Rocky River Gardens Rehab And Nursing Ctr
Inspection history, citations, penalties and survey trends for this long-term care facility in Cleveland, Ohio.
- Location
- 4102 Rocky River Dr, Cleveland, Ohio 44135
- CMS Provider Number
- 365392
- Inspections on file
- 31
- Latest survey
- January 14, 2026
- Citations (last 12 mo.)
- 6
Citation history
Health deficiencies cited at Rocky River Gardens Rehab And Nursing Ctr during CMS and state inspections, most recent first.
Two residents with wounds and an indwelling Foley catheter did not receive care in accordance with the facility’s Enhanced Barrier Precautions (EBP) policy. For a resident with stage 3 pressure injuries, an LPN performed wound care, including removing a soiled dressing and cleansing and redressing the wound, without wearing an isolation gown, despite EBP signage requiring gown and gloves for wound care and a visibly soiled isolation supply cart nearby. For another resident with an indwelling Foley catheter and EBP care plan interventions requiring gown and gloves for high-contact care, a CNA emptied 300 ml of urine from the catheter drainage bag without donning an isolation gown and stated it was not needed. The DON confirmed that staff should wear PPE, including gowns, for wound and catheter care and that these staff work throughout the facility, while both residents reported that staff never wore gowns during their care.
Surveyors found that the facility failed to maintain required hot water temperatures on an entire floor and did not keep resident rooms and hallways clean and in good repair. During an environmental tour, the Maintenance Director measured sink water that never reached the required 105–120°F range in multiple rooms and acknowledged ongoing issues with a broken mixing valve, while residents and CNAs reported that water used for bathing was often cold despite running it for extended periods. A resident with significant mobility and hygiene dependence reported a nonfunctioning toilet, a nonworking bed light, and an uncovered socket, which were confirmed on observation, and the Maintenance Director admitted removing a light bulb weeks earlier without replacement. Other rooms were observed with broken floor tiles, heavily soiled floors and mats, trash and soiled items under beds, missing bed sheets, and damaged furniture, and staff, including a CNA, the Housekeeping Manager, and an LPN, described the building as filthy and confirmed that floors had not received deep cleaning in over a year, contrary to the facility’s own homelike environment policy.
Surveyors found that medication carts on two different floors were left unlocked and unattended while residents were present in the hallways and near the nurse station. On two separate occasions, an LPN acknowledged leaving the carts unsecured while stepping away to perform other tasks, such as blood sugar checks. This practice conflicted with the facility’s written policy requiring all drugs and biologicals to be stored in locked compartments and that medication carts not be left unattended when open or otherwise accessible.
Surveyors found that staff failed to provide timely incontinence care and scheduled showers/baths to multiple residents who were dependent on staff for ADLs. Several residents reported being told they could not be changed during meal service, and observations confirmed residents remained in soiled briefs and clothing for extended periods because CNAs followed an asserted policy of no personal care during tray pass. Other residents, all needing staff assistance for bathing, did not receive their scheduled showers or bed baths on multiple occasions, sometimes being told there was not enough staff or that there were hot water issues. Review of shower records revealed missing entries on scheduled days, showers documented when a resident was hospitalized, and shower refusal forms bearing forged CNA signatures, which the DON and involved CNAs confirmed were inaccurate. These actions and inactions resulted in residents not receiving basic hygiene care as planned and in inaccurate ADL documentation.
Two residents at risk for falls, one with dementia and mobility impairments and another with systemic lupus, cerebral palsy, and a history of falls, did not receive the fall-prevention interventions specified in their care plans. For one resident, surveyors observed the bed not in the lowest position, no "call don't fall" signage, and nonskid strips rendered ineffective by the bed being placed over them. For the other resident, whose care plan required dycem on the wheelchair due to impaired balance and impulsive behavior, staff confirmed there was no dycem in the chair or room, and the resident did not recall ever having it, despite documentation indicating it should have been in place and a subsequent fall occurring.
The facility failed to ensure accurate and complete documentation of bathing care for two cognitively intact residents who required staff assistance with personal care. One resident, with chronic respiratory failure and muscle weakness, was documented as having received a shower while hospitalized and later as having received a bed bath with a CNA signature that did not match the CNA’s known signature; the CNA and scheduler confirmed she was not assigned to that resident on the documented date, and the CNA who was assigned stated she did not provide or document the bath. Another resident, with systemic lupus erythematosus and cerebral palsy, reported not having a shower for weeks and appeared unkempt, while records showed two shower refusals signed under a CNA’s name; that CNA denied the resident had refused, stated the signatures were not hers, and an LPN agreed the signatures did not match a prior authentic signature. The DON confirmed that only the CNA providing care should sign the documentation and that records must be objective, complete, and accurate.
A resident under APS with a guardian directive was taken off facility premises by her husband, despite restrictions. The facility failed to supervise adequately, leading to the resident's death from a gunshot wound. The resident had a history of psychosis and a protective order due to abuse accusations against her husband. Staff were aware of the restrictions but did not implement a care plan or assign supervision during visits.
A resident experienced inadequate monitoring after catheter removal, leading to urinary retention and a UTI. Despite orders for a bowel and bladder program, staff failed to document or assess the resident's urination or discomfort, resulting in a hospital visit. The facility's policy lacked guidelines for post-catheter removal monitoring.
A resident with a history of exit-seeking behavior eloped from a facility due to inadequate supervision and a non-functional WanderGuard device. The resident, who had multiple medical conditions, traveled from Ohio to Wisconsin undetected, missing essential medical treatments. Staff failed to check the functionality of the WanderGuard, only its placement, and the resident's care plan was not updated to reflect the high risk of elopement.
A resident with multiple health conditions, requiring two-person assistance, fell from bed while being cared for by a single STNA. The resident was not monitored post-fall as per protocol, leading to a failure in identifying an acute change in condition. This neglect resulted in the resident's death, highlighting lapses in staff adherence to care protocols and monitoring procedures.
A resident with multiple health conditions fell from her bed while a single STNA was changing sheets, despite needing two-person assistance. The STNA left the resident on the floor without addressing her distress and later blamed the resident for the fall. This incident violated the facility's policy on resident rights, which emphasizes respect and dignity.
The facility failed to secure medication rooms and did not discard expired tuberculin solution, potentially affecting all 110 residents. Observations revealed malfunctioning locks on medication room doors and partially used vials of Apisol Tuberculin solution without opened dates.
The facility failed to ensure that foods were labeled, dated, and not retained when expired, affecting 106 residents. Observations revealed expired yogurts and milk, unidentified substances, and undated containers in resident refrigerators. The Food Service Director confirmed the findings and indicated a lack of documentation for checking expired food.
The facility failed to ensure accurate documentation of a resident's weight, with inconsistent recordings taken while the resident was in a wheelchair or using a mechanical lift. Interviews with the DON and RD confirmed the inaccuracies, and the resident was reweighed at 131 lbs.
The facility failed to disburse a resident's funds in a timely manner after their death. The resident, who had multiple diagnoses including schizophrenia and severe malnutrition, expired in the facility. Despite contacting the resident's guardian, the Business Office Manager did not receive a response, leading to the funds not being disbursed within the required 30-day period.
The facility failed to complete a significant change MDS 3.0 assessment for a resident admitted to hospice services. The resident had multiple diagnoses, including dementia with behavioral disturbance, and was receiving hospice care. An MDS RN confirmed the oversight during an audit.
The facility failed to accurately complete MDS assessments for three residents, leading to discrepancies in their medical records. One resident had falls and injuries not reflected in the MDS, another had an incorrect indication of physical restraint use, and a third had inaccuracies regarding hospice status and pressure ulcers. These issues were confirmed through record reviews, observations, and staff interviews.
A resident with multiple diagnoses, including chronic kidney disease and Alzheimer's, was admitted without a timely skin assessment due to initial refusal. The staff failed to make further attempts to complete the assessment within the required timeframe, contrary to the facility's policy.
The facility failed to ensure timely responses to pharmacy recommendations for two residents, leading to deficiencies in medication management. One resident's pharmacy recommendation for a dose reduction was not addressed for over a month, and another resident's antipsychotic medication lacked an appropriate diagnosis despite a pharmacy request.
The facility failed to assess and monitor the use of Zyprexa for a resident with Alzheimer's Disease, COPD, heart failure, and high blood pressure. Despite no documented behaviors from 02/01/24 to 04/11/24, the resident continued to receive the medication. The DON confirmed the diagnosis of behaviors was not appropriate, and the facility did not follow up on a pharmacy recommendation to address the diagnosis.
The facility failed to maintain a medication administration error rate of less than 5%, resulting in a rate of 5.41%. An LPN crushed soft gel capsules of Omega 3 Fish Oil and B Vitamin Complex, contrary to manufacturing guidelines, leading to incorrect dosages for a resident.
Failure to Follow Enhanced Barrier Precautions During Wound and Catheter Care
Penalty
Summary
Surveyors identified a failure to implement the facility’s Enhanced Barrier Precautions (EBP) policy during high-contact care for two residents with wounds and an indwelling device. One resident, admitted with post-polio syndrome, hemiplegia, lymphedema, muscle weakness, and dependence for personal care, had two stage 3 pressure injuries present on admission and a physician order for daily wound care to the right hip. During observed wound care, the wound care LPN repositioned the resident, removed the soiled dressing, cleansed, assessed, and redressed the right hip wound without donning an isolation gown, despite an EBP sign on the door specifying gown and gloves for wound care. The LPN acknowledged she did not wear a gown and confirmed she should have. The EBP supply cart located next to the resident’s door was observed with a thick layer of dust and grime and dried liquid spill marks. The resident later reported that staff never wore an isolation gown when providing care. Another resident, admitted with neuromuscular bladder dysfunction, muscle weakness, and need for assistance with personal care, had an indwelling Foley catheter, frequent bowel incontinence, and dependence for personal hygiene. The care plan documented EBP related to the indwelling Foley, with interventions including gown and gloves for high-contact care, and physician orders required Foley output measurement every shift. During observation of catheter care, a CNA emptied 300 milliliters of urine from the resident’s catheter drainage bag without donning an isolation gown and stated he did not need to wear one. The DON stated that staff providing catheter care, including emptying the drainage bag, or wound care should wear PPE including gloves and an isolation gown, and confirmed that the involved CNA and LPN worked throughout the facility and could expose all residents requiring care. The facility’s EBP policy specified that residents with wounds or indwelling medical devices require gown and glove use during high-contact care activities to reduce transmission of multidrug-resistant organisms.
Failure to Maintain Adequate Hot Water and Environmental Cleanliness
Penalty
Summary
The deficiency involves the facility’s failure to maintain required hot water temperatures and to keep resident rooms and common areas clean and in good repair. On an environmental tour of the third floor, the Maintenance Director measured water temperatures in several occupied rooms using the facility thermometer. In one resident’s bathroom, the sink water reached only 100°F after running for five minutes and then quickly dropped to 62°F. In another room, the bathroom water did not rise above 54°F after running for over three minutes, and in a third room the bathroom water reached only 99°F after six minutes. The Maintenance Director stated that water temperatures should be between 105°F and 120°F and acknowledged ongoing concerns with the mixing valve. He reported that he ordered a rebuild kit on 12/23/25 after being made aware of hot water concerns, then went on vacation, and that the company he used was also on vacation when he returned. He confirmed that the facility did not contact an alternate company to obtain the part or service sooner. Residents and staff reported persistent problems with inadequate hot water on the third floor. One resident stated that staff had to run the water for a long time to get it slightly warm and that sometimes the water used for cleaning felt slightly warm and sometimes cold, adding that the problem had been going on a long time and that she had informed the Administrator. Another resident reported receiving bed baths with cold water. CNAs reported that residents had expressed concerns about water not getting hot enough and that staff had to let the water run for a while before it would get warm, but sometimes it could run for hours and still not get warm on the third floor. The Maintenance Director confirmed that the first and second floors had sufficient hot water if it ran long enough, but the third floor was not always reaching the appropriate temperature. The Administrator stated that the hot water issue was due to a broken mixing valve first identified on 12/23/25 and confirmed that no interventions were put in place so third-floor residents could wash or be washed with warm water. The deficiency also includes failures to maintain resident rooms and facility areas in a clean and orderly condition and in good repair. One resident, who was cognitively intact with end stage renal disease, muscle weakness, gait and mobility abnormalities, and total dependence for personal hygiene, bed mobility, and transfers, reported that his toilet had not flushed for a week, that a light above his bed had not worked correctly for several weeks, and that a socket by his bed had no cover since his admission. Observation confirmed the toilet would not flush, one of two bed lights had no bulb, and the phone jack socket was broken. The Maintenance Director stated he had removed the bulb two or three weeks earlier and had not replaced it because he was ordering new lights, and he was unaware of the broken socket. Additional observations showed significant uncleanliness and disrepair in other resident rooms and hallways. In one room, five visible floor tiles under the bed were broken with missing pieces, the floor and floor mat next to the bed were very dirty with ground-in dirt, dried spills, and apparent food particles, and there were large areas of thick black/brown substance resembling removed floor strips and remnants of a mat stuck to the floor. The dresser drawer had a broken handle, and the dresser surface had dust and dried spills. The resident stated that the facility needed to clean better and that he would like that. In another room, the floor was very dirty with ground-in dirt and mud throughout, and there were multiple trash items under and protruding from under the bed into the walkway, including used tissues, dirty clothing, crumpled papers, and wrappers, with embedded dirt and grime under and beside the trash. The resident was resting on a mattress without sheets, reported preferring to lie on sheets, and stated that the sheets provided did not fit and would not stay in place. He confirmed his room was very dirty and stated that staff only wiped the middle of the floor and did not perform deep cleaning, saying it had been that way forever. Staff interviews corroborated the poor environmental conditions. A CNA who viewed the two residents’ rooms described them as disgusting and stated that housekeeping did not do a good job. The CNA also confirmed that the third-floor halls, including around the entire nurses’ station, were scuffed with multiple large scrapes that were discolored gray, with the edges showing the tiles were originally light tan. The Administrator, observing the same rooms and hallways, confirmed the dirty floors, trash under the bed, lack of sheets on the mattress, and heavily scuffed, discolored hallway floors. The Housekeeping Manager stated that the conditions were not right and confirmed that none of the facility floors had received a deep cleaning in over a year, explaining that there was no equipment or person to perform it despite repeated requests. An LPN stated that the building was filthy and that everybody knew it. These conditions were inconsistent with the facility’s written policy on providing a safe, clean, comfortable, and homelike environment with clean, sanitary, and orderly surroundings and clean bed and bath linens in good condition.
Unattended, Unlocked Medication Carts on Multiple Units
Penalty
Summary
The deficiency involves the facility’s failure to store medications in a safe and secure manner as required by its own policy and professional standards. Surveyor observation on 01/08/26 at 8:15 A.M. showed that a medication cart on the third floor North hall was left unlocked with no staff present. A resident was seated nearby and additional residents were present in the hallway. At 8:20 A.M., an LPN returned to the cart and acknowledged that she had left it unlocked while she went down the hall to perform blood sugar checks. A second observation on 01/12/26 at 9:33 A.M. showed another medication cart on the second floor near the nurse station left unlocked and unattended, with residents present in the halls and near the nurse station. At 9:37 A.M., the same LPN confirmed that the cart had been left unattended while she stepped away. The facility’s written policy, revised April 2007, states that all drugs and biologicals must be stored in a safe, secure, and orderly manner, and that all compartments containing drugs and biologicals must be locked when not in use, and that carts used to transport such items must not be left unattended if open or otherwise available to others. The facility identified that this failure had the potential to affect most residents on the second and third floors, excluding those specifically noted as requiring assistance with mobility.
Failure to Provide Timely Incontinence Care and Scheduled Bathing, with Falsified ADL Documentation
Penalty
Summary
The deficiency involves the facility’s failure to provide timely incontinence care and scheduled bathing/showering for multiple residents who required assistance with activities of daily living. For one resident with spinal stenosis, muscle weakness, repeated falls, and schizoaffective disorder, the admission MDS documented total dependence or extensive assistance needs for toileting and hygiene, and the care plan required prompt response to needs and one‑to‑two staff assistance for toileting. Staff interviews revealed that when this resident requested to be changed during a meal service, CNAs and an LPN told him they could not provide incontinence care during tray pass due to a facility policy of “no patient care during meal passes.” The resident’s call light was turned off, he turned it back on, and ultimately removed his soiled brief and threw it into the hallway. Staff confirmed they delayed his incontinence care until after meal service. Other residents reported they were told they had to wait until after meals to be changed, and that they were not changed in the morning before breakfast despite being incontinent. Another resident with COPD, muscle weakness, and frequent bowel and bladder incontinence, who used a motorized wheelchair and was dependent for toileting hygiene, was care planned to be checked and changed every two hours and as needed. On the morning of observation, this resident was found in an electric wheelchair with pants saturated with urine and reported not having been changed since the start of the CNA’s shift at 7:00 a.m. because staff were doing breakfast and were “not allowed” to change residents during meals. Later that afternoon, observation of incontinence care showed the resident’s pants and chair pad were heavily soiled with urine and stool, and stool was present on the resident’s side and peri area. The primary CNA confirmed the last check/change had been around 9:00 a.m. and stated she usually waited for the resident to request changes, while the resident reported being unable to sense incontinence and that some CNAs did not routinely check her. Physical findings included deep red inner buttocks and creasing of the buttocks and thighs from prolonged sitting without movement. The facility also failed to provide scheduled showers or baths to several residents and had documentation irregularities. One cognitively intact resident, frequently incontinent and dependent for bathing, was scheduled for showers twice weekly but had multiple dates over several months with no shower record and no indication of being offered or receiving a bath or shower; the DON confirmed that on those dates the resident would not have received or been offered bathing as scheduled. Another cognitively intact resident requiring substantial assistance with bathing reported not receiving scheduled showers consistently, stating staff said there was not enough staff; shower records showed multiple missed or not‑offered showers on scheduled days, which the DON verified as accurate. A third resident, dependent for bathing and recently hospitalized, reported begging for a bath for several days, stated she only received about one shower a month, and complained of being offered showers in the middle of the night. Review of shower sheets showed a shower documented on a date when she was hospitalized, and a later bed bath entry bearing a CNA’s forged signature; the DON and the CNA confirmed the resident was not in the facility on the documented date and that the CNA had not signed the later record. A further resident with systemic lupus erythematosus, cerebral palsy, and muscle weakness, who required substantial assistance for bathing and was scheduled for twice‑weekly showers, reported not having a shower in three weeks and attributed this to hot water issues. Observation noted very oily hair. Shower sheets showed two recent entries indicating the resident refused showers, both signed with a CNA’s name and an illegible nurse signature. During review, the CNA whose name appeared on the forms stated the resident had never refused on those dates, denied the signatures were hers, and pointed out that the signatures did not match her known signature from a prior date. The DON confirmed that residents should receive at least two showers or baths per week, that lack of hot water would not constitute a refusal, and that no staff member should sign for a CNA who did not provide the care. These findings collectively demonstrate failures to provide timely incontinence care and scheduled bathing, as well as inaccurate and falsified documentation of ADL care.
Failure to Implement Care-Planned Fall-Prevention Interventions for Two Residents
Penalty
Summary
Surveyors identified a failure to implement care-planned fall-prevention interventions for two residents assessed as being at risk for falls. For one resident with dementia, gait abnormalities, muscle weakness, and a history of falls with injury, the care plan dated 05/20/22 included interventions such as "call don't fall" signage in the room, keeping the bed in the lowest position, and placing nonskid strips in front of the bed. During observation on 01/08/26, the resident was found lying in bed with the bed not in the low position, no "call don't fall" signage present, and the bed positioned over the nonskid strips. The CNA present confirmed the resident was at risk for falls, verified the bed was not low, stated she did not remember ever seeing the signage, and confirmed the bed was over the nonskid strips. For another resident with systemic lupus erythematosus, cerebral palsy, muscle weakness, impaired balance, use of psychotropic medications, history of TIA, impulsive behaviors, and two or more prior falls, the care plan initiated 11/11/20 included an intervention to apply dycem to the wheelchair, with this intervention dated 01/26/21. A fall risk assessment showed the resident was at moderate risk for falling. On observation with an LPN on 01/08/26, the resident was sitting in a chair and then transferred to bed; the LPN confirmed there was no dycem in the chair or in the room, and the resident did not recall ever having dycem in the wheelchair. Record review with the LPN confirmed the care plan required dycem to be applied to the chair. A progress note dated 01/09/26 documented that another nurse found the resident on the floor in another resident’s room and stated dycem was in place in the chair, but in a later interview the LPN clarified that dycem was not in the chair at the time the resident was found on the floor and that dycem was applied only afterward. The facility’s fall policy required review of the care plan and documentation of appropriate interventions to prevent future falls.
Inaccurate Bathing Documentation and Falsified Signatures for Two Residents
Penalty
Summary
The deficiency involves the facility’s failure to maintain accurate and complete documentation of bathing and hygiene care for two cognitively intact residents, contrary to its charting and documentation policy. One resident, admitted with chronic respiratory failure with hypoxia, muscle weakness, and needing assistance with personal care, used a wheelchair and was dependent on staff for bathing and showers per the care plan. The census showed this resident was hospitalized on a date in October and did not return until several days later, yet the shower record indicated a shower was provided during the hospitalization, which the DON confirmed could not have occurred. Shower records from mid-October through early January showed scheduled showers documented as completed, while the resident reported having begged for a bath for three days, stated there was no hot water, and that she only received one shower a month. A shower sheet dated early January showed a bed bath with a CNA’s signature that did not match the CNA’s prior signature; the CNA later confirmed by phone that she did not have that resident assigned that day and did not sign the sheet. The scheduler confirmed a different CNA had the resident that day, and that CNA confirmed she did not provide or document the scheduled bath or shower and did not know why it was not offered. The second resident, admitted with systemic lupus erythematosus, cerebral palsy, muscle weakness, and a need for assistance with personal care, used a wheelchair and required substantial to maximal assistance for bathing and showering. The care plan included providing a sponge bath when a full bath or shower could not be tolerated. This resident reported not having a shower in three weeks and attributed the lack of bathing to hot water issues on the unit; observation showed the resident’s hair was very oily, and the resident expressed feeling “disgusting.” Shower records indicated that showers were refused on two dates in January, with both sheets signed by the same CNA and an illegible nurse signature. During an interview and review of the shower sheets, the CNA stated the resident never refused showers on those dates, became upset, and asserted that the signatures on those sheets were not hers, pointing to an earlier shower sheet where her authentic signature appeared and looked different. An LPN confirmed the questioned signatures did not resemble the earlier signature, and the DON confirmed that no staff member should sign for a CNA other than the CNA providing the care. The facility’s policy required documentation in the medical record to be objective, complete, and accurate, which was not followed in these instances.
Failure to Prevent Unauthorized Leave of Absence Resulting in Resident's Death
Penalty
Summary
The facility failed to provide adequate supervision and comprehensive individualized interventions to prevent an unauthorized leave of absence (LOA) for a resident who was under adult protection services (APS) with a guardian directive prohibiting the resident's husband from taking her off facility premises or into his vehicle. This resulted in Immediate Jeopardy and actual harm when the resident's husband took her outside the facility and left the grounds with her in his vehicle without staff knowledge. The resident was later found deceased by local police with a gunshot wound to the head, along with her husband, who also had a self-inflicted gunshot wound. The resident had a history of unspecified psychosis, Crohn's disease, generalized anxiety disorder, depression, and delusional disorder. She had been hospitalized for acute psychosis and had a protective order in place due to accusations of abuse from her husband. Despite these circumstances, the facility did not implement a care plan for visitation or the resident's protection order, nor were there interventions to ensure adequate supervision or monitoring of her whereabouts during visits with her husband. The facility's LOA logbook showed that the resident's husband signed in for a visit, but there were no nursing progress notes from the time he arrived until the resident was discovered missing. Interviews with staff revealed that they were aware the resident was not supposed to leave the premises with her husband, but there was no clear plan or assigned person to supervise the resident during her husband's visits. The facility's policy on abuse, neglect, and exploitation emphasized the importance of providing necessary goods and services to avoid harm, which was not adhered to in this case.
Removal Plan
- LPN #300 notified the DON that Resident #200 was not in the facility.
- LPN #300 notified Physician #302 and left a voicemail to return call to facility.
- The DON attempted to contact Resident #200's husband and left a voicemail asking him to return the call.
- LPN #300 notified APS Guardian #320 that Resident #200 was not in facility.
- The DON notified the local police department of an unauthorized LOA for Resident #200.
- The DON arrived at facility and spoke with Police Officer #322 regarding the situation and supplied him with Resident #200's face sheet and diagnosis list.
- A root cause analysis was conducted by VPO #303, VPC #304, RDO #305, RDCS #306, Administrator, and DON related to the incident.
- VPCS #304 and VPO #303 educated the DON and Administrator on the facility adequate supervision of residents, LOA procedure, and facility abuse/neglect policy.
- The DON and Administrator educated all department heads on adequate supervision of residents, abuse/neglect policy and LOA procedure.
- RDCS #306 reviewed all residents' medical records for guardian status, to ensure appropriate LOA orders and any protective orders were in place and care planned.
- The DON, ADON #308, LPN #309, HR #310, DM #311, DOR #312, Housekeeping Supervisor #313, AD #314 educated their departments so that all staff were in-serviced on the facility adequate supervision of residents, LOA procedure, and facility abuse/neglect policy.
- Admissions Director #315 reviewed and updated the facility bed board per LOA orders.
- The DON updated the LOA sign-out books with a new form to include anticipated return time at all nurse's stations and the front desk.
- LPN #309 updated and implemented the nurse report sheets at all nurse's stations.
- A QAPI meeting was held with the IDT to review root cause analysis, facility interventions, facility policies, and facility response.
- LPN #319 reviewed LOA orders, protective orders and LOA care plans for accuracy and updated as necessary.
- Audits were initiated for bed board completion and accuracy.
- Audits were initiated for completion and accuracy of LOA books.
- Audits were initiated for accuracy and completion of nursing report sheets.
- Audits were initiated for new admission or existing residents for new or revised protective orders, guardian status, and updated LOA orders to reflect in the residents' care plans.
- Audits were initiated for new admission or existing residents with a mental health diagnosis to ensure they were offered psychological services.
- Observational audits were initiated of ten residents who required supervision of care to ensure monitoring was effective.
Failure to Monitor Resident Post-Catheter Removal
Penalty
Summary
The facility failed to appropriately monitor a resident's ability to urinate and signs of urinary discomfort following the removal of an indwelling urinary catheter. The resident, who had been admitted with diagnoses including acute kidney failure and benign prostatic hyperplasia, had an order to discontinue the Foley catheter and start a bowel and bladder program. However, documentation was incomplete, and there was no evidence of monitoring the resident's urination or any discomfort after the catheter removal. The resident's medical records showed that the catheter was removed early in the morning, and the resident was educated on voiding and when to alert staff if he did not urinate. Despite this, there was no documentation of any assessment or monitoring of the resident's urination, discomfort, or bladder/abdominal condition from the time of catheter removal until the resident was sent to the hospital the following morning. The resident was found to have urinary retention and a urinary tract infection with hematuria at the hospital. Interviews with facility staff and the resident confirmed the lack of monitoring and documentation. The facility's policy on urinary incontinence did not include guidelines for monitoring after catheter removal, contributing to the oversight. The resident expressed dissatisfaction with the care received, stating that no staff checked on him, leading him to contact emergency services independently.
Failure to Monitor WanderGuard Leads to Resident Elopement
Penalty
Summary
The facility failed to provide adequate supervision and ensure the proper functioning of a WanderGuard device for a resident with a history of exit-seeking behavior, leading to the resident's elopement. The resident, who had multiple medical conditions including schizophrenia, bipolar disorder, and end-stage renal disease, was able to leave the facility undetected through a smoking patio exit door. The WanderGuard system, which was supposed to prevent such incidents, did not function as intended, allowing the resident to travel from Ohio to Wisconsin without staff knowledge. The resident was not seen by facility staff for nearly three hours before being discovered missing. During this time, the resident missed essential medical treatments, including hemodialysis and several prescription medications for high blood pressure, angina, and mental illness. The resident was eventually found by a university police department in Wisconsin, approximately 425 miles away from the facility, and was transported to a local hospital for evaluation and treatment. Interviews and reviews of the facility's records revealed that the staff did not check the functionality of the WanderGuard device, only its placement. The facility's protocol for WanderGuard use was not clearly defined, leading to a lack of proper checks and balances. The resident's care plan and elopement risk assessments were not adequately updated to reflect the resident's high risk for elopement, contributing to the failure to prevent the incident.
Removal Plan
- RN #811 instructed STNA #823 and STNA #824 to search the unit for Resident #69.
- RN #811 called a code and LPN #825 and LPN #826 searched all facility floors and outside areas.
- RN #827 notified the Director of Nursing (DON) that Resident #69 was missing.
- The DON instructed RN #811 to complete a resident head count of the entire facility and obtain witness statements from all staff present.
- Police Officer (PO) #834 arrived from the local police department and took a report from RN #811. RN #811 provided the officer with Resident #69's demographic information, the last time he was seen and a brief description of what he was wearing prior to the elopement.
- A root cause analysis was conducted by RDO #800, RDCS #801, the Administrator and the DON. The root cause of Resident #69's elopement was determined to be a system failure to ensure the resident's WanderGuard was in place and/or functional and adequate supervision.
- RDO #800 re-educated the DON and the Administrator on the facility's elopement policy and best practice, WanderGuard protocol, elopement risk assessments and interventions, door alarm response and adequate supervision of residents.
- The DON initiated in-person education with all facility staff on the elopement policy and best practice, WanderGuard protocol, elopement risk assessments and interventions, door alarm response and adequate supervision of residents. Dietary Manager (DM) #828, Housekeeping Director (HD)#806, Activities Director (AD) #808 and Assistant Director of Nursing (ADON) #838 assisted with the education, after receiving the education from the DON and/or Administrator. Education will be provided for all new employees during orientation.
- ADON #838, Unit Manager (UM) #829 and Wound Nurse (WN) #830 re-assessed all residents for elopement and verified care plans were up to date.
- Director of Maintenance (DOM) #804 checked all doors equipped with WanderGuard sensors to ensure functionality.
- An Ad-Hoc Quality Assurance Performance Improvement (QAPI) meeting was held to review the root cause analysis, facility interventions, facility policies on wandering and elopement and facility response. The Administrator re-educated attendees on the elopement policy, WanderGuard protocol, door alarm response and supervision of residents.
- RDCS #801 reviewed residents with WanderGuard orders to ensure placement and functionality of the WanderGuards and the residents' care plans were accurate. All reviewed residents had functioning WanderGuards in place and care plans were updated.
- Minimum Data Set Nurse (MDSN) #833 conducted a second review of all resident care plans and updated, as needed, to ensure all care plans accurately reflected elopement risk and WanderGuard use/interventions.
- DOM #804, or designee, would conduct checks of doors equipped with WanderGuard sensors five times per week for two weeks then weekly.
- The DON, or designee, would audit nine WanderGuard placement and function three times weekly for four weeks then one time weekly for four weeks.
- LPN #812 was notified by university police in Milwaukee, WI that Resident #69 was found on their campus. LPN #812 immediately notified ADON #838, who then immediately notified the DON and Administrator.
- University police transported Resident #69 to an area hospital for further evaluation due to missed medications and hemodialysis treatments.
- AD #839 and STNA #840 picked-up Resident #69 from the hospital in Milwaukee, WI and transported the resident back to the facility.
- Resident #69 returned to the facility. LPN #814 assessed Resident #69 and the resident was placed on one-on-one supervision for safety. The resident's WanderGuard was replaced and tested to ensure it properly functioned.
- RDCS #801 reviewed Resident #69's care plan for accuracy.
- LPN #837 reassessed Resident #69 for elopement risk. Resident #69 was assessed to be at high risk for elopement.
- DOM #804 conducted an elopement drill with no concerns identified with staff response.
- MDSN #833 updated Resident #69's care plan to include updated elopement risk and interventions. Resident #69's physician orders were updated to check WanderGuard placement and function each shift.
- DOM #804 placed an order for an additional WanderGuard testing device and WanderGuard bracelets to provide additional supplies.
- DOM #804, or designee, would conduct elopement drills/resident supervision on each shift weekly for four weeks and then monthly indefinitely.
- The DON or designee, would audit elopement assessments and interventions for accuracy and completeness weekly for four weeks.
Neglect Leads to Resident's Fall and Death
Penalty
Summary
The facility failed to protect a resident from neglect, resulting in a fall with injury and subsequent death. The resident, who had a right leg amputation, diabetes, chronic kidney disease, and congestive heart failure, required two-person assistance for all care. However, on the evening of the incident, a single State Tested Nursing Assistant (STNA) was providing care alone. The STNA was changing the resident's bed linens when the resident fell from the bed, landing face down on the floor. The STNA did not immediately seek help or provide assistance, leaving the resident on the floor crying for help. After the fall, the resident was transported to the hospital and diagnosed with a rib fracture. Upon returning to the facility, the resident was not monitored according to protocol, which required neurological checks for 72 hours post-fall. The facility staff failed to identify an acute change in the resident's condition, including altered mental status and low blood pressure, which ultimately led to the resident's death. The lack of timely medical intervention and failure to follow established care protocols contributed to the severity of the incident. The facility's investigation revealed that the STNA did not adhere to the care plan requiring two-person assistance, and the resident was not adequately monitored after the fall. The facility's policies and procedures for preventing neglect and responding to changes in a resident's condition were not followed, leading to the resident's deterioration and eventual death. The incident highlighted significant lapses in staff adherence to care protocols and monitoring procedures.
Removal Plan
- RDCS #401 met with the Interdisciplinary Team to complete a root cause analysis and identified a system failure.
- RDCS #401 educated the Administrator, DON, ADON, and UM #171 on post fall monitoring including skilled charting, vital signs, neuro checks for all unwitnessed falls or witnessed falls with head injury per neuro check form, and two-person assist for care.
- A Quality Assurance Performance Improvement meeting was held to review the root cause analysis and all agreed on the system failure.
- RDCS #401 provided education to the team on post fall monitoring and checking binder at nurse's station for number of persons required to assist with resident care at the start of nursing shift.
- The Administrator, DON, ADON, UM #171, DM #180, HS #199, and BOM #110 educated all facility staff on post fall monitoring and checking the binder at nurse's station for two person assist for resident care at the start of nursing shift.
- UM #171 reviewed fall investigations to ensure interventions were in place and appropriate care plans were in place for all residents.
- The DON and MDS Nurse #251 audited care plans, Kardex, and physician orders for all residents to ensure all assistance orders were in place and care planned appropriately.
- The ADON and UM #171 created a binder for each nurse's station that contained the number of persons required to provide resident care.
- The RDO met with the IDT to complete an additional root cause analysis and identified a system failure as LPN #150 failed to identify Resident #101's change in condition and provide timely intervention.
- A QAPI meeting was held to review the root cause analysis and all agreed on the system failure.
- The RDO provided education to the team on abuse and neglect policy and acute change in condition policy.
- The Administrator, DON, ADON, UM #171, DM #180, HS #199, and BOM #110 educated all facility staff on the facility abuse and neglect policy and acute change in condition policy.
- UM #171 assessed residents with a BIMS score of 12 or lower to ensure further instances of neglect or change in condition without identification/intervention.
- The DON reviewed the report to ensure there were no residents with identified change in condition without appropriate follow-up.
- The DON reviewed change of condition assessments to ensure appropriate interventions.
- LPN #150 was suspended pending an investigation for resident neglect.
- The RDO submitted a Self-Reported Incident for neglect related to Resident #101.
- The facility implemented a plan for audits to be completed by the DON/designee for every fall occurrence to ensure appropriate post fall monitoring.
- The facility implemented a plan for audits to ensure the appropriate number of staff were providing care per identified needs.
- The facility implemented a plan for audits to ensure the person assist binders were accurate and up to date.
- The DON/designee would complete random staff interviews on all shifts to ensure binders were reviewed at start of shift.
- All new physician orders related to transfer status would be audited by DON/designee.
- The DON/designee would observe random residents to ensure no change in condition without assessment and intervention and no signs of abuse or neglect.
- The DON/designee would interview random residents to ensure no allegations of abuse or neglect.
- The DON/designee would randomly review charting to ensure no change in condition without assessment and intervention.
- All audits would be reviewed during QAPI meetings, and any identified concerns addressed immediately by QAPI committee.
- In-service sign-in sheets confirmed most facility staff received the training/education.
Failure to Ensure Resident Dignity and Safety
Penalty
Summary
The facility failed to ensure that residents were treated with respect and dignity, as evidenced by an incident involving a resident with a right leg amputation, diabetes, chronic kidney disease, and congestive heart failure. The resident required substantial assistance with daily activities and was ordered to have two-person assistance for all care. However, video footage revealed that a single STNA was attempting to change the resident's bed sheets while the resident was lying naked on her side at the edge of the bed. The resident expressed concern about falling, and despite her pleas, she fell face down onto the floor. The STNA then moved the bed, causing the resident's leg to drop to the floor, and left the room without addressing the resident's distress. When the STNA returned with additional staff, the resident expressed that she had been let fall, and the STNA blamed the resident for not holding onto the bed. The STNA and the resident argued, with the STNA dismissing the resident's claims. The facility's policy on resident rights, which emphasizes respect, kindness, and dignity, was not upheld in this situation. This incident was part of a complaint investigation, highlighting a deficiency in the facility's adherence to resident rights.
Medication Security and Expired Tuberculin Solution
Penalty
Summary
The facility failed to keep medication in a secured environment and did not discard expired tuberculin solution, potentially affecting all 110 residents. Observations revealed that the second-floor medication room door was ajar and not latched completely, allowing it to be pushed open without using the door handle. The door handle was part of a code locking system with the number 7 button stuck, enabling the door to be unlocked. Similarly, the third-floor medication room door was closed but not locked, and staff could enter without using a code. An STNA was observed entering the third-floor medication room without a nurse escort to retrieve supplies. Interviews with staff confirmed that the medication room doors had not been locked for several days due to the malfunctioning code boxes, and the facility policy stated that only authorized persons should have access to the medication room. Additionally, the facility failed to discard expired tuberculin solution. Observations in the first-floor medication refrigerator revealed two partially used vials of Apisol Tuberculin solution without opened dates. An LPN confirmed that these vials should have had opened dates. Similarly, the third-floor medication room refrigerator contained a partially used vial of Aplisol TB solution without an opened date. The ADON confirmed that the vials should have opened dates and should not be used past 30 days from the opened date. The manufacturer guidelines for Aplisol TB solution indicated that vials in use for more than 30 days should be discarded due to possible oxidation and degradation affecting potency.
Failure to Properly Label, Date, and Discard Expired Foods
Penalty
Summary
The facility failed to ensure that foods were labeled, dated, and not retained when expired, which had the potential to affect 106 residents receiving food from the facility's kitchen. During an observation of the facility's nourishment refrigerators, it was found that the first-floor resident refrigerator contained expired yogurts and milk, the second-floor resident refrigerator had an unidentified pink substance and frozen popsicle material, and the third-floor resident refrigerator had containers labeled with a resident's room number but no date. These findings were verified by the Food Service Director (FSD), who indicated that refrigerators were checked weekly for expired food, but there was no documentation to support this process. The facility's policy, revised in February 2014, stated that perishable foods must be stored in re-sealable containers with tightly fitting lids, labeled with the resident's name, the item, and the use-by date. The nursing staff was responsible for discarding perishable foods on or before the use-by date. However, the FSD confirmed that there was no documentation regarding staff going through these refrigerators for expired food, and the housekeeping staff helped with this process. This lack of adherence to the policy and absence of proper documentation led to the deficiency observed during the survey.
Inaccurate Documentation of Resident's Weight
Penalty
Summary
The facility failed to ensure accurate documentation of a resident's weight in the medical record, affecting one resident out of three reviewed for nutrition. Resident #107, who had diagnoses including chronic kidney disease, diabetes mellitus with diabetic nephropathy, protein-calorie malnutrition, and dementia with behavioral disturbance, had inconsistent weight recordings. The weights documented from August 2023 to March 2024 included weights taken while the resident was in a wheelchair, which weighed 40.8 lbs. Additionally, the methods of weighing the resident standing or using a mechanical lift were also noted to be inaccurate. Interviews with the Director of Nursing (DON) and Licensed Practical Nurse (LPN) revealed that the resident's weight of 170 lbs. was likely inaccurate, and the resident's son, a physician, had no concerns about the resident's weight. Further interviews with the DON and Registered Dietitian (RD) confirmed that the resident was always weighed in his wheelchair, and the documented weights were not accurate. The resident did not require the use of a mechanical lift, and the weights recorded using this method were also incorrect. The RD mentioned that the resident had a recent hospitalization and experienced some weight loss but had since gained weight. The resident was reweighed and found to be 131 lbs. The facility's policy on charting and documentation, revised in July 2017, stated that documentation in the medical record should be objective, complete, and accurate, which was not adhered to in this case.
Failure to Disburse Resident Funds Timely After Death
Penalty
Summary
The facility failed to ensure resident funds were disbursed as required and in a timely manner after the death of Resident #120. Resident #120, who had diagnoses including paranoid schizophrenia, unspecified psychosis, major depressive disorder, schizophrenia unspecified, unspecified severe protein-calorie malnutrition, psychotic disorder with hallucinations due to known physiological condition, and a history of COVID-19, expired in the facility. A review of the resident's fund statement revealed an ending balance of $1069.28, with no evidence of final disbursal. The Business Office Manager contacted the resident's guardian a week after the resident's death but did not receive any follow-up, resulting in the funds not being disbursed within the required 30-day period.
Failure to Complete Significant Change MDS Assessment
Penalty
Summary
The facility failed to ensure a significant change Minimum Data Set (MDS) 3.0 assessment was completed for Resident #14. Resident #14 was admitted to the facility with diagnoses including dementia with behavioral disturbance, diabetes, high blood pressure, anxiety, and depression. The resident was admitted to hospice services for dementia with behavioral disturbance. However, the comprehensive annual MDS 3.0 assessment indicated the resident did not have a life expectancy of less than six months, despite receiving hospice services. An interview with the MDS Registered Nurse confirmed that a significant change assessment was not completed after the resident was admitted to hospice, and this was missed during an MDS audit.
Inaccurate MDS Assessments for Multiple Residents
Penalty
Summary
The facility failed to accurately complete Minimum Data Set (MDS) assessments for three residents, leading to discrepancies in their medical records. Resident #5, who was admitted with multiple diagnoses including high blood pressure and a history of falls, had two documented falls with injuries that were not accurately reflected in the MDS assessment. Additionally, the MDS inaccurately indicated the use of a trunk restraint, which was not observed or reported by staff. These inaccuracies were confirmed by the MDS Registered Nurse (RN) during an interview. Resident #90, diagnosed with Alzheimer's disease and dementia, had an MDS assessment that incorrectly indicated the use of physical restraints. Observations and staff interviews confirmed that no restraints were used for this resident. The MDS RN admitted to accidentally marking the use of restraints in the assessment. Similarly, Resident #14, who was admitted with dementia and other conditions, had an MDS assessment that failed to accurately reflect their hospice status and the presence of a pressure ulcer. The MDS RN confirmed these inaccuracies during an interview. These deficiencies highlight the facility's failure to ensure accurate and complete MDS assessments, which are crucial for proper care planning and resident safety. The inaccuracies in the MDS assessments for Residents #5, #14, and #90 were identified through a combination of record reviews, observations, and staff interviews, revealing a pattern of documentation errors that could impact the quality of care provided to the residents.
Failure to Complete Timely Skin Assessment
Penalty
Summary
The facility failed to ensure a timely skin assessment upon admission for Resident #11, who was admitted with diagnoses including chronic kidney disease, heart failure, peripheral vascular disease, and Alzheimer's disease. Despite the resident's initial refusal to undergo a head-to-toe skin assessment, the staff did not make further attempts to complete the assessment within the required eight hours or thereafter. This lack of follow-up resulted in an incomplete initial assessment of the resident's skin condition. The resident's baseline care plan included interventions such as the use of a pressure-reducing mattress and cushion, and regular skin assessments. However, progress notes and weekly skin assessments revealed that no further attempts were made to complete the initial skin assessment after the resident's refusal. The facility's wound nurse confirmed that the staff should have made additional attempts to complete the assessment, as per the facility's policy on the prevention of pressure ulcers, which mandates an assessment within eight hours of admission.
Failure to Address Pharmacy Recommendations Timely
Penalty
Summary
The facility failed to ensure timely responses to pharmacy recommendations for two residents, leading to deficiencies in medication management. For Resident #90, who had diagnoses including Alzheimer's disease, dementia with behavioral disturbance, and PTSD, a pharmacy recommendation dated 10/31/23 suggested a gradual dose reduction of Divalproex. However, the recommendation was not addressed by the nurse practitioner until 12/06/23, exceeding the facility's expected 30-day response time. Additionally, the response form was incomplete, as the nurse practitioner did not select a response option, only indicating disagreement with the recommendation without further explanation. For Resident #109, who had diagnoses including dementia with behavioral disturbance, prostate cancer, shared psychotic disorder, anxiety, and depression, a pharmacy recommendation dated 12/21/23 requested an appropriate diagnosis for the use of the antipsychotic medication Zyprexa. The psychiatric nurse practitioner signed the recommendation on 01/12/24 but failed to provide an appropriate diagnosis from the list provided by the pharmacist. The facility's policy on Medication Regimen Reviews, revised in April 2007, did not specify a time frame for responses to pharmacy recommendations, contributing to the delay and incomplete responses observed in these cases.
Failure to Monitor and Assess Antipsychotic Medication Use
Penalty
Summary
The facility failed to assess and monitor the use of an antipsychotic medication, Zyprexa, for a resident diagnosed with Alzheimer's Disease, COPD, heart failure, and high blood pressure. The resident, who was dependent on staff for all personal hygiene, transfers, and dressing, had been prescribed Zyprexa for behaviors since 12/25/23. However, from 02/01/24 to 04/11/24, there were no documented behaviors that would justify the continued use of the medication. The Director of Nursing confirmed that the diagnosis of behaviors was not appropriate for the use of Zyprexa, as the resident had not exhibited any behaviors in the last 90 days. The facility's failure to document or address the continued use of Zyprexa was evident in the progress notes from 09/10/24 to 10/01/24, which lacked any entries reflecting the physician's assessment or changes to the diagnosis. Additionally, a pharmacy recommendation dated 09/10/23 had suggested that the physician address the diagnosis for the use of Zyprexa, but this was not followed up. The facility's policy on medication regimen reviews, dated 04/01/07, emphasizes the importance of appropriate medication use to maintain each resident's highest practicable level of functioning and to prevent adverse consequences, which was not adhered to in this case.
Medication Administration Error Rate Exceeds Acceptable Threshold
Penalty
Summary
The facility failed to maintain a medication administration error rate of less than 5%, resulting in a medication error rate of 5.41%. This deficiency was identified during an observation of medication administration for a resident. The Licensed Practical Nurse (LPN) prepared morning medications for the resident, which included crushing soft gel capsules of Omega 3 Fish Oil and B Vitamin Complex. The manufacturing guidelines for these medications explicitly state that they should not be crushed or split, as this can lead to incorrect dosages. Despite this, the LPN proceeded to crush the soft gel capsules and attempted to administer the liquid contents, which was not successful for the B Vitamin Complex, leading to a medication error. The resident's physician-signed medication orders required medications to be crushed for ease in swallowing, but the specific forms of Omega 3 Fish Oil and B Vitamin Complex used were not suitable for this method of administration. The LPN confirmed during an interview that the soft gel capsules should not have been crushed and that an alternative form of the medication should have been used. The facility's policy on administering medications, revised in December 2012, mandates that medications be administered in a safe and timely manner as prescribed. The failure to adhere to these guidelines and the manufacturer's instructions resulted in a medication error rate exceeding the acceptable threshold, affecting the resident's medication administration process.
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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 metabolic encephalopathy, muscle weakness, and a history of CVA experienced a fall in his room that was not documented in the medical record until the following morning as a late entry. Two RNs acknowledged that the fall was not recorded at the time it occurred and stated that fall incidents should be documented as soon as possible after the event, resulting in a deficiency for failure to maintain timely, professionally standard medical records.
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.
A resident with cirrhosis, ascites, mood disorder, and alcohol-induced major neurocognitive disorder, and with moderately impaired cognition, was observed sitting on a shower chair in a gown with buttocks exposed and visible from the hallway through an open room door. A CNA left the room quickly after hearing another resident yell and forgot to close the door or pull the privacy curtain, and an RN confirmed the exposure, demonstrating a failure to maintain the resident’s dignity and privacy.
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.
Untimely Documentation of Resident Fall Incident in Medical Record
Penalty
Summary
The deficiency involves the facility’s failure to document a resident’s fall incident in the medical record in a timely manner, in accordance with accepted professional standards. The resident was admitted with diagnoses including metabolic encephalopathy, muscle weakness, and cerebrovascular accident. According to the medical record, a progress note was entered as a late entry on 02/20/26 at 8:21 A.M., stating that the resident had suffered a fall in his room on 02/19/26 at 8:00 P.M. There was no evidence of any documentation of the fall incident entered in the medical record at the time of, or shortly after, the fall on 02/19/26 at 8:00 P.M. During an interview on 03/30/26 at 12:05 P.M., two RNs confirmed that the fall incident was not documented until the following morning and stated that fall incidents should be entered in the medical record as soon as possible following the event. This lack of timely documentation of the fall incident constituted non-compliance with requirements to safeguard resident-identifiable information and maintain medical records in accordance with professional standards.
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.
Resident Left Exposed and Visible From Hallway Due to Failure to Maintain Privacy
Penalty
Summary
The facility failed to ensure resident dignity and privacy when a cognitively impaired resident was left exposed and visible from the hallway. The resident, who had diagnoses including cirrhosis with ascites, mood disorder, and alcohol-induced major neurocognitive disorder, had a BIMS score of eight, indicating moderately impaired cognition. During an observation, the resident was seen sitting on a shower chair in a gown with buttocks exposed, and this exposure was visible from the open room door in the hallway. A Certified Resident Care Associate and a Registered Nurse confirmed that the resident’s buttocks were visible from the hallway. The Certified Resident Care Associate reported that she had left the resident’s room quickly after hearing a resident in an adjacent room yell and, in her haste, forgot to close the door or pull the privacy curtain, resulting in the resident’s exposed state being visible to others. This incident involved one resident out of three reviewed for dignity, in a facility with a census of 52 residents, and was identified through record review, observation, and staff interviews.
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