Park Vista Nursing And Rehab
Inspection history, citations, penalties and survey trends for this long-term care facility in Youngstown, Ohio.
- Location
- 1216 5th Ave, Youngstown, Ohio 44504
- CMS Provider Number
- 365275
- Inspections on file
- 56
- Latest survey
- January 16, 2026
- Citations (last 12 mo.)
- 8
Citation history
Health deficiencies cited at Park Vista Nursing And Rehab during CMS and state inspections, most recent first.
Two residents were affected when the facility failed to provide adequate supervision and implement ordered safety interventions. One resident with multiple comorbidities and a known history of remaining outside for long periods, including a prior hypothermia hospitalization, was allowed to stay outdoors in very cold weather without individualized supervision measures or documented safety checks, and was later found unresponsive and extremely cold by EMS. Another resident with dementia, high fall risk, and a history of falls had a care plan requiring bilateral floor mats and other fall-prevention measures, but during observation only one floor mat was in place while the other was stored against a wall, contrary to the ordered intervention.
The facility failed to provide palatable meals at safe, appetizing temperatures and did not consistently prevent possible food contamination. Multiple residents with complex medical conditions reported that meals were often cold and frequently served in Styrofoam take-out containers instead of on regular plates, with similar concerns documented in Resident Council minutes. Observation of a lunch meal showed sandwiches starting at a cold temperature, burnt sweet potato fries, and a staff member handling bread and cheese with gloved hands and then performing other tray line tasks without changing gloves or hand hygiene. The kitchen ran out of soup bowls, causing a delay while dishes were washed, and some residents received a different soup when the original soup ran out. A test tray at the end of service showed fries at 81°F and a sandwich at 60°F, which the dietary manager confirmed were not appropriate service temperatures, and staff acknowledged frequent dish shortages and recent reliance on Styrofoam containers when the dish machine was down, contrary to facility policy on timely, palatable meal service.
Two residents who required substantial to maximum assistance with ADLs, including bathing, were not consistently offered or provided scheduled showers as outlined in their care plans and the facility’s bathing policy. Record review showed that over a two‑month period each resident received only one shower and several bed baths despite being scheduled for twice‑weekly showers, with some refusals documented. One cognitively intact resident reported he was never offered a shower, and a CNA stated that bed baths were offered when showers were refused. The Administrator confirmed that showers, bed baths, and refusals were not consistently provided or documented for these residents.
Two residents did not receive timely and complete wound care as ordered. One resident with multiple chronic conditions developed a new area of moisture-associated skin damage on the flank; although an RN documented the new skin issue, there was no evidence that the provider or family were notified or that any treatment orders were obtained or implemented, and the resident reported that no dressing had been applied. Another resident with peripheral vascular disease and a chronic leg ulcer had physician orders for daily wound care to the lower leg and later the foot, but the treatment administration records showed that several ordered daily treatments were not completed over multiple months, with no documentation explaining the missed care, despite a family grievance alleging that wound treatments were not being done.
A resident with venous ulcers received wound care from an LPN and an RN who failed to perform hand hygiene after glove changes and between handling the resident's legs during dressing changes. The nurses confirmed that hand hygiene was not performed as required, and the facility's policy did not specifically address hand hygiene between glove changes. This deficiency was identified during a complaint investigation.
The facility did not maintain a functional dishwasher, leading to all meals being served on paper plates with plastic silverware for several weeks. Staff confirmed the dishwasher had been out of service due to a power surge, and delays in repair were caused by the need for parts and service scheduling. Most residents were affected, with adaptive devices cleaned manually in the kitchen.
The facility did not maintain a safe and comfortable temperature, with indoor readings consistently above 81°F during a period of high outdoor heat. Two residents were hospitalized for heat exhaustion symptoms, including lethargy, dizziness, and dehydration, after prolonged exposure to the hot environment. Staff and other residents reported significant discomfort, and the air conditioning system had been non-functional for an extended period, with insufficient interim measures in place.
Multiple concerns regarding cleanliness, maintenance, and environmental safety were documented, including sticky floors, stained and bubbled carpets, improperly hung curtains, frayed walking surfaces, and dirty linens. Staff interviews confirmed ongoing housekeeping challenges due to broken cleaning equipment and vacant supervisory positions, resulting in inconsistent adherence to daily cleaning protocols and resident dissatisfaction.
The facility failed to store food properly and maintain sanitation standards, as observed in the kitchen and on Nursing Unit One. Clean utensils were found in a dirty drawer, and there were no test strips for sanitation level testing at the dishwash station. A leaking dishwasher caused water accumulation on the floor. Several dried food items were improperly stored, being opened and undated. On Nursing Unit One, a refrigerator contained expired milk and had water with floating dirt at the bottom. The facility's policies on cleanliness and storage were not followed.
The facility failed to maintain essential kitchen and laundry equipment, affecting dietary services for 99 residents and potentially impacting all residents. Observations revealed issues with the walk-in refrigerator, freezer, and dishwasher, as well as non-working washers and dryers, lint buildup, and improper use of equipment in the laundry room. These deficiencies were confirmed by staff and violated facility policies requiring equipment to be maintained in good repair.
A facility failed to provide sufficient staffing, resulting in missed medical appointments and inadequate care for residents. One resident missed an appointment due to staff being occupied and not hearing the phone, while another missed an appointment because the day shift nurse was late, delaying preparations. A third resident experienced inadequate incontinence care, leading to skin issues, and another resident suffered severe pain due to delayed assistance. The facility's policies on transportation and incontinence management were not effectively implemented.
The facility failed to ensure proper isolation signage for two residents, potentially affecting others. A resident with CRE had incorrect signage for contact isolation precautions, confirmed by an RN. Another resident with VRE also had incorrect signage. Additionally, a glucometer was improperly sanitized after use on a resident, increasing the risk of cross-contamination. The RN used an alcohol swab instead of an EPA-approved disinfectant, contrary to the manufacturer's instructions.
The facility did not complete baseline care plans within 48 hours for three residents admitted with various health conditions, including osteomyelitis, pneumonia, and malignant neoplasm. Despite requiring assistance with daily activities, the care plans were delayed, contrary to facility policy.
The facility failed to conduct an initial care conference for a resident with multiple health issues and intact cognition, and missed a quarterly care conference for another resident with mild cognitive impairment and significant care needs. This was against the facility's policy requiring routine care conferences.
A resident with severe cognitive impairment and physical limitations did not receive adequate nail care as per their care plan. Observations revealed brown debris under the resident's fingernails, which staff attributed to food items. The facility's policy required regular cleaning and trimming of nails to prevent infections, but this was not consistently followed, as confirmed by staff interviews and observations.
A resident with rheumatoid arthritis, spinal stenosis, and anxiety disorder did not receive adequate activities due to staffing issues, despite having an intact cognition and a care plan requiring varied activities. The resident only received two one-to-one activity visits over a period of more than a month, as confirmed by the Activity Director, who cited recent staff terminations as the cause.
A facility failed to apply a right ankle foot orthosis (AFO) brace as ordered for a resident with limited ROM. The resident's AFO was broken and unavailable for a month, and there was no documentation of repair efforts. Observations showed the resident without the AFO, and staff interviews revealed a lack of awareness about the resident's need for the brace. The facility's policy on mobility and ROM was not followed, resulting in the deficiency.
A resident at high risk for falls experienced two unwitnessed falls in one day, but the facility failed to conduct comprehensive fall assessments or notify the physician. The incident log recorded the falls, but the medical record lacked documentation for one fall and necessary assessments for both. Staff interviews revealed a lack of recollection and potential staffing issues, indicating lapses in monitoring and documentation practices.
Two residents experienced inadequate incontinence care, leading to potential skin integrity issues. One resident, with multiple fractures and diabetes, was left in a urine-saturated brief, resulting in reddened skin and open areas around her hip staples. Another resident with IBS and mobility issues reported waiting up to four hours for care, despite a care plan specifying two-hour checks. Staff shortages contributed to delays in responding to call lights and providing care, contrary to facility policy.
The facility failed to provide a resident with the prescribed diet under the Personalized Food First program due to miscommunication among dietary staff, resulting in the resident receiving only one serving of cheesy eggs instead of two. Additionally, another resident was not weighed weekly as ordered, despite being on a weight gain regimen. These deficiencies affected two residents reviewed for nutrition.
A resident with a PEG tube for nutrition was not receiving tube feeding as ordered by the physician. Observations showed the feeding pump was off when it should have been running, and the feeding solution and flush bag were not dated correctly. The resident, who had a history of cerebral infarction and dysphagia, was dependent on the tube for nutrition. The LPN was unaware of the reason for the feeding being turned off, indicating a procedural lapse.
A resident with a history of severe pain following a below-the-knee amputation experienced a delay in receiving appropriate pain management. Despite having orders for oxycodone and acetaminophen, the resident's pain was not addressed promptly due to confusion over medication orders and a lack of immediate response from nursing staff. The resident reported severe pain, which affected her sleep and therapy participation, highlighting a failure to adhere to the care plan for timely pain relief.
A facility failed to assess a resident's dialysis thrill and bruit every shift as required by policy. The resident, with end-stage renal disease, had orders for dialysis and vital signs but lacked specific orders for thrill and bruit assessment. Records from January to February showed no evidence of these assessments, confirmed by the ADON. The facility's policy mandates these assessments every shift.
The facility failed to manage medications properly for two residents. One resident received Percocet without clear parameters, leading to potential overmedication, while another resident did not have regular pharmacy reviews or documented physician responses to medication adjustments. This lack of oversight and documentation contributed to deficiencies in medication management.
A facility failed to accurately document the status of a resident's right ankle foot orthosis (AFO) brace. The resident, with conditions including cerebral infarction and difficulty walking, had a broken AFO from late November to late December, yet the MARs inaccurately showed it was applied and removed as ordered. Staff interviews confirmed the documentation errors, violating the facility's policy on accurate medical record-keeping.
The facility failed to transport two residents to their scheduled medical appointments due to miscommunication and staffing issues. One resident missed an orthopedic appointment because the transportation driver left after a failed phone call to the nursing unit. Another resident missed a pulmonology appointment due to a delay in finding an appropriate oxygen tank and the absence of a day shift nurse. The facility's policy to ensure transportation was not effectively executed, resulting in noncompliance.
The facility failed to provide a clean and homelike environment for two residents. One resident, who is cognitively intact, reported her room was not cleaned for days, with an overflowing trash can and dirty bathroom. Another resident, with severe cognitive impairment, was found in unsanitary conditions with food crumbs and feces in his room. Despite staff requests for more frequent cleaning, the issues persisted, highlighting deficiencies in maintaining a sanitary environment.
A facility failed to complete a baseline care plan within 48 hours for a resident with multiple health issues, including acute respiratory failure and COPD. The resident was alert but had shortness of breath, unsteady gait, and required bedrest. An RN acknowledged the care plan was opened but not completed, missing the facility's policy requirement.
The facility failed to maintain a clean and sanitary kitchen and properly store and date food items, potentially affecting all 82 residents. Issues included a buildup of ice and debris in a freezer, expired heavy whipping cream, improperly stored and undated food items, and a significant ice buildup in the walk-in freezer. The Dietary Director confirmed these concerns during the observation.
The facility failed to follow physician's orders for two residents regarding the application and removal of Lidocaine pain relief patches. One resident with severe cognitive impairment and multiple medical conditions did not have documented evidence of patch removal after 12 hours, and another resident with borderline personality disorder and primary osteoarthritis did not have documented evidence of patch removal at hour of sleep.
A resident who was totally dependent on staff for bed mobility and toileting went almost six hours without incontinence care, resulting in skin breakdown and discomfort. The staff did not follow the physician's orders for incontinence care, including leaving the brief open and applying zinc cream after each episode.
A resident reported four hundred dollars missing from her purse, but the facility delayed reporting the incident to the state agency, violating the 24-hour reporting requirement. The case remains under police investigation.
Failure to Adequately Supervise Resident Outdoors and Maintain Ordered Fall-Prevention Interventions
Penalty
Summary
The deficiency involves the facility’s failure to ensure adequate supervision and monitoring to prevent accidents, including hypothermia and falls, for two residents. One resident with respiratory failure, COPD, kidney disease, hypertension, arthritis, and tobacco use had a known history of staying outside for long periods and had previously been hospitalized for hypothermia while living in the attached residential care facility. After admission to the skilled nursing facility, the resident’s care plan identified behavior problems of refusing treatment and oxygen and staying outside for long periods, but interventions were limited to education on motorized wheelchair use, offering choices, emotional support, and maintaining a routine schedule. The care plan did not include comprehensive or individualized interventions addressing the resident’s safety risk or supervision needs when outside, nor did it specify a frequency of monitoring or checks for safety and supervision, despite the resident’s known behavior and prior hypothermia episode. On the day of the incident, nursing documentation showed an assessment of the resident at approximately mid-afternoon, with no further nursing notes until late that night when the resident was found unresponsive. EMS records documented that the resident was found slumped over in his wheelchair outside the facility, very cold to the touch, with slow and shallow breathing, bradycardic peripheral pulses, and pinpoint, non-reactive pupils. Staff reported to EMS that the resident had been outside for an unknown amount of time. EMS was unable to obtain an accurate temperature, administer IV medications, or perform an ECG due to the resident’s condition and cold exposure, and they initiated warming measures. Hospital records later documented significantly low body temperatures and admission to critical care with altered mental status, low oxygen levels, and hypothermia. Interviews with the Administrator, DON, and Medical Director confirmed that the resident was known to stay outside for hours, that staff used routine one- to two-hour checks as a standard for all residents, and that more frequent checks specific to this resident’s risk had not been considered. There was no documentation of checks completed for the resident on the day of the incident, and the facility’s written investigation lacked staff statements, details of what the resident was wearing, and the temperature of the outdoor smoking area at the time he was found. The second component of the deficiency concerns the facility’s failure to ensure that ordered fall-prevention interventions were in place for another resident with dementia, cognitive communication deficit, heart failure, and a history of falls. This resident was admitted from the on-campus assisted living unit due to falls and later sustained a left femoral neck fracture after a fall requiring hospitalization. The resident’s care plan included multiple fall-prevention interventions, such as keeping the call light within reach, maintaining a clutter-free room, providing a visual reminder to call for assistance, bilateral floor mats on each side of the bed, and a defined perimeter mattress. The resident’s fall risk assessment later identified the resident as high risk for falls, and progress notes and fall investigations documented multiple falls, with neuro checks and review of fall risks and interventions after each event. However, during an observation, the resident was found in bed with only one floor mat in place on the left side of the bed, while the other floor mat, which was ordered to be on the opposite side of the bed, was propped against a wall behind an empty bed across the room. A CNA confirmed at the time of observation that the floor mat was not in place as ordered, indicating that the prescribed fall-prevention intervention was not consistently implemented.
Failure to Provide Palatable, Proper-Temperature Meals and Prevent Food Contamination
Penalty
Summary
The facility failed to ensure meals were palatable, attractive, and served at safe and appetizing temperatures, and did not consistently prevent possible contamination during meal service. Multiple residents with significant medical conditions, including diabetes, heart disease, respiratory failure, Parkinson’s disease, morbid obesity, depression, and protein-calorie malnutrition, reported that their meals were often served cold and frequently provided in Styrofoam take-out containers rather than on regular plates. Resident Council minutes from two consecutive months documented resident concerns about food being served cold. Several residents stated they had not received a hot meal in months and that meals were usually or often served in Styrofoam containers. Observations of the lunch tray line showed that while initial hot food temperatures were within or above expected ranges (tomato soup at 206.9°F and sweet potato fries at 187°F), the ham and cheese sandwiches were at 44.3°F at the start of service. During tray line, a staff member was observed using a gloved hand to retrieve hamburger buns and cheese slices and then continuing with other tray line tasks without changing gloves or performing hand hygiene, and she confirmed she had not followed infection control measures. Additional sweet potato fries retrieved from the oven appeared black on the ends, and staff confirmed they were burnt. The kitchen also ran out of soup bowls for approximately five to six residents, causing about a 10-minute delay while dishes were washed, and the last few residents received a different soup (chicken noodle) because the tomato soup had run out. The Dietary Manager reported that trays were normally passed within 1 hour 15 minutes to 1 hour 20 minutes and acknowledged that Styrofoam containers had been used for a two- to three-week period when the dish machine needed repair. She also confirmed that hot foods should be at least 135°F and cold foods between 40°F and 55°F by the time residents received them. A test tray taken when the last resident was served showed chicken noodle soup at 146°F, sweet potato fries at 81°F, and a sandwich at 60°F; the Dietary Manager confirmed the fries were cold, soggy, and burnt, and the sandwich was not at an appropriate temperature for service. Another staff member confirmed they often did not have enough dishes and had to wash breakfast dishes to have enough for lunch, yet still sometimes ran short. The Administrator acknowledged awareness of resident concerns about meals being cold upon delivery. These findings demonstrated the facility did not follow its policy requiring nourishing, palatable, well-balanced meals served within 45 minutes of scheduled mealtime, with trays inspected to ensure food was attractive and at safe, appetizing temperatures.
Failure to Consistently Offer and Document Scheduled Showers for Dependent Residents
Penalty
Summary
The deficiency involves the facility’s failure to consistently offer and provide showers to residents who required assistance with activities of daily living, as well as failure to consistently document showers, bed baths, and refusals, contrary to facility policy. One resident with dementia, severe cognitive impairment, and multiple medical conditions including a left femur fracture, heart disease, hypertension, kidney disease, and a history of falls was care planned to receive substantial to maximum assistance with showering or bathing and was scheduled for showers twice weekly. Review of shower records over a two‑month period showed he received only one shower and several bed baths, with a few documented refusals, indicating that showers were not provided as scheduled. The facility’s bathing policy required honoring bathing preferences, providing showers twice weekly, and documenting refusals with nurse notification. Another resident, cognitively intact with diagnoses including diabetes, chronic bronchitis, hyperlipidemia, and sleep apnea, was also care planned for substantial to maximum assistance with showering or bathing and scheduled for showers twice weekly. Review of his shower sheets for the same period showed he received only one shower and several bed baths, with multiple documented refusals, and he reported in an interview that he was never offered a shower. A CNA stated that when a resident refused a shower, a bed bath would be offered instead. The Administrator confirmed that showers, bed baths, and refusals were not consistently provided to or documented for these residents, demonstrating noncompliance with the facility’s own bathing policy.
Failure to Implement and Complete Ordered Wound Treatments for Two Residents
Penalty
Summary
The deficiency involves the facility’s failure to provide timely and ordered treatment for skin breakdown for two residents. One resident with diabetes with neuropathy, hypertension, and COPD was alert and oriented, required extensive assistance with ADLs, and used a mechanical lift and wheelchair. This resident had an existing treatment order for the right flank, but on a later date an RN documented a new area of impaired skin integrity on the left flank and noted that the wound care nurse had been notified. There was no documentation that the physician or responsible party were notified and no evidence that any treatment orders were obtained or implemented for the new left flank area. The resident reported having informed staff of discomfort at the left flank and that an RN had examined the area, but no dressing had been applied. When the wound care nurse later assessed the resident, a new red, 2 cm by 2 cm moisture-associated skin damage lesion was observed on the left flank, and it was confirmed that no treatment order existed for that area. The second resident had peripheral vascular disease and a chronic ulcer of the left lower leg and ankle and was alert, oriented, and largely independent with upper extremity ADLs but required more assistance for lower extremity care. This resident had physician orders for daily wound care to the left lower leg and later to the left foot, including cleansing, application of calcium alginate and gentamicin ointment, and appropriate dressings. Review of the treatment administration records showed multiple dates across three months when the ordered daily wound treatments were not completed. There was no documentation in the progress notes explaining why the wound care was missed on those dates. A family grievance had been filed alleging that the resident’s wound treatments were not being completed as ordered, and review of records confirmed that the treatments were not carried out on several specified days without documented justification.
Infection Control Lapse During Wound Care Procedure
Penalty
Summary
During a wound care and dressing change procedure for a resident with venous ulcers on both lower extremities, two nurses failed to maintain proper infection control practices. The resident, who was cognitively intact and required moderate assistance with activities of daily living, had a history of Charcot joint, heart failure, diabetes, and muscle weakness. The wound care orders specified daily dressing changes using normal saline, alginate, abdominal pad, gauze, and elasticized bandage. During the observed procedure, the nurses gathered supplies, established a clean field, and donned appropriate PPE. One nurse held the resident's right leg while the other cleansed and dressed the wound, then assisted with putting on a sock and shoe. After removing gloves, the nurse did not perform hand hygiene before donning new gloves to assist with the left leg. The other nurse also did not change gloves or perform hand hygiene between handling the right and left legs. Both nurses confirmed during interview that hand hygiene was not performed after glove changes or between handling the resident's legs. The facility's wound care policy required handwashing after glove removal but did not specifically address hand hygiene between glove changes from soiled to clean gloves. This lapse in infection control procedures was identified during a complaint investigation and affected one resident out of three reviewed for wound care.
Failure to Maintain Functional Dishwasher Resulting in Prolonged Use of Disposable Meal Service Items
Penalty
Summary
The facility failed to ensure that the dishwasher was in good working condition, resulting in all meals being served on paper plates with plastic silverware for an extended period. Observations confirmed that residents were eating meals on disposable products both in the dining room and in their rooms. The dishwasher had been out of service since a power surge occurred, and as of the time of the survey, it remained nonfunctional. The delay in repair was attributed to the need for ordering parts and scheduling maintenance service, with invoices confirming the timeline of the breakdown and ongoing repair attempts. Interviews with facility staff, including the Maintenance Director, Administrator, and Dietary Manager, confirmed the ongoing use of disposable meal service items for approximately six weeks. All adaptive devices continued to be used as ordered and were cleaned using the three-bay sink system. The deficiency affected 90 out of 92 residents, with two residents not receiving food from the kitchen. The facility census at the time was 92.
Failure to Maintain Safe and Comfortable Temperatures Leads to Resident Hospitalizations
Penalty
Summary
The facility failed to maintain a comfortable and safe temperature environment for its residents, as evidenced by multiple rooms and hallways being recorded at temperatures ranging from 81.2 to 86 degrees Fahrenheit over several days of high outdoor heat. The air conditioning system had been non-functional for approximately a year, and the facility had not restored adequate cooling despite ongoing high temperatures. Staff and residents consistently reported discomfort, with several residents experiencing symptoms related to excessive heat, such as sweating, dizziness, weakness, and lethargy. Two residents were sent to the hospital with symptoms consistent with heat exhaustion. One resident, with a history of adult failure to thrive, encephalopathy, atrial fibrillation, COPD, major depressive disorder, and hypertension, was found lethargic with slurred speech and low oxygen saturation after being exposed to the hot environment. Another resident with multiple sclerosis, anxiety, hypertension, and protein calorie malnutrition was observed lethargic and dizzy after spending most of the day outside and was later treated for dehydration at the hospital. Both residents returned from the hospital without new orders. Interviews with staff, residents, and family members confirmed the facility was uncomfortably hot and humid, with staff using personal fans and providing water to residents in an attempt to mitigate the effects of the heat. The facility's emergency preparedness policy required action when temperatures exceeded 81 degrees Fahrenheit for more than four hours, but observations and interviews indicated that these measures were insufficient or not fully implemented, resulting in ongoing resident discomfort and hospitalizations due to heat-related symptoms.
Failure to Maintain a Safe, Clean, and Comfortable Environment
Penalty
Summary
The facility failed to provide a safe, functional, sanitary, and comfortable environment for all residents, as evidenced by multiple documented concerns and direct observations. Resident concern logs and Resident Council meeting minutes revealed ongoing issues with room cleanliness, sticky floors, and inadequate housekeeping, particularly on weekends. Several residents reported dissatisfaction with the thoroughness of room cleaning. During a facility tour, numerous deficiencies were observed, including broken toilet handles, stained and bubbled carpets, improperly hung or non-functional curtains, frayed and uneven walking surfaces, visible insulation accessible to residents, stained ceiling tiles, and dirty or stained bed linens. In one unoccupied room, a urinal containing urine was left unattended for several days after the resident had been transferred to the hospital. Interviews with facility staff confirmed that the carpet cleaning machines had been out of service for several months and the Housekeeping Supervisor position had been vacant, contributing to ongoing housekeeping challenges. Housekeeping staff acknowledged that daily cleaning was required but noted that non-emergent repairs were reported to maintenance and that curtain maintenance was their responsibility. Facility policies and cleaning logs indicated that all surfaces, equipment, and linens were to be cleaned daily, but these standards were not consistently met, as evidenced by the observations and resident complaints.
Food Storage and Sanitation Deficiencies
Penalty
Summary
The facility failed to store food in a manner that prevents contamination, as observed during an initial tour of the kitchen. The drawer containing clean utensils at the puree food prep station was found to be dirty, with visible dirt and a dried green food substance. Additionally, there were no test strips available at the three-sink manual dishwash station to test for proper sanitation levels, and the Dietary Director was unaware of how staff were testing these levels. A significant amount of water was present on the floor between the automatic dishwasher and the three-sink manual dishwash station, which was attributed to a leaking dishwasher. Furthermore, several dried food items were improperly stored, being opened and undated, which was verified by the Dietary Director. On Nursing Unit One, a refrigerator was found to contain a small carton of milk past its expiration date, and a large amount of water with visible floating dirt was observed at the bottom of the refrigerator. The temperature sheet on the refrigerator was outdated. A Certified Nurse Assistant confirmed these findings and stated that housekeeping was responsible for cleaning the refrigerator. An interview with an LPN/Unit Manager revealed that the night shift was responsible for checking the refrigerator for cleanliness and expired food items. The facility's policies on kitchen sanitization, food storage, manual dishwashing, and refrigerator maintenance were reviewed, highlighting the requirements for cleanliness, proper storage, and regular checks, which were not adhered to in these instances.
Facility Fails to Maintain Kitchen and Laundry Equipment
Penalty
Summary
The facility failed to maintain essential kitchen equipment in a safe operating condition, which had the potential to affect 99 residents receiving dietary services. During an initial tour of the kitchen, it was observed that the first metal panel of the floor of the walk-in refrigerator was coming up, creating a gap between the concrete underflooring and the metal panel. Additionally, the walk-in freezer had heavy ice buildup in the right upper corner. The automatic dishwasher was leaking, resulting in a large amount of water on the floor between the dishwasher and the three-sink manual dishwashing area. These issues were verified by the Dietary Director, and the facility's Kitchen Sanitization Policy required that all equipment be maintained in good repair and free from defects that could affect their use or proper cleaning. The facility also failed to maintain the laundry room and its equipment in clean working order, potentially affecting all residents. Observations revealed that two industrial dryers and two manual washers were not in working order, with signage indicating they were out of service. There was a large lint buildup behind the dryers, on the ceilings, walls, and floors, and a dirty fan covered with dust was noted by the laundry press. A screwdriver was being used as a control knob on a manual dryer, and several washers and dryers were awaiting repairs. The Regional Environmental Service Manager confirmed that the lint buildup could be improved and that non-working equipment should have been removed. The facility's Maintenance Service policy required the maintenance director to ensure that equipment was maintained in a safe and operable manner.
Staffing Deficiencies Lead to Missed Appointments and Inadequate Care
Penalty
Summary
The facility failed to ensure sufficient staffing to meet the needs of several residents, leading to missed medical appointments and inadequate care. Resident #46, who required assistance for daily activities due to conditions such as congestive heart failure and chronic obstructive pulmonary disease, missed a scheduled medical appointment because the transportation driver left after not receiving a timely response from the facility. The staff, including a CNA and an LPN, were occupied with other residents' needs and did not hear the phone ring, resulting in the missed appointment. Resident #98, who was dependent on staff for various activities and required oxygen therapy, also missed a medical appointment. The day shift nurse did not arrive on time, leaving the night shift nurse stressed and unable to start the day shift duties. The Assistant Director of Nursing had to find an appropriate oxygen tank for Resident #98, which delayed the resident's readiness for transportation. The transportation driver left after waiting for five minutes, as per their policy, resulting in the missed appointment. Resident #203, who had multiple fractures and was dependent on staff for toileting and bathing, experienced inadequate incontinence care. The resident reported having to clean herself due to delayed responses to call lights and infrequent changes by the aides. Observations revealed reddened and open areas around her surgical staples, which were not documented in the progress notes. The facility's policy on incontinence management was not followed, as evidenced by the resident's condition and the lack of timely care. Resident #34 also experienced delays in care, as she had to wait for staff to assist her back to bed, resulting in severe pain due to prolonged sitting.
Failure to Ensure Proper Isolation Signage and Glucometer Sanitization
Penalty
Summary
The facility failed to ensure proper signage for isolation precautions for two residents, which could potentially affect additional residents. Resident #1, who was readmitted with diagnoses including osteomyelitis and chronic obstructive pulmonary disease, had a physician order for contact isolation precautions due to Carbapenem-Resistant Enterobacteriaceae (CRE). However, the signage on the resident's door incorrectly indicated Enhanced Barrier Precautions (EBP) instead of contact isolation precautions. This discrepancy was confirmed by a registered nurse during an observation. Similarly, Resident #96, admitted with conditions including a cutaneous abscess and resistance to vancomycin, had a physician order for contact isolation precautions for vancomycin-resistant enterococci (VRE). The signage on this resident's door also incorrectly displayed EBP instead of the required contact isolation precautions. This error was also confirmed by a registered nurse upon observation. The facility's policy on standard precautions requires appropriate personal protective equipment (PPE) to prevent the transmission of infectious diseases. Additionally, the facility failed to properly clean and sanitize a glucometer after use on Resident #40, who had diagnoses including diabetes and chronic obstructive pulmonary disease. The registered nurse used an isopropyl alcohol swab instead of an Environmental Protection Agency (EPA) approved disinfectant to clean the glucometer, contrary to the manufacturer's instructions. This oversight had the potential to affect other residents who were tested with the same glucometer, increasing the risk of cross-contamination of bloodborne pathogens.
Failure to Complete Baseline Care Plans Within 48 Hours
Penalty
Summary
The facility failed to ensure that a baseline care plan was completed within 48 hours of admission for three residents. Resident #11 was admitted with acute osteomyelitis, legal blindness, chronic heart failure, and COPD. Despite having intact cognition and requiring moderate assistance for daily activities, a baseline care plan was not initiated until several days after admission. This delay was confirmed by Unit Manager #859. Similarly, Resident #257, who was admitted with lobar pneumonia, chronic respiratory failure, and other conditions, did not have a baseline care plan initiated within the required timeframe. The resident had mild cognitive impairment and required significant assistance with daily activities. The delay in care planning was also confirmed by Unit Manager #859. Additionally, Resident #92, admitted with a malignant neoplasm and other health issues, experienced a similar delay in care planning, which was confirmed by Unit Manager #861. The facility's policy mandates that a baseline care plan be developed within 48 hours of admission, which was not adhered to in these cases.
Failure to Conduct Required Care Conferences
Penalty
Summary
The facility failed to conduct an initial care conference for a resident who was admitted with multiple diagnoses, including acute osteomyelitis, legal blindness, chronic heart failure, and chronic obstructive pulmonary disease. Despite the resident having intact cognition and requiring moderate assistance for daily activities, there was no documented evidence of a care conference being held since their admission. This was confirmed through an interview with the Social Service Designee. Additionally, the facility did not complete a quarterly care conference for another resident who had been admitted with conditions such as cerebral infarction, heart disease, chronic obstructive pulmonary disease, diabetes, obesity, and a psychotic disorder. This resident had mild cognitive impairment and required significant assistance for personal care. The last care conference for this resident was conducted several months prior, and the scheduled quarterly conference was missed. The facility's policy mandates care conferences to be held routinely and after admission, which was not adhered to in these cases.
Inadequate Nail Care for Resident with Severe Cognitive Impairment
Penalty
Summary
The facility failed to provide adequate nail care for Resident #29, who was dependent on staff for activities of daily living due to severe cognitive impairment and physical limitations from conditions such as hemiplegia and dementia. The resident's care plan included an intervention to check, trim, and clean nails on bath days and as necessary, with any changes to be reported to the nurse. However, observations and interviews revealed that this care was not consistently provided. During an observation, brown debris was noted under the resident's fingernails, which was attributed to food items from a meal. The Director of Nursing confirmed the presence of debris under the resident's nails during a subsequent observation. Interviews with staff, including a Registered Nurse, confirmed that staff were responsible for cleaning under fingernails and that the facility's policy aimed to prevent infections by maintaining clean and trimmed nails. Despite these protocols, the facility did not ensure that Resident #29 received the necessary nail care, as evidenced by the observations and concerns raised by the resident's power-of-attorney.
Failure to Provide Adequate Activities Program for Resident
Penalty
Summary
The facility failed to provide an ongoing activities program to meet the needs of a resident, identified as Resident #49. This resident was initially admitted with diagnoses including rheumatoid arthritis, spinal stenosis, and anxiety disorder, and had intact cognition according to the Minimum Data Set (MDS) 3.0 assessment. The resident's activity care plan, dated 11/17/23, indicated a need for a variety of activity types and locations to maintain interest. However, a review of the activity logs from 01/07/25 to 02/12/25 showed that the resident only received two one-to-one activity visits from the activity staff during this period. Interviews revealed that the resident had not received activities because she was unable to get into a wheelchair to attend them and was not provided with activities in her room. The Activity Director confirmed that the lack of one-to-one activities was due to the termination of two activity staff members in the prior month. The facility's activity policy, revised in 01/2020, stated that activity programming should promote the physical, mental, and psychosocial well-being of each resident, but this was not adhered to in the case of Resident #49.
Failure to Apply Orthotics as Ordered
Penalty
Summary
The facility failed to ensure that orthotics/braces were applied as ordered for a resident with limited range of motion (ROM). The resident, who was cognitively intact and had diagnoses including cerebral infarction and vascular dementia, had a physician's order for a right ankle foot orthosis (AFO) brace to be worn when out of bed. However, the AFO was broken and unavailable from late November to late December, and there was no documented evidence that the facility contacted the orthotics company to have it repaired during this time. Despite the AFO being returned at the end of December, there was no documentation of its return until a physical therapy evaluation in early February, which noted the resident's functional decline and need for gait training with the new AFO. Observations in February revealed that the resident was not wearing the AFO while up in a wheelchair, and interviews with staff indicated a lack of awareness and communication regarding the resident's need for the brace. A CNA was unaware of the resident's requirement for the AFO, and an RN confirmed the absence of the brace and only contacted the orthotics company in mid-February. The facility's policy on resident mobility and ROM, which mandates appropriate services and equipment to maintain or improve mobility, was not adhered to, leading to the deficiency.
Failure to Conduct Comprehensive Fall Assessment
Penalty
Summary
The facility failed to ensure a comprehensive fall assessment was completed for Resident #47 after experiencing falls. Resident #47, who was admitted with diagnoses including cerebral infarction, chronic obstructive pulmonary disease, and muscle weakness, was identified as being at high risk for falls due to factors such as debilitation, weakness, impaired balance, and impulsivity. Despite this, after experiencing unwitnessed falls on 12/26/24 at 9:00 A.M. and 2:23 P.M., there was no documentation of a fall assessment, pain assessment, or notification to the physician regarding these incidents. The facility's incident log recorded the falls, but the medical record lacked evidence of the 9:00 A.M. fall and did not include necessary documentation such as progress notes or assessments for either fall. Interviews with the Administrator and the Director of Nursing confirmed the absence of documentation and assessments. Additionally, there were no statements from staff on duty regarding the falls, and the facility's post-fall investigation procedures were not followed, which required documentation of the fall, physician and family notification, and completion of fall and pain assessments. Interviews with staff members, including a CNA and an LPN, revealed a lack of recollection of the events on the day of the falls. The CNA mentioned that Resident #47 was sometimes confused and attempted to get up without assistance, indicating a need for close monitoring. The CNA also noted staffing issues, as she worked with an aide in orientation who did not count towards staffing numbers. The LPN confirmed working late on the day of the falls but did not remember specific details about the incidents, highlighting potential issues with staff workload and documentation practices.
Inadequate Incontinence Care Leads to Skin Integrity Issues
Penalty
Summary
The facility failed to provide timely incontinence care for two residents, leading to potential skin integrity issues. Resident #203, who was admitted with multiple fractures and type II diabetes mellitus, was dependent on staff for toileting and hygiene. Observations revealed that Resident #203 was left in a urine-saturated incontinence brief for extended periods, resulting in reddened skin and open areas around her left hip staples. Despite activating her call light, Resident #203 reported that staff did not respond promptly, and when they did, they often did not return to provide the necessary care. The facility's policy required routine rounding every two hours, which was not adhered to, contributing to the resident's deteriorating skin condition. Resident #34, admitted with irritable bowel syndrome and difficulty walking, was also affected by the facility's failure to provide timely incontinence care. Although the care plan specified that staff should check and assist the resident every two hours, Resident #34 reported waiting up to four hours for care. Observations confirmed that the resident's incontinence brief was wet with urine, and her skin was reddened, although no breakdown was noted. Staff interviews revealed that the facility was understaffed, leading to delays in responding to call lights and providing care. The facility's policy on incontinence management emphasized the importance of maintaining skin integrity through timely care and routine checks. However, the observations and interviews indicated that these procedures were not consistently followed, resulting in inadequate care for the residents. The lack of timely response to residents' needs and insufficient staffing levels were significant factors contributing to the deficiencies observed in the care of Residents #203 and #34.
Dietary and Weight Monitoring Deficiencies
Penalty
Summary
The facility failed to provide Resident #13 with the diet as ordered, which was part of the Personalized Food First (PFF) program. Resident #13, who was admitted with diagnoses including hemiplegia, unspecified protein-calorie malnutrition, and paranoid schizophrenia, was supposed to receive a regular diet with specific modifications, including scrambled eggs with cheese for breakfast. However, due to a miscommunication between the dietary staff, Resident #13 only received one serving of cheesy eggs instead of the two servings required by the PFF program. This miscommunication was confirmed by the Dietary Director and was attributed to the staff not realizing the resident was supposed to receive double portions. Additionally, the facility failed to weigh Resident #86 weekly as ordered. Resident #86, who was admitted with conditions such as cerebral infarction, vascular dementia, and type II diabetes mellitus, was on a physician-prescribed weight gain regimen. Despite the order for weekly weights, there was no documented evidence of weights being taken from January 13 to February 13, 2025. This oversight was verified by a Dietary Technician, indicating a lapse in following the facility's weight policy, which mandates timely and accurate weight documentation. These deficiencies affected two residents out of the five reviewed for nutrition, highlighting issues in dietary management and adherence to physician orders. The facility's failure to provide the prescribed diet and to conduct regular weight checks as ordered compromised the nutritional care of the residents involved.
Failure to Administer Tube Feeding as Ordered
Penalty
Summary
The facility failed to ensure that a resident's tube feeding was administered as ordered by the physician. The resident, who had a history of cerebral infarction, dysphagia, and other medical conditions, was dependent on a PEG tube for nutrition and hydration. Observations revealed that the tube feeding solution was not infusing as it should have been, as the automatic tube feeding pump was turned off when it should have been running. The feeding solution and flush bag were also not dated correctly, and the piston syringe was undated, indicating a lack of adherence to the facility's enteral nutrition policy. The resident had been admitted to the facility with a PEG tube after a hospitalization for aspiration pneumonia and had failed swallow studies, necessitating tube feeding. Despite orders for specific feeding schedules and adjustments made by the dietitian to address weight loss, the resident's tube feeding was not managed according to the prescribed orders. The LPN on duty was unaware of why the tube feeding was turned off, highlighting a gap in communication or procedure adherence. This deficiency affected the resident's nutritional intake, as the tube feeding was their primary source of nutrition and hydration.
Failure to Timely Address Resident's Pain Management Needs
Penalty
Summary
The facility failed to address a resident's pain management needs in a timely manner. The resident, who was cognitively intact, had a history of severe pain following a left below-the-knee amputation and diabetic neuropathy. Despite having physician orders for pain management, including oxycodone and acetaminophen, there was a delay in administering appropriate pain relief. On the morning of the incident, the resident reported severe pain, rating it as an eight out of ten, but the nurse did not administer any medication immediately. The nurse was uncertain about the current orders and sought clarification from the nurse practitioner and the assistant director of nursing, which contributed to the delay. The resident's pain was not adequately managed until later in the day when the nurse practitioner updated the orders to include oxycodone and adjusted the acetaminophen dosage. The resident had been experiencing frequent pain that affected her sleep and participation in rehabilitation therapy. The care plan indicated that the resident should not experience discomfort related to analgesia side effects and that staff should anticipate and respond immediately to any pain complaints. However, the delay in addressing the resident's pain needs demonstrated a failure to adhere to the care plan and ensure timely pain management.
Failure to Assess Dialysis Thrill and Bruit Every Shift
Penalty
Summary
The facility failed to ensure that a resident receiving dialysis services had their thrill and bruit assessed every shift as per facility policy. The resident, who was admitted with end-stage renal disease and dependent on renal dialysis, had physician orders for vital signs to be taken before and after dialysis and for hemodialysis sessions three times a week. However, there was no specific order to assess the resident's thrill and bruit. A review of the resident's medication and treatment administration records from January 1 to February 13 did not show evidence of these assessments being conducted every shift. This was confirmed by the Assistant Director of Nursing, who acknowledged the lack of documentation in the resident's medical record and physician orders. The facility's Dialysis Care policy, revised in July 2020, mandates that the thrill and bruit of the fistula be assessed every shift for patency and recorded on the medication administration record.
Deficiency in Medication Management for Residents
Penalty
Summary
The facility failed to ensure that Resident #31 was free from unnecessary medications, as evidenced by the administration of Percocet without clear parameters for its use. Resident #31, who had diagnoses including cerebral infarction and major depressive disorder, was receiving Percocet for pain management. However, the medication was administered even when the resident's pain level was recorded as low or zero, indicating a lack of appropriate guidelines for its administration. Interviews with staff revealed that Percocet was given whenever the resident requested it, without specific criteria to guide its use, leading to potential overmedication. Additionally, the facility did not conduct monthly pharmacy reviews for Resident #14, who was diagnosed with major depressive disorder and anxiety disorder. The resident's medication regimen included antidepressants, but the facility failed to document regular pharmacy consultations or the physician's response to a recommended dose reduction. The only available pharmacy review was dated several months prior, and there was no evidence of ongoing evaluation or adjustment of the resident's medication, as required by the facility's policy. This lack of documentation and follow-up on pharmacy recommendations contributed to the deficiency in medication management for Resident #14.
Inaccurate Documentation of AFO Brace Status
Penalty
Summary
The facility failed to ensure that the medical record of a resident accurately reflected the status of a right lower extremity brace, specifically an ankle foot orthosis (AFO). The resident, who was admitted with diagnoses including cerebral infarction, vascular dementia, diabetes type two, and difficulty walking, had a physician's order for a right AFO brace to be used when out of bed. However, the AFO was broken and unavailable from November 30, 2024, to December 30, 2024, and there was no documented evidence in the medical record that the facility contacted the orthotics company to have the AFO fixed. Despite this, the Medication Administration Records (MARs) inaccurately indicated that the AFO brace was applied and removed as ordered during this period. Interviews with facility staff confirmed the inaccuracies in the documentation. A Registered Nurse verified that the AFO was broken on November 30, 2024, and there was no documentation of its return until a physical therapy evaluation on February 5, 2025. Additionally, a Unit Manager confirmed that the MARs documentation from December 1, 2024, through January 31, 2025, was inaccurate as there was no AFO to apply and remove. The facility's policy on charting and documentation requires that all services provided to the resident and any changes in the resident's condition be documented accurately, which was not adhered to in this case.
Failure to Transport Residents to Medical Appointments
Penalty
Summary
The facility failed to ensure that two residents, Resident #46 and Resident #98, were transported to their scheduled medical appointments. Resident #46, who was cognitively intact and required partial to moderate assistance for mobility, missed an orthopedic appointment due to a miscommunication with the transportation driver. The driver claimed to have called the nursing unit to announce their arrival, but no one answered the phone. As a result, Resident #46 was not at the main entrance at the scheduled pick-up time, leading to the missed appointment. Resident #98, who was also cognitively intact and required substantial assistance for mobility and used oxygen therapy, missed a pulmonology appointment. The delay was caused by the absence of a day shift nurse, which left the night shift nurse, RN #815, unable to leave on time. The Assistant Director of Nursing (ADON) took over but faced difficulties in finding an appropriate oxygen tank for Resident #98's bariatric wheelchair. By the time Resident #98 was ready, the transportation driver had already left, as they only waited for five minutes. The facility's policy required staff to arrange and ensure transportation for residents' medical appointments, but the execution was flawed. The staff's inability to coordinate effectively and ensure residents were ready for transportation at the scheduled times resulted in both residents missing their appointments. The facility's policy was not adhered to, leading to noncompliance with the requirement to accommodate residents' needs and preferences for medical appointments.
Failure to Maintain Sanitary and Homelike Environment for Residents
Penalty
Summary
The facility failed to maintain a clean, sanitary, and homelike environment for two residents, leading to deficiencies in their living conditions. Resident #57, who is cognitively intact and requires assistance for activities of daily living, reported that her room had not been cleaned for several days. She expressed frustration to a registered nurse about the overflowing trash can, dirty bathroom, and lack of toilet paper, which she had to find herself. An observation confirmed the resident's complaints, as the trash was full, the bathroom needed cleaning, and the toilet paper roll was empty. The housekeeping aide acknowledged the need for cleaning and confirmed the resident's room was not in a satisfactory condition. Resident #90, who has severe cognitive impairment and behavioral issues, was observed in unsanitary conditions over several days. His room was found with food crumbs, feces on the toilet seat and bed linens, and a chair marked with a sign indicating it needed cleaning due to feces. Despite requests from staff to clean the room more frequently due to the resident's behaviors, the chair remained uncleaned for several days. Observations confirmed the persistent unsanitary conditions, and the housekeeping staff acknowledged the issues during the surveyor's visit.
Failure to Complete Baseline Care Plan
Penalty
Summary
The facility failed to complete a baseline care plan for a resident within 48 hours of admission, as required by their policy. The resident, who was admitted and later discharged, had multiple diagnoses including acute respiratory failure with hypercapnia, COPD, tracheostomy status, gastrostomy status, other seizures, peripheral vascular disease, and GERD without esophagitis. The resident was alert and oriented but experienced shortness of breath, unsteady gait, and poor balance, requiring bedrest most of the time. Despite these conditions, the baseline care plan was not completed. An RN confirmed that the care plan was opened but not finished, citing that it was missed. The facility's policy mandates the development of a baseline care plan within 48 hours of admission, which was not adhered to in this case.
Kitchen Sanitation and Food Storage Deficiencies
Penalty
Summary
The facility failed to ensure the kitchen was clean and sanitary, and items were properly stored and dated, potentially affecting all 82 residents. During an observation of the kitchen, several issues were noted, including a buildup of ice and debris around the perimeter of a square chest freezer, and the absence of a thermometer in the unit. In the milk and juice walk-in cooler, three unopened quarts of heavy whipping cream with a use-by date that had already passed were found. Additionally, the cooler connected to the walk-in freezer had a clear plastic covering with numerous tears, and various food items were found improperly stored, undated, and exposed to air, including hard-boiled eggs, Canadian bacon, shredded cheese, sausage links, puree sausage, mechanical soft sausage, and French toast. The walk-in freezer also had a significant buildup of ice on the floor under the shelving, which was attributed to the condenser by the Dietary Director. The facility's policy on food storage, dated March 2022, was reviewed and it was found that the policy required leftover food to be stored in covered containers or wrapped securely, clearly labeled, and dated. The policy also mandated that all freezer units be kept clean and that all foods be consumed by their use-by date. Cooked foods were to be stored above raw foods to prevent contamination. The Dietary Director confirmed the areas of concern during the observation, acknowledging that the items should have been thrown out and that the ice buildup was from the condenser. This deficiency was identified during a complaint investigation.
Failure to Follow Physician's Orders for Pain Relief Patches
Penalty
Summary
The facility failed to ensure physician's orders were followed for two residents, resulting in non-compliance with prescribed treatments. Resident #83, who had severe cognitive impairment and multiple medical diagnoses including end-stage renal disease and severe protein-calorie malnutrition, had an order for a Lidocaine pain relief patch to be applied every 12 hours. However, there was no documented evidence that the patch was removed after 12 hours on 04/25/24, as required by the physician's order. The Assistant Director of Nursing (ADON) confirmed the lack of documentation for the removal of the Lidocaine patch during an interview on 05/15/24. Similarly, Resident #69, who was cognitively intact and had medical diagnoses including borderline personality disorder and primary osteoarthritis, had an order for a Lidocaine pain relief patch to be applied to the right knee daily and removed at hour of sleep. The Medication Administration Records (MARs) for March, April, and May 2024 showed the patch was administered daily, but there was no documented evidence of its removal at hour of sleep. The ADON confirmed the absence of documentation for the removal of the Lidocaine patch for Resident #69 during the same interview. This deficiency was investigated under Complaint Number OH00153521.
Failure to Provide Timely Incontinence Care
Penalty
Summary
The facility failed to provide adequate and timely incontinence care for Resident #87, who was totally dependent on staff for bed mobility and toileting. On 04/10/24, Resident #87 went almost six hours without being provided incontinence care, resulting in her being saturated in urine and developing a red, bleeding, open area on her right thigh. The resident expressed that her skin was raw, hurt, and burned due to the lack of timely care. Additionally, her incontinence brief was observed to be fastened rather than left open as ordered by the physician. Resident #87 had multiple diagnoses, including atrophy, urinary tract infection, morbid obesity, and adult failure to thrive, and required extensive assistance with ADLs. Her care plan included interventions such as changing disposable briefs as needed, cleaning the peri-area with each incontinence episode, and applying barrier cream to protect the skin. Despite these interventions, the resident's incontinence care was not performed as required, leading to skin breakdown and discomfort. Interviews and observations revealed that the staff did not follow the physician's orders for incontinence care, including leaving the brief open and applying zinc cream after each episode. The STNA assigned to Resident #87 admitted that she had not been able to provide care until almost six hours into her shift. The facility's policy on ADLs indicated that residents should receive care in accordance with their care plan, but this was not adhered to in the case of Resident #87, resulting in actual harm to the resident.
Failure to Timely Report Misappropriation
Penalty
Summary
The facility did not timely report an allegation of misappropriation to the state agency, affecting one resident. Resident #88, who had diagnoses including hypotension, cerebral palsy, anxiety disorder, and chronic pain, reported on 03/29/24 that an envelope containing four hundred dollars was missing from her purse. The resident counted her money at least twice daily and immediately informed an LPN about the missing money. The facility staff, including the Director of Nursing (DON) and Administrator, were notified, and a search was conducted, but the money was not found. Despite the immediate notification, the facility did not file a Self-Reported Incident (SRI) until 04/02/24, which was three days after the incident, thus not within the required 24-hour reporting window as per the facility's policy and state regulations. Interviews with the resident and staff confirmed the timeline of events and the delay in reporting. The facility's policy mandates that all allegations of misappropriation be reported to the Ohio Department of Health immediately, but no later than 24 hours after the incident. The facility's failure to adhere to this policy was identified during a complaint investigation. The case was still under investigation by the police at the time of the report.
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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