Monterey Care Center
Inspection history, citations, penalties and survey trends for this long-term care facility in Grove City, Ohio.
- Location
- 3929 Hoover Road, Grove City, Ohio 43123
- CMS Provider Number
- 365077
- Inspections on file
- 34
- Latest survey
- July 9, 2025
- Citations (last 12 mo.)
- 1
Citation history
Health deficiencies cited at Monterey Care Center during CMS and state inspections, most recent first.
A resident who left AMA had a pending urinalysis that later confirmed a UTI, but there was no documentation that the resident or their representative was notified of the abnormal results. Staff interviews confirmed that notification was expected, but no evidence of contact or attempts to notify was found in the record.
A resident with significant mobility and medical needs was transferred by a CNA using a mechanical lift without the required second staff member, contrary to the care plan and facility policy. During the transfer, the lift pad strap tore, causing the resident to fall and sustain dental injuries. Interviews confirmed the transfer was performed alone and that the lift equipment was not properly assessed prior to use.
A staff member was found preparing food without a beard restraint, in violation of the facility's policy requiring all food service employees to wear hair and beard restraints while working in food preparation and service areas. This lapse in sanitary practice was confirmed by both the staff member and the Dietary Manager, and had the potential to affect all residents except one who was NPO.
The facility's kitchen was found to be unsanitary, with a thick black buildup on the floor, food debris, and dust-like particles on the ceiling and shelves. The Dietary Manager confirmed these observations, which had the potential to affect all residents receiving food from the kitchen.
The facility did not implement a timely Water Management Program to prevent Legionella, affecting 108 residents. No evidence of testing or interventions was found before October 2024. The Administrator confirmed the absence of prevention measures, with a new Maintenance Director starting the plan in October 2024. The facility's policy outlined necessary control measures, but these were not documented or communicated before this date.
The facility failed to provide adequate nail care for four residents who were dependent on staff for assistance with ADLs. Observations revealed that these residents had long, dirty nails despite their care plans indicating the need for assistance. Interviews confirmed that the residents required help and did not refuse nail care, highlighting a lapse in the facility's responsibility to provide appropriate nail care.
The facility failed to provide adequate activities for residents in the memory care unit, especially during evenings and weekends. Four residents with cognitive impairments had limited engagement in activities, with observations showing them often unengaged in the lounge or dining room. The activity schedule was sparse, with few activities after 2:00 P.M. and minimal weekend offerings.
Two residents were left without breakfast while a newly admitted resident in the same room was served. Despite expressing hunger, the residents remained without meals as staff discussed responsibility but took no action. A CNA eventually served the meals, citing a delay due to assisting another resident.
The facility failed to provide proper bed hold notifications to two residents before hospital transfers. One resident with severe cognitive impairment was hospitalized after a fall, and another with minimal cognitive impairment was transferred due to PICC line complications. In both cases, the bed hold forms lacked the total number of days available, as confirmed by the Administrator.
The facility failed to apply TED hose as ordered for a resident with a history of venous thrombosis and embolism, and delayed urine collection and treatment for a UTI in another resident with Alzheimer's and other conditions. Observations confirmed the absence of TED hose, and treatment for the UTI was delayed due to issues with lab sample collection and processing.
A facility failed to assist a resident with the placement of hearing aids daily as ordered, affecting the resident's ability to hear. Despite a physician's order, there was no documentation of compliance, and the care Kardex lacked instructions. Observations showed the resident without hearing aids during surveyor visits, and the resident reported only one nurse and one aide knew how to place them properly. An LPN successfully placed the right hearing aid, but a CNA struggled with the left, requiring guidance. The facility's policy did not address hearing aid placement, and there was no evidence of staff education.
The facility failed to provide adequate pressure ulcer care for two residents. One resident was not given a bariatric extended bed as per their care plan, and another did not receive a comprehensive wound assessment upon admission. Additionally, staff were not educated on the appropriate settings for a low air loss mattress, leading to deficiencies in care.
The facility failed to implement timely and appropriate care to prevent contractures in two residents. One resident had a contracture of the left hand with no care plan or splint in place, despite recommendations. Another resident had contracted hands with no interventions documented, and staff confirmed the absence of care plans or physician orders addressing the issue.
A facility failed to implement fall interventions for a resident with muscle weakness, unsteadiness, and dementia. The care plan required grip strips on the floor by the bed, but an observation revealed their absence, confirmed by a Unit Manager. The facility's policy mandates a comprehensive care plan for fall management.
A resident with obstructive sleep apnea and COPD did not receive timely follow-up for sleep study results, leading to a deficiency in respiratory care. The resident was supposed to receive a CPAP machine, but the facility lost the sleep study results. The DON confirmed the sleep study device was sent to the pulmonologist, but the facility did not receive the results or follow up with the provider.
A facility failed to assess and address the PTSD triggers of a resident with a history of physical and sexual abuse. Despite the resident's intact cognition, their care plan lacked interventions to minimize re-traumatization risks. The DON confirmed the absence of a comprehensive assessment for stressors or triggers.
A resident with hypertension and other conditions was not monitored for blood pressure as ordered, despite receiving daily doses of Amlodipine Besylate. The care plan required blood pressure monitoring due to potential fluctuations, but this was not done from early to mid-November 2024. The oversight was confirmed by the DON.
A resident with multiple diagnoses, including dementia and dysphagia, was not served meals as prescribed by the physician. The resident was supposed to receive double entree portions, but an observation revealed that the lunch tray contained only one sandwich. The tray ticket did not reflect the physician's order, and a STNA confirmed the oversight.
The facility failed to provide necessary meal setup assistance and adaptive equipment for a resident with hemiplegia, resulting in difficulty accessing food and inadequate nutrition. Another resident did not receive required sippy cups, leading to spillage. The facility's policy on meal assistance and adaptive equipment was not followed.
The facility failed to accurately complete MDS assessments for several residents, leaving sections on cognitive patterns and mood incomplete. Staff interviews were not conducted when residents refused participation. Additionally, physical impairments were inaccurately documented, as confirmed by the DON.
Failure to Notify Former Resident of Post-Discharge UTI Diagnosis
Penalty
Summary
The facility failed to provide documented evidence of good faith efforts to notify a former resident of an active urinary tract infection (UTI) after the resident had left the facility against medical advice (AMA). The resident, who was cognitively intact and had an indwelling catheter, was admitted with diagnoses including retention of urine and presence of urogenital implants. During the resident's stay, intermittent confusion was observed, prompting a physician order for a urinalysis and culture. The urine sample was collected and sent to the laboratory, but before the results were available, the resident chose to leave the facility AMA. The laboratory results, which were received after the resident's departure, indicated a significant growth of Escherichia coli, confirming a UTI. Review of the medical record showed no documentation that the resident or their representative was notified of these abnormal results. Interviews with the Administrator, DON, and Unit Manager confirmed that there was an expectation to notify former residents of such findings, but no evidence of notification or attempts to contact the resident was found in the record. Facility policies required notification of changes in condition and post-discharge follow-up, but these were not followed in this case.
Failure to Provide Adequate Supervision and Equipment Assessment During Mechanical Lift Transfer
Penalty
Summary
A deficiency occurred when a resident, who was dependent on staff for transfers due to multiple complex medical conditions including bilateral leg amputations, multiple sclerosis, morbid obesity, legal blindness, and paraplegia, was transferred from a wheelchair to a bed using a mechanical lift by only one staff member. The resident's care plan specifically required two-person assistance for all mechanical lift transfers. Despite this, a CNA performed the transfer alone. During the transfer, the mechanical lift pad's strap tore, causing the resident to fall from the lift to the floor. As a result of the fall, the resident sustained dental injuries, including one missing tooth and another tooth broken in half. The resident was sent to the hospital for evaluation and returned with no other injuries noted, but required follow-up with an emergency dentist. Interviews with the resident, the CNA involved, and the DON confirmed that the transfer was conducted by a single staff member, contrary to the resident's care plan and facility policy, and that the mechanical lift pad failed during the process. The facility's policy required two staff members for mechanical lift transfers and proper assessment of lift equipment prior to use. The lack of adherence to these protocols directly contributed to the incident and resulting harm.
Failure to Enforce Beard Restraint Policy During Food Preparation
Penalty
Summary
A staff member was observed preparing lunch trays in the kitchen without wearing a beard restraint, as required by facility policy and professional food service standards. The staff member confirmed during the interview that he was not wearing the required beard restraint while preparing food for residents. The Dietary Manager also verified that the staff member was not in compliance with the policy, which mandates all food service employees to wear hair and beard restraints in food preparation and service areas. The facility's policy on employee sanitary practices, dated 06/26/20, specifies that all nutrition and food service employees must practice good personal hygiene and safe food handling procedures, including the use of hair and beard restraints to prevent hair from contacting exposed foods. This deficiency had the potential to affect all residents in the facility except one who was ordered nothing by mouth (NPO) and did not receive food from the kitchen.
Kitchen Sanitation Deficiency
Penalty
Summary
The facility failed to maintain the kitchen in a clean and sanitary manner, as observed during a survey. The kitchen had an area in the center that was about an inch lower than the rest, containing cooking equipment such as the oven, fryer, and soup kettle. This area had a thick black buildup on the floor, which was supposed to be red tile, and was littered with food and other debris, including a dome lid, plastic utensils, and French fries. Additionally, there was a large amount of dirt-like material behind and around the soup kettle. These observations were verified by the Dietary Manager (DM). Further observations revealed that the ceiling throughout the kitchen had multiple spots with a thick buildup of dust-like particles and food splatter. Two racks with three to four shelves each were also noted to have a large amount of dust-like particles stuck to them and hanging from them. These racks contained items such as bowls, lids, stainless-steel cooking containers, and other food service items. The DM confirmed these observations as well. The facility's census was 108, with one resident identified as consuming nothing by mouth.
Failure to Implement Water Management Program for Legionella Prevention
Penalty
Summary
The facility failed to implement a timely and appropriate Water Management Program to prevent the spread of Legionella, potentially affecting all 108 residents. A review of the facility's Water Management Program logs showed no evidence of testing or interventions to prevent Legionella prior to October 2024. An interview with the Administrator confirmed the absence of water testing, flushing, or any other Legionella prevention measures before this date. The Administrator noted that a new Maintenance Director had started implementing the Water Management Plan in October 2024. The facility's policy, reviewed in December 2023, outlined control measures to reduce the growth and spread of Legionella, including routine testing of chlorine and water temperature levels, monitoring and flushing pipes, and checking decorative and water fountains for debris and biofilm. The CDC guidance on water management programs emphasizes identifying hazardous conditions and minimizing the growth and transmission of Legionella. It includes establishing a team, describing water systems, identifying growth areas, applying control measures, and ensuring the program's effectiveness. However, these steps were not documented or communicated in the facility's activities prior to October 2024.
Failure to Provide Adequate Nail Care for Dependent Residents
Penalty
Summary
The facility failed to provide adequate nail care for four residents who were dependent on staff for assistance with activities of daily living (ADL). Resident #104, diagnosed with bipolar disorder, secondary parkinsonism, and other conditions, required partial to moderate assistance with personal hygiene. Despite this, observations over several days revealed that her nails were long and dirty, with food caked under them. Interviews confirmed that she required assistance and did not refuse nail care. Similarly, Resident #95, with diagnoses including Alzheimer's disease and cognitive communication deficit, was observed with long, dirty nails. His care plan indicated a need for supervision or touching assistance with personal hygiene, yet his nails were neglected. Resident #91, suffering from conditions such as Alzheimer's disease and aphasia, was dependent on staff for personal hygiene. Observations showed her nails were long and dirty, with some dirt underneath, despite her care plan specifying the need for assistance. Lastly, Resident #75, with Alzheimer's disease and other cognitive impairments, was observed with excessively long and dirty nails. His care plan also required assistance with personal hygiene. Interviews with CNA #197 confirmed that these residents required assistance and did not refuse nail care, indicating a failure in the facility's responsibility to provide appropriate nail care as per their policy.
Insufficient Activities in Memory Care Unit
Penalty
Summary
The facility failed to provide sufficient activities for residents in the memory care unit, particularly during evenings and weekends. This deficiency affected four residents who were reviewed for activities and had the potential to impact all 25 residents in the unit. The report highlights that the facility's activity schedule was limited, with few activities occurring after 2:00 P.M. and minimal engagement on weekends. Resident #95, diagnosed with Alzheimer's disease and other cognitive impairments, had a care plan indicating a need for cognitive stimulation and a preference for various activities. However, from October 20 to November 17, 2024, the resident had limited engagement in activities, with no independent or physical activities recorded and no activities on weekends. Observations showed the resident often sitting in the dining room or lounge with the television on but not engaged. Similarly, Resident #91, with Alzheimer's and memory problems, had a care plan encouraging socialization and mental stimulation. Despite this, the resident's activity records showed limited participation, with no physical activities and no weekend activities. Observations noted the resident facing a wall or a television without engagement. Other residents, such as #75 and #99, also experienced insufficient activity engagement, with records indicating a lack of weekend activities and minimal intellectual or physical activities.
Failure to Maintain Resident Dignity During Dining
Penalty
Summary
The facility failed to maintain resident dignity during dining experiences, affecting two residents during the annual survey. On the morning of the observation, two residents were found lying in bed without breakfast meal trays, while a newly admitted resident in the same room was already consuming breakfast. The two residents expressed hunger and a desire for a meal tray. Despite this, they remained without breakfast for an extended period. Three facility employees were observed discussing responsibility for one of the residents but did not take action to serve the meal. A registered nurse later confirmed the residents had not received their breakfast and promised to investigate. Eventually, a certified nurse assistant served the breakfast meal, explaining the delay was due to assisting another resident with dialysis preparation.
Failure to Provide Bed Hold Notifications
Penalty
Summary
The facility failed to provide proper bed hold notifications to residents prior to their transfer to a hospital, affecting two residents out of four reviewed for this requirement. Resident #15, who had severe cognitive impairment and multiple diagnoses including epilepsy and Alzheimer's disease, was sent to the hospital following a fall that resulted in a laceration. The Notification of Bed Hold form for this resident did not specify the total number of bed hold days available, which was confirmed by the Administrator during an interview. Similarly, Resident #39, who had minimal cognitive impairment and various medical conditions such as hallucinations and rheumatoid arthritis, was transferred to the hospital due to complications with a PICC line and abnormal lab results. The bed hold notification for this resident also lacked the total number of bed hold days, as verified by the Administrator. These deficiencies indicate a failure in the facility's process to inform residents or their representatives about bed hold policies during hospital transfers.
Failure to Apply TED Hose and Delay in UTI Treatment
Penalty
Summary
The facility failed to apply Thrombo-Embolic Deterrent (TED) hose as ordered by the physician for a resident with a history of venous thrombosis and embolism, chronic pain, and muscle weakness. Observations on multiple occasions revealed that the resident was without the prescribed TED hose while in the dining room and in their room. The Unit Manager confirmed the absence of the TED hose during these observations, indicating a failure to adhere to the physician's orders for managing the resident's edema. Additionally, the facility did not timely collect urine or treat a urinary tract infection (UTI) for another resident with Alzheimer's disease, dysphagia, dementia, and other conditions. Despite new orders to obtain a urinary analysis, there was a delay in collecting the urine sample, which was not obtained until several days later. The culture and sensitivity results were delayed, and treatment with Keflex was not initiated until over a week after the initial order. The Director of Nursing acknowledged the delay in treatment and attributed it to issues with laboratory sample collection and processing.
Failure to Assist Resident with Hearing Aids
Penalty
Summary
The facility failed to assist a resident with the placement of bilateral hearing aids daily as ordered, affecting one resident. The resident, who had medical diagnoses including dementia, unspecified bilateral hearing loss, and COPD, required assistance with activities of daily living and used hearing aids. Despite having a physician's order to assist the resident with hearing aids every day shift, there was no documentation of compliance, and the patient care Kardex lacked instructions for this assistance. Observations and interviews revealed that the resident did not have hearing aids in place during multiple surveyor visits and had difficulty hearing without them. The resident reported that only one nurse and one aide knew how to properly place the hearing aids, and staff did not offer assistance daily. During an observation, an LPN successfully placed the hearing aid in the resident's right ear, but a CNA struggled with the left ear, requiring guidance from the LPN. The facility's policy did not address the proper placement and use of hearing aids, and there was no evidence of staff education on this matter.
Deficiencies in Pressure Ulcer Care and Prevention
Penalty
Summary
The facility failed to ensure proper pressure ulcer prevention and care for two residents, leading to deficiencies in their treatment. Resident #43, who had diagnoses including hemiplegia and pressure ulcers, was not provided with a bariatric extended bed as per their care plan. The resident was observed lying in a regular-sized bed, which was confirmed by the Director of Nursing (DON) to be inappropriate as the bariatric bed was removed after hospice services ended and not replaced. This oversight was acknowledged by the DON, who confirmed the necessity of the bariatric bed to reduce pressure on the resident's feet. Resident #62, admitted with multiple pressure ulcers, did not receive a comprehensive wound assessment upon admission. The only assessment completed was a skin grid, which was not detailed. The resident's wounds were not fully assessed until three days post-admission by a wound physician. Additionally, there was a lack of education for the nursing staff regarding the appropriate settings for the resident's low air loss mattress, as confirmed by interviews with the Unit Manager, LPN, and DON. The facility's policy required a comprehensive skin evaluation upon admission, which was not adhered to in this case.
Failure to Address Contractures in Residents
Penalty
Summary
The facility failed to provide timely and appropriate care to prevent the development or worsening of contractures for two residents. Resident #43, who was admitted with diagnoses including hemiplegia and contracture of the left hand, had no care plan addressing the contracture. Despite an occupational therapy evaluation recommending a carrot splint, the resident declined therapy, and no physician orders for the splint were in place. Observations confirmed the absence of any splint or orthotic device, and interviews with staff verified the lack of a care plan to address the contracture. Resident #91, admitted with multiple diagnoses including Alzheimer's disease and rheumatoid arthritis, also had no care plan or physician orders addressing contractures. Observations revealed both hands were contracted into tight fists without intervention. Interviews with staff confirmed the absence of interventions for the contractures, and it was noted that the resident's husband did not want hand rolls or washcloths, although this was not documented in the medical record. The DON confirmed the presence of hand contractures since admission.
Failure to Implement Fall Interventions
Penalty
Summary
The facility failed to ensure that fall interventions were in place according to the care plan for a resident. The resident, who was admitted with diagnoses including muscle weakness, unsteadiness on feet, and dementia, was assessed to be rarely/never understood. The care plan, initiated earlier, identified the resident as being at risk for falls and potential injury, with specific interventions such as grip strips to be placed on the floor in front of the bed. However, during an observation, it was noted that there were no grip strips present by the resident's bed. This was confirmed by an interview with the Unit Manager. The facility's policy on Fall Management Guidelines requires staff to implement a comprehensive care plan addressing fall management, including individualized interventions to minimize risk factors.
Failure to Obtain Sleep Study Results for Resident
Penalty
Summary
The facility failed to complete timely follow-up to obtain sleep study results for a resident, identified as Resident #13, who was diagnosed with obstructive sleep apnea and chronic obstructive pulmonary disease (COPD). Resident #13 was admitted to the facility with a history of dementia, anxiety disorder, and depression. The resident had an order to use a sleep study machine at bedtime, which was administered as ordered. However, there was no evidence in the progress notes of any follow-up to obtain the results of the sleep study, which was conducted in February 2024. Interviews revealed that Resident #13 was supposed to receive a Continuous Positive Airway Pressure (CPAP) machine but had not due to the facility losing the sleep study results. The Director of Nursing (DON) confirmed that the sleep study device was sent back to the pulmonologist for interpretation, but the facility never received the results. There was no evidence of routine follow-up with the outside provider to obtain the sleep study results or further instructions for Resident #13, leading to a deficiency in providing appropriate respiratory care.
Failure to Address PTSD Triggers in Resident Care Plan
Penalty
Summary
The facility failed to ensure that a resident with Post Traumatic Stress Disorder (PTSD) was appropriately assessed to identify the cause of the PTSD and minimize triggers and/or re-traumatization. This deficiency affected one resident, who was admitted with diagnoses including anxiety, cognitive communication deficit, depression, and suicidal ideations, and had an active diagnosis of PTSD related to a history of physical and sexual abuse. Despite having intact cognition, as evidenced by a Brief Interview for Mental Status (BIMS) score of 14, the resident's care plan did not address the cause of PTSD, potential triggers, or interventions to reduce the risk of re-traumatization. Additionally, there was no comprehensive social history or assessment conducted to identify stressors or triggers that could prompt recall of previous traumatic events. An interview with the Director of Nursing (DON) confirmed that the resident did not have a care plan addressing individual triggers or a current plan to manage those triggers. The DON also verified the absence of an assessment for stressors or triggers that could lead to re-traumatization.
Failure to Monitor Blood Pressure as Ordered
Penalty
Summary
The facility failed to ensure that a resident's blood pressure was monitored as ordered, which is a critical component of managing their medication regimen. The resident, who was admitted with diagnoses including senile degeneration of the brain, dementia, and hypertension, had a care plan that required monitoring of blood pressure due to fluctuations related to various conditions and medications. Despite having a physician's order to hold Amlodipine Besylate if the systolic blood pressure was below 110 mmHg, the resident's blood pressure was not assessed from November 1 to November 18, 2024, while the medication was administered daily. This oversight was confirmed by the Director of Nursing during an interview.
Failure to Provide Prescribed Double Entree Portions
Penalty
Summary
The facility failed to ensure that a resident in the memory care unit received meals as prescribed by the attending physician. The resident, who has a medical history including dementia, cognitive communication deficit, schizoaffective disorder, anxiety disorder, dysphagia, and hypertension, was ordered to receive a regular diet with double entree portions. However, during an observation, it was noted that the resident's lunch tray contained only one sandwich, contrary to the physician's order. A review of the resident's tray ticket confirmed that it did not indicate the need for double entrees, and an interview with a State tested Nursing Assistant verified the discrepancy between the physician's order and the meal provided.
Failure to Provide Meal Assistance and Adaptive Equipment
Penalty
Summary
The facility failed to provide appropriate setup assistance and adaptive equipment during meals for Resident #43, who was affected by hemiplegia and hemiparalysis following a cerebral infarction, resulting in muscle weakness and a contracted left hand. Despite the resident's need for assistance, as indicated in the care plan and physician's orders, the Certified Nurse Assistant (CNA) did not remove the lids from the bowls or position the over-the-bed table within easy reach. This left the resident struggling to access his meal, resulting in one of the fried eggs falling to the floor and the resident being unable to consume the second bowl's contents. The room was inadequately lit, further complicating the resident's ability to eat independently. Additionally, another resident, Resident #47, was observed without the required lids on his cups, leading to spillage and a wet gown. The meal ticket specified the need for sippy cups or cups with lids, which were not provided. The Registered Dietitian confirmed the necessity of these items to ensure proper nutrition and hydration. The facility's policy mandates assistance for residents needing help with eating and the provision of adaptive equipment as per physician's orders, which was not adhered to in these instances.
Inaccurate MDS Assessments in LTC Facility
Penalty
Summary
The facility failed to accurately complete Minimum Data Set (MDS) assessments for six residents, affecting their care evaluations. For several residents, including those with dementia, Alzheimer's disease, and other cognitive impairments, sections of the MDS assessments, specifically Section C (Cognitive Patterns) and Section D (Mood), were left incomplete. In some cases, both resident and staff interviews were marked as 'not assessed,' indicating a lack of thorough evaluation. Interviews with MDS Coordinators and a Licensed Social Worker confirmed that these assessments were not completed as required, even when residents refused to participate, as staff interviews should have been conducted. Additionally, discrepancies were noted in the assessments of residents with physical impairments. For instance, one resident with bilateral hand contractures was inaccurately assessed as having no upper extremity impairments. This was verified through observation and confirmed by the Director of Nursing. These inaccuracies in MDS assessments highlight a significant deficiency in the facility's assessment process, impacting the accurate evaluation of residents' cognitive and physical conditions.
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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