Phoenix Of Maple Heights
Inspection history, citations, penalties and survey trends for this long-term care facility in Maple Heights, Ohio.
- Location
- 19900 Clare Ave, Maple Heights, Ohio 44137
- CMS Provider Number
- 365520
- Inspections on file
- 27
- Latest survey
- June 13, 2024
- Citations (last 12 mo.)
- 0
Citation history
Health deficiencies cited at Phoenix Of Maple Heights during CMS and state inspections, most recent first.
The facility failed to ensure RN coverage for at least eight hours daily, as required, on multiple occasions. This deficiency was confirmed through staffing data and interviews, affecting all 88 residents.
The facility did not ensure the medical director actively participated in the QAA committee, as required. A review of sign-in sheets from QAA meetings showed no evidence of the medical director's attendance, and the Administrator confirmed the absence of the medical director's signature. Although the medical director sometimes attended via phone, specific meetings were not identified. This deficiency potentially affected all 88 residents.
The facility failed to maintain an effective infection control program, with inadequate oversight of the Infection Preventionist role and incomplete infection control logs. Annual TB assessments were not documented for all residents, and the facility did not integrate these assessments into the EMR. Additionally, staff did not consistently adhere to Enhanced Barrier Precautions, failing to use appropriate PPE during high-contact activities with residents at risk of MDRO.
The facility failed to implement an effective antibiotic stewardship program, affecting all residents. The CCO overseeing the program confirmed that the LPN responsible for tracking infections had only recently received her IP certification. Infection control logs from March to May 2024 revealed inaccuracies and incomplete data, such as missing infection sites, signs, and symptoms, and incomplete documentation of antibiotic treatment durations. McGreer's Criteria for antibiotic use was not met or documented for many residents, and there was a lack of isolation precautions for residents with infections.
The facility failed to have a qualified Infection Preventionist overseeing the infection control program, affecting all residents. The designated LPN completed her certification only on the day of the interview, while the CCO had been acting as the IP for eight months. Infection control logs lacked necessary documentation, and annual TB screenings were incomplete. The Antibiotic Stewardship Program was not effectively implemented, with incorrect diagnoses and failure to meet McGreer's criteria for infections.
The facility failed to maintain a clean, sanitary, and well-repaired environment, affecting all residents. Surveyors observed numerous deficiencies, including non-skid strips coming off the floor, missing baseboard heater covers, and strong odors due to feces. Rooms had dirty floors, missing closet doors, stained curtains, and bathrooms with feces and strong urine odors. Infrastructure issues included bowing ceiling tiles, missing drywall, and broken blinds. High staff turnover contributed to these ongoing issues, and the facility's cleaning policy was not adequately followed.
The facility failed to ensure that medications administered to residents had appropriate diagnoses, affecting four residents. A resident received Omeprazole without a listed diagnosis, while another was given several medications, including Losartan and Prednisone, without corresponding diagnoses. Another resident had medications inaccurately prescribed for itching and pain, and a fourth resident received medications without correct diagnoses. The facility's policy required a written diagnosis for each medication, which was not followed.
The facility failed to ensure physician orders for psychotropic medications included necessary diagnoses for several residents, and did not adequately monitor behaviors and side effects. A resident received Klonopin and Aristada without documented monitoring orders, while another was prescribed Olanzapine and Sertraline without corresponding diagnoses. Additionally, a resident was given Depakote without a seizure diagnosis. The DON confirmed these discrepancies, acknowledging the need for review and consultation with a psychiatric nurse practitioner.
A medication cart was left unlocked and unattended in a psychiatric facility, potentially affecting all residents except those in a secure unit. An LPN did not recognize the cart was unlocked and did not immediately secure it upon being informed. The facility administrator confirmed the cart should have been locked, as residents with behavioral problems could have accessed it.
A facility failed to notify The Ohio Department of Mental Health of a significant change in a resident's mental health condition. The resident, admitted with multiple mental health diagnoses, received a new diagnosis of schizoaffective disorder, but the state agency was not informed. The last PASARR was completed several years prior, and the facility administrator acknowledged that a new assessment should have been conducted.
The facility failed to create comprehensive care plans for three residents, leading to deficiencies in addressing their specific needs. A resident with dental issues had no follow-up care plan, another with renal disease had an outdated care plan lacking dialysis management, and a third with behavioral issues had inadequate interventions. Staff were unaware of or did not address these deficiencies, indicating a lack of proper care planning and awareness.
A resident with multiple psychiatric diagnoses and cognitive intactness exhibited inappropriate behavior by exposing himself in the hallway. The care plan lacked interventions for this behavior, and staff did not intervene during the incident. The MDS Coordinator was unaware of the behavior and the care plan's deficiencies.
A resident with a urostomy experienced a deficiency in care due to the facility's failure to ensure proper orders and supplies were available. The resident's urostomy bag was leaking, and an LPN could not find replacement supplies, leading to temporary management with a towel. Interviews revealed the resident's dissatisfaction with the care provided, and the central supply person confirmed that supplies were available but not checked. The DON verified the absence of orders for changing the urostomy bags.
A resident receiving oxygen therapy did not have current physician orders or an oxygen care plan, and portable oxygen tanks were found unsecured in the room. The resident, with conditions including dementia and mobility issues, was observed using a nasal cannula without updated orders. Staff interviews revealed a lapse in re-entering orders after a hospital visit, and the facility's policy on securing oxygen tanks was not followed.
A facility failed to monitor and document pre and post dialysis assessments for a resident with end stage renal disease. The lack of documentation was confirmed by interviews with an LPN and the DON, who also noted the absence of communication with the dialysis center. The facility did not follow its policy for coordinating care, as it lacked required documentation of collaboration with the dialysis unit.
A facility failed to monitor and address the behavioral health needs of a resident with psychiatric disorders, who consistently refused medications and exhibited disruptive behaviors. Despite orders to document behaviors every shift, the facility lacked proper documentation and interventions. The resident was observed inappropriately exposed in a hallway without staff intervention, and the care plan was not resident-centered. The MDS Coordinator was unaware of these issues, affecting the resident's dignity and privacy.
A resident with multiple health conditions, including dementia and schizoaffective disorder, did not receive necessary dental services following a dental visit that identified the need for oral surgery. Despite being cognitively intact and experiencing dental pain, there was no follow-up on the dental referral, and the facility's policy for dental services was not followed.
The facility failed to ensure functional and accessible call lights for residents, affecting their ability to contact staff. A resident with impaired cognition and another with mobility issues were observed without call lights in reach, and the system was non-functional for weeks. Another resident's call light was found on the floor, out of reach. Staff confirmed these issues, violating the facility's policy.
A resident with a history of mental health disorders was observed in a hallway with genitals exposed, wearing only a T-shirt, for 17 minutes without staff intervention. The DON noted the resident's refusal to wear pants or underwear, highlighting a failure to maintain dignity as per the facility's policy.
The facility's assessment failed to include necessary information about contracted nurses and STNAs, despite regular use of agency staff to address staffing shortages. Interviews confirmed the reliance on agency staff, but the facility's documentation did not reflect this practice.
The facility did not ensure that two STNAs received the required 12 hours of continuing education annually. One STNA completed only four hours, and another completed nine hours in the past year. This was confirmed through staff education records and an interview with facility leadership, potentially impacting all 88 residents.
A resident's bilateral lower extremity wound care was not completed as ordered by the physician. Despite documentation indicating that wound care was performed, observations revealed that dressings were not changed as required, and interviews confirmed the lapse in care.
Failure to Maintain Required RN Coverage
Penalty
Summary
The facility failed to maintain the services of a registered nurse (RN) for at least eight consecutive hours a day, seven days a week, as required by regulations. This deficiency was identified through a review of the Payroll Based Journal (PBJ) staffing data report for the first quarter of 2023, which revealed six specific dates where there was no RN coverage. Further review and interviews confirmed that on these dates, no RNs were working as direct care staff for the required 24-hour periods. Additionally, another date in May 2024 was identified where no RN was scheduled, and the Director of Nursing (DON) confirmed that her management hours did not count towards the required RN coverage for direct care. Interviews with staff, including a State tested Nurse Aide (STNA), confirmed the absence of RNs on the specified dates. The STNA was unaware of the requirement for an RN to be present for at least eight hours each day to provide direct resident care. The DON also confirmed the lack of scheduled RNs for direct care on the identified dates, further highlighting the facility's failure to comply with the staffing requirements. This deficiency had the potential to affect all 88 residents residing in the facility.
Medical Director's Absence from QAA Meetings
Penalty
Summary
The facility failed to ensure the medical director was an active participant in the Quality Assessment and Assurance (QAA) committee, which is a requirement for the committee's composition. This deficiency was identified through a review of the facility's sign-in sheets for QAA meetings held between July 6, 2023, and May 1, 2024, which showed no evidence of the medical director's attendance. An interview with the Administrator confirmed that the medical director's signature was absent from all sign-in sheets. Although the Administrator mentioned that the medical director sometimes attended meetings via phone, they were unable to specify which meetings were attended in this manner. This oversight had the potential to affect all 88 residents of the facility.
Infection Control and PPE Deficiencies in LTC Facility
Penalty
Summary
The facility failed to maintain an effective infection prevention and control program, as evidenced by several deficiencies identified during the survey. The Infection Preventionist (IP) role was inadequately managed, with the Chief Clinical Officer (CCO) acting as the IP for several months without sufficient oversight. The facility's infection control logs lacked necessary laboratory and x-ray results, leading to incorrect diagnoses for antibiotic use. Additionally, the facility did not have a formal infection control committee, relying instead on informal conference calls to discuss infection control issues. The facility also failed to ensure annual Tuberculosis (TB) assessments were completed for all residents. Several residents did not have documented annual TB screenings, and the Director of Nursing (DON) was unable to locate previous records. The TB screening process was not integrated into the electronic medical records (EMR), leading to incomplete documentation and potential oversight of residents' TB status. This lack of documentation and follow-up was evident in the case of a resident whose TB test was not properly read and recorded. Furthermore, the facility did not adhere to its own Enhanced Barrier Precautions (EBP) policy, as staff failed to use appropriate personal protective equipment (PPE) during resident care. Observations revealed that staff did not consistently wear gowns and gloves when required, particularly during high-contact activities with residents at risk of multidrug-resistant organisms (MDRO). This non-compliance with PPE guidelines was observed during interactions with a resident who required substantial assistance and had multiple medical devices, highlighting a significant lapse in infection control practices.
Deficiency in Antibiotic Stewardship Program
Penalty
Summary
The facility failed to implement an effective antibiotic stewardship program, which had the potential to affect all 88 residents. The Chief Clinical Officer (CCO) overseeing the program confirmed that the Licensed Practical Nurse (LPN) responsible for tracking infections had only recently received her Infection Preventionist (IP) certification. The facility's infection control logs from March to May 2024 revealed inaccuracies and incomplete data, such as missing infection sites, signs, and symptoms, and incomplete documentation of antibiotic treatment durations. Additionally, McGreer's Criteria for antibiotic use was not met or documented for many residents, and there was a lack of isolation precautions for residents with infections. In March 2024, the infection control log showed that 12 residents had infections, but crucial information like the site of infection and signs and symptoms were missing for some. Only one resident had a culture obtained, and the duration of antibiotic treatment was not consistently documented. In April 2024, five residents were diagnosed with infections, but only two had signs and symptoms documented, and one resident was incorrectly listed as having an infection when they had hyponatremia. The May 2024 log showed eight residents with infections, but again, signs and symptoms were missing for some, and McGreer's criteria were not met for several residents. The CCO admitted to not knowing why McGreer's criteria were not met and confirmed that the infection control committee did not meet regularly. The logs revealed instances where antibiotics were prescribed without proper justification, such as an elevated white blood cell count without signs of infection or for non-infectious conditions like hyponatremia. The CCO acknowledged the need for better attention to the infection control tracking log, indicating a lack of oversight and adherence to the facility's antibiotic stewardship program.
Inadequate Infection Control Oversight and Documentation
Penalty
Summary
The facility failed to have a qualified Infection Preventionist (IP) providing oversight of the infection control program, affecting all 88 residents. The Licensed Practical Nurse (LPN) designated as the IP had only completed her certification on the day of the interview, and the Chief Clinical Officer (CCO) had been acting as the IP for the past eight months. The CCO had completed her certification program in 2021, but the infection control tracking was not accurately or thoroughly completed, with incorrect diagnoses for antibiotic use and failure to meet McGreer's criteria for infections. The facility's infection control logs for March, April, and May 2024 showed incomplete documentation, lacking laboratory and x-ray results necessary for determining appropriate antibiotic treatment. Additionally, the facility failed to conduct annual tuberculosis (TB) screenings for several residents, with no records found from the last annual survey in April 2022. The Director of Nursing (DON) was unaware of whether the previous DON had completed these screenings and confirmed the absence of records for the past year. The facility's Antibiotic Stewardship Program, last revised in 2022, was not effectively implemented, as evidenced by the failure to meet McGreer's criteria for infections and the lack of proper documentation and communication with physicians regarding antibiotic therapy. The CCO acknowledged the oversight and the need for increased supervision of the infection control process, confirming that the infection control committee should have discussed any deviations from the criteria.
Facility Fails to Maintain Clean and Safe Environment
Penalty
Summary
The facility failed to maintain a clean, sanitary, and well-repaired environment, which had the potential to affect all residents. During a tour, surveyors observed numerous deficiencies, including non-skid strips coming off the floor, missing baseboard heater covers exposing heating elements, and strong malodorous smells due to feces in the hallway. Several rooms had dirty, sticky floors, missing closet doors, stained privacy curtains, and bathrooms with feces on toilets, missing toilet paper holders, and strong urine odors. Additionally, the dining room and common areas were found to be dirty with food crumbs, debris, and stains. The facility's infrastructure was also in disrepair, with issues such as bowing ceiling tiles, missing drywall, loose handrails, and broken window blinds. Many rooms had missing or broken closet doors, peeling paint, rusted AC units, and damaged walls. Bathrooms shared by residents were particularly problematic, with missing tiles, broken fixtures, and inadequate lighting due to burned-out bulbs. The facility's maintenance and housekeeping staff faced high turnover, contributing to the ongoing issues. Interviews with residents and staff revealed concerns about the facility's condition. Residents reported difficulties with closet doors, flooding in bathrooms, and unsafe flooring in elevators. Staff members acknowledged the need for more investment in the building and cited challenges with maintaining cleanliness and repairs due to staffing issues. The facility's policy on environmental cleaning and disinfecting was not adequately followed, as evidenced by the numerous deficiencies observed during the survey.
Failure to Ensure Appropriate Medication Diagnoses
Penalty
Summary
The facility failed to ensure that all medications administered to residents had an appropriate diagnosis, affecting four residents out of five reviewed for unnecessary medications. Resident #1 was receiving Omeprazole without a listed diagnosis, despite having multiple diagnoses including HIV, respiratory failure, and schizophrenia. The Director of Nursing (DON) confirmed the absence of appropriate diagnoses on the physician orders. Resident #15 was administered several medications, including Losartan Potassium, Prednisone, Olanzapine, and Montelukast Sodium, without corresponding diagnoses. The resident had intact cognition and was receiving antipsychotic and antidepressant medications. The DON confirmed the lack of appropriate diagnoses on the orders. Resident #62 had multiple medications listed without diagnoses, including Insulin Glargine and Albuterol Sulfate, which were inaccurately prescribed for itching and pain, respectively. Resident #16 was receiving medications such as Divalproex sodium and Flomax without correct diagnoses. The facility's policy required a written diagnosis or indication for each medication, which was not adhered to, as confirmed by the DON.
Deficiencies in Psychotropic Medication Management
Penalty
Summary
The facility failed to ensure that physician orders for psychotropic medications included the necessary diagnoses for several residents, specifically Residents #11, #15, #16, and #62. This oversight was identified through a review of medical records, staff interviews, and facility policy. For instance, Resident #62, who had multiple psychiatric diagnoses, was receiving Klonopin and Aristada without documented orders to monitor for behaviors or side effects, and no diagnoses were listed for these medications. Similarly, Resident #15 was prescribed Olanzapine and Sertraline without the corresponding diagnoses being documented in the physician's orders. Additionally, the facility did not adequately monitor behaviors and adverse side effects from the use of psychotropic medications for Residents #16 and #62. Resident #16, who had a history of psychotic disorders, was receiving medications such as Desvenlafaxine and Olanzapine, but the orders listed medication classes instead of specific diagnoses, and there were no orders to monitor behaviors. The Director of Nursing (DON) confirmed these discrepancies and acknowledged that the facility was in the process of reviewing medications for correct diagnoses. Resident #11's records revealed that medications were prescribed for conditions not diagnosed, such as Depakote for anticonvulsant purposes without a seizure diagnosis. The DON confirmed the accuracy of the diagnoses and their associated medications but indicated a need to consult with the psychiatric nurse practitioner to obtain appropriate diagnoses. The facility's policy on medication management, which requires a written diagnosis or documented objective findings to support each medication, was not adhered to, leading to these deficiencies.
Medication Cart Left Unlocked in Psychiatric Facility
Penalty
Summary
The facility failed to ensure that a medication cart remained locked when unattended by a nurse, which is a violation of the requirement to store drugs and biologicals securely. This incident involved one of two medication carts on the second floor, potentially affecting all residents except for 14 in the secure unit. During an observation, the medication cart was found unlocked with no nurse present, while residents were in the hallway heading to lunch. A housekeeper in the hallway attempted to locate the nurse. A staff member, identified as an LPN, approached the cart but did not recognize that it was unlocked. Upon being informed, the LPN acknowledged the issue but did not immediately lock the cart, stating she needed access to it. The facility administrator confirmed that the cart should have been locked when unattended, noting that residents from both floors, except the secured unit, could have accessed the cart. The facility serves residents with behavioral problems, heightening the importance of secure medication storage.
Failure to Notify State Agency of Resident's Mental Health Change
Penalty
Summary
The facility failed to notify the appropriate state agency, The Ohio Department of Mental Health, of a significant change in a resident's mental health condition as required by regulations. This deficiency was identified during a review of the medical record and staff interview. The resident in question was admitted with diagnoses including delusional disorder, depression, vascular dementia, and mood disorder. The most recent PASARR Identification Screen was completed in December 2017, which indicated a serious mental illness diagnosis and recent psychiatric services. However, a new diagnosis of schizoaffective disorder was added in March 2021, and there was no evidence that the state agency was notified of this change. The facility administrator confirmed that a new PASARR should have been completed following the new diagnosis.
Deficiencies in Comprehensive Care Planning for Residents
Penalty
Summary
The facility failed to ensure comprehensive care plans were created for three residents, leading to deficiencies in addressing their specific needs. Resident #26, who was cognitively intact, had multiple diagnoses including delusional disorders and schizoaffective disorder. Despite requiring supervision for eating and oral hygiene, there was no dental care plan in place to address his dental issues. The resident expressed a desire for a dental appointment due to broken teeth and pain, but there was no follow-up for a dental consult after his last appointment. Resident #63, diagnosed with end-stage renal disease and other conditions, had a care plan that was not updated since admission. The care plan failed to address critical aspects such as the management of a dialysis port, meal provisions related to dialysis, and transportation needs. Interviews confirmed the absence of a dialysis care plan and the lack of updates to reflect changes in the resident's condition, such as the presence of a dialysis port instead of a fistula. Resident #72, with diagnoses including psychosis and schizoaffective disorder, had a care plan that inadequately addressed his behaviors and medication noncompliance. The care plan lacked resident-centered interventions for his disruptive behaviors, such as exposing himself in the hallway. Staff did not intervene during an observation of this behavior, and the MDS Coordinator was unaware of the issue, indicating a lack of awareness and appropriate interventions in the care plan.
Failure to Revise Care Plan for Inappropriate Behavior
Penalty
Summary
The facility failed to revise the care plan for a resident who exhibited inappropriate behaviors, specifically exposing his genitals in the hallway. The resident, who was admitted with diagnoses including psychosis, schizoaffective disorder, bipolar disorder, factitious disorder, and mood disorder, was cognitively intact according to a recent assessment. Despite the resident's refusal of medications and psychiatric care, and his disruptive behaviors, the care plan did not include interventions to address his behavior of exposing himself. During an observation, the resident was seen sitting in a wheelchair in the hallway wearing only a T-shirt, with his genitals exposed. Staff and other residents were present, but no staff intervened or redirected the resident. An interview with the MDS Coordinator revealed she was unaware of the resident's behavior and the lack of interventions in the care plan to address it.
Deficiency in Urostomy Care and Supply Management
Penalty
Summary
The facility failed to ensure that a resident, identified as Resident #67, had appropriate orders and supplies for urostomy care. The resident, who had a history of various medical conditions including colostomy status and an artificial opening of the urinary tract, required substantial assistance with toileting. Despite having a care plan that included interventions for managing her urostomy, there was no specific physician's order to change the urostomy bag. On one occasion, a Licensed Practical Nurse (LPN) discovered the resident's urostomy bag was leaking but was unable to find replacement supplies, resulting in the temporary use of a towel to manage the leakage. Interviews revealed that the resident was upset due to the lack of supplies and inconsistent care techniques compared to those used in the hospital. The central supply person confirmed that there were two urostomy bags available in the resident's closet, which the nurse did not check. The Director of Nursing verified the absence of orders for changing the urostomy bags. The facility's policy on ostomy care aimed to prevent infection and skin irritation, but the lack of proper orders and supply management led to a deficiency in care for Resident #67.
Failure to Ensure Safe and Appropriate Oxygen Therapy
Penalty
Summary
The facility failed to provide safe and appropriate respiratory care for a resident, identified as Resident #12, who was receiving oxygen therapy without current physician orders or an oxygen care plan. The resident, who had diagnoses including acute kidney failure, dementia, and mobility issues, was observed using a nasal cannula connected to an oxygen concentrator. However, the medical records did not reflect any current orders for oxygen therapy, and the care plan lacked any mention of oxygen use. Interviews with staff, including the MDS Nurse and LPNs, revealed that the resident was not on oxygen at the time of the last MDS assessment, and there was no explanation for why the resident was placed on oxygen without updated orders. The Director of Nursing confirmed that the oversight occurred when the resident returned from the hospital, and the nurse responsible for re-entering orders failed to include the oxygen order. Additionally, the facility did not adhere to its own policy regarding the secure storage of portable oxygen tanks. During an observation, it was noted that three portable oxygen tanks were present in the resident's room, with only one secured in a stand while the other two were unsecured. This was verified by an LPN, who acknowledged the unsecured tanks and stated that staff were responsible for removing empty tanks each morning. The facility's policy on oxygen safety mandates that cylinders be secured to prevent tipping, which was not followed in this instance.
Failure to Monitor and Document Dialysis Care
Penalty
Summary
The facility failed to ensure proper monitoring and documentation of pre and post dialysis assessments for a resident with end stage renal disease who was receiving dialysis treatments. The medical record review revealed multiple instances over several months where there was no documented evidence of these assessments being completed. Interviews with facility staff, including an LPN and the DON, confirmed the lack of communication and documentation regarding the resident's dialysis treatments. The LPN was unaware of any communication with the dialysis center, and the DON confirmed the absence of documented pre and post dialysis assessments, which also affected the monitoring of the resident's weights as ordered by the physician. Additionally, the facility did not adhere to its own policy regarding the coordination of care for residents receiving dialysis. The facility's policy required documented evidence of collaboration and communication between the LTC facility and the dialysis unit, including participation in care conferences and maintaining copies of short-term and long-term care plans. However, the DON confirmed that the facility did not have copies of these care plans as required by the dialysis contract. This lack of documentation and communication represents a failure to comply with the facility's policies and procedures for providing safe and appropriate dialysis care.
Failure to Monitor and Address Behavioral Health Needs
Penalty
Summary
The facility failed to adequately monitor and address the behavioral health needs of a resident diagnosed with multiple psychiatric disorders, including psychosis, schizoaffective disorder, bipolar disorder, factitious disorder, and mood disorder. The resident, who was admitted to the facility with these diagnoses, consistently refused all medications and psychiatric consultations. Despite a physician's order to document the resident's behaviors every shift, the facility did not maintain proper documentation of the resident's behaviors or implement effective interventions. The Medication Administration Record (MAR) indicated that the resident exhibited behaviors, but there was a lack of corresponding nursing documentation in the progress notes. The resident was observed sitting in a hallway in a wheelchair, wearing only a T-shirt, with genitals exposed, and staff did not intervene during this time. The care plan for the resident was not resident-centered and lacked specific interventions to address the resident's behavior of exposing himself. The MDS Coordinator was unaware of the resident's behavior and the absence of interventions for the resident's preference for wearing no clothes. This deficiency affected the resident's dignity and privacy, as well as the facility's ability to provide necessary behavioral health care and services.
Failure to Provide Necessary Dental Services
Penalty
Summary
The facility failed to provide necessary dental services to a resident, identified as Resident #26, who was admitted with multiple diagnoses including delusional disorders, depression, vascular dementia, and schizoaffective disorder. Despite being cognitively intact and requiring supervision for eating and oral hygiene, there was no evidence of a dental care plan in place for this resident. The last recorded dental visit for the resident was on June 27, 2023, during which it was noted that multiple root tips needed extraction, and a referral for oral surgery was made. However, there was no follow-up documented in the nursing progress notes from June 27, 2023, to June 10, 2024, regarding the dental consult or any subsequent treatment. Interviews conducted with the resident and the facility administrator, who also serves as the social worker, revealed that the resident was experiencing dental pain and desired a dental appointment. The administrator confirmed the presence of a chip in the root tips as per the last dental consult but was unable to provide documentation explaining the lack of follow-up for the resident's dental concerns. The facility's policy on dental services, dated April 12, 2016, states that nursing services should notify social services of a resident's need for dental services, and social services are responsible for assisting with appointments and transportation. This policy was not adhered to in the case of Resident #26, leading to the deficiency.
Deficiency in Call Light Accessibility and Functionality
Penalty
Summary
The facility failed to ensure that call lights were functional and within reach for three residents, affecting their ability to contact staff for assistance. Resident #12, who had impaired cognition and required substantial assistance, was observed without a call light in reach, and the call light system in the room was not functioning. Resident #13, who shared the room with Resident #12, also had no call light in reach. Interviews with the residents and staff confirmed that the call light system had been non-functional for several weeks, and residents had to resort to yelling or physically going to the nurses' station for help. Resident #5, who had impaired cognition and required moderate assistance, was found with the call light on the floor, out of reach while sleeping. The facility's policy required that call lights be in working order and within reach of residents at all times, but this was not adhered to, as evidenced by the observations and staff interviews. The failure to maintain functional and accessible call lights compromised the residents' ability to summon assistance when needed.
Failure to Prevent Public Indecency and Maintain Resident Dignity
Penalty
Summary
The facility failed to uphold the dignity of a resident, identified as Resident #72, by not preventing public indecency. Resident #72, who was cognitively intact and had a medical history including psychosis, schizoaffective disorder, bipolar disorder, factitious disorder, and mood disorder, was observed sitting in a wheelchair in the hallway wearing only a T-shirt, with genitals exposed. This observation occurred over a period of approximately 17 minutes, during which time other residents and staff were present in the hallway, yet no staff intervened or redirected the resident. The Director of Nursing (DON) later revealed that Resident #72 consistently refused to wear pants or underwear despite staff requests. The facility's dignity policy, which aligns with the Ohio Revised Code Section 3721.13 on Residents' Rights, emphasizes the right of residents to be treated with courtesy, respect, and full recognition of dignity and individuality. The failure to address Resident #72's public indecency represents a deficiency in maintaining the dignity of residents, as investigated under specific complaint numbers.
Deficiency in Facility Assessment for Contracted Nursing Staff
Penalty
Summary
The facility failed to ensure its facility-wide assessment included necessary information regarding contracted nurses and state-tested nurse aides (STNAs), which could potentially affect all 88 residents. Interviews with the Director of Nursing (DON) and the Administrator confirmed that the facility uses agency staff to address staffing shortages. The facility assessment, however, did not document the use of contracted direct care providers such as registered nurses (RNs), licensed practical nurses (LPNs), or STNAs, despite the facility's reliance on agency staff for regular staffing needs. The facility's assessment, dated [DATE], outlined various contracts and agreements with third-party service providers but omitted contracted direct care providers. The facility's contract agency Client Staffing Service Agreement, dated 01/06/22, indicated that the agency would provide staff on an as-needed basis to supplement the facility's workforce. Interviews with the facility scheduler confirmed the frequent use of agency staff to fill staffing gaps, yet this was not reflected in the facility's assessment documentation.
Deficiency in STNA Continuing Education
Penalty
Summary
The facility failed to ensure that two State tested Nurse Aides (STNAs) received the required 12 hours of continuing education credits annually. Specifically, STNA #494 had evidence of only four one-hour education in-services, while STNA #498 had evidence of nine one-hour education in-services over the past 12 months. This deficiency was identified through a review of staff education records and in-service sign-in sheets, which confirmed that these STNAs did not meet the required education hours. An interview with the Chief Clinical Officer and the Administrator confirmed the inability to produce proof of the required education credits for these STNAs, potentially affecting all 88 residents at the facility.
Failure to Complete Ordered Wound Care
Penalty
Summary
The facility failed to ensure that a resident's bilateral lower extremity non-pressure wound care was completed as ordered by the physician. Resident #35, who was readmitted with diagnoses including partial traumatic amputation of the left foot, sepsis, and chronic obstructive pulmonary disease, had physician orders to cleanse the bilateral lower extremities with normal saline, apply collagen powder to the wound bed, followed by Xeroform, and cover with gauze every two days. However, documentation and observation revealed that the wound care was not performed as ordered on multiple occasions. Specifically, the dressings dated 04/27/24 were still in place on 04/30/24, indicating that the wound care scheduled for 04/29/24 was not completed as required. Interviews with the LPN Nightshift Supervisor and LPNs involved confirmed that the wound care was not performed according to the physician's orders. The Medication Administration Records (MARS) and Treatment Administration Records (TARS) indicated that the wound care was signed off as completed on 04/27/24 and 04/29/24, but the actual observation of the dressings contradicted this documentation. This discrepancy highlights a failure in adhering to the prescribed wound care regimen, as well as potential issues in accurate record-keeping and compliance with facility policies for dressing changes.
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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