Park Center Healthcare And Rehabilitation
Inspection history, citations, penalties and survey trends for this long-term care facility in Youngstown, Ohio.
- Location
- 5665 South Ave, Youngstown, Ohio 44512
- CMS Provider Number
- 365185
- Inspections on file
- 41
- Latest survey
- August 11, 2025
- Citations (last 12 mo.)
- 30
Citation history
Health deficiencies cited at Park Center Healthcare And Rehabilitation during CMS and state inspections, most recent first.
The facility did not ensure food was served at palatable temperatures, affecting several residents. An LPN and residents reported issues with cold and unpalatable food, including spoiled milk and hard food. Observations confirmed inadequate food temperatures, with brussels sprouts being barely warm. The facility's policy lacked specific temperature guidelines.
A facility failed to involve a resident's Power of Attorney in care planning, affecting a resident with severe cognitive impairment and multiple diagnoses. Despite the facility's policy to include responsible parties in care conferences, the resident's representative was not contacted about changes in the resident's condition or invited to care meetings. Facility staff confirmed the lack of documentation for such invitations, and a care conference was missed.
A resident with Alzheimer's and other health issues experienced a significant decline in their ability to perform ADLs, including increased assistance needed for transfers and incontinence. Despite these changes, the facility failed to notify the resident's physician and responsible party in a timely manner, as required by their policy. Interviews with staff confirmed awareness of the decline, but communication with the family and physician was lacking.
A resident with Alzheimer's and other conditions experienced a decline in continence without a scheduled toileting program being implemented. Despite assessments indicating a need for such a program, facility staff did not establish one, and the resident's family was not informed of the incontinence issue. Interviews with staff confirmed the oversight, and the resident's decline in mobility was noted during therapy.
The facility failed to ensure a safe, functional, sanitary, and comfortable environment for residents, with issues such as holes in drywall, scuff marks, chipped paint, and dirt build-up in elevators and hallways. Residents expressed a desire for updates, and staff confirmed these observations, indicating non-compliance with the facility's policy on maintaining a homelike environment.
The facility failed to properly store and serve food, affecting all 92 residents. Undated food items were found in the refrigerator, and two dietary aides were observed without hair nets during tray service. The Director of Kitchen Operations confirmed these practices violated the facility's policies on food storage and dress code.
The facility failed to maintain a clean and homelike environment, affecting multiple residents. Observations revealed an overflowing sharps container, built-up dirt, and dried spit in a resident's room. Another hall had a black substance along baseboards, food and clothing on the floor, and uncleaned coffee spills. An LPN confirmed floors were not cleaned on weekends, despite policies requiring daily cleaning.
The facility failed to provide therapeutic activities as scheduled and in the evenings, affecting all 92 residents. Activity calendars showed a lack of scheduled activities after 4:00 P.M. and minimal weekend activities. Residents and staff reported dissatisfaction with the activity program, and the Activity Director admitted to not scheduling one-on-one visits or documenting refusals. The facility's policies on programming and preparation for activities were not followed.
The facility failed to store Tuberculin Purified Protein and Lispro Insulin properly, as both were found undated in the medication storage room. This deficiency affected a resident prescribed Lispro Insulin and had the potential to affect all residents in the facility.
The facility failed to ensure they had a qualified food service director, affecting all 92 residents who received food from the kitchen. The FSD had no formal dietary education, lacked necessary certifications or experience, and the quality of food was a significant issue. Interviews and record reviews confirmed the FSD did not meet the qualifications outlined in the facility's job description.
The facility failed to ensure a well-balanced menu in terms of calcium sources for all residents. Observations and interviews revealed that almost no residents were receiving milk with their lunch and dinner trays, and alternative calcium sources were not offered. The facility had communicated that milk would only be served at breakfast unless requested, but this information was not consistently provided to new residents. Dietary preferences were not consistently obtained or documented.
The facility failed to honor resident food preferences and provide appropriate substitutions, leading to widespread dissatisfaction with the food service. Residents were not routinely asked about their preferences, and alternate meal options were not provided if they disliked the scheduled menu items. The facility's policies on menus and resident rights were not being followed, contributing to ongoing issues with food quality and menu options.
The facility failed to follow proper sanitation practices in the kitchen and during meal tray delivery, including not washing hands, wearing artificial nails, improper sanitization of utensils, and delivering uncovered beverages. These actions were confirmed by the Food Service Director and violated the facility's policies.
The facility failed to maintain proper sanitation around the dumpster area, with one lid open and significant debris buildup, including medical gloves, plastic spoons, cigarette butts, and paper towels. The Food Service Director confirmed the area should be kept clean and the lids closed, as per facility policy.
The facility failed to administer its resources effectively and efficiently, impacting the well-being of all 92 residents. Issues included a lack of therapeutic activities, inadequate infection control measures, dietary issues, and environmental deficiencies. The Administrator and DON did not have effective systems in place to identify and correct these concerns, leading to substandard quality of care.
The facility failed to address ongoing food quality concerns, affecting all 92 residents. Food audits and Resident Council meetings revealed consistent dissatisfaction with food quality, lack of variety, and insufficient portions. Despite awareness of these issues, the administration and Food Service Director did not take effective corrective actions. The facility's QAPI plan was not effectively implemented to resolve the identified problems.
The facility failed to follow appropriate infection control procedures, including TBP and EBP, separation of clean and dirty linens, and proper storage of medical equipment. Staff lacked formal education on these precautions, and medical records showed no physician's orders for many residents. Additionally, the facility did not have an effective Legionella water management program.
The facility failed to provide knives on meal trays, affecting 64 residents, and did not ensure a privacy curtain for a resident, compromising their dignity and privacy. Despite having an adequate supply of knives and a request for a privacy curtain, the issues were not addressed, violating the facility's policies on resident rights and a homelike environment.
The facility failed to resolve ongoing food-related concerns expressed by residents, including repetitive meals, insufficient portions, and lack of alternatives for disliked items. Despite repeated complaints in Resident Council meetings and interviews, the Food Service Director's responses were unsatisfactory, and the Administrator was often too busy to address the concerns. The issues persisted due to inadequate follow-up and checks.
The facility failed to repair or replace broken window blinds for 14 residents and did not provide an adequately clean room for one resident. Observations revealed built-up visible dust and broken window blinds, which were confirmed by STNAs. The Director of Environmental Services acknowledged the issues but admitted that monthly audits for repairs or cleanliness were not conducted.
The facility failed to ensure proper storage and administration of oxygen and nebulizers according to physician's orders, affecting five residents. Observations revealed undated and improperly stored equipment, with staff confirming these deficiencies.
The facility failed to ensure call lights were within reach for two residents, leading to a deficiency in accommodating their needs and preferences. One resident's call light was hanging out of reach, and another's call light had fallen behind a dresser, making it inaccessible.
The facility failed to maintain a resident's funds under the Medicaid limit and did not notify the guardian when the funds exceeded the limit. The resident had multiple diagnoses, including secondary Parkinsonism and schizophrenia.
The facility failed to document a resident's end-of-life wishes in the medical record, despite the resident being cognitively intact and having multiple diagnoses. An LPN confirmed the absence of a code status in the EMR, contrary to facility policy.
The facility failed to thoroughly investigate potential resident-to-resident abuse, affecting two residents with severe cognitive impairments. The investigation did not include interviews or skin assessments of other residents on the unit, and there was no evidence of staff education on abuse following the incident.
The facility failed to ensure accurate dental status documentation for two residents. One resident's MDS assessment did not reflect missing teeth, and another's MDS assessment inaccurately stated the presence of natural teeth despite the resident not having any. An LPN confirmed these inaccuracies.
The facility failed to update care plans for three residents to reflect their current needs, including psychosis, dementia, and significant weight loss. Interviews with staff confirmed the deficiencies.
The facility failed to provide consistent showers and nail care according to resident preferences, affecting two residents. One resident did not receive showers as per his preference and physician's orders, while another had long and dirty fingernails despite expressing a desire to have them trimmed. Interviews and observations confirmed these deficiencies.
The facility failed to ensure adequate supervision and safety measures for three residents, leading to deficiencies in accident prevention. One resident at risk for elopement was found unsupervised outside, another resident with cognitive impairment was observed smoking unsupervised without a required apron, and a third resident at high risk for falls was found without necessary fall prevention interventions in place.
The facility failed to ensure accurate weights were obtained as ordered for two residents, leading to a deficiency in maintaining proper nutrition and hydration. Both residents had gaps in their weight records, and staff interviews confirmed that weights were not consistently obtained despite reminders.
The facility failed to ensure accurate dialysis orders and complete pre and post dialysis assessments for a resident with end stage renal disease. The resident's medical record showed missing vitals and weights on several occasions, and staff interviews confirmed inconsistent assessment practices and unclear blood draw instructions.
The facility failed to ensure staff were aware of known PTSD triggers for three residents, leading to inadequate care plans and lack of specific interventions. Despite residents communicating their triggers, this information was not included in their care plans or made accessible to staff.
The facility failed to document appropriate justifications for declining a GDR recommendation for a resident. The resident, with multiple diagnoses including dementia, was on Olanzapine. A pharmacist recommended clarifying the diagnosis and updating the EMR, but this was not addressed by the psychiatric nurse practitioner. An LPN confirmed the recommendation was not addressed, contrary to facility policy.
The facility failed to ensure non-pharmacological interventions were attempted before administering pain medication to a resident with multiple diagnoses, including COPD and lung cancer. The resident received morphine even when reporting a pain level of zero, and the LPN confirmed that non-pharmacological interventions were not documented. The facility's pain management policy was not followed.
The facility failed to ensure appropriate diagnoses for medications and did not track behaviors for medication efficacy for three residents. Medications were prescribed without documented indications, and behavior tracking was not conducted as required by facility policy.
The facility failed to document daily weights for a resident with congestive heart failure, did not ensure a resident's diet order matched their dietary needs, and lacked documentation of weekly body audits for a resident with a Stage IV pressure ulcer. These deficiencies were confirmed by the ADON and RD.
The facility failed to ensure a functional call light system for three residents, affecting their ability to request assistance. Despite residents reporting non-functional call lights, no work orders were submitted, and the maintenance department did not conduct routine audits. This oversight compromised resident safety and care.
Deficiency in Food Temperature and Palatability
Penalty
Summary
The facility failed to ensure that food served to residents was palatable and at appropriate temperatures, affecting four out of six residents reviewed for food and nutrition. Interviews with an LPN and several residents revealed complaints about food being served cold and not being palatable. One resident reported receiving spoiled milk, and another mentioned that the food was sometimes too hard. These issues were corroborated by observations during a tray line inspection, where food temperatures were recorded as being below the expected levels for hot food, with pasta and brussels sprouts not reaching adequate temperatures. The facility's policy on Food and Nutrition Services, dated October 2017, stated that residents should be provided with a nourishing and palatable diet, but it did not specify a temperature range to maintain palatable food temperatures. During the inspection, the Dietary Manager verified that the temperatures of various food items, including iced tea, milk, mandarin oranges, pasta with sausage, and brussels sprouts, were not within acceptable ranges, with the brussels sprouts being barely warm. This deficiency was investigated under Complaint Number OH00160967.
Failure to Involve Resident's Representative in Care Planning
Penalty
Summary
The facility failed to ensure that a resident's responsible party was included in the development and revision of the care plan. This deficiency affected a resident with severe cognitive impairment and multiple diagnoses, including Alzheimer's disease, anxiety disorder, chronic ischemic heart disease, and type two diabetes. The resident required assistance with certain activities of daily living (ADLs) and had a care plan that included interventions for neurological deficiencies and ADL self-care deficits. Despite these needs, the facility did not involve the resident's Power of Attorney (POA) in care planning discussions. The facility's records showed that the resident's care plan was reviewed and updated, and the resident and family were informed of changes. However, there was no evidence that the resident's representative was included in the quarterly assessments related to care planning. The resident's POA reported not being contacted about changes in the resident's condition or invited to care conferences, except for one near the time of admission. The POA expressed difficulty in communicating with facility staff and a desire to discuss the resident's placement in a secured unit. Interviews with facility staff revealed that care conferences were supposed to occur every three months and that responsible parties were to be invited via phone calls or emails. However, the staff confirmed that there was no documentation of such invitations for the resident's care conferences, and a care conference that should have occurred in October did not take place. The facility's policy emphasized the importance of involving residents and their representatives in care planning, but this was not adhered to in this case.
Failure to Notify of Resident's Change in Condition
Penalty
Summary
The facility failed to ensure timely notification of a change in condition for a resident, identified as Resident #45, to both the resident's primary care physician and responsible party. Resident #45, who had a history of Alzheimer's disease, white matter disease, anxiety disorder, chronic ischemic heart disease, and type two diabetes, experienced a significant decline in their ability to perform activities of daily living (ADLs). This included increased assistance needed for transfers, incontinence of bladder, and extensive assistance required for feeding. Despite these changes, there was no evidence that the resident's physician or responsible party were notified in a timely manner. On January 12, 2025, progress notes indicated that Resident #45 required increased assistance with ADLs and was incontinent of bladder, yet there was no documentation of notification to the physician or responsible party. The following day, the resident appeared fatigued and lethargic, prompting a call to the on-call Nurse Practitioner, who ordered laboratory tests. However, the responsible party was still not informed of these developments. Interviews with facility staff, including a Certified Nursing Assistant and a Registered Nurse, confirmed awareness of the resident's decline, but communication with the family member or physician was lacking. The facility's policy on notification of significant change in resident condition mandates prompt communication with family members or designated Power of Attorney within a reasonable timeframe, typically within 24 hours. Despite this policy, the responsible party, identified as Family Member #672, reported not being informed of the resident's condition changes, including incontinence and the need for incontinence briefs. Interviews with facility staff, including the Social Services Director and Clinical Director, revealed lapses in communication and documentation, contributing to the deficiency identified during the investigation of Complaint Number OH00161689.
Failure to Implement Toileting Program for Resident
Penalty
Summary
The facility failed to ensure that a resident, identified as Resident #45, was provided with appropriate toileting assistance to maintain their ability to perform activities of daily living, specifically toileting. Resident #45, who had diagnoses including Alzheimer's disease and chronic ischemic heart disease, was initially assessed to have high restorative potential for bowel and bladder continence. However, subsequent evaluations showed a decline to moderate restorative potential, indicating a need for a toileting program, which was not implemented. Despite the resident's care plan indicating the need for supervision and verbal cues for toileting, there was no evidence of a scheduled toileting program or trial to manage the resident's continence. Interviews with facility staff, including a registered nurse and the clinical director, revealed that although the resident was assisted to the bathroom, it was not done on a schedule. The clinical director acknowledged the lack of a scheduled toileting program and could not provide a reason for the oversight. The resident's family member, who was also the power of attorney, was not informed about the resident's incontinence or the use of incontinence briefs until it was mentioned by an aide. The director of nursing confirmed that no scheduled toileting program was implemented, despite the resident's decline in continence. The occupational therapist working with the resident was not informed of incontinence issues, and the resident's decline in mobility was noted during therapy sessions.
Environmental Deficiencies in Facility
Penalty
Summary
The facility failed to maintain a safe, functional, sanitary, and comfortable environment for its residents, as evidenced by multiple physical environment concerns observed during a survey. On the 300 hallway, there were 12 holes in the drywall, and the elevator near the activities room had excessive scuff marks, chipped paint, and dark debris in the corners. Similar issues were noted with the elevator entrance on the 300-hall. The flooring on the 200 and 300 halls had noticeable dark scuff marks and a build-up of a black, dirt-like substance along the baseboards. Additionally, the 300 hall unsecured unit had a PVC pipe protruding from the wall, and the secured unit had a PVC pipe and metal brackets extending from the wall at shoulder height. Further observations included a detached door frame in a resident's room, a build-up of dark dirt-like substance in the corners of the elevator near the rehab entrance, and a missing corner piece on the hand railing in the 200 hall, exposing a sharp edge. Interviews with several residents revealed a desire for the environment to be updated, and the Housekeeping Supervisor and Maintenance Director confirmed the observations. The facility's policy on providing a safe, clean, comfortable, and homelike environment was not adhered to, leading to this deficiency, which was investigated under multiple complaint numbers.
Food Storage and Hygiene Deficiencies
Penalty
Summary
The facility failed to ensure proper storage and serving of food, which could potentially affect all 92 residents. During a kitchen tour, it was observed that a two-quart container of chicken noodle soup, slices of bologna, sliced ham, hard-boiled eggs, and a package of cake mix were stored without dates in the refrigerator. The Director of Kitchen Operations confirmed these items should have been dated. Additionally, during tray service observation, two dietary aides were found not wearing hair nets, which was verified by the Director of Kitchen Operations as a requirement according to the facility's dress code policy. The facility's policies on food storage and dress code were not adhered to, leading to these deficiencies.
Facility Fails to Maintain Clean and Homelike Environment
Penalty
Summary
The facility failed to maintain a clean and homelike environment, affecting multiple residents across different halls. During a tour of the building, surveyors observed an overflowing sharps container with used razors in the shower room on Hall 2A, and razors were also found on top of the container. In Resident #42's room, there was built-up dirt in the bathroom corners, and dried spit was found on the floor, wall, and register. These findings were confirmed by a registered nurse and state-tested nurse aides present during the observations. Further observations on Hall 3B revealed a black substance along the baseboards, and Resident #72's room had food and clothing on the floor, along with built-up dirt at the door threshold. In the room shared by Residents #52, #62, and #65, dried and wet coffee was found on the floor, and a garbage can was without a bag. Clothing was also found on the floor. These findings were verified by an LPN, who noted that floors were not cleaned on weekends. The Director of Environmental Services confirmed that resident rooms were supposed to be cleaned daily, as per the facility's housekeeping checklist and room cleaning policy, which were not dated. The facility's Quality of Life-Homelike Environment policy, dated August 2009, emphasized providing a safe, clean, and homelike environment.
Failure to Provide Therapeutic Activities for All Residents
Penalty
Summary
The facility failed to ensure that all residents were provided with therapeutic activities as scheduled and in the evenings to meet their needs and preferences. The activity calendars for several months revealed a lack of scheduled activities after 4:00 P.M. and minimal activities on weekends. Additionally, there were no religious services scheduled for any of the months reviewed, and no specific activity calendar was provided for residents residing on the secured behavior unit (unit 3A). This deficiency affected all 92 residents in the facility, as evidenced by the lack of documented activity attendance and one-on-one visits for many residents. Interviews with residents and staff revealed dissatisfaction with the current activity program. Residents expressed that they were not asked for input on the activities they would like to see offered and that outings had been canceled for several months due to the lack of a driver for the facility van. Several residents reported that they had not received activity packets or one-on-one visits, and some activities listed on the calendar were either canceled or not conducted as scheduled. Staff members also confirmed that the secured unit did not receive updated activity calendars and that residents on this unit were not engaged in meaningful activities. The Activity Director (AD) admitted to not scheduling one-on-one visits and confirmed that the activity staff did not document refusals from residents. The AD also revealed that there was no specific training provided when she took over the position and that the facility did not have a formal checklist for activity director training. The Administrator confirmed that the facility had an operational van, but the AD was not comfortable driving it, resulting in the cancellation of social outings. The facility's policies on programming for residents with cognitive impairments and preparation for activities were not being followed, leading to a significant deficiency in providing meaningful and therapeutic activities for all residents.
Failure to Properly Date and Store Medications
Penalty
Summary
The facility failed to store Tuberculin Purified Protein and Lispro Insulin in a manner that ensures the efficacy of the medications. During an observation of the medication storage room, it was found that an open container of Tuberculin Purified Protein and an open vial of Lispro Insulin for a resident were undated. The package inserts for these medications indicate that Tuberculin Purified Protein should be discarded if in use for more than 30 days, and Lispro Insulin should be used within 28 days of opening. The facility's policy requires that the date of opening be recorded on multi-dose containers, which was not followed in this instance. This deficiency affected one resident prescribed Lispro Insulin and had the potential to affect all residents in the facility, which had a census of 92 at the time of the survey. An interview with the RN confirmed that both vials were undated, and a review of the facility policy corroborated that the date should be recorded on multi-dose containers when opened. The failure to date these medications could lead to the use of degraded or ineffective drugs, compromising resident care.
Unqualified Food Service Director
Penalty
Summary
The facility failed to ensure they had a qualified food service director, which had the potential to affect all 92 residents who received food from the kitchen. The Food Service Director (FSD) #499, who had no formal dietary education and had previously worked as the housekeeping director, was found to be unqualified for the position. The FSD had only a food protection manager certificate and lacked the necessary certifications or experience required for the role. Interviews with the FSD, a resident, and the registered dietitian revealed that the dietitian was not regularly involved in the kitchen, recipes were not always followed, and the quality of food was a significant issue at the facility. The personnel file review confirmed that FSD #499 did not meet the qualifications outlined in the facility's job description for the food service director position. The job description required a certified dietary manager or similar national certification, an associate degree in food service management or hospitality, or at least two years of experience as a director of food and nutrition services in a nursing facility. The FSD's certificate as a food protection manager was deemed equivalent to the ServSafe program but did not meet the higher qualifications required for the role. This deficiency was identified through interviews and record reviews conducted over several days, highlighting the facility's failure to employ a qualified individual to oversee the dietary department and ensure the quality of food service provided to residents.
Deficiency in Providing Calcium Sources in Resident Meals
Penalty
Summary
The facility failed to ensure that the menu was well-balanced in terms of calcium sources for all residents. This deficiency was identified through observations, interviews, and policy reviews. Specifically, it was noted that almost no residents were receiving milk with their lunch and dinner trays, despite the menu indicating that milk should be provided at all meals. The facility had sent letters to residents stating that milk would only be served at breakfast unless requested otherwise, but this information was not included in the admission packet or consistently communicated to new residents. Additionally, alternative calcium sources such as yogurt or cottage cheese were not offered to residents who did not want milk. Interviews with residents and staff revealed that dietary preferences were not being consistently obtained or documented, and residents were not aware of their options for calcium intake. The dietary cook confirmed that beverage carts were stocked with Kool-Aid and coffee, but not milk. The dietitian acknowledged the lack of documentation regarding residents' preferences for milk or calcium alternatives. The administrator admitted that the facility had not offered other calcium options at lunch and dinner and was unsure how new residents would be informed about the milk policy. The facility's policy stated that menus should provide a variety of foods from the basic daily food groups and offer alternatives if a food group was missing, but this was not being followed in practice.
Failure to Honor Resident Food Preferences and Provide Appropriate Substitutions
Penalty
Summary
The facility failed to ensure resident food preferences were honored and appropriate substitutions were made per resident preferences. Observations and interviews revealed that residents were not offered alternate vegetables or meal options if they disliked the scheduled menu items. For instance, during a meal service, no alternate vegetable was prepared, and residents who disliked the main dish were not provided with suitable alternatives. The Food Service Director confirmed that the facility did not offer a select menu, and residents were served whatever the kitchen prepared, which often did not align with their preferences. Additionally, the number of meal item dislikes that could be listed on a resident's tray card was limited, leaving staff to memorize multiple dislikes, which was not always feasible. Interviews with residents and staff highlighted ongoing dissatisfaction with the food quality and menu options. Residents reported that they were not routinely asked about their food preferences and that substitutions were not offered if they disliked certain items. For example, if a resident did not like peas, no alternate vegetable was provided. The Dietary Supervisor admitted to not preparing alternate vegetables and stated that requests for specific items like grilled cheese sandwiches were sometimes refused due to staffing issues. The Dietitian confirmed that food preferences were not routinely documented or honored, and there was no system in place to offer calcium alternatives when milk was not served at lunch and dinner. The facility's policies on menus and resident rights were not being followed. The Resident Council was supposed to be included in menu planning, and menus were to provide a variety of foods from the basic daily food groups. However, residents were not being offered alternate means of meeting their nutritional needs when certain food groups were missing from their diet. The Administrator acknowledged that residents were not happy with the menu and that the facility had not effectively communicated changes in meal service, such as the decision to serve milk only at breakfast unless requested. This lack of communication and failure to honor resident preferences contributed to widespread dissatisfaction with the food service at the facility.
Sanitation and Hygiene Deficiencies in Food Service
Penalty
Summary
The facility failed to ensure proper sanitation practices in the kitchen and during meal tray delivery, potentially affecting all 92 residents. Observations revealed that Dietary Cook and Dietary Aide did not wash their hands upon returning to the kitchen after delivering meal trays. Additionally, the Dietary Cook was observed wearing artificial nails with three-dimensional art, which is against the facility's dress code policy. The Food Service Director confirmed these observations and acknowledged that staff should wash their hands upon re-entering the kitchen and that artificial nails are not permitted for dietary employees. Further observations showed that the Dietary Supervisor did not follow proper sanitization procedures while preparing pureed food, as items were only washed and rinsed but not sanitized. Additionally, state-tested nursing assistants were seen delivering uncovered beverages, such as coffee and Kool Aid, down the hallway, which the Food Service Director confirmed should be covered or delivered using a beverage cart. These actions were in direct violation of the facility's policies on preventing foodborne illness, employee hygiene, and sanitation.
Improper Disposal of Garbage and Refuse
Penalty
Summary
The facility did not maintain garbage and refuse properly in a closed dumpster free of surrounding litter. During an initial kitchen tour, it was observed that one lid of the dumpster was open while the other was closed. There was a significant buildup of debris around the base of the dumpster, including approximately 20 blue medical examination gloves, numerous plastic white spoons, numerous cigarette butts, a broken blue storage bin, a small unidentifiable white plastic bottle with a lid, and numerous dried-up white papers, which appeared to be paper towels or napkins. This lack of sanitation was confirmed by the Food Service Director, who acknowledged that the dumpster lids should be closed when not in use and the area around the dumpster should be kept clean. The facility's policy on food-related garbage and rubbish disposal, revised in December 2008, mandates that outside dumpsters be kept closed and free of surrounding litter.
Facility Fails to Administer Resources Effectively and Efficiently
Penalty
Summary
The facility failed to administer its resources effectively and efficiently, impacting the well-being of all 92 residents. The Administrator and Director of Nursing (DON) did not have effective systems in place to identify and correct quality, care, and environmental concerns. This included a lack of therapeutic activities, inadequate infection control measures, dietary issues, and environmental deficiencies. The activity calendars lacked religious services, specific activities for the secured behavior unit, and evening activities. Residents and staff confirmed the absence of therapeutic activities, and the Activity Director admitted to not receiving proper training from the Administrator. The facility's infection control program was ineffective, with multiple concerns noted during the survey. Residents on contact and enhanced barrier precautions were not accurately identified, and staff were not formally educated on these precautions. Nebulizer equipment was improperly stored, and laundry practices did not follow infection control protocols. Additionally, the facility did not conduct Legionella testing, and multi-use glucometers were not properly sanitized. The DON was unaware of these issues, indicating a lack of oversight and follow-up on infection control concerns. Dietary staff did not follow proper infection control measures, and residents' dietary preferences were not consistently met. Observations revealed staff not washing hands, recipes not being followed, and milk not being provided with meals as indicated. Residents' food preferences were not obtained, and dietary concerns raised during resident council meetings were not addressed. The facility also failed to maintain a clean, safe, and homelike environment, with non-functioning call lights and broken window blinds in multiple residents' rooms. Maintenance staff did not conduct routine audits to ensure call lights were functioning, and work orders for repairs were not consistently made or addressed.
Failure to Address Ongoing Food Quality Concerns
Penalty
Summary
The facility failed to develop and implement a system to address, analyze, monitor, and resolve quality assurance and performance improvement related to ongoing food quality concerns. This deficiency had the potential to affect all 92 residents, as none were identified as not eating by mouth (NPO). Food audits conducted from January to April revealed consistent dissatisfaction with the food quality among residents. Resident Council meeting minutes from September to March also documented ongoing dietary issues, with residents repeatedly voicing concerns about the food quality, lack of variety, and insufficient portions. Despite these complaints, no effective corrective actions were taken by the facility's administration or the Food Service Director (FSD). Interviews with the Ombudsman, FSD, Dietary Supervisor (DS), and residents confirmed the persistent food quality issues and the lack of adherence to standardized recipes. The Dietitian acknowledged the problem but had not reviewed the upcoming menu changes. The Director of Nursing (DON) and Senior Administrator were aware of the ongoing kitchen concerns but had not conducted a root cause analysis or implemented a performance improvement plan. The facility's Quality Assurance Performance Improvement (QAPI) meetings discussed the food issues, but no substantial actions were taken to resolve them. The facility's policy on QAPI, revised in April 2014, mandates the development and maintenance of an ongoing plan to monitor and improve care quality, which was not effectively implemented in this case.
Infection Control Deficiencies in LTC Facility
Penalty
Summary
The facility failed to ensure appropriate infection control procedures were followed regarding transmission-based precautions (TBP) and enhanced barrier precautions (EBP). Observations revealed that several residents who were supposed to be on TBP or EBP did not have the necessary signage or personal protective equipment (PPE) outside their rooms. Interviews with staff confirmed a lack of formal education on these precautions, and medical records showed no physician's orders for TBP or EBP for many residents. This affected multiple residents and had the potential to impact all residents in the facility. The facility also failed to separate clean and dirty linens as required. Housekeepers admitted that both clean and dirty laundry entered and exited the laundry room through the same door, contrary to facility policy. This practice increases the risk of cross-contamination and infection spread among residents. Additionally, the facility did not have an effective Legionella water management program in place. The Director of Environmental Services was unaware of any documented evidence that the policy had been implemented. Furthermore, observations revealed improper storage of nebulizer masks and oxygen tubing, and multiuse glucometers were not cleaned according to facility policy. These lapses in infection control procedures were observed in multiple residents' rooms, further compromising the facility's infection prevention efforts.
Lack of Dining Utensils and Privacy Curtain
Penalty
Summary
The facility failed to ensure a dignified dining experience for residents by not providing knives on meal trays, affecting 64 residents receiving meals from the kitchen and 24 residents on the secured behavior unit. Observations revealed that residents were served meals that included items difficult to eat without a knife, such as a Hawaiian ham slice. Interviews with staff and residents confirmed that knives were typically not provided, despite the facility having an adequate supply. The Registered Dietitian had previously reported the issue to the administration, but the problem persisted. The facility's policy on resident rights emphasized treating residents with respect, kindness, and dignity, which was not upheld in this instance. Additionally, the facility did not provide a privacy curtain for Resident #45, who had been without one since admission. This resident, who had moderate cognitive impairment and various medical conditions, was unable to section off his bed and personal space for privacy. Despite the resident's request to the maintenance staff, no work order was placed for a privacy curtain. The facility's policies on maintaining a homelike environment and respecting resident rights were not followed, resulting in a lack of privacy for Resident #45.
Ongoing Food-Related Concerns Unresolved
Penalty
Summary
The facility failed to resolve ongoing food-related concerns expressed by residents during Resident Council meetings. Over several months, residents consistently reported issues with the quality and quantity of food, including repetitive meals, insufficient portions, and lack of alternatives for disliked items. Despite these repeated complaints, the Food Service Director's responses were unsatisfactory, and the Administrator was often too busy to address the concerns. Residents also reported not receiving milk at every meal, having to request alternatives an hour before meal service, and not being provided with knives during meals. These issues persisted despite being raised multiple times in Resident Council meetings and during interviews with surveyors. Interviews with the Dietary Supervisor and Registered Dietitian confirmed the residents' complaints, noting that the quality of food depended on the cook and that menu adjustments had not been adequately reviewed. The Director of Nursing acknowledged the ongoing kitchen concerns and stated that these issues were discussed during Quality Assurance Performance Improvement meetings but felt that resolving them was primarily the responsibility of the Administrator and Food Service Director. The facility lacked effective follow-up and checks to address the residents' food concerns, leading to continued dissatisfaction among the residents.
Failure to Maintain Clean and Safe Environment
Penalty
Summary
The facility failed to repair or replace broken window blinds for 14 residents and did not provide an adequately clean room for one resident. Observations revealed built-up visible dust on the chair rail in one resident's room, which was verified by a State tested Nurse Aide (STNA). Additionally, broken window blinds were observed in the rooms of 14 other residents, and these were confirmed by STNAs during the survey. The Director of Environmental Services (DES) acknowledged the issues and mentioned that resident rooms are cleaned daily and deep cleaned monthly, but admitted that monthly audits for repairs or cleanliness were not conducted. The facility uses a computer program (TELLS) to input work orders for repairs, and housekeeping staff also maintain a list of needed repairs. Despite being aware of the broken blinds and having replaced several over the past three weeks, the DES could not provide a list of the replaced blinds. The facility's policies on daily housekeeping and room cleaning were reviewed, revealing that resident rooms are supposed to be dusted daily and cleaned according to a predetermined schedule. The policy on maintaining a homelike environment emphasized the importance of providing a safe, clean, and comfortable setting for residents.
Failure to Properly Store and Administer Respiratory Care Equipment
Penalty
Summary
The facility failed to ensure that oxygen and nebulizers were stored and administered according to physician's orders, affecting five residents. Resident #52, who had diagnoses including COPD and lung cancer, had orders for oxygen at four liters continuously and nebulizer treatments. However, observations revealed that the oxygen tank was set at six liters, and the oxygen and nebulizer tubing were undated. Resident #71, diagnosed with dementia and heart failure, had nebulizer masks on the floor and undated tubing, which was confirmed by staff during the observation. Resident #246, with COPD and chronic respiratory failure, had oxygen tubing dated 04/03/24 and undated nebulizer tubing, contrary to the weekly change order. Staff interviews confirmed the discrepancies in tubing dating and storage practices for these residents. Resident #45, with multiple diagnoses including COPD and heart disease, had an uncovered nebulizer mask and undated tubing. Resident #16, diagnosed with Alzheimer's and chronic respiratory failure, had a nebulizer mask on the floor and undated nasal cannula tubing, which was also unbagged as per the physician's orders. Staff confirmed these observations during the survey. The facility's policy on oxygen and nebulizer use did not provide adequate guidelines for proper storage to prevent contamination and infection spread.
Failure to Ensure Call Lights Within Reach
Penalty
Summary
The facility failed to ensure call lights were within reach for two residents, leading to a deficiency in accommodating the needs and preferences of these residents. Resident #8, who had diagnoses including muscle wasting, irregular heartbeat, schizophrenia, emphysema, and repeated falls, was observed on 04/15/24 with his call light hanging from a box to the right upper side of his bed, out of reach. This was confirmed by an interview with STNA #429. The resident's care plan, dated 01/18/24, included interventions to minimize fall risks by ensuring the call bell was within reach, but this was not adhered to during the observation. Similarly, Resident #67, who had diagnoses including diabetes, hypertension, paralysis of the left dominant side due to stroke, and muscle weakness, was observed on 04/15/24 without her call light within reach. The resident confirmed she did not know where her call light was, and STNA #429 confirmed that the call light had fallen behind her dresser, making it inaccessible. The resident's care plan, dated 02/02/24, also included ensuring the call light was within reach to mitigate fall risks, but this intervention was not followed. The facility's policy on answering call lights, dated October 2010, was not adhered to in these instances.
Failure to Maintain Resident Funds Under Medicaid Limit
Penalty
Summary
The facility failed to ensure that resident funds were maintained under the Medicaid limit for one resident. Resident #8, who was admitted with diagnoses including secondary Parkinsonism, dysphagia, muscle wasting and atrophy, schizophrenia, anxiety, emphysema, and hypertension, had a balance in his resident fund account that exceeded the Medicaid limit on multiple occasions. Specifically, the balances were $4,253.24 on 09/30/23, $4,408.45 on 12/31/23, and $4,565.29 on 03/31/24. The Business Office Manager confirmed that Resident #8's guardian was not notified when the funds exceeded the Medicaid limit, which is a requirement for managing resident funds.
Failure to Document Resident's End-of-Life Wishes
Penalty
Summary
The facility failed to ensure a resident's wishes regarding end-of-life measures were clearly identified in the medical record. This deficiency affected one resident of three reviewed for Advanced Directives, with a facility census of 92. The medical record for the resident revealed an admission date and diagnoses including end-stage renal disease, colitis, anxiety, and depression. The comprehensive Minimum Data Set (MDS) 3.0 assessment indicated the resident was cognitively intact and required varying levels of assistance for daily activities. However, a review of the physician orders for April 2024 showed no evidence of a code status. An interview with an LPN confirmed that the electronic medical record (EMR) for the resident did not have a code status, despite facility policy stating that advance directives should be prominently displayed in the medical record.
Incomplete Investigation of Resident-to-Resident Abuse
Penalty
Summary
The facility failed to thoroughly investigate potential resident-to-resident abuse as required, affecting two residents. Resident #33, who had severe cognitive impairment and various mental health diagnoses, was found with a new left-hand skin tear. Resident #346, also severely cognitively impaired with behavioral disturbances, wandered into Resident #33's room, leading to a physical altercation that resulted in minor scratches and a skin tear on Resident #33's hand. The facility's Self-Reported Incident (SRI) documentation revealed that while immediate actions were taken to separate the residents and notify relevant parties, the investigation was incomplete. The Director of Nursing (DON) confirmed that the investigation did not include interviews or skin assessments of other residents on the unit who could have been affected by unwitnessed behavior. Additionally, there was no evidence of staff education on abuse following the incident. The facility's policy required thorough and objective investigations of all alleged abuse, but this was not adhered to in this case, as the investigation lacked comprehensiveness and follow-up actions to ensure resident safety and staff awareness.
Inaccurate Dental Status Documentation
Penalty
Summary
The facility failed to ensure resident assessments accurately reflected the dental status for two residents. For Resident #28, the quarterly Minimum Data Set (MDS) 3.0 assessment indicated that the resident had no broken or missing teeth, despite the care plan noting an oral health problem related to carious teeth. An observation and interview confirmed that the resident was missing some natural teeth, which was not accurately reflected in the MDS assessment. Licensed Practical Nurse (LPN) #451 confirmed the inaccuracy in the resident's dental status documentation. Similarly, for Resident #196, the comprehensive MDS 3.0 assessment stated that the resident had no broken or missing teeth, while the care plan indicated that the resident had no natural teeth and did not wear dentures. An observation and interview confirmed that the resident did not have her own natural teeth and chose not to wear dentures. LPN #451 also confirmed the inaccuracy in the MDS assessment for this resident. The facility's policy on charting and documentation requires that charting be complete and accurate, reflecting treatment and response to care, which was not adhered to in these cases.
Failure to Update Care Plans for Residents
Penalty
Summary
The facility failed to ensure care plans were updated to accurately reflect residents' needs, affecting three residents. Resident #31, who was moderately cognitively impaired, had physician orders for Olanzapine and Namenda, but the care plan did not include interventions for psychosis or dementia. Similarly, Resident #71, who was severely cognitively impaired, had physician orders for an Exelon patch and Namenda for dementia, but the care plan did not address dementia care. An interview with LPN #451 confirmed the absence of dementia and psychosis care in the care plans for these residents. Resident #50, who had multiple diagnoses including pneumonia, acute kidney failure, and dysphagia, experienced a significant weight loss of 11 pounds over a short period. Despite this, the care plan did not reflect the significant weight loss. A dietary note confirmed the weight loss, and an interview with Dietitian #503 verified that the care plan had not been updated to address this issue. The facility's policies on care plans and documentation were not followed, leading to these deficiencies.
Inconsistent Shower and Nail Care
Penalty
Summary
The facility failed to ensure showers and nail care were provided consistently and according to resident preference, affecting two residents. Resident #28, who was moderately cognitively impaired and required substantial assistance for showering, did not receive showers as per his preference and physician's orders. Despite his preference for showers on Wednesdays and Saturdays, records showed inconsistent documentation of showers and no refusals were documented. Interviews with the resident and an LPN confirmed the inconsistency in providing and documenting showers for Resident #28. Resident #50, who was severely cognitively impaired and required maximal assistance for personal hygiene, had long and dirty fingernails despite expressing a desire to have them trimmed. Observations and interviews with the resident and staff confirmed that his nails were not trimmed as required. The facility's policy on ADLs, which includes providing appropriate support and assistance with hygiene, was not followed in this case, leading to the deficiency in care for Resident #50.
Failure to Ensure Adequate Supervision and Safety Measures
Penalty
Summary
The facility failed to ensure adequate supervision and safety measures for three residents, leading to deficiencies in accident prevention. Resident #24, who was at risk for elopement due to severe cognitive impairment and a history of elopement, was observed outside the facility entrance unsupervised. Despite having a wanderguard and being identified as at risk for elopement, no follow-up elopement assessments had been conducted since 08/25/21. The facility policy required detailed monitoring for residents at high risk of elopement, which was not adhered to in this case. Resident #4, who had moderate cognitive impairment and visual deficits, was observed smoking outside unsupervised and without a required smoking apron. The resident's care plan and smoking risk assessment indicated the need for supervision and the use of a smoking apron during smoking breaks. The facility's policy mandated that all smokers be supervised and use safety aprons if they failed the smoking assessment, which was not followed for Resident #4. Resident #72, who was at high risk for falls due to severe cognitive impairment and a history of falls, was found without the necessary fall prevention interventions in place. Despite physician orders for a fall mat and a perimeter overlay mattress, these interventions were not consistently observed during the survey. The resident had experienced multiple falls, and the facility's policy required specific interventions to prevent falls, which were not adequately implemented for Resident #72.
Failure to Obtain Accurate Weights as Ordered
Penalty
Summary
The facility failed to ensure accurate weights were obtained as ordered for two residents, leading to a deficiency in maintaining proper nutrition and hydration. Resident #50, who had multiple diagnoses including pneumonia, acute kidney failure, and type two diabetes, was not weighed weekly for four weeks as required. The resident's weight was recorded on admission and then not again until 18 days later, missing the weekly weight checks. Interviews with the Registered Dietitian and Assistant Director of Nursing confirmed that weights were not consistently obtained despite reminders and emails sent to staff. The facility policy required weights to be taken on admission, the next day, and weekly for two weeks, but this was not followed for Resident #50. Similarly, Resident #196, who had diagnoses including end-stage renal disease and colitis, also did not have weights obtained weekly as ordered. The resident's weight records showed gaps in the weekly weight checks, and there was no evidence that the resident refused to be weighed. The Registered Dietitian confirmed that weights were not obtained weekly as ordered. The facility policy required weights to be taken on admission, the next day, and weekly for two weeks, but this was not followed for Resident #196 either.
Failure to Ensure Accurate Dialysis Orders and Assessments
Penalty
Summary
The facility failed to ensure accurate dialysis orders and complete pre and post dialysis assessments for Resident #196, who was diagnosed with end stage renal disease and required hemodialysis. The resident's medical record indicated that she was cognitively intact and required dialysis on specific days. However, the facility did not consistently perform pre and post dialysis assessments, as evidenced by missing vitals and weights on several occasions between January and April 2024. Additionally, the physician's order to avoid blood draws from a specific arm was not clearly specified, leading to potential confusion among the staff. Interviews with the resident and nursing staff confirmed these lapses in care, with staff admitting that pre and post dialysis assessments were not consistently completed and refusals were not documented properly. The facility's policy on caring for residents with end stage renal disease required daily or per shift documentation of the resident's condition and coordination with the dialysis facility. Despite this policy, the facility did not adhere to these guidelines, resulting in incomplete documentation and assessments. The resident reported that the facility did not perform the necessary assessments, and staff interviews corroborated this, revealing a lack of consistent practice in checking the resident's condition before and after dialysis sessions. The failure to document refusals and specify which arm to avoid for blood draws further highlighted the deficiencies in the facility's dialysis care procedures.
Failure to Identify and Communicate PTSD Triggers
Penalty
Summary
The facility failed to ensure staff were aware of known triggers for three residents with a diagnosis of post-traumatic stress disorder (PTSD). Resident #81, who was cognitively intact, reported that being woken up by an unfamiliar nurse triggered his PTSD. Despite this, the care plan for Resident #81 included avoiding potential PTSD triggers, but no specific triggers were identified or communicated to the staff. Social Services and nursing staff confirmed they were unaware of Resident #81's specific PTSD triggers, and the information was not accessible to the staff who needed it. Resident #5, who was also cognitively intact, had a history of abuse by her ex-husband and experienced anxiety and fear when working with male aides. Although she had communicated this history to the facility, her care plan did not include any specific techniques or triggers related to her PTSD. An interview with a licensed practical nurse confirmed the absence of this critical information in her care plan. Resident #45, who was moderately cognitively impaired, had a history of substance abuse and exhibited aggressive behaviors. His care plan included interventions for his cognitive loss and aggression but did not address his PTSD or identify any specific triggers. Both the Social Service Designee and the MDS Registered Nurse confirmed that Resident #45's care plan lacked information on his PTSD triggers, which was against the facility's trauma-informed care policy aimed at creating a safe and supportive environment for residents with PTSD.
Failure to Address Pharmacist's Recommendation for Antipsychotic Medication
Penalty
Summary
The facility failed to document appropriate justifications for declining a gradual dose reduction (GDR) recommendation for Resident #31. Resident #31, who was admitted with diagnoses including acute kidney failure, hypothyroidism, diabetes, dementia, and cognitive communication deficit, was moderately cognitively impaired and required supervision for certain activities. A pharmacist recommended clarifying the diagnosis and justification for the use of Olanzapine, an antipsychotic medication, and updating the electronic medical record (EMR). This recommendation was noted by the Director of Nursing (DON) but was not addressed by the psychiatric nurse practitioner as intended. An interview with an LPN confirmed that the pharmacist's recommendation had not been addressed, and a review of the facility's policy indicated that the physician should follow up on medications by changing or stopping them when necessary or documenting why the benefits outweighed the risks.
Failure to Attempt Non-Pharmacological Interventions Before Administering Pain Medication
Penalty
Summary
The facility failed to ensure non-pharmacological interventions were attempted prior to the administration of pain medication for Resident #52. The resident, who had diagnoses including COPD, lung cancer, muscle weakness, depression, and insomnia, was cognitively intact and required varying levels of assistance for daily activities. The physician's orders included Morphine Sulfate and Tylenol for pain management, but there was no specific guidance on when to administer each medication. The Medication Administration Record (MAR) showed multiple instances where morphine was administered even when the resident reported a pain level of zero, indicating unnecessary use of the opioid medication. An interview with an LPN confirmed that non-pharmacological interventions were not documented in the progress notes and that the nurse used her judgment to decide between Tylenol and Morphine, generally opting for Morphine for pain levels of five or higher. The facility's policy on Pain Assessment and Management stated that specific strategies should be used for different levels and sources of pain, but this was not followed in the case of Resident #52. This deficiency affected one resident out of seven reviewed for unnecessary medication, in a facility with a census of 92.
Failure to Ensure Appropriate Diagnoses and Behavior Tracking for Medications
Penalty
Summary
The facility failed to ensure appropriate diagnoses for medications and did not track behaviors for medication efficacy for three residents. Resident #31, who was moderately cognitively impaired, was prescribed Namenda, Olanzapine, and Duloxetine without documented indications for their use. An interview with an LPN confirmed the absence of a diagnosis for Olanzapine and the lack of behavior tracking for this resident. Similarly, Resident #35, who was cognitively intact but had anxiety and depression, was prescribed Effexor, Hydroxyzine, and Klonopin without evidence of behavior tracking, as confirmed by the same LPN. Resident #71, who was severely cognitively impaired, was prescribed Exelon, Namenda, Depakote, and Olanzapine without documented indications for their use and without behavior tracking. The facility's policy on antipsychotic medication use, which requires documentation of targeted symptoms and specific conditions for medication use, was not followed. The LPN confirmed that behaviors were usually tracked as a result of medication orders but were not tracked for these residents.
Documentation Failures in Weight Monitoring, Diet Orders, and Body Audits
Penalty
Summary
The facility failed to ensure daily weights were documented per physician orders for a resident with congestive heart failure. Despite the physician's order for daily weights to monitor heart failure, there were numerous dates over several months where weights or refusals were not documented. This was confirmed by the Assistant Director of Nursing (ADON), who acknowledged the lack of documentation for the specified dates. The facility's policy on charting and documentation requires daily treatment and vital signs to be recorded, which was not adhered to in this case. Additionally, the facility did not ensure that a resident's diet order accurately reflected their dietary needs. The resident, who had end-stage renal disease, was supposed to be on a liberalized renal diet, but the physician's orders incorrectly listed a regular diet. This discrepancy was confirmed by the Registered Dietician (RD), who verified that the diet order did not match the resident's actual dietary requirements. Furthermore, the facility failed to document weekly body audits for a resident with a Stage IV pressure ulcer as ordered by the physician. The ADON, who is also the wound care nurse, admitted that she was behind on inputting body audits and had no documented evidence to verify that the audits were completed on the specified dates. The facility's policy on the prevention of pressure ulcers requires timely and appropriate assessments, which were not documented in this instance.
Failure to Ensure Functional Call Light System
Penalty
Summary
The facility failed to ensure a functional call light system for three residents, affecting their ability to request assistance. Resident #82, who had multiple diagnoses including orthopedic aftercare and generalized muscle weakness, reported that her bathroom call light was not working. Despite informing aides months ago, no action was taken, and she resorted to carrying her cell phone for safety. Observations confirmed the call light was non-functional, and there was no work order for its repair. The facility's maintenance department only addressed call light issues when work orders were submitted, and no routine audits were conducted to ensure functionality. Resident #81, with diagnoses including a femur fracture and COPD, also had a non-functional call light. During an interview and observation, it was confirmed that the call light did not light up or sound when activated. Similar to Resident #82, there was no work order for the non-functioning call light until it was pointed out by the state surveyor. The maintenance department's lack of routine audits and reliance on work orders contributed to the oversight. Resident #27, who had paraplegia and other significant health issues, experienced a similar problem with a non-working call light. Observations confirmed that the call light did not activate, and there was no prior work order for its repair. The facility's policy required staff to report defective call lights to the nurse supervisor, but this was not effectively implemented. The maintenance department's failure to conduct routine audits and the reliance on staff-initiated work orders led to the continued malfunction of call lights, compromising resident safety and care.
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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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