staff did not reevaluate the resident's blood glucose after treatment for severe hyperglycemia. The resident, admitted with diagnoses including Alzheimer's disease, type II diabetes mellitus, and depression, had physician orders for Humalog insulin on a sliding scale before meals, Lantus insulin 25 units daily, and lisinopril 5 mg daily. The resident required extensive assistance with activities of daily living, including transfers, toileting hygiene, eating, and bathing. On the evening in question, the resident's blood glucose was documented as 532 mg/dL, and the on-call provider was notified. The provider gave a new order to administer an additional 8 units of lispro (Humalog) and to recheck the blood glucose in 30 minutes. The electronic medication administration record showed that the blood glucose of 532 mg/dL was obtained at 9:00 p.m. and that the additional 8 units of lispro were administered at 9:21 p.m. However, there was no documentation in the resident's chart that the blood glucose was rechecked after the additional insulin was given. In an interview, the DON confirmed there was no evidence of reevaluation and verified that, according to the facility's "Abnormal Blood Glucose Procedure" policy, the resident should have been reevaluated and that the evaluation step should have been included in the progress note documentation.
Plan Of Correction
F684 The facility will continue to ensure all residents, including #03, receive treatment in accordance with professional standards of practice and reevaluated for hyperglycemia. To ensure compliance with this standard the following measures have been taken: 1. The director of nursing assessed resident #03, reviewed documentation and orders and found no ill effects immediately 4/16/26. 2. All licensed nurses were re-educated to facility policy "Blood Glucose Monitoring" by the Director of Nursing/designee in April 2026. 3. Audits of like-residents that require blood sugar checks to be completed by the director of nursing/designee two times a week for 4 weeks and then monthly after that to validate correct follow through when there is abnormally high blood glucose result. The Administrator will bring results of these audits to the QAPI committee for ongoing monitoring and further direction.
Failure to Act on Pharmacist Drug Regimen Recommendation for Thyroid Medication
Penalty
Summary
The deficiency involves the facility’s failure to ensure that pharmacy recommendations from the monthly drug regimen review were acted upon and documented for a resident. The resident was admitted with diagnoses including Parkinson’s disease, dementia, and hypothyroidism, and had current physician orders for levothyroxine 150 mcg once daily, buspirone 50 mg twice daily, and losartan 100 mg once daily. A medication regimen review dated 11/25/2025 included a consultant pharmacist recommendation that levothyroxine be administered consistently in the morning on an empty stomach, at least 30–60 minutes before food, per manufacturer instructions. There was no specific physician response in the medical record to this recommendation, and the facility’s policy stated that consulting pharmacist reviews are sent to nursing and addressed with the primary care provider or consulting specialist for review and follow-up. Review of the resident’s medication administration record for April 2026 showed levothyroxine scheduled for 9:00 a.m. On observation, the resident was seen eating breakfast in the dining area at 8:03 a.m., and an LPN reported administering the levothyroxine 150 mcg to the resident while the resident was in the dining area eating breakfast. The DON confirmed there was no evidence in the resident’s medical record explaining why the consultant pharmacist’s recommendation from 11/25/2025 was or was not acted upon. This lack of documented physician review and action on the pharmacist’s identified irregularity constituted noncompliance with the drug regimen review requirements.
Plan Of Correction
F756 The facility will continue to ensure the pharmacy recommendations from the monthly drug regimen review by a licensed pharmacist are acted upon for all residents, including #08. To ensure compliance with this standard the following measures have been taken: 1. Resident #08 was assessed by the registered nurse and med review completed by 4/28/26. After review of resident's drug regime's, it was discovered that resident #8 had 2 separate medication recommendations on the same form, to be reviewed by two separate practitioners, pharmacy has been instructed and agreed to separate meds on individual forms. 2. Licensed nurses re-educated to facility policy "Drug Regimen Review" by Director of nursing/designee in April 2026 and no later than 5/8/26. Licensed nurses are responsible for ensuring the reviews and recommendations are given to the physician for timely review. 3. Review of all other current residents Drug Regimen orders completed by Director of nursing/designee on 4/16/26 to ensure recommendations were followed up on/reviewed by the physician and address concerns if needed. 4. Audit of drug regime recommendations, pharmacy recommendations, and physician follow up to be completed weekly for four weeks by the Director of nursing/designee. Administrator will present results of these audits to the QAPI committee for ongoing monitoring and further direction.
Failure to Use Required Gait Belt During Ambulation Resulting in Resident Fall
Penalty
Summary
The deficiency involves the facility’s failure to ensure that a required gait belt was used while assisting a high fall‑risk resident with ambulation, resulting in a fall with head injury. The resident had multiple diagnoses including metabolic encephalopathy, hypertension, osteoarthritis, muscle weakness, gait and mobility abnormalities, major depressive disorder, anxiety, and visual hallucinations. Admission and subsequent MDS and fall risk assessments documented that the resident was severely cognitively impaired, required moderate to maximal assistance with transfers and ambulation, could not independently come to a standing position, exhibited loss of balance while standing, used an assistive device, and had decreased muscle coordination. The resident had a history of falls prior to admission and was assessed as being at high, later moderate, risk for falls. The resident’s fall care plan identified her as at risk for falls and included interventions such as providing maximum to moderate assistance with transfers and walking short distances, use of a walker and wheelchair, and following the facility’s fall protocol. Therapy notes and care conference documentation indicated that the resident leaned backwards when standing, required contact guard to minimal assistance for bed mobility and transfers, and needed constant verbal cueing for safe sequencing during toilet transfers. The physical therapist confirmed that the resident was to use a gait belt with staff when ambulating, and the DON verified that therapy had assessed the resident as requiring contact guard assistance and a gait belt for ambulation and transfers. On the day of the incident, a CNA was assisting the resident from her recliner to the bathroom using a walker. The CNA walked beside the resident, providing guidance and support, and reported having a hand on the resident while assisting her. As they approached the bathroom door, the CNA reached for the doorknob to open it, and at that moment the resident began to lose her balance and fell backwards to the floor, striking the back of her head. The nurse who responded found the resident on her back at the foot of the bed with her feet near the bathroom, noted a red raised area on the back of the head, and documented that the resident was not wearing a gait belt and that the gait belt was on the dresser. In the facility’s investigative summary and in interviews, the CNA acknowledged that she did not have a gait belt on the resident while ambulating her, despite the resident’s assessed need for hands‑on assistance and gait belt use per facility policy and the resident’s care and therapy plans.
Failure to Implement PD Orders and Monitor Resident Receiving Peritoneal Dialysis
Penalty
Summary
The deficiency involves the facility’s failure to implement pre-admission physician orders for peritoneal dialysis (PD) and to provide ongoing monitoring for a resident with chronic kidney disease (CKD) stage five who required PD. Pre-admission orders dated 11/14/25 specified three daily PD exchanges at 6:00 A.M., 2:00 P.M., and 10:00 P.M., and directed staff to monitor for signs and symptoms of peritonitis, including fever, abdominal pain, and cloudy effluent. These monitoring orders were not entered into the facility’s physician orders. The resident’s care plan noted the need for PD and included general monitoring interventions (labs, signs of bleeding, bacteremia, septic shock, and significant vital sign changes), but did not specifically address the ordered monitoring for peritonitis. Review of PD documentation showed incomplete and inconsistent charting of treatments and resident condition. The paper peritoneal flowsheet had columns for time of PD and condition/comments, including instructions to call the nurse immediately for cloudy fluid, abdominal pain, or fever. However, the first entry on 11/15/26 at 2:00 P.M. only noted that the PD nurse completed the exchange, and the 10:00 P.M. entry that day had no condition/comment documentation. Subsequent days (11/16/25, 11/17/25, and 11/18/25) contained only one condition/comment entry per day rather than for each exchange, and there was no documentation that the 6:00 A.M. PD on 11/18/25 was completed. The PD cycler flowsheet starting 11/19/25 lacked any description of the effluent on multiple days. The PD nurse from the dialysis company stated facility staff were expected to monitor effluent for cloudiness and assess for abdominal pain and fever, and the DON confirmed there was no electronic physician order for peritonitis monitoring or for use of the PD cycler, that the paper charting did not allow for effluent description or symptom documentation for each treatment, and that PD was not documented at one ordered time. The facility’s dialysis policy required ongoing assessment and monitoring for complications before, during, and after treatments, which was not reflected in the documentation for this resident.
Improper Infection Control During Medication Administration
Penalty
Summary
Surveyors identified a deficiency in infection prevention and control related to medication administration for Resident #29. The resident was admitted on 02/28/14 with diagnoses including depression, traumatic brain injury, and anxiety, and had impaired cognition per a quarterly MDS assessment. During an observation on 03/25/26 at 6:58 A.M., RN #281 prepared the resident’s medications by removing an Amoxicillin-Pot Clavulanate tablet from the medication card and pushing it directly into her ungloved hand, then using her fingers to place the pill into a medication cup. The same process was observed for multiple other medications, including Escitalopram Oxalate, Furosemide, Sennosides, Lyrica, and Vitamin D, each being pushed from the card into the RN’s ungloved hand and then transferred by her fingers into the medication cup before administration to Resident #29. In a subsequent interview at 7:27 A.M. the same day, RN #281 confirmed she had placed each medication into her ungloved hands prior to administration and acknowledged that the proper procedure was to push the pills directly from the card into the medication cup. Review of the facility’s “Medication Administration – General guidelines” policy, revised 10/08/25, stated that medications are to be administered in accordance with good nursing principles and practices. This practice failure was cited as a deficiency under Complaint Number 2681777.
Improper Use of Wheelchair as a Physical Restraint
Penalty
Summary
Surveyors identified a deficiency related to the facility’s failure to ensure a resident was free from physical restraints. Resident #7, admitted with diagnoses including Alzheimer’s disease, diabetes mellitus, and anxiety disorder, was documented on a recent MDS as rarely understood and dependent for ADLs except eating. The resident ambulated independently on the unit without an assistive device and had documented verbal and other behaviors occurring one to three days during the look-back period. The care plan noted the resident had potential to be physically aggressive, chase staff, throw objects, and be combative with care, with interventions such as offering choices, administering medications as ordered, and intervening early when agitation occurred. During an observation and interview, Resident #7 was found sitting in a chair with the right arm of the chair positioned against the nursing station and a wheelchair placed directly in front of him. The left arm of the wheelchair was also against the nursing station, and both wheelchair wheels were locked, creating a barrier that appeared to restrain the resident, who was sleeping with his knees touching the locked wheelchair. An LPN confirmed both wheelchair wheels were locked and that the wheelchair should not have been placed in front of the resident. A CNA reported she had placed the wheelchair there in preparation to get the resident up for lunch, was unable to transfer him, and left the wheelchair in that position, acknowledging it was wrong to keep it there. The facility’s physical restraint policy stated that physical restraints are not used except when alternatives are not appropriate or effective for treating a medical symptom and defined physical restraints as any device attached or adjacent to the body that the individual cannot easily remove and that restricts freedom of movement or access to the body.
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