Mt Airy Gardens Rehabilitation And Nursing Center
Inspection history, citations, penalties and survey trends for this long-term care facility in Cincinnati, Ohio.
- Location
- 2250 Banning Road, Cincinnati, Ohio 45239
- CMS Provider Number
- 365293
- Inspections on file
- 41
- Latest survey
- September 8, 2025
- Citations (last 12 mo.)
- 2
Citation history
Health deficiencies cited at Mt Airy Gardens Rehabilitation And Nursing Center during CMS and state inspections, most recent first.
Surveyors identified unsanitary conditions in the kitchen, including sticky substances on the floor, chipped and peeling flooring, brown debris under and along the walls, and standing water in uncovered pipes near the dishwasher. These findings were confirmed by the Administrator and affected all but three residents who did not receive food from the kitchen.
The facility did not ensure the kitchen was free of pests, as multiple gnats were observed around the dishwasher and trash cans. Both the Administrator and a Dietary Aide confirmed the ongoing issue, which had persisted for several weeks, in violation of the facility's pest control policy. This affected all residents except for three who did not receive food from the kitchen.
The facility failed to serve appropriate portion sizes, affecting all 77 residents. A dietary staff member used a green-handled scoop for macaroni and cheese, providing only 2 and 2/3 ounces instead of the required 4 ounces. The Dietary Director confirmed the error, leading to a deficiency in portion control.
The facility failed to properly store and handle food, risking foodborne illness for all 77 residents. Observations revealed opened and undated food items not refrigerated, milk and cheese stored on the floor, expired sanitizer test strips, and unsanitary food preparation practices. Numerous unlabeled and improperly stored food items were found in nourishment rooms, violating facility policies.
The facility failed to cover catheter bags for two residents, compromising their dignity and privacy. One resident with severe cognitive impairment had a visible catheter bag, while another with a nephrostomy tube had an uncovered leg bag. Both instances were confirmed by nursing staff, violating the facility's catheter care policy.
A facility failed to provide a safe and homelike environment, as observed in a resident's room and the Heritage nursing unit's shower room. A resident's room had missing cove base, an unsecured sink, and exposed drywall, while the shower room had peeling drywall. These issues were confirmed by staff, and the facility's policy on Resident Rights was not upheld.
The facility failed to accurately complete MDS assessments for three residents, leading to deficiencies in documenting their care needs. A resident was discharged before a comprehensive MDS was completed, another's assessments did not reflect a fall or hospice admission, and a third's assessment missed documenting a hand contracture. These inaccuracies were confirmed by staff interviews and observations.
A facility failed to update the PASARR for a resident admitted to hospice care, despite completing a significant change MDS assessment. The resident had multiple diagnoses, including hemiplegia and schizophrenia. The Social Services Director confirmed the oversight, acknowledging that the PASARR should have been updated upon hospice admission.
A facility failed to update a resident's care plan to reflect the discontinuation of a g-tube, despite the resident being on a regular diet and able to eat independently. The care plan inaccurately included interventions for tube feeding, which were no longer applicable. Staff interviews confirmed the care plan was not updated to reflect the resident's current dietary status.
A facility failed to ensure timely suture removal for a resident with a history of traumatic brain injury and cognitive impairment. The resident sustained a laceration to the right eyebrow after a fall, and the hospital discharge summary lacked orders for suture removal. Observations and staff interviews confirmed that the sutures remained in place beyond the typical removal period, with no order for their removal, indicating a lapse in wound management protocol.
The facility failed to provide necessary care for residents with impaired mobility and contractures. A resident with peripheral vascular disease did not receive a prescribed hand orthotic, another with a shoulder injury was not encouraged to use a sling, and a third with hemiplegia had an undocumented hand contracture. Staff were unaware or unable to locate necessary equipment, leading to inadequate care.
A resident on hospice care with moderate protein-calorie malnutrition was found without fluids available at the bedside on multiple occasions. Despite being on a mechanically altered diet with regular liquids, the resident did not have a water pitcher or cup in her room. Staff interviews revealed the absence was due to the resident's behavior of throwing the pitcher or taking it to other rooms. The DON confirmed fluids should have been available, and the NP stated there was no medical reason to withhold water. The facility did not provide a hydration policy when requested.
The facility failed to monitor adverse effects of psychoactive medications for three residents. One resident on Seroquel did not receive required AIMS assessments quarterly. Another resident on Invega Sustenna had no AIMS assessments conducted. A third resident on Depakote and Rexulti had no Depakote levels monitored and lacked quarterly AIMS assessments. These oversights were confirmed by facility staff.
A resident with complex medical conditions did not receive a Lidocaine patch as ordered, which was found undated and unsupervised on the bedside table. The LPN confirmed the patch was not applied, and the facility lacked a medication administration policy.
A facility failed to collaborate with a hospice agency to develop a comprehensive care plan for a resident with dementia and malnutrition. The hospice plan included nursing and aide visits, but lacked coordination with facility staff. Interviews confirmed unsuccessful attempts to engage the hospice agency in care planning, and the facility's care plan did not reflect hospice services.
A facility failed to provide full visual privacy in a resident's room, affecting a resident with severe cognitive impairment and multiple diagnoses. The room's window curtains allowed visibility from the parking lot, were damaged, and lacked a privacy curtain despite having tracking in place. The Housekeeping Director confirmed these issues, which violated the facility's policy on resident rights to personal privacy.
The facility failed to maintain a safe, clean, and comfortable environment for residents, as observed in multiple rooms. A resident with severe cognitive impairment lived in a room with potentially moldy drywall, while other rooms had issues like torn curtains, peeling wallpaper, and unsanitary bathrooms. These deficiencies were confirmed by staff and the Administrator.
A resident with a complex medical history was discharged from the hospital with new medication orders, which were not transcribed or administered upon their return to the LTC facility. The oversight was discovered when the resident was readmitted to the hospital with health complications. The error occurred because the discharge orders were misplaced, and the responsible LPN did not verify the physician orders, leading to a significant medication error.
The facility failed to prevent a high-risk resident from eloping and did not provide adequate supervision for residents who smoked. A resident left the facility unsupervised and was found walking in a busy street. Additionally, several residents were observed smoking in non-designated areas without staff supervision, contrary to the facility's policy.
The facility failed to maintain elevators in good working order and did not provide appropriate containers for cigarette disposal. Observations revealed numerous cigarette butts around the entrance, and residents were seen smoking and disposing of butts improperly. One elevator was out of order, and the other frequently malfunctioned, confirmed by staff, residents, and the Ombudsman. The facility lacked a policy for elevator maintenance.
A resident with dementia and cognitive impairments eloped from the facility and was found on a main road by a housekeeper. The nursing staff was unaware of the elopement, and the resident's representative was not notified until two days later, contrary to the facility's policy.
The facility failed to ensure that an interdisciplinary team was present during care conference meetings for four residents with varying cognitive impairments and multiple diagnoses. Care conferences were attended only by the SSD and, in some cases, an additional nurse, contrary to the facility's policy requiring full interdisciplinary team participation.
Unsanitary Kitchen Conditions Identified During Survey
Penalty
Summary
Surveyors observed that the facility failed to maintain a clean and sanitary kitchen, as required for food procurement and service. During an inspection, a sticky substance was found on the floor at the kitchen entrance, and the floor by the walls was chipped and peeling. There was a brown substance on the floor under the dishwasher and along the kitchen walls, as well as brown debris in two black rubber mats. Additionally, an uncovered pipe with standing water and a rag was noted near the dishwasher, and a second pipe nearby contained standing brown water. These unsanitary conditions were confirmed by the Administrator during a concurrent interview. The deficiency affected all residents except for three who did not receive food from the kitchen, with a facility census of 91.
Failure to Maintain Pest-Free Kitchen Environment
Penalty
Summary
The facility failed to maintain a kitchen environment free of pests, as required by its pest control program policy. During an observation of the kitchen, multiple gnats were seen around the dishwasher and trash cans. Both the Administrator and a Dietary Aide confirmed the presence of gnats in these areas, with the Dietary Aide stating that the issue had persisted for several weeks. The facility's pest control policy indicated an obligation to eradicate and contain common household pests, but the ongoing presence of gnats demonstrated non-compliance with this policy. This deficiency affected all residents except for three who did not receive food from the kitchen.
Inadequate Portion Control in Meal Service
Penalty
Summary
The facility failed to ensure appropriate portion sizes were served to residents, which had the potential to affect all 77 residents in the facility. During an observation, a dietary staff member was seen using a green-handled scoop to serve macaroni and cheese, which was not the correct size according to the facility's portion control chart. The dietary spreadsheet specified a 4-ounce serving for macaroni and cheese, which required a dark gray-handled scoop. However, the green-handled scoop used provided only 2 and 2/3 ounces. The Dietary Director confirmed the incorrect scoop was used, leading to the deficiency in portion control.
Deficiencies in Food Storage and Handling Practices
Penalty
Summary
The facility failed to store and handle food in a manner that prevents the potential spread of foodborne illness, affecting all 77 residents. Observations in the kitchen revealed several issues, including a jar of grape jelly and a jug of barbeque sauce that were opened, partially used, and not dated, which should have been refrigerated according to manufacturer labels. Additionally, milk cartons and a box of cheese were stored directly on the floor in the walk-in cooler and freezer, respectively. The use of expired sanitizer test strips for the dishwasher was also noted, compromising the sanitation process. Further observations in the food preparation area showed unsanitary practices, such as draining green beans against the inside of a sink, which was not considered sanitary. In the nourishment rooms on both the first and second floors, numerous food items were found unlabeled, undated, and improperly stored, including a jar of applesauce with mold, opened bottles of chocolate syrup and coffee creamer, and various sandwiches and beverages. These items were not in compliance with the facility's policy, which requires all foods to be labeled, dated, and stored properly to prevent contamination. Interviews with staff, including the Dietary Director, Dietary Aid, and Licensed Practical Nurse, confirmed the deficiencies in food storage and handling practices. The facility's policies on food storage and personal food brought in from outside sources were not adhered to, as evidenced by the numerous unlabeled and improperly stored food items. The facility's failure to follow these policies posed a risk of foodborne illness to all residents.
Failure to Cover Catheter Bags
Penalty
Summary
The facility failed to ensure that catheter bags were covered, affecting two residents. Resident #235, who was admitted with diagnoses including metabolic encephalopathy, diabetes mellitus type two, and chronic kidney disease, was observed with a full catheter bag visible from the hallway, which was not covered with a dignity bag. This observation was confirmed by a registered nurse, who acknowledged that catheter bags should be covered. The resident had severe cognitive impairment and was dependent on staff assistance for activities of daily living. Similarly, Resident #236, who was admitted with diagnoses including complications of an incontinent external stoma of the urinary tract, chronic kidney disease, and cerebral infarction, was observed with a nephrostomy tube and a leg bag pinned to the outside of his pajama pants. The leg bag contained visible urine and was not covered with a dignity bag, contrary to the resident's plan of care, which required the nephrostomy bag to be covered at all times. This was confirmed by a licensed practical nurse. The facility's policy on catheter care, dated 2024, stated that privacy bags should be available and catheter drainage bags should be covered at all times to maintain resident dignity and privacy.
Facility Fails to Maintain Safe and Homelike Environment
Penalty
Summary
The facility failed to maintain a safe, clean, and homelike environment for its residents, as evidenced by the conditions observed in Resident #59's room and the Heritage nursing unit's shower room. Resident #59, who was cognitively intact and required supervision with activities of daily living, expressed dissatisfaction with the physical state of his room. Observations revealed a missing section of cove base by the bathroom door, an unsecured sink, a wide gap without grout between the countertop and backsplash, exposed drywall needing repair, and an extra cable wire on the floor. Resident #59 could not recall if he had reported these issues, but the Housekeeping Director confirmed the concerns. Additionally, the shower room on the Heritage nursing unit was found to have a ceiling with damaged drywall that was peeling and required repair or replacement and painting. This condition was confirmed by the Housekeeping Director and a Registered Nurse, who noted that two residents on the unit had the ability to use the shower room. The facility's policy on Resident Rights emphasizes the right to a safe, clean, comfortable, and homelike environment, which was not upheld in these instances.
Inaccurate MDS Assessments for Residents
Penalty
Summary
The facility failed to ensure accurate completion of Minimum Data Set (MDS) assessments for three residents, leading to deficiencies in the documentation of their care needs and conditions. Resident #77 was admitted with multiple diagnoses, including atherosclerosis and diabetes mellitus, and was discharged before the comprehensive MDS assessment was completed. The assessment was inaccurately dated after the resident's discharge, and the Minimum Data Coordinator confirmed the need to deactivate the incorrect submission. Resident #8, who had dementia and was admitted to hospice, had MDS assessments that failed to reflect a fall and the initiation of hospice services, as confirmed by the reviewing nurse. Resident #51, diagnosed with cerebral infarction and other conditions, had an MDS assessment that did not document contractures or limitations in range of motion, despite observations of a contracted left hand and the presence of a hand splint. The Rehab Director was unaware of the contracture, and the nurse confirmed the inaccuracy of the MDS assessment. These deficiencies highlight the facility's failure to maintain accurate and timely assessments, impacting the quality of care provided to the residents.
Failure to Update PASARR for Hospice Admission
Penalty
Summary
The facility failed to complete a significant change Preadmission Screening and Resident Review (PASARR) for a resident following their admission to hospice care. The resident, who was admitted with diagnoses including hemiplegia, hemiparesis following cerebral infarction, hypertension, congestive heart failure, unspecified dementia, and schizophrenia, had a physician's order for hospice admission dated 07/18/24. Although the facility completed a significant change Minimum Data Set (MDS) assessment due to the hospice admission, they did not update the PASARR as required. This oversight was confirmed during an interview with the Social Services Director, who acknowledged that the PASARR should have been updated on the date of the hospice admission.
Failure to Update Resident Care Plan
Penalty
Summary
The facility failed to update the care plan for a resident, which did not accurately reflect the resident's current health care status. The resident, who had a history of schizophrenia, subdural hemorrhage, traumatic brain injury, and a gastrostomy (g-tube), was admitted with orders to flush the g-tube every shift. However, the care plan continued to include interventions related to tube feeding, despite the resident not using the g-tube for nutritional support. The care plan included various interventions for tube feeding, such as monitoring tube placement and patency, which were no longer applicable. The deficiency was identified when a nurse practitioner noted that the g-tube was no longer in use and recommended its discontinuation. Despite this, the care plan was not updated to reflect the resident's ability to consume meals orally and the absence of g-tube use. Interviews with facility staff confirmed that the care plan was inaccurate and not updated to reflect the resident's current dietary status, as the resident was on a regular diet and able to eat independently.
Failure to Ensure Timely Suture Removal
Penalty
Summary
The facility failed to ensure timely suture removal for Resident #73, who was admitted with a history of physical injury, traumatic brain injury, and altered mental status. The resident, who was cognitively impaired, sustained a two-centimeter laceration to the right eyebrow after falling from a stretcher in the emergency room. The hospital discharge summary did not include orders for suture removal, and the physician's orders only instructed monitoring of the sutures twice daily without specifying removal. Observations and interviews revealed that the sutures remained in place beyond the typical removal period of seven to ten days. The Licensed Practical Nurse confirmed the absence of an order for suture removal, and the Assistant Director of Nursing acknowledged that the Wound Nurse Practitioner was not following the resident for the sutured wound. This oversight resulted in the resident having sutures in place without a plan for their removal, highlighting a lapse in the facility's care protocol for wound management.
Failure to Provide ROM and Contracture Care
Penalty
Summary
The facility failed to provide appropriate care and services for residents with impaired mobility and contractures, affecting three residents. Resident #9, who had diagnoses including peripheral vascular disease and schizophrenia, was ordered to wear a left-hand orthotic to maintain joint integrity. However, observations revealed the resident was not wearing the brace, and staff confirmed they had never applied it nor could they locate it. The resident indicated a willingness to wear the splint, but it was not provided as ordered. Resident #72, with a history of traumatic brain injury and shoulder injury, was supposed to wear a sling for his right arm and shoulder. Despite orders to encourage sling use, observations showed the resident was not wearing it, and staff were unable to find the sling. Interviews with staff confirmed the resident had not been seen wearing the sling, and it was not present in his room, indicating a failure to follow the care plan. Resident #51, diagnosed with cerebral infarction and hemiplegia, was found to have a contracted left hand, which was not documented in the care plan or MDS assessment. A splint was found in the resident's belongings, but staff were unaware of the contracture, and the MDS assessment was inaccurate. This oversight highlights a lack of proper assessment and documentation for the resident's condition, leading to inadequate care.
Failure to Provide Fluids at Bedside for Resident
Penalty
Summary
The facility failed to ensure that a resident had fluids available at the bedside, which is essential for maintaining hydration. The resident, who was on hospice care with a diagnosis of moderate protein-calorie malnutrition, was observed on multiple occasions without any fluids available in her room. Despite being on a mechanically altered diet with regular liquids, the resident did not have a water pitcher or cup at her bedside during observations on two separate days. Interviews with staff revealed that the resident had a history of throwing the water pitcher at staff or taking it to other residents' rooms, which led to the absence of fluids in her room. The Director of Nursing confirmed that the resident should have had fluids available, and the Administrator was unaware of the situation. The Nurse Practitioner stated there was no medical reason for the resident not to have water at the bedside, and no laboratory tests were conducted regarding hydration due to hospice services. The facility did not provide a policy related to hydration when requested during the survey, indicating a lack of documentation or adherence to hydration protocols.
Failure to Monitor Adverse Effects of Psychoactive Medications
Penalty
Summary
The facility failed to ensure timely monitoring of adverse side effects of psychoactive medications for three residents. Resident #08, diagnosed with dementia and psychotic disorders, was prescribed Seroquel. However, the required Abnormal Involuntary Movement Scale (AIMS) assessments were not completed quarterly as mandated, with the last assessment recorded in June 2024. The MDS Coordinator confirmed the oversight, acknowledging that the assessments were not conducted during the specified periods in 2025. Resident #72, with diagnoses including schizophrenia and traumatic brain injury, was prescribed Invega Sustenna. The facility's records showed no evidence of AIMS assessments being conducted, which was confirmed by the Director of Nursing. The resident's care plan required AIMS assessments every six months, but this was not adhered to, indicating a lapse in monitoring for potential adverse effects of the medication. Resident #06, with multiple diagnoses including dementia and mood disorder, was on Depakote and Rexulti. The facility failed to monitor Depakote levels as ordered, with no records of such tests being conducted since the medication was prescribed in January 2022. Additionally, the last AIMS assessment was conducted in June 2024, contrary to the policy requiring quarterly assessments. The Director of Nursing and a Nurse Practitioner confirmed the lack of monitoring, highlighting a significant oversight in the resident's medication management.
Medication Storage and Administration Deficiency
Penalty
Summary
The facility failed to ensure medications were stored and administered in accordance with professional standards, affecting a resident who was admitted with multiple complex medical conditions, including acute respiratory failure, diabetes, schizophrenia, and opioid dependence. The resident had a physician's order for a Lidocaine patch to be applied topically for pain management. However, during an observation, it was noted that the patch was left on the resident's bedside table, undated and with the protective backing still attached, indicating it was not applied as ordered. The resident confirmed that the nurse did not apply the patch the previous evening as required. The LPN and ADON present during the observation verified that the patch was not applied and should not have been left unsupervised in the resident's room. Additionally, the facility was unable to provide a policy related to medication administration upon request, further highlighting the deficiency in medication management and storage practices.
Lack of Collaboration with Hospice Agency in Care Planning
Penalty
Summary
The facility failed to collaborate effectively with a hospice agency to develop a comprehensive plan of care for a resident receiving hospice services. The resident, who was admitted with diagnoses including dementia with behavioral disturbances and psychotic disorders, had an advanced directive for do not resuscitate comfort care and was on hospice for moderate protein-calorie malnutrition. The facility's plan of care included dietary interventions and monitoring for swallowing difficulties, but there was no evidence of collaboration with the hospice agency to integrate their services into the care plan. The hospice plan of care outlined services such as skilled nursing visits, aide visits, and the provision of equipment, but did not indicate any coordination with the facility staff. Interviews with facility staff, including a CNA, the Administrator, the Social Service Director, and the MDS Coordinator, confirmed the lack of collaboration and communication with the hospice agency. The facility had attempted to contact the hospice agency for scheduling information and to involve them in care planning, but these efforts were unsuccessful. The hospice staff did not participate in a recent care conference, and the facility's plan of care did not include details of the hospice services being provided. Additionally, the facility was unable to provide a policy related to the development of the plan of care upon request during the survey.
Failure to Ensure Visual Privacy in Resident's Room
Penalty
Summary
The facility failed to ensure full visual privacy in the resident bedrooms, affecting one of the four residents reviewed for physical environment. The resident in question, admitted with diagnoses including Alzheimer's dementia, psychotic disorder with delusions, and depressive disorder, was observed to have severe cognitive impairment and was dependent on staff assistance for activities of daily living. During an observation, it was noted that the resident's room window overlooked the facility parking area, and the window curtains were made of a material that allowed observation from the parking lot into the room. Additionally, the curtains were ripped and torn, and there was no privacy curtain in place despite the presence of privacy curtain tracking. An interview with the Housekeeping Director confirmed these findings, and a review of the facility's Resident Rights policy indicated that residents have a right to personal privacy in their living accommodations.
Facility Fails to Maintain Safe and Clean Environment
Penalty
Summary
The facility failed to provide a safe, clean, and comfortable environment for its residents, as evidenced by multiple observations and interviews. Resident #8608, who had severe cognitive impairment and was frequently incontinent, was living in a room with exposed drywall that was black in color, potentially indicating mold. This issue was reported by the resident's family, but it remained unaddressed for approximately two weeks. Additionally, other residents' rooms were found to have various issues, such as torn privacy curtains, peeling wallpaper, missing ceiling tiles, and unsanitary bathroom conditions. During the initial tour, several deficiencies were noted in the rooms of other residents. These included a torn privacy curtain in the room of two residents, peeling wallpaper and a missing ceiling tile in an unoccupied room, and a toilet bowl covered in brown material resembling feces in another room. Furthermore, a large brown ring stain was observed on the bathroom ceiling tile in one room, and peeling wallpaper was noted in the bathroom of another room. These observations were confirmed by a State tested Nursing Assistant and the facility's Administrator, indicating a widespread issue with maintaining a safe and clean environment for residents.
Failure to Administer Medications Post-Hospital Discharge
Penalty
Summary
The facility failed to ensure that a resident's medications were ordered and administered following a hospital discharge, resulting in a significant medication error. The resident, who had a history of myocardial infarction, transient ischemic attacks, HIV, and cerebrovascular disease, was discharged from the hospital with new medication orders for Ticagrelor, ferrous sulfate, and metoprolol. Upon returning to the facility, these medications were not listed on the Medication Administration Record (MAR) and were never ordered, leading to a lapse in the resident's prescribed treatment. The deficiency was discovered when the resident was readmitted to the hospital with symptoms of shortness of breath and abnormal vital signs. A subsequent review of the resident's records revealed that the medications ordered upon hospital discharge were not transcribed into the facility's system. Interviews with staff indicated that the discharge orders were misplaced among other paperwork, and the error was not identified until the hospital contacted the facility to reconcile the resident's medications. The Director of Nursing confirmed that the responsible LPN failed to check and implement the physician orders upon the resident's readmission, which led to the medication error. The Medical Director was not informed of the error due to being on vacation at the time. The facility's policy on administering medications requires adherence to physician orders, which was not followed in this case, resulting in non-compliance with the standard of care.
Failure to Prevent Elopement and Ensure Supervised Smoking
Penalty
Summary
The facility failed to ensure adequate supervision to prevent a high-risk resident from eloping. Resident #26, who had been assessed as being at high risk for elopement, left the facility unsupervised and was found by an off-duty employee approximately 0.1 miles from the facility, walking in the middle of a busy street. The facility did not have a care plan or interventions in place to prevent the elopement, and staff were unaware of the resident's absence until notified by the off-duty employee. The facility did not document the elopement in the medical record or complete an investigation into the incident, as they did not consider it an elopement. Additionally, the facility failed to provide adequate supervision for residents who smoked, allowing them to smoke in non-designated areas without staff supervision. Residents #32, #33, #40, and #68 were observed smoking less than 10 feet from the facility entrance, under a 'No Smoking' sign, and without appropriate receptacles for cigarette butts. The facility's policy required residents who needed supervision to always have a staff member present while smoking and to smoke only in designated areas. However, these residents were left unsupervised, and the facility did not adhere to its smoking policy. The facility's deficiencies in supervision and policy adherence placed residents at risk for potential harm. Resident #26's elopement and the unsupervised smoking incidents highlight the facility's failure to implement and follow appropriate care plans and safety measures for high-risk residents and those requiring supervision while smoking.
Removal Plan
- Certified Nurse Practitioner (CNP) #91 assessed Resident #26 with no negative findings.
- The DON completed the Secured Unit Screening and Resident #26 was moved to the secured unit.
- DOO #01 educated the DON and Administrator on the definition of elopement.
- The Administrator and DON completed elopement in-services to all staff in-person, by telephone, and by text notification. Education included whom to notify and how to identify if an elopement had occurred. Agency staff will be provided with a copy of the education, and it will be in the assignment binder that the agency staff report to for each shift.
- The Administrator began investigating Resident #26's elopement. It was discovered that Resident #26 met qualifications for placement on the secured unit when Resident #26 was assessed to be at a high risk of elopement, but the resident was not moved to the unit. Root cause analysis indicates the system failure was an Elopement Risk Assessment was completed with no follow up action.
- The DON and designee completed audits of all 88 residents for Elopement Risk with no negative findings. No additional residents were impacted by the Elopement Risk Assessments. All 16 high-risk residents were appropriately located on the secured unit. All high-risk residents had care plans reviewed to ensure elopement risk was included. Care plans were revised to reflect changes for Residents #04, #13, #14, #21, and #26.
- The Administrator provided verbal education to the DON, and two unit managers [Registered Nurse (RN) #345 and Licensed Practical Nurse (LPN) #165] on identifying high elopement risk residents and the appropriate placement of exit-seeking individuals onto the secured unit as applicable.
- Minimum Data Set (MDS) Nurse #340 initiated a care plan for Resident #26. The care plan included that Resident #26 was an elopement risk/wanderer with an intervention of placement on a secured unit. Other interventions included identifying the pattern of wandering: divert as needed and intervene as appropriate.
- The facility held an ad hoc Quality Assurance Performance Improvement (QAPI) meeting with Medical Director #90, the Administrator, DOO #01, DOO #02, and the DON. The long-term care Ombudsman was also notified of the Immediate Jeopardy situation involving Resident #26.
- The DON or designee completed education to the nursing staff regarding Elopement Risk assessments and their completion/accuracy to ensure all nursing staff are knowledgeable.
- The Administrator or designee will complete weekly audits for four weeks for elopement risk assessments for all admissions, readmissions, and any resident with a change in condition.
Elevator Malfunctions and Improper Cigarette Disposal
Penalty
Summary
The facility failed to ensure the elevators were maintained in good working order and failed to ensure cigarette butts were disposed of in appropriate containers. Observations over several days revealed numerous cigarette butts lying on the ground in front of the facility entrance doors, in the mulch, and in the rocks located beside the entrance doors. Residents were observed smoking within ten feet of the entrance doors and disposing of cigarette butts on the ground due to the absence of appropriate receptacles. The Director of Nursing (DON) confirmed the area was not a designated smoking area and that residents continued to smoke and dispose of cigarette butts improperly despite a 'No Smoking' sign being present. The facility's smoking policy, revised in January 2024, stated that smoking was only permitted in designated areas with appropriate containers, which was not adhered to in this case. Additionally, the facility had issues with elevator maintenance. One of the two elevators was out of order, and the other frequently malfunctioned, failing to open its doors on the second floor and returning to the first floor without allowing passengers to disembark. Interviews with staff, residents, and the Ombudsman confirmed the frequent malfunctioning of the elevators. The DON and the Administrator acknowledged the ongoing issues despite multiple repair attempts. The facility did not have a policy pertaining to elevator maintenance, and concerns about the elevators were documented in the Resident Council Meeting minutes from April 2024.
Failure to Timely Notify Resident's Representative of Elopement
Penalty
Summary
The facility failed to timely notify the resident's representative of a resident's elopement from the facility. This deficiency affected Resident #26, who had diagnoses including dementia, altered mental status, cognitive communication deficits, and high blood pressure. On 04/20/24, Resident #26 was found by a housekeeper ambulating on the main road in front of the facility with his wheeled walker, approximately 0.1 miles away, and in the middle of the road with vehicles swerving around him. The housekeeper alerted the nursing staff, who were unaware that Resident #26 had left the floor. The resident was then brought back to the facility by an unknown staff member and escorted to the second floor. However, there was no documentation or recollection of the events in the nursing notes for that day. The facility's policy required the Nurse Supervisor/Charge Nurse to notify the resident's family or representative when the resident is involved in any accident or incident. Despite this, the resident's representative was not informed of the elopement until two days later, on 04/22/24, when the Social Services Director called the resident's niece to discuss future placement on the secure unit. The Director of Nursing confirmed that the facility should have notified the resident's representative immediately following the elopement, verifying the lapse in timely notification.
Failure to Ensure Interdisciplinary Team Participation in Care Conferences
Penalty
Summary
The facility failed to ensure that an interdisciplinary team was present during care conference meetings for four residents. Resident #5, who had severe cognitive impairments and multiple diagnoses including seizures and dementia, had a care conference attended only by the Social Services Director (SSD) and the MDS Nurse. Similarly, Resident #7, with severe cognitive impairments and diagnoses such as hypertension and dementia, had a care conference attended only by the SSD and an unidentifiable Licensed Practical Nurse (LPN), with no documentation indicating if the resident representative was invited. Both instances were verified by SSD #200 during an interview, confirming that the interdisciplinary team was not fully present as required by facility policy. Resident #26, who had moderate cognitive impairments and diagnoses including cerebrovascular disease and anemia, had a care conference attended solely by the SSD. Resident #67, with minimal cognitive impairments and multiple diagnoses such as metabolic encephalopathy and atrial fibrillation, also had a care conference attended only by the SSD. These deficiencies were confirmed through interviews with SSD #200, who acknowledged that the care conferences did not include all members of the interdisciplinary team as mandated by the facility's policy. The facility's policy, revised in December 2008, clearly states that care plans should be developed by the entire interdisciplinary team based on each resident's comprehensive assessment.
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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