Oaks Of West Kettering The
Inspection history, citations, penalties and survey trends for this long-term care facility in Kettering, Ohio.
- Location
- 1150 West Dorothy Lane, Kettering, Ohio 45409
- CMS Provider Number
- 365321
- Inspections on file
- 39
- Latest survey
- March 3, 2026
- Citations (last 12 mo.)
- 11
Citation history
Health deficiencies cited at Oaks Of West Kettering The during CMS and state inspections, most recent first.
A resident admitted without skin issues and assessed as at risk for pressure ulcers was ordered weekly skin assessments, a pressure-reducing mattress, and later preventive heel care. Over several weeks, nursing documentation, including weekly skin assessments and bathing records by an LPN, consistently noted only blanchable redness or soft, blanchable heels with no open areas. On the same day a bathing sheet documented no heel wounds, a late-entry nursing note identified an open area on the left heel with drainage, and subsequent assessments documented a sizable open area that was later classified by a wound NP as an in-house acquired unstageable pressure ulcer with significant necrotic tissue. The facility’s own wound management policy and NPIAP guidelines cited by surveyors required comprehensive, ongoing skin assessments of bony prominences such as heels, but the resident’s heel injury was not detected until it had advanced to an unstageable pressure ulcer.
A resident with severe cognitive impairment, multiple comorbidities, and total dependence for ADLs was receiving incontinence care from a CNA while the bed was in a high position with side rails down. After care was completed, the CNA turned away to reach for the bed remote, during which time the resident rolled off the bed onto the floor, sustaining a head laceration and closed head injury requiring staples in the ER. Although the care plan noted ADL deficits and resistive behaviors, there was no specific fall risk care plan or fall-related interventions in place before the incident, and a high fall risk assessment was not completed until after the fall, despite facility policy requiring fall risk assessment and individualized interventions on admission.
Surveyors determined that the facility failed to assess multiple residents for the appropriateness of bed rail use before installing bed rails on their beds. Observation with the DON revealed numerous residents with bed rails in place, and the DON confirmed that no prior safety risk assessments or evaluations of less restrictive alternatives had been completed, despite a written policy requiring such assessments and documentation before bed rails are used.
The facility failed to ensure effective communication and documentation of hospice services with a contracted hospice provider for three residents who had revoked services from one hospice and elected another. Each resident had serious conditions such as dementia, CHF, COPD, and acute kidney failure and was documented on the MDS as needing extensive ADL assistance and, in some cases, receiving hospice services. However, facility progress notes over the review period did not reflect hospice involvement, and the hospice communication book contained only isolated RN signatures without details of visits or care provided. The DON confirmed the absence of hospice documentation, and a hospice Business Development Director acknowledged that the hospice was behind on documentation and had not recorded visits, despite contractual and policy requirements for accurate records and coordinated care.
Surveyors observed that the biohazard room was left unlocked with used sharps accessible, and the shower room contained prescription medications and Micro-Kill Two Germicidal Wipes on top of an unlocked cabinet. The DON confirmed these items should have been secured, and facility policy requires chemicals to be kept out of resident-accessible areas. These lapses had the potential to affect all residents in the memory care unit.
A resident with dementia and other cognitive disorders was observed pulling another resident's hair, but staff did not file a required Self-Reported Incident (SRI) or initiate an investigation as mandated by facility policy. Review of records and staff interviews confirmed the incident was documented in the medical record but not reported to authorities as required.
The facility did not perform comprehensive wound assessments, including required measurements and detailed documentation, for two residents with pressure ulcers and other wounds upon admission and readmission. Despite facility policy requiring full assessment and documentation, staff failed to record necessary wound details, and wounds were not measured until later by a wound NP, with incomplete documentation.
A resident with an indwelling catheter and complex medical needs did not receive catheter care every shift as required by facility policy. Documentation was missing for catheter care after the resident's readmission, and the resident reported that care was often not performed, especially during the night shift. Facility leadership confirmed the lack of documentation and non-compliance with the established catheter care policy.
A resident who required dialysis did not receive safe and appropriate dialysis care and services as needed. The facility failed to ensure that dialysis care was provided according to the resident's needs.
Surveyors observed that staff failed to follow infection control procedures during wound and incontinence care for two residents. In one case, a staff member did not perform hand hygiene after removing gloves or before donning new gloves, and did not change gloves between cleaning different areas during catheter and incontinence care. In another case, an LPN did not wear a gown while providing wound care to a resident on enhanced barrier precautions, despite facility policy and posted signage requiring PPE. These lapses were confirmed by staff interviews and policy review.
A resident with multiple chronic conditions and moderate cognitive impairment was found to have ongoing issues with flies in their room, as confirmed by staff observations and interviews. Multiple rooms were reported to have similar pest problems, and although maintenance and pest control treatments were in place, flies and gnats persisted in resident areas.
A resident with moderate cognitive impairment was injured when a floating sink fell on him in a facility restroom, causing a laceration that required 17 sutures. The sink was not properly secured, posing a hazard. The incident was reported after a CNA noticed the resident bleeding. The facility's maintenance director confirmed the sink's improper installation, and the resident's family insisted on hospital evaluation. The facility's policy on accident investigation was reviewed.
A resident with cognitive impairment sustained a laceration when a floating porcelain sink fell from the wall in a bathroom, causing injury. The incident occurred after the resident used the bathroom following a smoking break. Facility staff initially treated the wound, but the resident's family insisted on hospital evaluation due to continued bleeding, resulting in 17 sutures. The sink was identified as a floating type, prone to tilting if weight was applied, and the deficiency was investigated under a complaint number.
A resident with multiple medical conditions sustained a laceration from a broken sink, requiring sutures. The facility failed to notify the resident's representative of the incident, despite policy requirements. The family discovered the injury during a visit and called 911, leading to hospital treatment.
The East Unit crash cart was found lacking essential equipment, including a suction machine canister and a backboard, affecting 49 residents. Observations and staff interviews revealed that the crash cart had not been regularly checked, and necessary equipment was missing or improperly stored. The facility's CPR policy requires maintaining necessary equipment at all times, which was not followed.
A resident with a history of cerebral infarction and schizoaffective disorder was sexually abused by a frequent visitor in the facility's smoking area. Despite the resident's verbal refusals, the visitor inappropriately touched her and exposed himself, leading to her feeling traumatized. The incident was captured on security footage and reported to the police, resulting in the visitor's arrest. The facility's failure to prevent this incident constitutes a deficiency in protecting residents from abuse.
The facility failed to ensure the dishwashing machine sanitized at the correct temperature, potentially affecting 85 residents. The Dietary Director suspected a broken thermostat, while a Dietary Aide checked the wrong thermostat. The Service Technician found the final rinse temperature was too low, and some dish racks didn't engage the rinse cycle. The DON and Administrator expected staff to check and report malfunctions, as per facility policy.
A long-term care facility failed to implement an effective infection control program, as evidenced by the lack of Enhanced Barrier Precautions for two residents and improper handling of soiled linens and respiratory equipment for another. Staff were unaware of EBP guidelines, and no training had been conducted, leading to non-compliance with infection control protocols.
A resident with intact cognition reported being inappropriately touched by a family member at the facility. Although the police were notified and the family member was arrested, the facility failed to report the incident to the state agency, as required by their policy. Staff interviews revealed that the decision not to report was influenced by instructions from the corporate office.
A resident with intact cognition reported being sexually abused by a family member. The facility failed to conduct a thorough investigation, lacking documentation of interviews, statements, and evidence analysis. The facility's policy required these actions, but they were not followed, resulting in a deficiency.
A resident in a persistent vegetative state receiving enteral nutrition through a feeding tube did not have their formula labeled with the date and time of infusion. Observations showed that the containers lacked this information, contrary to facility policy and physician orders. Interviews with staff confirmed the oversight, highlighting a failure to follow established procedures.
A resident with dementia on a pureed diet received an incorrect portion size, as the facility failed to follow the planned menu. The resident was served half the required serving of pureed Marzetti. Staff interviews revealed that the menu system change led to the omission of portion sizes on printed menus, although they were available on meal tickets.
A resident with multiple medical conditions and an indwelling urinary catheter had abnormal lab results, prompting a physician to order repeat tests. However, the facility failed to obtain the necessary blood specimen for these tests. Interviews revealed lapses in communication and documentation among staff, and the physician noted the resident's rapid decline and discussions about hospice care.
A resident with moderately impaired cognition had their debit card stolen and used by a former STNA for personal expenses, totaling about $1,600. The facility's investigation and a police report confirmed the misuse, leading to the STNA's termination.
Failure to Timely Identify and Assess Unstageable Heel Pressure Ulcer
Penalty
Summary
The deficiency involves the facility’s failure to thoroughly assess a resident’s skin and to timely identify a pressure ulcer on the left heel, despite the resident being known to be at risk for pressure-related skin breakdown. The resident was admitted without pressure ulcers and with no history of skin integrity issues, and an initial Braden Scale assessment identified a moderate risk for pressure sores. Physician orders at admission included weekly skin assessments and use of a pressure-reducing mattress, and later orders added bilateral heel cleansing and skin prep every shift as a preventive measure. Weekly skin assessments and multiple bathing/skin documentation entries over several weeks consistently recorded only soft, blanchable heels or blanchable redness to the heels, with no open areas or wounds documented. In the weeks leading up to the discovery of the wound, weekly skin assessments dated 11/25, 12/02, 12/06, and 12/12 documented no open areas on the left heel, and bathing documentation on multiple dates recorded only blanchable redness to the bilateral heels and no additional skin issues. Preventive heel care ordered on 11/24 was documented on the Treatment Administration Record as being completed twice daily on several dates. However, on the same day that a bathing sheet documented no wounds or skin integrity issues on the left heel, a late-entry nursing note recorded that an open area on the left heel with slight drainage was identified, measuring 4.5 cm by 3 cm by 0.1 cm. A weekly skin assessment and a skin breakdown assessment completed the following day documented the same open area and measurements, and a subsequent wound evaluation identified the wound as an in-house acquired unstageable pressure ulcer with 90% necrotic tissue and 10% granulation tissue. The wound nurse later stated that the left heel wound was discovered during a facility-wide skin sweep initiated because of an increase in self-reported incidents and wounds, and that she had started daily skin sweeps in the memory care unit. She also stated that the resident had no wound NP visits during two earlier weeks because a previous skin issue at a different site had resolved. The wound NP confirmed that the resident developed an in-house unstageable pressure ulcer to the left heel identified by staff. The facility’s wound management policy required accurate documentation of treatments and focused wound assessments weekly and as needed with changes in condition, and NPIAP guidelines cited by surveyors emphasized comprehensive, ongoing skin assessment, including head-to-toe inspection with particular focus on bony prominences such as heels and the use of each repositioning opportunity to assess skin. Despite these requirements and guidelines, the resident’s left heel pressure injury was not identified until it had progressed to an unstageable pressure ulcer.
Failure to Provide Safe Supervision During Incontinence Care Resulting in Fall and Head Injury
Penalty
Summary
The deficiency involves the facility’s failure to ensure a resident’s environment was free from accident hazards and that adequate supervision was provided during incontinence care, resulting in the resident falling from the bed. The resident had multiple diagnoses including toxic liver disease, congestive heart failure, anxiety disorder, Alzheimer’s disease, osteoarthritis, chronic kidney disease, sepsis due to E. coli, and dementia, with severely impaired cognition and dependence on staff for all ADLs. The comprehensive care plan identified an ADL self-care performance deficit related to confusion/dementia and noted the resident could be resistive to care, with interventions such as monitoring and anticipating care needs, using a scoop mattress, and assessing for fall risks. However, there was no specific fall risk care plan or fall-related interventions in place prior to the incident. During incontinence care, CNA #355 provided personal care to the resident while the bed was in a high position. After completing care, CNA #355 turned away from the resident to reach for the bed remote to lower the bed, at which point the resident shifted or rolled and fell from the bed to the floor. According to staff interviews and documentation, the bed rails were down at the time of the fall, and the CNA had diverted attention away from the resident while the bed remained elevated. RN #134 was called to the room and found the resident on the floor with a laceration to the head and a significant amount of bleeding. The nurse’s note documented that the resident had decided to roll toward the floor during personal care while the bed was up high and the bed rails were down. The resident was transferred to the ER, where records showed a closed head injury, scalp laceration measuring 3.2 cm, and cervical strain, with four staples placed in the scalp wound. Review of facility documentation showed that a fall risk assessment identifying the resident as high risk for falls was not completed until after the incident. The DON reported that falls were not reviewed by the full IDT and that, at the time of the incident, the nurse on duty was responsible for completing the fall risk assessment and immediate interventions, with only the DON reviewing falls afterward. The facility’s fall prevention policy required that each resident be assessed for fall risk upon admission and receive individualized interventions based on their level of risk, but the resident did not have a fall risk care plan or related interventions implemented before the fall occurred.
Failure to Assess Residents Prior to Bed Rail Use
Penalty
Summary
Surveyors found that the facility failed to assess residents for the use of bed rails prior to their application, contrary to the facility’s own policy. Observation conducted with the Director of Nursing (DON) showed that 19 identified residents had bed rails on their beds, and the DON confirmed that these residents had not been assessed for the appropriateness of bed rail use before the rails were applied. The facility’s written policy, dated 02/05/26, states that staff will assess residents for the appropriateness of bed rails prior to use and will attempt and document less restrictive measures before implementing bed rails. Despite this policy, the required safety risk assessments and consideration of less restrictive alternatives were not completed or documented for any of the 19 residents observed with bed rails in place. This deficiency affected 19 residents reviewed for bed rails out of a total facility census of 107 residents. The DON’s interview corroborated the observation findings and confirmed noncompliance with the facility’s policy regarding pre-use assessment of bed rails and documentation of attempts at less restrictive measures.
Failure to Coordinate and Document Hospice Services With Contracted Provider
Penalty
Summary
The deficiency involves the facility’s failure to ensure an effective communication process and proper documentation of hospice services and coordination of care with Hospice Company A, as required by facility policy and the hospice contract. For one resident with hypertension, chronic kidney disease, dementia, and anorexia, the record showed admission to Hospice Company B and later revocation of those services, followed by election and admission to Hospice Company A for senile degeneration of the brain. However, the resident’s MDS did not reflect receipt of hospice services, facility progress notes for the relevant months contained no documentation of hospice involvement, and the hospice communication book for Hospice Company A contained only a single RN signature for a visit with no additional information about services provided. A second resident with CHF, dysphagia, adult failure to thrive, hypertension, and peripheral vascular disease was initially admitted to Hospice Company B and later revoked those services and elected Hospice Company A with a diagnosis of COPD. The MDS for this resident indicated severe cognitive impairment, dependence in ADLs, and receipt of hospice services, yet the facility’s progress notes for the same time period did not document hospice services. The hospice communication book for Hospice Company A again contained only one RN signature for a visit and no further documentation of hospice care or coordination. A third resident with acute kidney failure, hypertension, CHF, generalized anxiety disorder, and vascular dementia was admitted to Hospice Company B, revoked those services, and then elected Hospice Company A with a terminal dementia diagnosis. The MDS reflected that this resident was severely cognitively impaired, dependent in ADLs, and receiving hospice services, but the facility’s progress notes for the review period lacked any hospice-related documentation. The hospice communication book for Hospice Company A contained only a single RN signature for a visit and no other information. The DON confirmed the lack of hospice documentation in the facility records and hospice communication book for all three residents, and the hospice Business Development Director acknowledged that Hospice Company A was behind on documentation and had failed to document visits, despite a contract and facility policy requiring accurate records and a communication process for coordination of care.
Improper Storage of Chemicals and Sharps in Memory Care Unit
Penalty
Summary
During an observation of the memory care unit, surveyors found that the biohazard room was left unlocked with sharps containers containing used needles and other medical supplies accessible. Additionally, the shower room was unlocked, and prescription Nystatin powder, Zinc/Nystatin cream, and Micro-Kill Two Germicidal Wipes were found on top of an unlocked cabinet. The label on the Micro-Kill Two Germicidal Wipes specifically stated to keep the product out of reach of children. The Director of Nursing confirmed that these items should have been stored in a locked cabinet. Review of the Safety Data Sheet for the germicidal wipes indicated the product is classified as acutely toxic if ingested and should be kept out of reach of children. Facility policy also requires that chemicals must never be left unattended or stored in resident-accessible areas. These findings had the potential to affect all 21 residents on the memory care unit.
Failure to Investigate and Report Resident-to-Resident Abuse
Penalty
Summary
The facility failed to investigate and report an allegation of abuse involving a resident diagnosed with Alzheimer's disease, vascular dementia with agitation, psychotic disorder with delusions, and delirium. According to the nurses note, the resident was observed pulling another resident's hair, and staff intervened immediately. However, a review of the Enhanced Information Dissemination and Collection system (EIDC) revealed that no Self-Reported Incident (SRI) was filed for this event. Interviews with the DON and Executive Director confirmed the existence of the incident in the medical record and acknowledged that an SRI should have been completed, but was not. The facility's policy requires immediate investigation and reporting of abuse allegations to the appropriate agencies within 24 hours, which was not followed in this case.
Failure to Complete Comprehensive Pressure Ulcer Assessments on Admission
Penalty
Summary
The facility failed to comprehensively assess pressure ulcer wounds upon admission for two residents. For one resident with multiple complex medical diagnoses, including end stage renal disease, diabetes, and a history of sepsis and cellulitis, the admission assessment and subsequent skin assessments documented the presence of multiple wounds, such as pressure ulcers and necrotic lesions. However, these assessments did not include required measurements or detailed descriptions of the wounds, despite facility policy mandating full documentation and measurement of wounds upon admission. Another resident, also with significant medical conditions including end stage renal disease, congestive heart failure, and dementia, was admitted and readmitted multiple times. Upon readmission, the resident had documented pressure ulcers and arterial ulcers, but the nursing evaluation and weekly skin assessments failed to include measurements or adequate descriptions of the wounds. The wounds were not measured until later by a wound nurse practitioner, and even then, only one measurement was recorded for both wounds, rather than individual measurements as required. Interviews with the DON and review of facility policies confirmed that the required comprehensive skin and wound assessments, including measurements and detailed documentation, were not completed as per protocol for these residents. The facility's own policies specified that wound assessments must include type, stage, measurements, and wound bed description, but these elements were missing from the records reviewed.
Failure to Provide Indwelling Catheter Care per Policy
Penalty
Summary
The facility failed to provide indwelling catheter care as required by its own policy for a resident with significant medical needs, including chronic respiratory failure, neurogenic bladder, and paraplegia. The resident was dependent on staff for all activities of daily living and had an indwelling catheter. The care plan specified that catheter care should be performed every shift. Documentation showed that catheter care was completed every shift prior to the resident's discharge to the hospital, but after the resident's readmission, there was no documentation of catheter care being performed for an extended period. Interviews with the resident revealed that catheter care was often not performed during the night shift, and the resident reported going several days without receiving this care. The President of Clinical Services confirmed that the medical record lacked documentation of catheter care following the resident's readmission, which was not in accordance with facility policy. Review of the facility's catheter care policy confirmed that care was to be provided every shift and as needed, but this standard was not met for the resident in question.
Failure to Provide Safe and Appropriate Dialysis Care
Penalty
Summary
A deficiency was identified regarding the provision of safe and appropriate dialysis care and services for a resident who required such services. The report notes that the facility failed to ensure that the necessary dialysis care was provided in accordance with the resident's needs. Specific details about the actions or omissions that led to this deficiency, as well as information about the resident's medical history or condition at the time, are not provided in the report.
Failure to Follow Infection Control Procedures During Wound and Incontinence Care
Penalty
Summary
Surveyors identified failures in infection control procedures during wound and incontinence care for two residents. For one resident with chronic respiratory failure, neurogenic bladder, and an indwelling catheter, staff did not follow proper hand hygiene protocols. During observed catheter and incontinence care, a State Tested Nursing Assistant (STNA) failed to perform hand hygiene after removing soiled gloves and before donning new gloves, and did not change gloves between cleaning different areas or before using clean towels. The STNA confirmed these lapses during an interview, and facility policy required hand hygiene before and after glove use. For another resident with multiple diagnoses including end stage renal disease, diabetes, and a stage three pressure ulcer, a Licensed Practical Nurse (LPN) did not don a gown while performing wound care, despite the resident being on enhanced barrier precautions due to wounds and dialysis. The LPN performed hand hygiene and changed gloves as required, but omitted the use of a gown, which was required by facility policy for high-contact care activities under enhanced barrier precautions. The LPN confirmed awareness of the precautions and the presence of PPE and signage, but did not use the gown during the procedure. Facility policies reviewed by surveyors specified the need for hand hygiene in conjunction with glove use and the use of appropriate PPE, including gowns, for residents on enhanced barrier precautions. These deficiencies were identified through direct observation, staff interviews, and review of facility policies and resident records.
Failure to Maintain Pest-Free Resident Room
Penalty
Summary
The facility failed to ensure that a resident's room was free from flies, resulting in a deficiency related to pest control. During observations, six flies were seen either flying in the room or sitting on the resident's bedsheets. The resident, who had a history of diabetes mellitus, chronic obstructive pulmonary disease, chronic kidney disease, and hypertension, reported ongoing issues with flies in his room since admission. The resident was assessed as having moderate cognitive impairment and required varying levels of staff assistance for daily activities. Staff interviews confirmed the presence of flies in the resident's room, with one LPN verifying the observation and another LPN stating that several rooms had ongoing issues with flies and gnats. The Maintenance Director, who had recently started at the facility, acknowledged the problem and noted that treatments had been applied to sinks and drains, with some improvement observed. The pest control company provided monthly treatments to common areas and the kitchen, and spot treatments to rooms as needed. Despite these efforts, the deficiency was identified due to the continued presence of pests in resident rooms.
Resident Injured by Falling Sink in Facility Restroom
Penalty
Summary
The facility failed to ensure a safe environment for Resident #66, resulting in an accident that caused actual harm. On December 15, 2024, Resident #66, who had moderate cognitive impairment and required assistance with transfers, used a first-floor restroom where a floating handwashing sink fell on him. This incident resulted in a laceration to his left knee that required 17 sutures, antibiotics for infection prevention, and continued wound care. The resident's medical history included toxic encephalopathy, schizophrenia, and other conditions that may have contributed to his vulnerability. The incident was reported by a CNA who noticed Resident #66 bleeding upon returning from smoking. The resident stated that the sink broke and cut him while he was washing his hands. The facility's maintenance director confirmed that the sink was a floating type, which could tilt and fall if too much weight was applied. The sink was not directly bolted to the wall, which posed a hazard. The maintenance director replaced the sink and repaired the bathroom following the incident. Interviews with facility staff, including the Administrator and DON, revealed that the resident's family was not initially notified of the injury, as Resident #66 was considered his own responsible party. However, the family later insisted on hospital evaluation, where the laceration was treated. The facility's policy on investigating and reporting accidents was reviewed, indicating a need for thorough investigation and reporting of such incidents. This deficiency was part of a complaint investigation, highlighting a lapse in ensuring a hazard-free environment for residents.
Unsafe Maintenance of Floating Sink Leads to Resident Injury
Penalty
Summary
The facility failed to maintain a floating porcelain sink in a safe manner, resulting in an incident involving a resident. The resident, who had a history of moderate cognitive impairment and required assistance with transfers, sustained a significant laceration on the left knee when the sink fell from the wall while the resident was using the bathroom. The incident was reported by a CNA who noticed the resident bleeding upon returning from a smoking break. The resident was initially treated at the facility, but due to continued bleeding, the family insisted on hospital evaluation where the laceration was closed with 17 sutures. The resident's medical history included diagnoses such as toxic encephalopathy, schizophrenia, and muscle weakness, which may have contributed to the resident's vulnerability during the incident. The resident reported that the sink fell on him while washing hands, causing the injury. The facility's staff, including the Administrator and DON, were aware of the incident, and the bathroom was subsequently locked to prevent further access. The Maintenance Director confirmed that the sink was a floating type, which could tilt and fall if excessive weight was applied. Interviews with staff revealed that the resident was taken to smoke by an Activities Aide, who did not initially notice the injury. The aide observed red drops in the elevator but did not realize it was blood until later. The facility's response included notifying the physician and applying initial wound care, but the family was not satisfied with the facility's handling of the situation, leading to the resident's transfer to the hospital. The deficiency was investigated under a specific complaint number, indicating non-compliance with safety standards.
Failure to Notify Resident's Representative of Change in Condition
Penalty
Summary
The facility failed to notify a resident's representative when the resident experienced a change in condition due to a laceration that required sutures and continued wound care. The incident involved a resident with a history of toxic encephalopathy, schizophrenia, chronic viral hepatitis-C, and other conditions, who sustained a large laceration on the left shin and a small cut under the right eye after a bathroom sink broke and injured him. The incident report noted that the resident's physician was informed, but there was no documentation indicating that the resident's representative was notified. The deficiency was further highlighted when the resident's family, upon visiting the facility, observed the injury and called 911, leading to the resident's transport to the hospital. The hospital records confirmed that the resident required 17 sutures for a five-centimeter laceration on the left knee. The Director of Nursing confirmed that the family was not notified initially, as the resident was considered his own responsible party. The facility's policy mandates notifying the resident, physician, and representative of any changes in medical condition, which was not adhered to in this case.
Deficiency in Crash Cart Equipment on East Unit
Penalty
Summary
The facility failed to ensure that the East Unit crash cart was properly equipped with an assembled suction machine with a canister and a backboard, affecting 49 residents residing on that unit. During an observation, it was noted that the suction machine was present on the crash cart but lacked a collection canister, and there was no backboard available. The Emergency Crash Cart Checklist was found to be incomplete, with no documentation of checks for several dates, indicating that the crash cart had not been regularly inspected. Interviews with staff, including RN #56 and the Director of Nursing (DON), confirmed the absence of the necessary equipment on the crash cart and the lack of regular checks. RN #56 acknowledged that the collection canister was stored in the medication room rather than on the crash cart, and the DON was informed by an agency nurse about the missing backboard and the need to restock the crash cart. The facility's CPR policy, dated February 2018, mandates the maintenance of necessary equipment and supplies for CPR at all times, which was not adhered to in this instance.
Failure to Protect Resident from Sexual Abuse by Visitor
Penalty
Summary
The facility failed to protect a resident from sexual abuse by a visitor, resulting in actual harm. Resident #137, who had a medical history including cerebral infarction, schizoaffective disorder, and anxiety, was admitted to the facility and had intact cognition as per the Minimum Data Set (MDS) assessment. On the day of the incident, Resident #137 was outside in the smoking area when Family Member (FM) #16, a frequent visitor to another resident, inappropriately touched her breasts and private area and exposed his genitalia, despite her verbal refusals. This incident was captured on security footage, although without audio, and was reported to the police by the facility's Administrator. The police report detailed the sequence of events, including FM #16's admission to the police of his actions and Resident #137's account of the incident, which left her feeling traumatized. The report also noted that another male was present during part of the incident but was unable to provide a statement due to mental disabilities. Interviews with staff and other residents confirmed the occurrence of the incident, and the facility's Director of Nursing (DON) and Administrator took immediate action by involving the police, leading to FM #16's arrest. Despite the immediate response, the facility's failure to prevent the incident from occurring in the first place constitutes a deficiency. The facility's policy on abuse, neglect, and exploitation clearly states a zero-tolerance approach, yet the incident occurred, resulting in significant emotional harm to Resident #137. The deficiency was investigated under a specific complaint number, highlighting the facility's non-compliance with regulations designed to protect residents from abuse.
Dishwashing Machine Temperature Deficiency
Penalty
Summary
The facility failed to ensure that the high temperature dishwashing machine sanitized at the proper temperature, potentially affecting 85 of 88 residents who received food from the kitchen. The Dietary Director (DD) acknowledged that the dishwashing machine rinse temperature should be 180 degrees Fahrenheit but suspected the thermostat was broken. However, a Dietary Aide (DA) reported that the temperature reached 190 degrees Fahrenheit, indicating a misunderstanding of which thermostat to check. The Service Technician clarified that there were two thermostats, and the DA had been checking the incorrect one. An observation revealed that the final rinse temperature was only 120 degrees Fahrenheit, far below the required temperature for proper sanitation. The Service Technician noted that some dish racks were too small to engage the final rinse cycle. The Director of Nursing (DON) and the Administrator both stated that staff should routinely check the dishwashing machine's temperature and report any malfunctions. The facility's policy required staff to ensure proper functioning and temperatures of the dishwashing machine before meals, which was not adhered to in this instance.
Infection Control Deficiencies in LTC Facility
Penalty
Summary
The facility failed to establish and maintain an effective infection control program, as evidenced by the lack of implementation of Enhanced Barrier Precautions (EBP) for two residents and improper handling of dirty linens and respiratory equipment for another resident. Resident #139, who had a urinary catheter due to a neurogenic bladder, did not have EBP signage posted, and the registered nurse providing catheter care did not wear a gown, which is part of the EBP protocol. The staff's lack of awareness and training on EBP contributed to this deficiency. Resident #37, who was in a persistent vegetative state and required tracheostomy care, also did not receive care under EBP guidelines. The registered nurse providing tracheostomy care did not wear a gown, and both the nurse and a state-tested nursing assistant were unaware of the EBP requirements. The Assistant Director of Nursing, who was also the Infection Preventionist, mistakenly believed that EBP was voluntary, and no training had been conducted for the staff, leading to non-compliance with infection control protocols. For Resident #5, the facility failed to properly handle soiled linens and store respiratory equipment. The resident's BiPAP mask and nebulizer mask were left uncovered, and the BiPAP tubing was on the floor, which is against the facility's policy for storing respiratory supplies. Additionally, a nursing assistant placed soiled washcloths on the floor during incontinence care, contrary to the facility's policy that requires soiled linens to be bagged immediately. These actions indicate a lack of adherence to infection prevention protocols, further compromising the facility's infection control program.
Failure to Report Allegation of Sexual Abuse to State Agency
Penalty
Summary
The facility failed to report an allegation of sexual abuse involving a resident to the state agency, as required by their policy. The incident involved a resident with a medical history of cerebral infarction, schizoaffective disorder, and other conditions, who reported being inappropriately touched by a family member on the facility's smoking patio. The resident had intact cognition, as indicated by a BIMS score of 13. The police were notified, and the family member was arrested, but the facility did not report the incident to the state agency. Interviews with facility staff revealed that the Director of Nursing and the Administrator were aware of the incident and acknowledged it as an allegation of sexual abuse. However, they did not report it to the state agency due to instructions from their corporate office. The facility's policy, dated 2016, clearly stated that allegations of abuse should be reported to the state agency. This deficiency was investigated under a specific complaint number, indicating non-compliance with the reporting requirements.
Failure to Investigate Alleged Abuse
Penalty
Summary
The facility failed to thoroughly investigate an allegation of sexual abuse involving a resident, identified as Resident #137, who reported being inappropriately touched by a family member, FM #16. The incident occurred while the resident was outside smoking, and the police were called immediately after the resident reported the incident to the Director of Nursing (DON). The police report indicated that security camera footage captured the inappropriate actions of FM #16, but the facility did not have documented evidence of reviewing this footage or conducting a comprehensive investigation. Resident #137, who had a medical history including cerebral infarction, schizoaffective disorder, and hemiplegia, was admitted to the facility in 2022 and had intact cognition as per a recent assessment. Despite the serious nature of the allegation, the facility's investigation lacked documentation of interviews or statements from the resident, the accused, or any witnesses, including staff and other residents who may have been in contact with Resident #137 on the day of the incident. The facility also failed to document the analysis of evidence or make a determination regarding the substantiation of the abuse allegation. The facility's policy on abuse, neglect, and exploitation required a thorough investigation, including interviews and documentation, which was not followed in this case. The DON and Administrator acknowledged the lack of documentation and the absence of a saved video recording of the incident. The deficiency was identified during a survey, highlighting the facility's non-compliance with its own policies and procedures for handling abuse allegations.
Failure to Label Enteral Nutrition Formula
Penalty
Summary
The facility failed to ensure that a resident receiving enteral nutrition through a feeding tube had their formula labeled with the date and time the infusion began. This deficiency was identified for one resident who was in a persistent vegetative state and relied on tube feedings for more than half of their caloric intake. The resident's care plan and physician orders specified the use of Isosource 1.5 formula at a specific rate and duration, but observations revealed that the containers of formula were not labeled with the required information. During interviews, a registered nurse admitted to not labeling the formula container with the date and time, and the Director of Nursing and the Administrator confirmed the necessity of such labeling to prevent the formula from going bad. The facility's policy on enteral tube feeding also required documentation of the date and time on the formula label, which was not adhered to in this case.
Failure to Follow Planned Menu for Pureed Diet
Penalty
Summary
The facility failed to adhere to the planned menu for a resident on a pureed diet, resulting in a deficiency. Resident #54, who has a medical history of dementia, was admitted to the facility and had an active order for a regular diet with pureed texture. On a specific date, the resident was observed receiving only one #8 scoop of pureed Marzetti, which is half of the required serving size according to the facility's planned menu. This discrepancy was confirmed by Dietary staff who acknowledged the error in portion size. Interviews with the Registered Dietitian, Dietary Director, Director of Nursing, and the Administrator revealed that the staff were expected to follow the menus and serve the correct portion sizes. However, due to a recent change in the menu system, the Dietary Director had not been printing menus with portion sizes, although this information was available on residents' meal tickets. The failure to serve the correct portion size was acknowledged as potentially leading to weight loss and malnutrition, as stated by the facility's staff.
Failure to Obtain Ordered Laboratory Services
Penalty
Summary
The facility failed to obtain laboratory services ordered by the physician for a resident who was reviewed for urinary catheter/urinary tract infection. The resident, who had a history of multiple fractures and other medical conditions, was admitted with an indwelling urinary catheter. The resident's care plan included obtaining laboratory work as ordered and notifying the physician of any abnormal results. On a specific date, the resident's laboratory results showed abnormalities, and the physician ordered repeat tests to be conducted as soon as possible. However, there was no documented evidence that the blood specimen was obtained for the repeat laboratory testing. Interviews with staff revealed that the registered nurse did not recall whether the physician ordered new laboratory tests, and the Director of Nursing was unable to provide any laboratory results for the specified date. The physician, when interviewed, did not remember the laboratory tests due to the time elapsed but mentioned that the resident was declining rapidly and discussions about hospice care had occurred with the family. This deficiency was investigated under a specific complaint number.
Misappropriation of Resident Property by Staff
Penalty
Summary
The facility failed to ensure residents were free from misappropriation of property, affecting one resident. Resident #41, who had moderately impaired cognition and multiple medical conditions, had their debit card stolen and used by a former State tested Nursing Assistant (STNA) #254. The family of Resident #41 reported the missing debit card and provided bank statements showing unauthorized transactions. The facility's investigation and a police report confirmed that STNA #254 used the card for personal expenses, including a car payment and purchases from a local store. The facility's investigation revealed that STNA #254 admitted to using Resident #41's debit card, leading to their termination. The facility's policy on abuse, neglect, exploitation, and misappropriation of resident property, which includes stealing personal items, was reviewed. The Administrator and Director of Nursing confirmed the total charges made by STNA #254 amounted to approximately $1,600. This deficiency was investigated under Control Number OH00153530.
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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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