Otterbein Monclova
Inspection history, citations, penalties and survey trends for this long-term care facility in Monclova, Ohio.
- Location
- 5069 Otterbein Way, Monclova, Ohio 43542
- CMS Provider Number
- 366361
- Inspections on file
- 35
- Latest survey
- December 11, 2025
- Citations (last 12 mo.)
- 4
Citation history
Health deficiencies cited at Otterbein Monclova during CMS and state inspections, most recent first.
A MaxiSky ceiling lift with a broken safety latch was used to transfer a resident who required maximum assistance for all activities of daily living. Two CNAs were aware of the broken latch but proceeded with the transfer. Manufacturer instructions required all safety features to be intact and inspected before each use, and the manufacturer's representative confirmed the latch was a critical safety feature.
A resident with ESRD and other chronic conditions did not receive a physician-ordered dose of Xphozah (tenapanor) on multiple occasions because the medication was not available in the facility. This resulted in a significant medication error, as confirmed by medical record review and staff interview.
A resident with significant medical conditions developed new pressure ulcers that were not promptly assessed, measured, or described by staff. Despite existing orders for skin protection, documentation lacked timely wound evaluation, and the physician was not notified when new sores appeared. The facility did not follow its policy for prompt identification and management of skin complications.
Staff did not follow enhanced barrier precautions during wound care for a resident with a surgical wound, as both the DON and an LPN wore only gloves instead of the required gloves and gowns. The LPN also failed to change gloves or perform hand hygiene after touching potentially contaminated surfaces before handling clean wound dressings, contrary to facility policy.
The facility failed to maintain an effective QAPI program, resulting in repeated deficiencies in pressure ulcer management. A resident with multiple medical conditions was not repositioned as required, and another resident's dressing changes were neglected after refusal, leading to drainage and bleeding. These issues highlight the facility's ongoing failure to adhere to care plans and policies.
The facility did not follow the approved menu, affecting 12 residents. CNAs served meals that did not match the planned menu, providing available items like fish filets and sandwiches instead of the scheduled cheeseburger meal. The previous week's menu was posted, and no current menu was available. The Dietetic Technician confirmed the lack of adherence to the menu and portion sizes.
The facility failed to maintain proper sanitation and food storage practices across multiple kitchens. Observations revealed dirty ovens, improperly stored food items, and dented cans, with issues confirmed by staff. The facility's food storage policy was not adhered to, posing potential risks to residents.
A resident with intact cognition and specific bathing preferences did not receive showers on preferred days due to the unavailability of a shower chair. The facility's documentation practices were inadequate, as the type of bathing was not recorded in the electronic medical record, and there was no policy regarding resident choices. Staff interviews revealed inconsistencies in documentation and a lack of clarity on honoring the resident's preferences.
A facility failed to notify a resident's representative of a transfer to the emergency room, despite the resident's request for the transfer due to increased pain. The resident had diagnoses including acute kidney failure and hypertensive heart disease. The DON confirmed the resident was his own responsible party and had not been in contact with his family, but there was no documentation of the resident's request not to contact them. The facility's policy required notification of the resident's representative, which was not followed.
A facility failed to implement a nursing plan of care for a resident dependent on staff for ADLs, specifically grooming. The resident, with severe cognitive impairment and limited mobility, was observed with long, jagged fingernails and debris, indicating neglect in grooming. CNAs confirmed the resident's dependence and were unaware of recent grooming care. The DON verified the absence of a documented care plan addressing these needs.
The facility failed to provide adequate grooming assistance for two residents. One resident with severe cognitive impairment was observed with long, dirty fingernails, while another resident with intact cognition was seen in soiled clothing, with heavy beard growth and unkempt hair. Staff confirmed the residents' dependency on assistance for daily activities and were unaware of recent grooming efforts.
A resident with severe cognitive impairment and limited range of motion did not have a right hand splint applied as ordered by the physician. Observations showed the resident without the splint, and staff interviews revealed a lack of awareness about the splint order and application schedule. The electronic care card also lacked instructions for the splint, leading to inconsistent application and potential impact on the resident's care.
A resident with impaired cognition and multiple health conditions was left with medications unattended at their bedside, contrary to facility policy. An LPN admitted to leaving the medications and forgetting to return to ensure they were ingested, affecting the resident and potentially impacting others with similar impairments.
A facility failed to ensure an appropriate diagnosis for the continued use of an indwelling urinary catheter and did not secure the catheter tubing for a resident. The resident, with multiple diagnoses including urinary tract infection and chronic kidney disease, had intact cognition and was dependent on toileting hygiene. Despite the physician's recommendation to remove the catheter, the resident refused due to concerns about incontinence and skin breakdown. Observations confirmed the catheter tubing was not secured, contrary to the facility's guidelines.
The facility failed to monitor psychotropic medications for two residents, leading to a deficiency in medication management. One resident with major depressive disorder and anxiety was not monitored for side effects and effectiveness of medications like bupropion and fluvoxamine. Another resident with Alzheimer's and depressive disorder was not monitored for medications like Seroquel and sertraline. The DON confirmed the absence of monitoring orders, violating the facility's psychotropic medication management policy.
A facility failed to maintain infection control standards for a resident with an indwelling urinary catheter. The resident's catheter drainage bag was found on the floor, contrary to the facility's guidelines. Additionally, two CNAs provided catheter care without wearing gowns, violating the facility's enhanced barrier precautions policy.
The facility failed to provide adequate care for pressure ulcers for two residents. One resident was not repositioned as required, despite having a stage four sacral ulcer, and there was no documentation of refusal. Another resident refused a dressing change, and the facility did not document attempts to re-approach or notify the physician. Observations showed unchanged dressings with drainage and bleeding. The facility did not adhere to its skin care management policy, leading to non-compliance.
The facility failed to provide a sanitary and comfortable environment for two residents. A resident's room had a missing windowsill, damaged paint, and debris on the floor, while another resident's restroom was unkept with towels and debris on the floor. These conditions were verified by staff during observations.
The facility failed to store food safely and sanitarily, affecting all 57 residents. Observations revealed multiple instances of improper food storage, including undated and expired items, moldy food, and unlabeled containers across several houses. Staff interviews confirmed these findings, and the facility's policy required proper labeling and dating of food items.
The facility failed to maintain a clean and sanitary environment in several houses, with observations of collapsed cabinets, discolored drywall, and musty odors. The Maintenance Director confirmed these issues, indicating previous moisture exposure and inadequate maintenance.
Failure to Maintain Ceiling Lift in Safe Working Condition
Penalty
Summary
The facility failed to ensure that a MaxiSky Lift, a ceiling-mounted lift used for transferring and repositioning residents, was maintained in safe working condition prior to use. During incontinence care for a resident with multiple complex medical conditions, including hemiplegia, heart failure, and diabetes, it was observed that the safety latch on the MaxiSky Lift was broken on one side. Both CNAs providing care were aware of the broken latch but were unsure how long it had been in that condition. The resident required substantial to maximum assistance or was dependent in all functional abilities, according to the most recent assessment. Review of the manufacturer's instructions for the MaxiSky Lift indicated that all safety features, including end stoppers and safety latches, must be intact and inspected before every use. The instructions specifically stated not to use the lift if any damage or missing parts were identified. Despite this, the lift was used to transfer the resident while the safety latch was broken, as confirmed by staff interviews and direct observation. The manufacturer's representative confirmed that the safety latch is a secondary safety feature designed to prevent patient falls during transfers.
Failure to Administer Physician-Ordered Medication Due to Unavailability
Penalty
Summary
The facility failed to ensure that a resident received medications as ordered by the physician, resulting in a significant medication error. Specifically, a resident with multiple diagnoses, including end stage renal disease (ESRD), chronic kidney disease (CKD), and type two diabetes mellitus, had a physician order for Xphozah (tenapanor) 30 mg to be administered orally once daily for ESRD. Review of the medication administration records (MAR) for November and December revealed that the ordered medication was not administered on several specified dates. Interviews and record reviews confirmed that the medication was not given because it was not available in the facility on those dates. The facility's policy requires medications to be administered in accordance with written physician orders, but this was not followed in this instance. The deficiency was identified during a complaint investigation and affected one resident out of three reviewed for medication administration, with a facility census of 54.
Failure to Timely Assess and Treat Newly Identified Pressure Ulcers
Penalty
Summary
The facility failed to ensure that newly identified wounds for a resident were promptly assessed, measured, and treated according to policy. Medical record review showed that a resident with multiple diagnoses, including spastic diplegic cerebral palsy, chronic kidney disease, and chronic respiratory failure, was at risk for pressure ulcers and had a care plan in place for impaired skin integrity. On several occasions, documentation indicated the presence of open sores on the resident's buttocks, but there was no evidence of wound assessment, measurement, or detailed description in the records. Orders for barrier cream were present, but the wounds were not properly evaluated or described until a wound physician assessment was completed nearly two weeks after the initial identification of the sore. Staff interviews confirmed that wound measurements and descriptions were not completed when new wounds were found, and the physician was not notified in a timely manner. Facility policy required prompt identification and management of skin complications, but this was not followed. The deficiency was identified through medical record review, staff interviews, and policy review, and affected one resident out of three reviewed for pressure ulcers.
Failure to Adhere to Enhanced Barrier Precautions and Hand Hygiene During Wound Care
Penalty
Summary
Staff failed to follow appropriate infection prevention and control measures during wound care for a resident with a surgical wound and an active order for enhanced barrier precautions (EBPs). Specifically, during an observed wound care procedure, the Director of Nursing and an LPN wore only gloves, omitting the required gowns as specified by the resident's physician order and facility policy. The signage at the resident's door indicated the need for EBPs, including gloves and gowns, but this was not adhered to during the procedure. Additionally, the LPN was observed touching various potentially contaminated surfaces, such as tray tables, bed sheets, and the bed itself, with gloved hands and then using the same gloves to handle clean wound dressing materials without performing hand hygiene or changing gloves. This failure to maintain proper hand hygiene and use of personal protective equipment was confirmed by both the DON and the LPN during interviews, and it was inconsistent with the facility's written policy on isolation precautions and EBPs for residents with wounds.
Repeated Deficiencies in Pressure Ulcer Management
Penalty
Summary
The facility failed to maintain an effective quality assurance and performance improvement (QAPI) program, as evidenced by repeated deficiencies related to pressure ulcer management over four consecutive comprehensive surveys. The CMS Provider History Profile document indicated that the facility had been cited for not providing adequate services or treatments to prevent or heal pressure ulcers in previous surveys and complaint investigations. This ongoing issue had the potential to affect all 54 residents in the facility. Resident #8, who was admitted with multiple complex medical conditions including a stage four sacral pressure ulcer, was observed multiple times over several days lying on her back without being repositioned by staff. Despite a care plan intervention requiring repositioning every two hours, observations and interviews revealed that staff did not consistently adhere to this protocol. The resident's Braden Scale assessment indicated a moderate risk for developing pressure ulcers, yet there was no documentation of refusal to be repositioned, highlighting a lack of adherence to the care plan and facility policy. Resident #11, who also had multiple medical conditions and was at risk for pressure ulcers, had a care plan that included specific interventions for skin impairment. However, after refusing a dressing change due to anxiety and pain, there was no documentation of attempts to re-approach the resident or notify the physician. Observations revealed that the resident's dressings were not changed for several days, resulting in drainage and fresh bleeding upon removal. This lack of documentation and follow-up on the resident's care plan further exemplifies the facility's failure to effectively manage pressure ulcer care and adhere to its own policies.
Failure to Follow Approved Menu
Penalty
Summary
The facility failed to ensure that the approved menu was followed, affecting 12 residents in home number 85. During an observation, CNAs were found serving meals that did not match the facility's menu for the day. The CNAs admitted to serving items that were available in the kitchen, such as fish filets, tater tots, potato salad, strawberries, turkey cold cut sandwiches, and peanut butter and jelly sandwiches, instead of the planned cheeseburger meal with specific sides. The previous week's menu was posted, and no current menu was available. The Dietetic Technician confirmed that the home was not following a menu or dietitian-calculated portion sizes, impacting the nutritional needs of the residents.
Sanitation and Food Storage Deficiencies
Penalty
Summary
The facility failed to adhere to proper sanitation and food storage practices, as observed in multiple kitchens. In house 5069, the built-in oven was found dirty with grime and dirt, and food items such as butter, cooked bacon, and scrambled eggs were left on the counter without proper temperature control. Additionally, open and undated packages of Egg-O waffles and a bag of French fries were found in the freezer, which also had a non-functioning thermometer. A can of apple pie filling was dented, and a foul odor was detected from the dishwasher. These findings were confirmed by a CNA present during the observation. In house 5076, similar issues were noted, including dirty storage areas, a dirty refrigerator floor, and grime-covered ovens. The cabinet door faces throughout the kitchen were also dirty, as verified by an LPN. In house 5090, the bottom of the refrigerator and freezer were dirty, and the kitchen storage room floor had paper and food debris. Dented cans of beets and enchilada sauce were found, and the ovens were again noted to be dirty. These observations were confirmed by a CNA. The facility's policy on food storage, dated 10/01/09, mandates proper storage, labeling, and dating of food to prevent foodborne illness, which was not followed in these instances.
Failure to Honor Resident Bathing Preferences
Penalty
Summary
The facility failed to honor the bathing preferences of a resident, identified as Resident #32, who had intact cognition and was dependent on staff for bathing. The resident preferred showers on specific days, but the facility did not provide showers on the preferred days of 01/08/25, 01/18/25, 01/29/25, 03/08/25, and 03/15/25. The resident did not refuse showers on these dates, and the failure to provide showers was attributed to the unavailability of a shower chair. The facility's documentation practices were inadequate, as the type of bathing provided was not recorded in the electronic medical record, and paper shower sheets used for documentation were not part of the medical record. Interviews with staff, including CNAs and the Director of Nursing, revealed inconsistencies in documentation practices and a lack of clarity on whether the resident's bathing preferences were honored. The Administrator confirmed that there was no policy regarding resident choices, although resident rights were followed. The facility's failure to document the type of bathing provided and the lack of a clear policy on resident choices contributed to the deficiency in honoring the resident's bathing preferences.
Failure to Notify Resident's Representative of Hospital Transfer
Penalty
Summary
The facility failed to notify a resident's representative of a change in condition, specifically a transfer to the emergency room, affecting one resident. The resident, who had diagnoses including acute kidney failure, atrial fibrillation, and hypertensive heart disease, requested to be transferred to the emergency room due to increased pain. Despite the resident's request, there was no documentation that the resident's power of attorney or family member was notified of this transfer. The Director of Nursing confirmed that the resident was his own responsible party and had not been in contact with his family member for a couple of years. However, there was no documentation indicating that the resident had requested not to contact his family member. The facility's policy required notification of the resident's representative in such situations, but this was not adhered to in this case.
Failure to Implement Nursing Plan for Resident's Grooming Needs
Penalty
Summary
The facility failed to implement a nursing plan of care to address a resident's need for assistance with activities of daily living (ADL), specifically grooming. This deficiency affected a resident who was admitted with diagnoses including cerebral infarction, type 2 diabetes mellitus, expressive language disorder, gastrostomy, and hypertension. The resident was assessed with severe cognitive impairment, limited range of motion on one side, and was dependent on staff for ADLs. Observations noted the resident had long, jagged fingernails with black/brown debris, indicating a lack of grooming care. Interviews with two Certified Nurse Aides confirmed the resident's dependence on staff for hygiene and their unawareness of when the resident's fingernails were last trimmed. The Director of Nursing verified that a nursing plan of care addressing the resident's ADL dependence was not developed or documented in the medical record.
Deficiency in Grooming Assistance for Residents
Penalty
Summary
The facility failed to provide adequate assistance with activities of daily living, specifically grooming, for two residents. Resident #53, who has severe cognitive impairment and is dependent on staff for daily activities, was observed on multiple occasions with long, jagged fingernails and black/brown debris underneath. Certified Nurse Aides confirmed the resident's dependency for hygiene and were unaware of when the resident's fingernails were last trimmed. Resident #11, who is also dependent on staff for daily activities and has intact cognition, was observed wearing the same soiled shirt with food debris, heavy beard growth, unkempt and matted hair, and long fingernails. The resident expressed a preference for being clean-shaven but did not want a straight razor used. An LPN verified the lack of grooming, including bathing, shaving, and clean clothing for this resident.
Failure to Apply Splint as Ordered for Resident
Penalty
Summary
The facility failed to ensure that devices to prevent contractures were applied in accordance with physician orders for a resident with severe cognitive impairment and limited range of motion. The resident, who was admitted with diagnoses including cerebral infarction and type 2 diabetes mellitus, had a physician order for a right hand splint to be applied during the day and removed at bedtime. However, the medical record lacked documentation confirming the application of the splint as ordered. Observations over two days noted the resident without the splint during various times, and interviews with CNAs and an LPN revealed that staff were unaware of the splint order or its application schedule. The electronic care card also lacked evidence of the splint or instructions for its use. This deficiency affected the resident's care, as the splint was not consistently applied according to the physician's directive, potentially impacting the resident's range of motion maintenance.
Medications Left Unattended at Bedside
Penalty
Summary
The facility failed to ensure medications were secured and not left at the bedside, affecting one resident and potentially impacting two others identified as cognitively impaired and independently mobile. The incident involved a resident with a history of dysphagia following cerebrovascular disease, heart failure, chronic respiratory failure, chronic kidney disease, and dementia. The resident required substantial assistance with eating and had no orders to self-administer medications. Despite this, medications mixed in pudding were left unattended on the resident's bedside table by a nurse from the previous shift. Interviews revealed that the night nurse left the medications and did not return to ensure they were ingested. An LPN confirmed that the medications were left by the previous shift nurse and admitted to forgetting to return and check if the resident took the medication. The facility's policy on medication administration, which requires observation to ensure the dose is completely ingested, was not followed, leading to this deficiency.
Failure to Ensure Appropriate Catheter Use and Securing
Penalty
Summary
The facility failed to ensure an appropriate diagnosis for the continued use of an indwelling urinary catheter and did not secure the catheter tubing for a resident. The resident, who was admitted with diagnoses including acute and chronic respiratory failure, depressive disorder, urinary tract infection, anxiety, chronic kidney disease stage three, and chronic obstructive pulmonary disease, had intact cognition and was dependent on toileting hygiene. The resident was occasionally incontinent of bowel and bladder and had an indwelling urinary catheter without a supporting diagnosis for its use. The physician orders did not include instructions for securing the catheter tubing, and the care plan lacked guidelines for securing the catheter. During an interview, the resident expressed a preference for keeping the catheter due to concerns about incontinence and skin breakdown. Observations confirmed that the catheter tubing was not secured, and this was verified by two CNAs. The Director of Nursing revealed that the resident had been diagnosed with urinary retention from the hospital, and although the physician recommended removing the catheter, the resident refused. The facility's skills checklist for catheter care and management indicated that the catheter should be secured properly, which was not adhered to in this case.
Failure to Monitor Psychotropic Medications
Penalty
Summary
The facility failed to ensure proper monitoring of psychotropic medications for two residents, leading to a deficiency in medication management. Resident #48, who had diagnoses including major depressive disorder and anxiety, was prescribed multiple psychotropic medications such as bupropion, fluvoxamine, buspirone, and escitalopram. Despite the care plan's requirement to monitor for side effects and effectiveness, there was no documentation of such monitoring in the medication administration record (MAR) from February 18 to March 25. The Director of Nursing (DON) confirmed the absence of orders for monitoring these medications. Similarly, Resident #161, with diagnoses including Alzheimer's disease, dementia, and depressive disorder, was prescribed medications like Seroquel, hydroxyzine, trazodone, and sertraline. The care plan required monitoring for side effects, effectiveness, and behavior interventions, but the MAR from March 10 to March 25 showed no documentation of such monitoring. The DON verified the lack of orders for monitoring targeted behaviors and medication effects. Additionally, the facility's policy on psychotropic medication management was not adhered to, as it requires adequate monitoring and indication for use.
Infection Control Deficiency in Catheter Care
Penalty
Summary
The facility failed to ensure proper infection control standards for a resident with an indwelling urinary catheter. The resident, who had diagnoses including acute and chronic respiratory failure, depressive disorder, urinary tract infection, anxiety, chronic kidney disease stage three, and chronic obstructive pulmonary disease, was observed with a catheter drainage bag lying on the floor beneath their recliner chair. This was confirmed by an LPN, indicating a failure to adhere to the facility's skills checklist, which requires the drainage bag to be below the level of the bladder but off the floor. Additionally, the facility did not follow its policy on enhanced barrier precautions (EBP) for residents with indwelling medical devices. During catheter care, two CNAs were observed wearing only gloves without gowns, despite the facility's policy requiring both gloves and gowns during high-contact resident care. This was verified through interviews with the CNAs, highlighting a lapse in adherence to infection control protocols designed to protect both residents and staff.
Failure to Provide Adequate Pressure Ulcer Care
Penalty
Summary
The facility failed to ensure proper interventions were in place to promote the healing of pressure ulcers for two residents. Resident #8, who has multiple health conditions including a stage four sacral pressure ulcer, was observed consistently lying on her back without being repositioned by staff, despite her care plan indicating the need for repositioning every two hours. Interviews with the resident and staff revealed that the resident was not being turned and repositioned as required, and there was no documentation of the resident refusing such care. Resident #11, who also has multiple health conditions and two stage four pressure ulcers, refused a dressing change due to anxiety and pain. The medical record lacked documentation of any attempts to re-approach the resident for the dressing change or notification to the physician about the refusal. Observations revealed that the dressings on Resident #11's back had not been changed for several days, resulting in drainage and bleeding when the dressing was finally removed. The facility's policy on skin care management requires staff to be alert to changes in skin condition and to document any identified changes. However, the facility failed to adhere to these protocols, as evidenced by the lack of documentation and failure to follow through with necessary interventions for both residents. This deficiency was investigated under a specific complaint number, indicating non-compliance with established care standards.
Facility Fails to Maintain Sanitary and Comfortable Environment
Penalty
Summary
The facility failed to maintain a sanitary and comfortable environment for its residents, as evidenced by the conditions observed in the rooms of two residents. Resident #33, who is cognitively intact with a BIMS score of 15, was found to have a room with a missing windowsill, allowing wind to enter, damaged door trim, damaged paint, and an unidentified brown substance on the doorframe and waste receptacle. Additionally, debris such as hair, food crumbs, and trash was observed on the floor throughout the room. These findings were verified by an LPN during the observation. Resident #212, with a BIMS score of 12 indicating moderate cognitive impairment, was found to have a restroom with damaged paint, two cups, and a towel on the floor, a towel on a shower chair, and generalized debris on the floor. The resident confirmed that the towels had been left since the previous night's shower. A CNA verified these observations. This deficiency was investigated under Complaint Number OH00162138.
Improper Food Storage and Labeling
Penalty
Summary
The facility failed to ensure food was stored in a safe and sanitary manner, potentially affecting all 57 residents. Observations across multiple houses revealed numerous instances of improper food storage. In House #4, a refrigerator contained opened and undated cartons of soup and a bag of food without a label or date, along with paper towels with a pinkish/red tint underneath the bottom drawer. In House #2, a refrigerator had an opened and undated container of macaroni salad with a puffed-up lid, a container of cream cheese with mold, and expired milk. Additionally, a dried pink substance, possibly dried blood, was found in the bottom drawer. Similar issues were observed in House #5, where a refrigerator contained undated and expired items, including apple juice and lunch meat, and a dried pink substance in the bottom drawer. Further observations in House #1 revealed a sipper cup with an off-white liquid, believed to be a nutrition supplement, that was unlabeled and undated. The refrigerator also contained undated and opened containers of soup and potato salad. In House #3, a refrigerator contained undated chicken broth and apple juice, along with liquid at the bottom of the drawer. The pantry had an open tub of flour, a scoop inside a container of oatmeal, and an open bag of hamburger buns. Interviews with staff confirmed these findings, and the facility's policy required food items to be labeled and dated, with leftovers discarded after four days. This deficiency was investigated under Complaint Number OH00160297.
Facility Fails to Maintain Sanitary Environment in Multiple Houses
Penalty
Summary
The facility failed to maintain a clean and sanitary environment, as observed in multiple houses within the nursing home. In House #1, a kitchen cabinet under the sink was found with a collapsed floor and separated veneer, exposing drywall with a black and dark brown substance across its width. The Maintenance Director (MD) confirmed the presence of a musty odor and believed the cabinet's base collapsed due to excessive weight. The cabinet contained two plungers and a bottle of dish soap. In House #4, the cabinet under the kitchen sink revealed drywall with a light brown substance and pinpoint-sized spots of white, black, and gray. The MD peeled the brown substance, revealing discolored and peeling drywall beneath. Similar conditions were observed in House #3, where the drywall showed light brown discoloration with gray and black spots, indicating previous moisture exposure. In House #2, the cabinet under the sink had drywall with light brown discoloration and gray and black spots, along with pieces of drywall at the back of the cabinet. These observations were confirmed by the MD, indicating a failure to maintain a sanitary environment.
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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