O'neill Healthcare Bay Village
Inspection history, citations, penalties and survey trends for this long-term care facility in Bay Village, Ohio.
- Location
- 605 Bradley Rd, Bay Village, Ohio 44140
- CMS Provider Number
- 365264
- Inspections on file
- 26
- Latest survey
- January 21, 2026
- Citations (last 12 mo.)
- 23
Citation history
Health deficiencies cited at O'neill Healthcare Bay Village during CMS and state inspections, most recent first.
Surveyors found that the facility did not ensure meals were palatable, visually appealing, or served at appetizing temperatures. A family member reported ongoing concerns about food quality and temperature, and multiple residents stated that their food was cold, overcooked, hard, unappetizing, or had declined in quality, with one resident needing to ask CNAs to reheat meals. Observation of a test breakfast tray with the Dietary Manager showed an extremely hard biscuit, bland and lukewarm sausage gravy, and thick, unseasoned oatmeal without typical enhancers, contrary to the facility’s policy that meals be promptly distributed to maintain adequate temperature and appearance.
Surveyors found that the facility failed to maintain a clean, safe, and well-maintained environment, with multiple rooms showing loose or damaged flooring under beds, dislodged baseboard covers with exposed heating elements, broken or cracked walls and windowsills, and holes or peeling drywall near beds. Some residents’ bedding was stained or damaged, with one room having a strong urine odor, and another bed cover showing a brown stain. Environmental cleanliness issues included dirty air conditioner filters, a wall unit vent with only a thin cover, dead bugs in overhead hallway light fixtures, and a dented, discolored, and sticky hallway air filter unit. One resident reported that loose floor planking under the bed was related to how she is positioned in bed.
Surveyors found that two residents were exposed to cold drafts in their rooms due to a window leak and a gap above an AC unit, resulting in discomfort. One resident used a rolled towel at the base of a closed window next to the bed to block cold air, while another resident’s room had a visible gap above the AC unit where cold air entered. Both residents reported feeling cold and uncomfortable, and the Director of Ancillary Services confirmed these environmental issues during rounds.
A high-risk resident with multiple comorbidities and a low Braden score was admitted without pressure ulcers but later sustained an unwitnessed fall resulting in a coccyx skin tear and right buttock bruising. The wound was not comprehensively measured or assessed at the time of injury, and although general skin integrity interventions were care planned, no problem or interventions specific to the new coccyx/right buttock wound were added. Days later, a CNP evaluated the area and classified it as an unstageable pressure ulcer with 100% slough, and new wound treatments and an air mattress were ordered. The care plan, however, was not revised to include the pressure ulcer, its specific treatment, or the added pressure-relieving interventions, contrary to facility policy requiring care plan modification and ongoing wound assessment for residents who develop pressure ulcers.
A resident with COPD, chronic atrial fibrillation, lumbago with bilateral sciatica, and moderate cognitive impairment had a care plan and MD order requiring all transfers to be done with a Hoyer lift and specified sling with 2-person assist. The resident later reported to family and a police officer that an aide picked her up under the arms and placed her in a wheelchair, causing back pain, with no mention of a mechanical lift. One CNA stated she and another CNA twice transferred the resident between bed and chair without using a gait belt or knowing the resident required a Hoyer lift, while the assisting CNA claimed a Hoyer was used and accused the family of lying. The Administrator confirmed the facility determined the CNAs had body-lifted the resident instead of using the ordered Hoyer lift, constituting a failure to follow the resident’s transfer requirements.
A resident with Parkinson’s disease, muscle weakness, and intact cognition had physician-ordered podiatry appointments but repeatedly missed them because transportation was not properly arranged. Although the resident had Ohio managed Medicaid coverage that allowed multiple round-trip visits and required transport scheduling in advance, the insurer reported no transports were ever set up. The resident stated he missed two appointments due to the facility’s failure to arrange transportation, outside office staff reported multiple no-shows without cancellation or rescheduling, and an NP was not informed of any missed visits. An RN unit manager indicated transport confirmations were sent by text to the resident’s phone, while the resident reported his phone had been broken for two years, and the RN confirmed the resident was not transported to at least one scheduled appointment due to transportation issues.
A resident with multiple comorbidities, cognitive impairment, a stage II pressure ulcer, MASD, and an MDRO-infected right foot wound was care planned for Enhanced Barrier Precautions (EBP). During observed wound care to the right fifth toe, an LPN entered the room marked for EBP without a gown, removed a soiled dressing, then cleansed the wound and applied calcium alginate using the same pair of gloves before changing gloves only to place the foam dressing. In interview, the LPN acknowledged both the EBP requirement for gown and gloves and that gloves should have been changed after removing the old dressing, which was inconsistent with the facility’s wound care policy requiring hand hygiene and new gloves between dressing removal and wound care.
A resident with a history of stroke and other conditions did not receive prescribed wound care for a skin tear on the left hand. Despite physician orders for daily treatment, the wound was left open and untreated, as confirmed by observations and family interviews. An LPN admitted to not being aware of the wound care orders.
A resident with severe cognitive impairment and multiple medical conditions did not receive adequate nutritional and hydration care in a facility. The resident required a mechanically altered diet and staff assistance for feeding, but the facility failed to consistently document meal intake and did not have a clear plan for feeding assistance. This led to the resident being hospitalized for dehydration and high sodium levels, highlighting deficiencies in the facility's care practices.
The facility failed to ensure call lights were within reach for three residents, including one with a femur fracture and dementia, another with multiple sclerosis and vision impairment, and a third with dementia and mobility issues. Observations revealed call lights were out of reach, confirmed by staff, despite facility policy requiring accessibility.
A facility failed to timely report an abuse allegation involving a resident who was cognitively intact and had multiple medical conditions. The resident's granddaughter reported that a male CNA refused bathroom assistance and took away the resident's call light, TV remote, and cell phone. The incident was reported to the DON but not fully communicated to the Administrator until several days later, violating the facility's policy on timely reporting of abuse allegations.
The facility failed to provide fortified pudding to several residents during lunch, as required by physician orders or dietitian recommendations. These residents, who had specific dietary needs due to various medical conditions, did not receive the fortified pudding because the facility ran out halfway through meal service. This resulted in non-compliance with the dietary interventions outlined for these residents.
The facility did not provide pureed foods at a smooth consistency for safe swallowing for three residents on prescribed pureed diets. Observations and taste tests revealed that the pureed peas were lumpy and contained pea shell pieces, which was confirmed by a Speech Therapist. This was contrary to the facility's guidelines that required pureed foods to hold their shape on a spoon and have a smooth texture.
The facility failed to honor dietary needs for three residents, including allergies to chocolate and wheat, and a preference for almond milk. Errors were identified during a tray line observation, affecting the potential dietary safety of 110 residents.
Failure to Provide Palatable, Appealing Meals at Appropriate Temperatures
Penalty
Summary
The facility failed to ensure that food and drink were palatable, visually appealing, and served at safe and appetizing temperatures for multiple residents. A family member of one resident reported multiple concerns about food quality and temperature. Several residents reported that the food was always cold, had declined in quality, or was gross. One resident stated they frequently had to ask CNAs to reheat their food, and that the CNAs did so reluctantly. During the annual survey’s resident council portion, numerous residents reported that the food was overcooked, hard, and did not taste good. Direct observation of a test tray for a breakfast meal with the Dietary Manager showed biscuits with sausage gravy, oatmeal, and orange juice that did not meet the facility’s own standards for meal service and distribution. The biscuit was extremely hard and required significant force with a spoon to cut. The sausage gravy was bland, lacked seasoning, and was only lukewarm at 145 degrees. The oatmeal had a thick paste-like texture and was served without milk, brown sugar, or other flavor enhancers. The Dietary Manager confirmed these findings at the time of observation. Review of the facility’s undated meal service and distribution policy showed that residents’ meals were supposed to be distributed promptly to maintain adequate temperature and appearance, which was not achieved in these instances.
Failure to Maintain Clean, Safe, and Well-Maintained Environment
Penalty
Summary
Surveyors identified a deficiency in maintaining a clean, safe, and sanitary environment based on observations during environmental rounds and resident and staff interviews. Multiple resident rooms had physical plant issues, including loose flooring or floorboards under bed legs or footers, dislodged floor baseboard covers with exposed heating elements, broken or damaged walls and windowsills, and an indented hole on a bathroom door. Specific examples included loose flooring under beds in several rooms, a broken windowsill ledge with dislodged triangular pieces and an 18-inch wall crack extending toward the floor, semi-plastered wall holes behind beds, peeling paint and drywall near beds, and exposed drywall in another room. One resident reported that the floor planking had been loose under her bed due to the way she is positioned in bed. Additional environmental concerns involved unclean or stained items and equipment. One resident’s bottom bed sheet had a small hole and two small yellow stains, and there was a strong urine odor in the room without visible urine. Another resident’s bed cover had a brown stain. An air conditioner filter in one room had visible dirt and debris, and a wall unit air conditioner vent had only a thin cover that was cold to the touch. Dead bugs were observed in overhead hallway lighting lids throughout the building. An air filter unit in the hallway had a dent, visible yellow/light brown discoloration on its exterior, and was sticky to the touch. These conditions were verified at the time of discovery by the Director of Ancillary Services and were associated with multiple complaint investigations.
Failure to Maintain Comfortable Room Temperatures Due to Drafty Windows and AC Gaps
Penalty
Summary
The facility failed to ensure a safe, clean, comfortable, and homelike environment when two residents experienced cold air infiltration in their rooms. For one resident, surveyors observed a rolled towel placed at the base of the closed window next to the bed, with cold air felt coming through the window; the resident reported that cold air entered through the window, caused discomfort, and that the towel was placed there for that reason. For another resident, surveyors observed a gap above the air conditioner unit below the window, with cold air felt through the gap; this resident stated he was cold in his room and was uncomfortable. During environmental rounds, the Director of Ancillary Services confirmed these findings. This deficiency represents non-compliance investigated under Complaint Numbers 2642470, 1266873 (OH00165876), and 1266871 (OH00165428).
Failure to Assess and Care Plan Newly Developed Coccyx/Buttock Wound
Penalty
Summary
The deficiency involves the facility’s failure to comprehensively assess a newly identified skin alteration on a resident’s sacral/buttock area and to timely revise the resident’s care plan for pressure ulcer prevention and treatment. The resident was admitted with multiple medical diagnoses, including senile degeneration of the brain, emphysema, heart block, obstructive and reflux uropathy, hyperlipidemia, heart failure, and atrial fibrillation. On admission, the resident had no pressure areas but did have scattered bruising, abrasions, scabs, and a surgical incision. A Braden Scale assessment completed on the day of admission showed a score of 12, indicating high risk for skin breakdown, with findings of very limited sensory perception, very moist skin, chairfast status, very limited mobility, probably inadequate nutrition, and a potential problem with friction and shear. A nutrition assessment documented that the diet was adequate and that the resident was at risk for skin breakdown but had no identified pressure ulcers. An MDS assessment confirmed no pressure ulcers and total dependence on staff for ADLs, with an indwelling urinary catheter and bowel incontinence. On a later date, the resident sustained an unwitnessed fall. An LPN found the resident on the floor sitting on his bottom, and the resident reported pain in that area. The LPN documented an injury on the coccyx described as a skin tear and redness, and the facility’s fall report listed a bruise to the coccyx, a bruise to the right cheek, and a skin tear to the coccyx. Weekly wound documentation for the right buttock and coccyx on the date of the fall recorded bruising measuring 4.5 cm by 2.6 cm with a wound bed described as 100% purple, and a skin tear to the coccyx without measurements or further description of the periwound area. There was no evidence in the medical record that the skin tear was fully measured and assessed or that a specific treatment was implemented immediately following the fall. A care plan initiated that same day addressed the resident’s potential for alteration in skin integrity with general preventive interventions such as turning and repositioning, heel offloading, pressure-reducing surfaces, and incontinence care, but it did not include a problem or interventions specific to the right buttock bruise and coccyx skin tear sustained from the fall. Subsequently, a treatment order for the right buttock/coccyx area was entered the day after the fall to cleanse with normal saline, pat dry, and apply Triad cream every shift and as needed for a skin tear related to the fall. Several days later, the wound team CNP evaluated the right buttock wound and classified it as a pressure ulcer with 100% yellow, soft slough and moderate serous drainage, measuring 4.5 cm by 2.5 cm with depth unable to be determined. Weekly wound documentation on that date described the wound as an unstageable pressure ulcer with intact periwound skin, and the treatment was changed to Medihoney, calcium alginate, and a dressing. An air mattress was also ordered at that time. Despite the reclassification of the wound as an unstageable pressure ulcer and the addition of new pressure-relieving interventions, the resident’s care plan was not updated to include the identified pressure ulcer, the new wound treatment, or the air mattress. Interviews with the DON, Regional Director of Clinical Services, MDS coordinator, and CNP confirmed that the initial skin tear and bruising were not comprehensively assessed and that the care plan was not revised to reflect the development and treatment of the pressure ulcer, contrary to the facility’s pressure ulcer prevention and treatment policy, which requires care plan modification to reflect changes in condition and weekly wound evaluation and discussion by the IDT. The facility’s policy on Pressure Ulcer Prevention and Treatment Protocol states that residents with a Braden score of 12 or less are considered high risk for pressure ulcer development and that residents who develop a pressure ulcer must have appropriate nutritional evaluation, wound care interventions per protocol or MD orders, referrals as needed, and care plan modifications to reflect changes in condition. The policy also requires daily monitoring of periwound skin, weekly wound measurements, and weekly IDT discussion of wound status, with adjustments to treatment as needed. In this case, the resident, who was identified as high risk on admission, developed a wound to the coccyx/right buttock area following a fall that was initially documented as a bruise and skin tear but not fully measured or assessed, and the care plan was not updated when the wound was later classified as an unstageable pressure ulcer and new interventions were ordered. These omissions constitute the failure to provide appropriate pressure ulcer care and to prevent new ulcers from developing as cited in the deficiency.
Failure to Follow Hoyer Lift Transfer Requirements for a Dependent Resident
Penalty
Summary
The deficiency involves the facility’s failure to ensure a resident was transferred in accordance with physician orders and the resident’s care plan, which required use of a Hoyer mechanical lift with a medium purple sling and assistance of two staff for all transfers. The resident had multiple diagnoses, including COPD, lumbago with sciatica on both sides, and chronic atrial fibrillation, and had a care plan intervention in place specifying mechanical lift transfers. A physician order also directed that a Hoyer lift be used for all transfers on all shifts. The resident’s MDS reflected moderate cognitive impairment. The incident came to light when the resident’s daughter reported that the resident complained of back pain after being gotten out of bed the previous evening and expressed concern that the pain was related to how staff had transferred the resident. The daughter contacted the local police department, and an officer subsequently interviewed the resident. The resident reported that an aide, described as a black female in her late 20s, picked her up under both armpits and placed her in a wheelchair, and that she experienced pain during the move from bed to chair. This description did not include the use of a Hoyer mechanical lift as required by the care plan and physician order. During the facility’s investigation, one CNA stated in a witness statement that she had cared for the resident on the relevant day shift and had transferred the resident twice, from bed to chair and later from chair back to bed, with assistance from another CNA. She acknowledged having a gait belt but not using it and stated she did not know the resident required a Hoyer lift, and that the resident appeared comfortable and voiced no concerns at the time. The assisting CNA, in a later telephone interview, claimed that a Hoyer lift had been used and alleged the family was lying. The Administrator, however, confirmed that the facility determined the two CNAs had not used a Hoyer mechanical lift and had instead body-lifted the resident from bed to chair and back, contrary to the resident’s care plan and physician orders.
Failure to Arrange Transportation for Outside Podiatry Appointments
Penalty
Summary
The deficiency involves the facility’s failure to ensure transportation was adequately arranged for an insured resident’s outside podiatry appointments. The resident was admitted with Parkinson’s disease, muscle weakness, and a cognitive communication deficit, but the admission MDS showed intact cognition. Physician orders documented podiatry appointments on 12/04/25 at 11:15 A.M. and 01/08/26 at 2:15 P.M., and the resident was covered by an Ohio managed Medicaid plan that, per facility transportation guidelines, required transportation to be scheduled at least two days in advance and allowed up to 30 round trips per year. Despite these provisions, the insurance transportation representative reported that no transportation had been set up for any past or future appointments for this resident. The resident reported missing two appointments because the facility did not set up transportation in a timely manner. Outside office staff stated the resident was a no-show to multiple appointments due to transportation issues and that facility staff did not call to cancel or reschedule. The NP reported she was not notified of any missed appointments and confirmed transportation was a problem. The RN unit manager stated that confirmation for transport had been sent to the resident’s phone, but the resident reported his phone had been broken for two years and he could not receive texts. The RN unit manager confirmed the resident was not transported to the 01/08/26 appointment due to transportation issues. Facility transportation guidelines also indicated that routine or unrelated appointments should be canceled or rescheduled during a skilled stay, and that certain Medicare transports without secondary insurance would be billed to the resident at booking, but there was no evidence these guidelines were effectively implemented to ensure the resident’s ordered podiatry appointments were supported with appropriate transportation.
Failure to Follow Enhanced Barrier Precautions During Wound Care
Penalty
Summary
The deficiency involves the facility’s failure to implement appropriate infection prevention and control measures during wound care for one resident on Enhanced Barrier Precautions (EBP). The resident was admitted with multiple diagnoses including hemiplegia, hemiparesis, type II diabetes, dysphagia, cerebral infarction (stroke), depression, anxiety, right knee contracture, hypertension, and heart failure. A quarterly MDS documented that the resident was cognitively impaired, dependent on staff for hygiene and transfers, and had a stage II pressure ulcer and moisture associated skin damage. The care plan indicated the resident required EBP due to a multidrug resistant organism (MDRO) infection in a right foot wound, and physician orders directed cleansing the right fifth toe with normal saline, patting dry, applying calcium alginate, and covering with a foam dressing. During an observation of wound care, an LPN gathered supplies and entered the resident’s room, which had signage indicating EBP and the requirement for staff to wear gloves and a gown when providing wound care to any skin opening requiring a dressing. The LPN did not don a gown, washed her hands, put on gloves, and removed the old dressing from the right fifth toe. Using the same gloves that had been used to remove the soiled dressing, she then cleansed the wound and applied calcium alginate before changing gloves to apply the foam dressing. In a subsequent interview, the LPN confirmed she did not change gloves after removing the dressing and before cleansing the wound, and acknowledged that the resident required EBP and that she was required to wear gloves and a gown while providing wound care. Review of the facility’s wound care policy showed it required handwashing, glove use to remove the dressing, handwashing again, and then new gloves to complete the dressing change. This deficiency was investigated under Complaint Numbers 2703441 and 2642470.
Failure to Provide Wound Care as Ordered
Penalty
Summary
The facility failed to provide appropriate wound care for a resident, identified as Resident #109, according to the physician's orders. Resident #109, who has a medical history including stroke, diabetes mellitus, kidney disease, anxiety, post-traumatic stress disorder, and cognitive impairment, experienced a fall and was transferred for evaluation. Following the fall, a physician's order was issued on 02/25/25 for the treatment of a skin tear on the resident's left hand. The order specified that the wound should be cleansed with normal saline, patted dry, treated with triple antibiotic ointment, covered with a non-adherent dressing, and wrapped with gauze once daily until healed. However, observations and interviews revealed that the prescribed wound care was not performed. On 02/26/25, the resident was observed with an open laceration on the left hand, covered only by steri-strips, some of which were peeling, and a moderate amount of dried blood was noted. Interviews with the resident's wife and son confirmed that no dressing was applied on 02/25/25 after the resident returned from the emergency department, nor was there a dressing in place the following morning. An LPN, who was responsible for the resident's care on 02/25/25, admitted to not performing the wound care, stating she was unaware of the wound orders. This deficiency was investigated under Complaint Number OH00161145.
Failure to Provide Adequate Nutritional and Hydration Care
Penalty
Summary
The facility failed to provide adequate nutritional and hydration care for a resident, identified as Resident #108, who was dependent on staff for feeding assistance. The resident had multiple medical conditions, including encephalopathy, dysphagia, and Alzheimer's disease, and required a mechanically altered diet with honey thickened liquids. Despite these needs, the facility did not consistently document the resident's meal intake on several occasions, and there was no clear plan addressing the extent of feeding assistance required. Resident #108 was admitted with a weight of 130.6 pounds and had a nutritional assessment indicating a need for 1800 calories and 1800 milliliters of fluid daily. However, the resident's meal intake records showed significant gaps, with no documentation on several days and instances of meal refusal. The resident was eventually admitted to the emergency department with dehydration and high blood sodium levels, conditions that had led to multiple hospitalizations in the past. Interviews with facility staff, including a registered dietician and the administrator, confirmed that the care plan did not adequately address the resident's feeding assistance needs. The facility's policies on activities of daily living and weight recording were not effectively implemented, contributing to the resident's nutritional and hydration deficiencies. This deficiency was investigated under two complaint numbers, indicating ongoing issues with the facility's care practices.
Failure to Ensure Call Lights Within Reach for Residents
Penalty
Summary
The facility failed to ensure that residents had their call lights within reach while unattended in their rooms, affecting three residents. Resident #39, who had a history of falls and was at high risk for falls due to a femur fracture, weakness, and dementia, was observed lying in bed with the call light on the opposite side of the room, out of reach. Despite being alert and responsive, the resident was unable to access the call light due to the bed's position against the wall. This was confirmed by an LPN who noted that the call light could reach the resident if stretched across the room. Resident #36, diagnosed with multiple sclerosis, paraplegia, and vision impairment, was also affected. The resident was observed sitting in a tilt chair with the call light connected to the bed and out of reach. Despite requiring assistance for mobility and being at high risk for falls, the resident confirmed the inability to reach the call light. A CNA verified the situation, acknowledging that the resident used the call light for assistance when it was accessible. Similarly, Resident #43, who had dementia and was at high risk for falls, was found in a wheelchair with the call light located behind the bed and out of reach. The resident, who required assistance for mobility and was dependent on staff for transfers, confirmed the inability to reach the call light. A CNA corroborated this, noting that the resident could normally use the call light but was unable to do so due to its placement. The facility's policy required call lights to be within reach, but this was not adhered to, as confirmed by the Administrator and DON.
Failure to Timely Report Allegation of Abuse
Penalty
Summary
The facility failed to timely report an allegation of abuse involving a resident, which was identified during a review of records, interviews, and the facility's self-reported incident (SRI). The incident involved a resident who was cognitively intact and had multiple medical conditions, including metabolic encephalopathy and cirrhosis of the liver. The resident's granddaughter reported that a male CNA refused to assist the resident to the bathroom, took away her call light, TV remote, and personal cell phone, and instructed her not to call anyone. This incident was initially reported to the DON on November 30th, but the SRI was not initiated until December 4th, indicating a delay in reporting. The facility's policy requires that all alleged violations involving abuse, neglect, or mistreatment be reported immediately, or within two hours if they involve abuse or result in serious bodily injury. However, the facility did not adhere to this policy, as the Administrator was not informed of the full extent of the allegations until December 4th. The investigation into the allegations was completed on December 11th and was found to be unsubstantiated. This deficiency was identified under Complaint Number OH00160465, highlighting non-compliance with timely reporting requirements.
Failure to Provide Fortified Pudding as Ordered
Penalty
Summary
The facility failed to provide fortified pudding to five residents during lunch, as required by physician orders or dietitian recommendations. These residents were identified as being at risk for altered nutrition or hydration due to various medical conditions, including dementia, diabetes mellitus, chronic obstructive pulmonary disease, depression, anxiety disorder, malignant neoplasm, chronic kidney disease, and dysphagia. The deficiency was observed when the facility ran out of fortified pudding halfway through the meal service, affecting residents who were supposed to receive it as part of their dietary interventions. The affected residents had specific dietary needs documented in their care plans and physician orders, which included fortified pudding to help maintain weight, support wound care, or prevent weight loss. Despite these documented needs, the facility's failure to provide the fortified pudding as ordered resulted in non-compliance with the dietary interventions outlined for these residents. The deficiency was noted during an observation of the tray line, where it was confirmed that the fortified pudding was unavailable for the residents in question.
Failure to Provide Smooth Pureed Foods for Residents
Penalty
Summary
The facility failed to provide pureed foods at a smooth consistency for safe swallowing for three residents who were prescribed pureed diets. During an observation of the tray line, it was noted that the pureed peas appeared lumpy, and a taste test confirmed the presence of pea shell pieces, indicating the food was not smooth in consistency. This was verified by a Speech Therapist who confirmed the inconsistency of the pureed food. The facility's guidelines stated that pureed foods should hold their shape on a spoon and have a smooth texture, which was not adhered to in this instance.
Failure to Honor Resident Dietary Needs
Penalty
Summary
The facility failed to honor food allergies and preferences for three residents, which was identified during an observation of the tray line. Resident #43, who has a diagnosis of hemiplegia, anxiety disorder, and depression, was noted to have a chocolate allergy. Despite this, their lunch tray included chocolate chip cookies, which were only replaced with fruit after the error was pointed out. Similarly, Resident #111, diagnosed with dementia, osteoarthritis, and atherosclerotic heart disease, was allergic to wheat but also received chocolate chip cookies on their tray. This mistake was corrected only after it was brought to the attention of the dietary aide. Additionally, Resident #69, who has quadriplegia, chronic obstructive pulmonary disease, anxiety disorder, and major depressive disorder, was supposed to receive almond milk as part of their dietary plan to address nutritional risks. However, the dietary aide confirmed that almond milk was not available for this resident. These deficiencies were noted to have the potential to affect 110 out of 111 residents who received meals from the facility kitchen, indicating a systemic issue in the dietary service's ability to accommodate resident-specific dietary needs.
Latest citations in Ohio
A resident with intact cognition receiving Medicare Part A skilled services for metabolic encephalopathy had services discontinued while benefit days remained, but the facility did not issue the required Skilled Nursing Facility Advance Beneficiary Notice (SNF ABN). The Social Services Director later confirmed that no SNF ABN was provided and reported she believed only a Notice of Medicare Non-Coverage (NOMNC) was needed when all skilled services were stopped. This practice conflicted with the facility’s written policy, which required SNF ABNs to be issued when extended care items or services were initiated, reduced, or terminated due to expected non-coverage by Medicare.
Surveyors identified that the facility exceeded the acceptable medication error rate when two residents with type 2 DM received insulin doses that were not administered according to orders or manufacturer instructions. In two separate observations, an LPN administered Novolog and another LPN administered insulin glargine and insulin lispro without priming the insulin pens, and the insulin lispro and Novolog were given after the residents had already consumed a significant portion of their breakfast meals, despite orders for administration before meals. Manufacturer information for both insulin products required priming before each injection to ensure accurate dosing, and facility policy required medications, including insulin, to be administered safely, timely, and in accordance with prescriber orders and specified time frames.
Surveyors found that the facility failed to document tray line food temperatures for multiple meals served from two dining room kitchenettes, despite having a “Trayline Taste & Temperature Log” and a policy requiring food to be stored, prepared, distributed, and served according to professional food safety standards. Review of logs showed repeated missing entries for breakfast, lunch, and dinner services in both the Harrison and McClellan dining areas, and the Senior Director of Culinary Services confirmed that temperatures had not been recorded for those meals, potentially affecting all residents receiving meals from those kitchenettes.
The facility failed to conduct and document required periodic care conferences for two residents, despite multiple comprehensive, quarterly, and significant change MDS assessments and a policy requiring periodic care conferences with resident and/or family participation. One resident with Parkinson’s disease, post-stroke hemiplegia, TIA, DMII, and depression had only two documented care conferences over a year, while another resident with aphasia, cerebrovascular disease, DMII, gait difficulty, coagulation defect, depression, and muscle weakness had no documented care conferences in the past year, aside from a declined invitation to the representative. The UCC confirmed that care conferences were expected to occur quarterly and that no additional documentation existed for either resident.
A resident with Alzheimer's disease and type II DM, who required extensive assistance with ADLs and was receiving scheduled Lantus and sliding-scale Humalog, experienced a severely elevated blood glucose level. The on-call provider was notified and ordered an additional dose of lispro insulin with a directive to recheck the blood glucose after administration. Nursing staff administered the extra insulin but did not document any follow-up blood glucose check, and the DON confirmed that this reevaluation was required by the facility's abnormal blood glucose policy and was not completed or documented.
A resident with Parkinson’s disease, dementia, and hypothyroidism was prescribed levothyroxine once daily along with other medications. A consultant pharmacist’s monthly drug regimen review recommended that levothyroxine be given in the morning on an empty stomach, 30–60 minutes before food, per manufacturer instructions. The medical record contained no documented physician response to this recommendation, and the MAR showed the drug scheduled for morning administration while the resident was observed eating breakfast and receiving the medication at the same time. An LPN confirmed administering levothyroxine during the meal, and the DON verified there was no documentation explaining whether or why the pharmacist’s recommendation was or was not followed, resulting in a failure to act on and document the identified irregularity.
A resident with severe cognitive impairment, multiple comorbidities, documented gait and balance abnormalities, and a high fall risk was care planned and assessed by therapy to require contact guard assistance and use of a gait belt for transfers and ambulation. While being assisted by a CNA from a recliner to the bathroom with a walker, the CNA did not apply a gait belt, even though the resident had a known tendency to lean backward when standing. As the CNA reached to open the bathroom door, the resident lost balance and fell backward, striking the back of the head, and was later found by an LPN without a gait belt in place, contrary to the facility’s gait belt policy and the resident’s assessed needs.
A resident with CKD stage five requiring peritoneal dialysis (PD) was admitted with pre-admission physician orders for three daily PD exchanges and monitoring for peritonitis (fever, abdominal pain, cloudy effluent), but these monitoring orders were not entered into the facility’s physician orders. The care plan referenced PD and general monitoring but did not specifically address peritonitis monitoring. Paper PD flowsheets showed incomplete and inconsistent documentation of exchanges and resident condition, including missing condition/comments for individual treatments and no record of one ordered PD exchange. The PD cycler flowsheet lacked effluent descriptions on multiple days. The PD nurse reported facility staff were expected to monitor effluent and symptoms, and the DON confirmed the absence of specific peritonitis monitoring orders, lack of an order for the PD cycler, and documentation gaps, despite a facility policy requiring ongoing assessment and monitoring for complications before, during, and after dialysis treatments.
A nurse was observed preparing multiple oral medications for a resident with depression, traumatic brain injury, anxiety, and impaired cognition by pushing tablets and capsules from unit-dose cards directly into her ungloved hand and then using her fingers to place them into a medication cup. In a follow-up interview, the RN confirmed this practice and acknowledged that the correct procedure is to dispense medications directly from the card into the cup, contrary to the facility’s medication administration policy requiring adherence to good nursing principles and practices.
A resident with Alzheimer’s disease, diabetes, anxiety, significant ADL dependence, and behavioral symptoms was observed seated in a chair positioned against the nursing station with a locked wheelchair placed directly in front, also against the nursing station, effectively restricting movement. An LPN confirmed both wheelchair wheels were locked and that it should not have been placed there, while a CNA stated she had positioned the wheelchair to prepare for lunch, was unable to complete the transfer, and left it in place, acknowledging this was wrong. This arrangement conflicted with the facility’s restraint policy, which prohibits physical restraints except when alternatives are ineffective for treating a medical symptom and defines restraints as devices adjacent to the body that cannot be easily removed and that restrict freedom of movement or access to the body.
Failure to Issue Required SNF ABN When Discontinuing Medicare Part A Services
Penalty
Summary
The deficiency involves the facility’s failure to issue a Skilled Nursing Facility Advance Beneficiary Notice (SNF ABN) when Medicare Part A services were discontinued for a resident who still had available benefit days. The resident was admitted with a diagnosis of metabolic encephalopathy and had intact cognition per the Minimum Data Set assessment. The facility’s own SNF Beneficiary Notification Review documented that Medicare Part A skilled services began on 02/11/26 and the last covered day was 03/11/26, and that the facility initiated discharge from Medicare Part A services before the resident’s benefit days were exhausted. Despite this, no SNF ABN was provided to the resident or the resident’s representative. During interviews, the Social Services Director stated that the SNF ABN was issued hours prior to the last covered day but, upon reviewing her files, confirmed that no SNF ABN had actually been issued for this resident. She further explained that she believed an SNF ABN was only required if one skilled service remained and that if all skilled services were being discontinued, only the Notice of Medicare Non-Coverage (NOMNC) needed to be issued. The Administrator, however, stated that a resident should always receive both a SNF ABN and a NOMNC when Medicare Part A services are discontinued and benefit days remain. Review of the facility’s written policy dated 03/28/23 showed that the facility was required to issue SNF ABNs for initiation, reduction, or termination of extended care items or services when Medicare payment was not expected, which did not occur in this case.
Plan Of Correction
This Plan of Correction is submitted as required under State and Federal law. This Plan of Correction does not constitute an admission on the part of the Facility that the findings cited are accurate, that the findings constitute a deficiency or that the scope and severity regarding the deficiency cited are correctly applied. Any changes to the Facility's policies and procedures should be inadmissible in any proceeding on that basis. Without admitting or denying the validity or the existence of the alleged noncompliance, the Facility submits this Plan of Correction with the intention that it be inadmissible by any third party in any civil or other action against the facility or any employee, agent, officer, director or shareholder of the Facility. The Facility is utilizing this Plan of Correction as its allegation of substantial compliance as of 05/29/2026 F-0582 Corrective action for resident/s: On 5/14/26 Resident #34 was informed of rights and responsibilities related to Advanced Beneficiary Notice and voiced understanding of information for future reference by administrator. Identification of other residents who may be affected: Any resident receiving skilled services from nursing or therapy services. The Administrator audited all residents who were discharged from skilled services in the past 30 days to ensure they were issued a Notice of Non-Coverage and Advanced Beneficiary Notice on 5/29/26. No non-compliance was noted. Measures for systemic change: On 5/14/2026 Business Office Manager, Director of Rehab, Minimum Data Set nurse, Director of Nursing and Social Services Director were educated on proper procedure of issuing of Notice Of Medicare Non Coverage and Advanced Beneficiary Notice by administrator. All upcoming discharges from skilled services will be reviewed weekly at Utilization Review meeting to ensure notices will be delivered timely. How Corrective Action will be monitored: Administrator or designee to complete audits of all residents being discharged from skilled services to ensure they were issued a Notice of Non-Coverage and Advanced Beneficiary. This audit will be completed weekly x 4 weeks, then monthly x 2 months. Corrective action will be initiated for any noted non-compliance. Audit findings will be reviewed as part of the monthly quality assurance process to determine the need for further monitoring. Date of Compliance 5/29/26
Insulin Administration Errors and Failure to Prime Insulin Pens
Penalty
Summary
The deficiency involves the facility’s failure to maintain a medication error rate below 5%, with surveyors identifying 3 errors out of 28 medication administration opportunities, resulting in a 10.71% error rate. For one resident with type 2 diabetes mellitus and moderate cognitive impairment, the physician’s order directed Novolog insulin 10 units via subcutaneous pen-injector to be given before meals. During an observed medication pass, the LPN administered 10 units of Novolog insulin without priming the pen and did so after the resident had already consumed approximately 50% of the breakfast meal. The LPN later confirmed she did not prime the pen and acknowledged that the insulin was ordered to be administered prior to meals. Manufacturer instructions for the Novolog FlexPen specified that an air shot (priming) must be performed before each injection to ensure proper dosing. Another resident, also diagnosed with type 2 diabetes mellitus and with intact cognition, had orders for insulin glargine 35 units subcutaneously twice daily and insulin lispro 20 units subcutaneously before meals, plus 12 units subcutaneously if blood glucose was between 251 mg/dL and 300 mg/dL. During an observed medication administration, an LPN administered 35 units of insulin glargine and 32 units of insulin lispro without priming the insulin pens and after the resident had consumed approximately 90% of the breakfast meal, despite orders for insulin lispro to be given before meals. The LPN later stated she could not remember if she had primed the pen and acknowledged that the insulin was ordered to be administered prior to meals. Manufacturer information for insulin lispro stated that the pen must be primed before each injection to confirm insulin delivery and remove air, and that failure to prime could result in too much or too little insulin. The DON confirmed the expectation that insulin be administered as ordered, including priming each pen with two units before dialing the prescribed dose, and facility policy required medications, including insulin, to be administered safely, timely, and in accordance with prescriber orders and required time frames.
Plan Of Correction
This Plan of Correction is submitted as required under State and Federal law. This Plan of Correction does not constitute an admission on the part of the Facility that the findings cited are accurate, that the findings constitute a deficiency or that the scope and severity regarding the deficiency cited are correctly applied. Any changes to the Facility's policies and procedures should be inadmissible in any proceeding on that basis. Without admitting or denying the validity or the existence of the alleged noncompliance, the Facility submits this Plan of Correction with the intention that it be inadmissible by any third party in any civil or other action against the facility or any employee, agent, officer, director or shareholder of the Facility. The Facility is utilizing this Plan of Correction as an allegation of substantial compliance as of 5/29/2026. F-0759 Corrective action for resident/s: Residents #21 and #22 were assessed and evaluated by nurse and Director of Nursing 5/14/26. Resident #21 and #22 both denied any adverse effects and none were noted upon assessment by the Director of Nursing on 5/14/2026. Notification made to physician on 5/14/2026. LPN # 2 competency Eval on insulin administration with the Director of Nursing completed 5/14/2026. Identification of other residents who may be affected: Diabetic residents on assignment of LPN #2/station 2 have the potential to be affected and were assessed by the DON/Designee on 5/14/26 and found to be within normal limits. Measures for systemic change: All Nurses were educated by the Director of Nursing on the steps for Insulin administration per competency, diabetes clinical protocol policy, Medication and treatment orders policy, administering medications policy, and Obtaining fingerstick Glucose Level policy On 5/14/2026. How Corrective Action will be monitored: Director of Nursing and Assistant Director of Nursing will complete insulin administration audits on 5 nurses. This audit will be completed weekly x 4 weeks, then monthly x 2 months. Corrective action will be initiated for any noted non-compliance. Audit findings will be reviewed as part of the monthly quality assurance process to determine the need for further monitoring. Date of Compliance: 5/29/2026
Failure to Document Tray Line Food Temperatures in Dining Room Kitchenettes
Penalty
Summary
The deficiency involves the facility’s failure to document tray line food temperatures for meals served from the Harrison and McClellan Dining Room kitchenettes, as required by professional standards for food service safety and the facility’s own policy. Review of the “Trayline Taste & Temperature Log” (revised September 2018) showed missing temperature documentation for multiple meals from the Harrison Dining Room kitchenette, including dinner on 03/30/26 and 03/31/26, lunch and dinner on 04/01/26 and 04/02/26, dinner on 04/07/26, and lunch and dinner on 04/08/26 and 04/10/26. The Senior Director of Culinary Services confirmed during interview that tray line food temperatures were not documented on the log for these meals. Similarly, review of the same log for the McClellan Dining Room kitchenette revealed that tray line food temperatures were not documented for dinner on 04/01/26, breakfast and lunch on 04/02/26, and lunch and dinner on 04/07/26. The Senior Director of Culinary Services also verified these omissions during interview. The facility census at the time was 27 residents, and the governing “Food and Nutrition” policy, approved on 09/07/21, stated that the facility must store, prepare, distribute, and serve food in accordance with professional standards for food service safety.
Plan Of Correction
F812 The facility will continue to ensure food temperatures are completed before meals are served for all residents. To ensure compliance with this standard the following measures have been taken: 1. Immediately 4/15/26 culinary supervisor #224 was re-educated by Dietary Manager to this standard and policy "Food and Nutrition" which includes documentation of food temperatures. 2. All dietary staff have been re-educated to the standard and policy "Food and Nutrition" during the month of April 2026. 3. Audits of food temperature documentation to be completed by Dietary Manager 4 x per week for 4 weeks then weekly for 4 weeks. 4. Administrator to validate audits/compliance and provide additional training as needed. Administrator will present to QAPI committee for ongoing monitoring and further direction.
Failure to Conduct and Document Required Care Conferences
Penalty
Summary
The deficiency involves the facility’s failure to complete and document comprehensive care conferences at required intervals in accordance with care plan regulations and facility policy. For one resident with Parkinson’s disease with dyskinesia, cognitive communication deficit, hemiplegia and hemiparesis following cerebral infarction, transient cerebral ischemic attack, type II diabetes mellitus, and major depressive disorder, the record showed multiple MDS assessments over a one-year period, including annual, quarterly, and significant change assessments. However, only two care conferences were documented during the last 12 months, despite the expectation that care conferences be conducted quarterly with the resident and family when possible. The Unit Care Coordinator confirmed that no additional care conference documentation existed for this resident beyond the notes dated 04/21/25 and 01/02/26. A second resident, with diagnoses including aphasia following cerebrovascular disease, cerebral infarction, type II diabetes mellitus, unsteadiness on feet, difficulty in walking, coagulation defect, depression, and muscle weakness, also had multiple MDS assessments completed over the review period, including quarterly and annual assessments. The record contained a note that a care conference was offered to the resident’s representative, who declined to attend, but there was no documentation of any care conferences for the most recent 12 months. The Unit Care Coordinator confirmed that no other care conference documentation was available for this resident. Facility policy stated that periodic care conferences involving the resident, family, and the interdisciplinary team are part of the care planning process, but the required periodic care conferences and corresponding documentation were not completed for these two residents.
Plan Of Correction
THIS PLAN OF CORRECTION SERVES AS BERKELEY SQUARE'S CREDIBLE ALLEGATION OF SUBSTANTIAL COMPLIANCE AS OF June 1, 2026. Without admitting or denying the validity or existence of the alleged deficiencies, Berkeley Square provides the following Plan of Correction: F657 The facility will continue to document completion of care conferences at the required intervals for all residents, including residents #04 & #15. To ensure compliance with this standard the following measures have be taken: 1. The social service designee and the inter- disciplinary team were re-educated by the administrator to the facility policy "Care Conference" on 4/29/26 and verbalized understanding. 2. Care conferences for resident #04 and resident #15 were conducted on or before 4/29/2026 by the interdisciplinary team. 3. Review of all other residents was conducted by the social service designee to validate and ensure that care conference schedule is up to date with timely care conferences scheduled for them on 4/15/2026. Audits of care conferences to be completed weekly for four weeks and then monthly after that by the social service designee. Documentation of the care conference including any identified concerns in the medical record. Administrator to validate audits/compliance and provide additional training as needed. Administrator will present results of these audits to QAPI committee for ongoing monitoring and further direction.
Failure to Reevaluate Blood Glucose After Treatment for Hyperglycemia
Penalty
Summary
The facility failed to ensure that a resident with diabetes received treatment in accordance with professional standards of practice when nursing staff did not reevaluate the resident's blood glucose after treatment for severe hyperglycemia. The resident, admitted with diagnoses including Alzheimer's disease, type II diabetes mellitus, and depression, had physician orders for Humalog insulin on a sliding scale before meals, Lantus insulin 25 units daily, and lisinopril 5 mg daily. The resident required extensive assistance with activities of daily living, including transfers, toileting hygiene, eating, and bathing. On the evening in question, the resident's blood glucose was documented as 532 mg/dL, and the on-call provider was notified. The provider gave a new order to administer an additional 8 units of lispro (Humalog) and to recheck the blood glucose in 30 minutes. The electronic medication administration record showed that the blood glucose of 532 mg/dL was obtained at 9:00 p.m. and that the additional 8 units of lispro were administered at 9:21 p.m. However, there was no documentation in the resident's chart that the blood glucose was rechecked after the additional insulin was given. In an interview, the DON confirmed there was no evidence of reevaluation and verified that, according to the facility's "Abnormal Blood Glucose Procedure" policy, the resident should have been reevaluated and that the evaluation step should have been included in the progress note documentation.
Plan Of Correction
F684 The facility will continue to ensure all residents, including #03, receive treatment in accordance with professional standards of practice and reevaluated for hyperglycemia. To ensure compliance with this standard the following measures have been taken: 1. The director of nursing assessed resident #03, reviewed documentation and orders and found no ill effects immediately 4/16/26. 2. All licensed nurses were re-educated to facility policy "Blood Glucose Monitoring" by the Director of Nursing/designee in April 2026. 3. Audits of like-residents that require blood sugar checks to be completed by the director of nursing/designee two times a week for 4 weeks and then monthly after that to validate correct follow through when there is abnormally high blood glucose result. The Administrator will bring results of these audits to the QAPI committee for ongoing monitoring and further direction.
Failure to Act on Pharmacist Drug Regimen Recommendation for Thyroid Medication
Penalty
Summary
The deficiency involves the facility’s failure to ensure that pharmacy recommendations from the monthly drug regimen review were acted upon and documented for a resident. The resident was admitted with diagnoses including Parkinson’s disease, dementia, and hypothyroidism, and had current physician orders for levothyroxine 150 mcg once daily, buspirone 50 mg twice daily, and losartan 100 mg once daily. A medication regimen review dated 11/25/2025 included a consultant pharmacist recommendation that levothyroxine be administered consistently in the morning on an empty stomach, at least 30–60 minutes before food, per manufacturer instructions. There was no specific physician response in the medical record to this recommendation, and the facility’s policy stated that consulting pharmacist reviews are sent to nursing and addressed with the primary care provider or consulting specialist for review and follow-up. Review of the resident’s medication administration record for April 2026 showed levothyroxine scheduled for 9:00 a.m. On observation, the resident was seen eating breakfast in the dining area at 8:03 a.m., and an LPN reported administering the levothyroxine 150 mcg to the resident while the resident was in the dining area eating breakfast. The DON confirmed there was no evidence in the resident’s medical record explaining why the consultant pharmacist’s recommendation from 11/25/2025 was or was not acted upon. This lack of documented physician review and action on the pharmacist’s identified irregularity constituted noncompliance with the drug regimen review requirements.
Plan Of Correction
F756 The facility will continue to ensure the pharmacy recommendations from the monthly drug regimen review by a licensed pharmacist are acted upon for all residents, including #08. To ensure compliance with this standard the following measures have been taken: 1. Resident #08 was assessed by the registered nurse and med review completed by 4/28/26. After review of resident's drug regime's, it was discovered that resident #8 had 2 separate medication recommendations on the same form, to be reviewed by two separate practitioners, pharmacy has been instructed and agreed to separate meds on individual forms. 2. Licensed nurses re-educated to facility policy "Drug Regimen Review" by Director of nursing/designee in April 2026 and no later than 5/8/26. Licensed nurses are responsible for ensuring the reviews and recommendations are given to the physician for timely review. 3. Review of all other current residents Drug Regimen orders completed by Director of nursing/designee on 4/16/26 to ensure recommendations were followed up on/reviewed by the physician and address concerns if needed. 4. Audit of drug regime recommendations, pharmacy recommendations, and physician follow up to be completed weekly for four weeks by the Director of nursing/designee. Administrator will present results of these audits to the QAPI committee for ongoing monitoring and further direction.
Failure to Use Required Gait Belt During Ambulation Resulting in Resident Fall
Penalty
Summary
The deficiency involves the facility’s failure to ensure that a required gait belt was used while assisting a high fall‑risk resident with ambulation, resulting in a fall with head injury. The resident had multiple diagnoses including metabolic encephalopathy, hypertension, osteoarthritis, muscle weakness, gait and mobility abnormalities, major depressive disorder, anxiety, and visual hallucinations. Admission and subsequent MDS and fall risk assessments documented that the resident was severely cognitively impaired, required moderate to maximal assistance with transfers and ambulation, could not independently come to a standing position, exhibited loss of balance while standing, used an assistive device, and had decreased muscle coordination. The resident had a history of falls prior to admission and was assessed as being at high, later moderate, risk for falls. The resident’s fall care plan identified her as at risk for falls and included interventions such as providing maximum to moderate assistance with transfers and walking short distances, use of a walker and wheelchair, and following the facility’s fall protocol. Therapy notes and care conference documentation indicated that the resident leaned backwards when standing, required contact guard to minimal assistance for bed mobility and transfers, and needed constant verbal cueing for safe sequencing during toilet transfers. The physical therapist confirmed that the resident was to use a gait belt with staff when ambulating, and the DON verified that therapy had assessed the resident as requiring contact guard assistance and a gait belt for ambulation and transfers. On the day of the incident, a CNA was assisting the resident from her recliner to the bathroom using a walker. The CNA walked beside the resident, providing guidance and support, and reported having a hand on the resident while assisting her. As they approached the bathroom door, the CNA reached for the doorknob to open it, and at that moment the resident began to lose her balance and fell backwards to the floor, striking the back of her head. The nurse who responded found the resident on her back at the foot of the bed with her feet near the bathroom, noted a red raised area on the back of the head, and documented that the resident was not wearing a gait belt and that the gait belt was on the dresser. In the facility’s investigative summary and in interviews, the CNA acknowledged that she did not have a gait belt on the resident while ambulating her, despite the resident’s assessed need for hands‑on assistance and gait belt use per facility policy and the resident’s care and therapy plans.
Failure to Implement PD Orders and Monitor Resident Receiving Peritoneal Dialysis
Penalty
Summary
The deficiency involves the facility’s failure to implement pre-admission physician orders for peritoneal dialysis (PD) and to provide ongoing monitoring for a resident with chronic kidney disease (CKD) stage five who required PD. Pre-admission orders dated 11/14/25 specified three daily PD exchanges at 6:00 A.M., 2:00 P.M., and 10:00 P.M., and directed staff to monitor for signs and symptoms of peritonitis, including fever, abdominal pain, and cloudy effluent. These monitoring orders were not entered into the facility’s physician orders. The resident’s care plan noted the need for PD and included general monitoring interventions (labs, signs of bleeding, bacteremia, septic shock, and significant vital sign changes), but did not specifically address the ordered monitoring for peritonitis. Review of PD documentation showed incomplete and inconsistent charting of treatments and resident condition. The paper peritoneal flowsheet had columns for time of PD and condition/comments, including instructions to call the nurse immediately for cloudy fluid, abdominal pain, or fever. However, the first entry on 11/15/26 at 2:00 P.M. only noted that the PD nurse completed the exchange, and the 10:00 P.M. entry that day had no condition/comment documentation. Subsequent days (11/16/25, 11/17/25, and 11/18/25) contained only one condition/comment entry per day rather than for each exchange, and there was no documentation that the 6:00 A.M. PD on 11/18/25 was completed. The PD cycler flowsheet starting 11/19/25 lacked any description of the effluent on multiple days. The PD nurse from the dialysis company stated facility staff were expected to monitor effluent for cloudiness and assess for abdominal pain and fever, and the DON confirmed there was no electronic physician order for peritonitis monitoring or for use of the PD cycler, that the paper charting did not allow for effluent description or symptom documentation for each treatment, and that PD was not documented at one ordered time. The facility’s dialysis policy required ongoing assessment and monitoring for complications before, during, and after treatments, which was not reflected in the documentation for this resident.
Improper Infection Control During Medication Administration
Penalty
Summary
Surveyors identified a deficiency in infection prevention and control related to medication administration for Resident #29. The resident was admitted on 02/28/14 with diagnoses including depression, traumatic brain injury, and anxiety, and had impaired cognition per a quarterly MDS assessment. During an observation on 03/25/26 at 6:58 A.M., RN #281 prepared the resident’s medications by removing an Amoxicillin-Pot Clavulanate tablet from the medication card and pushing it directly into her ungloved hand, then using her fingers to place the pill into a medication cup. The same process was observed for multiple other medications, including Escitalopram Oxalate, Furosemide, Sennosides, Lyrica, and Vitamin D, each being pushed from the card into the RN’s ungloved hand and then transferred by her fingers into the medication cup before administration to Resident #29. In a subsequent interview at 7:27 A.M. the same day, RN #281 confirmed she had placed each medication into her ungloved hands prior to administration and acknowledged that the proper procedure was to push the pills directly from the card into the medication cup. Review of the facility’s “Medication Administration – General guidelines” policy, revised 10/08/25, stated that medications are to be administered in accordance with good nursing principles and practices. This practice failure was cited as a deficiency under Complaint Number 2681777.
Improper Use of Wheelchair as a Physical Restraint
Penalty
Summary
Surveyors identified a deficiency related to the facility’s failure to ensure a resident was free from physical restraints. Resident #7, admitted with diagnoses including Alzheimer’s disease, diabetes mellitus, and anxiety disorder, was documented on a recent MDS as rarely understood and dependent for ADLs except eating. The resident ambulated independently on the unit without an assistive device and had documented verbal and other behaviors occurring one to three days during the look-back period. The care plan noted the resident had potential to be physically aggressive, chase staff, throw objects, and be combative with care, with interventions such as offering choices, administering medications as ordered, and intervening early when agitation occurred. During an observation and interview, Resident #7 was found sitting in a chair with the right arm of the chair positioned against the nursing station and a wheelchair placed directly in front of him. The left arm of the wheelchair was also against the nursing station, and both wheelchair wheels were locked, creating a barrier that appeared to restrain the resident, who was sleeping with his knees touching the locked wheelchair. An LPN confirmed both wheelchair wheels were locked and that the wheelchair should not have been placed in front of the resident. A CNA reported she had placed the wheelchair there in preparation to get the resident up for lunch, was unable to transfer him, and left the wheelchair in that position, acknowledging it was wrong to keep it there. The facility’s physical restraint policy stated that physical restraints are not used except when alternatives are not appropriate or effective for treating a medical symptom and defined physical restraints as any device attached or adjacent to the body that the individual cannot easily remove and that restricts freedom of movement or access to the body.
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