Prestige Gardens Rehabilitation And Nursing Center
Inspection history, citations, penalties and survey trends for this long-term care facility in Marysville, Ohio.
- Location
- 755 South Plum Street, Marysville, Ohio 43040
- CMS Provider Number
- 365577
- Inspections on file
- 28
- Latest survey
- May 13, 2025
- Citations (last 12 mo.)
- 0
Citation history
Health deficiencies cited at Prestige Gardens Rehabilitation And Nursing Center during CMS and state inspections, most recent first.
A resident with a fractured leg and multiple chronic conditions experienced severe, unmanaged pain for over two days, despite clear physician orders and a care plan for pain management. Staff observed and were informed of the resident's pain but did not assess, medicate, or implement non-pharmacological interventions, nor did they notify the NP as required. Facility policy for pain assessment and management was not followed, resulting in actual harm.
The facility did not provide palatable meals, as a lunch meal observation revealed the meatloaf was dark, crunchy, and dry, which was confirmed by the dining services director and several residents. The issue was attributed to the meatloaf being left in the oven too long, and the food was also cut too thin. This did not align with the facility's policy requiring meals to be appetizing and properly prepared.
Staff did not follow infection control protocols in multiple areas, including carrying unbagged soiled linens in the hallway, failing to change gloves and clean the area during g-tube care for a resident, and using an alcohol swab instead of approved germicidal wipes to clean a glucometer. These actions were contrary to facility policies and had the potential to impact all residents.
The facility did not maintain complete infection control logs or ensure proper documentation and assessment of infections and antibiotic use. Several residents were started on antibiotics without adequate evidence or documentation, and the facility's policy lacked clear procedures for determining appropriateness of antibiotic therapy.
A CNA failed to complete the required annual in-service education, attending only three out of twelve sessions, missing key topics such as abuse prevention and communication. Two residents with intact cognition reported or witnessed disrespectful treatment by this CNA, though no abuse was alleged. The incomplete training and reported conduct had the potential to affect all residents.
The facility did not address ongoing resident concerns raised during council meetings, including delayed call light responses, issues with smoke breaks, untimely showers, and lack of activity variety. Documentation of concerns and follow-up actions was inconsistent or missing, and when completed, often lacked detail or evidence of resolution. Multiple residents and staff confirmed that the same issues persisted over several months without satisfactory action.
Residents were unable to access their personal care needs accounts outside of restricted banking hours, as staff did not have procedures or authority to provide funds after hours or on weekends. This affected all residents who authorized the facility to manage their finances, contrary to facility policy requiring timely access to funds.
Surveyors found that the facility did not maintain a clean and homelike dining environment, with dirty dishes, food debris, and cleaning equipment left in the dining area during meal service. Additionally, a resident with multiple medical conditions was observed using blood-stained linens, which was confirmed by an LPN, contrary to facility policy requiring clean linens.
A resident with mild cognitive impairment and a history of chronic conditions was assisted with feeding by a CNA who stood over her during mealtime, contrary to facility policy requiring dignified assistance. Staff interviews confirmed that standing while feeding is a common practice, despite the resident's care plan specifying the need for supervision and one-person assistance.
A resident with multiple medical conditions was subjected to verbal abuse by a CNA, who yelled and made threatening gestures. The incident was witnessed and verbally reported to a unit manager, but not escalated to the DON or Administrator, and no written report was found. The accused CNA continued working, in violation of facility policy requiring immediate removal of staff accused of abuse. The DON and Administrator were unaware of the incident until surveyors intervened.
A resident with cognitive deficits and multiple diagnoses was prescribed PRN Lorazepam for 180 days without the physician documenting a rationale in the medical record, despite pharmacist recommendations and facility policy requiring such documentation. Staff interviews and record reviews confirmed the absence of a documented rationale for the continued use of the psychotropic medication.
The facility did not follow its abuse prevention and reporting policy in two cases: one involving verbal abuse by a CNA toward two residents, and another involving a resident who sustained serious injuries during transport. In both cases, required steps such as immediate reporting to the DON and Administrator, removal of accused staff, and thorough investigation were not completed as outlined in facility policy.
The facility did not report an allegation of verbal abuse involving a resident and a CNA, nor did it report an injury of unknown origin sustained by another resident during transport, to the state agency as required by policy. In both cases, staff were aware of the incidents, but the required notifications and self-reports were not made.
Two residents experienced serious incidents—one involving alleged verbal abuse by a CNA and another sustaining multiple fractures during transport by an outside service. In both cases, the facility did not follow its own protocols for reporting and investigation, as key staff were not informed, written reports were missing, and essential steps such as obtaining a police report were not taken, resulting in incomplete investigations.
A resident with multiple complex medical conditions was transferred to the hospital due to low hemoglobin, but the facility failed to document that appropriate and pertinent information was provided to the receiving institution. The DON confirmed that required clinical details were not communicated at the time of transfer, contrary to facility policy.
The facility did not provide required bed hold notices, transfer/discharge reasons, or ombudsman notifications for three residents who were transferred or discharged, including those with complex medical and mental health conditions. Staff interviews and record reviews confirmed that these notifications and documentation were not completed as required by facility policy.
The facility did not ensure that PASARR documentation was accurate and up-to-date for two residents with multiple mental health diagnoses. In both cases, the PASARR forms failed to reflect all current diagnoses as recorded in the medical records, and staff confirmed that required reviews and updates were not performed according to facility policy.
Two residents experienced deficiencies in care planning and care conference practices, including failure to update a nutritional care plan after significant weight loss and lack of timely, interdisciplinary care conferences. One resident's care plan was not revised despite notable weight changes, while another did not receive required care conferences with appropriate team involvement.
Staff did not follow physician orders for a resident requiring a specialized wedge for turning and repositioning to prevent pressure ulcers. The wedge was missing for several days, and staff used a pillow instead, but continued to document that the wedge was used. Facility leadership confirmed orders should be followed as written, and no policy for following physician orders was provided.
A resident who was cognitively intact and continent did not receive proper perineal care when a CNA failed to clean the labia area during peri-care, contrary to facility policy that requires thorough cleaning of the perineal area. The CNA acknowledged the omission during an interview.
A resident with multiple chronic conditions required documentation of an external appointment. When a surveyor requested a copy of the appointment record, the receptionist, with the involvement of a clinical RN, delayed and then altered the document to provide only the appointment date rather than the full original record, resulting in incomplete information being supplied.
Failure to Assess and Manage Severe Pain for Resident with Fracture
Penalty
Summary
A deficiency occurred when a resident with a fractured tibia and fibula experienced severe breakthrough pain that was not adequately assessed or managed by facility staff. Despite physician orders for as-needed Norco and Tylenol, and a care plan specifying the need for prompt pain management and monitoring, the resident went without any pain medication or documented non-pharmacological interventions for over 48 hours. During this period, the resident was observed multiple times displaying clear signs of pain, such as moaning, tearfulness, and fist-clenching, both during general observation and while receiving direct care. Medical record review showed the resident had multiple comorbidities, including heart failure, renal insufficiency, diabetes, depression, and COPD, and was cognitively intact but dependent on staff for most activities of daily living. The resident's pain was documented as frequent and severe, with a pain score of 7 out of 10 and a goal of 1. However, there was no documentation of pain assessment, administration of pain medication, or use of non-pharmacological interventions during the period in question. Staff interviews confirmed that the resident's pain was reported to nursing staff, but no action was taken to address or escalate the issue, and the nurse practitioner was not notified of the resident's pain as required. Facility policy required staff to assess and manage pain promptly, including identifying residents at risk, using standardized pain assessment tools, and anticipating pain during care activities. Despite these requirements, the resident's pain was not addressed, and there was no evidence of staff following the pain protocol or care plan interventions. This failure resulted in the resident experiencing actual harm due to unmanaged pain.
Failure to Provide Palatable and Properly Prepared Meals
Penalty
Summary
The facility failed to provide palatable meals to residents, as evidenced by observations and interviews. During a lunch meal observation, the meatloaf served was found to be dark, crunchy, and dry. The Regional Director of Dining Services confirmed that the meatloaf was dry due to being left in the oven too long. Interviews with three residents confirmed that the meatloaf was dry, crunchy, and cut too thin. Review of the facility's Food Presentation policy indicated that meals should be served in a manner that enhances appetite and prevents overcooking, with checks for proper temperature, taste, and consistency prior to serving. These findings demonstrate that the facility did not adhere to its policy regarding food preparation and presentation.
Infection Control Lapses in Linen Handling, Glucometer Sanitization, and G-Tube Care
Penalty
Summary
Staff failed to follow proper infection control procedures in several instances. A certified nurse aide was observed carrying unbagged soiled linens in the hallway after leaving a resident's room, despite facility policy requiring contaminated laundry to be bagged at the point of use. The aide confirmed awareness of the correct procedure but did not follow it. Additionally, a licensed practical nurse was observed providing care to a resident with a gastrostomy tube and did not change gloves between removing a soiled dressing and applying a clean treatment. The nurse also did not clean the area around the g-tube site, contrary to facility policy, and confirmed these actions during an interview. Another deficiency was noted during a blood glucose test, where the same nurse cleaned a glucometer with an alcohol swab instead of the facility-approved germicidal wipes. The nurse stated this was her usual practice, although facility policy specifies the use of Clorox Germicidal Wipes or Super Sani-Cloth Germicidal Disposable Wipes. These lapses in infection control practices had the potential to affect all 56 residents in the facility.
Failure to Implement Comprehensive Antibiotic Stewardship Program
Penalty
Summary
The facility failed to implement a comprehensive antibiotic stewardship program to adequately monitor infections and determine the appropriateness of antibiotic use for all residents. Infection control logs only included residents who were started on antibiotics and did not document other possible infectious findings, symptom onset dates, specific symptoms, or whether diagnostic tests such as chest x-rays or laboratory values were ordered and completed. Interviews confirmed that the infection control logs were missing critical information required to assess infections according to McGeer's criteria. Medical record reviews revealed several deficiencies in the management of infections and antibiotic use. One resident with a stage four pressure wound was started on antibiotics without evidence of wound cultures or documentation supporting the presence of infection, despite meeting McGeer's criteria. Another resident with a UTI had urine cultures that did not meet the threshold for infection, and the facility could not provide documentation of the organism identified. A third resident was admitted with a UTI and started on antibiotics in the hospital, but the facility did not complete a McGeer's assessment to determine appropriateness upon admission. The facility's antibiotic stewardship policy lacked guidance on ensuring appropriateness before starting antibiotics and did not address proper documentation of infection-related information.
Failure to Ensure Required CNA In-Service Education and Respectful Resident Treatment
Penalty
Summary
The facility failed to ensure that a certified nurse aide (CNA) completed the required minimum of twelve hours of in-service education annually, as mandated. Review of CNA #22's employee file showed that only three out of twelve required in-service sessions were attended in the previous twelve months, totaling just three hours of education. The missed in-services included critical topics such as resident rights, infection control, code of conduct compliance and ethics, emergency preparedness, elopement, customer service with a person-centered approach, first aid basics, behavior management, communication and conflict resolution, and abuse and neglect. This deficiency was confirmed by the Business Office Manager, who verified the incomplete training record. Interviews with two residents, both with intact cognition and relevant psychiatric diagnoses, revealed concerns regarding CNA #22's conduct. One resident reported being treated in a disrespectful manner by CNA #22, though she did not feel threatened. Another resident witnessed the same CNA treating the first resident in an undignified and disrespectful way, describing the behavior as disrespectful but not abusive. These findings, combined with the incomplete in-service education, had the potential to affect all 56 residents in the facility.
Failure to Address Resident Council Concerns Timely and Appropriately
Penalty
Summary
The facility failed to address resident concerns raised during resident council meetings in a timely and appropriate manner. Multiple residents reported ongoing issues such as delayed call light responses, problems with smoke breaks, untimely showers and incontinence care, lack of activity variety, and insufficient staff responsiveness. These concerns were repeatedly brought up at council meetings over several months, with residents and staff confirming that the same issues persisted without satisfactory resolution. Documentation of concerns and follow-up actions was inconsistent or missing, and when forms were completed, they often lacked detail regarding the actions taken or plans for monitoring compliance. Record reviews showed that concern forms were either incomplete, missing, or failed to provide evidence of audits, interviews, or specific corrective actions. For example, audits claimed to have been performed to check call light response times and incontinence care, but the facility could not provide supporting documentation. In some cases, responses to concerns simply stated that more information was needed, without indicating any steps taken to resolve the issues. Additionally, concerns about staff behavior, pain medication administration, and food choices were either inadequately addressed or not documented at all. Interviews with residents, the Activity Director, and the Administrator confirmed that the same topics were repeatedly discussed at council meetings without effective resolution. The Administrator acknowledged the lack of detailed documentation and missing concern forms, as well as the inadequacy of responses that did not demonstrate corrective action. The ongoing nature of these unresolved concerns affected several residents who regularly attended the council meetings, as reflected in the facility's census and meeting records.
Limited Access to Resident Personal Funds
Penalty
Summary
The facility failed to ensure that residents had ongoing access to their personal care needs accounts, as required. Interviews with the Business Office Manager and the Administrator revealed that residents could only access their funds between 10:00 A.M. and 3:00 P.M., with no provision for access after these hours, including weekends, despite a sign indicating that funds could be obtained from the manager on duty or receptionist on weekends. The Administrator confirmed that supervisors on other shifts did not have access to petty cash and expressed distrust in allowing nursing staff to handle cash. Facility policy requires access to up to fifty dollars within a reasonable period and larger amounts within three banking days, but the observed practices did not ensure residents could access their funds as needed outside of the stated hours. This deficiency had the potential to affect all 24 residents who had authorized the facility to manage their personal financial accounts.
Failure to Maintain Homelike Dining Environment and Provide Clean Linens
Penalty
Summary
Surveyors observed that the facility failed to maintain a homelike and clean dining environment for residents during lunch service. Specifically, the main dining room contained a full-size refrigerator with a padlock and visible dust and dry food on it, a counter with dirty dishes, silverware, and cups left from breakfast, and a mop bucket with dirty water and a dirty mop in the corner. Additionally, a sheet pan rack held bins and trays with leftover breakfast remains. These conditions were confirmed by the Regional Dietary Services Director during the lunch period and affected eight residents who were present in the dining room at the time. In a separate incident, a resident with a history of urinary tract infection, metabolic encephalopathy, and neurocognitive disorder was observed to have a cut on her elbow and was using a pillow without a pillowcase that had several dried blood stains. The resident's bed sheet also had multiple spots of dried blood on both the top and side. This condition was confirmed by an LPN later in the day. Review of the facility's policy indicated that residents should be provided with clean bed and bath linens in good condition, which was not adhered to in this case.
Failure to Maintain Dignity During Dining Assistance
Penalty
Summary
Staff failed to maintain resident dignity during dining by standing over a resident while assisting with feeding. Observation revealed that a Certified Nursing Aide (CNA) was standing over a resident during mealtime assistance, which was confirmed by both a Licensed Practical Nurse (LPN) and another CNA, who stated that it was common practice for CNAs to stand while feeding residents. The facility's policy on meal assistance specifically states that residents should be fed with attention to dignity, including not standing over them during meals. The resident involved had a history of hypertension, osteoarthritis, major depressive disorder, and generalized anxiety disorder. Her most recent assessment indicated mildly impaired cognition and that she was independent with eating. However, her care plan noted a risk for self-care deficit, requiring supervision and one-person assistance depending on her mood, energy, and pain levels. Despite these documented needs and facility policy, staff did not provide assistance in a manner that preserved the resident's dignity.
Failure to Remove Staff After Allegation of Verbal Abuse
Penalty
Summary
The facility failed to protect a resident from verbal abuse by a staff member and did not follow its own policy regarding the immediate removal of the accused staff member from duty pending investigation. A cognitively intact resident with multiple medical conditions, including vascular dementia and an above-the-knee amputation, was involved in a verbal altercation with a certified nursing assistant (CNA). The CNA was reported to have yelled, pointed a finger, and made threatening and aggressive comments toward the resident, which was witnessed by another CNA. The incident was reported by the witness to the unit manager by phone and through a written report, but the written report could not be located during the investigation. The unit manager acknowledged receiving the verbal report but did not escalate the incident to the Director of Nursing (DON) or the Administrator, and no state report was filed until surveyor intervention. The accused CNA continued to work scheduled shifts after the incident, contrary to facility policy requiring immediate removal of staff accused of abuse. Interviews with the resident confirmed feelings of being threatened and verbally abused. The DON and Administrator were unaware of the incident until informed by surveyors, and no internal documentation or investigation was initiated prior to the survey.
Lack of Physician Rationale for Extended Psychotropic Medication Use
Penalty
Summary
A deficiency was identified when the facility failed to ensure that the physician or prescribing practitioner documented a rationale in the medical record for the use of a psychotropic medication for a period of 180 days. Specifically, a resident with mild cognitive deficits and multiple diagnoses, including traumatic brain injury and hemiplegia, had a physician order for Lorazepam (Ativan) 1 mg to be given every 12 hours as needed. The consultant pharmacist made recommendations to the physician on two occasions to either specify the duration for the PRN order or discontinue the medication, in accordance with federal guidelines. The physician responded by agreeing to continue the PRN use of Lorazepam for 180 days, stating that the benefit outweighed the risk, but did not provide a specific rationale in the resident's medical record or on the recommendation form. Further review of the resident's physician progress notes and psychiatric visit notes revealed no documentation of a rationale for the continued use of Lorazepam. Interviews with facility staff, including the DON, pharmacist, and regional clinical RN, confirmed that the physician did not document the required rationale in the medical record or on the pharmacy recommendation forms. Additionally, psychiatric notes did not reference Lorazepam as a prescribed medication for the resident. The facility's policy required the consultant pharmacist to document findings and recommendations and for the physician to provide a pertinent response, which was not met in this case.
Failure to Follow Abuse Policy and Reporting Procedures
Penalty
Summary
The facility failed to follow its abuse prevention policy in two separate incidents involving residents. In the first case, a resident with multiple medical conditions, including vascular dementia and an above-the-knee amputation, was involved in a verbal altercation with a CNA. Another CNA witnessed the staff member yelling, pointing, and making threatening comments toward the resident, which was reported as verbal abuse. The incident was reported by the witnessing CNA to the Unit Manager Nurse (UMN) by phone and via a written report, but the UMN did not escalate the report to the Director of Nursing (DON) or the Administrator. The written report could not be located, and neither the DON nor the Administrator were aware of the incident until informed by surveyors. Despite the facility's policy requiring immediate removal of accused staff pending investigation, the CNA continued to work scheduled shifts after the allegation was reported to the UMN. In the second incident, another resident, who was cognitively intact and dependent for several activities of daily living, sustained a serious injury while being transported by an outside service. The resident fell from her wheelchair during transport, resulting in multiple leg fractures that required surgery. The DON was notified by the hospital of the injury and received hospital records indicating a motor vehicle accident. However, the DON did not conduct a thorough investigation, did not obtain a police report, and did not report the incident as potential abuse or follow the facility's abuse policy regarding injuries of unknown origin. Both incidents demonstrate a failure to adhere to the facility's written policy on abuse, neglect, exploitation, and misappropriation of resident property. The policy requires immediate reporting of all allegations and injuries of unknown source to the state agency, removal of accused staff from duty, and a thorough investigation within five working days. In both cases, these procedures were not followed, resulting in deficiencies related to the facility's handling of abuse allegations and injuries of unknown origin.
Failure to Report Abuse Allegation and Injury of Unknown Origin
Penalty
Summary
The facility failed to timely report allegations of verbal abuse and an injury of unknown origin to the state agency as required by policy. In the first incident, a resident with multiple medical conditions, including vascular dementia and an above-the-knee amputation, was involved in a verbal altercation with a CNA. The CNA was reported by another staff member to have yelled at and threatened the resident, which the resident later confirmed made him feel threatened and constituted verbal abuse. Although the incident was reported to the Unit Manager Nurse (UMN) by the witnessing CNA, the UMN did not escalate the report to the Director of Nursing (DON) or the Administrator, and no Self-Reported Incident (SRI) was filed with the state agency. In the second incident, another resident with diagnoses including heart failure, renal insufficiency, and COPD, suffered a fall and subsequent leg fracture while being transported by an outside service. The resident described the transport driver slamming on the brakes, causing her to slide out of her wheelchair and sustain the injury. The facility was notified by the hospital of the incident and received hospital records indicating the injury occurred during a motor vehicle accident. Despite this, the DON did not report the injury to the state agency, relying solely on the hospital's account of the event. Both incidents were not reported to the state agency as required by the facility's policy on abuse, neglect, exploitation, and injuries of unknown source. The failure to report affected two of three residents reviewed for abuse reporting, despite clear internal and external notifications of the incidents and the facility's own policy mandating immediate reporting.
Failure to Thoroughly Investigate Alleged Abuse and Injury of Unknown Origin
Penalty
Summary
The facility failed to thoroughly investigate two separate incidents involving residents. In the first case, a resident with multiple complex diagnoses, including carcinoma in situ of the esophagus, severe protein calorie malnutrition, vascular dementia, and an above-the-knee amputation, was involved in an incident of alleged verbal abuse by a CNA. The incident was witnessed by another CNA, who reported that the accused CNA became verbally aggressive, yelled, and threatened the resident and another individual. The witness reported the event to the Unit Manager Nurse (UMN) and submitted a written report, but the UMN did not escalate the report to the Director of Nursing (DON) or the Administrator. Interviews confirmed that neither the DON nor the Administrator were aware of the incident, and the written report could not be located. The resident involved confirmed feeling threatened and described the event as verbal abuse. In the second case, another resident, who was cognitively intact and dependent for several activities of daily living, sustained a significant injury while being transported by an outside service. The resident fell from her wheelchair during transport, resulting in multiple fractures that required surgery. The facility's investigation included a timeline, resident interview, and hospital paperwork, but the DON did not attempt to obtain a police report or further details about the motor vehicle accident, relying solely on the hospital's account. The investigation was not comprehensive, as it did not include efforts to gather all relevant information about the circumstances of the injury. The facility's policy requires that all allegations of abuse and injuries of unknown origin be thoroughly investigated, including interviews with all relevant parties and, when necessary, expansion of the investigation to include additional staff or shifts. In both incidents, the facility did not follow its own protocols for reporting and investigating, resulting in incomplete investigations and a failure to ensure that all aspects of the incidents were properly addressed.
Failure to Communicate Pertinent Information During Resident Transfer
Penalty
Summary
The facility failed to ensure that appropriate and pertinent information was communicated to the receiving health care institution during the transfer of a resident. Medical record review showed that a resident with multiple complex diagnoses, including arthritis due to bacteria, chronic pain, acute kidney failure, low back pain, hypo-osmolality and hyponatremia, multiple myeloma, hypertension, pneumonia, ileus, and muscle weakness, was admitted and subsequently had laboratory orders to monitor hemoglobin levels. The resident's hemoglobin was found to be low, prompting a transfer to the hospital. Despite the transfer, the facility did not document that the resident was transported with the necessary information provided to the receiving facility. This was confirmed during an interview with the DON, who acknowledged the failure to ensure proper communication of the resident's clinical information at the time of transfer. Review of facility policy indicated that a standard tool should be used for early recognition and management of acute changes, including communication of situation, background, and assessment, but this protocol was not followed in this instance.
Failure to Provide Required Transfer/Discharge Notices and Ombudsman Notification
Penalty
Summary
The facility failed to provide required documentation and notifications related to resident transfers and discharges for three of five residents reviewed. Specifically, for one resident with multiple complex diagnoses including arthritis, chronic pain, acute kidney failure, and multiple myeloma, there was no evidence that a bed hold notice or a notice of transfer was given to the resident or their representative when the resident was transferred to the hospital due to low hemoglobin. Additionally, the ombudsman was not notified of this transfer. Interviews with the Administrator, DON, and Regional Director of Operations confirmed these omissions. Another resident with chronic respiratory failure, COPD, multiple sclerosis, and mental health diagnoses was discharged to the hospital for uncontrolled pain, but there was no evidence of ombudsman notification at the time of discharge. A third resident with COPD, pulmonary hypertension, and heart disease left the facility and did not return, and again, there was no evidence that the ombudsman was notified of the transfer. Review of facility policy confirmed that written notice of transfer or discharge, including the reason, bed hold policy, and ombudsman contact information, should be provided to the resident or representative and sent to the ombudsman, but this was not done in these cases.
Failure to Accurately Complete and Update PASARR Documentation
Penalty
Summary
The facility failed to ensure that Pre-admission Screening and Resident Review (PASARR) documents were accurately completed and updated for two residents. For one resident, the PASARR form only listed a mood disorder, despite the medical record showing additional diagnoses such as schizoaffective disorder, insomnia, diabetes, cognitive communication deficit, and encephalopathy. Staff interviews confirmed that the PASARR was not reviewed for accuracy at admission and was not updated to reflect changes in diagnosis. For another resident, the PASARR form listed mood disorder, anxiety, and conversion disorder, but did not include later diagnoses of schizophrenia and unspecified psychosis, as documented in the medical record. Staff confirmed that they were not informed of changes in the resident's diagnoses and that the PASARR was not updated accordingly. Facility policy requires that all residents be screened for serious mental disorders and that records be maintained and updated, but this was not followed in these cases.
Deficient Care Planning and Care Conference Practices
Penalty
Summary
The facility failed to ensure timely and appropriate care planning and care conference practices for two residents. For one resident with diagnoses including schizophrenia, diabetes, and cognitive communication deficit, the nutritional care plan had not been updated or revised for over two years, despite a significant weight loss of more than 20 pounds (12.22%) over six months. The care plan interventions remained unchanged, only including monitoring for weight loss and making diet recommendations as needed. Progress notes showed a lack of documentation regarding nutrition for nearly a year, and although the resident's weight loss was eventually noted and determined to result in a healthy BMI, no new interventions were added or adjusted in the care plan following this significant change in nutritional status. For another resident with heart failure, PVD, renal insufficiency, and diabetes, care conferences were not held in a timely manner and lacked appropriate interdisciplinary team (IDT) participation. The only documented care conference was conducted late and attended solely by a social worker assistant. There was no documentation of care conferences being conducted with the resident or other IDT members, and the resident reported not receiving a care conference on admission or quarterly. The social worker assistant confirmed the delay and lack of documentation, as well as the practice of not inviting IDT members if the resident did not request their presence.
Failure to Follow Physician Orders for Pressure Ulcer Prevention Device
Penalty
Summary
Staff failed to follow physician orders for the use of a specialized wedge device to assist with turning and repositioning a resident at risk for pressure ulcers. The resident, who had multiple diagnoses including morbid obesity, chronic kidney disease, and a stage II pressure ulcer on the right buttocks, was dependent on staff for bed mobility and personal care. Physician orders specified that the resident should be turned and repositioned using a wedge every two hours as tolerated. However, both the resident and an LPN confirmed that the wedge had been missing for several days, and staff substituted a pillow when the wedge was unavailable. Documentation showed that staff signed off on the treatment record as if the wedge was used, despite its absence. Interviews with facility leadership confirmed that staff are expected to follow orders as written and verify the presence of required equipment before documenting care. The facility was unable to provide a policy regarding adherence to physician orders.
Inadequate Perineal Care Provided to Resident
Penalty
Summary
A deficiency was identified when a resident, who was cognitively intact and continent of bowel and bladder, did not receive adequate perineal care during an observed episode. The resident was on a bedpan and a CNA provided peri-care by wiping down each side of the resident's inner thigh area but failed to clean either side of the resident's labia. The CNA then removed the bedpan, rolled the resident to the left side, and provided care to the resident's bottom in an upward motion. The CNA later confirmed in an interview that he did not clean the labia area, attributing the omission to nervousness and stating that this was not his usual practice. Review of the facility's perineal care policy indicated that staff are required to separate the labia and wash the area downward from front to back, using a clean washcloth and water for each area, and to thoroughly rinse and dry the perineum. The observed care did not follow these procedures, as the labia area was not cleaned. This failure to provide care as outlined in the policy resulted in the resident not receiving adequate peri-care as required.
Incomplete Medical Record Documentation Provided to Surveyor
Penalty
Summary
The facility failed to provide complete and accurate medical record documentation as requested by surveyors for a resident with multiple medical diagnoses, including heart failure, renal insufficiency, diabetes, depression, and chronic obstructive pulmonary disease. The resident was cognitively intact and required varying levels of assistance for daily activities, with frequent incontinence noted. During the survey, the surveyor requested a copy of an appointment record from the receptionist, who was also responsible for scheduling appointments. Instead of providing the original requested document, the receptionist delayed the process and was later found creating a new appointment form to give to the surveyor, rather than copying the existing record. Both the receptionist and a clinical regional registered nurse confirmed that the document was being altered to reflect only the date of the appointment, despite the surveyor's request for the entire original document. This action resulted in the facility not providing the complete information as required.
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.
Trusted data from CMS and state health departments
Every citation, penalty and Plan of Correction is sourced from public CMS records (latest release May 27, 2026) and official state health department websites — never guesswork.
Trusted by long-term care providers and associations.
