Park Terrace Rehabilitation Center
Inspection history, citations, penalties and survey trends for this long-term care facility in Toledo, Ohio.
- Location
- 2735 Darlington Rd, Toledo, Ohio 43606
- CMS Provider Number
- 365339
- Inspections on file
- 44
- Latest survey
- March 11, 2026
- Citations (last 12 mo.)
- 16
Citation history
Health deficiencies cited at Park Terrace Rehabilitation Center during CMS and state inspections, most recent first.
An LPN worked while appearing to be under the influence of an illegal substance, with residents reporting late or missed medications, improper administration of pain medication after it was dropped on the floor, and the LPN falling asleep while standing and on a resident’s bed. Staff repeatedly reported the LPN’s erratic behavior to an on-call LPN, but the concerns were not promptly escalated to the DON or Administrator, and the impaired LPN completed one full shift and part of another while continuing to provide care. Residents reported not receiving medications, tube feedings, treatments, and other ordered interventions during this time. The facility’s subsequent internal review confirmed that the LPN tested positive for cocaine and that the investigation was incomplete, as not all residents were assessed or interviewed, and key oversight processes, including timely notification of the Medical Director and QAPI review, were not carried out as required by facility policies and resident care agreements.
An LPN who appeared impaired, was falling asleep while standing, dozing off during conversations, and dropping medications was allowed to continue working a full shift despite multiple reports from residents and staff to an on‑call LPN. The DON and Administrator were not fully informed that day, and the LPN was not removed from resident care. As a result, multiple residents with complex conditions such as COPD, DM2, CHF, seizures, anoxic brain damage, CKD, and depression did not receive numerous ordered medications, tube feedings, PEG flushes, respiratory treatments, blood glucose checks, insulin doses, pain assessments, behavior monitoring, head‑of‑bed elevation, enhanced barrier precautions, and other prescribed interventions during that shift, as later confirmed by EMR, MAR, and TAR review by the DON.
Multiple residents with complex medical and behavioral conditions did not receive physician-ordered care and monitoring during a day shift, including missed pain assessments, failure to elevate the HOB for residents with respiratory conditions, and lack of ordered blood glucose checks. Residents with PEG tubes did not receive prescribed flushes, placement checks, or gastric residual checks, and required SpO2 monitoring was not completed. Ordered enhanced barrier precautions were not implemented for residents requiring infection control measures, and safety interventions such as increased supervision after meals, use of an Acapella device, application of TED hose, and placement of a call-for-assistance sign were not carried out. Behavior monitoring and documentation of interventions ordered every shift were also not completed, and the DON confirmed these omissions in ordered care and services.
Surveyors found that the facility failed to administer multiple physician-ordered medications and supplements for several residents on a single day, as shown by EMR and MAR review and confirmed by the DON. Residents with complex cardiac, neurologic, respiratory, renal, and nutritional conditions did not receive ordered doses of ASA, potassium chloride, vitamin D, vitamin B12, magnesium, multivitamins, bowel regimens, nutritional supplements, topical agents, lidocaine patches, acetaminophen, and other medications. The facility’s own resident agreement and medication administration policy require adequate and appropriate medical treatment and medication administration consistent with professional standards, but these requirements were not followed in the cited cases.
Surveyors found that multiple residents with complex cardiac, respiratory, neurologic, endocrine, and psychiatric conditions did not receive numerous ordered medications on the same day, based on EMR and MAR review and confirmation by the DON. Missed medications included antihypertensives, anticoagulants, antiepileptics, psychotropics, insulin (both basal and sliding scale), oral hypoglycemics, respiratory inhalers and nebulizers, diuretics, and other chronic therapies. Residents ranged from cognitively intact to severely impaired and required varying levels of assistance with ADLs, yet their scheduled morning, afternoon, and sometimes evening doses were not administered as ordered, despite facility policies and resident agreements requiring adequate and appropriate medical treatment and nursing care.
A resident with multiple serious conditions, including anoxic brain damage, respiratory failure, dysphagia, and gastrostomy status, had physician orders for Jevity 1.5 bolus tube feedings every four hours and PEG flushes with 60 mL water before and after each feeding and every four hours. EMR and MAR review showed that on one day the resident did not receive the ordered bolus feedings or PEG flushes at two scheduled administration times, contrary to physician orders, the facility’s medication administration policy, and the resident’s right to adequate and appropriate medical and nursing care.
A resident with schizophrenia, PTSD, anxiety, and depression, and with moderate cognitive impairment, had an altercation in the dining room with a CNA over returning a meal tray. The resident became visibly distressed and cried as the CNA stood in close proximity with assertive body language, leading another CNA to intervene and escort the resident away. An LPN documented the incident and notified the unit manager and physician, but did not treat or report it as a possible abuse allegation. The resident later reported to an outside provider that an aide had gotten in her face and also left a voicemail for an admissions manager describing the incident, but this voicemail was not identified promptly. The administrator did not become aware of the allegation until days later, during which time the CNA continued working on the unit, resulting in a failure to timely report an abuse allegation as required by the facility’s abuse policy.
A resident with significant mobility and medical needs was injured when a bed rail detached during in-bed care, causing a fall and a displaced upper arm fracture. Staff interviews and documentation revealed the bed rails had been installed incorrectly on the bed frame, were previously reported as loose, and were not compatible with the bed's crossbar. The facility lacked the correct user manual for the bed rails, and staff had previously adjusted the rails improperly, leading to the incident.
Multiple residents with severe cognitive and physical impairments were exposed to extremely hot portable heaters in their rooms without documented safety monitoring or staff training. Observations confirmed that the heaters were hot to the touch and set to maximum heat, while staff and maintenance interviews revealed no established or documented process for monitoring either the heaters or the residents. Manufacturer instructions highlighted risks, and facility policies lacked guidance on portable heater use prior to the deficiency being identified.
Two residents with significant cognitive and physical impairments did not have access to functioning call lights, despite care plans requiring accessibility. Observations and staff interviews confirmed that the call lights were either missing or not working, and facility policy requiring immediate reporting and resolution of such issues was not followed.
Three residents, including two with severe cognitive impairment and one who was cognitively intact, were found in rooms with air temperatures ranging from 59 to 63°F. The cool temperatures were confirmed by observation and the Maintenance Director, affecting residents with significant medical conditions.
The facility did not have a policy requiring staff to immediately report abuse allegations to the Administrator and failed to complete a background check for an LPN, despite policy requirements for such checks and screenings for abuse, neglect, or exploitation history.
The facility did not ensure timely reporting or thorough investigation of alleged staff-to-resident abuse and missing narcotics. In two cases, residents reported feeling threatened or being physically mistreated by CNAs, but investigations were incomplete and protective measures were not promptly implemented. Additionally, an LPN suspected in a narcotic diversion case was not properly drug tested, and documentation was later found to be forged.
A resident with multiple complex medical conditions did not receive physician-ordered chest physiotherapy and oral suctioning at several scheduled times. Documentation inaccurately reflected the resident's status, and staff confirmed that the required respiratory care was not provided while the resident was still in the facility.
A resident with multiple complex medical conditions received Midodrine without documented blood pressure checks prior to administration, despite physician orders requiring this monitoring. Review of records and staff interview confirmed that blood pressures were not obtained or documented before giving the medication over several months.
The facility did not maintain accurate and timely documentation for two residents, including delayed and incorrect entries regarding a resident's death and missed treatments. Nursing notes were created or corrected well after the events occurred, and the MAR contained inaccurate codes indicating a resident was deceased or out of the facility when this was not the case. Staff interviews confirmed the documentation issues, which were not in line with facility policy.
A resident with significant medical needs was verbally abused by a CNA during a smoking break, including threats and mocking related to the resident's disabilities. Multiple residents witnessed the incident, and one reported it to facility staff after initial hesitation. The facility's investigation confirmed the abuse through interviews with the victim and witnesses, revealing a failure to protect the resident from verbal abuse.
A resident with multiple chronic conditions and complex wounds did not receive wound care and dressing changes as ordered by the physician. Observations showed soiled and missing dressings, and documentation confirmed that required treatments were not performed as scheduled. The DON verified that wound care orders were not followed, contrary to facility policy.
A resident with severe cognitive impairment and multiple health conditions did not receive timely incontinence checks or assistance as required by their care plan. Staff were unaware of the last incontinence check, and the resident was observed unattended and incontinent, resulting in soiled clothing and bedding. Documentation and interviews confirmed that the resident's needs for frequent toileting assistance were not met, in violation of facility policy.
Two residents with PICC lines did not receive timely dressing changes, and staff failed to follow sterile technique during dressing changes. Dressings were observed to be overdue and improperly maintained, with staff handling sterile supplies with non-sterile gloves and not establishing a clean field, contrary to facility policy and physician orders.
The facility did not report an elopement incident involving a cognitively impaired resident to the SSA and failed to conduct thorough investigations into multiple allegations of abuse and injuries of unknown origin. Investigation files lacked required documentation such as interviews and assessments, and in one case, no investigation records were found. Staff confirmed that investigation procedures outlined in facility policy were not followed.
A resident admitted with multiple complex medical conditions, including acute respiratory failure and tracheostomy status, did not have a baseline care plan completed within 48 hours of admission as required by facility policy. The omission was confirmed by the interim DON and was not included in the admission assessment or medical record.
A resident with cognitive impairment and a history of elopement was admitted to a secure memory care unit after being found outside the facility. The care plan developed for this resident did not include person-centered interventions or reflect the resident's transfer to the secured unit, instead listing only general actions such as medication administration and anticipating needs. The DON confirmed the care plan was not person-centered, contrary to facility policy.
A resident with cognitive impairment and poor decision-making skills eloped from the facility and was found in the parking lot heading toward a busy road. Although the resident had previously wandered within the facility, no interventions or increased supervision were implemented immediately after the elopement, and the care plan was not updated to address elopement risk until two days later. Staff documentation and interviews confirmed a lack of timely safety measures following the incident.
A resident with severe cognitive impairment and chronic pain was administered a new Fentanyl patch by an LPN without removal of the previous patch, which was missing and not reported. The resident subsequently exhibited overdose symptoms and was found by EMS to be wearing two Fentanyl patches, requiring Narcan administration and hospital evaluation. The facility failed to accurately assess the resident, did not report missing patches, and lacked consistent documentation and monitoring of controlled substance use, leading to a significant medication error.
The facility did not provide sufficient nursing and support staff to meet resident needs, resulting in multiple residents arriving late to dialysis, missed or infrequent showers for several residents, and a lack of respiratory therapy staff to support ventilator weaning. Staff and resident interviews, along with facility documentation, confirmed that inadequate staffing directly contributed to these care deficiencies.
A review of personnel records and staff interviews revealed that CNAs did not receive the required 12 hours of annual in-service training, with no documentation of training dates, topics, or attendance. The facility only provided policies for staff to read, lacking evidence of formal in-service sessions. This deficiency was identified during a complaint investigation and had the potential to impact all residents.
The administration failed to ensure effective use of resources, resulting in an uninvestigated medication overdose, incorrect medication orders, unaddressed allegations of verbal abuse, and inadequate staffing for ventilator care, bathing, and dialysis. These deficiencies led to missed or delayed care for multiple residents and incomplete investigations into serious incidents.
A resident's allegation of verbal abuse by a CNA was not thoroughly investigated, as the facility failed to collect statements, conduct assessments, or document the investigation as required by policy. The CNA was suspended and later terminated, but no evidence of a comprehensive abuse investigation was provided.
A resident with impaired cognition and a history of traumatic brain injury was placed on a secured behavioral unit without a physician order, signed consent, or a determination of incompetence, contrary to facility policy requiring such authorizations for secured unit placement.
The facility did not ensure that residents requiring assistance with bathing received scheduled showers, as evidenced by documentation and resident interviews. Several residents with complex medical needs received fewer showers or baths than scheduled, and staff did not consistently document offered or refused showers as required by policy.
A resident with a tracheostomy and mechanical ventilation order to be weaned at night did not receive appropriate care because there was insufficient respiratory therapy staff available during required times, and floor nurses were not trained in ventilator weaning. This resulted in no progress toward ventilator weaning, in violation of facility policy and physician orders.
A resident with hypotension and on renal dialysis was prescribed Midodrine with instructions to hold the medication if systolic blood pressure was less than 110 mmHg, which did not align with the intended use of the drug. The DON confirmed the order was incorrect, as Midodrine should be held when blood pressure is elevated, not low.
Two residents with significant medical needs were not properly screened for therapy services, and therapy staff did not pursue insurance authorization or follow up on denials, resulting in no therapy being provided despite documented requests and recommendations. Required quarterly therapy screenings were not completed, and staff could not provide evidence of necessary notifications or follow-up.
Three residents with multiple chronic conditions did not have documentation in their medical records showing that evening medications were administered as ordered. The MARs lacked entries for the scheduled medication pass, and the DON confirmed that the medication aide was unable to document due to not having her badge and did not use a paper backup. Facility policy required accurate and timely documentation, which was not met.
Nursing staffing information was not updated and posted daily, with outdated information remaining posted for several days. A staff member confirmed that required daily postings were missed, affecting all residents in the facility.
The facility did not provide eight consecutive hours of RN coverage on 17 days, as confirmed by timecard review and staff interviews. This affected all 91 residents and was acknowledged by both the DON and Administrator, with no existing policy for RN staffing coverage.
A review of personnel files and staff interviews revealed that five CNAs did not receive required training or competency verification in dementia management and abuse prevention, despite facility policies mandating such education. The DON confirmed the absence of training records, and this deficiency had the potential to impact all residents in the facility.
The facility did not ensure that residents who required supervision while smoking were properly supervised, did not keep smoking materials in their possession, and smoked only in designated areas. Several residents with chronic illnesses and cognitive impairments were observed smoking unsupervised, possessing cigarettes and lighters, and smoking outside designated areas, while staff interviews confirmed inconsistent enforcement of the facility's smoking policy.
Two residents with serious mental illnesses were not accurately coded in their MDS assessments, despite documentation and diagnoses indicating the need for a positive PASRR Level II status. The MDS Coordinator confirmed the errors, and both the DON and Administrator stated they expected accurate coding but were not involved in the assessment process.
A resident with critical illness myopathy and moderate cognitive impairment was readmitted from the hospital without physician notification or medication and treatment orders in place. Staff, including an LPN, confirmed they lacked the necessary orders to provide proper care, and both the medical director and nurse practitioner were not informed of the readmission. The DON acknowledged the orders were not transcribed as required.
A resident with significant medical needs did not receive their prescribed continuous tube feeding when staff failed to promptly replace an empty feeding bottle and restart the feeding pump. Interviews with the UM, LPN, and DON confirmed that continuous feeding should not be interrupted except for specific care tasks, and any interruption should be documented. The facility's policy required adherence to feeding tube protocols, but there was no documentation or justification for the lapse in care.
Three residents with tracheostomies and ventilator dependence did not consistently receive physician-ordered respiratory care, including oxygen therapy, suctioning, tracheostomy care, and medication administration. Documentation and staff interviews confirmed that required interventions were missed or not performed, especially during night shifts when respiratory therapists were unavailable. Nursing staff reported feeling unable or unqualified to complete all respiratory tasks, and facility leadership acknowledged that undocumented care was not completed.
A resident with a history of critical illness myopathy was discharged from the hospital with orders for intravenous Cefazolin to be given after hemodialysis on specific days. Facility records indicated the medication was to be administered by dialysis staff, but there was no documentation in dialysis notes confirming administration. The dialysis RN reported he was not routinely responsible for administering this medication, lacked access to the EMAR, and had no way to document administration, leading to a failure in coordination and documentation as required by facility policy.
A resident with severe cognitive impairment and multiple psychiatric diagnoses continued to have a PRN order for lorazepam despite repeated monthly recommendations from the pharmacy consultant to discontinue or limit the order per federal guidelines. The facility did not act on these recommendations for several months, and staff interviews confirmed that pharmacy recommendations were not addressed in a timely manner, contrary to facility policy.
Surveyors found that staff failed to follow physician orders and facility policy during medication administration, resulting in a medication error rate of 38.5%. Two residents were affected: one received all oral medications combined and administered together via gastrostomy tube instead of individually, and another received only one puff of Spiriva Respimat instead of the ordered two puffs. Both errors were confirmed through observation and staff interviews.
Staff did not consistently follow enhanced barrier precautions or proper hand hygiene protocols during high-contact care activities for two residents, including one with a chronic wound and MDRO history and another with bladder and bowel incontinence. In both cases, required PPE was not fully used and glove changes with hand hygiene were not performed as per facility policy, as confirmed by staff interviews and direct observation.
The facility failed to properly contain soiled linen, affecting all 88 residents receiving laundry services. Observations revealed that soiled clothing and linens were mixed in bins and spilled onto the floor, with clean laundry handled in the same area. The Environmental Director confirmed the use of one washer due to plumbing issues, and the facility's policy required separation of soiled and clean linen, which was not followed.
The facility failed to provide adequate washcloths and towels, affecting care for all residents. Observations showed linen shortages across units, with CNAs cutting larger linens to cleanse residents. A resident was found heavily soiled, and CNAs used a bath towel for incontinence care due to the shortage. The Environmental Director confirmed the issue, linked to a malfunctioning washing machine.
The facility failed to provide appropriately fitting incontinence garments for 43 residents, resulting in the use of ill-fitting briefs that did not effectively contain elimination. A resident with paraplegia and neurogenic bowel was placed in a brief that was too tight and failed to contain his perineum. The DON confirmed the lack of appropriately sized incontinence briefs.
Failure to Address Impaired Nurse and Missed Resident Care
Penalty
Summary
The deficiency involves the facility’s failure to ensure that care and services were provided in accordance with professional standards of practice, comprehensive resident assessments, and physician orders when an LPN worked while appearing to be under the influence of an illegal substance and continued to provide resident care. Multiple residents and staff reported that on 02/22/26 the LPN appeared disheveled, very tired, was falling asleep while standing, dozing off mid-conversation, and acting "weird" or erratic. Residents reported that medications were administered late, that some medications were not received at all, and that at least one resident’s pain medication was administered after being dropped on the floor. One resident reported that the LPN entered her room and fell asleep on her bed. Another resident reported not receiving any medications that day. Staff interviews showed that concerns about the LPN’s behavior were repeatedly reported to the on-call manager, another LPN, but were not escalated to the DON or Administrator on the day of the incident. The on-call LPN stated she contacted the DON and was instructed to call and speak with the LPN in question, who reported being tired from lack of sleep; no further direction was reported. The DON later stated she was not made aware of the extent of the erratic behavior on that date, and the LPN completed the full shift on 02/22/26 and returned to work the following day, working part of another shift before residents’ complaints prompted further action. Residents and staff reported that during this period, residents did not receive medications, tube feedings, treatments, and other interventions as ordered. The facility’s own self-reported incident documentation confirmed that residents had reported the LPN was dropping pills and appeared to be under the influence of an unknown substance, and that the on-call LPN did not report the incident to the Administrator at the time. The LPN later tested positive for cocaine. The investigation documentation showed that not all residents were assessed for possible negative effects related to the incident, and statements were not obtained from all affected residents. Facility staff, including an RN and the DON, verified that the investigation was not completed thoroughly, that there was no evidence of a QAPI meeting related to the incident, and that the Medical Director was not notified until several days after the event. These actions and inactions occurred despite facility policies and resident agreements requiring protection of resident rights, provision of adequate and appropriate medical and nursing care, prohibition of illegal drug use, and immediate, thorough investigation and reporting of suspected abuse or neglect.
Failure to Remove Impaired LPN Resulting in Widespread Missed Medications and Care
Penalty
Summary
The deficiency involves the facility’s failure to protect residents from neglect by allowing an LPN who appeared to be under the influence of an unknown substance to continue providing care and medications throughout a full shift. Multiple residents and staff observed the LPN on a specific date appearing impaired, including falling asleep while standing, dozing off mid-conversation, appearing disheveled and very tired, and dropping medications on the floor before administering them. Residents reported late medication administration and, in at least one case, receiving pain medication after it had been dropped on the floor. Staff, including another LPN and a CNA, repeatedly contacted the on‑call manager (an LPN) to report the LPN’s erratic behavior and residents’ complaints about not receiving medications, tube feedings, treatments, and other ordered interventions. Despite these reports, the impaired LPN was not removed from resident care during that shift, and the DON and Administrator were not directly notified of the extent of the behavior on that date. The on‑call LPN spoke with the impaired LPN by phone, accepted the explanation that the LPN was tired from lack of sleep, and did not escalate the concerns to the Administrator that day. The DON later stated she was not made aware of the full extent of the erratic behavior at the time and confirmed that the LPN completed the scheduled shift and returned to work the following day. Residents subsequently reported the LPN’s behavior and the missed or improperly administered medications to the DON and Administrator. Record review showed that numerous residents assigned to this LPN did not receive multiple physician‑ordered medications, treatments, assessments, monitoring, and safety interventions during that day shift. For example, one cognitively intact resident with alcohol abuse, depression, anxiety, HTN, insomnia, and vitamin deficiencies did not receive ordered doses of cholecalciferol, cyanocobalamin, hydrochlorothiazide, paroxetine, or a required pain assessment. Another resident with severe cognitive impairment, anoxic brain damage, heart failure, CKD3B, chronic respiratory failure, seizures, PBA, depression, anxiety, and dysphagia missed multiple cardiac, antiplatelet, anticonvulsant, psychotropic, pain, and behavioral medications, as well as ordered head‑of‑bed elevation, pain assessment, behavior monitoring, diet communication, and clothing interventions. Additional residents with complex conditions such as anoxic brain damage with PEG tube and tracheostomy, severe malnutrition, COPD, DM2, CVA, seizures, CHF, prostate cancer, and other chronic diseases did not receive ordered cardiac, anticoagulant, antiplatelet, respiratory, diabetic, seizure, GI, nutritional, and pain medications, PEG tube feedings and flushes, oxygen saturation checks, blood glucose monitoring, insulin administration, head‑of‑bed elevation, enhanced barrier precautions, behavior monitoring, and safety signage during that shift, as confirmed by the DON through EMR, MAR, and TAR review. The DON verified that, for each of the affected residents, the specific physician‑ordered medications and treatments listed in the EMR, MAR, and TAR were not provided during the day shift covered by the impaired LPN. These omissions included, but were not limited to, antihypertensives (such as amlodipine, carvedilol, lisinopril, metoprolol, minoxidil), antiplatelet and anticoagulant agents (aspirin, clopidogrel, apixaban), anticonvulsants (levetiracetam, valproic acid, clobazam, Depakote Sprinkles), psychotropics and anxiolytics (sertraline, duloxetine, quetiapine, buspirone, diazepam, paliperidone), diabetic medications and insulin (metformin, glipizide, insulin glargine, insulin aspart), respiratory medications and inhalers (Anoro Ellipta, Breo Ellipta, Incruse Ellipta), GI agents and supplements (omeprazole, pantoprazole, lactulose, MiraLAX, Jevity tube feedings, PEG flushes, vitamins, potassium, magnesium), pain medications and lidocaine patches, as well as ordered assessments such as pain scales, behavior monitoring, head‑of‑bed elevation, oxygen saturation checks, blood sugar checks, PEG placement and residual checks, diet communication, enhanced barrier precautions, and safety signage. These documented failures occurred while the LPN was reported by residents and staff to be acting impaired and while the facility did not effectively intervene to remove the LPN from resident care or ensure completion of the ordered care during that shift.
Failure to Implement Physician Orders and Required Monitoring Across Multiple Residents
Penalty
Summary
The deficiency involves the facility’s failure to ensure that physician-ordered medications, treatments, assessments, monitoring, and interventions were implemented as ordered for multiple residents during a specific day shift. Surveyors found that required pain assessments ordered every shift were not completed for several residents with conditions such as alcohol abuse, depression, anxiety, chronic pain, and other complex medical issues. For example, residents with orders for 0–10 pain scale assessments each shift did not have these assessments documented on the Treatment Administration Record (TAR) for the identified day shift. The DON confirmed that these ordered pain assessments were not completed as required. The report also details failures to carry out specific clinical and safety-related orders for residents with significant medical and functional needs. One resident with chronic respiratory failure and severe cognitive impairment had an order for head-of-bed (HOB) elevation each shift, a diet communication for a mechanical soft diet with thin liquids, behavior monitoring with documentation of interventions, and use of t‑shirts instead of nightgowns; these orders were not implemented or documented on the day shift. Another resident with anoxic brain damage, a PEG tube, tracheostomy, and multiple orders related to tube feeding and respiratory status did not receive ordered PEG tube flushes, PEG placement checks, gastric residual checks, HOB elevation, SpO2 monitoring, or the ordered pain assessment during the same shift. Additional residents with COPD and other respiratory diagnoses had orders for HOB elevation that were not carried out, and residents with diabetes did not receive ordered blood glucose monitoring. Further, the facility did not implement infection control and safety interventions as ordered. Residents with orders for enhanced barrier precautions (EBP) every shift did not have these precautions implemented during the day shift, despite orders requiring staff to use gloves and gowns during high-contact care. One resident with COPD and other conditions did not have EBP or HOB elevation implemented, and monitoring associated with oxygen therapy, PT/OT range-of-motion exercises, and use of an Acapella device for secretion clearance was not documented. Other residents with behavioral health or cognitive conditions had physician orders for behavior monitoring and documentation of interventions every shift, as well as increased supervision after meals for safe transfers and placement of a sign instructing the resident to call for assistance before self-transferring; these interventions were not completed or documented. The DON consistently confirmed during interview that the various ordered assessments, monitoring, precautions, and safety measures were not implemented on the identified day shift, resulting in multiple residents not receiving ordered care and services.
Failure to Administer Multiple Physician-Ordered Medications
Penalty
Summary
The deficiency involves the facility’s failure to provide routine medications and biologicals as ordered by physicians for multiple residents, resulting in missed doses documented on the Medication Administration Records (MARs) and confirmed by the Director of Nursing (DON). For one resident with alcohol abuse, depression, anxiety, HTN, insomnia, and vitamin deficiencies, physician orders for daily cholecalciferol and cyanocobalamin were in place, but the resident did not receive these medications on a specified date. Another resident with extensive cardiac, respiratory, renal, and neurologic conditions, including anoxic brain damage, NSTEMI, heart failure, CKD3B, seizures, and depression, had orders for daily aspirin for antiplatelet therapy and a lidocaine patch for pain; these medications were also not administered on the same date. Additional residents with complex medical histories similarly did not receive ordered medications. One resident with anoxic brain damage, acute respiratory failure, intracerebral hemorrhage, seizures, dysphagia, CHF, and other conditions had physician orders for daily aspirin, MiraLAX, and chlorhexidine gluconate mouth/throat solution; none of these were given on the identified date. Another resident with malignant neoplasm of the prostate, severe protein-calorie malnutrition, hepatitis C, SVT, HTN, chronic pain, and other diagnoses had multiple daily medications ordered, including cetirizine, magnesium, a multivitamin, pantoprazole, potassium chloride, and vitamin D3, all of which were not administered on that date. A resident with central cord syndrome, severe malnutrition, TIA, COPD, epilepsy, quadriplegia, and other comorbidities had orders for aspirin, a lidocaine patch, and scheduled acetaminophen; the aspirin, lidocaine patch, and two scheduled doses of acetaminophen were not given on the same date. Further review showed that other residents also did not receive ordered medications. One resident with COPD, DM2, functional quadriplegia, dementia, and malnutrition had orders for aspirin, ergocalciferol, vitamin B12, and magnesium, which were not administered on the specified date. Another resident with COPD, DM2, malnutrition, OSA, ARF, heart disease, HTN, hypothyroidism, TIA, neurocognitive disorder, schizoaffective disorder, and convulsions had multiple ordered medications, including aspirin, potassium chloride, ProStat, vitamin C, cyclosporine ophthalmic drops, and famotidine; the morning doses of these medications were not given. A resident with monoplegia following cerebral infarction, HTN, depression, GERD, hyperlipidemia, atherosclerotic heart disease, DM2, and other neurologic conditions had an order for daily aspirin for DVT prevention that was not administered. Another resident with chronic respiratory failure, major depressive disorder, BPH, atrial fibrillation, HTN, OSA, COPD, neuropathy, and other conditions had multiple orders, including a multivitamin, polyethylene glycol, vitamin D, azelaic acid gel, potassium chloride, sennosides-docusate, and Ensure; the MAR showed that the resident did not receive these medications and supplements as ordered on the identified date. The DON confirmed in each case that the ordered medications were not administered. The facility’s own resident agreement and medication administration policy require adequate and appropriate medical treatment and that medications be administered in accordance with professional standards of practice, but these requirements were not met in the instances cited.
Widespread Failure to Administer Ordered Medications as Prescribed
Penalty
Summary
The deficiency involves the facility’s failure to ensure residents were free from significant medication errors when numerous ordered medications were not administered as prescribed to multiple residents on the same day. For one cognitively intact resident with alcohol abuse, depression, anxiety, HTN, and vitamin deficiencies, EMR and MAR review showed that ordered doses of hydrochlorothiazide and paroxetine were not given on the identified date, which the DON confirmed. Another resident with severe cognitive impairment, extensive ADL dependence, and complex cardiac, respiratory, renal, neurologic, and psychiatric conditions did not receive multiple ordered medications, including amlodipine, Nuedexta, carvedilol, Depakote Sprinkles, diazepam, levetiracetam, minoxidil, buspirone, and gabapentin on the same date, as verified by MAR review and the DON. Additional residents with significant neurologic, cardiac, respiratory, and nutritional diagnoses also did not receive ordered medications. One resident with anoxic brain damage, seizures, CHF, and gastrostomy status missed ordered doses of lactulose, levetiracetam, and valproic acid on the identified date, and the DON confirmed additional missed medications including omeprazole and clobazam. Another resident with prostate cancer, severe protein-calorie malnutrition, SVT, HTN, and urinary retention did not receive ordered doses of amlodipine, bicalutamide, and tamsulosin on the same date. A cognitively intact quadriplegic resident with COPD, asthma, epilepsy, HTN, and other comorbidities did not receive ordered doses of Anoro Ellipta, lisinopril, sertraline, levetiracetam, metoprolol, and baclofen during that day shift, which the DON also confirmed. Further review showed residents with DM2, COPD, HTN, anticoagulation needs, and psychiatric conditions missed critical medications, including anticoagulants and insulin. One resident with COPD, DM2, functional quadriplegia, and dementia did not receive ordered doses of apixaban, buspirone, carvedilol, metformin, and multiple doses of insulin aspart per sliding scale on the identified date. Another resident with COPD, DM2, HTN, schizoaffective disorder, seizures, and multiple other conditions missed numerous ordered medications, including antihypertensives, inhalers, psychotropics, diuretics, oral hypoglycemics, basal insulin, and multiple sliding scale insulin doses, as confirmed by the DON. A resident with post-stroke deficits and DM2 did not receive ordered sliding scale insulin doses at several scheduled times that day. Two additional residents with complex cardiopulmonary and psychiatric histories also experienced missed medications. One cognitively intact resident with COPD, major depressive disorder, generalized anxiety disorder, severe protein-calorie malnutrition, HTN, and bradycardia did not receive ordered morning doses of Coreg and minoxidil for HTN. Another resident with chronic respiratory failure, COPD, atrial fibrillation, HTN, BPH, depression, anxiety, and other comorbidities did not receive multiple ordered medications, including amiodarone, citalopram, Lasix, loratadine, a multivitamin, polyethylene glycol, vitamin D, Spiriva, Advair Diskus, apixaban, azelaic acid, tamsulosin, guaifenesin, buspirone, and ipratropium-albuterol on the identified date. The facility’s own Resident Agreement stated residents have the right to adequate and appropriate medical treatment and nursing care, and the facility’s medication administration policy required medications to be administered in accordance with professional standards of practice.
Failure to Provide Ordered Tube Feeding and PEG Flushes
Penalty
Summary
The deficiency involves the facility’s failure to administer physician-ordered enteral nutrition and PEG tube care for a resident with complex medical conditions. The resident was admitted with diagnoses including anoxic brain damage, acute respiratory failure with hypoxia, nontraumatic intracerebral hemorrhage, seizures, encephalopathy, dysphagia, iron deficiency anemia, gastrostomy status, history of sudden cardiac arrest, CHF, liver disease, and cerebral infarction. A recent MDS assessment showed the resident was unable to complete a BIMS cognitive assessment and required total assistance for hygiene, dressing, repositioning, transferring, and locomotion via wheelchair. Review of the EMR and MAR showed that the resident had a physician order, dated 10/24/25, for Jevity 1.5, 237 mL bolus tube feeding every four hours, and an order to flush the PEG tube with 60 mL of water before and after each bolus feeding and every four hours. On 02/22/26, the MAR documented that the resident did not receive the ordered Jevity 1.5 bolus feedings at 10:00 a.m. and 2:00 p.m., nor the required PEG tube flushes at 10:00 a.m. and 2:00 p.m. This failure occurred despite facility documentation stating that medications are to be administered in accordance with professional standards of practice and the resident agreement stating the right to adequate and appropriate medical and nursing care. The deficiency was investigated under Complaint Number 2793023.
Failure to Timely Report Allegation of Verbal Abuse in Secured Behavioral Unit
Penalty
Summary
The deficiency involves the facility’s failure to timely report an allegation of abuse involving a resident on the secured behavioral unit. The resident had diagnoses of schizophrenia, PTSD, anxiety, and depression, and a quarterly MDS documented moderate cognitive function, verbally abusive behaviors, and frequent rejection of care. On the evening of 01/03/26, a nursing progress note by an LPN described an altercation in the dining room between the resident and a CNA over returning a meal tray to the food cart. The note stated that the resident became upset, got into the CNA’s face, and spoke with an aggressive attitude, while another CNA intervened and escorted the resident out to calm down. The note indicated that the unit manager and physician were notified, but there was no indication that the incident was treated or reported as a possible abuse allegation at that time. Subsequently, on 01/13/26, the unit manager accompanied the resident to an appointment where the resident reported to the provider that an aide had gotten in her face a few days earlier. Upon returning to the facility, the unit manager reported this as a possible allegation of abuse, and an investigation was initiated. During the investigation, the social worker interviewed the resident and learned that the resident experienced emotional distress from the 01/03/26 dining room incident. The resident reported that the CNA stood in close proximity, raised her voice, and demanded that the resident return her meal tray, which the resident perceived as abusive. The investigation also revealed that the resident had left a voicemail on the admissions manager’s phone line on 01/05/26 describing the incident, but this voicemail was not identified or acted upon until 01/14/26. Video surveillance of the dining room on 01/03/26 showed the resident eating with another resident, then standing up and walking away from the table as two CNAs sat nearby looking at their phones. After one CNA said something to the resident, the resident approached the CNA, and both were seen flailing their arms and pointing fingers at each other in an aggressive manner, with the CNA in close proximity and using assertive body language. The resident appeared visibly distressed and was observed crying before the second CNA stepped between them and led the resident out of the dining room. Staff schedules confirmed that the involved CNA continued to work multiple shifts on the secured behavioral unit between the date of the incident and the date the administrator became aware of the allegation. The administrator acknowledged that the CNA should have handled the situation differently and confirmed that the LPN who documented the incident on 01/03/26 should have reported it as an allegation of abuse at that time, in accordance with the facility’s abuse policy requiring immediate reporting of alleged violations of abuse. The facility’s abuse, neglect, and exploitation policy required that all alleged violations of abuse be reported to the administrator, state agency, Adult Protective Services, and other required agencies immediately, but not later than two hours after the allegation is made if it involves abuse or results in serious bodily injury, and no later than 24 hours if the events do not involve abuse and do not result in serious bodily injury. In this case, the initial altercation and the resident’s distress were documented on 01/03/26, and the resident attempted to report the incident via voicemail on 01/05/26, yet the incident was not reported as a possible abuse allegation to the administrator and state agency until 01/13/26. During this period, the CNA involved continued to work on the unit. The administrator verified that the delay in recognizing and reporting the incident as an abuse allegation, including the failure of the LPN to report it on 01/03/26 and the missed voicemail from 01/05/26, constituted a failure to ensure timely reporting of an allegation of abuse as required by facility policy.
Improper Bed Rail Installation Resulting in Resident Injury
Penalty
Summary
The facility failed to ensure that bed rails were properly installed and maintained, resulting in actual harm to a resident. The resident, who had multiple complex medical conditions including a recent traumatic amputation, diabetes with polyneuropathy, COPD, pulmonary hypertension, and an activities of daily living (ADL) self-care deficit, required maximum assistance from staff for bed mobility and personal care. Documentation indicated that the resident expressed a desire for bed rails to assist with autonomy, and bilateral bed rails were provided. However, the Minimum Data Set assessment did not indicate bed rail use, and there was no evidence that the bed rails were consistently or correctly installed according to manufacturer instructions. On the day of the incident, three staff members were providing in-bed care when the resident was rolled to the side and the bed rail detached from the bed frame. The staff attempted to lower the resident to the floor, but the resident sustained a displaced fracture of the right humeral neck. Staff statements and interviews confirmed that the resident was holding onto the bed rail when it broke off, and that the bed rail had been previously reported as loose and had been moved to an insecure location on the bed frame. The Maintenance Director confirmed that the bed rails were not compatible with the crossbar where they had been attached, and that staff had previously adjusted and installed the bed rails incorrectly. The facility did not have the correct user manual for the bed rails in use, and the manual provided to surveyors did not match the equipment used. Facility policy required that bed rails be installed and maintained according to manufacturer specifications, including ensuring compatibility with the bed and mattress, and regular inspection for secure installation. Despite these requirements, the bed rails were not properly installed or maintained, and staff were not able to identify who had moved or adjusted the rails prior to the incident. This failure directly resulted in the resident's fall and injury during routine care.
Failure to Monitor and Document Safe Use of Portable Heaters
Penalty
Summary
The facility failed to ensure that portable heaters were safe and adequately monitored in the Memory Care unit, affecting nine residents directly and potentially impacting all 19 residents in the unit. Multiple residents with severe cognitive impairment, physical disabilities, and dependence on staff for activities of daily living were exposed to oil radiator and ceramic space heaters that were extremely hot to the touch and set to maximum heat, while room temperatures remained at 71-72 degrees Fahrenheit. There was no documentation in the medical records of any safety monitoring related to the use of these space heaters for any of the affected residents. Observations confirmed the presence of multiple space heaters in resident rooms, with exposed metal surfaces that became extremely hot within less than a second of contact. The Director of Maintenance verified the use of these heaters in several rooms and acknowledged that residents were typically in common areas during the day, but there was no established or documented process for monitoring either the heaters or the residents for safety. Staff interviews further revealed that there was no ongoing or documented monitoring of residents or the space heaters since their implementation, and staff training on the use and monitoring of the heaters was only verbal and undocumented. Review of manufacturer instructions for the heaters indicated that they posed risks of fire, electric shock, and injury, especially for individuals with reduced physical, sensory, or mental capabilities. The facility's existing policies did not provide guidelines for the use of portable heaters, and the policy addendum for emergency use of space heaters was only adopted after the deficiency was identified. Prior to this, there was no documentation of safety rounds, inspections, or staff education regarding the use of space heaters in resident rooms.
Failure to Ensure Functioning Call Lights for Dependent Residents
Penalty
Summary
The facility failed to ensure that call lights were functioning properly for two residents who were dependent on staff for care and had significant cognitive and physical impairments. For one resident with Alzheimer's disease, dementia, and other chronic conditions, both the wall call light button and the handheld device were missing, rendering the call light non-functional. This resident was assessed as severely cognitively impaired but capable of using the call light, and the care plan required the call light to be within reach. A CNA confirmed the call light was not working for this resident. Another resident, who had hemiplegia, diabetes with nephropathy, blindness in one eye, and cognitive communication deficits, also had a non-functioning call light. This resident was dependent for all care and at risk for falls and incontinence, with a care plan intervention to ensure the call light was within reach and to encourage its use. Observation and staff interview confirmed the call light did not work when pressed by the resident. Facility policy required call systems to be accessible and for staff to report and address any problems immediately, but this was not followed in these cases.
Failure to Maintain Comfortable Room Temperatures
Penalty
Summary
The facility failed to maintain comfortable room temperatures for three residents, as identified through medical record review, observation, and staff interviews. Two residents, both severely cognitively impaired and dependent for care, shared a room where the air temperature was observed to be cool. Another resident, who was cognitively intact, was also found in a room with similarly cool air temperatures. The affected residents had significant medical histories, including Alzheimer's disease, heart failure, dementia, orthopedic aftercare, and other chronic conditions. On the day of observation, the ambient room temperatures for these residents ranged from 59 to 63 degrees Fahrenheit, which was verified by the Maintenance Director. The low temperatures were directly observed during the survey, and the Maintenance Director confirmed the findings. This deficiency was identified during the investigation of specific complaints and affected three out of ten residents reviewed for room temperature concerns.
Failure to Ensure Immediate Reporting of Abuse Allegations and Completion of Employee Background Checks
Penalty
Summary
The facility failed to develop and implement a comprehensive abuse policy that directed staff to immediately report any allegations to the Administrator. The existing policy on Abuse, Neglect, and Exploitation included procedures for investigating allegations and required reporting to the Administrator, but did not specify a timeframe or explicitly instruct staff to report allegations immediately. This omission was identified during a review of the facility's undated policy documents. Additionally, the facility did not ensure that background checks were completed for new employees as required by its own policy. A review of an LPN's personnel file showed no evidence of a completed background check, and an interview with Human Resources confirmed that a background check was submitted but rejected and never rerun. The facility's policy required screening potential employees for a history of abuse, neglect, exploitation, or misappropriation of resident property, as well as conducting background, reference, and credential checks for all potential employees and affiliated personnel.
Failure to Timely Report, Protect, and Investigate Alleged Abuse and Misappropriation
Penalty
Summary
The facility failed to ensure timely reporting, protection, and thorough investigation of alleged staff-to-resident abuse and misappropriation of medications. In one instance, a certified nurse aide (CNA) was accused by a resident of making the resident feel threatened, resulting in the resident staying awake all night out of fear. Despite the complaint being brought to the attention of the Administrator, the CNA continued to work with residents before being suspended, and the investigation lacked statements from all potential witnesses. The facility's policy required immediate investigation and protection of residents, but these steps were not fully implemented. Another incident involved a resident with multiple chronic conditions, including respiratory failure and cognitive communication deficit, who reported that a CNA smacked her hand during care. The resident reported the incident to a registered nurse (RN), who relayed it to the former Director of Nursing (DON). The investigation was incomplete, as it did not include interviews with other residents, ongoing monitoring, or staff education. The CNA was not suspended during the investigation, and there was no documentation of disciplinary action. Additionally, the facility failed to properly investigate a case of missing narcotic medication. Thirty Norco tablets were reported missing from a medication cart, and a drug test was allegedly administered to the last nurse with access. However, there was no evidence that the drug test was actually completed, and it was later determined that the drug test form had been forged by a former human resources staff member. The facility's employee handbook required drug testing under reasonable suspicion, but this process was not followed.
Failure to Provide Ordered Respiratory Care
Penalty
Summary
The facility failed to provide respiratory care as ordered for a resident with multiple complex diagnoses, including dementia, morbid obesity, end stage renal disease, diabetes, obstructive sleep apnea, and other serious conditions. A physician order was in place for chest physiotherapy and oral suctioning every six hours for 48 hours due to chest congestion. Documentation showed that the initial treatment was administered, but subsequent scheduled treatments were not completed at several required times. The medication administration record indicated missed administrations, with some entries marked as 'other/see nurse notes' and others incorrectly documented as the resident being out of the facility, even though the resident remained in the facility until later that day. Staff interview confirmed that the resident did not receive the ordered respiratory care during the specified times while still present in the facility.
Failure to Monitor Blood Pressure Prior to Midodrine Administration
Penalty
Summary
The facility failed to obtain and document blood pressure readings prior to administering Midodrine, as ordered by the physician, for one resident with multiple complex diagnoses including dementia, morbid obesity, end stage renal disease, type 2 diabetes mellitus, obstructive sleep apnea, hypertension, metabolic encephalopathy, and dependence on renal dialysis. The physician's order specified that Midodrine 5 mg should be administered three times daily for hypotension, but to hold the medication if the systolic blood pressure was greater than 90. Medical record review showed that for the months of September and October, and for multiple days in November, there was no documentation that blood pressures were obtained before administering Midodrine to the resident. This was confirmed during an interview with a registered nurse, who verified the absence of blood pressure documentation prior to medication administration for the specified periods. The deficiency was identified during the investigation of two complaint numbers.
Failure to Ensure Accurate and Timely Medical Record Documentation
Penalty
Summary
The facility failed to ensure accurate and timely documentation in the medical records for two of three residents reviewed. For one resident with multiple complex diagnoses, including chronic respiratory failure, severe malnutrition, COPD, dementia, and dependence on a respirator, nursing progress notes were not documented at the time of care but were instead created or corrected hours or days later. Several notes were struck out, sometimes without a reason, and documentation of the resident's death was not completed properly at the time of the event. Staff interviews confirmed that a new LPN did not feel she documented the death properly and was assisted by the ADON, but there was no evidence of falsification. The facility's policy requires documentation to be completed at the time of service or by the end of the shift, which was not followed in these instances. For another resident with diagnoses including dementia, morbid obesity, ESRD, DM2, OSA, and hypertension, physician orders for chest physiotherapy and oral suctioning were not accurately documented as completed. The medication administration record (MAR) showed missed administrations, with chart codes indicating the resident was deceased or out of the facility, even though the resident was alive and not transferred until later. Staff interviews confirmed the inaccuracies in the documentation. These findings demonstrate a failure to maintain accurate and timely medical records in accordance with professional standards and facility policy.
Resident Subjected to Verbal Abuse by CNA During Smoking Break
Penalty
Summary
A deficiency occurred when a resident, who was cognitively intact and dependent on staff for multiple activities of daily living due to conditions such as quadriplegia, central cord syndrome, and other significant medical issues, was subjected to verbal abuse by a certified nurse aide (CNA). The incident took place during a smoking break, where the CNA threatened to slap the resident, mocked him, and threatened to wipe the resident's behind with an alcohol wipe. Multiple residents witnessed the event, and one reported the incident to the facility receptionist after initially hesitating due to fear of retaliation. The facility's investigation confirmed the allegations through interviews with the victim and witnesses. The resident who was verbally abused reported that the CNA teased him about his disabilities and made threatening remarks. Witnesses corroborated the account, stating that the CNA's behavior was degrading and made them feel uncomfortable. The CNA denied the allegations, claiming the interactions were joking in nature, but the facility's findings supported the residents' statements. The incident was reported to the facility's administration, which had recently changed leadership. The administrator verified the occurrence of the verbal abuse based on the investigation and witness statements. The facility's policy required protections against abuse, but the incident demonstrated a failure to ensure the resident was free from verbal abuse by staff.
Failure to Follow Physician Orders for Wound Care and Dressing Changes
Penalty
Summary
The facility failed to provide wound treatments and dressing applications in accordance with physician orders for one resident reviewed for wound care and treatment services. The resident, who had multiple complex medical conditions including type II diabetes mellitus with a foot ulcer, chronic kidney disease stage four, atrial fibrillation, anemia, heart failure, depression, above-the-knee amputation of the left leg, non-pressure chronic ulcer of the right foot, absence of right toes, and hypertension, was admitted to the facility and later readmitted from the hospital with specific wound care orders. These orders included detailed instructions for cleansing, dressing, and frequency of dressing changes for wounds on the right foot, heel, and calf. Observations revealed that the resident was found with a soiled gauze-wrapped dressing and a fracture boot on the right lower extremity, with no border foam dressing present on the right calf as ordered. Further inspection by the wound specialist and RN confirmed that the dressing on the right calf had not been applied and the existing dressing was heavily soiled and undated. The medical record lacked documentation of dressing changes to the right calf since the resident's return from the hospital, and the right foot dressing had not been changed for several days. The DON verified that the wound treatments were not completed as ordered, and facility policy required wound treatments to be provided according to physician orders.
Failure to Provide Timely Incontinence Care and Assistance
Penalty
Summary
The facility failed to provide timely and appropriate interventions to prevent urinary incontinence for a resident with multiple medical conditions, including severe cognitive impairment, irritable bowel syndrome, and impaired mobility. Despite care plans indicating the need for two-hour incontinence checks and maximum assistance with toileting, documentation showed a lack of consistent checks and assistance. Staff interviews revealed that both the LPN and CNA assigned to the resident were unaware of the last incontinence check and had not observed the resident since assuming care. Observations confirmed the resident was left unattended, resulting in incontinence episodes that were not contained by the adult brief, leading to soiling of clothing, bedding, and the mattress. Medical record reviews and staff interviews indicated that the resident's daughter often had to assist with changes and cleaning, as staff did not consistently provide the required support. The facility's incontinence policy required appropriate treatment and services based on comprehensive assessment, but the resident did not receive the necessary care to prevent incontinence episodes. The deficiency was identified through observation, record review, and interviews, confirming non-compliance with the facility's own policies and care plans.
Failure to Maintain Sterile Technique and Timely PICC Line Dressing Changes
Penalty
Summary
The facility failed to ensure the safe and appropriate administration and maintenance of peripherally inserted central catheters (PICC) for two residents. For one resident with multiple complex medical conditions, including diabetes, chronic kidney disease, and pressure ulcers, the PICC line dressing was observed to be peeling and dated well beyond the required weekly change interval. The responsible LPN confirmed the dressing was overdue for change and, during the observed dressing change, did not follow sterile technique as outlined in facility policy. Specific lapses included not establishing a clean field, handling sterile items with non-sterile gloves, and multiple instances of cross-contamination during the procedure. Another resident, also with significant medical issues such as open wounds, cirrhosis, and chronic kidney disease, was found with a PICC line dressing that was dislodged, peeling, and dated beyond the required change interval. The site was observed to have dried blood around the insertion area. The LPN confirmed the dressing was overdue for change and acknowledged the expectation for weekly dressing changes. Review of the facility's policy confirmed that PICC dressings are to be changed weekly or as needed, using a sterile technique to minimize infection risk. The policy details specific steps for maintaining sterility, including hand hygiene, use of masks, establishment of a clean field, and proper handling of sterile supplies. The observed failures to follow these procedures resulted in non-compliance with physician orders and facility policy for PICC line care and dressing changes.
Failure to Report Elopement and Incomplete Abuse Investigations
Penalty
Summary
The facility failed to report an incident of resident elopement to the State Survey Agency (SSA) and did not conduct thorough investigations into multiple allegations of abuse. Specifically, a resident with cognitive impairment and a history of senile degeneration of the brain, anxiety, and diabetes mellitus type II eloped from the facility and was found in the parking lot heading toward a busy road. Although staff intervened and returned the resident to safety, the incident was not reported to the SSA as required. Additionally, the facility did not complete thorough investigations for several self-reported incidents (SRIs) involving allegations of verbal and physical abuse, as well as injuries of unknown origin. In each case, the investigation files only contained the SRI submitted to the SSA, with no evidence of staff or resident interviews, assessments of other potentially affected residents, or documentation of staff education. For one allegation of resident-to-resident physical abuse, there was no investigation documentation available at all. Interviews with facility staff, including the newly appointed Administrator, confirmed that the investigation files were incomplete and that no further documentation could be located. Review of the facility's own policy indicated that immediate and thorough investigations should occur for all allegations of abuse, neglect, or exploitation, including interviews and complete documentation, but these procedures were not followed in the cited cases.
Failure to Complete Baseline Care Plan Within 48 Hours of Admission
Penalty
Summary
The facility failed to complete a baseline care plan within 48 hours of admission for a resident with diagnoses including acute respiratory failure, tracheostomy status, malignant neoplasm of the lung and supraglottis, anxiety, and COPD. Medical record review showed that although the resident was cognitively intact and an admission assessment was completed, there was no evidence that a baseline care plan was developed or included as part of the assessment. This was confirmed during an interview with the interim DON, who verified that the baseline care plan had not been completed. Facility policy requires that a baseline care plan be developed within 48 hours of admission to provide effective and person-centered care, but this was not followed in this instance.
Failure to Develop Person-Centered Care Plan for Elopement Risk
Penalty
Summary
The facility failed to develop and implement a person-centered care plan for a resident with cognitive impairment and a history of elopement. The resident, admitted with diagnoses including senile degeneration of the brain, diabetes mellitus type II, and anxiety, was found walking in the parking lot toward the street. Following this incident, the resident was admitted to the secure memory care unit. However, the care plan created did not include person-centered interventions or reflect the resident's transfer to the secured unit. Review of the care plan showed only generic interventions such as administering medications as ordered and anticipating the resident's needs, without addressing the unique factors contributing to the resident's elopement risk. The Director of Nursing confirmed that the care plan lacked a person-centered approach. Facility policies require comprehensive, person-centered care plans with measurable objectives and timeframes, but these were not evident in the resident's documentation.
Failure to Provide Adequate Supervision and Timely Interventions Following Resident Elopement
Penalty
Summary
The facility failed to provide adequate supervision to prevent an incident of elopement involving a resident with cognitive impairment and poor decision-making skills. The resident, admitted with diagnoses including senile degeneration of the brain, anxiety, and diabetes mellitus type II, was assessed as cognitively impaired and expressed a desire to leave the facility, but the initial wandering risk assessment did not indicate a risk score or clear risk level. On the date of the incident, the resident was found in the facility parking lot heading toward a busy road and was returned to the facility by staff. Prior to the elopement, the resident was known to wander within the facility but had not shown exit-seeking behaviors, and no interventions or increased supervision were implemented immediately following the incident. Review of the medical record and interviews with staff confirmed that there was no documentation of one-to-one monitoring or other safety interventions after the elopement, aside from a general instruction to keep an eye on the resident. The care plan was not updated to include interventions related to elopement or wandering until two days after the incident, and the resident was not transferred to a secure memory care unit until that time. The facility's policy required adequate supervision and individualized care planning for residents at risk of wandering or elopement, but these measures were not implemented in a timely manner for this resident.
Failure to Prevent Significant Medication Error with Fentanyl Patch Administration
Penalty
Summary
A significant medication error occurred when a resident with severe cognitive impairment and chronic pain, who had a physician's order for a Fentanyl transdermal patch, was administered a new Fentanyl patch without the removal of the previous one. The LPN responsible was unable to locate or remove the previously administered patch but proceeded to apply a new patch and did not report the missing patch at the time. This resulted in the resident wearing two Fentanyl patches simultaneously, which was not discovered until after the resident exhibited symptoms of overdose, including lethargy, inability to walk or sit upright, and drooling. The facility failed to accurately assess the resident when the change in condition was noted. The nurse who responded to the resident's altered state did not complete a head-to-toe assessment and was unaware that the resident was receiving Fentanyl. Emergency Medical Services were called, and upon their assessment, two Fentanyl patches were found on the resident, one of which was initially hidden under a blood pressure cuff. Narcan was administered, and the resident was transported to the hospital, where an accidental overdose was confirmed. Documentation and monitoring of Fentanyl patch placement were inconsistent and inaccurate in the days leading up to the incident. There were multiple instances where the location of the patch was incorrectly documented or not documented at all, and missing patches were not reported to the physician or nursing management. Staff interviews revealed a lack of standardized procedures for patch administration, removal, and documentation, as well as insufficient training and communication regarding controlled substance protocols. The facility did not initiate an incident investigation or implement immediate interventions following the discovery of the overdose.
Removal Plan
- The DON completed a skin sweep on Resident #86 to ensure there were no additional patches applied.
- The DON completed a review of Resident #86's care plan and verified to show chronic pain and potential side effects.
- The DON completed a skin sweep on a like resident (Resident #50) who had discontinued orders for Fentanyl patches. The DON verified there were no patches present.
- RNCC #302 educated the Administrator and DON on reporting risk events and initiating investigation and implementing interventions.
- The Narcotic Pain Patch Policy was updated to include: Both nurses, oncoming and off going to check placement and document in medication administration record at shift change, and removal of Fentanyl pain patch to be completed by two nurses and documented in the controlled substance/narcotic log with two nurses for disposal.
- The DON updated Resident #86's orders to include documentation of Fentanyl patch location.
- The DON updated Resident #86's order to check Fentanyl patch placement every shift to also include location observed.
- The DON provided a standard list of locations and abbreviations placed on the unit for staff reference to ensure correct abbreviation documentation.
- The DON placed a reminder sheet in the narcotic book for the nurses to physically go to check narcotic placement at shift change.
- The DON provided education on the narcotic pain patch policy to include: Checking patch physically during count and documenting in the record; disposal of patch with two nurses and to fold patch and dispose by flushing and both nurses to document on the controlled substances/narcotic log with both nurses signing the log; using the standard list of locations and abbreviations to ensure correct abbreviation of location of Fentanyl patch; and on call manager to be notified immediately if Fentanyl patch missing.
- A root cause analysis was completed by the Interdisciplinary Team (IDT) including Medical Director (MD) #102, the Administrator, the DON, Assistant Director of Nursing (ADON) #208, and RNCC #302 with an ad hoc QAPI meeting.
- Auditing includes DON or designee to review shift to shift count with physical checking of patch placement is completed, validating placement of patch to match the medical record once daily for two weeks, then four times a week for four weeks.
- Auditing to include DON or designee to audit removal of Fentanyl patch to be with two nurses and documented accurately in the narcotic log daily for two weeks, then four times a week for four weeks.
- The DON provided education to LPN #242 on completing head-to-toe assessments.
Failure to Provide Adequate Staffing for Resident Care Needs
Penalty
Summary
The facility failed to provide adequate nursing staff to meet the needs of all residents, as evidenced by multiple instances of residents arriving late to scheduled in-house dialysis treatments. Medical record reviews and staff interviews revealed that several residents with end stage renal disease or chronic kidney disease, who required regular dialysis, were consistently late for their treatments. Documentation showed delays ranging from over an hour to nearly three hours, with staff and residents attributing these delays to insufficient staffing. The facility's own assessment indicated a need for 28 CNAs daily, but staffing records showed significantly fewer CNAs scheduled on the days when residents were late for dialysis. In addition to dialysis delays, the facility did not consistently provide scheduled showers to residents who required assistance. Review of shower schedules and documentation for several residents revealed that showers and baths were missed or infrequently provided, with some residents receiving only two or three showers over a month-long period. Staff interviews confirmed that inadequate staffing contributed to the inability to complete scheduled showers, and documentation was lacking for missed or refused showers. The facility also failed to provide necessary respiratory therapy staffing to support a resident's ventilator weaning process. A resident with a tracheostomy and mechanical ventilator had physician orders for a gradual weaning process at night, requiring close supervision by respiratory therapy. However, staff schedules and interviews confirmed that no respiratory therapist was present on several nights, and floor nurses were not trained to perform ventilator weaning. As a result, the resident was not making progress in the weaning process due to the lack of appropriate staff coverage.
Failure to Document and Provide Required CNA Annual In-Service Training
Penalty
Summary
The facility failed to ensure that certified nurse aides (CNAs) received the required minimum of 12 hours of annual in-service training. Personnel records for five CNAs were reviewed, and in each case, there was no documentation showing completion of the mandated annual in-service training hours. The records lacked evidence of in-service dates, times, topics, or attendance, and only included an undated list of CNAs with a note indicating 'Message received' and copies of facility policies. During an interview, the Director of Human Resources confirmed that the facility did not have documentation of in-service training sessions, including dates, times, topics, or attendance records. Instead, CNAs were provided with policies to read, but there was no evidence that formal in-service training was conducted or tracked as required. This deficiency was identified during a complaint investigation and had the potential to affect all 89 residents in the facility.
Failure to Use Resources Effectively and Ensure Resident Well-Being
Penalty
Summary
The administration team failed to use facility resources effectively and efficiently, resulting in multiple deficiencies affecting resident care and safety. One resident experienced an accidental overdose when two Fentanyl patches were applied without removing the previous patch as ordered. The incident was not immediately investigated, and no interventions were implemented to prevent recurrence. The DON stated the incident was not investigated due to working on the floor and being off duty, while the Administrator was unaware of the specifics and did not ensure an investigation or follow-up occurred. Another deficiency involved incorrect physician orders for a resident's medication, midodrine, which was not properly entered into the medical record, potentially affecting the intended administration. The DON confirmed the error and acknowledged responsibility for ensuring medical record accuracy. Additionally, an allegation of staff-to-resident verbal abuse was not thoroughly investigated; the Administrator could not provide evidence of an investigation, statements, or staff education related to the incident, despite the suspension and subsequent termination of the accused CNA. Staffing shortages were also documented, with the facility consistently scheduling fewer CNAs than required by the Facility Assessment, leading to delays in residents receiving dialysis and missed scheduled showers or baths. Respiratory therapy staffing was insufficient to support ventilator weaning as ordered for a resident, and nursing staff were not trained to perform this task. Multiple interviews with staff and review of records confirmed that inadequate staffing contributed to missed care and delays in essential services.
Failure to Investigate Allegation of Verbal Abuse
Penalty
Summary
The facility failed to thoroughly investigate an allegation of verbal abuse made by a resident against a Certified Nurse Aide (CNA). Upon receiving the allegation, the Administrator suspended the CNA and subsequently terminated her employment for violating the resident care policy. However, there was no evidence provided of a comprehensive investigation into the abuse allegation. Specifically, the Administrator could not produce any statements from residents or staff, assessments of the resident involved or others with similar concerns, or documentation of staff education regarding abuse identification and reporting. Additionally, there were no attachments or supporting documents included with the self-reported incident submitted to the State Survey Agency. Review of facility policy indicated that an immediate and thorough investigation is required when abuse is suspected, including interviews with all involved parties and documentation of findings. Despite this, the Administrator confirmed that no such investigation or documentation was completed. The deficiency was identified during a complaint investigation and affected one of three residents reviewed for abuse allegations, with the facility census at 89 at the time.
Resident Placed on Secured Unit Without Required Authorization or Consent
Penalty
Summary
The facility failed to ensure that a resident placed on a secured behavioral unit met the established criteria for admission to that unit. Specifically, the resident had diagnoses including subdural hemorrhage, intracranial injury, hypotension, generalized anxiety disorder, and impaired cognition, and was identified as being at risk for elopement and wandering. The care plan indicated the resident resided on the secure unit for safety, with interventions to manage wandering behaviors. However, there was no physician order authorizing the resident's placement on the secured unit, and the resident had not signed a consent form for this placement. Further review revealed that the resident had not been declared incompetent, nor did they have a power of attorney or guardian. The facility's policy required that residents admitted to the secure behavioral unit must have a current mental health diagnosis, psychosocial or behavioral disturbance, be deemed incompetent by a physician, and have a current or active power of attorney or guardian. These requirements were not met in this case, as confirmed by staff interview and medical record review.
Failure to Provide Scheduled Showers to Dependent Residents
Penalty
Summary
The facility failed to provide showers as scheduled to residents who required assistance with activities of daily living, specifically bathing. Three residents with varying medical needs, including dependence on renal dialysis, tracheostomy status, and congestive heart failure, were affected. Documentation and interviews revealed that these residents were scheduled for showers twice weekly, but records showed they received significantly fewer showers or baths than scheduled. For example, one resident received only three showers or baths over a month, another received three since admission, and a third received only two showers in the same period. Staff interviews confirmed that shower sheets were not completed for each scheduled shower, nor was resident refusal consistently documented as required by facility policy. Resident interviews further corroborated the lack of scheduled showers, with one resident expressing a preference for showers over bed baths and another stating that staff were too busy to provide showers, leading him to clean himself at the sink. Review of the facility's policy indicated that residents should receive showers per their requests or according to the facility's schedule, but this was not consistently followed. The deficiency was substantiated through medical record review, resident and staff interviews, and documentation audits.
Failure to Provide Adequate Ventilator Weaning Due to Lack of Trained Staff
Penalty
Summary
The facility failed to provide adequate respiratory care for a resident who required mechanical ventilation and had physician orders to be weaned from the ventilator at night in two-hour increments under close supervision by respiratory therapy. The resident, who had diagnoses of acute respiratory failure and tracheostomy status, was not aware of any progress in weaning from the ventilator. Interviews with staff confirmed that there was insufficient respiratory therapy coverage at night, and floor nurses were not trained to perform ventilator weaning. As a result, the resident was not making progress in being weaned from the ventilator due to the lack of qualified staff during the required times. Review of staff schedules corroborated that no respiratory therapy staff were scheduled on several nights when the weaning process was ordered to occur. The facility's policy required that appropriate staff be trained and maintain competency in the use of mechanical ventilation, but this was not met. The deficiency was identified during a complaint investigation and was noted as continued non-compliance from previous surveys.
Incorrect Medication Order Instructions for Blood Pressure Management
Penalty
Summary
The facility failed to ensure that a medication order for a resident was written with the correct instructions for its intended use. A review of the medical record showed that a resident with hypotension and dependence on renal dialysis was prescribed Midodrine 10 mg to be administered three times daily for low blood pressure, with instructions to hold the medication if the systolic blood pressure (SBP) was less than 110 mmHg. During an interview, the DON confirmed that the order did not accurately reflect the intended use of the medication, as Midodrine should be held when SBP is elevated, not when it is low. This discrepancy in the physician's order was identified during a complaint investigation.
Failure to Screen and Pursue Authorization for Therapy Services
Penalty
Summary
The facility failed to ensure that residents were properly screened for therapy services and that therapy staff pursued authorization to provide those services. For one resident with dependence on renal hemodialysis and tracheostomy status, care conference documentation indicated requests for rehabilitation services to improve strength and ambulation. However, the Director of Rehabilitation (DOR) was unaware of the resident's wheelchair and could not provide evidence of therapy screenings or follow-up on insurance authorization denials. The resident was evaluated by physical and occupational therapy but discharged from both without receiving treatment due to lack of insurance authorization, and there was no documentation of follow-up with the insurance company or evidence of quarterly therapy screenings after the initial evaluations. Another resident with diagnoses including gout, COPD, and right foot drop was also not properly screened for therapy services. Although this resident was evaluated by physical therapy and recommended for services, no treatment was provided due to lack of insurance approval, and there was no evidence of follow-up with the insurance company. Additionally, there was no documentation of quarterly therapy screenings by occupational or physical therapy for this resident. The facility's policy stated that therapy screens should be completed quarterly, but this was not consistently done, and staff could not provide evidence of required notifications or follow-up actions.
Failure to Document Medication Administration in Resident Medical Records
Penalty
Summary
The facility failed to ensure accurate and complete documentation in the medical records for three residents, resulting in the absence of records reflecting the administration of prescribed medications. For each of the three residents, medical records and medication administration records (MARs) did not show documentation that evening medications were administered as ordered by the physician. The residents involved had various diagnoses, including depression, dementia, schizophrenia, cirrhosis, heart failure, anxiety, type 2 diabetes, and schizoaffective disorder. Despite physician orders for multiple medications, there was no record in the MARs for the scheduled 7:00 P.M. medication pass on the specified date. Interviews with the residents and the Director of Nursing (DON) confirmed the lack of documentation. One resident recalled receiving medications, while another was unsure. The DON verified that the medication aide responsible for administering the medications was unable to document in the electronic record due to forgetting her badge and did not use a paper MAR as a backup. A medication administration audit corroborated the absence of documentation for the affected residents. Facility policy required complete, accurate, and timely documentation, which was not followed in these instances.
Failure to Post Daily Nurse Staffing Information
Penalty
Summary
The facility failed to ensure that nursing staffing information was printed and posted daily as required. Observations on multiple dates revealed that the posted staffing information was outdated, with the same information from 04/01/25 remaining posted through at least 04/07/25. An interview with a receptionist confirmed that the nursing staffing information was not updated or posted daily, and there was no available staffing information for several consecutive days. This deficiency affected all 89 residents in the facility, as the daily posting of nurse staffing information was not maintained during the period reviewed. No specific details about individual residents' medical history or conditions at the time of the deficiency were provided in the report.
Failure to Provide Required RN Coverage
Penalty
Summary
The facility failed to ensure that a Registered Nurse (RN) was present for eight consecutive hours each day, as required, over a period of 17 days between 02/01/25 and 03/13/25. Review of the Daily Timecard confirmed that on multiple specific dates within this timeframe, there was not consecutive eight-hour RN coverage. This lapse had the potential to affect all 91 residents in the facility at the time. Interviews with the Human Resources Coordinator and the Staffing and Scheduling Coordinator confirmed the absence of required RN coverage on the identified dates. Further interviews revealed that the facility did not have a policy in place for RN staffing coverage. The Director of Nursing acknowledged the deficiency in maintaining the required RN coverage and stated that the facility had only recently become aware of the issue. The Administrator, who had been in the role for five weeks, expressed surprise at the lack of compliance and reiterated the expectation for daily eight-hour RN coverage. The deficiency was identified during the investigation of two complaint numbers.
Failure to Provide Required Dementia and Abuse Prevention Training to CNAs
Penalty
Summary
The facility failed to provide required training and competency verification in dementia management and abuse prevention for five Certified Nurse Aides (CNAs) as evidenced by a review of their personnel files. The files for these CNAs, who had hire dates ranging from 2011 to 2023, contained no documentation of training or competency in abuse, neglect, exploitation, or dementia care. This lack of documentation was confirmed during an interview with the Director of Nursing (DON), who acknowledged that the necessary training had not been provided as required and that there were no records of such training for the staff in question. Policy review revealed that the facility's own procedures require in-service training for nurse aides in areas including effective communication, dementia management, and abuse prevention, as well as annual education for existing staff on abuse, neglect, and exploitation. Despite these policies, the facility did not ensure that the five CNAs received the mandated education, which had the potential to affect all 91 residents in the facility.
Failure to Supervise Resident Smoking and Enforce Smoking Policies
Penalty
Summary
The facility failed to ensure that residents assessed as requiring supervision while smoking were properly supervised, did not keep smoking materials in their possession, smoked only in designated areas, and had accurate smoking evaluations. Multiple residents with medical histories including chronic obstructive pulmonary disease, nicotine dependence, and dementia were observed smoking unsupervised, possessing their own cigarettes and lighters, and smoking outside of designated areas. Staff interviews confirmed that residents routinely smoked without supervision and often retained their smoking materials, contrary to facility policy and individual care plans. One resident, with intact cognition and a diagnosis of chronic obstructive pulmonary disease, was observed smoking alone outside the facility and keeping cigarettes and a lighter in their possession, despite care plan interventions requiring supervision and staff storage of smoking materials. Another resident, also with intact cognition and a diagnosis of nicotine dependence and dementia, reported smoking multiple times daily without supervision and keeping their own smoking materials. A third resident, with similar medical history, was seen smoking outside the designated area, not signing out as required, and possessing their own lighter, despite being assessed as needing supervision. A fourth resident, with severe cognitive impairment and respiratory diagnoses, was observed smoking unsupervised outside the front door, contrary to their care plan and an inaccurate smoking safety evaluation that stated the resident did not smoke. Staff interviews revealed inconsistent enforcement of the smoking policy, with some staff unaware of which residents required supervision and others acknowledging that residents did not always follow the policy. The facility's policy required supervision for residents assessed as needing it, storage of smoking materials by staff, and smoking only in designated areas, but these measures were not consistently implemented.
Inaccurate Coding of MDS Assessments for Serious Mental Illness
Penalty
Summary
The facility failed to ensure that Minimum Data Set (MDS) assessments were coded accurately for two of three residents reviewed. For one resident with diagnoses including anxiety disorder, dementia, schizoaffective disorder, and major depressive disorder, the annual MDS assessments indicated the resident was not considered by the state Level II PASRR process to have a serious mental illness, despite the care plan showing a positive Level II PASRR due to serious mental illnesses. The MDS also listed active diagnoses of anxiety disorder, depression, and schizophrenia. Another resident, admitted with schizoaffective disorder, anxiety disorder, and adjustment disorder with mixed anxiety and depressed mood, had a significant change in status MDS assessment that also failed to indicate the presence of a serious mental illness as determined by the PASRR process. The MDS Coordinator acknowledged during interview that both assessments were coded incorrectly and should have indicated the presence of serious mental illnesses. The DON and Administrator both stated they were not involved in the MDS process but expected accurate coding.
Failure to Notify Physician and Obtain Orders on Resident Readmission
Penalty
Summary
Licensed nursing staff failed to notify the physician of a resident's readmission and did not obtain medication or treatment orders to guide care for the resident upon return from the hospital. The resident, who had a diagnosis of critical illness myopathy and moderate cognitive impairment, was readmitted to the facility, but there was no evidence in the medical record that physician orders for medications or treatments were in place on the date of readmission. Staff interviews confirmed that the LPN working on the unit at the time did not have any orders to properly care for the resident and did not notify the provider of the resident's return. Further interviews revealed that both the medical director and nurse practitioner were not informed of the resident's readmission, and the director of nursing acknowledged that there was no reason for the failure to transcribe or enter the necessary orders. The administrator stated that it was expected for all orders to be entered and the provider notified immediately upon admission or readmission, but this did not occur in this instance.
Failure to Provide Continuous Tube Feeding as Ordered
Penalty
Summary
A deficiency was identified when a resident with multiple complex medical conditions, including cerebral infarction, chronic respiratory failure, tracheostomy, ventilator dependence, protein-calorie malnutrition, and gastrostomy status, did not receive their physician-ordered continuous tube feeding as required. The resident's care plan and physician orders specified continuous enteral feeding via gastrostomy tube at a set rate, along with scheduled water flushes, and a nothing by mouth (NPO) diet. During observation, it was found that the resident's tube feeding pump was off and the feeding bottle was empty, despite orders for continuous feeding. Interviews with facility staff, including a unit manager, LPN, DON, and the administrator, confirmed that continuous tube feeding should not be interrupted except for specific care tasks and that any interruption should be documented and the physician notified if necessary. The facility's policy also required staff to follow protocols for feeding tube care. However, there was no documentation or justification for the interruption in feeding, and staff acknowledged that the feeding should have been restarted immediately once the bottle was empty. This failure resulted in the resident not receiving their prescribed nutrition and hydration as ordered.
Failure to Provide Physician-Ordered Respiratory Care and Services
Penalty
Summary
The facility failed to provide physician-ordered respiratory care and services for three residents with significant respiratory needs, including those with tracheostomies and ventilator dependence. For one resident with COPD, acute respiratory failure, and tracheostomy status, there were multiple instances where staff did not document or complete required respiratory interventions such as placing artificial noses, administering oxygen, providing inhalation treatments, changing inner cannulas, performing oral care, checking oxygen saturation, suctioning, and conducting tracheostomy care and checks. The resident reported uncertainty about receiving all breathing treatments and delays in suctioning when needed. Documentation gaps were confirmed by the Director of Nursing (DON), who acknowledged that if care was not documented, it was not completed. Another resident with quadriplegia, chronic respiratory failure, and ventilator dependence also did not receive all ordered respiratory care. The care plan required frequent interventions, including ventilator checks, tracheostomy care, suctioning, and monitoring of oxygen saturation. However, staff failed to document or perform these tasks on several occasions, particularly during night shifts when respiratory therapists were not present. A registered nurse stated that it was not possible to complete all required respiratory and nursing duties simultaneously and admitted to only providing immediate respiratory care, such as suctioning, when necessary. The DON again confirmed that missing documentation indicated the care was not provided. A third resident with acute respiratory failure and tracheostomy status was similarly affected. The care plan required regular changes of suction equipment, tracheostomy ties, inner cannulas, and provision of oral and tracheostomy care. Staff interviews revealed that these interventions were not performed as ordered on multiple occasions. Nurses on duty during the relevant shifts confirmed they did not complete the required respiratory care tasks. Facility policies reviewed indicated that care should be provided according to physician orders and professional standards, with sufficient numbers of trained and competent staff, but these standards were not met for the residents involved.
Failure to Coordinate and Document Dialysis Medication Administration
Penalty
Summary
The facility failed to ensure proper coordination and administration of prescribed intravenous Cefazolin for a resident requiring dialysis. The resident, who had a diagnosis of critical illness myopathy and was their own responsible party, was discharged from the hospital with specific orders for Cefazolin to be administered after hemodialysis on certain days. Facility records showed that the medication was ordered and documented in the electronic medication administration record (EMAR) as to be administered by dialysis staff. However, dialysis notes did not provide evidence that the medication was actually administered on the specified dates. An interview with the dialysis RN revealed that he was primarily responsible for administering Mircera and Venofer, and would only administer other medications like Cefazolin if asked by nursing staff and if time permitted. The RN also stated he had no access to the EMAR to verify orders and relied on what the nurse provided. Furthermore, he had no means to document the administration of such medications, and this limitation was communicated to nursing and administrative staff. The facility's policy required coordination and documentation of dialysis-related care, but these requirements were not met in this instance.
Failure to Timely Implement Pharmacy Recommendations for PRN Psychotropic Medication
Penalty
Summary
The facility failed to ensure timely implementation of pharmacy recommendations for one resident reviewed for unnecessary medications. The resident in question had a history of multiple psychiatric disorders, including paranoid personality disorder, schizoaffective disorder, adjustment disorder with mixed anxiety and depressed mood, and anxiety disorder. The resident was noted to have severe cognitive impairment and was prescribed antipsychotic, antidepressant, hypoglycemic, and anticonvulsant medications, including a PRN order for lorazepam (Ativan) for anxiety. Over several months, the pharmacy consultant made repeated written recommendations to discontinue the PRN lorazepam or to reorder it for a specific number of days in accordance with federal guidelines, as PRN psychotropic medications require a 14-day stop date and subsequent reevaluation. These recommendations, dated across four consecutive months, were not addressed by the facility, as evidenced by the blank physician/prescriber response sections on each recommendation. The medication order for lorazepam remained active until it was eventually ended, citing the pharmacy recommendation, but this occurred months after the initial recommendation was made. Interviews with facility staff, including the pharmacy consultant, unit manager, DON, and administrator, confirmed that pharmacy recommendations were not being acted upon in a timely manner. Staff acknowledged that recommendations should be addressed within a few days to 72 hours, especially with daily provider presence, but this did not occur. The facility's own policy required staff to act upon all pharmacy recommendations according to established procedures, which was not followed in this case.
Medication Error Rate Exceeds Acceptable Threshold Due to Improper Administration
Penalty
Summary
The facility failed to maintain a medication error rate of five percent or less, as required, with 10 errors observed out of 26 opportunities, resulting in a 38.5% error rate. For one resident with a gastrostomy tube, a registered nurse crushed and combined all prescribed oral medications, including docusate sodium, potassium chloride, sertraline, alprazolam, baclofen, buspirone, Robinul, Senna-Time S, and simethicone, and administered them together through the tube, contrary to physician orders and facility policy, which required each medication to be given separately. The nurse admitted to combining medications to save time, and both the DON and Administrator confirmed that medications should have been administered individually as ordered. In another instance, a licensed practical nurse failed to ensure a resident received the correct dose of Spiriva Respimat for chronic obstructive pulmonary disease, administering only one puff instead of the two puffs ordered. The nurse was unaware of the correct dosage and did not prompt the resident to take the second puff. Both medication administration events were observed and confirmed through staff interviews and record reviews, and were not in accordance with physician orders or facility policy.
Failure to Follow Enhanced Barrier Precautions and Hand Hygiene Protocols
Penalty
Summary
Staff failed to don the recommended personal protective equipment (PPE) when providing care to a resident requiring enhanced barrier precautions (EBP) due to a chronic wound and a history of multi-drug-resistant organisms (MDROs). The resident's room was clearly labeled with EBP signage, and facility policy required the use of gloves and gowns during high-contact care activities such as incontinence care and transferring. However, a certified nurse aide (CNA) provided incontinence care and transferred the resident while wearing only gloves and not a gown, stating she did not notice the posted signage. Both the Director of Nursing and the Administrator confirmed that staff are expected to follow posted PPE requirements for residents on EBP. In a separate incident, two agency CNAs provided incontinence care to another resident with functional bladder and bowel incontinence. While the CNAs wore gowns, gloves, and masks, they did not change gloves or perform hand hygiene between the dirty and clean portions of care. After completing perineal care, the CNAs touched various items in the resident's room, such as the over-bed table, ventilator tubing, and fan, without changing gloves or performing hand hygiene. Hand hygiene and glove changes were only performed at the doorway upon leaving the room, contrary to facility policy and standard infection control practices. Interviews with staff, including the CNAs, a unit manager, an LPN, and the DON, revealed inconsistent understanding and implementation of hand hygiene and glove change protocols during incontinence care. Facility policies clearly directed staff to perform hand hygiene before and after care, and to change gloves and perform hand hygiene when moving from contaminated to clean body sites. These lapses in infection prevention and control practices were observed during direct care of residents with significant medical needs, including chronic wounds and incontinence.
Improper Containment of Soiled Linen in Laundry Area
Penalty
Summary
The facility failed to ensure proper containment of soiled linen, which had the potential to affect all 88 residents receiving laundry services. During an observation of the facility's laundry area, it was noted that the facility was operating with only one functional washing machine and three dryers. Soiled clothing and linens were mixed together in wheeled laundry bins, with some spilling over onto the floor. Additionally, large piles of soiled laundry were placed on the floor in front of the dryers, where clean laundry was also being handled. This practice was confirmed by Housekeeper/Laundry Staff, who acknowledged the mixing of soiled linens with resident personal clothing and the placement of soiled laundry on the floor. The Environmental Director confirmed that the facility was using only one washer due to plumbing issues with the second machine. The facility's policy on handling soiled linen, which was undated, stated that linen could become contaminated with pathogens and should not touch the uniform or floor. It also specified that soiled linen should be collected at the bedside, placed in a linen bag or designated receptacle, and kept separate from clean linen. The observed practices were in violation of this policy, as soiled linen was not properly contained and was mixed with clean items, posing a risk of cross-contamination.
Linen Shortage Affects Resident Care
Penalty
Summary
The facility failed to ensure that washcloths and towels were adequately provided to residents, affecting the quality of care for all 88 residents. Observations revealed that the main unit linen storage room had only seven washcloths and nine bath towels, while other units had none or very few. Certified Nurse Aides (CNAs) reported that due to the lack of washcloths and towels, they resorted to cutting larger linens, such as sheets and bath blankets, to cleanse residents. This practice was confirmed by multiple CNAs across different units, indicating a widespread issue with linen availability. Further investigation showed that the facility was operating with only one functional washing machine, as the second was out of service due to plumbing issues. This contributed to the shortage of clean linens. During an observation, a resident was found heavily soiled with urine, and CNAs had to use a bath towel instead of a washcloth for incontinence care due to the shortage. The Environmental Director confirmed the lack of clean washcloths and towels, acknowledging the ongoing issue with the laundry facilities.
Inadequate Supply of Appropriately Fitting Incontinence Garments
Penalty
Summary
The facility failed to provide appropriately fitting incontinence garments for 43 residents who required them. This deficiency was identified through record reviews, observations, and interviews with residents and staff. The facility's central supply storage was found to have only medium-sized briefs and pull-up garments in extra-large and medium sizes, with no availability of sizes XXXL, XXL, XL, large, or small. This lack of appropriate sizes resulted in residents being placed in ill-fitting garments that did not effectively contain elimination, as confirmed by Licensed Practical Nurse (LPN) #302. Resident #2, who was admitted with diagnoses including paraplegia and neurogenic bowel, was one of the affected residents. Observations and interviews revealed that the resident was placed in a brief that was too tight and failed to contain his perineum. Certified Nurse Aides (CNAs) #204 and #205 confirmed the inadequacy of the supply and the use of available briefs that did not fit properly. The Director of Nursing (DON) acknowledged the deficiency, confirming the lack of appropriately sized incontinence briefs for the residents.
Latest citations in Ohio
A resident with intact cognition receiving Medicare Part A skilled services for metabolic encephalopathy had services discontinued while benefit days remained, but the facility did not issue the required Skilled Nursing Facility Advance Beneficiary Notice (SNF ABN). The Social Services Director later confirmed that no SNF ABN was provided and reported she believed only a Notice of Medicare Non-Coverage (NOMNC) was needed when all skilled services were stopped. This practice conflicted with the facility’s written policy, which required SNF ABNs to be issued when extended care items or services were initiated, reduced, or terminated due to expected non-coverage by Medicare.
Surveyors identified that the facility exceeded the acceptable medication error rate when two residents with type 2 DM received insulin doses that were not administered according to orders or manufacturer instructions. In two separate observations, an LPN administered Novolog and another LPN administered insulin glargine and insulin lispro without priming the insulin pens, and the insulin lispro and Novolog were given after the residents had already consumed a significant portion of their breakfast meals, despite orders for administration before meals. Manufacturer information for both insulin products required priming before each injection to ensure accurate dosing, and facility policy required medications, including insulin, to be administered safely, timely, and in accordance with prescriber orders and specified time frames.
Surveyors found that the facility failed to document tray line food temperatures for multiple meals served from two dining room kitchenettes, despite having a “Trayline Taste & Temperature Log” and a policy requiring food to be stored, prepared, distributed, and served according to professional food safety standards. Review of logs showed repeated missing entries for breakfast, lunch, and dinner services in both the Harrison and McClellan dining areas, and the Senior Director of Culinary Services confirmed that temperatures had not been recorded for those meals, potentially affecting all residents receiving meals from those kitchenettes.
The facility failed to conduct and document required periodic care conferences for two residents, despite multiple comprehensive, quarterly, and significant change MDS assessments and a policy requiring periodic care conferences with resident and/or family participation. One resident with Parkinson’s disease, post-stroke hemiplegia, TIA, DMII, and depression had only two documented care conferences over a year, while another resident with aphasia, cerebrovascular disease, DMII, gait difficulty, coagulation defect, depression, and muscle weakness had no documented care conferences in the past year, aside from a declined invitation to the representative. The UCC confirmed that care conferences were expected to occur quarterly and that no additional documentation existed for either resident.
A resident with Alzheimer's disease and type II DM, who required extensive assistance with ADLs and was receiving scheduled Lantus and sliding-scale Humalog, experienced a severely elevated blood glucose level. The on-call provider was notified and ordered an additional dose of lispro insulin with a directive to recheck the blood glucose after administration. Nursing staff administered the extra insulin but did not document any follow-up blood glucose check, and the DON confirmed that this reevaluation was required by the facility's abnormal blood glucose policy and was not completed or documented.
A resident with Parkinson’s disease, dementia, and hypothyroidism was prescribed levothyroxine once daily along with other medications. A consultant pharmacist’s monthly drug regimen review recommended that levothyroxine be given in the morning on an empty stomach, 30–60 minutes before food, per manufacturer instructions. The medical record contained no documented physician response to this recommendation, and the MAR showed the drug scheduled for morning administration while the resident was observed eating breakfast and receiving the medication at the same time. An LPN confirmed administering levothyroxine during the meal, and the DON verified there was no documentation explaining whether or why the pharmacist’s recommendation was or was not followed, resulting in a failure to act on and document the identified irregularity.
A resident with severe cognitive impairment, multiple comorbidities, documented gait and balance abnormalities, and a high fall risk was care planned and assessed by therapy to require contact guard assistance and use of a gait belt for transfers and ambulation. While being assisted by a CNA from a recliner to the bathroom with a walker, the CNA did not apply a gait belt, even though the resident had a known tendency to lean backward when standing. As the CNA reached to open the bathroom door, the resident lost balance and fell backward, striking the back of the head, and was later found by an LPN without a gait belt in place, contrary to the facility’s gait belt policy and the resident’s assessed needs.
A resident with CKD stage five requiring peritoneal dialysis (PD) was admitted with pre-admission physician orders for three daily PD exchanges and monitoring for peritonitis (fever, abdominal pain, cloudy effluent), but these monitoring orders were not entered into the facility’s physician orders. The care plan referenced PD and general monitoring but did not specifically address peritonitis monitoring. Paper PD flowsheets showed incomplete and inconsistent documentation of exchanges and resident condition, including missing condition/comments for individual treatments and no record of one ordered PD exchange. The PD cycler flowsheet lacked effluent descriptions on multiple days. The PD nurse reported facility staff were expected to monitor effluent and symptoms, and the DON confirmed the absence of specific peritonitis monitoring orders, lack of an order for the PD cycler, and documentation gaps, despite a facility policy requiring ongoing assessment and monitoring for complications before, during, and after dialysis treatments.
A nurse was observed preparing multiple oral medications for a resident with depression, traumatic brain injury, anxiety, and impaired cognition by pushing tablets and capsules from unit-dose cards directly into her ungloved hand and then using her fingers to place them into a medication cup. In a follow-up interview, the RN confirmed this practice and acknowledged that the correct procedure is to dispense medications directly from the card into the cup, contrary to the facility’s medication administration policy requiring adherence to good nursing principles and practices.
A resident with Alzheimer’s disease, diabetes, anxiety, significant ADL dependence, and behavioral symptoms was observed seated in a chair positioned against the nursing station with a locked wheelchair placed directly in front, also against the nursing station, effectively restricting movement. An LPN confirmed both wheelchair wheels were locked and that it should not have been placed there, while a CNA stated she had positioned the wheelchair to prepare for lunch, was unable to complete the transfer, and left it in place, acknowledging this was wrong. This arrangement conflicted with the facility’s restraint policy, which prohibits physical restraints except when alternatives are ineffective for treating a medical symptom and defines restraints as devices adjacent to the body that cannot be easily removed and that restrict freedom of movement or access to the body.
Failure to Issue Required SNF ABN When Discontinuing Medicare Part A Services
Penalty
Summary
The deficiency involves the facility’s failure to issue a Skilled Nursing Facility Advance Beneficiary Notice (SNF ABN) when Medicare Part A services were discontinued for a resident who still had available benefit days. The resident was admitted with a diagnosis of metabolic encephalopathy and had intact cognition per the Minimum Data Set assessment. The facility’s own SNF Beneficiary Notification Review documented that Medicare Part A skilled services began on 02/11/26 and the last covered day was 03/11/26, and that the facility initiated discharge from Medicare Part A services before the resident’s benefit days were exhausted. Despite this, no SNF ABN was provided to the resident or the resident’s representative. During interviews, the Social Services Director stated that the SNF ABN was issued hours prior to the last covered day but, upon reviewing her files, confirmed that no SNF ABN had actually been issued for this resident. She further explained that she believed an SNF ABN was only required if one skilled service remained and that if all skilled services were being discontinued, only the Notice of Medicare Non-Coverage (NOMNC) needed to be issued. The Administrator, however, stated that a resident should always receive both a SNF ABN and a NOMNC when Medicare Part A services are discontinued and benefit days remain. Review of the facility’s written policy dated 03/28/23 showed that the facility was required to issue SNF ABNs for initiation, reduction, or termination of extended care items or services when Medicare payment was not expected, which did not occur in this case.
Plan Of Correction
This Plan of Correction is submitted as required under State and Federal law. This Plan of Correction does not constitute an admission on the part of the Facility that the findings cited are accurate, that the findings constitute a deficiency or that the scope and severity regarding the deficiency cited are correctly applied. Any changes to the Facility's policies and procedures should be inadmissible in any proceeding on that basis. Without admitting or denying the validity or the existence of the alleged noncompliance, the Facility submits this Plan of Correction with the intention that it be inadmissible by any third party in any civil or other action against the facility or any employee, agent, officer, director or shareholder of the Facility. The Facility is utilizing this Plan of Correction as its allegation of substantial compliance as of 05/29/2026 F-0582 Corrective action for resident/s: On 5/14/26 Resident #34 was informed of rights and responsibilities related to Advanced Beneficiary Notice and voiced understanding of information for future reference by administrator. Identification of other residents who may be affected: Any resident receiving skilled services from nursing or therapy services. The Administrator audited all residents who were discharged from skilled services in the past 30 days to ensure they were issued a Notice of Non-Coverage and Advanced Beneficiary Notice on 5/29/26. No non-compliance was noted. Measures for systemic change: On 5/14/2026 Business Office Manager, Director of Rehab, Minimum Data Set nurse, Director of Nursing and Social Services Director were educated on proper procedure of issuing of Notice Of Medicare Non Coverage and Advanced Beneficiary Notice by administrator. All upcoming discharges from skilled services will be reviewed weekly at Utilization Review meeting to ensure notices will be delivered timely. How Corrective Action will be monitored: Administrator or designee to complete audits of all residents being discharged from skilled services to ensure they were issued a Notice of Non-Coverage and Advanced Beneficiary. This audit will be completed weekly x 4 weeks, then monthly x 2 months. Corrective action will be initiated for any noted non-compliance. Audit findings will be reviewed as part of the monthly quality assurance process to determine the need for further monitoring. Date of Compliance 5/29/26
Insulin Administration Errors and Failure to Prime Insulin Pens
Penalty
Summary
The deficiency involves the facility’s failure to maintain a medication error rate below 5%, with surveyors identifying 3 errors out of 28 medication administration opportunities, resulting in a 10.71% error rate. For one resident with type 2 diabetes mellitus and moderate cognitive impairment, the physician’s order directed Novolog insulin 10 units via subcutaneous pen-injector to be given before meals. During an observed medication pass, the LPN administered 10 units of Novolog insulin without priming the pen and did so after the resident had already consumed approximately 50% of the breakfast meal. The LPN later confirmed she did not prime the pen and acknowledged that the insulin was ordered to be administered prior to meals. Manufacturer instructions for the Novolog FlexPen specified that an air shot (priming) must be performed before each injection to ensure proper dosing. Another resident, also diagnosed with type 2 diabetes mellitus and with intact cognition, had orders for insulin glargine 35 units subcutaneously twice daily and insulin lispro 20 units subcutaneously before meals, plus 12 units subcutaneously if blood glucose was between 251 mg/dL and 300 mg/dL. During an observed medication administration, an LPN administered 35 units of insulin glargine and 32 units of insulin lispro without priming the insulin pens and after the resident had consumed approximately 90% of the breakfast meal, despite orders for insulin lispro to be given before meals. The LPN later stated she could not remember if she had primed the pen and acknowledged that the insulin was ordered to be administered prior to meals. Manufacturer information for insulin lispro stated that the pen must be primed before each injection to confirm insulin delivery and remove air, and that failure to prime could result in too much or too little insulin. The DON confirmed the expectation that insulin be administered as ordered, including priming each pen with two units before dialing the prescribed dose, and facility policy required medications, including insulin, to be administered safely, timely, and in accordance with prescriber orders and required time frames.
Plan Of Correction
This Plan of Correction is submitted as required under State and Federal law. This Plan of Correction does not constitute an admission on the part of the Facility that the findings cited are accurate, that the findings constitute a deficiency or that the scope and severity regarding the deficiency cited are correctly applied. Any changes to the Facility's policies and procedures should be inadmissible in any proceeding on that basis. Without admitting or denying the validity or the existence of the alleged noncompliance, the Facility submits this Plan of Correction with the intention that it be inadmissible by any third party in any civil or other action against the facility or any employee, agent, officer, director or shareholder of the Facility. The Facility is utilizing this Plan of Correction as an allegation of substantial compliance as of 5/29/2026. F-0759 Corrective action for resident/s: Residents #21 and #22 were assessed and evaluated by nurse and Director of Nursing 5/14/26. Resident #21 and #22 both denied any adverse effects and none were noted upon assessment by the Director of Nursing on 5/14/2026. Notification made to physician on 5/14/2026. LPN # 2 competency Eval on insulin administration with the Director of Nursing completed 5/14/2026. Identification of other residents who may be affected: Diabetic residents on assignment of LPN #2/station 2 have the potential to be affected and were assessed by the DON/Designee on 5/14/26 and found to be within normal limits. Measures for systemic change: All Nurses were educated by the Director of Nursing on the steps for Insulin administration per competency, diabetes clinical protocol policy, Medication and treatment orders policy, administering medications policy, and Obtaining fingerstick Glucose Level policy On 5/14/2026. How Corrective Action will be monitored: Director of Nursing and Assistant Director of Nursing will complete insulin administration audits on 5 nurses. This audit will be completed weekly x 4 weeks, then monthly x 2 months. Corrective action will be initiated for any noted non-compliance. Audit findings will be reviewed as part of the monthly quality assurance process to determine the need for further monitoring. Date of Compliance: 5/29/2026
Failure to Document Tray Line Food Temperatures in Dining Room Kitchenettes
Penalty
Summary
The deficiency involves the facility’s failure to document tray line food temperatures for meals served from the Harrison and McClellan Dining Room kitchenettes, as required by professional standards for food service safety and the facility’s own policy. Review of the “Trayline Taste & Temperature Log” (revised September 2018) showed missing temperature documentation for multiple meals from the Harrison Dining Room kitchenette, including dinner on 03/30/26 and 03/31/26, lunch and dinner on 04/01/26 and 04/02/26, dinner on 04/07/26, and lunch and dinner on 04/08/26 and 04/10/26. The Senior Director of Culinary Services confirmed during interview that tray line food temperatures were not documented on the log for these meals. Similarly, review of the same log for the McClellan Dining Room kitchenette revealed that tray line food temperatures were not documented for dinner on 04/01/26, breakfast and lunch on 04/02/26, and lunch and dinner on 04/07/26. The Senior Director of Culinary Services also verified these omissions during interview. The facility census at the time was 27 residents, and the governing “Food and Nutrition” policy, approved on 09/07/21, stated that the facility must store, prepare, distribute, and serve food in accordance with professional standards for food service safety.
Plan Of Correction
F812 The facility will continue to ensure food temperatures are completed before meals are served for all residents. To ensure compliance with this standard the following measures have been taken: 1. Immediately 4/15/26 culinary supervisor #224 was re-educated by Dietary Manager to this standard and policy "Food and Nutrition" which includes documentation of food temperatures. 2. All dietary staff have been re-educated to the standard and policy "Food and Nutrition" during the month of April 2026. 3. Audits of food temperature documentation to be completed by Dietary Manager 4 x per week for 4 weeks then weekly for 4 weeks. 4. Administrator to validate audits/compliance and provide additional training as needed. Administrator will present to QAPI committee for ongoing monitoring and further direction.
Failure to Conduct and Document Required Care Conferences
Penalty
Summary
The deficiency involves the facility’s failure to complete and document comprehensive care conferences at required intervals in accordance with care plan regulations and facility policy. For one resident with Parkinson’s disease with dyskinesia, cognitive communication deficit, hemiplegia and hemiparesis following cerebral infarction, transient cerebral ischemic attack, type II diabetes mellitus, and major depressive disorder, the record showed multiple MDS assessments over a one-year period, including annual, quarterly, and significant change assessments. However, only two care conferences were documented during the last 12 months, despite the expectation that care conferences be conducted quarterly with the resident and family when possible. The Unit Care Coordinator confirmed that no additional care conference documentation existed for this resident beyond the notes dated 04/21/25 and 01/02/26. A second resident, with diagnoses including aphasia following cerebrovascular disease, cerebral infarction, type II diabetes mellitus, unsteadiness on feet, difficulty in walking, coagulation defect, depression, and muscle weakness, also had multiple MDS assessments completed over the review period, including quarterly and annual assessments. The record contained a note that a care conference was offered to the resident’s representative, who declined to attend, but there was no documentation of any care conferences for the most recent 12 months. The Unit Care Coordinator confirmed that no other care conference documentation was available for this resident. Facility policy stated that periodic care conferences involving the resident, family, and the interdisciplinary team are part of the care planning process, but the required periodic care conferences and corresponding documentation were not completed for these two residents.
Plan Of Correction
THIS PLAN OF CORRECTION SERVES AS BERKELEY SQUARE'S CREDIBLE ALLEGATION OF SUBSTANTIAL COMPLIANCE AS OF June 1, 2026. Without admitting or denying the validity or existence of the alleged deficiencies, Berkeley Square provides the following Plan of Correction: F657 The facility will continue to document completion of care conferences at the required intervals for all residents, including residents #04 & #15. To ensure compliance with this standard the following measures have be taken: 1. The social service designee and the inter- disciplinary team were re-educated by the administrator to the facility policy "Care Conference" on 4/29/26 and verbalized understanding. 2. Care conferences for resident #04 and resident #15 were conducted on or before 4/29/2026 by the interdisciplinary team. 3. Review of all other residents was conducted by the social service designee to validate and ensure that care conference schedule is up to date with timely care conferences scheduled for them on 4/15/2026. Audits of care conferences to be completed weekly for four weeks and then monthly after that by the social service designee. Documentation of the care conference including any identified concerns in the medical record. Administrator to validate audits/compliance and provide additional training as needed. Administrator will present results of these audits to QAPI committee for ongoing monitoring and further direction.
Failure to Reevaluate Blood Glucose After Treatment for Hyperglycemia
Penalty
Summary
The facility failed to ensure that a resident with diabetes received treatment in accordance with professional standards of practice when nursing staff did not reevaluate the resident's blood glucose after treatment for severe hyperglycemia. The resident, admitted with diagnoses including Alzheimer's disease, type II diabetes mellitus, and depression, had physician orders for Humalog insulin on a sliding scale before meals, Lantus insulin 25 units daily, and lisinopril 5 mg daily. The resident required extensive assistance with activities of daily living, including transfers, toileting hygiene, eating, and bathing. On the evening in question, the resident's blood glucose was documented as 532 mg/dL, and the on-call provider was notified. The provider gave a new order to administer an additional 8 units of lispro (Humalog) and to recheck the blood glucose in 30 minutes. The electronic medication administration record showed that the blood glucose of 532 mg/dL was obtained at 9:00 p.m. and that the additional 8 units of lispro were administered at 9:21 p.m. However, there was no documentation in the resident's chart that the blood glucose was rechecked after the additional insulin was given. In an interview, the DON confirmed there was no evidence of reevaluation and verified that, according to the facility's "Abnormal Blood Glucose Procedure" policy, the resident should have been reevaluated and that the evaluation step should have been included in the progress note documentation.
Plan Of Correction
F684 The facility will continue to ensure all residents, including #03, receive treatment in accordance with professional standards of practice and reevaluated for hyperglycemia. To ensure compliance with this standard the following measures have been taken: 1. The director of nursing assessed resident #03, reviewed documentation and orders and found no ill effects immediately 4/16/26. 2. All licensed nurses were re-educated to facility policy "Blood Glucose Monitoring" by the Director of Nursing/designee in April 2026. 3. Audits of like-residents that require blood sugar checks to be completed by the director of nursing/designee two times a week for 4 weeks and then monthly after that to validate correct follow through when there is abnormally high blood glucose result. The Administrator will bring results of these audits to the QAPI committee for ongoing monitoring and further direction.
Failure to Act on Pharmacist Drug Regimen Recommendation for Thyroid Medication
Penalty
Summary
The deficiency involves the facility’s failure to ensure that pharmacy recommendations from the monthly drug regimen review were acted upon and documented for a resident. The resident was admitted with diagnoses including Parkinson’s disease, dementia, and hypothyroidism, and had current physician orders for levothyroxine 150 mcg once daily, buspirone 50 mg twice daily, and losartan 100 mg once daily. A medication regimen review dated 11/25/2025 included a consultant pharmacist recommendation that levothyroxine be administered consistently in the morning on an empty stomach, at least 30–60 minutes before food, per manufacturer instructions. There was no specific physician response in the medical record to this recommendation, and the facility’s policy stated that consulting pharmacist reviews are sent to nursing and addressed with the primary care provider or consulting specialist for review and follow-up. Review of the resident’s medication administration record for April 2026 showed levothyroxine scheduled for 9:00 a.m. On observation, the resident was seen eating breakfast in the dining area at 8:03 a.m., and an LPN reported administering the levothyroxine 150 mcg to the resident while the resident was in the dining area eating breakfast. The DON confirmed there was no evidence in the resident’s medical record explaining why the consultant pharmacist’s recommendation from 11/25/2025 was or was not acted upon. This lack of documented physician review and action on the pharmacist’s identified irregularity constituted noncompliance with the drug regimen review requirements.
Plan Of Correction
F756 The facility will continue to ensure the pharmacy recommendations from the monthly drug regimen review by a licensed pharmacist are acted upon for all residents, including #08. To ensure compliance with this standard the following measures have been taken: 1. Resident #08 was assessed by the registered nurse and med review completed by 4/28/26. After review of resident's drug regime's, it was discovered that resident #8 had 2 separate medication recommendations on the same form, to be reviewed by two separate practitioners, pharmacy has been instructed and agreed to separate meds on individual forms. 2. Licensed nurses re-educated to facility policy "Drug Regimen Review" by Director of nursing/designee in April 2026 and no later than 5/8/26. Licensed nurses are responsible for ensuring the reviews and recommendations are given to the physician for timely review. 3. Review of all other current residents Drug Regimen orders completed by Director of nursing/designee on 4/16/26 to ensure recommendations were followed up on/reviewed by the physician and address concerns if needed. 4. Audit of drug regime recommendations, pharmacy recommendations, and physician follow up to be completed weekly for four weeks by the Director of nursing/designee. Administrator will present results of these audits to the QAPI committee for ongoing monitoring and further direction.
Failure to Use Required Gait Belt During Ambulation Resulting in Resident Fall
Penalty
Summary
The deficiency involves the facility’s failure to ensure that a required gait belt was used while assisting a high fall‑risk resident with ambulation, resulting in a fall with head injury. The resident had multiple diagnoses including metabolic encephalopathy, hypertension, osteoarthritis, muscle weakness, gait and mobility abnormalities, major depressive disorder, anxiety, and visual hallucinations. Admission and subsequent MDS and fall risk assessments documented that the resident was severely cognitively impaired, required moderate to maximal assistance with transfers and ambulation, could not independently come to a standing position, exhibited loss of balance while standing, used an assistive device, and had decreased muscle coordination. The resident had a history of falls prior to admission and was assessed as being at high, later moderate, risk for falls. The resident’s fall care plan identified her as at risk for falls and included interventions such as providing maximum to moderate assistance with transfers and walking short distances, use of a walker and wheelchair, and following the facility’s fall protocol. Therapy notes and care conference documentation indicated that the resident leaned backwards when standing, required contact guard to minimal assistance for bed mobility and transfers, and needed constant verbal cueing for safe sequencing during toilet transfers. The physical therapist confirmed that the resident was to use a gait belt with staff when ambulating, and the DON verified that therapy had assessed the resident as requiring contact guard assistance and a gait belt for ambulation and transfers. On the day of the incident, a CNA was assisting the resident from her recliner to the bathroom using a walker. The CNA walked beside the resident, providing guidance and support, and reported having a hand on the resident while assisting her. As they approached the bathroom door, the CNA reached for the doorknob to open it, and at that moment the resident began to lose her balance and fell backwards to the floor, striking the back of her head. The nurse who responded found the resident on her back at the foot of the bed with her feet near the bathroom, noted a red raised area on the back of the head, and documented that the resident was not wearing a gait belt and that the gait belt was on the dresser. In the facility’s investigative summary and in interviews, the CNA acknowledged that she did not have a gait belt on the resident while ambulating her, despite the resident’s assessed need for hands‑on assistance and gait belt use per facility policy and the resident’s care and therapy plans.
Failure to Implement PD Orders and Monitor Resident Receiving Peritoneal Dialysis
Penalty
Summary
The deficiency involves the facility’s failure to implement pre-admission physician orders for peritoneal dialysis (PD) and to provide ongoing monitoring for a resident with chronic kidney disease (CKD) stage five who required PD. Pre-admission orders dated 11/14/25 specified three daily PD exchanges at 6:00 A.M., 2:00 P.M., and 10:00 P.M., and directed staff to monitor for signs and symptoms of peritonitis, including fever, abdominal pain, and cloudy effluent. These monitoring orders were not entered into the facility’s physician orders. The resident’s care plan noted the need for PD and included general monitoring interventions (labs, signs of bleeding, bacteremia, septic shock, and significant vital sign changes), but did not specifically address the ordered monitoring for peritonitis. Review of PD documentation showed incomplete and inconsistent charting of treatments and resident condition. The paper peritoneal flowsheet had columns for time of PD and condition/comments, including instructions to call the nurse immediately for cloudy fluid, abdominal pain, or fever. However, the first entry on 11/15/26 at 2:00 P.M. only noted that the PD nurse completed the exchange, and the 10:00 P.M. entry that day had no condition/comment documentation. Subsequent days (11/16/25, 11/17/25, and 11/18/25) contained only one condition/comment entry per day rather than for each exchange, and there was no documentation that the 6:00 A.M. PD on 11/18/25 was completed. The PD cycler flowsheet starting 11/19/25 lacked any description of the effluent on multiple days. The PD nurse from the dialysis company stated facility staff were expected to monitor effluent for cloudiness and assess for abdominal pain and fever, and the DON confirmed there was no electronic physician order for peritonitis monitoring or for use of the PD cycler, that the paper charting did not allow for effluent description or symptom documentation for each treatment, and that PD was not documented at one ordered time. The facility’s dialysis policy required ongoing assessment and monitoring for complications before, during, and after treatments, which was not reflected in the documentation for this resident.
Improper Infection Control During Medication Administration
Penalty
Summary
Surveyors identified a deficiency in infection prevention and control related to medication administration for Resident #29. The resident was admitted on 02/28/14 with diagnoses including depression, traumatic brain injury, and anxiety, and had impaired cognition per a quarterly MDS assessment. During an observation on 03/25/26 at 6:58 A.M., RN #281 prepared the resident’s medications by removing an Amoxicillin-Pot Clavulanate tablet from the medication card and pushing it directly into her ungloved hand, then using her fingers to place the pill into a medication cup. The same process was observed for multiple other medications, including Escitalopram Oxalate, Furosemide, Sennosides, Lyrica, and Vitamin D, each being pushed from the card into the RN’s ungloved hand and then transferred by her fingers into the medication cup before administration to Resident #29. In a subsequent interview at 7:27 A.M. the same day, RN #281 confirmed she had placed each medication into her ungloved hands prior to administration and acknowledged that the proper procedure was to push the pills directly from the card into the medication cup. Review of the facility’s “Medication Administration – General guidelines” policy, revised 10/08/25, stated that medications are to be administered in accordance with good nursing principles and practices. This practice failure was cited as a deficiency under Complaint Number 2681777.
Improper Use of Wheelchair as a Physical Restraint
Penalty
Summary
Surveyors identified a deficiency related to the facility’s failure to ensure a resident was free from physical restraints. Resident #7, admitted with diagnoses including Alzheimer’s disease, diabetes mellitus, and anxiety disorder, was documented on a recent MDS as rarely understood and dependent for ADLs except eating. The resident ambulated independently on the unit without an assistive device and had documented verbal and other behaviors occurring one to three days during the look-back period. The care plan noted the resident had potential to be physically aggressive, chase staff, throw objects, and be combative with care, with interventions such as offering choices, administering medications as ordered, and intervening early when agitation occurred. During an observation and interview, Resident #7 was found sitting in a chair with the right arm of the chair positioned against the nursing station and a wheelchair placed directly in front of him. The left arm of the wheelchair was also against the nursing station, and both wheelchair wheels were locked, creating a barrier that appeared to restrain the resident, who was sleeping with his knees touching the locked wheelchair. An LPN confirmed both wheelchair wheels were locked and that the wheelchair should not have been placed in front of the resident. A CNA reported she had placed the wheelchair there in preparation to get the resident up for lunch, was unable to transfer him, and left the wheelchair in that position, acknowledging it was wrong to keep it there. The facility’s physical restraint policy stated that physical restraints are not used except when alternatives are not appropriate or effective for treating a medical symptom and defined physical restraints as any device attached or adjacent to the body that the individual cannot easily remove and that restricts freedom of movement or access to the body.
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