Otterbein Loveland
Inspection history, citations, penalties and survey trends for this long-term care facility in Loveland, Ohio.
- Location
- 6405 Small House Circle, Loveland, Ohio 45140
- CMS Provider Number
- 366445
- Inspections on file
- 20
- Latest survey
- March 26, 2026
- Citations (last 12 mo.)
- 20
Citation history
Health deficiencies cited at Otterbein Loveland during CMS and state inspections, most recent first.
Surveyors found that kitchen staff failed to maintain sanitary food storage and preparation conditions and did not ensure proper equipment and food temperatures for residents served from one house kitchen. Inspectors observed uncovered and undated food items in the refrigerator and freezer, dirty wash cloths stored next to food, and brown residue on the pantry freezer and cabinets holding cooking equipment and utensils. The dishwasher was operating below required wash and rinse temperatures, hot food (sausage) was held below the facility’s policy standard of 135°F, and a CNA cooked eggs and bacon on an electric skillet without wearing a hair net.
A resident who was cognitively intact and required supervision with ADLs was discharged, and an LPN mistakenly sent that resident’s representative home with another resident’s medications and written discharge instructions, which included detailed information on multiple prescribed drugs for serious conditions such as cerebral infarction, seizures, and sepsis. The error was discovered at shift change when the night nurse could not locate the second resident’s medications in the cart. The administrator and DON confirmed that the wrong medications and paperwork had been provided, and the discharging resident’s representative later reported to police that they had received another resident’s private health information, although none of the incorrect medications were taken.
A resident who was cognitively intact and required supervision with ADLs was discharged AMA at the request of a representative, and an LPN mistakenly sent home another resident’s medications and discharge instructions. The error was discovered at shift change when staff could not locate the other resident’s medications, and the discharged resident’s representative later reported the issue to police and returned the incorrect medications and paperwork. The Administrator and DON stated staff realized the error a few hours after discharge, and facility policy required a discharge planning process to ensure a safe transition that met the resident’s needs.
A resident admitted with a lumbar compression fracture and significant back pain had a PRN oxycodone order, but staff were unable to obtain the medication from the emergency supply machine due to repeated malfunctions. The nurse verified orders with the on-call provider, faxed prescriptions to the pharmacy, and administered Tylenol while the resident continued to report moderate to severe pain. Despite multiple attempts to access the emergency supply and arranging for pharmacy delivery, no oxycodone was administered, and the physician was not notified that the ordered pain medication was unavailable, contrary to facility policy requiring prescriber contact when controlled substances are delayed or not available.
A deficiency occurred when staff failed to follow enhanced barrier precautions (EBP) for a resident with an indwelling urinary catheter. The resident had severe cognitive impairment, required total assistance with ADLs, and had a care plan and MD orders specifying EBP due to the catheter. An EBP cart with PPE was available outside the room, but during observed catheter care a CNA did not don a gown, despite acknowledging that the resident was supposed to be on EBP. Facility policy required EBP for residents with urinary catheters for the duration of their stay.
The facility did not obtain food from approved or satisfactory sources and failed to store, prepare, distribute, and serve food according to professional standards.
The facility did not provide documentation that the Medical Director attended or participated in required quarterly QA committee meetings, as sign-in sheets lacked the Medical Director's signature and no alternative evidence was available. This failure to document participation affected all residents, as the QA committee did not meet the required membership per facility policy.
Multiple residents experienced unsanitary and uncomfortable living conditions, including stained carpets, soiled bathrooms, torn window blinds, and inadequate lighting. Several residents received cold showers due to water temperatures consistently below facility requirements, with maintenance delays in addressing the issue. Residents with significant care needs were affected, and cleaning was inconsistent, sometimes requiring family intervention.
Two residents were affected by lapses in infection control: a CNA handled soiled linens without gloves or a bag, allowing them to touch her body while transporting them, and an LPN failed to change gloves or sanitize hands between treating multiple wound sites on a resident's legs. Both actions were contrary to facility policy and were confirmed by staff interviews and policy review.
The facility did not provide scheduled activity programs or encourage participation for several residents with cognitive and physical impairments, despite documented care plans and preferences for engagement. Staff reported being too busy with other duties to conduct activities, and observations confirmed that residents were not invited or assisted to participate, resulting in a lack of meaningful engagement as required by facility policy.
The facility did not ensure that the Medical Director conducted required face-to-face visits with several residents, all of whom had complex medical conditions such as dementia, diabetes, and Alzheimer's disease, within the mandated 60-day interval. The Medical Director was unaware of this requirement, resulting in missed visits for these individuals.
A deficiency was cited due to the facility's failure to keep an area free from accident hazards and to provide adequate supervision to prevent accidents. The environment did not meet safety standards, and there was insufficient monitoring in the affected area.
A resident with multiple health conditions who was dependent on staff for toileting experienced a significant delay in receiving assistance after activating the call light, resulting in an incontinence episode. Staff interviews and observations confirmed that only one RN and one CNA were on duty at the time, and both acknowledged the facility was short staffed, leading to delayed care and resident distress.
A resident with multiple medical conditions was admitted with conflicting documentation regarding code status, including both full code and DNRCC orders. Neither the electronic health record nor the paper chart contained a signed advance directive, despite facility policy requiring such documentation. Staff interviews confirmed the absence of the required advance directive in the medical record.
A resident with multiple medical conditions reported to two CNAs that a staff member intentionally turned cold water on him during a shower. The CNAs attempted to inform their supervisor, but the allegation was not escalated to the Administrator as required by policy. The incident was only reported after being discovered by a surveyor, indicating a failure by staff and management to follow immediate reporting procedures for abuse allegations.
Two residents dependent on staff for toileting and hygiene did not receive timely or adequate incontinence care. One resident was not properly cleaned according to facility policy, with key steps omitted during perineal care. Another resident waited over an hour for assistance after an incontinence episode, despite staff being aware of the situation, resulting in prolonged exposure to soiled clothing and resident distress.
Failure to Maintain Sanitary Food Storage, Preparation, and Safe Temperatures in House Kitchen
Penalty
Summary
Surveyors identified a deficiency in food storage, preparation, and sanitation practices in House Five’s kitchen affecting 21 residents who received food from that kitchen. Observation of the refrigerator showed an undated and uncovered pitcher of pink liquid and a piece of cardboard from a drink box used to hold the water dispenser shut. The freezer contained two undated medical ice packs, two undated gallon bags of ice with ice crystals, and an undated, open loaf of gluten-free bread exposed to air. In the pantry, a bucket full of dirty wash cloths was stored next to a shelf holding potatoes, and the pantry freezer and multiple cabinets and drawers (including those containing a crock pot, skillet, mixing bowl, cutting board, and measuring cups) had a brown substance on them. The dietary technician present confirmed these observations. Further observations showed the House Five kitchen dishwasher was operating below required sanitizing temperatures, with a wash temperature of 148°F and a rinse temperature of 175°F, which the dietary technician acknowledged were below the expected 160°F wash and 180°F rinse. During meal service, a CNA measured sausage being held at 127.6°F, below the facility’s policy requirement that hot foods be maintained at 135°F or higher, and confirmed this temperature. On another observation of meal preparation, a CNA was cooking eggs and bacon on an electric skillet without wearing a hair net, despite having her hair in a ponytail, and confirmed she was not wearing a hair net. These conditions collectively demonstrated failure to store and prepare food in a sanitary manner, to ensure proper dishwasher temperatures, and to maintain hot foods at safe holding temperatures for residents served from House Five’s kitchen.
Privacy Breach When Wrong Discharge Medications and Instructions Given to Another Resident
Penalty
Summary
The facility failed to ensure the privacy and confidentiality of a resident's health information when discharge medications and paperwork for one resident were mistakenly given to another resident's representative. Resident #70, who was cognitively intact and required supervision with ADLs, was discharged on 09/30/25. At discharge, LPN #142 accidentally provided Resident #70's representative with Resident #71's medications and written discharge instructions instead of Resident #70's. Resident #71 had been admitted with diagnoses including cerebral infarction, seizures, and sepsis and had active physician orders for multiple medications, including Norvasc, aspirin, Biotin, Cozaar, folic acid, Keppra, Lipitor, methotrexate, metoprolol, polyethylene glycol, prednisolone eye drops, sennoside, and Synthroid. The error was not identified by facility staff until shift change, when the night shift nurse was unable to locate Resident #71's medications in the medication cart. The Administrator and DON reported that nursing staff realized the wrong medications and discharge instructions had been given to Resident #70 approximately two to three hours after the resident left the facility. Resident #70's representative later reported the incident to the police and confirmed that the facility had sent home another resident's medications and discharge instructions, and that none of those medications had been taken. Both the Administrator and Resident #70's representative confirmed that private health information for Resident #71 had been disclosed to Resident #70 and her representative, contrary to the facility's HIPAA policy, which states that the facility will protect the privacy and confidentiality of residents' individually identifiable health information.
Failure to Ensure Safe and Orderly Resident Discharge
Penalty
Summary
The facility failed to provide a safe and orderly discharge for a cognitively intact resident who required supervision with ADLs and had diagnoses including COVID-19, depression, and macular degeneration. The resident was admitted on 09/10/25 and discharged on 09/30/25, leaving against medical advice at the request of the resident’s representative. At discharge, an LPN mistakenly provided the resident’s representative with another resident’s medications and written discharge instructions. The error was not identified until shift change when the night shift nurse could not locate the other resident’s medications in the medication cart. The other resident, admitted on 09/17/25 with diagnoses including cerebral infarction, seizures, and sepsis and with multiple active medication orders, remained in the facility. The resident’s representative discovered that the medications and discharge instructions belonged to a different resident and reported concerns about the resident’s care to the police the following day. The representative informed the police that the facility had acknowledged the error when she called and had asked her to return the medications and discharge instructions so they could be exchanged for the correct ones. A police officer accompanied the representative back to the facility, where the exchange occurred without issue, and the representative confirmed that none of the incorrect medications had been administered to the resident. The Administrator and DON reported that nursing staff realized the error approximately two to three hours after the resident left the facility. Review of the facility’s Discharge/Transfer policy showed that the facility was required to develop and implement a discharge planning process involving the resident or representative and the interdisciplinary team to ensure the resident’s needs were identified and there was a safe transition to a location that met the resident’s needs.
Failure to Ensure Availability of Prescribed Pain Medication and Notify Prescriber of Delay
Penalty
Summary
The deficiency involves the facility’s failure to ensure prescribed pain medication was available for administration to a resident with significant back pain. The resident was admitted with osteoporosis and a wedge compression fracture of the first lumbar vertebra and reported lower back pain rated as six out of ten shortly after admission. A baseline care plan documented that the resident was alert and oriented with short-term memory problems, required supervision for mobility and toileting, and was independent with eating. A physician’s order was in place for oxycodone 5 mg by mouth every four hours as needed for moderate pain, and one to two 5 mg tablets every four hours as needed for moderate to severe pain, for up to twenty doses in total. On the evening of admission, the nurse verified admission medication orders with the on-call provider and faxed the medication list and prescriptions, including oxycodone, to the pharmacy. The Medication Administration Record showed that the resident received Tylenol 600 mg for a pain level of six out of ten, but no oxycodone or other pain medications were documented as administered. Pain assessments documented pain levels of six out of ten at 8:30 p.m. and 9:55 p.m., and seven out of ten at 11:24 p.m. The nurse contacted the pharmacy at 9:20 p.m. to verify receipt of the oxycodone prescription and was given a code to obtain two 5 mg oxycodone tablets from the facility’s emergency supply machine. When the nurse attempted to retrieve the oxycodone from the emergency supply machine with a second nurse, the drawer malfunctioned and would not open despite multiple attempts. The nurse called the pharmacy again to report the problem and was advised to contact the DON or the machine’s support number. The nurse notified the ADON and DON and continued unsuccessful attempts to access the medication, then requested immediate delivery of oxycodone, which the pharmacy indicated would arrive in the early morning hours. The resident was informed of the situation and offered Tylenol while continuing to report pain at a level of seven out of ten. The Administrator and DON later confirmed that the nurses did not notify the resident’s physician that the oxycodone was not available, despite a facility policy stating the prescriber would be contacted when delivery of a controlled substance would be delayed or the medication would not be available.
Failure to Follow Enhanced Barrier Precautions During Catheter Care
Penalty
Summary
Surveyors identified a deficiency in the facility’s infection prevention and control program related to the use of enhanced barrier precautions (EBP) for a resident with an indwelling urinary catheter. The resident, admitted with diagnoses including right hip fracture, dementia, insomnia, and anxiety disorder, had a Minimum Data Set assessment indicating severe cognitive impairment and dependence on staff for ADLs. The resident’s care plan documented the presence of an indwelling catheter for skin breakdown and urinary retention, with an intervention specifying that staff were to maintain EBP due to the catheter, and physician orders also directed that the resident be on EBP. During observation, an EBP cart stocked with PPE was present outside the resident’s room, but when a CNA provided catheter care, the CNA did not don a gown as required. In a subsequent interview, the CNA confirmed awareness that the resident was supposed to be on EBP and acknowledged not wearing a gown while providing care. Review of the facility’s Isolation Precautions Process policy showed that EBP was to be used for residents with urinary catheters during their entire stay, which was not followed in this instance.
Failure to Follow Food Procurement and Safety Standards
Penalty
Summary
The facility failed to procure food from sources that are approved or considered satisfactory and did not store, prepare, distribute, and serve food in accordance with professional standards. This deficiency was identified during the survey process, indicating that the facility did not meet regulatory requirements for food safety and handling. No additional details about specific residents, staff, or events are provided in the report.
Lack of Documented Medical Director Participation in QA Committee Meetings
Penalty
Summary
The facility failed to provide evidence that the Medical Director attended and participated in the required quarterly Quality Assurance (QA) committee meetings. Review of the QA meeting sign-in sheets for four consecutive quarters showed that the Medical Director did not sign the attendance paperwork. During staff interview, the Administrator confirmed that the Medical Director was required to attend and participate in each quarterly QA meeting, and acknowledged that there was no documentation, aside from a statement that the Medical Director attended by telephone, to verify participation. The facility's policy specifies that the QA committee must include the Medical Director, Administrator, Infection Preventionist, Director of Nursing, and at least two other care partners. This deficiency had the potential to affect all 58 residents in the facility, as the required committee composition and participation were not documented as required.
Failure to Maintain Safe, Clean, and Homelike Environment for Residents
Penalty
Summary
The facility failed to provide a safe, clean, comfortable, and homelike environment for its residents, as evidenced by multiple observations and interviews. Several resident rooms were found with heavily stained carpets, soiled toilets, dirty bathroom floors, torn window blinds, and black substances around window frames and walls. In one instance, a resident's pillow had a dried substance that appeared to be blood, and food debris was scattered throughout the carpet. Residents and staff confirmed that cleaning was inconsistent, with some families resorting to cleaning the bathrooms themselves due to ongoing issues such as toilets not flushing properly and persistent soiling. Additionally, lighting issues were identified, with bathroom lights so dim they were nearly out, as confirmed by the maintenance supervisor. Water temperature logs revealed that hot water in several residents' rooms consistently failed to meet the facility's minimum requirement of 108 degrees Fahrenheit, with recorded temperatures ranging from 77 to 104 degrees Fahrenheit over several months. Residents reported receiving cold showers despite staff efforts to let the water run, and the maintenance director acknowledged delays in obtaining repairs and not implementing immediate interventions when water temperatures were below the required threshold. Medical records reviewed for affected residents indicated significant care needs, including cognitive impairment, dependence on staff for medication administration, assistance with activities of daily living, and various medical diagnoses such as congestive heart failure, pressure ulcers, hemiplegia, and seizure disorders. The facility's own policy states that residents have the right to a clean and safe environment, which was not upheld in these instances.
Infection Control Deficiencies in Linen Handling and Wound Care
Penalty
Summary
The facility failed to ensure proper infection prevention and control practices in two separate instances involving two residents. In the first case, a certified nurse aide was observed exiting a resident's room carrying uncovered soiled linens with ungloved hands, allowing the linens to touch her body as she transported them through the hallway to the laundry room. The aide confirmed she did not use gloves or a bag for the linens, stating there were no bags available. Facility policy requires staff to wear gloves, minimize handling, and keep soiled linens covered and away from the body when transporting them. In the second instance, a licensed practical nurse performed wound care on a resident with multiple skin tears on both legs but did not change gloves or sanitize hands between treating the different wound sites. The nurse acknowledged this lapse and stated she should have changed gloves and sanitized hands between each wound treatment. The facility's hand hygiene policy specifies that hand hygiene should occur after contact with wound dressings. Both incidents were verified through staff interviews and policy review.
Failure to Provide Scheduled Activities and Resident Engagement
Penalty
Summary
The facility failed to provide activity programs that support the physical, mental, and psychosocial well-being of residents, as required. Observations, medical record reviews, and interviews revealed that scheduled activities such as morning reminiscing, pottery, morning stretches, and one-on-one visits were not conducted as listed on the activity calendars across multiple houses. Staff interviews confirmed that activities were not held because CNAs were occupied with other duties, such as working in the kitchen, and residents were not encouraged or invited to participate in activities. Several residents with severe cognitive impairments and multiple medical diagnoses, including dementia, diabetes, Parkinson's disease, and depression, were affected. Their care plans indicated a need for encouragement, reminders, and motivation to participate in activities, with preferences for group and individual engagement such as watching television, crafts, BINGO, and socializing. Despite these documented needs and preferences, observations showed that residents were often left in their rooms or sitting idle, with no staff engagement or activity facilitation. Staff interviews further confirmed that activities were inconsistently provided, and residents were not routinely invited or encouraged to join. The facility's policy emphasized the importance of meaningful engagement and staff accountability for activity documentation, but this was not reflected in practice. As a result, the facility did not meet the requirement to provide activities that promote independence and community interaction for all residents reviewed.
Failure to Ensure Timely Physician Visits
Penalty
Summary
The facility failed to ensure that the Medical Director conducted face-to-face visits with residents at least once every 60 days, as required. Medical record reviews and staff interviews revealed that four residents, each with significant medical diagnoses such as pneumonia meningitis, ulcerative colitis, viral hepatitis, non-traumatic brain dysfunction, dementia, diabetes, cancer, coronary artery disease, Alzheimer's disease, renal insufficiency, and psychotic disorder, had not been seen by the Medical Director within the mandated timeframe. The last documented visit for these residents was on the same date, and subsequent review confirmed that no follow-up visits occurred within 60 days. During an interview, the Administrator acknowledged that the Medical Director was unaware of the requirement to see residents every 60 days.
Failure to Maintain Accident-Free Environment and Adequate Supervision
Penalty
Summary
A deficiency was identified in the facility's failure to ensure that an area was free from accident hazards and that adequate supervision was provided to prevent accidents. The report notes that the environment did not meet safety standards, which could contribute to the risk of accidents for residents. Specific actions or inactions leading to this deficiency include the lack of proper hazard identification and insufficient monitoring or supervision in the affected area. No additional details about individual residents, their medical history, or their condition at the time of the deficiency are provided in the report.
Inadequate Staffing Leads to Delayed Incontinence Care
Penalty
Summary
The facility failed to provide adequate nursing staff to meet the needs of all residents, resulting in delayed care for a resident who was dependent on staff for toileting and transfers. The resident, who had multiple diagnoses including type 2 diabetes mellitus, severe sepsis, cellulitis, rheumatoid arthritis, and atrial fibrillation, was frequently incontinent of bladder and bowel and required substantial assistance with daily activities. On the day in question, the resident activated the call light and waited over an hour for assistance. Although a nurse and a nurse aide entered the room after approximately 30 minutes, the resident had already experienced an incontinence episode and expressed frustration and embarrassment about the situation, noting concerns about her sensitive skin. Staff interviews confirmed that only one RN and one CNA were on duty at the time, and both acknowledged the facility was short staffed. The CNA reported being aware of the resident's accident but stated she needed to prioritize preparing breakfast for other residents before providing assistance. Another CNA confirmed being called in later due to staffing shortages. These observations and interviews demonstrate that the facility did not have sufficient nursing staff on duty to provide timely care and services, directly impacting the resident's dignity and comfort.
Failure to Document Resident Advance Directive and Code Status
Penalty
Summary
The facility failed to obtain and maintain written documentation of a resident's code status and advance directive in the medical record. Upon admission, the resident was noted to have multiple diagnoses, including type two diabetes mellitus, severe sepsis, cellulitis, rheumatoid arthritis, and atrial fibrillation. The admission summary indicated the resident was alert and listed as a full code, while a physician order documented a Do Not Resuscitate Comfort Care (DNRCC) status. However, a subsequent physician progress note again listed the resident as a full code. Review of both the electronic health record (EHR) and the hard copy medical record revealed no copy of an advance directive, although the hard chart was labeled with DNRCC on the outside and the EHR banner also indicated DNRCC. Interviews with facility staff confirmed that there was no signed advance directive in either the paper chart or the EHR for the DNRCC code status. The Quality of Life Coordinator stated that code status was discussed during care conferences, but could not provide documentation of a signed directive. The Administrator confirmed that the resident was admitted with a DNRCC code status according to received records, but later discussions with the resident and family revealed a preference for full code status. The facility's policy required obtaining and placing copies of all advance directives in the medical record, but this was not done for the resident in question.
Failure to Timely Report Alleged Resident Abuse
Penalty
Summary
A deficiency occurred when the facility failed to timely report an allegation of abuse involving a resident with diagnoses including hemiplegia, cerebral infarction, right hip fracture history, seizure disorder, and hypertension. The resident, who had intact cognition and required moderate staff assistance, reported to two CNAs that a staff member had intentionally turned cold water on him during a shower as a form of mistreatment. The CNAs, after being informed of the allegation, attempted to communicate the incident to their supervisor, the Coach Manager (CM), but the CM did not follow up or report the allegation to the Administrator as required by facility policy. The incident was not reported to the Administrator until it was brought to attention by a surveyor during the annual survey, despite multiple opportunities for staff and the CM to escalate the allegation. Interviews confirmed that neither the CNAs nor the CM reported the abuse allegation to the Administrator or other management in a timely manner, contrary to the facility's policy that mandates immediate reporting of all abuse allegations. The Administrator verified that she was unaware of the incident until the surveyor's inquiry and emphasized that immediate reporting to her or a supervisor is required.
Failure to Provide Timely and Adequate Incontinence Care
Penalty
Summary
The facility failed to provide timely and adequate incontinence care for two residents who were dependent on staff for toileting and personal hygiene. For one resident with a history of impaired mobility, pneumonia meningitis, ulcerative colitis, and viral hepatitis, observation revealed that a CNA did not follow proper perineal care procedures. The CNA did not retract the foreskin or adequately clean and dry the scrotal area during incontinence care, despite the resident being saturated with urine and having feces present. The CNA admitted to rushing the care due to being late, and this was inconsistent with the facility's policy, which outlines specific steps for thorough cleaning and drying to prevent infection. Another resident, who was frequently incontinent of bowel and bladder and dependent on staff for toileting, reported waiting over an hour for assistance after activating the call light. Staff interviews confirmed that both a nurse and a CNA were aware of the resident's need for toileting assistance but prioritized other tasks, resulting in the resident remaining in soiled clothing for an extended period. The resident expressed frustration and embarrassment about the incident, noting concerns about sensitive skin. These findings demonstrate that the facility did not ensure prompt and adequate incontinence care as required.
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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