Otterbein New Albany
Inspection history, citations, penalties and survey trends for this long-term care facility in New Albany, Ohio.
- Location
- 6690 Liberation Way, New Albany, Ohio 43054
- CMS Provider Number
- 366424
- Inspections on file
- 22
- Latest survey
- May 15, 2025
- Citations (last 12 mo.)
- 0
Citation history
Health deficiencies cited at Otterbein New Albany during CMS and state inspections, most recent first.
Two residents suffered significant injuries due to improper transfer assistance and failure to follow safety protocols. One resident, dependent on staff for transfers, was injured when a sit-to-stand lift was used incorrectly by a single CNA, resulting in bruising, hematoma, fractured ribs, and anemia. Another resident, requiring assistance for ambulation, was helped to the bathroom without a gait belt, leading to a fall and a dislocated shoulder. Facility policies requiring gait belt use and proper lift operation were not followed in these incidents.
CNAs did not consistently wash their hands between glove changes or after donning hair nets while preparing and serving food. This lapse in infection control was observed during food handling and distribution, and both CNAs confirmed the lack of proper hand hygiene during interviews. The issue had the potential to affect all residents in the affected unit.
A resident with multiple chronic conditions, including CHF, did not have weekly weights obtained as ordered by the physician. Medical records showed inconsistent documentation of weights, and the DON confirmed that weekly weights were not performed according to orders, despite facility policy requiring them.
The facility failed to follow prescribed menus and recipes, leading to inconsistent meal portions and substitutions that did not meet residents' nutritional needs. Observations revealed that STNAs prepared meals without measuring utensils or following recipes, resulting in omitted or substituted food items. A resident with severe cognitive deficits was served a meal that did not adhere to the prescribed soft and bite-sized diet, highlighting the facility's failure to meet dietary requirements.
The facility failed to store food safely and sanitarily, with observations revealing food debris, improper temperatures, and expired items in multiple houses. STNAs confirmed the issues and were unable to locate temperature logs.
The facility failed to develop comprehensive care plans for residents, leading to deficiencies in addressing medical needs. A resident with a forearm wound had no care plan for it, another with bowel incontinence and TED hose use lacked relevant care plans, and a third on diuretics had no plan for potential fluid imbalance. Additionally, a resident with a stage four pressure ulcer had a delayed care plan update. These issues were confirmed by staff interviews.
The facility failed to manage and document respiratory care properly for several residents, including those with COPD and acute respiratory failure. Observations revealed undated oxygen tubing and improperly stored respiratory equipment, contradicting facility records. Residents were unaware of tubing change schedules, and a regional nurse confirmed these deficiencies.
The facility failed to maintain infection control during a dressing change, did not implement enhanced barrier precautions (EBP) for residents with specific medical needs, and improperly placed a urinary catheter bag. An LPN did not wash hands between glove changes and used uncleaned scissors during a dressing change. EBP signage and PPE were missing for residents requiring precautions, and a catheter bag was unsanitarily placed on a trash can.
A resident with significant medical conditions requiring assistance with eating was observed being fed by an STNA who was standing, despite the resident's request for the aide to sit. This action was contrary to the facility's dining standards, which emphasize a relaxed dining experience with residents seated in dining room chairs unless otherwise care-planned.
A resident with quadriplegia and moderately impaired cognition was not provided with a functional call light system, forcing her to yell for assistance. Staff interviews revealed confusion and delays in addressing the issue, with an order for a suitable device only confirmed after surveyor inquiry.
A resident with dementia and other medical conditions was not provided a table knife during meals, despite expressing difficulty using a spoon and fork. Staff interviews revealed that residents in the unit were generally not offered table knives due to dementia, although two residents, including this one, should have been exceptions.
A facility failed to assist a resident with Alzheimer's in managing their personal funds, resulting in an account balance exceeding Medicaid limits. The resident's account was non-transferable, and notification letters were unsigned and unacknowledged. The Business Office Manager confirmed the lack of a plan to address the excess funds.
The facility failed to maintain a safe and homelike environment for two residents. One resident's room had missing paint and a window frame with sharp splinters, while another's room had a missing wood trim exposing sharp drywall edges. Despite staff awareness, maintenance requests were not addressed, indicating a communication breakdown.
A resident with dementia and a history of falls was frequently seated in a wheelchair with foot pedals in place, pushed under a counter or table, restricting movement and constituting a physical restraint. Despite the facility's policy for a restraint-free environment, this practice was confirmed by staff interviews and observed over several days, highlighting a deficiency in adhering to the restraint policy.
A facility failed to update the PASARR evaluation for a resident with a new diagnosis of anxiety disorder. The resident, with multiple complex medical conditions and a moderate cognitive deficit, did not receive a timely PASARR update following the diagnosis. This delay was confirmed by a Regional Nurse during an interview.
The facility failed to assess and provide activities that matched the preferences of its residents, leading to a deficiency in meaningful engagement. A resident with quadriplegia was left watching TV despite expressing interest in music and trivia. Another resident with dementia lacked personalized activity engagement, and a third resident with chronic pain had not received an updated activity assessment, resulting in her staying in her room due to disinterest in available activities.
The facility failed to provide adequate wound care and edema prevention for three residents. A resident with severe cognitive impairment did not receive ordered treatment for a skin tear, and another resident with severe cognitive deficits had a forearm wound not properly documented or treated. Additionally, a resident with moderate cognitive deficits did not have TED hose applied as ordered for DVT prevention, despite records indicating otherwise.
A resident with quadriplegia and diabetes had a stage four pressure ulcer and an unstageable ulcer that were not properly assessed or treated by the facility. The facility failed to conduct timely skin assessments and missed multiple wound care treatments, as confirmed by the resident and the wound nurse. The facility's policy required specific documentation for wound care, which was not consistently followed, leading to inadequate monitoring and treatment of the resident's pressure ulcers.
A resident with a history of falls and multiple health issues fell in her doorway without wearing non-skid footwear, which she had removed herself. Despite being at high risk for falls, the facility did not implement an intervention to address the lack of non-skid footwear or the resident's removal of fall prevention measures, as confirmed by the Regional Nurse.
A facility failed to assess and manage a resident's bowel and bladder incontinence, leading to a decline in their condition. Additionally, two residents with indwelling catheters did not receive appropriate and timely catheter care, as evidenced by missed catheter patency checks, output monitoring, and catheter care. The deficiencies were confirmed by interviews with the Director of Nursing and Regional Nurse.
Two residents in an LTC facility experienced significant weight loss due to the facility's failure to monitor and address their nutritional needs. One resident, with multiple medical conditions, did not receive double meat portions as ordered, and weekly weights were not consistently recorded. Another resident, with severe cognitive impairment, was not offered prescribed Ensure supplements, leading to an eight-pound weight loss. The facility did not follow its policy for re-weighing residents with significant weight changes.
The facility failed to timely address pharmacy recommendations for two residents. One resident on Remeron did not have a GDR reviewed for nearly three months, while another resident's insulin adjustment was delayed for over two months. Interviews confirmed the untimely response to these recommendations.
The facility failed to monitor medication regimens for two residents, leading to deficiencies in care. A resident with diabetes was not monitored for blood sugar levels as required, and another resident with hypertension did not have blood pressure assessed before medication administration. These oversights were confirmed by a regional nurse.
Two residents experienced significant medication errors. One resident received blood pressure medications outside prescribed parameters, while another missed scheduled doses of Percocet for pain management. These errors were confirmed through medical record reviews and staff interviews.
The facility failed to secure and store medications properly, affecting two residents. One resident had multiple opened medications on the bedside table without proper labeling, while another had an unauthorized Hydrocortisone cream brought in by a family member. An LPN confirmed these deficiencies and removed the medications for secure storage.
The facility failed to timely obtain laboratory values for two residents, impacting their care. A resident with severe cognitive impairment and multiple diagnoses had STAT labs delayed due to the lab's inability to send a phlebotomist. Another resident with moderate cognitive deficit and various health issues experienced a delay in a STAT urinalysis. The facility's policy requires timely lab services as ordered, which was not followed.
The facility failed to report lab results promptly for two residents, leading to deficiencies in care. One resident's STAT lab results were delayed by three days due to being left on the printer, while another resident's lab results were delayed due to a lack of phlebotomist availability and were not communicated to the physician until four days later.
A resident reported that the green beans served in the facility always tasted awful, resembling canned beans. An observation confirmed that the green beans were rubbery and flavorless. An STNA acknowledged warming the beans from a can and only adding salt, as not everyone liked pepper.
The facility failed to provide food in a form designed to meet the needs of two residents on a soft and bite-sized diet. Despite having physician orders for such a diet, they were served inappropriate items like crackers. The facility's policy, based on the IDDSI, was not followed by the STNA, who served the same meal to all residents without necessary texture modifications.
The facility failed to maintain accurate medical records for two residents. A resident's fall was not documented in their medical record, and there were discrepancies between the MAR and nurse aides' documentation regarding another resident's supplement intake. The DON confirmed the aides' records should be accurate, while the Dietitian believed the MAR should be the sole source of truth.
The facility failed to properly assess and prescribe antibiotics for UTIs in residents. A resident with an indwelling catheter was on prophylactic Bactrim without ongoing evaluation. Another resident received Bactrim despite resistance shown in UA/C&S results, leading to hospitalization. A third resident was also given Bactrim without considering C&S results. The facility's UTI care policy was not followed.
The facility failed to provide the required 12 hours of annual in-service training for STNAs, affecting two employees. One STNA received only one hour and 45 minutes of training, while another did not complete the required training for the year. The facility used a computerized system to assign and track training, but it was the employees' responsibility to complete it. This deficiency potentially affected all 52 residents.
Failure to Provide Safe Transfer Assistance and Proper Use of Equipment Resulting in Resident Injuries
Penalty
Summary
The facility failed to ensure residents received appropriate assistance with transfers and proper use of transfer equipment, resulting in actual physical harm to two residents. In one instance, a resident with multiple complex medical conditions, including multiple sclerosis, morbid obesity, and an above-knee amputation, was dependent on staff for all transfers. During a transfer to bed using a sit-to-stand lift, the sling was not applied correctly, and only one CNA was present to operate the lift. The resident subsequently developed significant bruising, a hematoma, fractured ribs, and anemia from blood loss, requiring hospitalization and a blood transfusion. In another case, a resident with diagnoses including heart failure, diabetes, and chronic kidney disease required staff assistance for transfers and ambulation. A CNA assisted the resident to the bathroom without using a gait belt, as required by facility policy. When the resident began to fall, the CNA attempted to support the resident by holding her under the arms and laying her down, resulting in a dislocated shoulder. The resident was found on the floor, unresponsive to commands, and was transferred to the hospital, where a shoulder dislocation was diagnosed and surgical intervention was recommended but declined by the resident and family. Both incidents were confirmed through record review, interviews, and facility investigations. The facility's own policies required the use of gait belts during transfers and ambulation, and proper use of mechanical lifts, but these protocols were not followed in the cases reviewed, directly leading to significant injuries for the residents involved.
Failure to Follow Hand Hygiene During Food Preparation and Service
Penalty
Summary
Certified Nurse Aides (CNAs) failed to follow proper infection control procedures during food preparation and service. Observations revealed that one CNA washed her hands, put on a hair net and gloves, then handled food items such as baked beans and hot dogs, but repeatedly changed gloves without washing her hands in between glove changes. She also put on a hair net and gloves without handwashing, handled food, and then removed her gloves and hair net before leaving the area without washing her hands. Another CNA washed her hands, put on a hair net and gloves, distributed silverware and napkins to residents, then changed gloves and prepared drinks, again without washing hands between glove changes. Both CNAs confirmed in interviews that they did not wash their hands between glove changes or after putting on hair nets. These actions had the potential to affect all 12 residents in the specified house, with a total facility census of 56.
Failure to Obtain Weekly Weights as Ordered for Resident with CHF
Penalty
Summary
The facility failed to follow physician orders for obtaining weekly weights for a resident with multiple complex medical conditions, including congestive heart failure. The physician's order specified that the resident's weight should be checked weekly and that the physician should be notified if there was a weight gain of five pounds in one week. However, medical record review showed that weights were not consistently documented on a weekly basis, with significant gaps between recorded weights. The resident involved had diagnoses such as multiple sclerosis, diabetes, atrial fibrillation, morbid obesity, chronic kidney disease, and lymphedema, and was dependent on staff for several activities of daily living. Despite facility policy requiring weekly weights when ordered, the documentation revealed that this was not done as directed. The DON confirmed during interview that weekly weights had not been obtained according to the physician's orders.
Failure to Follow Prescribed Menus and Recipes
Penalty
Summary
The facility failed to adhere to the prescribed menus and recipes for resident meals, which were intended to meet the nutritional needs of the residents. On August 13, 2024, an observation in House #400 revealed that a State Tested Nurse Aide (STNA) was preparing tuna salad without using any measuring utensils, resulting in inconsistent portion sizes. The STNA also substituted mixed berries for mixed vegetables and crackers for croissants due to ordering errors. Additionally, the residents did not receive the dessert as planned, and the STNA admitted to not following a recipe for the tuna salad, instead relying on memory or online sources. On August 14, 2024, in House #300, residents were served a meal that did not include milk or cheese, as specified in the menu. An STNA confirmed that cheese was omitted from the meal and that milk was only provided at breakfast. Furthermore, a review of the menus from August 2 to August 19, 2024, showed multiple instances where food items were omitted from the soft and bite-sized diet without appropriate substitutions, contrary to the facility's policy and the International Dysphagia Diet Standardization Initiative (IDDSI) guidelines. The report also highlights the case of a resident with severe cognitive deficits and multiple health conditions, who was on a soft and bite-sized diet. On August 19, 2024, the resident was served a meal that did not follow the prescribed menu, lacking appropriate soft food replacements for certain items. The STNA responsible for preparing the meal confirmed that they did not adhere to the menu and provided what was available, further illustrating the facility's failure to meet the dietary needs of its residents.
Food Storage and Sanitation Deficiencies
Penalty
Summary
The facility failed to store food in a safe and sanitary manner, as observed in multiple houses within the facility. In House #300, food debris was found in both the pantry and kitchen refrigerators, with the pantry refrigerator feeling warm and its sensor reading 72 degrees Fahrenheit. The internal temperatures were recorded at 54 degrees Fahrenheit for the refrigerator and 24 degrees Fahrenheit for the freezer, with food items such as milk, eggs, cheese, and various frozen foods starting to soften. The State tested Nurse Aide (STNA) #126 was unable to locate a filled temperature log for House #300 and had not checked the temperatures that morning, indicating uncertainty about how long the refrigerator had been malfunctioning. In addition to temperature issues, expired foods were found in several houses. House #200 had expired thousand island dressing, mozzarella cheese, hot dog buns, and sour cream. House #100 contained expired chip dip, coleslaw, carrots, and hamburger buns, along with food debris and what appeared to be hair in the pantry refrigerator and freezer. House #500 had expired wheat bread, coleslaw, burrito tortillas, flour tortillas, sandwich sauce, provolone cheese, and an open, undated, and hardened container of Swiss cheese. House #400 had expired bread, caramel topping, and ham, with a large liquid stain and other food debris in the pantry refrigerator. Interviews with various STNAs confirmed the presence of expired foods and the lack of temperature documentation, with some STNAs unable to find the temperature logs for the respective houses.
Failure to Develop Comprehensive Care Plans
Penalty
Summary
The facility failed to develop comprehensive care plans for several residents, leading to deficiencies in addressing their medical needs. Resident #13, who had multiple diagnoses including severe cognitive deficit and incontinence, had a wound on the right forearm that was not included in the care plan. Despite having a physician's order for wound care, the care plan lacked any mention of this condition, as confirmed by the Director of Nursing during an interview. Resident #42, diagnosed with conditions such as Parkinson's disease and dementia, was frequently incontinent of both bowel and bladder. The care plan did not address the resident's bowel incontinence or the use of thrombo-embolic deterrent (TED) hose, which was ordered for deep vein thrombosis prevention. This omission was verified by the Director of Nursing, indicating a lack of comprehensive planning for the resident's needs. Resident #26, with a history of cerebral infarction and diabetes, was prescribed Lasix for edema related to hypertension. However, there was no care plan addressing the potential fluid imbalance due to diuretic use. Similarly, Resident #35, who developed a stage four pressure ulcer, did not have an updated care plan for the ulcer until nearly a month after its identification. These lapses in care planning were confirmed through interviews with facility staff, highlighting a failure to adhere to the facility's comprehensive care planning policy.
Deficiencies in Respiratory Care Management
Penalty
Summary
The facility failed to properly manage and document the respiratory care of several residents, leading to deficiencies in the care provided. Resident #154, who has chronic obstructive pulmonary disease (COPD) and chronic respiratory failure, was observed receiving oxygen therapy without a date on the oxygen tubing, indicating it had not been changed as per the physician's order. The resident was unaware of when the tubing was last changed, and the treatment administration record showed the tubing was marked as changed on a specific date, but there was no evidence of this during the observation. Similarly, Resident #155, who has acute respiratory failure and pleural effusion, was found with oxygen tubing that was not dated, despite orders to change and date the tubing weekly. The resident, who had been at the facility for a short time, was also unaware of the tubing change schedule. The facility's records indicated the tubing was changed on a specific date, but this was not verified during the observation. Additionally, Resident #13, who has COPD and severe cognitive deficits, was observed with oxygen tubing dated from a month prior, and the nebulizer delivery system was not stored in a protective cover. The facility's records showed the tubing was marked as changed on specific dates, but the observation contradicted this. Resident #42, who uses a CPAP machine for sleep apnea, had the CPAP mask stored without a protective covering, which was confirmed by a regional nurse. These observations highlight the facility's failure to adhere to physician orders and maintain sanitary conditions for respiratory equipment.
Infection Control and EBP Failures in LTC Facility
Penalty
Summary
The facility failed to maintain proper infection control practices during a dressing change for a resident with multiple diagnoses, including Down syndrome and a stage four pressure injury. An LPN conducted the dressing change without washing hands between glove changes and used uncleaned bandage scissors to cut dressing foam. The LPN also failed to clean the scissors before returning them to the medication cart, which was confirmed during an interview. The facility did not implement enhanced barrier precautions (EBP) for several residents with various medical conditions, including cancer, respiratory failure, and the need for PICC lines. Observations revealed a lack of signage and personal protective equipment (PPE) outside the rooms of these residents, which was confirmed by a regional nurse. This affected multiple residents who had orders for EBP, but the necessary precautions were not in place. Additionally, the facility failed to maintain sanitary placement of a urinary catheter bag for a resident with severe cognitive impairment and an indwelling catheter. The catheter bag was observed hanging from a trash can, which was confirmed by staff interviews. This practice was not addressed appropriately, as the staff was unsure of alternative placement options for the catheter bag when the resident was in a recliner.
Failure to Provide Dignified Dining Experience
Penalty
Summary
The facility failed to provide a dignified dining experience for a resident, which was identified during an observation. The resident, who was admitted with diagnoses including cerebral infarction, arteriovenous malformation of cerebral vessels, and chronic motor or vocal tic disorder, required substantial to maximal assistance with eating. During an observation, a State tested Nurse Aide (STNA) was seen standing while feeding the resident breakfast in bed. The STNA confirmed that she was standing and acknowledged that the resident had previously requested her to sit while feeding him. The facility's policy for dining standards, which was reviewed, indicated that meals should be a time for quiet, relaxed dining and conversation, with each elder sitting in a dining room chair unless otherwise specified in the care plan.
Failure to Provide Call Light for Quadriplegic Resident
Penalty
Summary
The facility failed to provide a means for a resident with quadriplegia to contact staff, which is a deficiency in accommodating the needs and preferences of residents. The resident, who also had moderately impaired cognition, was unable to use a standard call light due to her condition and had to resort to yelling for assistance. This issue was observed during a survey, where the resident was seen calling out for help, and staff confirmed that she did not have a functional call light system. Interviews with staff revealed a lack of clarity and action regarding the provision of an appropriate call light system for the resident. A maintenance staff member was unsure of the status of obtaining a suitable device, and a regional nurse believed an order had been placed, but it was only confirmed after surveyor inquiry. The delay in ordering a call cord pad further highlighted the facility's failure to promptly address the resident's needs.
Failure to Provide Dining Utensils of Choice
Penalty
Summary
The facility failed to honor the resident's right to self-determination by not providing a table knife to Resident #21, despite her expressed difficulty in using a spoon and fork to cut her food. Resident #21, who has a moderate cognitive deficit and multiple medical conditions including dementia and diabetes, was observed multiple times without a table knife during meals. There was no care plan, physician order, or progress note indicating that Resident #21 should not have a table knife. Interviews with staff revealed that residents in House 100, where Resident #21 resides, are generally not offered table knives due to their dementia diagnoses. However, it was noted that only two residents, including Resident #21, should receive table knives with meals. Despite this, Resident #21 was consistently not provided with a table knife, which hindered her ability to eat comfortably and independently.
Failure to Manage Resident Personal Funds
Penalty
Summary
The facility failed to assist residents in managing their personal funds accounts, specifically when the balance approached the Medicaid allowable limit. This deficiency was identified during a review of resident funds accounts, medical records, and staff interviews. One resident, diagnosed with Alzheimer's disease and having dual payer sources of Medicaid and commercial insurance, was affected by this oversight. The resident's account balance significantly exceeded the Medicaid allowable limit of $2,000, reaching $11,582.10, without any plan in place to spend down the excess funds. The facility's documentation revealed that the resident's account was marked as non-transferable, with no automatic transfer of deposits to cover care costs. Notification letters regarding the resident's fund balance were not signed by a facility representative or acknowledged by the resident, and there were no receipts of delivery available for review. An interview with the Business Office Manager confirmed the lack of a plan to address the excess funds and the absence of delivery receipts for the notification letters, highlighting the facility's failure to manage the resident's personal funds in compliance with Medicaid requirements.
Failure to Maintain Safe and Homelike Environment
Penalty
Summary
The facility failed to maintain a safe and homelike environment for its residents, as evidenced by the conditions in the rooms of two residents. Resident #36, who has multiple diagnoses including autistic disorder and heart failure, was observed to have a room with significant environmental hazards. The room had paint chips missing from the wall and a window frame with chipped wood, exposing sharp splinters. Despite staff acknowledging the issue, the Maintenance Director had not received any work orders to address these hazards, indicating a breakdown in communication and maintenance processes. Similarly, Resident #31, who has dementia and a history of falls, was found to have a room with a missing wood trim from the window frame, exposing drywall with sharp edges. This condition was noted in the maintenance request logs, but the issue remained unresolved. The exposed sharp edges and drywall were within reach of the resident's bed, posing a potential risk. The Regional President of Clinical confirmed the hazardous conditions, highlighting the facility's failure to address maintenance requests in a timely manner.
Failure to Ensure Resident Freedom from Physical Restraints
Penalty
Summary
The facility failed to ensure that residents were free from physical restraints, as evidenced by the case of a resident with dementia, anxiety, osteoarthritis, major depressive disorder, and a history of falls. This resident required assistance for transfers and activities of daily living and used a wheelchair for mobility. The resident had severely impaired cognition, as indicated by a Brief Interview of Mental Status (BIMS) score of zero out of 15. The resident had experienced falls in the past, and interventions included therapy evaluations and increased supervision. Observations revealed that the resident was frequently seated in a wheelchair with foot pedals in place, pushed up under the counter or dining room table, with the wheelchair brakes not engaged. This positioning was intended for close supervision by staff due to the resident's history of falls. However, it effectively restricted the resident's ability to stand or self-propel the wheelchair, which constitutes a form of physical restraint. Staff interviews confirmed that the resident was seated in this manner to prevent falls when attempting to ambulate independently. The facility's policy aimed to achieve a restraint-free environment, yet the practice of positioning the resident in a way that restricted movement contradicted this goal. The resident's inability to move freely while seated in the wheelchair, combined with the lack of engagement of the wheelchair brakes, demonstrated a failure to adhere to the facility's restraint policy. This deficiency was identified through observations, medical record reviews, staff interviews, and policy reviews.
Failure to Update PASARR Evaluation for Resident with New Anxiety Disorder Diagnosis
Penalty
Summary
The facility failed to ensure that Pre-admission Screening and Resident Review (PASARR) evaluations were updated in a timely manner for a resident with a new diagnosis of anxiety disorder. The resident, who had a range of complex medical conditions including bipolar disorder, dementia with anxiety, and alcohol-induced dementia, was admitted with a moderate cognitive deficit. Despite the addition of an anxiety disorder diagnosis, the facility did not complete a significant change PASARR evaluation until several months later. This oversight was confirmed during an interview with the Regional Nurse, who acknowledged the delay in updating the PASARR evaluation.
Failure to Meet Residents' Activity Preferences
Penalty
Summary
The facility failed to adequately assess and address the activity preferences of its residents, leading to a deficiency in meeting their needs for meaningful engagement. Resident #103, who has multiple diagnoses including quadriplegia and moderately impaired cognition, was not provided with activities that matched her interests as outlined in her activity screening. Despite expressing a desire to participate in activities involving music and trivia, she was primarily left to watch television, with no evidence of participation in other activities listed on the facility's calendar. Resident #42, diagnosed with major depressive disorder and vascular dementia, also experienced a lack of personalized activity engagement. His care plan indicated a preference for being in common areas and participating in activities, yet his activity assessment lacked details on specific interests. Observations showed that he was often left without activities, and the facility's activity tracker did not reflect a variety of engagements that matched his preferences. Resident #6, with intact cognition and a history of chronic pain, had not received an updated activity assessment in over a year. Her care plan noted a need for encouragement to participate in activities, but she reported a lack of interest in the available options, leading her to stay in her room. The facility's failure to complete her annual assessment and provide activities aligned with her interests contributed to the deficiency. The facility's policy emphasized the importance of meaningful engagement, yet the observations and interviews revealed inconsistencies in its implementation.
Failure to Provide Adequate Wound Care and Edema Prevention
Penalty
Summary
The facility failed to adequately assess and provide treatments for non-pressure skin injuries and did not administer treatment as ordered to prevent edema, affecting three residents. Resident #102, with severe cognitive impairment and multiple diagnoses, sustained a skin tear on her left shin. Despite a physician's order for daily treatment, the treatment was not completed on several occasions, and no additional measurements of the skin tear were documented. The wound nurse confirmed the lack of documentation and treatment. Resident #13, also with severe cognitive deficits and multiple health issues, had a wound on the right forearm that was not addressed in the care plan. Although there was a physician's order for daily dressing, there was no documentation of the wound's type, cause, or assessment. Observations revealed inconsistencies in the dressing's presence, and the DON confirmed the lack of documentation and adherence to the physician's order. Resident #42, with moderate cognitive deficits and various diagnoses, had an order for TED hose to prevent DVT. However, observations showed the resident without TED hose on multiple occasions, despite the treatment administration record indicating otherwise. An RN verified the absence of TED hose and confirmed the resident's room lacked them.
Failure to Timely Assess and Treat Pressure Ulcers
Penalty
Summary
The facility failed to ensure timely assessment and monitoring of pressure ulcers and did not administer treatments as ordered for a resident with significant medical conditions, including quadriplegia and diabetes. The resident had a stage four pressure ulcer on the coccyx and an unstageable ulcer on the right thigh, which were not properly documented or measured upon admission. The facility's policy required a full skin assessment within two to six hours of arrival, but this was not completed for the resident. Throughout the resident's stay, there were multiple instances where wound care was not documented or performed as ordered. The medical record showed gaps in wound measurements and descriptions from 07/19/24 to 08/12/24, and the medication administration record indicated missed wound care on several occasions. The resident expressed concerns about the care received, noting that wound care was often missed, and the facility's wound nurse confirmed the lack of measurements and treatments. The facility's policy outlined specific documentation requirements for wound care, including the date observed, location, staging, size, depth, and other wound characteristics. However, these requirements were not consistently met, leading to inadequate monitoring and treatment of the resident's pressure ulcers. The wound physician's notes indicated that the ulcers had been present for extended periods, and the lack of timely assessments and treatments contributed to the deficiency identified by the surveyors.
Failure to Implement Effective Fall Prevention Interventions
Penalty
Summary
The facility failed to implement an effective intervention to reduce fall risk and determine effectiveness following a fall for a resident. The resident, who had a history of falls and multiple diagnoses including bipolar disorder, morbid obesity, and dementia, was found sitting on the floor in her doorway after a fall. The resident reported that she was walking when she fell and was not wearing non-skid footwear, which she had removed herself. Despite the resident's fall risk score indicating a high risk for falls, the facility did not implement an intervention to address the lack of non-skid footwear or the resident's removal of fall prevention interventions. The facility's fall investigation form for the incident did not document any new interventions to address the specific issue of the resident not wearing non-skid footwear. The facility's policy on falls management, which aims to assist residents in minimizing fall risks, was not effectively followed in this case. The Regional Nurse confirmed that the fall investigation did not include an intervention to address the resident's removal of non-skid footwear, highlighting a gap in the facility's response to the resident's fall risk.
Deficiencies in Bowel, Bladder, and Catheter Care
Penalty
Summary
The facility failed to comprehensively assess and implement interventions for a resident's bowel and bladder function, leading to a decline in their condition. The resident, who had multiple diagnoses including Parkinson's disease and vascular dementia, was frequently incontinent of both bowel and bladder. Despite this, the facility did not conduct a comprehensive assessment or implement a toileting program to manage or improve the resident's incontinence. The Director of Nursing confirmed the lack of documentation or evidence of any interventions to restore normal function or prevent further decline. Additionally, the facility did not provide appropriate and timely catheter care for two residents with indwelling catheters. One resident, with diagnoses including ulcerative colitis and neuromuscular dysfunction of the bladder, had orders for catheter care and monitoring that were not consistently followed. The medication administration record showed multiple instances where catheter patency checks, output monitoring, and catheter care were not completed as ordered. Similarly, another resident with an indwelling catheter and severe cognitive impairment did not receive the required catheter care and monitoring. Orders for catheter irrigation, patency checks, and output monitoring were not consistently followed, as evidenced by the medication administration record. Interviews with the Regional Nurse confirmed the lack of evidence for the required catheter care and monitoring for both residents.
Failure to Monitor and Address Nutritional Needs
Penalty
Summary
The facility failed to adequately monitor and address the nutritional needs of Resident #103, who experienced a severe weight loss of 8.8% (16 pounds) over a period of less than thirty days. Despite having orders for a regular diet with double meat portions and weekly weight checks, these were not consistently implemented. The resident's medical record showed that weights were not recorded as required, and the diet list did not reflect the need for double meat portions. Interviews with staff revealed a lack of awareness and communication regarding the resident's dietary needs and significant weight loss. Resident #103, who has multiple medical conditions including quadriplegia, diabetes, and pressure ulcers, was found to have moderately impaired cognition and was dependent on staff for eating. Despite these vulnerabilities, the facility did not provide the necessary dietary interventions or monitor her weight as ordered. The resident reported not receiving double portions and expressed a desire for ice cream as a supplement, indicating a lack of individualized nutritional support. Similarly, Resident #20 experienced a significant weight loss of eight pounds in seven days, which was not promptly addressed by the facility. The resident, who has severe cognitive impairment and requires substantial assistance with eating, was not consistently offered the prescribed Ensure nutritional supplements. Observations and interviews confirmed that the supplements were not provided as scheduled, and the facility did not follow its policy to re-weigh residents with significant weight changes in a timely manner.
Delayed Response to Pharmacy Recommendations for Two Residents
Penalty
Summary
The facility failed to address pharmacy recommendations in a timely manner for two residents, leading to deficiencies in medication management. Resident #5, who was admitted with multiple diagnoses including dementia and depression, had been on the antidepressant Remeron for six months without a gradual dose reduction (GDR) or documented contraindication. The pharmacist recommended a trial discontinuation of the medication on 02/08/24, but the physician did not review or respond to this recommendation until 05/03/24, significantly exceeding the expected 72-hour response time. Similarly, Resident #26, with diagnoses including cerebral infarction and diabetes, had a pharmacy recommendation to increase their Lantus insulin dose based on their hemoglobin A1C levels. This recommendation was made on 09/05/23, but the physician did not address it until 11/15/23. Both cases highlight a delay in addressing pharmacy recommendations, as confirmed by interviews with Regional Nurse #300, who acknowledged the untimely response to the pharmacist's suggestions.
Failure to Monitor Medication Regimens
Penalty
Summary
The facility failed to appropriately monitor two residents' medication regimens, leading to deficiencies in care. Resident #103, who has multiple diagnoses including quadriplegia and diabetes mellitus, was prescribed Glipizide to manage diabetes. The physician's order specified that the medication should be withheld if the resident's blood sugar was below 90 mg/dL. However, from July 20 to August 13, there was no evidence that Resident #103's blood sugar levels were monitored as required. This lack of monitoring was confirmed by Regional Nurse #300 during an interview. Similarly, Resident #102, who has severe cognitive impairment and conditions such as hypertensive heart disease, was prescribed Metoprolol for hypertension. The medication was to be held if the resident's systolic blood pressure was below 110 mmHg. Despite this, the resident's blood pressure was not assessed on several occasions before administering the medication. This oversight was also verified by Regional Nurse #300, who noted that blood pressure monitoring should have been linked to the medication order to prevent such errors.
Medication Errors Affect Two Residents
Penalty
Summary
The facility failed to ensure that residents were free from significant medication errors, affecting two residents. Resident #26, who had diagnoses including sepsis, cerebral infarction, and hypertension, was administered blood pressure medications outside of the prescribed parameters. Despite physician orders to hold medications like losartan potassium, amlodipine besylate, and metoprolol succinate if blood pressure was less than 110/60 mmHg, these medications were administered on multiple occasions in May 2024 when the resident's blood pressure was below the specified threshold. This was confirmed through a review of the medication administration record and an interview with the Regional Nurse. Resident #6, with diagnoses including bipolar disorder, chronic pain syndrome, and rheumatoid arthritis, experienced missed administrations of the prescribed narcotic pain medication, Percocet. The resident's medical record indicated frequent pain affecting sleep and daily activities, yet scheduled doses of Percocet were missed on several days in August 2024. The missed doses were verified through a review of the medication administration record and an interview with the Regional Nurse, indicating a failure in pain management for the resident.
Medication Storage and Labeling Deficiencies
Penalty
Summary
The facility failed to secure and store medications appropriately, affecting two residents during medication administration. For one resident, several containers of opened medications, including Flonase nasal spray, Ofloxacin ear drops, and Mucinex liquid decongestant, were observed on the bedside table. These medications were not properly labeled with open dates, and their presence in the resident's room was confirmed by an LPN, who subsequently removed them for secure storage. Another resident was found to have an opened container of Hydrocortisone cream on the bedside table, which was brought in by a family member without a physician's order. The presence of this medication was confirmed by an LPN, who explained the need for a physician's order and proper storage. Both incidents highlight the facility's failure to adhere to regulations regarding the secure storage and labeling of medications.
Delayed Laboratory Services for Residents
Penalty
Summary
The facility failed to obtain laboratory values in a timely manner as ordered for two residents, affecting their care. Resident #13, who had severe cognitive impairment and multiple diagnoses including acute respiratory failure and dementia, exhibited unusual behavior and altered mental status. A Family Nurse Practitioner ordered STAT laboratory tests, including a complete blood count, chest x-ray, comprehensive metabolic panel, and urinary analysis. However, the laboratory was unable to send a phlebotomist to collect the samples immediately, resulting in a delay until the following day. The Director of Nursing confirmed that the STAT labs were not conducted promptly. Similarly, Resident #39, who had a moderate cognitive deficit and multiple health issues such as cerebrovascular accident and vascular dementia, required a STAT urinalysis with culture and sensitivity. The collection of the sample was delayed, and it was not picked up by the laboratory until several days later. The Regional Nurse verified that the labs for Resident #39 were not completed in a timely manner. The facility's policy on laboratory scheduling and tests mandates that laboratory services be provided as ordered by physicians, which was not adhered to in these cases.
Delayed Reporting of Lab Results for Two Residents
Penalty
Summary
The facility failed to report laboratory results in a timely manner for two residents, leading to deficiencies in care. Resident #20, who had severe cognitive impairment and multiple health issues, was ordered a STAT comprehensive metabolic panel (CMP) and complete blood count (CBC) due to significant weight loss. Although the lab results were available shortly after collection, they were not reported to the Family Nurse Practitioner (FNP) until three days later, as they were found on the printer. This delay in communication was confirmed by the Director of Nursing and the Regional Nurse, who expected STAT lab results to be reported on the same day they were ordered. Similarly, Resident #13, who also had severe cognitive impairment and multiple diagnoses, exhibited unusual behavior prompting the FNP to order several lab tests. However, due to the unavailability of a phlebotomist, the labs were collected two days later than ordered. Even after collection, the results were not communicated to the physician until four days later. The Director of Nursing verified that the lab results were not reported in a timely manner, which was contrary to the facility's policy that required laboratory services to be provided as ordered.
Unappetizing Food Served to Resident
Penalty
Summary
The facility failed to ensure that appetizing food was served to a resident, affecting one of the 11 residents in House #300. During an interview, a resident expressed dissatisfaction with the taste of the green beans, describing them as tasting awful and as if they had come straight from the can. An observation conducted in House #300 revealed that the green beans served during lunch were indeed rubbery and flavorless. A State tested Nurse Aide (STNA) admitted to warming up the green beans from a can and only adding a sprinkle of salt, as not everyone in the building liked pepper.
Failure to Provide Soft and Bite-Sized Diet
Penalty
Summary
The facility failed to provide food prepared in a form designed to meet the individual needs of residents on a soft and bite-sized diet. This deficiency was identified through observations, medical record reviews, and staff interviews. Specifically, two residents, one with paranoid schizophrenia and emphysema, and another with adult failure to thrive and heart disease, were affected. Both residents had physician orders for a regular diet with a soft and bite-sized texture. However, during a lunch observation, they were served meals that included items not suitable for their dietary needs, such as crackers, which were not in compliance with the prescribed diet. The facility's dietary initiative, based on the International Dysphagia Diet Standardization Initiative (IDDSI), requires that food be tested with a fork pressure test to ensure it is soft and bite-sized. Despite this policy, the State tested Nurse Aide (STNA) #172 served all residents, regardless of their dietary requirements, the same meal without adhering to the necessary texture modifications. The dietitian confirmed that nurse aides were aware of the fork test procedure, yet it was not applied in this instance, leading to the deficiency.
Inaccurate Medical Records and Documentation Discrepancies
Penalty
Summary
The facility failed to maintain a complete and accurate medical record for two residents. For Resident #4, the medical record did not document a fall that occurred on 04/01/24 at 3:00 A.M., despite the fall being recorded on a fall investigation form. This omission was confirmed during an interview with the Regional Nurse, who verified that the fall was not documented in the resident's medical record. Resident #4 had multiple diagnoses, including bipolar disorder, morbid obesity, and dementia with anxiety, which could have implications for their care and safety. For Resident #13, there was a discrepancy between the medication administration record (MAR) and the nurse aides' documentation regarding the intake of the nutritional supplement Ensure. The MAR indicated varying levels of consumption, while the nurse aides' records showed different amounts consumed on the same dates. The Director of Nursing confirmed the inconsistency and stated that the nurse aides' documentation should be considered accurate, as they directly observed the resident's intake. However, the Dietitian believed the MAR should be the sole source of correct documentation. Resident #13 had complex medical conditions, including acute and chronic respiratory failure, COPD, and Parkinson's disease, which necessitate accurate documentation for proper nutritional management.
Inadequate Antibiotic Management for UTIs
Penalty
Summary
The facility failed to ensure proper assessment and prescription of antibiotics for residents with urinary tract infections (UTIs). Resident #11, who had an indwelling catheter due to neurogenic bladder, was placed on prophylactic Bactrim without documented evaluation of its continued necessity by a physician. The resident's medical records from April to August 2024 showed a lack of documentation regarding the prophylactic use of Bactrim, except for a single note by a family nurse practitioner (FNP) on May 2, 2024. This oversight was confirmed by Regional Nurse #300, who could not find evidence of ongoing evaluation by the physician. Resident #4, with a history of UTIs, was prescribed Bactrim DS despite the urinalysis and culture and sensitivity (UA/C&S) results indicating resistance to the antibiotic. The resident was hospitalized for falls, syncope, acute kidney injury, and UTI, with the discharge summary suggesting Bactrim may have contributed to the kidney injury. Upon readmission, the resident was switched to Cephalexin, which was sensitive to the organisms identified in the UA/C&S. Regional Nurse #300 and FNP #313 acknowledged the inappropriate antibiotic choice, with the FNP admitting to not having seen the C&S results. Resident #39, who had a moderate cognitive deficit and was frequently incontinent, was also prescribed Bactrim DS for a UTI. The UA/C&S results showed resistance to Bactrim, yet the medication was administered. The FNP stated that Bactrim was used initially until C&S results were available, but admitted to not reviewing the results for this resident. The facility's policy on UTI care was not adhered to, as evidenced by the inappropriate antibiotic prescriptions and lack of proper assessment and documentation.
Deficiency in Annual In-Service Training for STNAs
Penalty
Summary
The facility failed to provide the required 12 hours of annual in-service training for state tested nurse aides (STNAs), affecting two out of nine employee records reviewed. STNA #45, hired on 11/02/15, only received one hour and 45 minutes of in-service training over a twelve-month period, as confirmed by Coach #200. Similarly, STNA #71, hired on 09/16/22, did not complete the required 12-hour yearly in-services for the last year. The facility utilized a computerized educational program to assign and track training, with notifications sent by the corporate human resource team. However, it was the responsibility of the employees to complete the assigned in-services, which STNA #71 failed to do, as confirmed by Coach #200 and the Administrator. This deficiency had the potential to affect all 52 residents in the facility.
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A resident with intact cognition receiving Medicare Part A skilled services for metabolic encephalopathy had services discontinued while benefit days remained, but the facility did not issue the required Skilled Nursing Facility Advance Beneficiary Notice (SNF ABN). The Social Services Director later confirmed that no SNF ABN was provided and reported she believed only a Notice of Medicare Non-Coverage (NOMNC) was needed when all skilled services were stopped. This practice conflicted with the facility’s written policy, which required SNF ABNs to be issued when extended care items or services were initiated, reduced, or terminated due to expected non-coverage by Medicare.
Surveyors identified that the facility exceeded the acceptable medication error rate when two residents with type 2 DM received insulin doses that were not administered according to orders or manufacturer instructions. In two separate observations, an LPN administered Novolog and another LPN administered insulin glargine and insulin lispro without priming the insulin pens, and the insulin lispro and Novolog were given after the residents had already consumed a significant portion of their breakfast meals, despite orders for administration before meals. Manufacturer information for both insulin products required priming before each injection to ensure accurate dosing, and facility policy required medications, including insulin, to be administered safely, timely, and in accordance with prescriber orders and specified time frames.
Surveyors found that the facility failed to document tray line food temperatures for multiple meals served from two dining room kitchenettes, despite having a “Trayline Taste & Temperature Log” and a policy requiring food to be stored, prepared, distributed, and served according to professional food safety standards. Review of logs showed repeated missing entries for breakfast, lunch, and dinner services in both the Harrison and McClellan dining areas, and the Senior Director of Culinary Services confirmed that temperatures had not been recorded for those meals, potentially affecting all residents receiving meals from those kitchenettes.
The facility failed to conduct and document required periodic care conferences for two residents, despite multiple comprehensive, quarterly, and significant change MDS assessments and a policy requiring periodic care conferences with resident and/or family participation. One resident with Parkinson’s disease, post-stroke hemiplegia, TIA, DMII, and depression had only two documented care conferences over a year, while another resident with aphasia, cerebrovascular disease, DMII, gait difficulty, coagulation defect, depression, and muscle weakness had no documented care conferences in the past year, aside from a declined invitation to the representative. The UCC confirmed that care conferences were expected to occur quarterly and that no additional documentation existed for either resident.
A resident with Alzheimer's disease and type II DM, who required extensive assistance with ADLs and was receiving scheduled Lantus and sliding-scale Humalog, experienced a severely elevated blood glucose level. The on-call provider was notified and ordered an additional dose of lispro insulin with a directive to recheck the blood glucose after administration. Nursing staff administered the extra insulin but did not document any follow-up blood glucose check, and the DON confirmed that this reevaluation was required by the facility's abnormal blood glucose policy and was not completed or documented.
A resident with Parkinson’s disease, dementia, and hypothyroidism was prescribed levothyroxine once daily along with other medications. A consultant pharmacist’s monthly drug regimen review recommended that levothyroxine be given in the morning on an empty stomach, 30–60 minutes before food, per manufacturer instructions. The medical record contained no documented physician response to this recommendation, and the MAR showed the drug scheduled for morning administration while the resident was observed eating breakfast and receiving the medication at the same time. An LPN confirmed administering levothyroxine during the meal, and the DON verified there was no documentation explaining whether or why the pharmacist’s recommendation was or was not followed, resulting in a failure to act on and document the identified irregularity.
A resident with severe cognitive impairment, multiple comorbidities, documented gait and balance abnormalities, and a high fall risk was care planned and assessed by therapy to require contact guard assistance and use of a gait belt for transfers and ambulation. While being assisted by a CNA from a recliner to the bathroom with a walker, the CNA did not apply a gait belt, even though the resident had a known tendency to lean backward when standing. As the CNA reached to open the bathroom door, the resident lost balance and fell backward, striking the back of the head, and was later found by an LPN without a gait belt in place, contrary to the facility’s gait belt policy and the resident’s assessed needs.
A resident with CKD stage five requiring peritoneal dialysis (PD) was admitted with pre-admission physician orders for three daily PD exchanges and monitoring for peritonitis (fever, abdominal pain, cloudy effluent), but these monitoring orders were not entered into the facility’s physician orders. The care plan referenced PD and general monitoring but did not specifically address peritonitis monitoring. Paper PD flowsheets showed incomplete and inconsistent documentation of exchanges and resident condition, including missing condition/comments for individual treatments and no record of one ordered PD exchange. The PD cycler flowsheet lacked effluent descriptions on multiple days. The PD nurse reported facility staff were expected to monitor effluent and symptoms, and the DON confirmed the absence of specific peritonitis monitoring orders, lack of an order for the PD cycler, and documentation gaps, despite a facility policy requiring ongoing assessment and monitoring for complications before, during, and after dialysis treatments.
A nurse was observed preparing multiple oral medications for a resident with depression, traumatic brain injury, anxiety, and impaired cognition by pushing tablets and capsules from unit-dose cards directly into her ungloved hand and then using her fingers to place them into a medication cup. In a follow-up interview, the RN confirmed this practice and acknowledged that the correct procedure is to dispense medications directly from the card into the cup, contrary to the facility’s medication administration policy requiring adherence to good nursing principles and practices.
A resident with Alzheimer’s disease, diabetes, anxiety, significant ADL dependence, and behavioral symptoms was observed seated in a chair positioned against the nursing station with a locked wheelchair placed directly in front, also against the nursing station, effectively restricting movement. An LPN confirmed both wheelchair wheels were locked and that it should not have been placed there, while a CNA stated she had positioned the wheelchair to prepare for lunch, was unable to complete the transfer, and left it in place, acknowledging this was wrong. This arrangement conflicted with the facility’s restraint policy, which prohibits physical restraints except when alternatives are ineffective for treating a medical symptom and defines restraints as devices adjacent to the body that cannot be easily removed and that restrict freedom of movement or access to the body.
Failure to Issue Required SNF ABN When Discontinuing Medicare Part A Services
Penalty
Summary
The deficiency involves the facility’s failure to issue a Skilled Nursing Facility Advance Beneficiary Notice (SNF ABN) when Medicare Part A services were discontinued for a resident who still had available benefit days. The resident was admitted with a diagnosis of metabolic encephalopathy and had intact cognition per the Minimum Data Set assessment. The facility’s own SNF Beneficiary Notification Review documented that Medicare Part A skilled services began on 02/11/26 and the last covered day was 03/11/26, and that the facility initiated discharge from Medicare Part A services before the resident’s benefit days were exhausted. Despite this, no SNF ABN was provided to the resident or the resident’s representative. During interviews, the Social Services Director stated that the SNF ABN was issued hours prior to the last covered day but, upon reviewing her files, confirmed that no SNF ABN had actually been issued for this resident. She further explained that she believed an SNF ABN was only required if one skilled service remained and that if all skilled services were being discontinued, only the Notice of Medicare Non-Coverage (NOMNC) needed to be issued. The Administrator, however, stated that a resident should always receive both a SNF ABN and a NOMNC when Medicare Part A services are discontinued and benefit days remain. Review of the facility’s written policy dated 03/28/23 showed that the facility was required to issue SNF ABNs for initiation, reduction, or termination of extended care items or services when Medicare payment was not expected, which did not occur in this case.
Plan Of Correction
This Plan of Correction is submitted as required under State and Federal law. This Plan of Correction does not constitute an admission on the part of the Facility that the findings cited are accurate, that the findings constitute a deficiency or that the scope and severity regarding the deficiency cited are correctly applied. Any changes to the Facility's policies and procedures should be inadmissible in any proceeding on that basis. Without admitting or denying the validity or the existence of the alleged noncompliance, the Facility submits this Plan of Correction with the intention that it be inadmissible by any third party in any civil or other action against the facility or any employee, agent, officer, director or shareholder of the Facility. The Facility is utilizing this Plan of Correction as its allegation of substantial compliance as of 05/29/2026 F-0582 Corrective action for resident/s: On 5/14/26 Resident #34 was informed of rights and responsibilities related to Advanced Beneficiary Notice and voiced understanding of information for future reference by administrator. Identification of other residents who may be affected: Any resident receiving skilled services from nursing or therapy services. The Administrator audited all residents who were discharged from skilled services in the past 30 days to ensure they were issued a Notice of Non-Coverage and Advanced Beneficiary Notice on 5/29/26. No non-compliance was noted. Measures for systemic change: On 5/14/2026 Business Office Manager, Director of Rehab, Minimum Data Set nurse, Director of Nursing and Social Services Director were educated on proper procedure of issuing of Notice Of Medicare Non Coverage and Advanced Beneficiary Notice by administrator. All upcoming discharges from skilled services will be reviewed weekly at Utilization Review meeting to ensure notices will be delivered timely. How Corrective Action will be monitored: Administrator or designee to complete audits of all residents being discharged from skilled services to ensure they were issued a Notice of Non-Coverage and Advanced Beneficiary. This audit will be completed weekly x 4 weeks, then monthly x 2 months. Corrective action will be initiated for any noted non-compliance. Audit findings will be reviewed as part of the monthly quality assurance process to determine the need for further monitoring. Date of Compliance 5/29/26
Insulin Administration Errors and Failure to Prime Insulin Pens
Penalty
Summary
The deficiency involves the facility’s failure to maintain a medication error rate below 5%, with surveyors identifying 3 errors out of 28 medication administration opportunities, resulting in a 10.71% error rate. For one resident with type 2 diabetes mellitus and moderate cognitive impairment, the physician’s order directed Novolog insulin 10 units via subcutaneous pen-injector to be given before meals. During an observed medication pass, the LPN administered 10 units of Novolog insulin without priming the pen and did so after the resident had already consumed approximately 50% of the breakfast meal. The LPN later confirmed she did not prime the pen and acknowledged that the insulin was ordered to be administered prior to meals. Manufacturer instructions for the Novolog FlexPen specified that an air shot (priming) must be performed before each injection to ensure proper dosing. Another resident, also diagnosed with type 2 diabetes mellitus and with intact cognition, had orders for insulin glargine 35 units subcutaneously twice daily and insulin lispro 20 units subcutaneously before meals, plus 12 units subcutaneously if blood glucose was between 251 mg/dL and 300 mg/dL. During an observed medication administration, an LPN administered 35 units of insulin glargine and 32 units of insulin lispro without priming the insulin pens and after the resident had consumed approximately 90% of the breakfast meal, despite orders for insulin lispro to be given before meals. The LPN later stated she could not remember if she had primed the pen and acknowledged that the insulin was ordered to be administered prior to meals. Manufacturer information for insulin lispro stated that the pen must be primed before each injection to confirm insulin delivery and remove air, and that failure to prime could result in too much or too little insulin. The DON confirmed the expectation that insulin be administered as ordered, including priming each pen with two units before dialing the prescribed dose, and facility policy required medications, including insulin, to be administered safely, timely, and in accordance with prescriber orders and required time frames.
Plan Of Correction
This Plan of Correction is submitted as required under State and Federal law. This Plan of Correction does not constitute an admission on the part of the Facility that the findings cited are accurate, that the findings constitute a deficiency or that the scope and severity regarding the deficiency cited are correctly applied. Any changes to the Facility's policies and procedures should be inadmissible in any proceeding on that basis. Without admitting or denying the validity or the existence of the alleged noncompliance, the Facility submits this Plan of Correction with the intention that it be inadmissible by any third party in any civil or other action against the facility or any employee, agent, officer, director or shareholder of the Facility. The Facility is utilizing this Plan of Correction as an allegation of substantial compliance as of 5/29/2026. F-0759 Corrective action for resident/s: Residents #21 and #22 were assessed and evaluated by nurse and Director of Nursing 5/14/26. Resident #21 and #22 both denied any adverse effects and none were noted upon assessment by the Director of Nursing on 5/14/2026. Notification made to physician on 5/14/2026. LPN # 2 competency Eval on insulin administration with the Director of Nursing completed 5/14/2026. Identification of other residents who may be affected: Diabetic residents on assignment of LPN #2/station 2 have the potential to be affected and were assessed by the DON/Designee on 5/14/26 and found to be within normal limits. Measures for systemic change: All Nurses were educated by the Director of Nursing on the steps for Insulin administration per competency, diabetes clinical protocol policy, Medication and treatment orders policy, administering medications policy, and Obtaining fingerstick Glucose Level policy On 5/14/2026. How Corrective Action will be monitored: Director of Nursing and Assistant Director of Nursing will complete insulin administration audits on 5 nurses. This audit will be completed weekly x 4 weeks, then monthly x 2 months. Corrective action will be initiated for any noted non-compliance. Audit findings will be reviewed as part of the monthly quality assurance process to determine the need for further monitoring. Date of Compliance: 5/29/2026
Failure to Document Tray Line Food Temperatures in Dining Room Kitchenettes
Penalty
Summary
The deficiency involves the facility’s failure to document tray line food temperatures for meals served from the Harrison and McClellan Dining Room kitchenettes, as required by professional standards for food service safety and the facility’s own policy. Review of the “Trayline Taste & Temperature Log” (revised September 2018) showed missing temperature documentation for multiple meals from the Harrison Dining Room kitchenette, including dinner on 03/30/26 and 03/31/26, lunch and dinner on 04/01/26 and 04/02/26, dinner on 04/07/26, and lunch and dinner on 04/08/26 and 04/10/26. The Senior Director of Culinary Services confirmed during interview that tray line food temperatures were not documented on the log for these meals. Similarly, review of the same log for the McClellan Dining Room kitchenette revealed that tray line food temperatures were not documented for dinner on 04/01/26, breakfast and lunch on 04/02/26, and lunch and dinner on 04/07/26. The Senior Director of Culinary Services also verified these omissions during interview. The facility census at the time was 27 residents, and the governing “Food and Nutrition” policy, approved on 09/07/21, stated that the facility must store, prepare, distribute, and serve food in accordance with professional standards for food service safety.
Plan Of Correction
F812 The facility will continue to ensure food temperatures are completed before meals are served for all residents. To ensure compliance with this standard the following measures have been taken: 1. Immediately 4/15/26 culinary supervisor #224 was re-educated by Dietary Manager to this standard and policy "Food and Nutrition" which includes documentation of food temperatures. 2. All dietary staff have been re-educated to the standard and policy "Food and Nutrition" during the month of April 2026. 3. Audits of food temperature documentation to be completed by Dietary Manager 4 x per week for 4 weeks then weekly for 4 weeks. 4. Administrator to validate audits/compliance and provide additional training as needed. Administrator will present to QAPI committee for ongoing monitoring and further direction.
Failure to Conduct and Document Required Care Conferences
Penalty
Summary
The deficiency involves the facility’s failure to complete and document comprehensive care conferences at required intervals in accordance with care plan regulations and facility policy. For one resident with Parkinson’s disease with dyskinesia, cognitive communication deficit, hemiplegia and hemiparesis following cerebral infarction, transient cerebral ischemic attack, type II diabetes mellitus, and major depressive disorder, the record showed multiple MDS assessments over a one-year period, including annual, quarterly, and significant change assessments. However, only two care conferences were documented during the last 12 months, despite the expectation that care conferences be conducted quarterly with the resident and family when possible. The Unit Care Coordinator confirmed that no additional care conference documentation existed for this resident beyond the notes dated 04/21/25 and 01/02/26. A second resident, with diagnoses including aphasia following cerebrovascular disease, cerebral infarction, type II diabetes mellitus, unsteadiness on feet, difficulty in walking, coagulation defect, depression, and muscle weakness, also had multiple MDS assessments completed over the review period, including quarterly and annual assessments. The record contained a note that a care conference was offered to the resident’s representative, who declined to attend, but there was no documentation of any care conferences for the most recent 12 months. The Unit Care Coordinator confirmed that no other care conference documentation was available for this resident. Facility policy stated that periodic care conferences involving the resident, family, and the interdisciplinary team are part of the care planning process, but the required periodic care conferences and corresponding documentation were not completed for these two residents.
Plan Of Correction
THIS PLAN OF CORRECTION SERVES AS BERKELEY SQUARE'S CREDIBLE ALLEGATION OF SUBSTANTIAL COMPLIANCE AS OF June 1, 2026. Without admitting or denying the validity or existence of the alleged deficiencies, Berkeley Square provides the following Plan of Correction: F657 The facility will continue to document completion of care conferences at the required intervals for all residents, including residents #04 & #15. To ensure compliance with this standard the following measures have be taken: 1. The social service designee and the inter- disciplinary team were re-educated by the administrator to the facility policy "Care Conference" on 4/29/26 and verbalized understanding. 2. Care conferences for resident #04 and resident #15 were conducted on or before 4/29/2026 by the interdisciplinary team. 3. Review of all other residents was conducted by the social service designee to validate and ensure that care conference schedule is up to date with timely care conferences scheduled for them on 4/15/2026. Audits of care conferences to be completed weekly for four weeks and then monthly after that by the social service designee. Documentation of the care conference including any identified concerns in the medical record. Administrator to validate audits/compliance and provide additional training as needed. Administrator will present results of these audits to QAPI committee for ongoing monitoring and further direction.
Failure to Reevaluate Blood Glucose After Treatment for Hyperglycemia
Penalty
Summary
The facility failed to ensure that a resident with diabetes received treatment in accordance with professional standards of practice when nursing staff did not reevaluate the resident's blood glucose after treatment for severe hyperglycemia. The resident, admitted with diagnoses including Alzheimer's disease, type II diabetes mellitus, and depression, had physician orders for Humalog insulin on a sliding scale before meals, Lantus insulin 25 units daily, and lisinopril 5 mg daily. The resident required extensive assistance with activities of daily living, including transfers, toileting hygiene, eating, and bathing. On the evening in question, the resident's blood glucose was documented as 532 mg/dL, and the on-call provider was notified. The provider gave a new order to administer an additional 8 units of lispro (Humalog) and to recheck the blood glucose in 30 minutes. The electronic medication administration record showed that the blood glucose of 532 mg/dL was obtained at 9:00 p.m. and that the additional 8 units of lispro were administered at 9:21 p.m. However, there was no documentation in the resident's chart that the blood glucose was rechecked after the additional insulin was given. In an interview, the DON confirmed there was no evidence of reevaluation and verified that, according to the facility's "Abnormal Blood Glucose Procedure" policy, the resident should have been reevaluated and that the evaluation step should have been included in the progress note documentation.
Plan Of Correction
F684 The facility will continue to ensure all residents, including #03, receive treatment in accordance with professional standards of practice and reevaluated for hyperglycemia. To ensure compliance with this standard the following measures have been taken: 1. The director of nursing assessed resident #03, reviewed documentation and orders and found no ill effects immediately 4/16/26. 2. All licensed nurses were re-educated to facility policy "Blood Glucose Monitoring" by the Director of Nursing/designee in April 2026. 3. Audits of like-residents that require blood sugar checks to be completed by the director of nursing/designee two times a week for 4 weeks and then monthly after that to validate correct follow through when there is abnormally high blood glucose result. The Administrator will bring results of these audits to the QAPI committee for ongoing monitoring and further direction.
Failure to Act on Pharmacist Drug Regimen Recommendation for Thyroid Medication
Penalty
Summary
The deficiency involves the facility’s failure to ensure that pharmacy recommendations from the monthly drug regimen review were acted upon and documented for a resident. The resident was admitted with diagnoses including Parkinson’s disease, dementia, and hypothyroidism, and had current physician orders for levothyroxine 150 mcg once daily, buspirone 50 mg twice daily, and losartan 100 mg once daily. A medication regimen review dated 11/25/2025 included a consultant pharmacist recommendation that levothyroxine be administered consistently in the morning on an empty stomach, at least 30–60 minutes before food, per manufacturer instructions. There was no specific physician response in the medical record to this recommendation, and the facility’s policy stated that consulting pharmacist reviews are sent to nursing and addressed with the primary care provider or consulting specialist for review and follow-up. Review of the resident’s medication administration record for April 2026 showed levothyroxine scheduled for 9:00 a.m. On observation, the resident was seen eating breakfast in the dining area at 8:03 a.m., and an LPN reported administering the levothyroxine 150 mcg to the resident while the resident was in the dining area eating breakfast. The DON confirmed there was no evidence in the resident’s medical record explaining why the consultant pharmacist’s recommendation from 11/25/2025 was or was not acted upon. This lack of documented physician review and action on the pharmacist’s identified irregularity constituted noncompliance with the drug regimen review requirements.
Plan Of Correction
F756 The facility will continue to ensure the pharmacy recommendations from the monthly drug regimen review by a licensed pharmacist are acted upon for all residents, including #08. To ensure compliance with this standard the following measures have been taken: 1. Resident #08 was assessed by the registered nurse and med review completed by 4/28/26. After review of resident's drug regime's, it was discovered that resident #8 had 2 separate medication recommendations on the same form, to be reviewed by two separate practitioners, pharmacy has been instructed and agreed to separate meds on individual forms. 2. Licensed nurses re-educated to facility policy "Drug Regimen Review" by Director of nursing/designee in April 2026 and no later than 5/8/26. Licensed nurses are responsible for ensuring the reviews and recommendations are given to the physician for timely review. 3. Review of all other current residents Drug Regimen orders completed by Director of nursing/designee on 4/16/26 to ensure recommendations were followed up on/reviewed by the physician and address concerns if needed. 4. Audit of drug regime recommendations, pharmacy recommendations, and physician follow up to be completed weekly for four weeks by the Director of nursing/designee. Administrator will present results of these audits to the QAPI committee for ongoing monitoring and further direction.
Failure to Use Required Gait Belt During Ambulation Resulting in Resident Fall
Penalty
Summary
The deficiency involves the facility’s failure to ensure that a required gait belt was used while assisting a high fall‑risk resident with ambulation, resulting in a fall with head injury. The resident had multiple diagnoses including metabolic encephalopathy, hypertension, osteoarthritis, muscle weakness, gait and mobility abnormalities, major depressive disorder, anxiety, and visual hallucinations. Admission and subsequent MDS and fall risk assessments documented that the resident was severely cognitively impaired, required moderate to maximal assistance with transfers and ambulation, could not independently come to a standing position, exhibited loss of balance while standing, used an assistive device, and had decreased muscle coordination. The resident had a history of falls prior to admission and was assessed as being at high, later moderate, risk for falls. The resident’s fall care plan identified her as at risk for falls and included interventions such as providing maximum to moderate assistance with transfers and walking short distances, use of a walker and wheelchair, and following the facility’s fall protocol. Therapy notes and care conference documentation indicated that the resident leaned backwards when standing, required contact guard to minimal assistance for bed mobility and transfers, and needed constant verbal cueing for safe sequencing during toilet transfers. The physical therapist confirmed that the resident was to use a gait belt with staff when ambulating, and the DON verified that therapy had assessed the resident as requiring contact guard assistance and a gait belt for ambulation and transfers. On the day of the incident, a CNA was assisting the resident from her recliner to the bathroom using a walker. The CNA walked beside the resident, providing guidance and support, and reported having a hand on the resident while assisting her. As they approached the bathroom door, the CNA reached for the doorknob to open it, and at that moment the resident began to lose her balance and fell backwards to the floor, striking the back of her head. The nurse who responded found the resident on her back at the foot of the bed with her feet near the bathroom, noted a red raised area on the back of the head, and documented that the resident was not wearing a gait belt and that the gait belt was on the dresser. In the facility’s investigative summary and in interviews, the CNA acknowledged that she did not have a gait belt on the resident while ambulating her, despite the resident’s assessed need for hands‑on assistance and gait belt use per facility policy and the resident’s care and therapy plans.
Failure to Implement PD Orders and Monitor Resident Receiving Peritoneal Dialysis
Penalty
Summary
The deficiency involves the facility’s failure to implement pre-admission physician orders for peritoneal dialysis (PD) and to provide ongoing monitoring for a resident with chronic kidney disease (CKD) stage five who required PD. Pre-admission orders dated 11/14/25 specified three daily PD exchanges at 6:00 A.M., 2:00 P.M., and 10:00 P.M., and directed staff to monitor for signs and symptoms of peritonitis, including fever, abdominal pain, and cloudy effluent. These monitoring orders were not entered into the facility’s physician orders. The resident’s care plan noted the need for PD and included general monitoring interventions (labs, signs of bleeding, bacteremia, septic shock, and significant vital sign changes), but did not specifically address the ordered monitoring for peritonitis. Review of PD documentation showed incomplete and inconsistent charting of treatments and resident condition. The paper peritoneal flowsheet had columns for time of PD and condition/comments, including instructions to call the nurse immediately for cloudy fluid, abdominal pain, or fever. However, the first entry on 11/15/26 at 2:00 P.M. only noted that the PD nurse completed the exchange, and the 10:00 P.M. entry that day had no condition/comment documentation. Subsequent days (11/16/25, 11/17/25, and 11/18/25) contained only one condition/comment entry per day rather than for each exchange, and there was no documentation that the 6:00 A.M. PD on 11/18/25 was completed. The PD cycler flowsheet starting 11/19/25 lacked any description of the effluent on multiple days. The PD nurse from the dialysis company stated facility staff were expected to monitor effluent for cloudiness and assess for abdominal pain and fever, and the DON confirmed there was no electronic physician order for peritonitis monitoring or for use of the PD cycler, that the paper charting did not allow for effluent description or symptom documentation for each treatment, and that PD was not documented at one ordered time. The facility’s dialysis policy required ongoing assessment and monitoring for complications before, during, and after treatments, which was not reflected in the documentation for this resident.
Improper Infection Control During Medication Administration
Penalty
Summary
Surveyors identified a deficiency in infection prevention and control related to medication administration for Resident #29. The resident was admitted on 02/28/14 with diagnoses including depression, traumatic brain injury, and anxiety, and had impaired cognition per a quarterly MDS assessment. During an observation on 03/25/26 at 6:58 A.M., RN #281 prepared the resident’s medications by removing an Amoxicillin-Pot Clavulanate tablet from the medication card and pushing it directly into her ungloved hand, then using her fingers to place the pill into a medication cup. The same process was observed for multiple other medications, including Escitalopram Oxalate, Furosemide, Sennosides, Lyrica, and Vitamin D, each being pushed from the card into the RN’s ungloved hand and then transferred by her fingers into the medication cup before administration to Resident #29. In a subsequent interview at 7:27 A.M. the same day, RN #281 confirmed she had placed each medication into her ungloved hands prior to administration and acknowledged that the proper procedure was to push the pills directly from the card into the medication cup. Review of the facility’s “Medication Administration – General guidelines” policy, revised 10/08/25, stated that medications are to be administered in accordance with good nursing principles and practices. This practice failure was cited as a deficiency under Complaint Number 2681777.
Improper Use of Wheelchair as a Physical Restraint
Penalty
Summary
Surveyors identified a deficiency related to the facility’s failure to ensure a resident was free from physical restraints. Resident #7, admitted with diagnoses including Alzheimer’s disease, diabetes mellitus, and anxiety disorder, was documented on a recent MDS as rarely understood and dependent for ADLs except eating. The resident ambulated independently on the unit without an assistive device and had documented verbal and other behaviors occurring one to three days during the look-back period. The care plan noted the resident had potential to be physically aggressive, chase staff, throw objects, and be combative with care, with interventions such as offering choices, administering medications as ordered, and intervening early when agitation occurred. During an observation and interview, Resident #7 was found sitting in a chair with the right arm of the chair positioned against the nursing station and a wheelchair placed directly in front of him. The left arm of the wheelchair was also against the nursing station, and both wheelchair wheels were locked, creating a barrier that appeared to restrain the resident, who was sleeping with his knees touching the locked wheelchair. An LPN confirmed both wheelchair wheels were locked and that the wheelchair should not have been placed in front of the resident. A CNA reported she had placed the wheelchair there in preparation to get the resident up for lunch, was unable to transfer him, and left the wheelchair in that position, acknowledging it was wrong to keep it there. The facility’s physical restraint policy stated that physical restraints are not used except when alternatives are not appropriate or effective for treating a medical symptom and defined physical restraints as any device attached or adjacent to the body that the individual cannot easily remove and that restricts freedom of movement or access to the body.
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