Pickerington Care And Rehabilitation
Inspection history, citations, penalties and survey trends for this long-term care facility in Pickerington, Ohio.
- Location
- 1300 Hill Road North, Pickerington, Ohio 43147
- CMS Provider Number
- 365636
- Inspections on file
- 29
- Latest survey
- March 4, 2026
- Citations (last 12 mo.)
- 27
Citation history
Health deficiencies cited at Pickerington Care And Rehabilitation during CMS and state inspections, most recent first.
A resident with complex medical conditions, intact cognition, and dependence on assistance for ADLs lost insurance coverage and was informed of appeal options and potential nonpayment but had no documented assistance from facility staff in applying for or changing Medicaid coverage. After an unsuccessful insurance appeal, the administrator and social services issued a 30‑day discharge notice for nonpayment, and no further social service notes were documented. The resident was later sent to the hospital for severe diarrhea and discharged from the facility the same day; the hospital social worker and the resident’s family reported the facility stated the resident owed a large balance, would not be accepted back, and did not provide an itemized bill or assist with Medicaid changes, despite a policy stating residents appealing discharge would be allowed to return from the hospital.
A dependent, severely cognitively impaired resident with multiple comorbidities, including post-CVA hemiplegia, contractures, HTN, anemia, diabetes, depression, and chronic pain, required staff assistance with all ADLs except eating. Documentation showed the resident refused hair washing on several shower days, but there was no documentation of refusals for hair care on non-shower days. On multiple observations, the resident’s hair was found matted to the back of the head, and a CNA acknowledged the hair was matted and needed to be combed, resulting in a cited deficiency related to inadequate hair care.
A resident with severe cognitive impairment, hemiplegia, and multiple chronic conditions was found to be living in a room where a brown stain on the floor under a small bedside dresser and a dry, crumbly brown substance on the dresser’s lower front and corner were observed on two separate occasions the same day. A CNA confirmed the presence of these soiled areas. Review of the facility’s routine cleaning and disinfection policy showed that visibly soiled surfaces were to receive detailed cleaning, but this was not done, resulting in a failure to maintain a clean and comfortable environment.
Two residents' room flooring was found peeling and in disrepair, and facility carpeting throughout hallways and common areas was observed to be dirty and stained. The Maintenance Director confirmed both issues, noting slow progress on repairs and unsuccessful cleaning efforts, with no documentation of steps taken toward carpet replacement.
Staff failed to follow infection control protocols during fingerstick blood glucose monitoring and meal service. An LPN did not perform hand hygiene between glove changes or properly disinfect a glucometer, and a CNA did not perform hand hygiene while serving and assisting with meal trays for three residents, all of whom had significant medical conditions.
Staff failed to provide privacy during care and treatment for three residents with significant cognitive and physical impairments. In separate incidents, a nurse administered medications and a respiratory therapist performed trach care without closing doors or pulling privacy curtains, and a certified nursing aide left a resident exposed during incontinence care with the door open. Staff later acknowledged that privacy should have been maintained, in violation of facility policy.
Two residents with impaired cognition and high care needs were found in unsanitary conditions, including a dirty wheelchair and soiled wall padding, which remained unaddressed by staff despite multiple opportunities to clean or report the issues, contrary to facility policy.
Three dependent residents with cognitive and physical impairments were found to have long, dirty, or jagged fingernails and toenails due to staff not consistently providing nail care as required by facility policy. Documentation and observations confirmed that nail care was missed during multiple showers, and staff interviews acknowledged the issue.
A resident with a Foley catheter did not receive documented catheter care or urine output monitoring for several months, and when the catheter came out, staff did not replace it or notify the physician due to missing orders. Facility policy requiring regular catheter care, monitoring, and prompt physician notification was not followed, as confirmed by staff interviews and record review.
A resident with complex medical conditions developed a new sacral pressure ulcer due to inadequate care and inconsistent treatment documentation. The facility failed to follow proper protocols for pressure ulcer management, including inappropriate use of dressings and insufficient repositioning. Observations revealed improper dressing changes and failure to float the resident's heels, violating facility policies.
A facility failed to maintain accurate medical records for a resident with a sacral wound. Initially documented as a non-pressure wound, the wound was later identified by a physician as a chronic sacral ulcer. Despite this, nursing assessments continued to inaccurately record it as a non-pressure wound, and a progress note incorrectly stated the resident's skin was intact. Interviews with staff confirmed these documentation inaccuracies.
The facility failed to maintain infection control practices for two residents. One resident's air mattress pump was improperly placed and non-functional, causing discomfort. Another resident had an outdated droplet isolation sign, leading to a visitor entering without PPE. Staff confirmed these lapses in protocol.
The facility failed to post daily nursing staff data, affecting all 65 residents. On a specific day, the Daily Staffing Log was outdated, and the responsible staff was off due to a holiday. The Administrator confirmed the required information was not updated. This was found during a complaint investigation.
The facility failed to dispose of expired Covid-19 vaccine syringes, potentially affecting residents receiving vaccines. An opened box of Spikevax vaccine with expired syringes was found in the medication storage refrigerator. An LPN confirmed the expired syringes, stating they would be administered upon request. Manufacturer guidelines indicate syringes should be refrigerated for up to 30 days.
A resident with multiple health conditions, including Parkinson's and dementia, was observed inadequately dressed in a hospital gown, exposing his chest to passersby. Despite the facility's policy on resident rights, staff failed to ensure the resident was dressed in personal clothing, attributing the oversight to being busy and actions of the night shift.
The facility failed to complete initial comprehensive MDS assessments within 14 days for two residents with complex medical conditions. Additionally, a resident's oral status was inaccurately coded on the annual MDS, despite evidence of edentulous status. Interviews confirmed these deficiencies.
The facility failed to assess medication side effects for two residents on psychoactive medications. One resident exhibited involuntary mouth movements, while another had upper body tremors. Despite these observations, AIMS evaluations and medication records did not document these side effects. Staff interviews confirmed the presence of these movements, but assessments failed to capture them, indicating a gap in monitoring and documentation.
A facility failed to document the rationale for declining a gradual dose reduction (GDR) of antipsychotropic medications for a resident with a complex medical history. Despite pharmacist recommendations for GDR on medications like Lexapro and Buspar, the CNP disagreed without providing specific reasons or symptoms, contrary to facility policy. The Director of Nursing confirmed the need for documentation of the rationale for such decisions.
A facility failed to maintain proper infection control practices for a resident on droplet isolation due to human metapneumovirus pneumonia. Staff, including an RN and a housekeeper, were observed not using the required PPE, such as gowns, gloves, and properly worn masks, as per the facility's policy. This non-compliance was confirmed through interviews with the staff involved.
A resident, who was non-verbal and dependent on staff for daily activities, had their call light placed on the floor out of reach, preventing them from alerting staff for assistance. This was observed on two consecutive days and confirmed by STNAs, despite facility policy requiring call lights to be accessible to residents.
The facility failed to ensure proper orders for ventilator services and oxygen monitoring for a resident with multiple serious diagnoses. Observations and staff interviews revealed inconsistencies in oxygen rates and a lack of documented guidelines for titration and monitoring, leading to a deficiency in care.
Failure to Provide Appropriate Discharge Planning and Allow Return After Hospitalization
Penalty
Summary
The deficiency involves the facility’s failure to provide timely and appropriate discharge planning and to permit a resident to return following hospitalization after issuance of a 30‑day discharge notice. The resident was admitted with multiple complex diagnoses, including cervical spine fusion, Ehlers‑Danlos syndrome, secondary malignant neoplasm of the lung, depression, anxiety, and neoplasm‑related pain, and had a care plan goal to eventually discharge to an apartment with cancer support. The admission MDS showed intact cognition and a need for supervision or touching assistance with ADLs. On 11/10/25, social services documented that the resident’s insurance coverage ended with a last covered day of 11/08/25, discussed appeal options and upcoming cancer treatment, and noted the resident required assistance with dressing, meal setup, and incontinence care and could not return to her previous residence. There is no documentation that staff provided or documented assistance with Medicaid application or plan changes despite the resident’s dependence on a payor source. On 12/03/25, social services documented that the resident’s appeal of the insurance termination was unsuccessful, that the family was exploring other medical plans with LTC benefits, and that the resident was informed she might receive a 30‑day discharge notice if no payor was secured. The resident expressed that she felt at home and hoped to stay, and there is no documentation that staff offered or provided assistance with the Medicaid application or plan change process. On 12/23/25, the administrator and social services director issued a 30‑day discharge notice for nonpayment, citing failure to pay or to have Medicare or Medicaid pay on the resident’s behalf, with a planned discharge date of 01/22/26. No further social service progress notes were documented in the resident’s record after issuance of the notice. On 01/04/26, nursing documented that the resident was sent to the hospital for nonstop diarrhea, and the record shows the resident was discharged from the facility that same day, with no further documentation after transfer. A hospital social worker later documented that he contacted the facility multiple times and was told the resident owed $28,000, had been given a notice to leave before hospitalization, and that the facility was unable to take her back. The appeal decision dated 01/20/26 found the facility had not met its burden to prove the discharge and denied the facility’s request to discharge the resident. The resident’s daughter and the hospital social worker reported that the facility told the hospital the resident could not return due to nonpayment, that the family did not receive an itemized bill despite requesting it, and that the facility did not assist with changing Medicaid plans. The administrator confirmed there was no documentation that the resident or family did not want to return, no documented communication with the hospital regarding discharge planning, and that facility policy required allowing a resident to return from the hospital during an appeal, which did not occur in this case.
Failure to Provide Hair Care to Dependent Resident
Penalty
Summary
Surveyors identified a deficiency related to failure to provide hair care to a dependent resident. The resident was admitted with multiple diagnoses including encephalopathy, hemiplegia and hemiparesis following cerebral infarction affecting the right dominant side, contracture of the right upper arm, hypertension, anemia, diabetes, depression, and chronic pain syndrome. An admission MDS initiated but not yet completed showed, through assessments dated 01/26/26, that the resident was severely cognitively impaired with a brief interview for mental status score of zero and was dependent on staff for all ADLs except eating, for which setup assistance was required. Review of shower sheets for several dates showed the resident refused to have her hair washed on those shower days. Record review revealed no documentation that the resident refused hair care on days other than scheduled shower days. On 01/27/26, surveyors twice observed the resident’s hair to be matted to the back of her head, first at 11:55 AM and again at 1:49 PM. During the second observation, a CNA confirmed that the resident’s hair was matted and acknowledged that it needed to be combed. This deficiency was cited as non-compliance and was investigated under Complaint Numbers 2727003 and 2678134.
Failure to Maintain Cleanliness of Resident Room Surfaces
Penalty
Summary
The deficiency involves the facility’s failure to maintain a clean and comfortable environment in a resident’s room, as required by its own routine cleaning and disinfection policy. The resident involved had been admitted with multiple diagnoses, including encephalopathy, hemiplegia and hemiparesis following cerebral infarction affecting the right dominant side, contracture of the right upper arm, hypertension, anemia, diabetes, depression, and chronic pain syndrome. Assessment information completed in preparation for the admission MDS showed the resident was severely cognitively impaired, with a brief interview for mental status score of zero, and was dependent on staff for all activities of daily living except eating, for which setup assistance was required. On two separate observations conducted on the same day, surveyors noted a brown stain on the floor under the resident’s small two-drawer bedside dresser and a dry, crumbly brown substance adhered to the lower front and corner of the dresser. These conditions were observed in the resident’s room both late morning and early afternoon. A CNA interviewed at the time confirmed the presence of the brown stain on the floor and the dry, crumbly brown substance on the dresser. Review of the facility’s undated “Routine Cleaning and Disinfection” policy showed that routine surface cleaning and disinfection was to be conducted with a detailed focus on visibly soiled surfaces, which was not carried out in this instance. This deficiency was investigated under Complaint Numbers 2727003, 2685197, and 2678134.
Failure to Maintain Safe and Sanitary Flooring and Carpeting
Penalty
Summary
The facility failed to maintain safe and sanitary flooring for two residents, as observed by surveyors. The flooring under and around the room air conditioner in these residents' room was peeling up about an inch off the floor, affecting approximately eight tiles. The Maintenance Director confirmed awareness of the issue and stated that the facility was working through a list of rooms needing flooring replacement, but progress had been slow, with only five rooms completed over several months. Additionally, the facility did not maintain carpeting in a clean and sanitary manner throughout the building. Observations revealed dirty carpeting in hallways, with grime, dark staining, and old moisture marks visible outside resident rooms, down hallways, and around offices and nursing stations. The Maintenance Director confirmed the carpet's condition and stated that cleaning attempts had been unsuccessful. There was no evidence of steps taken toward carpet replacement, such as obtaining quotes or order confirmations. The facility's policy requires maintaining a safe, functional, and sanitary environment, but these standards were not met in the areas observed.
Infection Control Deficiencies During Blood Glucose Monitoring and Meal Service
Penalty
Summary
The facility failed to maintain proper infection control practices during fingerstick blood glucose monitoring for one resident, with the potential to affect three additional residents receiving similar care. During observation, an LPN placed a glucometer directly on a resident's overbed table without a barrier, used gloves to obtain a blood sample, and then placed the glucometer on a tissue. The LPN changed gloves multiple times without performing hand hygiene between glove changes, and cleaned the glucometer for only five seconds, despite manufacturer guidelines requiring a two-minute contact time for disinfection. The LPN also prepared medication after glove removal, using hand sanitizer only after several glove changes without prior hand hygiene. These actions were confirmed during an interview with the LPN, and a review of facility policy indicated that hand hygiene should be performed after glove removal. Additionally, the facility failed to ensure hand hygiene was performed during meal service for three residents in the main dining room. A CNA was observed serving and assisting with meal trays for these residents without performing hand hygiene before or during the process. The CNA confirmed during an interview that hand hygiene was not completed as required. Facility policy identifies hand hygiene as the primary means to prevent the spread of healthcare-associated infections. The affected residents had various medical conditions, including high blood pressure, dysphagia, dementia, respiratory failure, epilepsy, anxiety, depression, and heart failure.
Failure to Provide Privacy During Resident Care and Treatment
Penalty
Summary
The facility failed to ensure that residents were treated with dignity by providing adequate privacy during care and treatment, as evidenced by observations and staff interviews involving three residents. In one instance, a resident with severe cognitive impairment and multiple medical conditions, including a tracheostomy and gastrostomy, received medication administration via gastrostomy tube from a registered nurse who did not close the door or pull the privacy curtain during the procedure. The nurse later confirmed that privacy was not provided. In another case, a resident dependent on staff for all activities of daily living, including tracheostomy care, had trach suctioning and tie changes performed by a respiratory therapist with the door and blinds open and the privacy curtain not pulled. The therapist acknowledged that privacy should have been provided. Additionally, a resident with impaired cognition and dependence for toileting was observed receiving incontinence care with the curtain only partially closed and the door wide open, allowing the resident to be exposed and visible from the hallway. A soiled brief was also observed being tossed onto the floor by a certified nursing aide, who admitted that the door should have been closed but did not do so, mistakenly believing it was stuck. Review of facility policy confirmed that residents have the right to privacy and confidentiality during medical treatment and personal care.
Failure to Maintain Clean and Sanitary Resident Environment
Penalty
Summary
The facility failed to maintain a clean and sanitary environment for its residents, as evidenced by observations and staff interviews. One resident with impaired cognition and dependent on staff for bathing and hygiene was observed sitting in a wheelchair with a stained cushion, food particles in the seams, and rails and footrest pegs covered in a white substance and dried food. Staff confirmed the wheelchair was dirty and stated that while the night shift usually cleaned wheelchairs, they would clean them if visibly soiled. The facility's cleaning schedule indicated wheelchairs were to be cleaned weekly, but this was not adhered to in this instance. Another resident, also with impaired cognition and dependent on staff for personal hygiene, was found to have a navy-blue wall padding next to their bed that was smeared with a dried brownish material. Multiple observations over the course of a day showed the soiled padding remained uncleaned despite several staff entering and exiting the room to provide care. A CNA confirmed the presence of the dirty substance but did not take action to clean it or alert other staff. The soiled mat remained unaddressed until the following day when housekeeping staff cleaned it. Facility policy required all personnel to report and address unclean or defective equipment and furnishings, but this was not followed in these cases.
Failure to Provide Nail Care for Dependent Residents
Penalty
Summary
The facility failed to provide adequate nail care for dependent residents, as evidenced by record reviews, observations, and staff interviews. Three residents with significant cognitive and physical impairments, who were dependent on staff for activities of daily living (ADLs), were found to have long, dirty, or jagged fingernails and toenails. Documentation showed that nail care was not completed during multiple showers for these residents, and there were no refusals documented for some of the missed care. Observations confirmed the poor nail condition, including long nails with dark substances underneath and thick, jagged toenails. Staff interviews corroborated the findings, with CNAs acknowledging the residents' unkempt nails and stating that nail care should be performed after bathing or showering. The facility's policy required staff to provide care and services for ADLs, including grooming and personal hygiene, but this was not consistently followed for the affected residents. The deficiency was identified through a combination of medical record review, direct observation, and staff confirmation.
Failure to Provide and Document Required Catheter Care and Monitoring
Penalty
Summary
A deficiency was identified regarding the care and management of a resident with a Foley catheter. The resident, who had multiple diagnoses including cardiac arrest, open wound, malnutrition, spinal stenosis, vascular disease, dysphagia, muscle weakness, intellectual disabilities, and urinary retention, was admitted with a Foley catheter in place due to obstructive uropathy. The care plan indicated the need for regular catheter care, monitoring of urine output, and prompt physician notification of any changes. However, review of the medical record revealed no evidence that catheter care was provided or that urine output was measured and documented from July through September. Additionally, there were no documented physician orders for the catheter prior to late September. An incident occurred when the resident's catheter came out overnight. The resident reported waiting for a nurse to replace it, but staff interviews revealed that the night nurse did not attempt to replace the catheter or notify the physician. The following day, the LPN on duty discovered the lack of catheter orders and contacted the physician for clarification. The RN on duty also did not replace the catheter or notify the physician, citing the absence of orders. There was no documentation of the resident's urine output during the 16-hour period without a catheter, nor was there evidence of physician notification regarding the catheter's removal. Facility policy required prompt physician notification of significant changes, regular catheter care each shift, and comprehensive care planning. Interviews with the DON and other staff confirmed that catheter care was not documented for several months and that the lack of orders was an oversight. The deficiency was substantiated by the absence of documentation, lack of physician notification, and failure to provide required catheter care and monitoring as outlined in facility policy.
Inadequate Pressure Ulcer Care for Resident
Penalty
Summary
The facility failed to provide adequate care and services for a resident with a history of pressure ulcers, leading to the development of a new sacral pressure ulcer. The resident, who was admitted with multiple complex medical conditions including functional quadriplegia and ventilator dependence, was initially assessed to have a resolved sacral Stage IV pressure ulcer. However, subsequent assessments revealed the development of a right lateral sacrum abscess, which was not properly managed according to the facility's guidelines. The facility's records indicated inconsistencies in the treatment and documentation of the resident's pressure ulcer care. The treatment plan included the use of Calcium Alginate dressings, which were not appropriate for dry wounds, and there was a lack of documented evidence that wound treatments were completed on several occasions. Additionally, the air mattress settings were not specified, and the resident was observed lying on a static air mattress, which may not have provided adequate pressure relief. Observations and interviews with staff revealed further deficiencies in care, including improper dressing changes and failure to reposition the resident adequately. The resident's heels were not floated off the bed surface as required, and the soiled dressing was left in the resident's room, contributing to an unpleasant odor. These actions and inactions were in violation of the facility's policies on pressure injury prevention and management, as well as turning and repositioning protocols.
Inaccurate Medical Record Documentation for Resident's Sacral Wound
Penalty
Summary
The facility failed to maintain accurate medical records for a resident, identified as Resident #100, who was admitted with multiple diagnoses including aortic aneurysm, cerebral infarction, respiratory failure with ventilator dependence, functional quadriplegia, and encephalopathy. The resident's quarterly Minimum Data Set (MDS) assessment indicated severe impairment in daily decision-making and noted the presence of a pressure-relieving device on the bed, with no pressure ulcers reported. However, a nursing Skin Grid Non-Pressure assessment later documented a right lateral sacrum abscess, which was initially recorded as a non-pressure wound. Further review revealed discrepancies in the documentation of the resident's sacral wound. A physician's progress note indicated the presence of a chronic sacral ulcer, recommending evaluation by the wound team for possible debridement. Despite this, a nursing progress note inaccurately stated the resident's skin was intact, and subsequent weekly assessments continued to document the sacral pressure ulcer as a non-pressure wound. Interviews with the Assistant Director of Nursing and a Licensed Practical Nurse confirmed the inaccuracies in the documentation, highlighting a failure to accurately record the resident's medical condition.
Infection Control Deficiencies in Resident Care
Penalty
Summary
The facility failed to maintain proper infection control practices, as evidenced by two separate incidents involving residents. In the first case, Resident #103, who was admitted with multiple diagnoses including primary central nervous system lymphoma and depression, was found to have an air mattress pump sitting on the floor without a barrier, and the pump was not functioning because it had been unplugged. The air mattress was deflated, causing discomfort to the resident. The Occupational Therapist confirmed the absence of a footboard, which typically supports the pump, and the Registered Nurse acknowledged that the pump should not have been on the floor without a barrier. In the second incident, Resident #9, who was admitted with acute respiratory failure and other serious conditions, was observed with a droplet isolation sign on the door, despite the isolation precautions having expired. A visitor was seen in the room without personal protective equipment, which was required under the posted isolation precautions. The Assistant Director of Nursing verified that the isolation sign should have been removed after the precautions ended, indicating a lapse in updating the resident's status and ensuring compliance with infection control protocols.
Failure to Post Daily Nursing Staff Data
Penalty
Summary
The facility failed to ensure that daily nursing staff data was posted as required, which had the potential to affect all 65 residents residing within the facility. On December 26, 2024, at 8:10 A.M., an observation of the reception area revealed that the Daily Staffing Log posted was dated December 24, 2024. This was verified by the Business Office Manager (BOM) at the time of the observation. During an interview at 9:17 A.M., the BOM confirmed that the nursing staff information had not been posted on December 25 or December 26 because the staff responsible for posting the data was off on December 25 due to the holiday and had just returned to work. Later, at approximately 4:15 P.M., an interview with the Administrator revealed that the required nursing staff information was behind the posting dated December 24, 2024, but had not been flipped over on December 25. This deficiency was identified as an incidental finding during a complaint investigation.
Expired Covid-19 Vaccine Syringes Not Disposed
Penalty
Summary
The facility failed to properly dispose of expired Covid-19 vaccine syringes, which could potentially affect any resident receiving a Covid-19 vaccine or booster. During an observation, an opened box of Spikevax (Covid-19) vaccine was found in the medication storage refrigerator in the North unit's medication storage room. The box contained two pre-filled syringes from an original set of ten, with a lot number #3032713 and an expiration date that had passed. There were no opened dates on the box or syringes. An interview with an LPN Unit Manager confirmed the presence of the expired syringes, and it was stated that the vaccines would be administered upon resident request. The manufacturer's guidelines for the Moderna Spikevax vaccine indicate that single-dose pre-filled syringes may be stored refrigerated for up to 30 days prior to use.
Resident Dignity Compromised Due to Inadequate Dressing
Penalty
Summary
The facility failed to ensure that a resident was treated with respect and dignity, as evidenced by multiple observations of the resident being inadequately dressed. The resident, who was dependent on staff for all activities of daily living due to conditions such as Parkinson's disease and dementia, was observed sitting in a Broda chair wearing only a hospital gown with a blanket covering his legs. On one occasion, the gown had fallen down to the resident's waist, exposing his chest to staff and passersby. This situation was not addressed by the staff, as evidenced by an interview with a State Tested Nursing Assistant (STNA) who acknowledged the resident should have been dressed in personal clothing but had not considered it due to being busy. The resident's medical record indicated a range of diagnoses, including human metapneumovirus pneumonia, pulmonary fibrosis, and generalized muscle weakness, which contributed to his dependency on staff for care. Despite the facility's policy on resident rights, which mandates that all direct care staff are educated on the rights of residents, the staff failed to uphold these rights by not ensuring the resident was dressed appropriately. The STNA attributed the resident's state of dress to the night shift's actions and did not take steps to rectify the situation, highlighting a lapse in the facility's adherence to its own policies regarding resident dignity and care.
Deficiencies in MDS Completion and Oral Status Assessment
Penalty
Summary
The facility failed to complete an initial comprehensive, accurate standardized Minimum Data Assessment (MDS) within the first 14 days following admission for two residents. Resident #175, who was admitted with multiple complex diagnoses including pneumonia, Parkinsonism, and dementia, had an MDS assessment with an assessment reference date (ARD) that remained incomplete beyond the required 14-day period. Similarly, Resident #177, admitted with conditions such as metabolic encephalopathy and acute respiratory failure, also had an incomplete MDS assessment with an ARD that exceeded the 14-day requirement. Interviews with the MDS Coordinator confirmed that the assessments were not completed within the mandated timeframe. Additionally, the facility failed to accurately assess and code the oral status of Resident #30 on the annual MDS. Despite being documented as edentulous in dental consultations and observed without visible teeth, the MDS assessments inaccurately reflected the resident's dental status. The MDS nurse confirmed the discrepancy in coding, which did not align with the resident's actual oral condition as noted in previous assessments and consultations.
Failure to Assess Medication Side Effects
Penalty
Summary
The facility failed to comprehensively assess residents for possible medication side effects, affecting two residents. Resident #19, diagnosed with schizophrenia and Parkinson's disease, was on multiple medications, including antipsychotics and antidepressants. Despite observations of involuntary mouth movements, the AIMS evaluations and medication administration records did not document any side effects. Interviews with staff confirmed the presence of these movements, yet the assessments and progress notes failed to identify them. Resident #11, diagnosed with schizoaffective disorder, was also on several medications, including antipsychotics and anticonvulsants. Observations noted upper body tremors, but the AIMS evaluations and medication records did not reflect these findings. Although psychiatry progress notes documented fine hand tremors, there was no further assessment or documentation regarding the cause or treatment. Staff interviews confirmed the presence of tremors, but the assessments did not capture these involuntary movements. The facility's policy required routine monitoring for side effects using the AIMS assessment for residents on psychoactive medications. However, the assessments for both residents failed to identify involuntary movements, and there was a lack of documentation and reporting of these side effects. The deficiency highlights a gap in the facility's adherence to its policy for monitoring and documenting medication side effects.
Failure to Document Rationale for Declining GDR of Antipsychotropic Medications
Penalty
Summary
The facility failed to document the rationale for declining a gradual dose reduction (GDR) of antipsychotropic medications for a resident. The resident, who had a complex medical history including conditions such as muscular dystrophy, anxiety disorder, and depression, was receiving medications like Buspar and Lexapro via a peg-tube. Despite recommendations from the pharmacist for GDR on multiple occasions, the Certified Nurse Practitioner (CNP) disagreed with these recommendations without providing a rationale or symptoms for the denial. This lack of documentation was contrary to the facility's policy, which requires the attending physician to document the rationale for any decision not to change medication. The resident's medical record showed that the pharmacist recommended GDR for Lexapro and Buspar on several dates, but the CNP consistently disagreed, citing potential increased distressed behavior or worsening of target symptoms. However, the CNP did not provide specific reasons or symptoms to support these decisions. An interview with the Director of Nursing confirmed that the CNP should have documented the reason for declining the GDR. The facility's policy mandates that any irregularity identified by the pharmacist must be reviewed and documented by the attending physician, including the rationale for not making any changes to the medication regimen.
Inadequate Infection Control Practices in Droplet Isolation
Penalty
Summary
The facility failed to maintain proper infection control practices in the area of droplet isolation, affecting one resident who was admitted with human metapneumovirus pneumonia. The resident's care plan required droplet isolation due to the infection, with specific interventions outlined to manage the condition and prevent the spread of infection. However, observations revealed that staff did not adhere to the required personal protective equipment (PPE) protocols. A registered nurse was observed taking the resident's blood pressure without wearing the necessary PPE, including a gown, gloves, and surgical mask. Further observations showed a housekeeper cleaning the resident's room with a mask improperly worn under the nose and only wearing gloves, failing to utilize the full required PPE. Interviews with the staff members confirmed the lack of proper PPE usage. The facility's policy on transmission-based precautions required healthcare personnel to wear a facemask for close contact with infectious residents and additional PPE if there was a risk of exposure to respiratory secretions. The failure to adhere to these precautions was a direct violation of the facility's infection control policy.
Resident's Call Light Out of Reach
Penalty
Summary
The facility failed to ensure that a resident's call light was within reach, which is a critical means for the resident to alert staff for assistance. The deficiency was observed when the call light for a resident, who had no speech and was dependent on staff for activities of daily living, was found on the floor out of reach. This was confirmed by two separate observations on consecutive days, where the call light was noted to be on a floor mat next to the resident's bed, rendering the resident unable to summon facility staff for needs. Interviews with State tested Nursing Assistants verified the resident's inability to access the call light, which was the only means to alert staff of any needs. The facility's policy requires that call lights be within reach of residents and secured as needed, but this was not adhered to in this instance.
Failure to Ensure Proper Ventilator and Oxygen Monitoring
Penalty
Summary
The facility failed to ensure proper orders for ventilator services and oxygen monitoring for Resident #23. The resident, who was admitted with multiple serious diagnoses including chronic obstructive pulmonary disease and malignant neoplasms, did not have a physician order specifying the rate of oxygen or guidelines for titrating oxygen levels. This lack of documentation persisted from December 2023 to April 2024, with no evidence of pulse oxygen levels being checked according to facility policy and professional standards. Observations on April 16, 2024, revealed inconsistencies in the resident's oxygen rate, which varied from eight liters per minute to approximately 3.5 liters per minute. Interviews with various staff members, including RNs, LPNs, and the respiratory therapist, confirmed that there were no documented instructions or guidelines in the resident's medical record for titrating oxygen or monitoring it after titration. The staff admitted that the orders for oxygen rate and titration were only added to the resident's medical records on the day of the surveyor's inquiry. The Director of Nursing and the Administrator acknowledged the lack of proper documentation and adherence to the facility's oxygen administration policy. The facility's guidelines require checking the resident's pulse oxygen level five minutes and one hour after titration, but these steps were not consistently followed. The respiratory therapist admitted to not documenting titration events specifically in progress notes, further contributing to the deficiency in care for Resident #23.
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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