New Dawn Rehabilitation And Healthcare Center
Inspection history, citations, penalties and survey trends for this long-term care facility in Dover, Ohio.
- Location
- 865 East Iron Avenue, Dover, Ohio 44622
- CMS Provider Number
- 365990
- Inspections on file
- 39
- Latest survey
- February 26, 2026
- Citations (last 12 mo.)
- 8
Citation history
Health deficiencies cited at New Dawn Rehabilitation And Healthcare Center during CMS and state inspections, most recent first.
Surveyors found multiple failures to follow infection prevention and control practices, including Enhanced Barrier Precautions (EBP), wound care, glucometer disinfection, and catheter care. An LPN administered IV antibiotics through a PICC line for a resident on EBP without wearing a gown, despite posted EBP signage and a policy requiring gown and gloves for high-contact device care. An RN performed a dressing change on a resident’s toe wound under an EBP care plan using only gloves and no gown, even though the door sign indicated EBP for the wounds. Another LPN used a shared glucometer for a resident’s blood glucose check, placed the glucometer and test strip container on the bed and then on the med cart, and did not clean or disinfect the equipment between residents, contrary to facility policy. In addition, a CNA provided catheter care to a resident and then continued to handle the call light, bed controls, bedding, and the urinary drainage bag without removing the contaminated gloves.
Staff failed to consistently monitor a resident’s blood pressure before administering antihypertensive medications. An RN gave lisinopril and metoprolol succinate, then checked the resident’s blood pressure afterward, despite acknowledging it should have been taken beforehand. Review of the MAR showed no specific hold parameters for these drugs, though there was a section to document BP and pulse with metoprolol tartrate, and multiple prior low BP readings had led to doses being withheld. The DON confirmed that BP should ideally be checked before giving medications that can lower BP, particularly for residents with a history of low readings.
A resident with dementia, repeated falls, generalized muscle weakness, gait difficulty, incontinence, and multiple medications (including diabetic, BP, narcotic, and psychotropic drugs) was care-planned and had MD orders for Dycem/non-skid material on the wheelchair as a fall-prevention intervention. A fall risk assessment identified the resident as high risk for falls and continued the Dycem intervention. During surveyor observation, the resident was found sitting in a wheelchair without the Dycem or other non-skid material in place, and an LPN confirmed its absence, resulting in a cited failure to implement the ordered fall-prevention measure.
A resident with multiple medical conditions, including a wrist fracture and CHF, was assessed as needing catheter care, which was scheduled every shift but documented as completed on only a few shifts, with the DON attributing the lack of entries to documentation issues. The resident’s skin was initially documented as intact with no wounds, yet later skilled evaluations recorded skin concerns and dressings as dry and intact on several occasions, while no wound assessments could be found. During interviews, an RN, a CNA, and the DON all denied the presence of wounds or dressings beyond a wrist cast and stated that the skin remained intact, creating discrepancies that showed the medical record was incomplete and inaccurate.
The facility failed to implement its antibiotic stewardship program for two residents who were documented in the infection control log as having in-house UTIs and were treated with antibiotics, despite no recorded UTI signs or symptoms in their medical records. For both residents, who had intact cognition and were dependent for ADLs, the infection control log indicated that McGeer’s criteria were met, yet there was no supporting clinical documentation or completed McGeer’s assessments. The DON confirmed the absence of documented UTI symptoms and assessments, even though the facility’s antibiotic stewardship policy required the infection control nurse or designee to review antibiotic utilization to ensure appropriate prescribing and use.
Surveyors found that staff failed to keep call lights within reach for two cognitively impaired, ADL-dependent residents who were care planned as fall risks. In one case, a resident seated in a Broda chair had the call light lying on the floor beside the bed, despite a care plan requiring it to be within reach and a sign to prompt use; a CNA confirmed it was not accessible and noted a loop on the cord intended for the resident’s wrist due to blindness. In another case, a resident lying in bed had the call light positioned behind a refrigerator, also out of reach, which a CNA verified. These observations showed the facility did not follow its own policy requiring call lights to be easily reachable when residents are in bed or confined to a chair.
A CNA failed to follow infection control protocols during incontinence care for a resident with multiple comorbidities, including diabetes and morbid obesity. The CNA reused washcloths for different body areas, did not follow the required front-to-back cleaning method, and did not use separate cloths as outlined in facility policy. The CNA acknowledged not following proper infection control procedures during the care.
A resident with type 1 diabetes and multiple comorbidities experienced critically high blood glucose readings that exceeded the prescribed insulin sliding scale. Despite facility policy requiring physician notification for such elevated levels, documentation showed only that a supervisor was notified, with no evidence that a physician or on-call provider was contacted for follow-up orders.
A facility failed to administer medications according to physician orders and manufacturer directions, resulting in a 10.8% error rate. An LPN gave medications to a resident with a heart rate below the prescribed threshold, and another LPN used an undated Lantus vial and rubbed the injection site against instructions. The DON confirmed the errors.
A resident with a complex medical history was administered Gleevec beyond the ordered duration due to the facility's failure to document and follow orders to hold the medication. Despite instructions from a hematology/oncology consultant and hospital discharge orders, the facility resumed the medication, leading to adverse symptoms and a significant medication error.
A resident's MAR was found incomplete, with missing documentation for lidocaine patch application and removal, blood glucose monitoring, and clindamycin administration. The DON confirmed the MARs were incomplete, and the facility's policy required documentation of medication administration.
A resident with diabetes and a leg amputation experienced a delay in receiving care after repeatedly requesting a snack and drink to manage low blood sugar. Despite using the call light multiple times, the resident's needs were not promptly addressed by a CNA, leading to frustration and a call to 911. The facility's investigation did not adequately address the timeline of events or the delay in meeting the resident's needs.
The facility failed to prevent the misappropriation of controlled medications, affecting 11 residents on the 200 hall. Inconsistencies in the Controlled Medication Shift Change Log led to discrepancies in medication counts, with missing Morphine not properly documented or located. Staff interviews confirmed the lack of adherence to procedures for handling discontinued or expired medications, and the facility's policy did not adequately address narcotics reconciliation.
The facility failed to accurately reconcile controlled medications for 33 residents, as revealed by discrepancies in the Controlled Medication Shift Change Logs. Interviews with LPNs indicated inconsistent documentation, particularly by agency nurses, leading to potential discrepancies in medication counts. The facility's policy did not adequately address the reconciliation process, contributing to the deficiency.
A resident with diabetic foot ulcers did not receive proper wound care as prescribed, with missed dressing changes on multiple occasions. The resident reported pain and uncompleted dressing changes, while an LPN admitted to not performing a change and incorrectly signing off the treatment sheet. The DON confirmed lapses in documentation and care.
A facility failed to provide proper care for a resident with a Stage IV pressure ulcer, as evidenced by missed dressing changes and incorrect mattress settings. Despite orders for Enhanced Barrier Precautions, LPNs only used gloves during wound care. The resident's care plan was not adequately followed, leading to this deficiency.
The facility failed to adequately monitor and document the administration of narcotic pain medications for two residents. One resident received Oxycodone without proper documentation on the MAR, and another had Tramadol removed from the controlled substance drawer without corresponding records. The Director of Nursing confirmed the discrepancies and lack of comprehensive pain assessments, violating the facility's Pain Management Policy.
The facility failed to label narcotic medications according to professional standards, affecting two residents. One resident's Tramadol label included conflicting orders, causing confusion about administration frequency. Another resident's Tramadol was labeled for routine dosing despite an as-needed order, leading to administration errors. LPNs confirmed these discrepancies.
The facility failed to maintain accurate medical records for two residents, with discrepancies in the administration of controlled substances. A nurse signed out multiple doses of morphine and oxycodone without explanation or proper documentation, violating the facility's policies. The Director of Nursing confirmed the lack of documentation for excess medication.
A facility failed to follow infection control measures during a dressing change for a resident with a Stage IV pressure ulcer. Despite orders for Enhanced Barrier Precautions, two LPNs only used gloves and did not wear masks or gowns as required. The facility's policy aimed at preventing multidrug-resistant organism transmission was not adhered to, and the oversight was confirmed in an interview with one of the LPNs.
The facility did not ensure food was served at palatable temperatures, affecting all residents who ate meals prepared in the kitchen. Interviews with residents revealed concerns about food often being cold. An observation showed that while food on the steam table was initially hot, it cooled significantly by the time it was served. A test tray revealed BBQ ribs at 98°F and sweet potato fries at 94.3°F, both cool to the touch and lukewarm in taste.
The facility failed to properly sanitize dishes and utensils as the dish machine did not reach the required temperature for sanitization. Observations showed temperatures between 145-147°F, below the necessary 180°F. Staff were not instructed on handling inadequate temperatures, and the issue was linked to a faulty hot water tank. The problem persisted from April to June 2024, with no proper sanitization process in place until the deficiency was identified.
The facility failed to provide facial protection for staff handling soiled linens and did not implement its water management program for legionella prevention. Observations revealed no facial shields in the laundry room, and the Maintenance Director was unaware of key plan components. Additionally, the TB risk assessment was outdated, using data from 2021 despite more current information being available.
The facility failed to secure and discard expired medications, affecting three residents and potentially impacting all 25 residents on the 200 unit. An LPN verified expired insulin for two residents, while another resident had medications without a physician's order. Expired over-the-counter medications were also found in the storage room, violating facility policies.
The facility failed to forward the personal funds of two deceased residents to their estates within 30 days. One resident, with altered mental status, diabetes, and hypertension, passed away, but her funds were not dispersed until months later due to contact issues with her representative. Similarly, another resident with congestive heart failure, diabetes, and hypertension experienced a delay in fund disbursement for the same reason. In both cases, the funds were eventually used to settle outstanding balances with the facility.
A facility failed to document a resident's wish for CPR in the medical record. The resident initially had a DNRCCA-DNI order, but later signed an Advance Directive Questionnaire indicating a desire for CPR. A social service note also documented the resident's request for full measures, but this was not immediately updated in the medical record. The discrepancy was later addressed by the DON, who clarified and updated the resident's code status.
The facility failed to establish comprehensive care plans for two residents. One resident with anxiety was prescribed Vistaril, but their care plan did not address the anxiety diagnosis or medication use. Another resident, who fell and sustained fractures, had a care plan that addressed only one of the fractures. These deficiencies were confirmed by the DON.
The facility failed to update care plans for two residents to include necessary fall interventions. One resident's care plan did not reflect the use of hipsters after a fall, and another resident's care plan had not been updated since 2022 despite a fall resulting in a fracture. Interviews confirmed the need for revisions.
A resident with a preference for group activities and outdoor time was unable to participate due to meal times conflicting with scheduled activities. The facility lacked a formal tracking system for resident preferences, and policy restrictions limited outdoor access. The Activity Director confirmed the scheduling issues and absence of evidence for offered activities.
A facility failed to document non-pharmacological interventions before administering Ativan to a resident with multiple diagnoses, including Parkinson's and anxiety disorders. The Director of Nursing confirmed the absence of such documentation, and the facility lacked a specific policy for anti-anxiety medications.
The facility failed to offer pneumococcal vaccinations according to CDC guidelines, affecting two residents. One resident did not receive a required additional dose of PCV 20 or PPSV 23, and another was not offered Prevnar 13 or its alternatives. An LPN confirmed the oversight and lack of documentation for immunization education or consent forms.
The facility failed to maintain a safe and sanitary environment, affecting all residents on one hall and one resident observed for incontinence care. Towels and bath blankets were found on the floor, and an STNA threw soiled linens on the floor during care, unaware of the infection control issue until later instructed.
The facility failed to implement fall interventions for three residents, leading to a deficiency in ensuring a safe environment. Residents with significant fall risk factors were observed without the required fall mats beside their beds, contrary to their care plans and physician orders. These observations were verified by staff, highlighting non-compliance in preventing accidents.
A resident's nebulizer equipment was not stored in a sanitary manner, with the mask left on the nightstand and liquid remaining in the canister, contrary to the facility's policy requiring disassembly and storage in a plastic bag after use.
The facility failed to provide physician-ordered adaptive equipment for meals to three residents, despite these being specified in their care plans and meal tickets. This non-compliance was verified through observations, medical record reviews, and staff interviews.
The facility failed to provide safe and appropriate transportation for three residents to their dialysis treatments, resulting in them being pushed in wheelchairs up an unlit, steep road in adverse weather conditions. Staff and residents expressed concerns about the safety and discomfort of this practice.
Failure to Implement Infection Control Practices for EBP, Device Care, Wound Care, and Shared Equipment
Penalty
Summary
The deficiency involves the facility’s failure to implement its infection prevention and control program, specifically Enhanced Barrier Precautions (EBP), device and wound care practices, and cleaning and disinfection of shared equipment. For a resident with type 2 diabetes mellitus and a urinary tract infection receiving IV meropenem via a PICC line, an LPN administered the medication without donning a gown, despite an EBP sign on the door and a facility policy requiring gown and gloves for high-contact care involving central lines. The LPN confirmed she had not implemented EBP and stated she had never been told it was required. The facility’s EBP policy, revised March 2024, required gown and glove use for high-contact resident care activities, including device care such as central lines, and indicated EBP for residents with indwelling medical devices regardless of multidrug-resistant organism colonization. Another deficiency occurred during wound care for a resident with peripheral vascular disease and chronic obstructive pulmonary disease who had wounds on the left toe and coccyx and a care plan intervention for EBP, including wearing a gown and gloves when providing care. A physician’s order directed daily and as-needed dressing changes to the left third toe wound. During an observed dressing change to the lateral aspect of the third toe, an RN wore gloves but did not don a gown, despite an EBP sign posted on the door. The RN verified that the EBP sign was related to the resident’s wounds and acknowledged she had not worn a gown during the wound care. The same EBP policy requiring gown and glove use for high-contact resident care activities applied in this situation. Additional infection control failures involved shared equipment and catheter care. For a resident with type 2 diabetes mellitus requiring daily blood glucose monitoring, an LPN used a shared glucometer, placed the glucometer and test strip container on the resident’s bed, then later on the medication cart and mouse pad, and did not clean or disinfect the glucometer or container after use before proceeding to administer medications to another resident. The LPN gave inconsistent answers about cleaning frequency and confirmed she had not cleaned the items after use, contrary to the facility’s policy requiring reusable items to be cleaned and disinfected between residents. In a separate observation, a CNA provided urinary catheter care to a resident with congestive heart failure, vascular dementia, and obstructive and reflux uropathy, then failed to remove gloves afterward and continued to handle the call light, bed controls, bedding, and the urinary collection bag and cover with the same contaminated gloves. The CNA confirmed she had not removed the gloves used for catheter care before touching these items.
Failure to Monitor Blood Pressure Before Administering Antihypertensive Medications
Penalty
Summary
Staff failed to monitor a resident’s blood pressure prior to administering antihypertensive medications. On 02/25/26 between 8:55 A.M. and 9:05 A.M., an RN administered lisinopril 20 mg and metoprolol succinate 50 mg to Resident #18 and obtained the resident’s blood pressure only after giving the medications. In a subsequent interview, the RN confirmed that the resident’s blood pressure should have been taken before administering these medications. Review of the February 2026 MAR for this resident showed no specific parameters for holding lisinopril or metoprolol tartrate, although there was a designated area to document blood pressure and pulse with metoprolol tartrate administration. The MAR indicated five instances when metoprolol tartrate was not administered due to low blood pressure readings, including 90/67, 93/51, 95/61, and 105/90 on various mornings, and additional readings of 99/63 and 98/52 on other dates. In an interview, the DON stated that blood pressures should ideally be monitored prior to giving medications that could affect blood pressure, especially for residents with a history of low readings. This deficiency was investigated under Complaint Number 2706361.
Failure to Implement Ordered Non-Slip Wheelchair Intervention for High Fall-Risk Resident
Penalty
Summary
Surveyors found that the facility failed to implement a care-planned fall intervention for a resident assessed as high risk for falls. The resident had dementia, repeated falls, generalized muscle weakness, difficulty walking, incontinence, and multiple co-morbidities, and was taking diabetic, blood pressure, narcotic, and psychotropic medications. A fall risk plan of care initiated on 11/11/22 identified the resident as at risk for falls related to weakness, co-morbidities, incontinence, and medication use, and an intervention dated 11/16/23 specified placing Dycem, a non-slip material, on the resident’s wheelchair. A physician order dated 11/05/23 also directed use of a non-skid sheet on the wheelchair. A fall risk evaluation dated 11/04/25 again identified the resident as high risk for falls, with risk factors including multiple recent falls, memory problems, frequent incontinence, behavioral issues, confinement to a chair, loss of balance when standing, need for hands-on assistance for mobility, use of an assistive device, and decreased muscle coordination, and it continued the intervention of Dycem to the wheelchair. During an observation and interview on 02/25/26 at 1:25 P.M., the resident was observed sitting in a wheelchair without Dycem or a non-skid sheet in place, despite the ongoing care plan and physician orders requiring this intervention. An LPN present at the time confirmed that the resident was in the wheelchair and that there was no Dycem present. This failure to implement the ordered and care-planned non-slip wheelchair intervention for a high fall-risk resident constituted the cited deficiency.
Incomplete and Inaccurate Medical Record for Resident Catheter Care and Skin Status
Penalty
Summary
The facility failed to maintain a complete and accurate medical record for a resident with multiple diagnoses, including a non-displaced left wrist fracture, depression, bipolar disorder, malignant melanoma of the trunk, and congestive heart failure. An admission nursing assessment documented that the resident was alert but confused and indicated that catheter care was to be provided by nursing assistants. The nursing assistant task bar showed catheter care scheduled every shift from late December through late January, but there was no documentation that this care was completed except for three day shifts in January. The urinary catheter was discontinued on 01/22/25. The DON stated there was no catheter care documentation in December because the task did not appear on the aide task bar until the baseline care plan evaluation was completed and acknowledged that only three days in January showed completion, characterizing the issue as a documentation problem rather than a failure to provide care. The resident’s admission assessment and a wound nurse practitioner note shortly after admission both documented intact skin with no open wounds. However, multiple skilled evaluations later documented skin concerns and dressings as dry and intact on several dates in January, yet no corresponding skin or wound assessments could be located in the medical record. During interviews, an RN and a CNA both denied that the resident had any wounds or dressing changes, stating they were only aware of a wrist cast. The DON also reported that the resident’s skin remained intact throughout the stay and stated that the skilled evaluations indicating skin concerns and dressings were incorrect. These inconsistencies between clinical documentation, staff interviews, and the absence of wound assessments demonstrated that the resident’s medical record was not complete or accurate.
Failure to Implement Antibiotic Stewardship for Suspected UTIs
Penalty
Summary
The deficiency involves the facility’s failure to implement its antibiotic stewardship program to ensure appropriate use of antibiotics, specifically related to urinary tract infection (UTI) management. For one resident admitted in December 2024 and readmitted in September 2025 with diagnoses including heart failure, COPD, and diabetes mellitus, record review showed no documentation of any UTI signs or symptoms in the medical record. Despite this, the infection control log for January 2026 listed the resident as having acquired an in-house UTI and receiving antibiotics from January 27, 2026, to February 3, 2026, and indicated that McGeer’s criteria were met. The DON confirmed there was no documentation of UTI signs or symptoms, and although a urinalysis was ordered on January 19, 2026, there was no documentation of signs and symptoms or a completed McGeer’s assessment for UTI. A second resident, admitted in August 2023 and readmitted in March 2024 with diagnoses including chronic kidney disease, major depressive disorder, and anxiety disorder, similarly had no documentation of UTI signs or symptoms in the medical record. The quarterly MDS showed this resident had intact cognition and was dependent on staff for ADLs. The facility’s infection control log for February 2026 recorded that this resident acquired an in-house UTI and was on antibiotics from February 1, 2026, to February 6, 2026, and again indicated that McGeer’s criteria were met. The DON verified there was no documentation of UTI signs or symptoms and no McGeer’s assessment completed for this UTI. Review of the facility’s undated Antibiotic Stewardship Program policy showed that the infection control nurse or designee was responsible for infection control line listing and review of antibiotic utilization to ensure appropriate prescribing and use of antibiotics, which was not carried out as required in these cases.
Failure to Ensure Call Lights Were Accessible to Dependent Residents
Penalty
Summary
The deficiency involves the facility’s failure to maintain a call light system that was readily accessible to residents in accordance with its policy requiring call lights to be within easy reach when residents are in bed or confined to a chair. For one resident with Alzheimer’s disease, schizophrenia, and major depressive disorder, the care plan identified a risk for falls and included interventions to ensure the call light was within reach and a sign was in place to remind the resident to use the call light for assistance. The quarterly MDS showed this resident was moderately cognitively impaired and dependent on staff for ADLs. On two separate observations the resident was seated in a Broda chair next to the bed while the call light was found on the floor beside the bed, not within reach. A CNA confirmed the call light was not accessible and explained that a loop was placed around the call light cord to go around the resident’s wrist because the resident was blind. A second resident, admitted with dementia, chronic kidney disease, and diabetes mellitus, also had a care plan identifying fall risk with an intervention to ensure the call light was within reach. The quarterly MDS indicated this resident was severely cognitively impaired and dependent on staff for ADLs. During observation, this resident was lying in bed while the call light was located behind the refrigerator, out of the resident’s reach. A CNA verified that the call light was not accessible to the resident. These findings were identified during the course of a complaint investigation and showed that, for two of three residents reviewed for call light accessibility, the facility did not ensure call lights were positioned so residents could use them as required by facility policy and care plan interventions.
Failure to Maintain Infection Control During Incontinence Care
Penalty
Summary
A deficiency was identified when a Certified Nurse's Aide (CNA) failed to maintain proper infection control procedures during incontinence care for a resident with multiple diagnoses, including congestive heart failure, morbid obesity, diabetes, and erythema intertrigo. The resident was dependent on staff for most activities of daily living and was always incontinent of bowel and occasionally incontinent of urine. During observed care, the CNA placed soiled washcloths and towels directly on the bed, reused washcloths for different areas, and did not follow the facility's perineal care policy, which requires separate cloths and specific cleaning directions to prevent cross-contamination. The CNA was observed removing gloves, washing hands over the washcloths in the sink, and then reapplying gloves multiple times throughout the care process, but continued to use the same washcloths for different body areas. The CNA confirmed in an interview that proper infection control procedures were not followed. The facility's policy specifically instructs not to use the same cloth or water to clean the urethra or labia and to follow a front-to-back cleaning method, which was not adhered to during the observed care.
Failure to Notify Physician of Critically High Blood Glucose Levels
Penalty
Summary
The facility failed to ensure physician notification occurred when a resident experienced significantly elevated blood glucose levels. The resident, who had multiple diagnoses including type 1 diabetes, end stage renal disease, malnutrition, and cognitive impairment, had blood glucose readings of 578 and 537 on consecutive checks. Despite these readings exceeding the highest range of the prescribed sliding scale for insulin administration, there was no documentation that a physician or on-call provider was notified to provide follow-up orders. Review of the resident's care plan and medication orders confirmed that insulin was to be administered according to a sliding scale, with specific instructions for blood glucose levels up to 450. Facility policy, as described by an LPN, required staff to notify the on-call provider for blood glucose readings over 450. However, progress notes only indicated that the end of the scale was given and a supervisor was notified, with no evidence of physician notification for the elevated readings. This deficiency was identified during a complaint investigation.
Medication Administration Errors in LTC Facility
Penalty
Summary
The facility failed to ensure medications were administered in accordance with physician orders and drug manufacturer directions, resulting in a 10.8% medication error rate. One incident involved a Licensed Practical Nurse (LPN) administering medications to a resident with a heart rate of 55, despite physician orders specifying that the medications should be withheld if the heart rate was less than 60. The medications involved were amlodipine, hydralazine, and metoprolol succinate. The Director of Nursing (DON) confirmed that the orders required withholding the medications under these conditions. Another incident involved an LPN administering Lantus insulin to a resident without noting the date the vial was opened, contrary to the facility's policy requiring the date to be recorded. The Lantus vial was delivered over a month prior, and manufacturer instructions indicated it should be discarded after 28 days. Additionally, the LPN rubbed the injection site post-administration, which was against the manufacturer's instructions. The DON verified the need for dating insulin vials and acknowledged the manufacturer's instructions regarding the injection site.
Medication Management Error with Anti-Neoplastic Drug
Penalty
Summary
The facility failed to properly manage the medication orders for a resident, leading to the administration of an anti-neoplastic medication, Gleevec, beyond the ordered duration. The resident, who had a complex medical history including pleural effusion, pneumonia, and leukemia, was initially prescribed Gleevec by a hematologist. However, the facility did not document the order to hold the medication as instructed by the hematology/oncology consultant and the hospital discharge instructions. This oversight resulted in the continued administration of Gleevec, which was not authorized by the attending physician upon the resident's return to the facility. The resident experienced adverse symptoms, including coughing up blood, which prompted communication with the hematology/oncology office. Despite instructions to hold the medication until a follow-up appointment, the facility resumed administering Gleevec. Laboratory results indicated a significant decrease in hemoglobin and platelet levels, which were attributed to the continued use of the medication. The resident's condition worsened, leading to further medical evaluations and hospital admissions. Interviews with the resident's physician and the hematology/oncology office confirmed that the continued administration of Gleevec was a medication error. The physician was unaware of the orders to hold or discontinue the medication and stated that he would not have contradicted a specialist's orders. The facility's failure to properly document and communicate medication orders resulted in a significant medication error, affecting the resident's health and requiring additional medical intervention.
Incomplete Medication Administration Records
Penalty
Summary
The facility failed to maintain accurate and complete medication administration records for a resident with multiple diagnoses, including hypertension, type two diabetes mellitus with diabetic neuropathy, intervertebral disc disorders, and arthropathies of the right shoulder. The resident's January 2025 Medication Administration Record (MAR) showed missing documentation for the application and removal of a prescribed lidocaine patch on several dates. Additionally, there were missing blood glucose monitoring results, which were necessary to determine the administration of sliding scale insulin. These omissions made it unclear whether the insulin should have been administered. In February 2025, further discrepancies were noted in the MAR, including the lack of documentation for the administration of clindamycin and missing blood sugar recordings. The Director of Nursing confirmed the incompleteness of the MARs and acknowledged that any reasons for not administering medication should have been documented. The facility's policy required the individual administering medication to document it in the MAR, which was not adhered to in these instances.
Resident's Needs Unmet, Calls 911 for Assistance
Penalty
Summary
The facility failed to provide timely care and services to Resident #72, who had a history of diabetes mellitus type two, depression, and a right below-the-knee amputation. The resident, who was cognitively intact, experienced a delay in receiving assistance after repeatedly requesting a snack and drink to manage his blood sugar levels. Despite using the call light multiple times, the resident's needs were not addressed promptly by CNA #100, leading to frustration and the resident calling 911 for help. On the evening of the incident, Resident #72 activated the call light around 7:30 P.M. and requested a peanut butter and jelly sandwich, two sodas, and assistance from the nurse, as he felt his blood sugar was low. CNA #100 responded but did not fulfill the request, stating she was busy with rounds. The resident's repeated requests over the next few hours were similarly unmet, leading to increased agitation. Eventually, the resident crawled to the hallway to seek help, where he encountered CNA #100 and LPN #150, who did not provide immediate assistance. The situation escalated when Resident #72 called 911, prompting LPN #200 to intervene. The facility's investigation into the incident did not adequately address the timeline of events or the delay in meeting the resident's needs. The Clinical Manager and Administrator acknowledged the failure to provide timely care, with expectations that the resident's requests should have been met within a reasonable timeframe. This deficiency was investigated under Complaint Number OH00161322.
Misappropriation of Controlled Medications
Penalty
Summary
The facility failed to prevent the misappropriation of controlled medications, specifically narcotics, affecting 11 residents on the 200 hall. The Controlled Medication Shift Change Log revealed inconsistencies in documenting the number of medications and signature sheets counted during shift changes. Medications were removed from the controlled medication drawer without proper documentation, leading to discrepancies in the medication count. Interviews with staff, including LPNs and the Director of Nursing (DON), confirmed these discrepancies, and the DON was unable to locate completed signature sheets or the missing medications. The investigation revealed that Resident #71 had expired, and there were missing cards of Morphine that were not accounted for in the log. Staff interviews indicated that the usual procedures for handling discontinued or expired medications were not followed, as the DON did not receive any medications or signature sheets for destruction from the 200 hall. The facility's Controlled Substance policy did not adequately address the reconciliation process for narcotics, contributing to the lack of proper documentation and oversight. The facility's Administrator and DON confirmed that a Self Reported Incident and a Police Report were filed regarding the misappropriation. The facility's Pharmacy Policy required immediate reporting of suspected theft or loss of drugs, but the policy lacked specific procedures for documenting and reconciling controlled substances. The investigation led to the resignation of an RN involved in the medication count discrepancies, and the missing Morphine was not located.
Inaccurate Reconciliation of Controlled Medications
Penalty
Summary
The facility failed to ensure accurate reconciliation of controlled medications, affecting 33 residents who were prescribed controlled medications. The deficiency was identified through a review of medical records, facility policy, and staff interviews. The Controlled Medication Shift Change Logs for various halls revealed discrepancies in the recording of medication counts, with fluctuations in the number of medication cards and signature sheets without corresponding entries of medications being added or removed. This lack of documentation made it difficult to track the controlled medications accurately. Interviews with Licensed Practical Nurses (LPNs) highlighted that the process of counting controlled substances was not consistently recorded, leading to potential discrepancies in medication counts. Agency nurses were sometimes involved, and they did not always sign the logs or know the proper way to record controlled medications. This inconsistency in documentation meant that staff could not verify if medications were missing, as the check and balance step of tracking all controlled medications was not being followed. The Director of Nursing (DON) and the facility's Controlled Substance policy were also reviewed. The policy did not address the specific reconciliation process used by the facility, nor did it include procedures for documenting when medications were added or removed from the locked drawer. The policy required controlled substances to be stored in a locked container in the medication room, but the facility stored them in a locked drawer of a medication cart in the hall. The deficiency was investigated under a Master Complaint Number, indicating non-compliance with regulations related to handling, storage, disposal, and documentation of controlled substances.
Failure to Provide Proper Wound Care for Diabetic Foot Ulcers
Penalty
Summary
The facility failed to ensure proper care and treatment for diabetic foot ulcers for a resident, leading to a deficiency. The resident, who was admitted with multiple medical conditions including type 2 diabetes and diabetic foot ulcers, had specific physician orders for wound care. These orders included cleansing the wounds with normal saline, applying bacitracin, and covering with a dry dressing or Band-Aid daily. However, there were documented instances where the dressings were not changed as required, specifically on 10/18/24, 10/27/24, and 11/06/24. Additionally, on 11/11/24, the resident reported that the nurse left the dressings in the room but did not return to change them, despite the treatment record being signed off as completed. Interviews with the resident and staff revealed discrepancies in the documentation and actual care provided. The resident expressed that his right foot was in pain and that he did not receive the necessary dressing changes. An LPN admitted to not performing the dressing change on 11/11/24 due to being occupied with an admission and incorrectly signing off the treatment sheet. The Director of Nursing confirmed that there were days when the foot dressings were not signed off as completed, indicating a lapse in the facility's adherence to the prescribed treatment plan for the resident's diabetic foot ulcers.
Failure to Provide Proper Pressure Ulcer Care
Penalty
Summary
The facility failed to provide appropriate care and treatment for pressure ulcers in accordance with professional standards, affecting a resident with multiple medical conditions, including a Stage IV pressure ulcer on the sacrum. The resident, who was moderately impaired in daily decision-making and required substantial assistance to move, had a history of osteomyelitis, MRSA infection, and multiple pressure ulcers. Despite physician orders for specific wound care and the use of a low air loss mattress set according to the resident's weight, there were lapses in care. The treatment record showed that the sacral dressing was not changed on several occasions, and the mattress was set incorrectly at a higher weight than the resident's actual weight. During an observation, it was noted that the resident's sacral wound dressing change was conducted by LPNs who only used gloves as PPE, despite an order for Enhanced Barrier Precautions, which required additional protective equipment. An interview with one of the LPNs confirmed the incorrect mattress setting and the failure to adhere to the PPE requirements during the dressing change. The facility's policy on pressure ulcer prevention emphasized reviewing the resident's care plan for special needs, which was not adequately followed, leading to the deficiency.
Inadequate Monitoring and Documentation of Narcotic Administration
Penalty
Summary
The facility failed to ensure adequate monitoring and documentation of narcotic pain medication administration for two residents. Resident #8, admitted with multiple diagnoses including a fractured neck of the right femur and chronic lymphocytic leukemia, had an order for Oxycodone 5 mg to be administered as needed for pain. However, there were discrepancies in the medication administration records, with 13 doses of Oxycodone removed from the controlled substance drawer without corresponding documentation on the Medication Administration Record (MAR). Additionally, there was no evidence of comprehensive pain assessments being conducted to justify the use of the narcotic, as required by the facility's Pain Management Policy. Similarly, Resident #26, readmitted with conditions such as sepsis, myocardial infarction, and chronic kidney disease, had an order for Tramadol HCL 50 mg for pain management. The records indicated that six doses of Tramadol were removed from the controlled substance drawer without documentation on the MAR. Like Resident #8, there was a lack of pain assessments to support the administration of the narcotic medication, and the necessary details such as date, time, drug, and dosage were not recorded. Interviews with the Director of Nursing (DON) confirmed the discrepancies in medication administration and the lack of adequate monitoring for both residents. The facility's undated Pain Management Policy mandates that pain assessments be conducted prior to administering pain medication, with documentation of the drug, dose, and route on the Pain Management Flow Sheet and MAR. The absence of such documentation and assessments for the narcotic medications administered to Residents #8 and #26 represents a deficiency in compliance with the facility's policies and procedures.
Medication Labeling Deficiency for Controlled Substances
Penalty
Summary
The facility failed to ensure that narcotic medications were labeled according to professional standards, affecting two residents. For one resident, the controlled medication shift change log and signature sheets revealed a prescription for Tramadol with a label that included two different orders: one for a single daily dose and another for as-needed administration. This discrepancy led to confusion about the correct administration schedule, as confirmed by an LPN who noted that the resident was receiving the medication only as needed, not daily. For another resident, the medical record indicated a readmission with multiple diagnoses, including sepsis and heart failure. The physician's order specified Tramadol to be administered every eight hours as needed, but the medication label incorrectly stated it should be given three times daily. This error was not flagged to alert staff of the dosage change, resulting in the medication being administered as needed from a mislabeled card. An LPN verified the inconsistency between the label and the actual administration practice.
Medication Administration and Record-Keeping Deficiencies
Penalty
Summary
The facility failed to ensure accurate medical records for two residents, which was identified through a review of medical records, interviews, and policy review. Resident #71's medical record showed discrepancies in the administration of Morphine Sulfate. On multiple occasions, Registered Nurse (RN) #174 signed out two doses of morphine instead of one without providing an explanation. Additionally, there was no evidence of proper documentation or witness verification for wasted medication, as required by the facility's policy. The Director of Nursing confirmed that excess medication was signed out without proper documentation. Similarly, Resident #16's medical record revealed issues with the administration of Oxycodone. RN #174 signed out two doses of Oxycodone instead of one on two separate occasions, again without explanation. The Director of Nursing verified that excess medication was signed out without documentation of its disposition. These findings were part of an investigation under a master complaint number, indicating non-compliance with the facility's medication management policies.
Infection Control Breach During Dressing Change
Penalty
Summary
The facility failed to adhere to infection control measures during a dressing change for a resident with a Stage IV pressure ulcer. The resident, who was admitted with multiple diagnoses including hyperkalemia, congestive heart failure, and dementia, had a chronic sacral pressure ulcer that required specific dressing changes. Physician orders included Enhanced Barrier Precautions (EBP) for wounds, which mandated the use of gowns and gloves during high-contact care activities. However, during an observed dressing change, two LPNs only used gloves and did not wear masks or gowns as required by the EBP policy. The facility's EBP policy, implemented to prevent the transmission of multidrug-resistant organisms, was not followed. The policy required gowns and gloves to be used during wound care, and face protection if there was a risk of splash or spray. Despite the presence of a sign indicating EBP at the resident's door, the LPNs did not comply with the necessary precautions. An interview with one of the LPNs confirmed the oversight and acknowledged that the dressing changes were not consistently documented.
Food Served at Inadequate Temperatures
Penalty
Summary
The facility failed to ensure that food was served at palatable temperatures, potentially affecting all 59 residents who consumed meals prepared in the kitchen. Interviews conducted on July 1, 2024, with several residents revealed concerns about the palatability of food, specifically noting that it was often served cold. An observation on July 2, 2024, showed that while food temperatures on the steam table were above 165 degrees Fahrenheit, a test tray plated at 12:22 P.M. and delivered to the floor at 12:31 P.M. had significantly cooled by the time it was served. By 12:43 P.M., the BBQ ribs on the test tray measured 98 degrees Fahrenheit, and the sweet potato fries were 94.3 degrees Fahrenheit, both of which were verified by a staff member. The food was described as cool to the touch and lukewarm in taste.
Inadequate Dish Sanitization Due to Low Temperature
Penalty
Summary
The facility failed to ensure proper sanitization of dishes and eating utensils due to the high-temperature dish machine not reaching the required temperature for sanitization. Observations revealed that the dish machine's temperature ranged between 145-147 degrees Fahrenheit, below the required 180 degrees Fahrenheit for sanitization. The kitchen staff was using a rinse aid that was not intended for sanitization, and there was no sanitizing solution in the bus tubs used for rinsing dishes. Interviews with staff indicated that the dish machine's temperature was inconsistent, and there were no instructions provided on what to do when the temperature was inadequate for sanitization. The issue was compounded by the facility's hot water tank needing replacement, which affected the dish machine's performance. The maintenance staff was uncertain about how long the dish machine had been failing to reach the appropriate temperature. The dietary staff was not observed sanitizing items after they were run through the dish machine, contrary to what the Administrator was informed. Additionally, the Registered Dietitian initially used incorrect test strips for chlorine levels, and the proper sanitization process using bleach was only initiated after the deficiency was identified. The dish machine temperature logs from April to June 2024 showed consistently low temperatures, indicating a prolonged period of inadequate sanitization.
Infection Control and Water Management Deficiencies
Penalty
Summary
The facility failed to ensure proper infection prevention and control measures were in place, as evidenced by the lack of facial protection in areas where staff handled soiled linens. During an observation in the laundry room, it was noted that no facial shields were available to prevent splatter from soiled linens. Housekeeping staff confirmed that soiled laundry was sent back to the floor for aides to rinse, yet no facial shields were available in the utility rooms where this rinsing occurred. The facility's policy required protective gloves and other appropriate protective equipment when handling soiled laundry, which was not adhered to. Additionally, the facility did not implement its water management program for legionella prevention effectively. The Maintenance Director was unaware of key components of the plan, such as the meaning of TMV, and could not provide evidence of monthly checks or other required actions. There was no documentation of shower heads being descaled, cleaned, and disinfected quarterly, nor were records kept of hot water tank maintenance. Furthermore, the facility's tuberculosis risk assessment was outdated, using data from 2021 despite more current information being available. The Administrator acknowledged that the TB risk assessment had not been updated with the latest data, which was available from the Ohio Department of Health.
Medication Management Deficiencies
Penalty
Summary
The facility failed to ensure that medications were properly secured and discarded when expired, affecting three residents and potentially impacting all 25 residents on the 200 unit. For Resident #21, a bottle of Lantus insulin was found to be expired, as it was opened beyond the 28-day limit. Similarly, Resident #37 had an expired bottle of Insulin Aspart, which was also not discarded after 28 days. Both instances were verified by the respective LPNs, who acknowledged the oversight in checking expiration dates prior to medication administration. Additionally, Resident #36 was found to have Tums and Preparation H at her bedside without a physician's order, which was confirmed by an LPN. The facility's medication storage room contained expired over-the-counter medications, including Loratadine, Naproxen Sodium, and Melatonin, which were not discarded as required. These lapses were in violation of the facility's policies on administering and storing medications, which mandate checking expiration dates and ensuring medications are administered according to physician orders.
Delayed Disbursement of Deceased Residents' Personal Funds
Penalty
Summary
The facility failed to ensure that the personal funds of two deceased residents were forwarded to their estates within the required 30-day period. Resident #227, who had diagnoses including altered mental status, diabetes mellitus, and hypertension, passed away on December 8, 2023. Despite this, her personal funds, amounting to $50.15, were not dispersed until July 1, 2024, when the facility debited her account and made a check out to itself. The delay was attributed to the facility's inability to contact the resident's representative until June 2024, at which point the representative agreed to use the funds to settle the resident's outstanding balance with the facility. Similarly, Resident #228, who had diagnoses including congestive heart failure, diabetes mellitus, and hypertension, passed away on February 20, 2024. Her personal funds, totaling $100.22, were not dispersed until June 30, 2024, when the facility debited her account and issued a check to itself. The facility also cited difficulties in reaching the resident's representative until June 2024, who then agreed to apply the funds towards the resident's outstanding balance. These actions resulted in a failure to comply with the requirement to forward personal funds to the residents' estates within 30 days of their passing.
Failure to Document Resident's CPR Wishes
Penalty
Summary
The facility failed to ensure that a resident's wish for cardiopulmonary resuscitation (CPR) was clearly documented in the medical record. The resident, identified as Resident #128, had an initial order for Do Not Resuscitate - Comfort Care - Arrest - Do Not Intubate (DNRCCA - DNI) upon admission. However, an Advance Directive Questionnaire signed by the resident indicated a desire for CPR. A social service progress note later documented the resident's request to change her advance directive to full measures, but this change was not immediately reflected in the medical record. Interviews revealed that the Licensed Social Worker (LSW) responsible for the admission paperwork left the documents with the resident and forgot to retrieve them until later. Upon discovering the resident's signed full code status, the LSW informed a floor nurse but failed to notify the Director of Nursing (DON). The discrepancy between the resident's wishes and the medical record was eventually discussed with the DON, who clarified the resident's code status and updated the medical record accordingly. The facility's Advance Directives policy requires that residents be informed of their rights to make medical decisions, and that their care plans align with their documented preferences.
Failure to Establish Comprehensive Care Plans for Residents
Penalty
Summary
The facility failed to ensure comprehensive care plans were established for two residents, leading to deficiencies in their care. Resident #14, who was admitted with diagnoses including congestive heart failure, depression, and chronic kidney disease, was prescribed Vistaril for anxiety. However, the care plan did not address the anxiety diagnosis or the use of anti-anxiety medication. This was confirmed by the Director of Nursing during an interview. Resident #54, admitted with conditions such as a fracture of the left femur, dementia, adult failure to thrive, and difficulty in walking, experienced a fall after self-ambulating without a necessary mobility device. This resulted in an intertrochanteric fracture and a humeral fracture. While the care plan addressed the intertrochanteric fracture, it failed to include the humeral fracture, as confirmed by the Director of Nursing.
Failure to Update Care Plans for Fall Interventions
Penalty
Summary
The facility failed to ensure that the care plans for two residents were revised to include all necessary fall interventions. Resident #55, who was admitted with diagnoses including syncope, difficulty in walking, and repeated falls, experienced a fall on 03/01/24. Although a new intervention of wearing hipsters was identified to reduce the risk of fractures, this intervention was not updated in the resident's care plan, nor was there a physician's order for the hipsters in July 2024. The Director of Nursing confirmed that the care plan did not reflect this intervention. Similarly, Resident #43, admitted with diagnoses of weakness, congestive heart failure, and a history of falls, had a care plan related to falls that had not been updated since 2022. After an unwitnessed fall on 03/03/24, which resulted in a humerus fracture, the care plan still lacked necessary revisions. Interviews with the Minimum Data Set Nurse and the Director of Nursing confirmed that the care plan should have been updated following the fall with injury.
Failure to Provide Individualized Activity Program
Penalty
Summary
The facility failed to provide an individualized activity program and schedule group activities to accommodate a resident's preferences and needs. The resident, who was cognitively intact and had a preference for group activities, expressed that it was important to have access to reading materials, music, and outdoor activities, as well as being around animals. However, the activity participation logs from May to July 2024 showed no evidence of pet visits, outdoor activities, or participation in other preferred activities such as cards, crafts, gardening, or Bingo. The resident reported that meal times conflicted with scheduled activities, preventing participation. The Activity Director acknowledged that activities were scheduled during meal times and that the activity calendar was not adjusted after changes in meal delivery times. Additionally, the facility's policy required residents to be accompanied by staff to go outdoors, limiting the resident's ability to sit outside. There was no formal tracking system to ensure residents were offered activities they were interested in, and the staff relied on memory to determine resident preferences. The lack of coordination between meal times and activity scheduling, along with inadequate tracking of resident preferences, contributed to the deficiency.
Failure to Attempt Non-Pharmacological Interventions Before Administering Ativan
Penalty
Summary
The facility failed to ensure that non-pharmacological interventions were attempted before administering an anti-anxiety medication, Ativan, to a resident with multiple diagnoses including Parkinson's disease, neurocognitive disorder with Lewy bodies, cerebrovascular disease, generalized anxiety disorder, and major depressive disorder. The medication was prescribed on an as-needed basis, with a specific instruction to document any unsuccessful non-pharmacological interventions in the progress notes prior to its administration. However, the medical records did not contain any such documentation for the dates when Ativan was administered. The Director of Nursing confirmed the absence of evidence for attempted non-pharmacological interventions before the administration of Ativan on the specified dates. Additionally, when a policy was requested regarding the use of psychotropic medications on an as-needed basis, the facility could only provide a policy related to antipsychotic medication use, indicating a lack of specific guidelines for anti-anxiety medications.
Failure to Offer Pneumococcal Vaccinations per CDC Guidelines
Penalty
Summary
The facility failed to offer pneumococcal vaccinations in accordance with CDC guidelines, affecting two residents. Resident #226's medical record indicated he was up to date on pneumococcal vaccinations, having received a PPV 23 vaccine in 2017 and a Prevnar 13 vaccine in 2018. However, the guidelines require an additional dose of PCV 20 or PPSV 23 for residents with certain conditions, which was not offered. An LPN confirmed the oversight after reviewing the guidelines and noted the absence of immunization education or consent forms for Resident #226 upon admission. Similarly, Resident #130's records showed receipt of the PPSV 23 vaccine in 2013 and 2019, but no evidence of Prevnar 13 or its alternatives being offered, as per CDC guidelines. The LPN verified the lack of documentation regarding education or offering of the pneumococcal vaccination to Resident #130. The facility's existing vaccination program policy, dated March 2017, was not followed, leading to these deficiencies.
Failure to Maintain a Safe and Sanitary Environment
Penalty
Summary
The facility failed to maintain a safe and sanitary environment, which had the potential to affect all residents on the 100 hall and one resident observed for incontinence care. During a tour of the facility, a towel and bath blanket were observed on the floor in the 100 hall bathroom, and a bath blanket was observed on the floor in the 100 hallway with safety cones. An STNA reported that the towel on the floor was due to a leak, and the towel and bath blanket in the bathroom were from a resident's shower and had not been removed. No leaks were observed during multiple observations over two days. Additionally, an STNA was observed providing incontinence care to a resident, during which stool got onto a cloth pad and a pillowcase. The soiled linens were thrown onto the floor until the care was completed. The STNA later verified that she had thrown the soiled linen on the floor and indicated she was not aware it was an infection control issue until later in the day when another staff member provided instruction. This deficiency was investigated under specific complaint numbers.
Failure to Implement Fall Interventions
Penalty
Summary
The facility failed to implement fall interventions for three residents, leading to a deficiency in ensuring a safe environment free from accident hazards. Resident #45, diagnosed with encephalopathy, vascular dementia, and other conditions, was observed without the prescribed fall mat beside the bed on multiple occasions. Despite the care plan indicating the need for a mat since 08/26/22, the mat was found folded and not in place during observations. Similarly, Resident #46, with a history of multiple falls and other risk factors, was observed without the required mat beside the bed, contrary to the intervention implemented on 12/07/23. Both instances were verified by STNA #170, who then placed the mats correctly after the observations were made. Resident #56, diagnosed with encephalopathy, type two diabetes mellitus, and other conditions, was also found without the prescribed fall mat beside the bed. The mat was instead found under the bed, contrary to the physician's order dated 02/02/23. This was verified by STNA #150, who acknowledged the mat's incorrect placement. These observations and failures to implement fall interventions were part of a complaint investigation under Complaint Number OH00153104, highlighting the facility's non-compliance in preventing accidents and ensuring adequate supervision.
Improper Storage of Nebulizer Equipment
Penalty
Summary
The facility failed to store nebulizer equipment in a sanitary manner for one resident. Resident #51, who has diagnoses including cerebral infarction, congestive heart failure, and heart disease, had orders for albuterol sulfate and nebusal inhalation nebulization solution via nebulizer. On two separate observations, the resident's nebulizer mask was found not stored in a bag and was left on the nightstand, with liquid remaining in the canister. These observations were verified by State tested Nursing Assistants and shared with a Licensed Practical Nurse. The facility's policy, revised in January 2018, requires that nebulizer equipment be disassembled and stored in a plastic bag after use, which was not followed in this case.
Failure to Provide Physician-Ordered Adaptive Equipment for Meals
Penalty
Summary
The facility failed to ensure that three residents received their physician-ordered adaptive equipment for meals. Resident #68, who had diagnoses including cerebral infarction and congestive heart failure, was observed during meal service without his two-handled cup and built-up utensils, despite these being specified in his physician's orders and meal ticket. Similarly, Resident #32, with diagnoses such as hydronephrosis and diabetes, did not receive his built-up silverware during meal service, as verified by a dietary aide. Resident #24, who had multiple diagnoses including left and right below the knee amputation and end-stage renal disease, also did not receive her two-handled cup or built-up utensils during meal service, contrary to her physician's orders and care plan. The facility's policy on adaptive equipment and accommodation of needs, which mandates evaluation and ongoing review of residents' needs for adaptive devices, was not adhered to in these cases. The deficiency was identified through observations, medical record reviews, and staff interviews, affecting three out of five residents reviewed for nutrition. This non-compliance was investigated under Complaint Number OH00151926.
Inadequate Transportation Services for Dialysis Patients
Penalty
Summary
The facility did not ensure that three residents had safe and appropriate transportation services to their dialysis treatments. Observations revealed that residents were pushed in wheelchairs up a road approximately 1000 feet from the facility to the dialysis center. The road had no edge lines, was not lit by streetlights, and included a steep hill, making the journey difficult and unsafe, especially in adverse weather conditions. The facility census was 71, and four residents required transportation to dialysis, but only three were affected by the deficiency. Resident #48, who had a history of a broken neck and other significant medical conditions, reported being pushed in a wheelchair to dialysis three times in two weeks, including once in a thunderstorm. She described the journey as uncomfortable due to the jarring and bumps on the road. Resident #40, with chronic obstructive pulmonary disease and end-stage renal disease, also reported being pushed to dialysis three times, including once in heavy snow. Resident #17, with multiple medical issues including spina bifida and end-stage renal disease, reported being pushed to dialysis at least six times and expressed concern about the safety of traveling on a road used by cars. Interviews with staff confirmed the practice of pushing residents in wheelchairs to dialysis when transportation was unavailable. Staff members expressed concerns about the safety of this practice, particularly when navigating the steep hill and in adverse weather conditions. The Director of Nursing acknowledged the issue and stated that transportation was scheduled but did not always show up. She also mentioned that the facility did not have a transport vehicle and that rescheduling dialysis appointments was not always possible. The deficiency was investigated under Complaint Number OH00152858.
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.
Trusted data from CMS and state health departments
Every citation, penalty and Plan of Correction is sourced from public CMS records (latest release May 27, 2026) and official state health department websites — never guesswork.
Trusted by long-term care providers and associations.
