Riverside Landing Nursing And Rehabilitation
Inspection history, citations, penalties and survey trends for this long-term care facility in Mcconnelsville, Ohio.
- Location
- 856 South Riverside Drive, Mcconnelsville, Ohio 43756
- CMS Provider Number
- 366130
- Inspections on file
- 30
- Latest survey
- June 10, 2025
- Citations (last 12 mo.)
- 0
Citation history
Health deficiencies cited at Riverside Landing Nursing And Rehabilitation during CMS and state inspections, most recent first.
Staff did not provide meals in the required mechanical soft form for several residents, serving unchopped vegetables instead of the prescribed chopped version. This failure was confirmed by dietary management and affected all residents identified as needing a mechanical soft diet.
A resident with a history of aggressive behavior struck another resident in the face during a dining room altercation, resulting in a facial scratch. The incident was witnessed by a dietary employee, and both residents were able to provide statements. The resident who was struck had multiple medical conditions and was unable to move due to a dead wheelchair battery. Despite a care plan for the aggressive resident, the facility failed to prevent the physical abuse, and the initial investigation did not substantiate the incident as abuse.
The facility did not ensure that prn orders for psychotropic medications, including anti-psychotics and anti-anxiety drugs, were limited to 14 days and only extended with proper face-to-face evaluations and clinical rationales. Two residents received prn medications for extended periods without required end dates or documentation of non-pharmacological interventions prior to administration, contrary to facility policy and federal regulations.
Multiple residents had inaccurate MDS assessments, including incorrect coding of non-insulin diabetes medications as insulin, failure to document broken dentures despite resident reports and observation, and reporting of restorative nursing services that were not ordered or documented. The DON confirmed these inaccuracies were due to errors by staff responsible for completing the MDS.
A resident with multiple mental health diagnoses, including bipolar disorder, was not accurately represented on a PASRR Identification Screen when the assessor failed to indicate a mood disorder. The error was later discovered during a self-audit, revealing that the PASRR did not reflect all current diagnoses as required by facility policy.
A resident with an indwelling urinary catheter and multiple medical conditions did not have a care plan in place for catheter care, despite physician orders detailing specific catheter management requirements. The DON confirmed the absence of a catheter care plan during interview.
Care plans for three residents were not updated to reflect current care needs and physician orders. One resident's care plan included discontinued diuretic therapy, another's listed a visual cue intervention that was no longer appropriate, and a third resident's care plan omitted a physician-ordered arm sling. These deficiencies were confirmed through record review, staff interviews, and observation.
A resident with a deep tissue pressure injury to the left heel did not receive required weekly wound assessments and documentation on two occasions, despite having a care plan and facility policy mandating weekly evaluation. The responsible LPN was absent during the missed assessments, and no other staff documented the wound assessment in her absence, as confirmed by the interim DON.
A resident with multiple medical conditions was referred to the restorative nursing program for passive and active ROM and bed mobility, but there was no documentation or physician orders indicating that these restorative services were provided. The DON confirmed that the restorative nursing interventions were not being delivered as recommended.
A resident with hypothyroidism received Levothyroxine, Ferrous Sulfate, and Magnesium Oxide at administration times that did not follow pharmacy recommendations or physician orders, resulting in frequent administration of these medications within four hours of each other. Despite clear guidance and agreement from the prescriber, staff continued to administer the medications at incorrect intervals, and the facility's policy did not require implementation of agreed-upon pharmacy recommendations.
A resident with multiple chronic conditions and an indwelling catheter was prescribed ciprofloxacin for a UTI, despite urine culture results not meeting the facility's criteria for infection. The DON confirmed that the antibiotic was administered even though the established protocol for UTI diagnosis was not followed.
The facility failed to ensure an RN was on duty for eight consecutive hours daily and did not have a full-time DON from February to April. Despite QAPI interventions, no audits were completed, and no RN staff were hired. The Corporate Nurse listed as the DON was not present full-time, and the MDS nurse was not designated as the full-time DON.
The facility failed to implement enhanced barrier precautions and properly map infections, affecting multiple residents with indwelling devices and wounds. The Infection Preventionist admitted to not being up to date with new regulations, and improper catheter care was observed, violating hygiene protocols.
The facility failed to protect residents from abuse, affecting five residents. Incidents included inappropriate touching and physical abuse by a male resident, with insufficient interventions to prevent recurrence. The facility's response was inadequate, leading to continued resident discomfort and safety concerns.
The facility failed to ensure proper administration of prn medications for several residents, including administering Oxycodone HCL outside of specified pain levels, lacking parameters for prn Norco and Acetaminophen, not monitoring blood pressure as required for Metoprolol Succinate ER, and not documenting the reason for Vistaril administration.
The facility failed to provide bread products to residents on mechanical soft or regular diets as per the cycle menu, due to damaged rolls and an oversight in substituting with bread and butter. This affected all but six residents on a pureed diet.
The facility failed to prepare pureed food according to recipes, affecting six residents on a pureed diet. Dietary Cook #350 added unmeasured amounts of water instead of broth or beef base, resulting in bland and nutritionally compromised meals. Dietary Manager #370 confirmed the recipes were not followed.
The facility failed to ensure pureed food was prepared correctly for residents on pureed diets. Dietary Cook did not follow recipes or taste the food to verify proper consistency, resulting in improperly textured food being served. This affected six residents.
The facility failed to ensure lunch meals were served in a sanitary manner, potentially affecting all 46 residents. An STNA placed a condiment container on the floor to access coffee and then returned it to the meal cart with the meal trays, citing unclear instructions.
The facility failed to ensure appropriate antibiotic use for three residents by not fully completing the McGeer Criteria for Infection Surveillance Checklist, as confirmed by an LPN.
A resident with multiple health conditions was repeatedly observed with an uncovered urinary catheter bag visible from the hallway, contrary to the facility's policy requiring the use of a privacy bag. The resident expressed embarrassment, and staff confirmed the lack of a dignity cover.
The facility failed to ensure a clean, comfortable, and homelike environment for its residents, affecting three individuals. One resident reported dirty and scuffed floors, another had a crack in the floor filled with a dark substance, and a third had a recliner in disrepair. The issues were confirmed by the Maintenance Director and attributed to short staffing.
A facility failed to ensure a resident was free from restraints. The resident, with significant medical conditions, was observed with a seatbelt in his wheelchair without proper orders or assessments. Staff did not consider the seatbelt a restraint, and the facility did not follow its policy on restraint use.
The facility failed to report allegations of abuse and an injury of unknown origin to the state agency in a timely manner for three residents. Incidents involving physical altercations and a fracture were either reported late or not reported at all, violating the facility's abuse policy and state reporting requirements.
The facility failed to ensure accurate MDS assessments for three residents, leading to discrepancies in their medical records. One resident's hyperlipidemia and medication were not properly documented, another resident's vision impairment was not accurately assessed, and a third resident's dental issues were not recorded. These errors were confirmed through staff interviews and record reviews.
The facility failed to ensure accurate PASRRs for two residents. One resident's PASRR did not list diagnoses of psychosis or anorexia nervosa, and another resident's PASRR did not include a diagnosis of psychosis. These omissions were confirmed by the SSD during interviews.
The facility failed to provide adequate nail care for a resident dependent on staff for hygiene assistance. Despite the care plan and MDS assessment indicating the need for extensive assistance, the resident's fingernails were observed to be long on multiple occasions. Interviews confirmed that nails should be checked daily and trimmed weekly, but this was not done, indicating a lapse in adherence to facility policies.
The facility failed to provide timely care for a resident with worsening respiratory symptoms, did not arrange follow-up appointments for another resident post-hospitalization, and delayed sending a resident in severe pain to the hospital. Additionally, the facility did not follow its bowel protocol for a resident who went eight days without a bowel movement.
The facility failed to implement ROM services and provide necessary therapy for two residents, leading to a decline in their conditions. One resident returned from the hospital with significant weakness and immobility but did not receive timely therapy services. Another resident with multiple diagnoses was not receiving the restorative therapy outlined in his care plan, and staff were not adequately trained to perform the required exercises.
A resident with a history of falls did not have fall prevention interventions consistently implemented according to the physician's orders and care plan. Despite being cognitively intact, the resident experienced multiple falls, and observations revealed that the resident was not wearing the required gripper socks or shoes while out of bed. An LPN confirmed the non-compliance, indicating a failure to adhere to the facility's fall management policy.
The facility failed to administer tube feeding as ordered and did not implement new orders timely for a resident with aphasia, dysphagia, and gastrostomy. The resident's preference for house supplements was not honored until days after the order was given, and there were multiple instances where the resident did not receive Jevity despite eating less than 50% of meals.
A resident with chronic pain and multiple diagnoses was not referred to a pain management clinic in a timely manner. Despite a physician's order and the resident's expressed desire for pain management, the necessary CT scan was not completed, delaying the appointment.
The facility failed to ensure insulin flexpens were properly dated after being removed from the refrigerator and used for the first time. This affected three residents, whose insulin flexpens were found without proper dating during a review of two medication administration carts. An LPN confirmed the deficiency and removed the undated flexpens for disposal.
The facility failed to complete ordered laboratory tests for a resident with multiple diagnoses, leading to the resident's hospitalization for sepsis related to pneumonia. The resident had informed staff about her worsening condition, but the lab orders were not obtained as per the facility's policy.
A resident with multiple dental issues did not receive timely dental care due to communication and follow-up failures. Despite a dental plan and a referral to an oral surgeon, the resident's appointment was canceled and not rescheduled, leaving the resident with ongoing dental problems and difficulty eating.
A resident with multiple diagnoses was denied an alternate meal of two cheeseburgers because her request was not submitted before the kitchen's cut-off time. Despite having the requested food items available, the kitchen staff adhered strictly to the rule, leaving the resident without a meal and feeling hungry. The facility's administrator later clarified that residents could request alternate meals at any time.
The facility failed to administer the pneumococcal vaccine to a resident who had consented to receiving it. The resident, admitted with acute respiratory failure, metabolic encephalopathy, type II diabetes, and hypertension, had a consent form signed on 11/08/23. However, the medical record showed no evidence of the vaccination being administered, confirmed by an LPN on 04/24/24. The facility's policy to offer vaccines upon admission was not followed.
The facility failed to offer COVID-19 vaccinations to three residents, despite having a policy in place that mandates offering the vaccine unless medically contraindicated, refused, or already administered. An LPN confirmed that the residents were not offered the vaccine, indicating a failure to adhere to the facility's immunization policy.
The facility failed to ensure the activities director was qualified, potentially affecting all 46 residents. The personnel file review revealed that the AD, hired on 06/13/23, did not meet the required qualifications. The Administrator confirmed the hiring and acknowledged the mistake, stating that the regulatory requirements were misread.
Failure to Serve Mechanical Soft Diets as Prescribed
Penalty
Summary
The facility failed to provide meals in the appropriate form for residents requiring a mechanical soft diet. Review of the facility's summer cycle menu and accompanying spreadsheet indicated that residents on a mechanical soft diet were to receive chopped Italian blend mixed vegetables. However, during an observation of the lunch meal service, it was noted that the Italian blend mixed vegetables were not chopped as required for these residents. Instead, the vegetables were served directly from the steam table without modification. This deficiency was confirmed when the dietary manager verified the menu requirements and consulted with the facility's dietitian, who also confirmed that the vegetables should have been chopped for residents on a mechanical soft diet. Seven residents identified as requiring a mechanical soft diet were potentially affected by this failure to follow prescribed dietary modifications.
Failure to Protect Resident from Physical Abuse by Another Resident
Penalty
Summary
A deficiency occurred when a resident was not protected from physical abuse by another resident with a known history of aggressive behaviors. The incident took place in the dining room, where one resident, whose electric wheelchair battery had died, was unable to move, blocking the path of another resident. The second resident became irritated and, after a verbal altercation, struck the first resident in the face, knocking off his glasses and causing a scratch near his nose. A dietary employee witnessed the altercation and reported that only the second resident struck the first, with no evidence that the first resident attempted to hit back. The facility's investigation included statements from both residents and staff. The resident who was struck had significant medical conditions, including hemiplegia, aphasia, Alzheimer's disease, dementia, bipolar disorder, and a history of brain injury, and was dependent on a wheelchair. Despite these vulnerabilities, the resident was left in a situation where he was exposed to potential harm from another resident known to have behavioral issues. The second resident, who struck the first, had diagnoses including paraplegia, psychosis, anxiety disorder, depression, and a documented history of physical aggression and prior altercations with other residents. The facility's abuse policy prohibited physical abuse and required individualized care plans for residents identified as potentially abusive. However, the care plan for the aggressive resident only included general interventions such as reminders about unacceptable behavior and ensuring basic needs were met. The incident was initially unsubstantiated by the facility's prior administrator, who concluded there was no willful intent to harm, despite witness statements and the facility's own policy defining physical abuse as the willful infliction of injury through deliberate acts such as hitting.
Failure to Limit PRN Psychotropic Medication Orders and Document Non-Pharmacological Interventions
Penalty
Summary
The facility failed to comply with federal regulations regarding the use of psychotropic medications, specifically by allowing as-needed (prn) orders for anti-psychotic and anti-anxiety medications to extend beyond the required 14-day limit without appropriate face-to-face evaluations and clinical rationales. In one case, a resident with schizo-affective disorder, bipolar disorder, anxiety, depression, and insomnia had a prn order for Zyprexa (an anti-psychotic) to be administered intramuscularly for agitation, with the order set for 180 days. Despite pharmacy recommendations referencing the 14-day regulatory limit and the need for prescriber evaluation, the psychiatrist continued to order the medication for extended periods. The medication was administered 12 times over five months, and in 10 of those instances, there was no documentation that non-pharmacological interventions (NPIs) were attempted prior to administration. Another resident, admitted with diagnoses including a sacrum fracture, stomach cancer, neuropathy, anemia, hypertension, and anxiety, and who was on hospice care, had prn orders for Xanax and lorazepam for anxiety. These orders did not include end dates, failing to specify the duration of use as required by regulation. The DON confirmed that these prn orders lacked the necessary time limitations. The facility's policy stated that prn orders for anti-psychotic medications should be limited to 14 days and not renewed without an in-person evaluation by the prescriber. However, the facility did not adhere to this policy in the cases reviewed, resulting in extended prn orders and a lack of documented attempts at NPIs prior to administering anti-psychotic medications.
Inaccurate MDS Assessments for Medications, Dental Status, and Restorative Care
Penalty
Summary
The facility failed to ensure the accuracy of Minimum Data Set (MDS) assessments for multiple residents, resulting in inaccurate documentation of clinical care and services provided. For one resident with adult onset diabetes mellitus, the quarterly MDS assessment was coded to indicate receipt of an insulin injection during the assessment period, but the medication administration record (MAR) showed no evidence of insulin being administered. Instead, the resident received Trulicity, a GLP-1 receptor agonist, which is not classified as insulin. Similarly, another resident was coded as having received an insulin injection, but the MAR indicated only an order for Wegovy, also a GLP-1 receptor agonist, and no actual injections were administered during the assessment period. The DON confirmed that both medications were incorrectly coded as insulin on the MDS due to a misunderstanding by the MDS nurses. Another resident's admission MDS assessment inaccurately documented oral/dental status. Despite the resident and her daughter reporting concerns about a broken lower denture during a care conference, and the resident being observed as edentulous on the bottom with a broken lower denture, the MDS was marked as indicating no broken or loosely fitting dentures. The DON verified that this section of the MDS was marked inaccurately. Additionally, a fourth resident's annual MDS assessment indicated participation in restorative nursing programs for passive and active range of motion and bed mobility, with documentation of minutes provided. However, a review of the resident's medical record and physician's orders revealed no evidence of restorative nursing program orders or documentation of services provided in the past year. The DON confirmed the absence of such documentation and acknowledged the MDS was marked inaccurately for these services.
Failure to Accurately Complete PASRR Identification Screen for Mental Illness Diagnoses
Penalty
Summary
The facility failed to ensure that a Preadmission Screening and Resident Review (PASRR) Identification Screen was completed accurately to reflect all of a resident's mental illness diagnoses. Specifically, a resident admitted with diagnoses including paranoid schizophrenia, bipolar disorder, anxiety disorder, and other specified depressive disorder had a PASRR Identification Screen completed for a significant change in condition. During this assessment, the assessor did not check the box for a mood disorder, despite the resident having a diagnosis of bipolar disorder, which qualifies as a mood disorder. This omission resulted in the PASRR not accurately reflecting the resident's mental health status at the time of the review. A subsequent self-audit by the Social Service Designee (SSD) identified the inaccuracy in the previous PASRR screen, leading to the completion of a new PASRR Identification Screen that correctly included the mood disorder diagnosis. The SSD acknowledged that audits of PASRRs were conducted every three to four months, but the inaccurate PASRR had not been identified or corrected in a timely manner. The facility's policy required accurate completion of PASRRs upon significant changes in condition, but this was not followed in this instance, resulting in the deficiency.
Failure to Develop Comprehensive Catheter Care Plan
Penalty
Summary
The facility failed to develop a comprehensive care plan for catheter care for a resident with multiple complex medical diagnoses, including malignant neoplasm of the endometrium, diabetes, chronic obstructive pulmonary disease, neurogenic bladder, and urinary retention. The resident was admitted with an indwelling urinary catheter, and physician orders specified monitoring urine characteristics every shift, catheter irrigation as needed, catheter care every shift, and scheduled catheter and bag changes. Despite these orders and the resident's use of a catheter, review of the care plan revealed that no care plan addressing catheter care was in place. The Director of Nursing confirmed during interview that a catheter care plan had not been developed for this resident.
Failure to Revise and Update Resident Care Plans
Penalty
Summary
The facility failed to ensure that comprehensive care plans were revised to accurately reflect the current care and treatment needs of residents. For one resident with a history of acute renal failure, the care plan continued to include interventions for diuretic therapy nearly a year after the medication had been discontinued, as confirmed by the DON. This discrepancy was identified through a review of the resident's medical record, care plan, and physician orders, which showed no active diuretic order since the previous year. Additionally, another resident's care plan included an intervention for a visual cue (sign) to remind the resident to use the call light for assistance, despite staff and social services confirming that the resident found the sign demeaning and it was supposed to have been removed from the care plan. In a third case, a resident with a physician's order for a left arm sling for pain and swelling did not have this intervention reflected in the care plan. These findings were based on record reviews, staff interviews, and direct observation, demonstrating a failure to keep care plans updated and consistent with current physician orders and resident needs.
Failure to Complete Weekly Pressure Ulcer Assessments
Penalty
Summary
The facility failed to ensure that a resident's deep tissue pressure injury (DTPI) to the left heel was assessed and documented weekly as required by facility policy and regulatory guidelines. The resident, who was admitted with multiple diagnoses including a pelvic fracture, diabetes with neuropathy and a foot ulcer, malnutrition, anemia, and peripheral vascular disease, had a care plan in place for impaired skin integrity related to the DTPI. The care plan required weekly skin assessments and documentation. However, review of the medical record showed that weekly wound assessments were not completed or documented on two specific dates, and there was no evidence that the resident was unavailable or refused assessment on those days. Interviews with staff revealed that the LPN responsible for weekly wound assessments was absent during the missed assessments, and no other staff documented that the wound was assessed in her absence. The interim DON confirmed the lack of documentation and was unable to provide any additional evidence that the required assessments were performed. Facility policy required that skin areas be measured and documented every seven days until resolved, but this was not followed for the resident's DTPI during the identified period.
Failure to Provide and Document Restorative Nursing Program for Resident
Penalty
Summary
A resident with diagnoses including acute respiratory failure, paraplegia, unspecified psychosis, asthma, and chronic hepatitis was evaluated by occupational therapy, which determined that occupational therapy was not required and referred the resident to the restorative nursing program. The resident's quarterly restorative assessment indicated that a restorative nursing program was recommended and should be continued, specifically for passive range of motion (ROM), active ROM, and bed mobility. The annual MDS assessment documented that restorative nursing programs were performed for at least 15 minutes a day for five days in the past week for these interventions. However, a review of the resident's medical record did not reveal any documentation of restorative nursing program minutes being provided for passive ROM, active ROM, or bed mobility. Additionally, there were no physician orders for a restorative program in the past year. The DON confirmed that there was no documentation of restorative nursing program minutes and that the restorative nursing programs for passive ROM, active ROM, and bed mobility were not being provided.
Failure to Implement Pharmacy Recommendations for Medication Administration Times
Penalty
Summary
The facility failed to ensure that pharmacy recommendations regarding medication administration times were implemented as agreed upon by the physician for a resident with hypothyroidism. The resident was prescribed Levothyroxine Sodium, Ferrous Sulfate, and Magnesium Oxide, and the contracted pharmacist made two separate recommendations to adjust the administration times to prevent potential binding and ensure proper absorption of Levothyroxine. Both the nurse practitioner and physician agreed to these recommendations, which specified that Levothyroxine should be administered first thing in the morning, at least 30 minutes before other medications, and separated by at least four hours from iron and magnesium-containing products. Despite these recommendations and physician agreements, review of the resident's electronic medication administration records (eMAR) for several months showed that Levothyroxine, Ferrous Sulfate, and Magnesium Oxide were frequently administered within four hours of each other, and sometimes at the same time. Out of 30 documented administrations, only two instances met the recommended separation interval, while the majority did not. There was also an instance where Levothyroxine was administered in the evening rather than in the morning as recommended. The facility's Regional Director of Quality Assurance confirmed these findings and was unable to explain why the administration times were not adjusted according to the recommendations and physician orders. The facility's policy required monthly medication regimen reviews by a consultant pharmacist and communication of findings to the prescriber and director of nursing. However, the policy did not address the need for facility staff to implement recommendations that had been agreed to by the physician. This gap contributed to the ongoing failure to adjust medication administration times as recommended and ordered, resulting in the identified deficiency.
Failure to Follow Protocols for Antibiotic Use in UTI Treatment
Penalty
Summary
The facility failed to follow its established protocols for antibiotic use in the treatment of a urinary tract infection (UTI) for one resident. The resident, who had multiple diagnoses including malignant neoplasm of the endometrium, diabetes, chronic obstructive pulmonary disease, and neurogenic bladder, was admitted with an indwelling catheter. Progress notes indicated that a urine specimen was ordered and collected after the resident was observed to have cloudy urine with an abnormal smell. The urine culture revealed the presence of two organisms, Klebsiella pneumoniae and Proteus mirabilis, each at 70-99,000 CFU/ml. Despite the facility's UTI surveillance criteria requiring a culture result of greater than 100,000 CFU/ml for diagnosis, the resident was prescribed ciprofloxacin for a UTI. The Director of Nursing confirmed that the resident was treated for a UTI even though the culture results did not meet the facility's criteria for such a diagnosis. This action was based on the culture findings and symptoms, but did not align with the facility's established protocol for antibiotic use.
Failure to Ensure RN and Full-Time DON Coverage
Penalty
Summary
The facility failed to ensure there was a Registered Nurse (RN) on duty for eight consecutive hours daily and a full-time Director of Nursing (DON). This deficiency was identified through a review of staffing daily postings, schedules, timecards, facility assessments, and QAPI documentation. Specifically, there was no RN coverage on multiple days in January, and the facility's QAPI interventions to address the issue were not effectively implemented, as no audits were completed, and no RN staff were hired to meet the facility's needs. The Administrator confirmed the lack of RN coverage and the challenges in hiring RNs despite advertising and offering bonuses. Additionally, the facility did not have a full-time DON from February 21, 2024, to April 8, 2024. The Corporate Nurse listed as the DON during this period was not present full-time, visiting the facility only a few days a week without documented evidence of her presence. The MDS nurse, who worked part-time at the facility, was not designated as the full-time DON. This lack of consistent DON coverage was confirmed through interviews with the ADON, MDS nurse, Corporate Nurse, and the Administrator.
Failure to Implement Enhanced Barrier Precautions and Proper Infection Mapping
Penalty
Summary
The facility failed to ensure enhanced barrier precautions were in place and properly map infections, potentially affecting all 46 residents. Resident #3, admitted with multiple diagnoses including chronic obstructive pulmonary disease and chronic kidney disease, had an uncovered catheter bag visible from the hallway without enhanced barrier precautions. The Infection Preventionist, LPN #361, admitted that the facility had not initiated enhanced barrier precautions due to the absence of a Director of Nursing to inform her of new regulations. LPN #361 also acknowledged not being up to date with the policy and stated that staff education on enhanced barrier precautions was scheduled for a later date. Resident #27, who had an indwelling catheter and was dependent on staff for toileting hygiene, was also not placed under enhanced barrier precautions. The Infection Preventionist confirmed that enhanced barrier precautions had not been initiated for any resident requiring them. Additionally, the infection control log for May 2023 was incomplete and inaccurately mapped, making it difficult to read and track infections properly. LPN #361 confirmed the inaccuracies in the infection control mapping. Resident #44, with a gastrostomy tube, and Resident #8, with a colostomy and wound, were also not placed under enhanced barrier precautions. Observations and interviews confirmed that these residents should have been under enhanced barrier precautions but were not. Furthermore, improper catheter care was observed for Resident #3, where the State-tested Nurse Assistant (STNA) used the same water basin for multiple washcloths, violating proper hygiene protocols. The STNA admitted to not performing catheter care for some time and confirmed the improper handling of washcloths and personal protective equipment (PPE).
Failure to Protect Residents from Abuse
Penalty
Summary
The facility failed to ensure residents were free from abuse, affecting five residents. Resident #2 was slapped by another resident and later had her breast grabbed by a male resident. Despite the incident being reported, the male resident continued to reside in the facility, making Resident #2 feel uncomfortable and unsafe. The facility did not implement effective measures to prevent the recurrence of such incidents. Resident #6, who had severely impaired cognition, was touched inappropriately by a male resident. The facility's investigation deemed the incident unsubstantiated due to the resident's cognitive impairment. However, the male resident admitted to the inappropriate behavior, and no effective interventions were put in place to prevent further incidents. The facility failed to conduct 15-minute checks consistently, and the male resident's inappropriate behaviors continued. Resident #17, with severely impaired cognitive function, was kissed and held hands with a male resident. The facility's response included 15-minute checks, but these were not consistently maintained. The male resident's inappropriate behaviors had been ongoing since February, and the facility's interventions were insufficient. Other residents, including Resident #20 and Resident #21, also experienced inappropriate touching by the same male resident, indicating a pattern of abuse that the facility failed to address adequately.
Failure to Ensure Proper Administration of PRN Medications
Penalty
Summary
The facility failed to ensure proper administration of as-needed (prn) medications for several residents. Resident #14 was given Oxycodone HCL for pain levels below the physician-specified range of 6-10, including instances where the pain level was 0. The resident's prn Acetaminophen, which was ordered for pain levels between 1-5, was not used at all during the month. This was confirmed by an LPN who stated that nurses administered the Oxycodone HCL even when the resident's pain levels were below 6, as requested by the resident. Resident #42 had orders for prn Norco and Acetaminophen without clear parameters for their use. The resident's pain levels were not recorded when these medications were administered, and the prn Norco was used more frequently than the prn Acetaminophen, despite the latter being effective in managing pain. Additionally, the resident's blood pressure was not consistently monitored in accordance with the parameters set for Metoprolol Succinate ER, and there was no evidence that the physician was notified when the resident's systolic blood pressure was outside the specified range. Resident #3 had orders for prn Norco and Tylenol without parameters to determine which medication to administer based on pain levels. The Norco was administered for pain levels as low as 0, which was inappropriate. Resident #41 had an order for Vistaril to be used for both allergies and anxiety, but the reason for administration was not consistently documented. The resident received Vistaril 27 times in one month, with only two instances where the indication for use was recorded. These deficiencies were confirmed through staff interviews and record reviews.
Failure to Provide Bread Product as per Cycle Menu
Penalty
Summary
The facility failed to ensure residents received all food items for each meal in accordance with the cycle menu. During an observation of the tray line, it was noted that residents on a pureed diet received pureed bread, but those on mechanical soft or regular diets did not receive any bread product. The cycle menu for the lunch meal specified a choice of roll, which was not provided to these residents. This discrepancy was verified by the Dietary Manager, who acknowledged that the rolls delivered to the facility were damaged and should have been substituted with bread and butter, but this substitution was overlooked during meal preparation. The deficiency was observed on 04/24/24, affecting all but six residents who were on a pureed diet. The Dietary Manager confirmed that without surveyor intervention, the residents would not have received the meal as per the cycle menu. The facility census at the time was 46 residents. The oversight occurred despite the facility's protocol to ensure menus meet the nutritional needs of residents and are followed as planned.
Failure to Follow Pureed Food Recipes
Penalty
Summary
The facility failed to prepare pureed food in a manner that conserved the nutritional value of the food being pureed, affecting six residents on a pureed diet. During an observation, Dietary Cook #350 was noted to puree parsley noodles, sweet and sour meatballs, and carrots without referring to the recipes. The cook added unmeasured amounts of water to the noodles and meatballs to achieve the desired consistency, instead of using broth or beef base as specified in the recipes. This resulted in the pureed food being bland and lacking flavor, as confirmed by Dietary Manager #370, who acknowledged that the recipes were not followed and the nutritive value of the food was not maintained. The dietary manager confirmed that recipes were available in a binder but were not consulted during the preparation of the pureed food. The recipes indicated that hot broth or beef base should have been added to the noodles and meatballs to maintain their nutritional value and flavor. The failure to follow these recipes affected six residents identified as being on a pureed diet, compromising the quality and palatability of their meals.
Improper Preparation of Pureed Food
Penalty
Summary
The facility failed to ensure pureed food was prepared in a form that met the needs of residents on pureed diets. During an observation of the lunch meal preparation, Dietary Cook #350 pureed three different food items without following any recipes or tasting the food to verify proper consistency. The pureed sweet and sour meatballs were found to be gritty and contained noticeable flecks of seasoning, which was confirmed by both the surveyor and Dietary Manager #370 as not being at the desired texture for a pureed diet. The dietary cook did not taste any of the pureed items before serving them to the residents. An interview with Dietary Manager #370 confirmed that Dietary Cook #350 did not follow recipes or taste the pureed food to ensure it was suitable for residents on pureed diets. The facility identified six residents who were on pureed diets, and the improper preparation of pureed food affected these residents. The dietary manager acknowledged the deficiency in the preparation process, which did not meet the required standards for pureed diets.
Unsanitary Meal Service
Penalty
Summary
The facility failed to ensure lunch meals were served in a sanitary manner, potentially affecting all 46 residents. During an observation of lunch meal service, a State tested Nurse's Assistant (STNA) removed a container filled with condiments from the meal cart and placed it directly on the floor to access the coffee. The STNA then placed the condiment container back into the meal cart with the meal trays. In an interview, the STNA confirmed she had placed the condiment container on the floor and then back into the meal cart, stating she was unsure of what to do because she was instructed not to place anything on top of the meal cart and the kitchen staff always placed the coffee behind the condiment container.
Failure to Ensure Appropriate Antibiotic Use
Penalty
Summary
The facility failed to ensure residents met infection criteria for appropriate antibiotic use, affecting three residents. Resident #7, admitted with diagnoses including atrial fibrillation, dementia, and atherosclerotic heart disease, was treated for a UTI. The infection control log and McGeer Criteria for Infection Surveillance Checklist revealed that while Resident #7 met the criteria for section two, section one was left blank. This was confirmed by an LPN during an interview, indicating incomplete documentation for appropriate antibiotic use. Similarly, Resident #17, with diagnoses including senile degeneration of the brain and dementia, and Resident #24, with diagnoses including type II diabetes, asthma, and hypertension, were also treated for UTIs. Both residents met the criteria for section two of the McGeer Criteria, but section one was left blank. Interviews with an LPN confirmed that the McGeer criteria were not fully completed for these residents, leading to inappropriate antibiotic use.
Failure to Maintain Dignity in Catheter Care
Penalty
Summary
The facility failed to provide care in a dignified manner for a resident with a urinary catheter. The resident, who had multiple diagnoses including chronic obstructive pulmonary disease, hypertensive heart and chronic kidney disease with heart failure, type II diabetes, and neuromuscular dysfunction of the bladder, was observed multiple times with his catheter bag uncovered and visible from the hallway. This was against the facility's policy, which required the catheter bag to be placed inside a privacy bag. The resident expressed concern and embarrassment about the uncovered catheter bag, indicating that staff only used the privacy bag when he was in his wheelchair. On several occasions, the resident was observed in bed with his catheter bag hanging from a lower bar of the bed, uncovered and visible from the hallway. These observations were confirmed by a State tested Nursing Assistant (STNA), who acknowledged that the catheter bag did not have a dignity cover at the time. The facility's undated policy on Foley Catheter Care clearly stated that the catheter drainage bag should be placed inside a privacy bag, which was not adhered to in this case.
Failure to Maintain a Clean and Homelike Environment
Penalty
Summary
The facility failed to ensure a clean, comfortable, and homelike environment for its residents, affecting three residents. Resident #3, who has chronic obstructive pulmonary disease, hypertensive heart and chronic kidney disease with heart failure, type II diabetes, and neuromuscular dysfunction of the bladder, reported that his room's floors had not been stripped or waxed since his admission. Observations confirmed the floors were dirty, scuffed, and had debris. The Maintenance Director and Housekeeping Director acknowledged the issue, attributing it to short staffing. The facility's housekeeping policy mandates maintaining a homelike environment, which was not met in this case. Resident #23, with chronic obstructive pulmonary disease, acute respiratory failure with hypoxia, hemiplegia, and depression, had a crack in the floor under his bed filled with a dark substance. The Maintenance Director confirmed the issue during a tour. Similarly, Resident #17, diagnosed with senile degeneration of the brain, dementia with behaviors, type II diabetes, and osteoarthritis, had a recliner in disrepair, with peeling fabric scattered across the chair. The Maintenance Director confirmed the recliner's poor condition. The facility's housekeeping policy, which requires maintaining a clean and homelike environment, was not adhered to in these instances.
Failure to Ensure Resident is Free from Restraints
Penalty
Summary
The facility failed to ensure that a resident was free from the use of physical restraints. Resident #1, who was admitted with diagnoses including intracranial injury with loss of consciousness, hemiplegia affecting the right dominant side, and type II diabetes, was observed on two separate occasions with a seatbelt on while in his motorized wheelchair. Despite the presence of the seatbelt, there were no orders or assessments for its use, and the facility staff did not consider it a restraint since the resident could release it himself. Interviews with two Licensed Practical Nurses (LPNs) revealed that the facility did not have any residents with restraints and that there were no assessments or orders for the seatbelt used by Resident #1. The facility's policy on Restraint Management and Reduction requires a restraint assessment, physician's order, consent, and care plan update when a restraint is used, none of which were completed for Resident #1. This oversight indicates a failure to adhere to the facility's own policy and regulatory requirements regarding restraint use.
Failure to Timely Report Abuse and Injuries
Penalty
Summary
The facility failed to report allegations of abuse to the state agency in a timely manner for three residents. Resident #8 was involved in a physical altercation with another male resident, which was discovered on 02/25/24 but not reported to the state agency until 02/26/24, despite the incident occurring on 02/24/24. The facility's policy requires such incidents to be reported within two hours. Additionally, Resident #2 was slapped by another resident on 12/14/23, but the incident was not reported because there was no visible harm. The Administrator confirmed the incident but did not report it due to the lack of physical injury. Lastly, Resident #17 sustained a fracture of the left hand, an injury of unknown origin, which was not reported to the state agency. The Administrator speculated that the injury occurred due to the resident's tight grip on her wheelchair wheels, but no observation or explanation was available to confirm this. The facility's failure to report these incidents in a timely manner is a clear violation of their abuse policy, which mandates reporting all allegations of abuse or serious bodily injury to the state agency within two hours of discovery. The Administrator confirmed the late reporting and acknowledged that staff were educated on the abuse policy, but there was no evidence that the Administrator was educated on timely reporting to the state agency. The facility's policy also requires reporting injuries of unknown origin when the source is not observed, cannot be explained by the resident, and is suspicious due to the extent or location of the injury. The Administrator's failure to report these incidents highlights a significant lapse in adhering to the facility's abuse policy and state reporting requirements.
Inaccurate MDS Assessments for Residents
Penalty
Summary
The facility failed to ensure that Minimum Data Set (MDS) assessments were completed accurately for three residents, leading to discrepancies in their medical records. Resident #31's quarterly MDS assessment did not accurately reflect the diagnosis of hyperlipidemia, despite the resident receiving Atorvastatin for this condition. Additionally, the MDS inaccurately indicated that the resident had received an anticoagulant, which was not the case. These errors were confirmed by the facility's MDS Coordinator, RN #310, during an interview. Resident #23's quarterly MDS assessment inaccurately documented the resident's vision status as adequate, despite the resident reporting significant vision impairment and the need for new glasses. The Social Services Designee (SSD) #347, who completed the vision section of the MDS, admitted to not asking the resident or staff about the resident's visual function and instead relied on observations and previous MDS assessments. This led to the resident not receiving the necessary eye care and glasses. Resident #8's significant change MDS assessment failed to document the resident's dental issues, despite the resident having dental caries and broken teeth as noted in the dental plan of care and dental notes. The MDS Nurse #335 confirmed that the MDS was inaccurately coded, as the resident's dental issues were present at the time of the assessment. The resident reported poor dental condition and the need for tooth extraction, which had not been addressed. These deficiencies highlight the facility's failure to ensure accurate and comprehensive MDS assessments for its residents.
Inaccurate PASRRs for Two Residents
Penalty
Summary
The facility failed to ensure that the Pre-Admission Screening and Resident Reviews (PASRRs) for two residents were accurate. Resident #6 was admitted with multiple diagnoses including dementia, chronic obstructive pulmonary disease, hypertension, anxiety disorder, obsessive-compulsive disorder, mild cognitive impairment, and major depression. Additional diagnoses of anorexia nervosa and psychosis were added later. However, the PASRR dated 03/28/24 did not list the diagnoses of psychosis or anorexia nervosa. This was confirmed by the Social Services Designee (SSD) during an interview on 04/25/24. Similarly, Resident #17 was admitted with diagnoses including senile degeneration of the brain, dementia with behaviors, major depressive disorder, anxiety disorder, and bipolar disorder. A diagnosis of psychosis was added later. The PASRR dated 08/02/23 did not include the diagnosis of psychosis. This omission was also confirmed by the SSD during an interview on 04/25/24. The facility's policy on Pre-Admission, dated 03/24/20, requires that all level one and level two residents with newly diagnosed or possible serious mental disorders be referred for a resident review upon significant change in status assessment, which was not followed in these cases.
Failure to Provide Adequate Nail Care
Penalty
Summary
The facility failed to provide adequate nail care for a resident who was dependent on staff for assistance with hygiene. The resident, who had a history of brain injury, hemiplegia, type II diabetes, aphasia, hypertension, contracture of muscles, and Alzheimer's disease, required extensive assistance for personal hygiene and grooming. Despite the care plan indicating that the resident's ADL needs should be met daily, observations revealed that the resident had long fingernails and could not recall the last time they were trimmed. Interviews with the resident and an LPN confirmed that the resident's fingernails needed trimming and that nails should be checked daily and trimmed weekly or as needed, usually after a shower. The deficiency was identified through record reviews, observations, and interviews. The care plan dated 01/28/10 and 08/30/19 indicated the resident's need for assistance with self-care and personal hygiene. The MDS assessment also confirmed the resident required maximum assistance for personal hygiene. Despite these documented needs, the resident's fingernails were observed to be long on multiple occasions, and the facility's policy on personal care and bathing, which required daily checks and weekly trimming of nails, was not followed. This failure affected the resident's personal hygiene and indicated a lapse in the facility's adherence to its own policies and care plans.
Failure to Provide Timely Care and Follow-Up
Penalty
Summary
The facility failed to provide timely care when a change in condition was noted for Resident #41. Despite the resident's complaints of worsening cold symptoms, shortness of breath, and sinus congestion, there was no documented evidence that the physician was notified of these symptoms prior to the resident's hospitalization. Additionally, the facility did not obtain the ordered CBC and Chem 8 labs, and there was no respiratory assessment completed before administering the as-needed Albuterol inhaler. The resident was eventually sent to the hospital and diagnosed with sepsis related to pneumonia, respiratory failure, and hypokalemia. Furthermore, follow-up appointments with gastroenterology and neurosurgery were not arranged as per the hospital discharge orders, and the resident's care plan was not updated to reflect these needs in a timely manner. Resident #27 experienced severe pain due to a urinary tract infection and kidney stones but was not provided timely care. Despite the resident's repeated requests to go to the hospital and visible signs of pain, the ADON delayed sending the resident to the hospital until the nurse practitioner could evaluate her. The resident was eventually sent to the hospital and diagnosed with a urinary tract infection, and an indwelling urinary catheter was reinserted. Multiple staff members, including STNAs and LPNs, confirmed that the resident was in visible pain and crying throughout the day, but the ADON did not believe the resident's pain was genuine. Resident #32 did not receive timely intervention for constipation as per the facility's bowel protocol. The resident went eight days without a documented bowel movement, but the ordered Bisacodyl suppository was not administered. The facility's policy required the initiation of the bowel protocol if no bowel movement occurred for three consecutive days, but this was not followed. The ADON confirmed that the necessary interventions were not implemented, leading to the resident's prolonged period without a bowel movement.
Failure to Implement ROM Services and Provide Therapy
Penalty
Summary
The facility failed to ensure range of motion (ROM) services were implemented per the plan of care and failed to provide therapy services when a resident had a noted decline. This affected two residents. Resident #41 was admitted with multiple diagnoses and initially had no neurological or mobility impairments. However, after a hospital stay, the resident returned with significant weakness and immobility. Despite the need for extensive rehab, there was no evidence that the resident was screened by therapy upon re-admission. The resident only received limited therapy sessions before being discharged to hospice care. Interviews revealed communication issues and staff shortages, which contributed to the lack of timely therapy services for the resident. Additionally, there was a failure to document therapy refusals properly and notify relevant staff or physicians about the resident's condition and therapy needs. Resident #8, who had multiple diagnoses including paraplegia and muscle weakness, was not receiving the restorative therapy as outlined in his plan of care. The plan included specific ROM exercises, but interviews with the resident and staff revealed that these exercises were not being performed. The facility did not have a restorative program in place, and staff were not adequately trained to carry out the ROM exercises. The resident expressed a desire to receive therapy to improve his strength and ROM, but there was no documented evidence that the restorative program was being implemented. Interviews with various staff members, including occupational therapists and nurse aides, confirmed the lack of a restorative program and the failure to provide necessary therapy services. The facility's administrator also acknowledged that the restorative program was not being implemented as per the residents' care plans. This lack of proper implementation and documentation of therapy services led to a decline in the residents' conditions, which was not addressed in a timely manner by the facility.
Failure to Implement Fall Prevention Interventions
Penalty
Summary
The facility failed to ensure that Resident #14, who had a history of falls, had fall prevention interventions in place according to the physician's orders and plan of care. Resident #14 was admitted with multiple diagnoses, including malignant neoplasm of the frontal lobe, unspecified psychosis, Type I diabetes mellitus, epilepsy, unsteadiness on her feet, abnormalities of gait and mobility, and a history of falling. Despite being cognitively intact and not displaying any behaviors or rejecting care, the resident experienced multiple falls. On 06/08/23, the resident fell while attempting to stand up, and the immediate intervention was the use of gripper socks. However, on 07/06/23, the resident fell again while in another resident's room, and it was noted that she was not wearing the prescribed gripper socks at the time of the fall. The physician's orders and care plan required the resident to wear gripper socks when out of bed if shoes were not being worn, but this intervention was not consistently followed. Observations on 04/23/24 and 04/24/24 further revealed that the resident was not wearing the required gripper socks or shoes while out of bed in the common area, indicating a failure to adhere to the prescribed fall prevention measures. An interview with LPN #327 confirmed that the resident was not wearing the required gripper socks during the observed times and that the LPN did not consider the resident to be at risk for falls, despite the resident's history and care plan. The facility's undated Fall Management policy stated that each resident at risk for falls would have a plan of care with implemented interventions to manage falls, and any fall would prompt an investigation and immediate intervention to prevent future falls. The facility's failure to consistently implement the prescribed fall prevention interventions for Resident #14, as outlined in the care plan and physician's orders, led to multiple falls and demonstrated non-compliance with their fall management policy.
Failure to Administer Tube Feeding as Ordered and Implement New Orders Timely
Penalty
Summary
The facility failed to ensure tube feeding was administered as ordered by the physician and did not implement new orders in a timely manner for Resident #44. The resident, who was admitted with diagnoses including aphasia, dysphagia, and gastrostomy, had a dietary note indicating a preference for house supplements if oral intake was less than 50%. Despite this, the order for Jevity remained active until 04/22/24, and the new order for house supplements was not implemented until 04/22/24 due to a computer system hack and staff scheduling issues. This delay resulted in the resident not receiving the appropriate nutritional support as per their preference and physician's orders. Additionally, the facility's documentation and administration of tube feeding were inconsistent. The resident's meal intake records showed multiple instances where the resident ate less than 50% of their meals, yet there was no evidence that Jevity was administered as required. The Assistant Director of Nursing confirmed that the meal intakes were not consistently documented, and the resident did not receive Jevity on several occasions when it was needed. This lack of proper documentation and adherence to feeding orders contributed to the resident's weight loss and inadequate nutritional support.
Failure to Ensure Timely Pain Management Referral
Penalty
Summary
The facility failed to ensure timely referral of a resident to a pain management clinic. The resident, who had multiple diagnoses including chronic pain and paraplegia, was referred to a pain management clinic by the physician on 08/31/23. However, the facility did not schedule the appointment until 10/11/23, and the pain management clinic required a CT scan of the lumbar spine before the appointment could be made. The CT scan was ordered on 10/23/23 and scheduled for 11/17/23, but the resident did not attend the appointment, and there was no documentation explaining the missed appointment. Interviews with the resident and staff confirmed that the pain management appointment had not been scheduled due to the incomplete CT scan. The resident expressed a desire to visit the pain management clinic, but the necessary steps were not taken by the facility to ensure the appointment was made. The Assistant Director of Nursing confirmed that the CT scan of the lumbar spine, which was required by the pain management clinic, was never completed, leading to a delay in the resident receiving appropriate pain management services.
Failure to Properly Date Insulin Flexpens
Penalty
Summary
The facility failed to ensure insulin flexpens were properly dated after being removed from the refrigerator and used for the first time. This deficiency was observed during a review of two medication administration carts. Specifically, insulin flexpens for three residents were found without proper dating, which is necessary to track their usage and ensure they are discarded after 28 days. Resident #16 had a Lantus flexpen with a blank label where the date should have been noted. Resident #13 had two insulin flexpens (Toujeo and Insulin Aspart) that were also not dated. Additionally, Resident #10 had a Lantus flexpen that was not dated and was stored in the same bag as an Insulin Aspart flexpen, which had been dated but was stored incorrectly. The findings were verified by an LPN, who confirmed that insulin flexpens should be dated after being removed from refrigeration and used for the first time. The LPN acknowledged the importance of dating the flexpens, as they are only effective for up to 28 days after first use. Since the discard dates could not be determined, the LPN removed the flexpens from the medication administration cart for disposal. The facility's policy from PharMerica Corp. requires that medications and biologicals be stored properly and that insulin products be dated when first used, which was not followed in these instances.
Failure to Complete Ordered Laboratory Tests
Penalty
Summary
The facility failed to ensure laboratory testing was completed as ordered for Resident #41, who was admitted with multiple diagnoses including dementia with behavioral disturbance, chronic obstructive pulmonary disease, acute respiratory failure with hypoxia, acute kidney failure, chronic kidney disease, hepatitis, and mental disorders. The Nurse Practitioner (NP) wrote orders for a complete blood count (CBC) and Chem 8, but there was no evidence that these tests were entered into the Medication and Treatment Records or obtained as per the facility's policy. The Assistant Director of Nursing (ADON) confirmed that the lab orders were not obtained and that the lab comes twice weekly. Resident #41's health status deteriorated, leading to hospitalization for sepsis related to pneumonia. The resident reported that she had informed the staff and doctor about her worsening condition, but they did not listen to her. The facility's policy on lab draws stated that lab orders should be implemented as written, and the nurse should review, clarify, and enter the lab orders into the computer system. However, this process was not followed, resulting in the resident's condition worsening and subsequent hospitalization.
Failure to Arrange Timely Dental Services
Penalty
Summary
The facility failed to ensure dental services were arranged in a timely manner for Resident #8, who had multiple dental issues including dental caries and abscess teeth. Despite a dental plan of care being in place since 05/16/22, which included coordinating dental care and monitoring for dental problems, the resident's dental issues persisted. A dental note from 07/26/23 indicated the resident had generalized caries and broken teeth, and a referral to an oral surgeon was made. However, the resident's appointment with the oral surgeon on 10/27/23 was canceled by the resident, and there was no documented evidence that the appointment was rescheduled, despite the resident's claim that he did not refuse to have it rescheduled. Interviews with the resident and the Social Service Designee (SSD) revealed discrepancies in communication and follow-up actions regarding the dental appointment. The resident expressed frustration over his inability to eat a variety of foods and his desire for dentures to improve his quality of life. The SSD confirmed that it took several months to find an oral surgeon who would accept the resident's insurance, and an appointment was eventually made. However, the resident reported not being notified of the appointment, leading to his refusal to attend. The SSD provided evidence that the resident was notified, but there was no follow-up to reschedule the appointment after the initial refusal. The resident's dental condition remained poor, with visible discolored and partially broken teeth, and he continued to experience difficulty eating, relying on soft foods like mashed potatoes. The lack of timely dental care and proper follow-up contributed to the ongoing dental issues faced by Resident #8.
Failure to Provide Alternate Meal Choice
Penalty
Summary
The facility failed to provide a nutritious meal of choice to a resident when she declined the main meal being served for lunch. The resident, who had multiple diagnoses including schizo-affective disorder, morbid obesity, and GERD, requested an alternate meal of two cheeseburgers instead of the hotdog and sauerkraut being served. However, her request was denied because it was not submitted before the kitchen's cut-off time of 10:00 A.M. Despite the resident's cognitive intactness and ability to communicate her needs, she was left without a meal and reported feeling hungry. During the lunch meal process, a nursing assistant confirmed that the resident's request was denied due to the kitchen's rule requiring alternate meal requests to be submitted by 10:00 A.M. Further interviews with the LPNs and dietary staff revealed that the kitchen staff strictly adhered to this rule, even though the facility's administrator later clarified that residents could request alternate meals at any time. The dietary manager acknowledged that the kitchen had the requested food items available and could have prepared the cheeseburgers within 10 minutes. The facility's administrator was informed of the incident and confirmed that the dietary staff were following the instructions on the alternate meal menu, which specified cut-off times for meal requests. The administrator stated that this directive would be removed to ensure that residents could make alternate meal requests when meals were refused. The incident highlighted a miscommunication and strict adherence to a rule that ultimately led to the resident being denied a meal of her choice.
Failure to Administer Pneumococcal Vaccine
Penalty
Summary
The facility failed to administer the pneumococcal vaccine to a resident who had consented to receiving it. Resident #21, who was admitted with diagnoses including acute respiratory failure, metabolic encephalopathy, type II diabetes, and hypertension, had a consent form signed by their responsible party on 11/08/23 for the pneumococcal vaccination. However, a review of the medical record showed no evidence that the vaccination had been administered. This was confirmed during an interview with an LPN on 04/24/24. The facility's undated policy stated that each resident would be offered the medically appropriate vaccine upon admission and as needed, but this was not followed in the case of Resident #21.
Failure to Offer COVID-19 Vaccinations
Penalty
Summary
The facility failed to offer COVID-19 vaccinations to three residents, despite having a policy in place that mandates offering the vaccine unless medically contraindicated, refused, or already administered. Resident #3, who has chronic obstructive pulmonary disease, hypertensive heart and chronic kidney disease, type II diabetes, and respiratory failure, was not offered a COVID-19 vaccination since 11/14/22. A handwritten statement dated 04/24/24 indicated that the resident had declined the vaccine, but this was the only consent available from 2022. An interview with LPN #361 confirmed this lapse in offering the vaccine. Resident #8, diagnosed with paraplegia, chronic hepatitis, unspecified atherosclerosis, hypertension, and neuromuscular dysfunction of the bladder, was also not offered the COVID-19 vaccination. Similarly, Resident #21, with diagnoses including respiratory failure, metabolic encephalopathy, type II diabetes, and hypertension, was not offered the vaccine. LPN #361 confirmed that both residents were not offered the COVID-19 vaccination, indicating a failure to adhere to the facility's immunization policy.
Unqualified Activities Director
Penalty
Summary
The facility failed to ensure the activities director was qualified, potentially affecting all 46 residents. The undated facility assessment listed the individual as the Activity Director (AD), but a review of the personnel file revealed that the AD, hired on 06/13/23, did not meet the required qualifications. The job description required the AD to be a qualified therapeutic recreation specialist, a licensed activities professional, or have two years of experience in a social or recreation program within the last five years, among other criteria. However, there was no evidence in the personnel file that the AD met these qualifications. The Administrator confirmed the hiring and acknowledged the mistake, stating that the regulatory requirements were misread.
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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