Otterbein Sunset Village
Inspection history, citations, penalties and survey trends for this long-term care facility in Sylvania, Ohio.
- Location
- 9640 Sylvania-metamora Road, Sylvania, Ohio 43560
- CMS Provider Number
- 366242
- Inspections on file
- 30
- Latest survey
- February 19, 2026
- Citations (last 12 mo.)
- 5
Citation history
Health deficiencies cited at Otterbein Sunset Village during CMS and state inspections, most recent first.
Surveyors identified that nursing staff did not follow physician orders and facility policy for medication administration, resulting in a medication error rate above 5%. One resident with hypertension and chronic kidney disease received metoprolol succinate ER without required pre-dose vital signs to determine if hold parameters were met. Another resident receiving cephalexin 500 mg QID for cellulitis was given a dose outside the prescribed and policy-defined time window for equally spaced antibiotic dosing. These two observed errors out of 28 opportunities resulted in a calculated medication error rate of 7.14%.
The facility failed to ensure medications were administered according to physician orders and facility policy, resulting in significant medication errors affecting three residents. A resident with multiple chronic conditions and an active PRN morphine order, but no Dilaudid order, received Dilaudid in error instead of morphine, with documentation noting that medication was not given according to the six rights and lacking clear details of the drug and dose administered. Another resident with an order for metoprolol succinate ER, to be held for low BP or HR, received the medication without the RN obtaining vital signs beforehand. A third resident with an order for cephalexin 500 mg QID at evenly spaced times received the antibiotic outside the prescribed timeframe, contrary to the facility’s liberal med administration policy requiring time-sensitive antibiotics to be given at scheduled hours.
A resident with multiple chronic conditions, including cerebrovascular disease, diabetes, epilepsy, and cortical blindness, had an order for PRN morphine sulfate but no active order for Dilaudid. On one occasion, the resident reported pain while sitting in a recliner, and documentation noted that medication was not administered according to the six rights of medication administration, with low O2 saturation that improved after PRN oxygen and the resident later drowsy but resting in bed. However, the medical record did not specify which medication or dose was given, lacked detailed description of the medication error, and contained no ongoing assessment or physician instructions related to the event. In interviews, the DON reported that an LPN had administered Dilaudid instead of the ordered morphine but could not identify for whom the Dilaudid was prescribed and had not verified the amount in the bottle, and the Administrator acknowledged there was no documented procedure to ensure accurate documentation of such incidents.
A resident with diabetes, hemiplegia, and severe cognitive impairment was not properly monitored for a diabetic foot ulcer. Required interventions, such as applying protective boots and floating legs, were not consistently implemented, and weekly wound assessments lacked necessary measurements and descriptions. Staff interviews and observations confirmed lapses in following the care plan and facility policy for wound care documentation and intervention.
A resident with severe cognitive impairment and a diabetic foot ulcer did not have protective boots applied as ordered by the physician, despite documentation in the MAR indicating they were in place. Both an LPN and a CNA confirmed the boots were not applied during observation, revealing inaccurate medical records and a failure to follow prescribed care interventions.
A facility failed to maintain accurate medical records for a resident with complex medical conditions, as a dressing change was documented but not performed by an LPN. The resident's daughter and a hospice RN confirmed the discrepancy, revealing non-compliance with the facility's skin care management policy.
The facility failed to ensure proper linen handling and lacked an effective Legionella water management program. An STNA was observed transporting linens uncovered and pressed against her body, and gowns were not worn by a Laundry Aide when handling soiled linens. The Legionella Risk Assessment indicated high risk, but the Administrator and DES were unfamiliar with the plan's elements, and there was no regular monitoring of water temperatures or flushing of faucets in empty rooms.
The facility's memory care unit kitchen was found to be unsanitary, with sticky floors and food debris on surfaces, potentially affecting 18 residents. Dietary staff confirmed the lack of regular cleaning and could not recall the last cleaning. Despite some cleaning efforts, dried food remained on various surfaces.
The facility failed to maintain cleanliness and sanitation, as evidenced by a resident's soiled wheelchair and another resident's persistently malodorous room. Despite protocols, the wheelchair remained dirty, and staff confirmed the odor issue. Additionally, food debris from the previous night was found in the dining room, indicating broader sanitation lapses.
A resident with dementia and aphasia was left with food spilled on their clothing and body after a meal, despite multiple staff members, including STNAs and nursing students, passing by without providing assistance. The resident remained in this state for an extended period, which was verified by an LPN, indicating a failure to uphold the facility's policy on resident dignity.
A resident with a history of bipolar disorder, panic disorder, anxiety, and epilepsy was found with a call light out of reach, despite a care plan intervention to keep it accessible due to fall risk and need for assistance with ADLs. An STNA confirmed the call light's location, and the facility lacked a policy on call lights.
A resident with multiple health conditions refused several doses of critical medications, including insulin and anticoagulants, on multiple occasions. An LPN documented the refusals due to nausea or vomiting but failed to notify the physician or the resident's family, as required by the facility's policy.
A facility failed to implement fall interventions for a resident at risk for falls. Despite the care plan requiring a fall mat next to the bed, observations showed the mat was not in place, but leaning against the wall. An LPN confirmed the mat should have been positioned correctly, indicating non-compliance with the care plan.
The facility failed to serve meals at an appetizing temperature, affecting two residents who received food from the memory care unit. Meals were consistently cold when served in rooms, with observations confirming inadequate temperature maintenance due to unheated plates and insufficient covers. A test tray showed significantly cooled food, and Resident Council Meeting Minutes documented ongoing concerns about food temperatures.
The facility failed to ensure pneumococcal vaccinations were offered or administered per CDC recommendations, affecting two residents. One resident, cognitively intact, had not received an updated vaccine since 2017 and was not educated on CDC guidelines until the survey. Another resident, moderately cognitively impaired, had no record of being offered the vaccine, and their representative's consent form was incomplete. The facility's policy to offer and educate residents on pneumococcal immunizations upon admission was not followed.
A facility failed to administer medications as ordered by a physician, resulting in a 25% medication error rate. An LPN crushed medications for a resident without a physician's order, contrary to the facility's procedures. The medications included Amlodipine, Cholecalciferol, Citalopram, and others. The facility's procedure requires medications to be administered according to physician orders, with crushing only allowed if indicated in the resident's orders and MAR.
Medication Administration Errors Resulting in Error Rate Above 5%
Penalty
Summary
The deficiency involves failure to ensure medications were administered in accordance with physician orders, resulting in a medication error rate of 7.14% (2 errors out of 28 opportunities), which exceeded the 5% threshold. For one resident with hypertension related to hypertensive chronic kidney disease, a physician order dated 09/11/25 directed administration of metoprolol succinate ER 25 mg by mouth once daily, with instructions to hold the dose if systolic blood pressure was less than 100 mmHg or heart rate was less than 60 beats per minute. On 02/18/26, an RN prepared and administered this medication whole with water without obtaining the resident’s vital signs beforehand, as confirmed by the RN during interview, meaning the medication was given without verifying the hold parameters specified in the order. The second error involved an antibiotic order for cephalexin 500 mg by mouth four times daily for cellulitis for 10 days, with prescribed administration times of 8:00 A.M., 12:00 P.M., 4:00 P.M., and 8:00 P.M. Facility policy required medications to be administered within one hour before or after the scheduled time, and a liberal medication administration policy specified that time-sensitive medications requiring equally spaced dosing, such as antibiotics given four times daily, must follow those scheduled times. On 02/18/26, an RN prepared the cephalexin capsule with other medications in applesauce and administered it at approximately 9:19 A.M., which was outside the physician-prescribed timeframe for that dose, as verified by the RN. These two observed errors, confirmed through observation, record review, and staff interview, led to a medication error rate above the acceptable limit.
Significant Medication Errors and Failure to Follow Physician Orders
Penalty
Summary
The deficiency involves the facility’s failure to ensure medications were administered in accordance with physician orders, resulting in significant medication errors for multiple residents. One resident with extensive medical conditions including cerebrovascular disease, type II diabetes, epilepsy, hypertension, chronic pain, cortical blindness, and morbid obesity had an active order for morphine sulfate oral solution 20 mg/mL, 0.5 mL by mouth every two hours as needed for pain or shortness of breath, and no active order for Dilaudid. Event documentation for this resident noted an incident in which the resident was sitting in a recliner, reported pain, and was found to have oxygen saturation below 90%, requiring application of as-needed oxygen to return saturation above 90% on 2.5 L via nasal cannula. The documentation referenced that medication was not administered according to the six rights of medication administration, but did not specify the medication or dose given, nor did it contain detailed content of the incident, ongoing assessment of the resident’s health status, or physician instructions. Further information obtained through interview with the DON and the Administrator revealed that an LPN reported administering two different doses of Dilaudid in error to this resident instead of the ordered morphine. The DON was unable to identify the resident for whom the Dilaudid had been prescribed and there was no documentation in the medical record of the specific medication or dose administered. The DON also stated she did not check the Dilaudid suspension level before or after the LPN’s shift, and concluded that the LPN did not identify the correct medication before administration. The medical record lacked additional progress notes related to this medication error in the days following the incident. Another deficiency involved a resident with an order for metoprolol succinate ER 25 mg once daily for hypertension related to hypertensive chronic kidney disease, with instructions to hold the medication if systolic blood pressure was less than 100 mmHg or heart rate less than 60 beats per minute. Observation showed an RN preparing and administering this medication without obtaining vital signs beforehand, and the RN confirmed that no vital signs were taken prior to administration. A third resident had an order for cephalexin 500 mg by mouth four times daily for cellulitis, scheduled at 8:00 A.M., 12:00 P.M., 4:00 P.M., and 8:00 P.M., with facility policy specifying that such antibiotics must be administered at equally spaced times. Observation showed the RN administering the cephalexin at 9:19 A.M., outside the prescribed timeframe, and the RN confirmed the medication was given outside the ordered schedule. These actions were inconsistent with the facility’s medication administration policies requiring adherence to physician orders and specified timing.
Incomplete Documentation of Medication Error and Resident Assessment
Penalty
Summary
The deficiency involves the facility’s failure to maintain complete and accurate medical record documentation regarding a medication error for one resident. The resident had multiple diagnoses, including cerebrovascular disease, type II diabetes mellitus, major depressive disorder, epilepsy, hypertension, cortical blindness, anxiety disorder, and morbid obesity, and was receiving antidepressant, diuretic, opioid, antiplatelet, and anticonvulsant medications, as well as oxygen therapy and hospice care. A physician order dated 11/24/25 directed that morphine sulfate oral solution 20 mg/mL be given at 0.5 mL by mouth every two hours as needed for pain or shortness of breath, and there was no active order for Dilaudid. On 11/25/25, an event note documented that the resident, who was sitting in a recliner watching television, reported pain, and that medication was not administered according to the six rights of medication administration. The assessment noted oxygen saturation below 90%, application of as-needed oxygen with improvement above 90% on 2.5 L via nasal cannula, and that the resident was drowsy but resting comfortably in bed. The medical record did not contain documentation of the specific medication error, including the medication name, dose given, or detailed description of the incident, nor did it include ongoing assessments of the resident’s health status or physician instructions related to the error. There were no additional progress notes between the event on 11/25/25 and 11/29/25, and the next progress note on 12/01/25 did not mention the medication error, ongoing assessments, or physician recommendations following the error. During interviews, the DON stated that an LPN had reported administering two different doses of Dilaudid in error instead of the ordered morphine, but the DON could not identify the resident for whom the Dilaudid was prescribed, and there was no verification of the amount of Dilaudid in the bottle before or after the incident. The DON confirmed that the medical record lacked documentation reflecting the details of the medication error, and the Administrator acknowledged there was no documented facility guidance or procedures to ensure accurate resident information and experiences, including medication errors, were consistently recorded in the medical record.
Failure to Monitor and Implement Wound Care Interventions
Penalty
Summary
A resident with multiple complex medical conditions, including hemiplegia, diabetes mellitus with a foot ulcer, and severe cognitive impairment, was not properly monitored or treated for a diabetic foot ulcer. The care plan required the application of protective boots, floating of legs with pillows, and ongoing monitoring and documentation of the wound's size, depth, margins, and healing progress. However, medical record review showed that weekly wound assessments were incomplete, often missing measurements and detailed descriptions of the wound bed. Additionally, hospice notes provided to the facility lacked detailed weekly wound documentation, and the DON confirmed she had not reviewed these reports, which misidentified the wound as a stage two pressure ulcer. Observation revealed the resident was found in bed without the required protective boots, and their heels and legs were directly on the mattress, contrary to care plan interventions. Staff interviews confirmed inconsistent understanding and implementation of the boot application schedule. Facility policy required comprehensive wound documentation with each dressing change or at least weekly, but this was not followed, resulting in a failure to monitor the resident's wound and implement necessary interventions as outlined in the care plan and facility policy.
Failure to Accurately Document and Implement Physician Orders for Protective Boots
Penalty
Summary
The facility failed to ensure the accuracy of a resident's medical records and the implementation of physician orders regarding the application of protective boots. A review of the medical record for a resident with multiple diagnoses, including hemiplegia, diabetes with a foot ulcer, and severe cognitive impairment, showed that the care plan and physician orders required bilateral green boots to be applied in the morning and removed at night, with legs floated on pillows twice daily. The Medication Administration Review (MAR) indicated that the boots were applied as ordered. However, during an observation, the resident was found in bed without the boots, and both an LPN and a CNA confirmed that the boots were not applied at that time, despite documentation in the MAR stating otherwise. The CNA also reported being told that the boots were to be applied at night and removed in the morning, which conflicted with the physician's orders. This discrepancy demonstrates a failure to maintain accurate medical records and to follow prescribed care interventions.
Inaccurate Medical Record Keeping for Resident's Dressing Change
Penalty
Summary
The facility failed to maintain a complete and accurate medical record for a resident, identified as Resident #30, who was admitted with multiple complex medical conditions including hemiplegia, diabetes, and atherosclerotic heart disease, among others. The resident required substantial assistance for all functional abilities and was dependent on others for transfers. A discrepancy was found in the documentation of a dressing change for the resident's left foot ulcer. The resident's daughter reported that the dressing was not changed on a specified date by the facility nurse, despite documentation indicating otherwise. Interviews with the Director of Nursing and a Hospice Registered Nurse confirmed that the dressing change documented by an LPN did not occur. The hospice nurse verified that the dressing she applied on a previous date was still in place, indicating that the facility nurse had not performed the dressing change as recorded. This discrepancy in the medical record was identified during a complaint investigation, highlighting a failure to adhere to the facility's policy on skin care management and accurate record-keeping.
Deficiencies in Linen Handling and Legionella Management
Penalty
Summary
The facility failed to ensure proper handling of linens to prevent contamination. During an observation, a State tested Nursing Assistant (STNA) was seen carrying two large stacks of linens pressed against her body and the door while entering a code to unlock doors, confirming that the linens were transported uncovered and pressed against her body. Additionally, in the laundry room, it was observed that gowns were not worn by the Laundry Aide when handling soiled linens, which could lead to cross-contamination. The facility also lacked an appropriate Legionella water management program. The Legionella Risk Assessment indicated a high risk for Legionella, but the Administrator and the Director of Environmental Services (DES) were not familiar with the necessary elements of the plan. The DES was unable to articulate routine control measures, and there was no regular monitoring of water temperatures or flushing of faucets in empty rooms to prevent Legionella growth. The facility's policy required competent personnel to carry out maintenance and monitoring, but this was not effectively implemented.
Sanitation Deficiency in Memory Care Unit Kitchen
Penalty
Summary
The facility failed to maintain a clean and sanitary serving kitchen in the secured memory care unit, which had the potential to affect 18 residents. During an observation, the floor was found to be sticky and covered in food debris and splatters, with a build-up of food debris in the corners and along the bottom of the cabinets and equipment. The stickiness of the floor was significant enough to cause a shoe to become partially stuck. Additionally, there were splatters and dried food on the front of the lower cabinets and on the wall behind the kitchen sink and steam table. The juice machine also had a build-up of a sticky substance behind the nozzles and along the wall next to it. Dietary Staff #342 confirmed the presence of food build-up on the floor, the stickiness of the floor, and the need for cleaning the juice machine, cabinets, and walls. The staff member was unable to recall the last time the serving kitchen had been cleaned, stating that she attempted to clean it once a week during her dinner service shifts, but could not remember the last time she worked that shift. A subsequent observation revealed that while the floors had been swept and mopped and the juice machine wiped down, dried food remained on the lower cupboards and walls behind the steam table, next to the juice machine, and behind the sink.
Sanitation and Odor Issues in Facility
Penalty
Summary
The facility failed to maintain a clean and sanitary environment for its residents, as evidenced by the condition of Resident #4's wheelchair and the persistent odor in Resident #15's room. Resident #4, who has severe cognitive impairment and multiple health conditions, was observed in a wheelchair that was heavily soiled with dirt, food crumbs, and an intact pretzel. Despite the facility's protocol for cleaning wheelchairs on shower days and as needed, the wheelchair remained dirty over multiple observations. Staff interviews confirmed the lack of cleanliness, indicating a lapse in the facility's maintenance procedures. Additionally, Resident #15's room was consistently malodorous over several days, with staff acknowledging the persistent unpleasant smell. The Director of Nursing also verified the odor issue, highlighting a failure in maintaining a comfortable and odor-free environment for residents. Furthermore, the dining room was found to have food debris on the floor from the previous night's dinner, which was not cleaned up by the kitchen staff during breakfast service. This indicates a broader issue with cleanliness and sanitation practices within the facility.
Failure to Maintain Resident Dignity Post-Meal
Penalty
Summary
The facility failed to ensure the dignity of a resident, identified as Resident #33, by not cleaning them up after meals. Resident #33, who has dementia, a history of stroke, and aphasia, was observed sitting in a wheelchair at a dining room table with food spilled on their shirt saver and lap blanket. Despite multiple staff members, including nursing students and State Tested Nursing Assistants (STNAs), passing by the resident, none addressed the spilled food on the resident's clothing or provided assistance. This lack of action persisted over a period of time, as various staff members were observed walking past the resident without offering help. Further observations revealed that Resident #33 had a quarter-sized glob of oatmeal in their hair, food on their headband, and dried food on their face and right hand. These conditions were verified by a Licensed Practical Nurse (LPN) during an interview. The facility's policy on resident rights emphasizes treating each resident with respect and dignity, which was not upheld in this instance, as the resident remained in a soiled state for an extended period, affecting their dignity and quality of life.
Call Light Accessibility Deficiency
Penalty
Summary
The facility failed to ensure that call lights were within reach of residents, specifically affecting one resident. The medical record for the resident indicated a history of bipolar disorder, panic disorder, anxiety, and epilepsy, and the care plan, revised in October 2024, included an intervention to keep the call light within reach due to the resident's need for assistance with activities of daily living and fall risk. However, during an observation, the call light was found at the bottom of the bed, out of the resident's reach. A State Tested Nursing Assistant confirmed the call light's location and acknowledged that the resident was capable of using it to communicate needs. The facility administrator admitted that there was no policy in place regarding call lights.
Failure to Notify Physician and Family of Missed Medications
Penalty
Summary
The facility failed to ensure that the physician and responsible party were notified when medications were not administered as ordered by the physician. This deficiency affected a resident who was moderately cognitively impaired and required substantial assistance with activities of daily living. The resident had multiple diagnoses, including type II diabetes mellitus, seizure disorder, and depression, among others. The resident's physician orders included medications for diabetes, atrial fibrillation, Alzheimer's disease, benign prostatic hypertrophy, and depression. The Medication Administration Record (MAR) for October 2024 showed that an LPN documented that the resident was nauseated or vomiting, leading to missed doses of several medications on multiple occasions. The LPN confirmed that the resident refused the bedtime doses of medications, including insulin, an anticoagulant, and mood disorder medications, on specific dates. However, there was no evidence that the physician or the resident's family were notified of these medication refusals, which was a requirement according to the facility's policy on Notification of Change of Condition.
Failure to Implement Fall Interventions
Penalty
Summary
The facility failed to implement fall interventions for a resident, leading to a deficiency in ensuring a safe environment free from accident hazards. Resident #9, who was admitted with diagnoses including osteoarthritis, dementia, anxiety, and bipolar disorder, was identified as being at risk for falls. The resident's care plan, revised in October 2024, included the use of a fall mat as an intervention. However, observations on two consecutive days revealed that the fall mat was not in place next to the resident's bed as required, but was instead leaning against the wall. An interview with LPN #473 confirmed that the fall mat should have been positioned next to the bed when the resident was in bed, indicating a failure to adhere to the care plan. The facility's Falls Management policy, revised in December 2019, mandates that care plans be reviewed and updated to reflect the current needs of residents to prevent falls.
Failure to Serve Meals at Appetizing Temperature
Penalty
Summary
The facility failed to ensure that meals were served at an appetizing temperature, affecting two residents who received food from the secured memory care unit serving kitchen but did not reside on the secured unit. Resident #98 and Resident #3, both alert and aware, reported that their meals were consistently cold when served in their rooms. Observations confirmed that the lunch meal cart was delivered to the serving kitchen with food temperatures initially within acceptable ranges. However, the plates used were not heated, and there were no insulated bases or lids to maintain the food's temperature. The clear plastic covers used had holes, which contributed to the cooling of the food. Further observations revealed that the meals were plated and placed on an open cart without sufficient covers, leading to a delay in delivery. Approximately 30 minutes after plating, the meals were delivered, resulting in cold food. Resident #3 reported that the burger was cold and the cheese unmelted, while the soup was lukewarm. A test tray confirmed that the food temperatures had dropped significantly, with mashed potatoes at 113 degrees F, pureed green beans at 100 degrees F, and soup at 110 degrees F. The Resident Council Meeting Minutes from May and June also documented concerns about food temperatures, indicating a recurring issue.
Failure to Administer Pneumococcal Vaccinations
Penalty
Summary
The facility failed to ensure that residents were offered or administered pneumococcal vaccinations according to CDC recommendations. This deficiency affected two residents. Resident #22, who was cognitively intact, had not received an updated pneumococcal vaccine since 2017. Although the resident initially consented to receive the PCV20 vaccine, she later refused it, believing she was not due for another dose for ten years. The facility did not provide evidence that Resident #22 was educated on the different pneumococcal vaccinations and CDC recommendations until the day of the survey. Resident #30, who was moderately cognitively impaired, had no record of being offered or receiving a pneumococcal vaccination. The resident's representative had consented to influenza and COVID-19 vaccines, but the pneumococcal vaccination section was left blank. An email communication with the resident's representative did not mention the pneumococcal vaccine. The facility's policy required that each resident be offered the pneumococcal immunization upon admission, with education provided regarding its benefits and potential side effects, but this was not followed for Resident #30.
Medication Administration Error Due to Non-Compliance with Physician Orders
Penalty
Summary
The facility failed to ensure medications were administered as ordered by the physician, resulting in a medication error rate of 25%, which is above the acceptable threshold of 5%. During an observation of medication administration, an LPN prepared and crushed several medications for a resident without a physician's order to do so. The medications included Amlodipine, Cholecalciferol, Citalopram, Famotidine, Ferrous Sulfate, Magnesium Oxide, Senna-Docusate Sodium, and Calcium Citrate. The LPN confirmed that there was no physician order to crush the medications, which was a deviation from the facility's medication administration procedure. The facility's procedure requires medications to be administered according to the written orders of the attending physician. Crushing medications is only permitted if indicated in the resident's orders and the Medication Administration Record (MAR), ensuring all personnel are aware and the consultant pharmacist can advise on safety issues. The failure to adhere to these procedures led to a medication error rate of 25%, affecting one of the three residents observed during the medication administration process. This deficiency was investigated under Complaint Number OH00158467.
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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