Oak Grove Manor
Inspection history, citations, penalties and survey trends for this long-term care facility in Mansfield, Ohio.
- Location
- 1670 Crider Rd, Mansfield, Ohio 44903
- CMS Provider Number
- 365837
- Inspections on file
- 36
- Latest survey
- September 25, 2025
- Citations (last 12 mo.)
- 19
Citation history
Health deficiencies cited at Oak Grove Manor during CMS and state inspections, most recent first.
The facility did not ensure that food was served at safe and appetizing temperatures, resulting in repeated resident complaints about cold and unpalatable meals. Observations showed that food temperatures dropped significantly during tray delivery, and staff confirmed that plate warmers were not used due to safety concerns. The facility's policy requiring hot foods to remain above 135°F was not followed.
A resident with chronic ischemic heart disease and CHF did not receive a timely cardiology appointment as ordered, despite ongoing symptoms and repeated documentation of the need for specialist follow-up. Staff interviews confirmed that after initial attempts to refer the resident, no further action was taken to ensure the appointment was scheduled, resulting in a lapse in care coordination.
The facility failed to provide residents with adequate hot water in their bathrooms, affecting three residents. Despite installing a new hot water heater, issues persisted with the system, including a malfunctioning thermostat and a seized mixing valve. Residents reported dissatisfaction with the water temperature, and observations confirmed that the water was not reaching appropriate temperatures. There was also a lack of documentation for water temperature checks in the affected rooms.
The facility failed to provide timely wound care treatment for three residents. A resident with an abrasion on the buttock experienced a delay in treatment and a dermatology appointment. Another resident with a venous ulcer and a third resident with a Stage II pressure ulcer also faced delays in receiving ordered treatments. These issues were confirmed by the ADON and DON, highlighting non-compliance in wound care management.
The facility failed to store food safely and maintain cleanliness in the kitchen. Boxes of food were improperly stored on the floor of a walk-in cooler, and unsanitary conditions were observed in the dish room and under the steam table. These actions were contrary to the facility's policies on food storage and cleaning.
The facility failed to maintain a pest-free environment, affecting all 67 residents. Observations revealed gnats and flies in the kitchen and flies on a resident. The Dietary Manager and Administrator confirmed these findings. The facility's Pest Control Policy acknowledges the importance of pest control, yet deficiencies were noted under specific complaint numbers.
A resident with a history of knee and hip prosthesis issues experienced a leg injury while being assisted to the bathroom, resulting in a femur fracture. Despite the incident being witnessed and the resident receiving pain medication, the facility failed to document or investigate the injury, violating their policy on handling injuries of unknown origin.
The facility failed to ensure food temperatures were assessed and recorded to maintain safe ranges before resident consumption, affecting all 64 residents. Residents reported issues with food temperature and quality, and staff confirmed daily complaints. Observations revealed that only main entrees were checked for temperature, and not all items were recorded, contrary to facility policy.
A resident did not receive their prescribed Gabapentin for two days due to unavailability, despite the medication being in the emergency kit. The facility failed to document the missed doses or notify the pharmacy or physician, violating their medication error and emergency service policies.
The facility failed to provide mechanically altered diets as ordered for three residents with specific dietary needs. Despite physician orders for mechanical soft diets, regular texture meals were prepared. The issue was identified when a surveyor intervened, and the Dietary Manager confirmed the error, highlighting noncompliance with the facility's therapeutic diet policy.
The facility failed to provide meals that honored the dietary preferences and allergies of three residents on mechanically altered diets. Despite specific dietary needs, meals served included unsuitable items like spaghetti with tomato sauce. One resident, allergic to tomatoes, was not offered an alternative meal. Interviews confirmed the meals did not align with dietary restrictions or preferences, violating the facility's policy on therapeutic diets.
The facility failed to ensure mail was delivered to residents on Saturdays, affecting nine residents and potentially impacting all 70 residents. The business office, where mail was delivered, was closed on Saturdays, causing delays in mail distribution by the activities department.
The facility failed to ensure proper disposal of garbage and refuse, with trash scattered around two exterior dumpsters. The Dietary Supervisor confirmed the debris and mentioned issues with raccoons.
The facility failed to maintain comfortable sound levels, with a loud alarm at the nursing station causing disruption and annoyance to residents. Despite ongoing complaints and acknowledgment from the Administrator, no effective measures were taken to address the issue.
The facility failed to ensure residents were offered or assisted in attending scheduled activities, affecting six of nine residents reviewed. On one occasion, five residents were left without scheduled activities, and a resident with dementia was not reminded or assisted to attend a BINGO activity.
The facility failed to ensure the activities program was directed by a qualified individual. The Activities Director did not have the necessary certification, experience, or education, and no specific training program or start date had been established. The Administrator confirmed the AD's lack of qualifications and the recent termination of the previous activities director.
A resident with multiple medical conditions reported rough care by a nurse aide. The facility investigated but failed to identify the alleged perpetrator in the report to the State Survey Agency, contrary to their abuse policy.
The facility failed to provide a resident with bed mobility bars as ordered by a physician, despite the resident's repeated requests. The Maintenance Director confirmed the absence of grab bars and indicated that none were available in the facility.
The facility failed to ensure consistency in the advanced directives for a resident with moderately impaired cognition. The resident's medical record showed conflicting information regarding her code status, with physician orders indicating Full Code and the care plan stating DNR-CC. The inconsistency was not addressed or evaluated on an ongoing basis, as confirmed by an LPN.
A resident with asthma and bipolar disorder requested her Ventolin inhaler, but the staff failed to check the emergency medication supply and instead called the pharmacy for a refill. The facility's policy requires checking the emergency supply first, and the inhaler was available in the emergency supply.
A resident with multiple diagnoses had their antipsychotic medication Abilify incorrectly discontinued instead of increased, as ordered. The error was identified through MARs review and confirmed by staff and the resident, who reported no significant mental health changes.
The facility failed to ensure accurate documentation for a resident with a left femur fracture, diabetes, and anxiety. Orders for wound care, podus boots, and liquid protein were not properly documented, and an order for surgical site cleansing was not discontinued after healing. Nursing staff confirmed these inaccuracies.
Failure to Maintain Palatable and Safe Food Temperatures
Penalty
Summary
The facility failed to ensure that food served to residents was palatable and maintained at appropriate temperatures, as required by facility policy. Resident council meeting records indicated ongoing dissatisfaction with the quality of food, specifically noting repetitive menus, dry meat, and lack of seasoning, with no resolution documented. Interviews with residents revealed that breakfast was consistently served cold, leading at least one resident to stop eating breakfast altogether, despite reporting the issue to CNAs. Another resident reported that food was frequently cold by the time trays were delivered, and although she continued to eat due to hunger, she preferred warmer meals. Observations confirmed that while food temperatures were within acceptable ranges when initially measured in the kitchen, significant drops occurred during tray transport and distribution. By the time the last tray was served, food temperatures had fallen well below the required 135 degrees Fahrenheit, with sausage patties at 101 degrees and waffles at 88 degrees. Test trays were found to be lukewarm, dry, and unappetizing. The Dietary Manager acknowledged the issue, noting that plate warmers were not being used due to safety concerns and that necessary protective gloves had not been procured. The facility's policy mandates that hot foods remain above 135 degrees Fahrenheit during holding and plating, a standard that was not met during the survey.
Failure to Schedule Timely Cardiology Appointment for Resident with CHF
Penalty
Summary
The facility failed to ensure that a resident with chronic ischemic heart disease and acute diastolic congestive heart failure (CHF) received a timely cardiology appointment as ordered by the physician. Medical record review showed that after experiencing shortness of breath and chest pain, the resident was evaluated by a nurse practitioner, who ordered an EKG and a follow-up with a cardiologist. Although the facility faxed a consultation request to cardiology, there was no evidence that an appointment was scheduled or that the resident was seen by a cardiologist over a period of several months. Interviews with the resident, transportation aide, and Director of Nursing confirmed that the cardiology appointment had not been made, despite ongoing symptoms and physician orders. The transportation aide noted previous issues with missed appointments and acknowledged that no further attempts were made to schedule the cardiology consult after the last fax. Facility policy required staff to schedule and arrange transportation for medical appointments, but this process was not completed for the resident in question.
Inadequate Hot Water Supply in Resident Bathrooms
Penalty
Summary
The facility failed to ensure that residents had access to water at appropriate temperatures in their bathrooms, affecting three residents. The issue began when the hot water heater for one resident's room malfunctioned, leading to the installation of a new hot water heater. However, the new system experienced multiple issues, including a frequently tripping high limit switch and breaker, a burnt-out heating element, and a malfunctioning thermostat. These problems persisted over several weeks, resulting in inconsistent water temperatures in the affected residents' rooms. Interviews with the residents revealed their dissatisfaction with the water temperature, as they were unable to take warm baths or showers. Observations confirmed that the water temperatures in the residents' rooms were below the appropriate levels, with temperatures dropping after initially reaching a warm state. The maintenance supervisor verified that the water temperatures were controlled by the same hot water tank and discovered that the mixing valve was seized, preventing proper adjustment. Additionally, there was no documentation of water temperatures being checked in the affected rooms since October, indicating a lapse in monitoring and maintenance.
Delayed Wound Care Treatment for Residents
Penalty
Summary
The facility failed to ensure timely implementation of treatments for three residents with wounds. Resident #3, who was cognitively intact, had an abrasion on the buttock identified on 11/06/24, but the treatment was not initiated until 11/13/24, and a dermatology appointment was delayed until 12/09/24. The resident expressed that the area was sore, and the delay in treatment and appointment was confirmed by the Assistant Director of Nursing (ADON) and the Director of Nursing (DON). Resident #6, also cognitively intact, had a venous ulcer on the right lower extremity identified, but the treatment was not implemented until 12/23/24, despite being ordered earlier. Similarly, Resident #7, who had severe cognitive impairment, had a Stage II pressure ulcer on the sacrum, but the treatment was not put in place until 12/23/24. These delays in treatment were verified by the ADON and DON, indicating a pattern of non-compliance with timely wound care management.
Food Storage and Sanitation Deficiencies
Penalty
Summary
The facility failed to store food in a safe and sanitary manner, as observed during a kitchen inspection. Boxes of food were found stored directly on the floor inside walk-in cooler #1, making it difficult for staff to access the cooler. Dietary Aide #134 confirmed that the boxes were left unpacked due to a recent delivery and lack of time to organize them. The facility's policy on food storage, which requires refrigerated food to be stored off the floor, was not adhered to. Additionally, the facility did not maintain cleanliness in the food service areas. Observations revealed that the shelf under the steam table was dirty with food crumbs and dried liquids, and the dish room floor near the walls had a buildup of dirt and debris. The bottom shelf of the clean dish rack was also covered in dust. Dietary Manager #119 verified these unsanitary conditions. The facility's cleaning task list and policy on cleaning and sanitation require daily cleaning of the dish room and equipment, as well as weekly dusting of pot and pan shelves, which were not followed.
Pest Control Deficiency in Facility
Penalty
Summary
The facility failed to maintain a pest-free environment, which had the potential to affect all 67 residents. During an observation in the kitchen's dishwasher room, at least four to five gnats and a fly were noted, and a fly was also observed in the kitchen serving area. This was confirmed by the Dietary Manager. Additionally, a resident was observed with five flies flying off of him when he moved, and another resident reported frequent flies in his room. The Administrator confirmed the presence of flies in the resident's room and removed a bag of garbage, although no flies were observed near it. The facility's Pest Control Policy, dated August 2016, acknowledges the importance of pest control in maintaining a safe living environment, yet the deficiency was noted under Complaint Numbers OH00158146 and OH00157659.
Failure to Investigate Resident's Injury of Unknown Origin
Penalty
Summary
The facility failed to investigate an injury of unknown origin for a resident, which is a violation of their policy on abuse, neglect, mistreatment, exploitation, and misappropriation. The resident, who had a history of knee and hip prosthesis issues, was admitted to the facility and was at high risk for falls. On a particular day, the resident experienced a leg injury while being assisted to the bathroom by a CNA, resulting in intense pain. Despite the incident being witnessed by a registered nurse and the resident receiving pain medication, there was no documentation of the incident in the resident's medical record or the facility's incident and accident log. Interviews with the resident's family and staff revealed that the resident's leg was twisted during the bathroom assistance, leading to a femur fracture that was not present upon admission. The orthopedic nurse confirmed that the fracture was identified during a post-operative appointment, and the facility was instructed to send the resident to the hospital for treatment. The Director of Nursing and the Administrator acknowledged that no investigation was initiated into the incident, mistakenly believing the fracture was present on admission. This oversight represents a failure to adhere to the facility's policy requiring immediate reporting and investigation of injuries of unknown source.
Failure to Ensure Safe Food Temperatures
Penalty
Summary
The facility failed to ensure that food temperatures were assessed to maintain safe ranges before resident consumption, potentially affecting all 64 residents receiving meals from the facility kitchen. The deficiency was identified through a review of the facility menu, resident and staff interviews, observations, and examination of the facility's food temperature logs and policy. Residents reported that hot food items were sometimes not hot enough, and staff confirmed hearing daily complaints about food temperature and quality. During an observation, it was noted that a staff member checked the temperatures of only the main entrees and did not record these temperatures or check other items on the steam table, including milk. The facility's policy on food preparation and storage, revised in November 2022, outlined that food temperatures should be maintained above 41 degrees Fahrenheit and below 135 degrees Fahrenheit to prevent the growth of pathogenic microorganisms. However, the staff did not adhere to this policy, as they failed to monitor and record the temperatures of all food items, including potentially hazardous foods like milk, throughout the meal service. This oversight was confirmed by the Dietary Manager, who acknowledged that all food items should have been checked and recorded to ensure they were at safe temperatures.
Failure to Administer Medication as Ordered
Penalty
Summary
The facility failed to ensure that residents were free from significant medication errors, specifically affecting one resident who did not receive their prescribed medication, Gabapentin, for two consecutive days. The resident, who was cognitively intact and had diagnoses including parkinsonism, bipolar disorder, osteoarthritis, and depression, was supposed to receive Gabapentin 600 mg three times daily. However, the medication was not administered on two consecutive days because it was not available in the facility. Despite the availability of Gabapentin in the emergency kit, there was no evidence that it was used to provide the missed doses to the resident. The facility's progress notes and interviews confirmed that the resident missed six doses of Gabapentin over the two days, and there was no documentation of notification to the pharmacy or attending physician about the missed doses. Additionally, the facility's emergency kit log showed no record of Gabapentin being signed out for the resident. The facility's policies on medication errors and emergency pharmacy services were not adhered to, as there was a lack of documentation and failure to administer the medication as ordered.
Failure to Provide Mechanically Altered Diets as Ordered
Penalty
Summary
The facility failed to provide mechanically altered diets as ordered by physicians for three residents, leading to a deficiency. Resident #11, diagnosed with Alzheimer's disease, oral phase dysphagia, muscle weakness, and complete loss of teeth, was ordered a mechanical soft diet. Resident #16, with malnutrition, dementia, aphasia, dysphagia, and edentulous, was ordered a no added salt mechanical soft texture diet. Resident #18, with a history of cancer, asthma, schizoaffective disorder, GERD, and mild intellectual disabilities, was also ordered a mechanical soft diet. Despite these orders, the facility prepared regular texture meal trays for these residents, which included chicken parmesan with spaghetti, cauliflower, and garlic toast. The deficiency was identified when a surveyor observed the meal preparation and intervened before the meals were served. The Dietary Manager confirmed that the meals prepared did not match the mechanically altered diet orders for the residents. The facility's policy on therapeutic diets, which requires adherence to physician orders for diet modifications, was not followed. This oversight was documented under Complaint Number OH00155626, indicating noncompliance with dietary requirements for residents with specific dietary needs.
Failure to Honor Dietary Preferences and Allergies
Penalty
Summary
The facility failed to provide meals that honored the dietary preferences and allergies of three residents on mechanically altered diets. Resident #11, diagnosed with Alzheimer's disease and oral phase dysphagia, required a mechanical soft diet due to being edentulous and at risk for malnutrition. Resident #16, with malnutrition and dysphagia following a cerebral vascular accident, also required a mechanically altered diet with no added salt. Resident #18, with a history of cancer and an allergy to tomatoes, was similarly on a mechanical soft diet. Despite these dietary needs, the facility served meals that did not accommodate these requirements. On a specific observation, the Dietary Manager prepared meals that included spaghetti with tomato sauce, which was unsuitable for the residents involved. Resident #18, allergic to tomatoes, was unable to eat the meal provided and was not offered an alternative. Interviews confirmed that the meals did not align with the residents' dietary restrictions or preferences, as indicated on their tray tickets. The facility's policy on therapeutic diets, which should align with physician orders and resident preferences, was not adhered to, leading to this deficiency.
Failure to Deliver Mail on Saturdays
Penalty
Summary
The facility failed to ensure mail was delivered to residents on Saturdays, affecting nine residents who were interviewed and potentially impacting all 70 residents in the facility. During a Resident Council meeting, residents expressed concerns that mail delivered to the business office on Saturdays was not distributed within 24 hours. The business office was typically closed on Saturdays, and the activities department, responsible for mail distribution, had to wait until the business office reopened to sort and distribute the mail. This delay was confirmed by an Activities Assistant, who verified that mail received on Saturdays was not normally delivered the same day.
Improper Garbage Disposal
Penalty
Summary
The facility failed to ensure proper disposal of garbage and refuse, which had the potential to affect all 70 residents. During an observation, two exterior facility dumpsters were found with trash scattered around them, including various food wrappers, containers, a used brief, and a disposable glove. Unidentified animal track marks were also observed near the dumpsters. The Dietary Supervisor confirmed the presence of the debris and mentioned that the facility had issues with raccoons.
Failure to Maintain Comfortable Sound Levels
Penalty
Summary
The facility failed to maintain comfortable sound levels, affecting nine residents who voiced concerns about the loud alarm at the nursing station. Observations on 05/15/24 identified a very loud alarm that sounded whenever the door to the patio was opened. This alarm, located at the front of the nursing station, was heard multiple times in a short period, causing annoyance to residents nearby. Interviews with residents confirmed that the alarm was disruptive, waking them up from sleep and being a frequent topic of complaint at Resident Council meetings. The Maintenance Director confirmed that the alarm could not be turned down or off and that there had been ongoing complaints from residents about the noise. The facility's concern log showed resident complaints about the loud alarm dating back to January 2024. The Administrator acknowledged being aware of the residents' concerns and mentioned that a company had assessed the alarm system but found no way to reduce the sound. Despite these complaints and the apparent disruption caused by the alarm, no effective measures had been taken to address the issue, leading to the deficiency noted in the report.
Failure to Ensure Resident Participation in Scheduled Activities
Penalty
Summary
The facility failed to ensure residents were offered or assisted in attending scheduled activities, affecting six of nine residents reviewed. On 05/15/24, five residents were observed sitting in the dining area where a detective activity and a daily walk were scheduled to take place, but no staff were present, and no activities occurred. Residents reported that it was not uncommon for scheduled activities to be canceled without notice. The Activities Director confirmed that the activities did not occur as scheduled, and the Administrator acknowledged that staff should have informed residents of the changes. Additionally, Resident #46, who has dementia and requires reminders and assistance to participate in activities, was not reminded or assisted to attend a scheduled BINGO activity on 05/14/24. Despite BINGO being scheduled and taking place in the dining room, Resident #46 was observed lying in her bed and was not informed or assisted by staff to attend. Interviews with staff revealed a lack of clarity on whose responsibility it was to assist residents in attending activities, contributing to the resident's non-participation.
Unqualified Activities Director
Penalty
Summary
The facility failed to ensure the activities program was directed by a qualified individual as required. The Activities Director (AD) did not have the necessary certification, experience, or education to hold the position. This was confirmed through personnel file review, staff interviews, and a review of the job description. The AD acknowledged the lack of qualifications and stated that the facility planned to provide training, but no specific training program or start date had been established. The Administrator confirmed the AD's lack of qualifications and the recent termination of the previous activities director. The facility census was 70, with two residents identified as not participating in activities.
Failure to Identify Alleged Perpetrator in Abuse Report
Penalty
Summary
The facility failed to ensure alleged perpetrators were identified in reports of abuse allegations submitted to the State Survey Agency. This deficiency affected a resident who had been admitted with multiple medical diagnoses including non-stemi myocardial infarction, anemia, hypertension, generalized weakness, depression, obesity, and hypokalemia. The resident reported that a nurse aide was rough with her care, and although the facility conducted an investigation and asked her questions, they omitted the alleged perpetrator in the report submitted to the State Survey Agency. The Social Services Director confirmed the omission, which was against the facility's abuse policy that required immediate investigation and thorough documentation, including identifying all persons involved.
Failure to Provide Bed Mobility Bars for Resident
Penalty
Summary
The facility failed to provide reasonable accommodations for a resident's needs and preferences to enhance self-mobility. Resident #71, who was admitted with diagnoses including morbid obesity, congestive heart failure, high blood pressure, diabetes, and chronic kidney disease, required partial/moderate assistance with rolling and had a physician's order for bilateral bed mobility bars. Despite the resident's repeated requests and the physician's order dated 04/13/24, the grab bars had not been installed by 05/15/24. The Maintenance Director confirmed the absence of grab bars and indicated that none were available in the facility.
Inconsistent Advanced Directives for Resident
Penalty
Summary
The facility failed to ensure consistency in the advanced directives for one resident, identified as Resident #38. The resident's medical record showed conflicting information regarding her code status. While the physician orders dated 03/25/24 indicated that the resident was to be a Full Code, the current plan of care stated that the resident wished to have a Do Not Resuscitate - Comfort Care (DNR-CC) status. This inconsistency was not addressed or evaluated on an ongoing basis, as confirmed by an interview with an LPN who could not find any evidence of such evaluations. Resident #38, who was admitted to the facility on 09/18/20, had medical diagnoses including congestive heart failure, edema, pain, morbid obesity, and diabetes. The resident was assessed with moderately impaired cognition according to the most recent Minimum Data Set (MDS) assessment. During an interview, the resident explicitly stated that she did not want life-saving measures performed in the event of cardiac or respiratory arrest. Despite this, the physician orders and care plan were not aligned, leading to a deficiency in honoring the resident's advanced directive wishes.
Failure to Provide As-Needed Medication from Emergency Supply
Penalty
Summary
The facility failed to provide an as-needed medication from the emergency supply for a resident with asthma and bipolar disorder. The resident, admitted on 10/19/17, requested a respiratory assessment on 05/14/24, which showed no concerns. However, the resident later requested her Ventolin inhaler and was informed that it was not available. The nurse called the pharmacy for a refill, which was scheduled to be delivered later that evening. The resident expressed concern about the unavailability of her medication when needed. An interview with an LPN confirmed that the staff did not check the emergency medication supply for the Ventolin inhaler, as they should have, and instead called the pharmacy. The facility's emergency medication policy requires staff to check the emergency supply and use it if the medication is not available in the medication cart. A review of the facility's emergency medication list confirmed that a Ventolin inhaler was available. This deficiency was investigated under Complaint Numbers OH00153898 and OH00152383.
Medication Error Leading to Discontinued Antipsychotic
Penalty
Summary
The facility failed to ensure that residents were free from significant medication errors, specifically affecting one resident. Resident #59, who had multiple diagnoses including type two diabetes, chronic obstructive pulmonary disease, major depressive disorder, and unspecified dementia, had a physician's order to increase the dosage of the antipsychotic medication Abilify from 2 mg to 5 mg. This order, dated 04/22/24, was received and acknowledged by an LPN but was inadvertently discontinued instead of being transcribed correctly. As a result, the increased dosage of Abilify was not administered from 04/23/24 to 05/15/24, as evidenced by the medication administration records (MARs) for April and May 2024. A certified nurse practitioner (CNP) noted on 05/10/24 that the Abilify dosage was supposed to be increased but had been discontinued instead. The CNP documented that the medication would be restarted. Interviews with another LPN and Resident #59 confirmed the medication error. The resident reported no significant changes in mental health due to the error. This deficiency was investigated under Complaint Number OH00153898.
Inaccurate Documentation of Wound Care and Supplement Orders
Penalty
Summary
The facility failed to ensure accurate documentation in the medical record for Resident #66, who had diagnoses including a displaced fracture of the left femur, diabetes mellitus, and anxiety. The physician's orders included cleansing the surgical site on the left hip, using podus boots for heel pressure injury prevention, and administering house liquid protein for wound healing. However, the medication administration record (MAR) and treatment administration record (TAR) revealed that the podus boots were not documented as being used on specific dates, and the house liquid protein was not documented as administered on several consecutive days in May 2024. Additionally, the order to cleanse the surgical site was documented as completed daily even after the site had healed by the end of March 2024, indicating that the order should have been discontinued but was not, leading to inaccurate documentation of a treatment that was no longer necessary. Interviews with nursing staff confirmed these documentation inaccuracies and the failure to discontinue the order for the surgical site cleansing. This deficiency was identified during an investigation under Complaint Numbers OH00153898 and OH00152383. The failure to accurately document wound care treatments, prevention devices, and supplement orders affected Resident #66, highlighting lapses in the facility's adherence to professional standards for maintaining medical records. The nursing staff's inability to accurately document and discontinue orders as needed contributed to the deficiency, impacting the quality of care provided to the resident.
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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