Roscoe Gardens Skilled Nursing And Rehab
Inspection history, citations, penalties and survey trends for this long-term care facility in Coshocton, Ohio.
- Location
- 100 South Whitewoman Street, Coshocton, Ohio 43812
- CMS Provider Number
- 365880
- Inspections on file
- 23
- Latest survey
- December 30, 2025
- Citations (last 12 mo.)
- 20
Citation history
Health deficiencies cited at Roscoe Gardens Skilled Nursing And Rehab during CMS and state inspections, most recent first.
Staff were observed preparing and serving food without wearing facial hair coverings and by handling food with bare hands, including when preparing a mechanically altered diet for a resident with dementia and no teeth. These actions were not in accordance with the facility's food handling policy, and beard covers were available but not used.
A resident with multiple medical conditions did not receive weekly skin inspections as outlined in their care plan. Although initial and one follow-up inspection were documented, subsequent weekly inspections were missed prior to discharge, as confirmed by the DON.
The facility failed to provide alternate menu items, such as cottage cheese, as reported by several residents. Despite being listed on the alternative menu, cottage cheese had not been ordered since mid-September. The dietary department, contracted to an external company, was unaware of this oversight, leading to the deficiency.
The facility failed to maintain the ice machine and clean the cold air vents, potentially affecting all 57 residents. Observations revealed dusty air ducts and a clogged floor drainpipe causing stagnant water to back up into the ice machine drainpipe. These issues were confirmed with the District Manager, despite the contracted company's responsibility for cleaning and sanitizing.
A resident with anoxic brain injury and mental health disorders reported physical abuse by family, but the facility delayed reporting the allegation to the state survey agency by three days, contrary to policy requiring a two-hour reporting window.
The facility failed to ensure accurate MDS assessments for two residents, leading to discrepancies in medication and diagnosis documentation. One resident's opioid use was not accurately recorded, and another resident's active diagnosis of anxiety was omitted. These inaccuracies were confirmed by interviews with nursing staff.
The facility failed to ensure accurate PASRR documentation for two residents. One resident's PASRR did not reflect an anxiety diagnosis despite being prescribed medication for it. Another resident's PASRR was outdated and did not include current mental health and intellectual disability diagnoses, which were confirmed by staff interviews.
A facility failed to maintain consistent communication with a dialysis center for a resident receiving hemodialysis. The resident, with end-stage renal disease and other conditions, had missing dialysis communication logs on several dates, which were crucial for managing their care. The facility's administrator confirmed the absence of these logs, highlighting a deficiency in maintaining essential records.
A facility failed to address pharmacy recommendations for a resident's pain management and lab work. The resident, with conditions including diabetes and hip pain, was prescribed acetaminophen and tramadol without proper pain parameters, as recommended by the pharmacy. Additionally, the facility did not conduct a recommended HbA1c test every three months. These deficiencies were confirmed by the Regional Care Consultant and the DON during a survey.
A resident with a spinal surgical wound infection did not receive scheduled doses of vancomycin due to unavailability and communication lapses. The facility's pharmacy adjusted the dosage without proper coordination with the infectious disease pharmacist, leading to further missed doses. The facility's policy on medication administration was not adhered to, resulting in significant medication errors.
The facility failed to ensure proper medication storage and administration. An LPN left a medication cart unlocked and unattended, and the DON found a resident's medications left on a bedside table, contrary to policy. Medications should be secured and administered when prepared.
A resident with hemiplegia and hemiparesis experienced significant dental pain after losing a filling, but the LTC facility failed to provide timely dental services. Despite multiple complaints and requests for pain relief, the resident's care plan lacked a dental plan, and the social worker did not secure an emergency dental appointment, mistakenly believing the resident did not meet emergency criteria. The facility's policy to assist in obtaining dental care was not followed.
A facility failed to provide a resident with the prescribed assistive eating device, a small maroon spoon, as ordered by a physician. The resident, who had hemiplegia and was receiving hospice services, was observed using a regular spoon instead. Interviews with staff confirmed the oversight.
A facility failed to implement Enhanced Barrier Precautions (EBP) for a resident with a chronic venous ulcer. The resident was observed without an EBP sign or available PPE, and there was no physician order for EBP, contrary to facility policy. The DON confirmed that EBP should have been in place.
The facility failed to lock three medication carts when unattended, potentially affecting 12 cognitively impaired and independently mobile residents. The carts were found unlocked outside the nurse's station, and a nurse confirmed leaving them unattended while going to the restroom. Facility policy mandates that medication supplies remain locked when not in use or attended by authorized personnel.
A resident with multiple health conditions was mistakenly given another resident's medication, including morphine and other drugs, due to a nurse's failure to follow the six rights of medication administration. The resident became lethargic but did not require Narcan. The incident was reported and investigated, revealing the error's root cause.
A nurse failed to perform proper hand hygiene during medication administration, affecting three residents. After administering medication to a resident, the nurse interacted with visitors and family members without washing her hands before preparing medication for another resident. She used her bare hand to handle medication and continued to administer medication to another resident without washing her hands, only doing so after completing the process. This deficiency was identified during a complaint investigation.
A resident was physically assaulted by another resident in the dining room where no staff were present, resulting in multiple injuries and psychosocial harm. The facility failed to provide timely medical care, notify the physician and authorities promptly, and implement appropriate interventions to ensure resident safety.
The facility failed to maintain an effective abuse prohibition program, resulting in an incident of resident-to-resident physical abuse. The investigation by the DON was inadequate, lacking comprehensive documentation and necessary notifications, leading to a delay in treatment for a resident and potential recurrence of such incidents.
The facility failed to ensure a complete and thorough investigation following an allegation of physical abuse involving two residents. The investigation lacked staff interviews, additional resident interviews, and proper documentation of the incident and injuries in the medical record. The facility's abuse policy was not adequately followed, leading to a deficiency in ensuring resident safety and thorough investigation of abuse allegations.
Failure to Maintain Sanitary Food Handling Practices
Penalty
Summary
During meal service, staff failed to maintain sanitary conditions in the kitchen by not wearing facial hair coverings and by handling food with bare hands. Specifically, one staff member was observed preparing a cheeseburger for a resident on a mechanically altered diet by placing bread and cheese on the plate using bare fingers, rather than gloves or utensils. This was confirmed by another staff member who witnessed the incident. Additionally, two staff members were observed behind the steam table preparing trays and serving food without covering their facial hair, despite beard covers being available in the kitchen. The affected resident had diagnoses including dementia, weakness, and indigestion, required assistance with activities of daily living, and was on a mechanically altered, soft-textured diet due to having no teeth. The facility's food handling policy required food to be stored, prepared, handled, and served in a manner that minimized the risk of foodborne illness. All residents in the facility received food prepared in the kitchen, indicating the potential for widespread impact.
Failure to Complete Weekly Skin Inspections as Care Planned
Penalty
Summary
The facility failed to complete weekly skin inspections for a resident as required by the resident's comprehensive care plan. Medical record review showed that the resident, who had a history of fall with nasal fracture, influenza A, cerebrovascular accident, and traumatic brain injury, was admitted and received a skin inspection upon admission and again on 01/15/25. However, no further weekly skin inspections were documented prior to the resident's discharge on 02/01/25. The care plan specifically included an intervention for weekly skin inspections, but these were not performed on 01/22/25 and 01/29/25. The DON confirmed during interview that the required weekly inspections were missed.
Failure to Provide Alternate Menu Items
Penalty
Summary
The facility failed to ensure that alternate menu items were available to residents, as evidenced by multiple interviews and observations. Residents reported that the facility did not honor food alternatives ordered, and specific items such as cottage cheese, lettuce, and orange juice were unavailable. The alternative menu listed items like tossed salad and cottage cheese, but the facility had not ordered cottage cheese since 09/17/24, as confirmed by the review of food invoices and interviews with staff. The dietary department, contracted out to an external company, was unaware that cottage cheese was on the alternative menu, leading to its unavailability. Resident #56, who had diagnoses including endocarditis, diabetes mellitus, and sepsis, also reported that alternate food items were not always available. The resident's medical record indicated an intact and independent cognition level. The facility's certified dietary manager confirmed that the last order of cottage cheese was on 09/17/24, and none was available at the time of the survey. The food service contract stipulated that all food and supplies would be prepared and served by the contracted company, including items on the alternative menu, but this was not adhered to, resulting in the deficiency.
Ice Machine and Air Vent Maintenance Deficiency
Penalty
Summary
The facility failed to maintain the ice machine and clean the cold air vents, which had the potential to affect all 57 residents residing in the facility. During an observation of the kitchen, it was noted that three cold air ducts and one unused duct were visibly dusty. Additionally, the bottom drainpipe for the ice machine was improperly installed, running directly into the floor drainpipe without a gap. The floor drainpipe was clogged, causing stagnant water to back up into the ice machine drainpipe. These findings were confirmed during an observation with the District Manager. The review of the food service contract from April 25, 2021, indicated that the contracted company was responsible for various tasks, including cleaning and sanitizing. However, the observed deficiencies in the maintenance of the ice machine and cleanliness of the air vents suggest a lapse in fulfilling these responsibilities.
Delayed Reporting of Abuse Allegation
Penalty
Summary
The facility failed to report an allegation of abuse to the state survey agency in a timely manner, affecting one resident. The resident, who had anoxic brain injury, schizoaffective disorder, and bipolar disorder, was admitted with an independent and intact cognition level. On a specified date, the resident reported an allegation of physical abuse by her family, claiming she was hit in the face. Upon assessment, no injuries or signs of abuse were found. However, the facility did not create a self-reported incident (SRI) until three days after the allegation was made, which was verified by the Director of Nursing and Administrator. This delay was contrary to the facility's policy, which required reporting any abuse allegation to the state survey agency within two hours of receipt.
Inaccurate MDS Assessments for Medications and Diagnoses
Penalty
Summary
The facility failed to ensure that the Minimum Data Set (MDS) assessments accurately reflected the medication and pertinent diagnoses for two residents. For Resident #6, the medical record indicated that the resident was prescribed Tramadol, an opioid, and received it on specific dates in August and September 2024. However, the quarterly MDS assessment dated September 5, 2024, inaccurately reported that the resident received an opioid for zero days during the seven-day look-back period. This discrepancy was confirmed during an interview with the MDS/Registered Nurse. For Resident #9, the medical records showed that the resident had diagnoses including schizophrenia, bipolar disorder, major depression, and anxiety. A psychiatry progress note instructed staff to monitor anxiety and schizophrenia. Despite this, the MDS assessment dated June 5, 2024, did not reflect an active diagnosis of anxiety. This inaccuracy was also confirmed during an interview with a Registered Nurse. These findings indicate a failure in accurately documenting the residents' medication use and diagnoses in the MDS assessments.
Inaccurate PASRR Documentation for Residents
Penalty
Summary
The facility failed to ensure that the Pre-Admission Screening and Resident Review (PASRR) documents accurately reflected the diagnoses of two residents. Resident #6 was admitted with diagnoses including schizoaffective disorder, dysphagia, chronic kidney disease, low back pain, and muscle wasting and atrophy. Despite having a diagnosis of anxiety disorder and being prescribed Clonazepam for anxiety, the PASRR document did not indicate this diagnosis. This discrepancy was confirmed by the Social Services Director during an interview. Resident #9 was admitted with multiple diagnoses, including schizoaffective disorder, bipolar disorder, major depressive disorder, general anxiety, and intellectual disabilities. However, the PASRR document from 2018 did not reflect any mental illness or intellectual disability, and there was no evidence of a PASRR update since then. The resident's current diagnoses and treatment plan indicated serious mental illness and intellectual disabilities, which were not captured in the PASRR. This was confirmed by a social worker, who acknowledged that the resident would require a Level II PASRR screening based on current diagnoses.
Inconsistent Communication with Dialysis Center
Penalty
Summary
The facility failed to ensure consistent communication between the facility and the dialysis center regarding a resident's hemodialysis treatments. This deficiency affected a resident who was the only individual in the facility receiving dialysis treatments. The resident had been admitted with diagnoses including end-stage renal disease, essential hypertension, and type two diabetes mellitus with diabetic nephropathy. The resident's care plan included interventions for outpatient dialysis three times a week and required communication with the dialysis center regarding medication, diet, and lab results. Upon review, it was found that the dialysis communication logs for the resident were missing on several dates in September 2024. These logs were crucial as they contained vital information such as the resident's code status, transfer time, allergies, mental status, medications, skin issues, and pre and post-dialysis weights. The absence of these logs was confirmed by the facility's administrator, indicating a lapse in maintaining essential communication records necessary for the resident's dialysis care.
Failure to Address Pharmacy Recommendations for Pain Management and Lab Work
Penalty
Summary
The facility failed to address pharmacy recommendations regarding a resident's pain medication and lab work in a timely manner. The resident, who was admitted with diagnoses including type two diabetes mellitus, pain in the left hip, and a non-pressure chronic ulcer of the left foot, was prescribed acetaminophen and tramadol for pain management. However, the pharmacy recommended evaluating these medications and establishing proper pain parameters, which the facility did not implement. Additionally, the resident's October 2024 physician orders did not include pain parameters for the prescribed medications. Furthermore, the facility did not obtain a Hemoglobin A1C (HbA1c) test every three months as recommended by the pharmacy. This oversight was confirmed during interviews with the Regional Care Consultant and the facility's Director of Nursing (DON), who acknowledged that the lab work was not completed as required. These deficiencies affected the resident's care and were identified during a survey of the facility.
Failure to Administer Vancomycin as Prescribed
Penalty
Summary
The facility failed to ensure that a resident was free from significant medication errors, specifically concerning the administration of vancomycin for a spinal surgical wound infection. The resident, who was admitted with diagnoses including infection and inflammatory reaction due to orthopedic prosthetic devices, did not receive scheduled doses of vancomycin on multiple occasions. On the day of admission, the resident missed the second dose of vancomycin, and the first dose the following day, due to the medication not being available in the emergency medication kit. Additionally, the resident missed another dose later in the month for the same reason. There was no documented evidence that the infectious disease physician or the facility's physician was notified of these missed doses. Further issues arose when the facility's pharmacy adjusted the vancomycin dosage without proper communication with the infectious disease pharmacist. The infectious disease pharmacist had recommended holding certain doses and re-drawing trough levels, but these instructions were not followed, and no orders were written to hold the medication. The Director of Nursing confirmed these lapses in medication administration and communication. The facility's policy on medication administration, which requires adherence to prescriber's written orders, was not followed in these instances.
Medication Storage and Administration Deficiencies
Penalty
Summary
The facility failed to ensure medications were stored appropriately, as observed on two separate occasions. On the first occasion, a medication cart in the Sycamore Valley area was left unlocked and unattended while the LPN responsible was in a resident's room at the other end of the hall. This was confirmed by a State tested Nurse's Aide who noted the cart was not secured as per the facility's policy, which mandates that medication carts must be closed and locked when out of the nurse's sight. On the second occasion, the Director of Nursing observed a pill cup with several pills on a resident's bedside table. The resident explained that the nurse had left the medications there earlier because she preferred to take them with her breakfast. The DON confirmed that medications should not be left unattended and should be administered at the time they are prepared, as per the facility's policy. The medications involved included a range of prescriptions such as aspirin, budesonide, and metoprolol succinate, among others.
Failure to Provide Timely Dental Services
Penalty
Summary
The facility failed to ensure timely dental services for a resident who was admitted with hemiplegia and hemiparesis following a cerebral infarction, among other conditions. The resident, whose primary insurance was Medicaid, lost a filling in a bottom right tooth and began experiencing significant pain. Despite multiple complaints of pain documented in progress notes from early September, the resident did not receive a dental appointment. The resident's care plan lacked any evidence of a dental plan, and the facility's social worker did not complete an emergency referral form, believing the resident did not meet the criteria for an emergency visit. The resident continued to experience pain, requiring Tylenol for relief, and expressed frustration over the delay in receiving dental care. The social worker was aware of the dental issues but did not attempt to secure an appointment with an outside dentist, mistakenly believing that the resident would have to wait for the facility dentist's next visit. It was only after further inquiry that the social worker discovered a local dental office would see Medicaid patients promptly. The facility's policy stated that they would assist residents in obtaining both routine and emergency dental care, which was not adhered to in this case.
Failure to Provide Assistive Eating Device
Penalty
Summary
The facility failed to provide an appropriate assistive device for a resident, leading to a deficiency in care. Resident #5, who was admitted with diagnoses including hemiplegia and hemiparesis following a cerebral infarction, muscle wasting, lack of coordination, and cognitive communication deficit, was affected by this oversight. The resident was cognitively intact and receiving hospice services, with a care plan indicating limited ability to eat and drink due to weakness and dysphagia. A physician's order specified the use of a small maroon spoon as an assistive device during meals. However, during an observation, the resident was seen using a regular spoon instead of the prescribed assistive device. Interviews with the Regional RN Consultant and the Dietary Manager confirmed the absence of the small maroon spoon, as ordered by the physician.
Failure to Implement Enhanced Barrier Precautions
Penalty
Summary
The facility failed to implement Enhanced Barrier Precautions (EBP) for a resident admitted with a chronic venous ulcer. The resident, who had diagnoses including unspecified venous ulcer, cellulitis, morbid obesity, and peripheral vascular disease, was observed without an EBP sign on the door or available Personal Protective Equipment (PPE) near the resident's door. The medical record review revealed that there was no physician order for EBP, despite the facility's policy indicating that EBP should be in place for residents with chronic wounds. The Director of Nursing confirmed that EBP should have been implemented for the resident.
Unattended and Unlocked Medication Carts
Penalty
Summary
The facility failed to ensure that three medication carts were locked when unattended, which had the potential to affect 12 cognitively impaired and independently mobile residents. During an observation on the Buckeye Unit, three medication carts were found outside the nurse's station, unlocked and unattended. An interview with a nurse confirmed that she had left the medication carts unlocked while she went to the restroom. The facility's policy on medication storage requires that medications and biologicals be stored properly and accessible only to authorized personnel, with medication supplies remaining locked when not in use or attended by authorized individuals. This deficiency was identified during a complaint investigation.
Medication Error Involving a Resident
Penalty
Summary
The facility failed to ensure that a resident's drug regimen was free from unnecessary drugs, resulting in a medication error involving Resident #58. The resident, who had multiple diagnoses including cellulitis, urinary tract infection, cognitive communication deficit, dysphagia, hypertension, dementia, atherosclerotic heart disease, chronic kidney disease, and atrial fibrillation with a pacemaker, was given another resident's medication. This error occurred on the morning of 06/13/24 when Nurse #100 administered the wrong medication to Resident #58, which included a combination of drugs such as mycophenolate, cyclosporine, famotidine, Ativan, magnesium oxide, morphine, nystatin, and prednisone. Following the medication error, the nurse reported the incident, and the Nurse Practitioner was contacted. Orders were given to administer Narcan if the resident's respirations fell below 10 per minute and did not improve with arousal, and to send the resident to the emergency room if Narcan was administered. The resident's vital signs were closely monitored, and additional tests were ordered to assess hepatic and kidney function. The resident was noted to be lethargic and drowsy but did not require Narcan administration as her condition did not deteriorate to that extent. The facility's investigation determined that the root cause of the medication error was the failure of Nurse #100 to adhere to the six rights of medication administration. The Director of Nursing confirmed the error and noted that the resident's only change in condition was a slight drop in oxygen levels. The facility's policy on medication discrepancies required documentation and reporting of such incidents, which was followed in this case. This deficiency was investigated under Complaint Number OH00154888.
Failure to Perform Proper Hand Hygiene During Medication Administration
Penalty
Summary
During a medication administration observation, Nurse #101 failed to perform proper hand hygiene, affecting three residents. After administering medication to Resident #51, the nurse hugged a visitor and shook hands with a family member without washing her hands before preparing medication for Resident #54. She used her bare hand to remove a gabapentin capsule from the medication card and placed it into a medication cup. The surveyor intervened, and a new capsule was administered. The nurse continued to set up medication for Resident #25 without washing her hands, only washing them after completing the administration. An interview with Nurse #101 confirmed the lack of hand hygiene during the medication administration process for Residents #25, #51, and #54. This deficiency was identified during a complaint investigation.
Failure to Prevent Resident-to-Resident Abuse
Penalty
Summary
The facility failed to ensure Resident #2 was free from an incident of resident-to-resident abuse. On 04/21/24, Resident #2 was physically assaulted by Resident #3 in the dining room where no staff were present. Resident #3 struck Resident #2 multiple times, resulting in two facial lacerations, a laceration to the lower lip, and multiple hematomas on the arms, upper breasts, and chest wall. Resident #2 also experienced psychosocial harm, expressing fear of reoccurrence and isolating herself from activities and meals. The facility did not provide timely medical evaluation, failed to notify the physician and authorities promptly, and did not implement appropriate interventions to ensure resident safety. Resident #2 had a history of schizoaffective disorder, bipolar type, anxiety, major depressive disorder, personality disorder, cognitive communication disorder, dysphagia, heart failure, muscle weakness, and seizure disorder. The care plan for Resident #2 included interventions for verbal behaviors and supervision during meals due to poor self-monitoring and impulsivity with eating. Despite these interventions, the incident occurred, and the facility's response was inadequate. The facility did not conduct a thorough investigation, failed to provide timely medical care, and did not offer psychosocial support to Resident #2 following the incident. Resident #3 had a history of diffuse traumatic brain injury, major depressive disorder, mood disorder, anxiety disorder, and muscle weakness. The care plan for Resident #3 included monitoring for anxiety, restlessness, poor impulse control, and fear/apprehension. Despite these interventions, Resident #3 exhibited aggressive behavior towards Resident #2. The facility did not provide adequate supervision in the dining room, failed to implement appropriate interventions to prevent further incidents, and did not conduct a comprehensive investigation following the altercation. The facility's failure to ensure resident safety and provide appropriate care resulted in Immediate Jeopardy and physical and psychosocial harm to Resident #2.
Removal Plan
- 1:1 supervision was initiated for Resident #3 with one staff member assigned for supervision of the resident. Additional staff were added to the shifts (as needed) to ensure monitoring occurred until the resident's discharge. The following staff provided 1:1 supervision through discharge: State tested Nursing Assistant (STNA) #130, #148, #160, and Activities Staff #160.
- An Ad-Hoc Quality Assurance Performance Improvement (QAPI) meeting was held. Regional DON #702 and VPCO #703 educated the Administrator, DON, Medical Director #701, Business Office Manager (BOM) #96, Therapy Manager #95, SSD #100, the ADON, LPN #132, Dietary Manager (DM) #92, Plant Operations (PO) #90, Activities Director #91 on the facility abuse policy, Centers for Medicare and Medicaid abuse reporting guidelines, future expectations with reporting abuse and completing investigations. Topics also discussed during the meeting were resident behaviors and care planned interventions as well as the facility removal plan. QAPI committee meetings would be held weekly for weeks, then monthly for recommendations and further follow-up regarding the removal plan based upon evaluation of audits and observations. Audits would continue to be submitted to the QAPI committee for review and to ensure compliance goals. QAPI committee reserved the right to modify or extend monitoring times according to outcomes. The Administrator was responsible for the oversight of this plan to ensure ongoing compliance. Any issues identified thru the audits would be reviewed and revised thru the facility QAPI process.
- The DON and Licensed Practical Nurse (LPN) #132 completed a record review for all 57 residents (the current census) for behavioral diagnosis including but not limited to traumatic brain injury (TBI), dementia and schizophrenia with no newly identified residents at risk for resident-to-resident abuse through diagnoses.
- LPN #132 reviewed residents (Residents #51, #27, #49, #20, #60, #9, #17, #35, #32, #36, #13, #2, #8, #29, #38, #23, #64, #6, #54, and #58) determined to be at risk for potential aggressive behaviors to ensure care planned interventions were appropriate.
- Resident #3 was placed in a private room by Plant Director #158 and Medical Records #126.
- The Director of Nursing spoke with Resident #6 (the resident who witnessed the incident between Resident #3 and Resident #2) to offer emotional/psychosocial support, but the resident declined.
- Facility resident profiles for residents at risk for potential aggressive behaviors (Residents #51, #27, #49, #20, #60, #9, #17, #35, #32, #36, #13, #2, #8, #29, #38, #23, #64, #6, #54, and #58) were updated to reflect care planned interventions to be followed when caring for a resident with a behavioral care plan by SSD #100, LPN #132 and/or the ADON.
- Resident #2 was evaluated by Physician #810 regarding the incident with Resident #3 via telehealth. The provider's progress note indicated there were no lasting effects from the incident. There were no current updates made to the resident's care plan and no new orders were received.
- All 82 staff (17 nurses, 23 STNA, two Activity Aides, 14 Department Managers, two Agency Nurses, 12 therapy, seven dietary and five housekeeping/laundry) were educated by the Administrator, DON or ADON either in-person or by phone regarding the facility abuse policy and reporting abuse to the Administrator (the facility abuse coordinator).
- All nursing staff (17 nurses, 23 STNA and two agency nurses) were educated either in person or via phone on access to resident care plans by SSD #100, LPN #132, the DON, or the Assistant Director of Nursing (ADON). A hand-out was also provided regarding how to access the information and the staff who received education via phone will receive the hand-out on their next scheduled shift. Staff will also be required to show a return demonstration or recite the process on their next scheduled shift. The resident profiles are in the electronic medical record (EMR).
- The facility implemented a plan that any facility initiated Self Reportable Incident(s) and facility investigation(s) would be escalated to regional support, Regional DON #702, and [NAME] President of Clinical Operations (VPCO) #703 for review to ensure the facility policy was followed.
- A plan for Social Services Designee (SSD) #100 to conduct weekly psychosocial follow-up with Resident #2 was implemented to ensure no lingering effects from the incident had occurred. Follow up would be completed for four weeks.
- The DON, ADON, and/or LPN #132 would review all new admissions for behavior risks.
- Auditing would be completed by the Director of Nursing/Assistant Director of Nursing and/or LPN #132 five days a week for the next eight weeks then three times a week for four weeks for all residents, which includes all new admissions.
- The Director of Nursing, ADON and/or LPN #132 would review/audit all nursing staff documentation including progress notes, events, observations, and Care Assist documentation to ensure all residents with behaviors have care planned interventions to ensure safety. Auditing would be completed on all current residents five days a week for eight weeks, then three times a week for four weeks.
- Resident #3 was discharged to a sister facility related to the resident's behavioral health needs.
- The Administrator, DON, Medical Director #701, Business Office Manager (BOM) #96, Therapy Manager #95, SSD #100, the ADON, LPN #132, Dietary Manager (DM) #92, Plant Operations (PO) #90, and Activities Director #91 conducted an audit (questionnaire) of current interviewable residents, whose Brief Interview for Mental Status (BIMS) score was eight and higher with no reported incidents of abuse and the residents interviewed indicated they felt safe within the facility.
- Non-interviewable residents (#27, #71, #47, #9 and #58), received a skin assessment.
Failure to Maintain Effective Abuse Prohibition Program
Penalty
Summary
The facility failed to maintain effective administrative services to provide a comprehensive abuse prohibition program, resulting in an incident of resident-to-resident physical abuse. The incident involved Resident #2 and Resident #3, where Resident #2 alleged that Resident #3 attacked her in the dining room. The initial investigation by the Director of Nursing (DON) was inadequate, as it did not include obtaining witness statements from all involved staff, conducting thorough resident interviews, or completing necessary skin assessments for non-interviewable residents. Additionally, the DON did not notify the psychiatric providers or the attending physician of the incident, resulting in a delay of treatment for Resident #2. The DON was administering medications at the time of the incident and was working as a floor nurse due to staffing needs. The DON's investigation concluded that the incident did not constitute abuse, as she believed Resident #3 did not act willfully to harm Resident #2. However, the investigation lacked comprehensive documentation, including staff statements and interviews, and failed to implement preventative interventions following the altercation. The facility's self-reported incident (SRI) indicated that Resident #2 had scratches on her face and later developed bruises on her chest and forearms, but the DON did not document these injuries in the resident's medical record or notify the physician. The Administrator, who was also the facility Abuse Coordinator, confirmed that the investigation should have included staff interviews and resident assessments. The facility's policy on abuse, neglect, and misappropriation of property required a thorough investigation and documentation of all allegations, which was not followed in this case. The failure to conduct a comprehensive investigation and implement corrective actions resulted in the potential for recurrence and compromised the safety and well-being of the residents in the facility.
Incomplete Investigation of Physical Abuse Allegation
Penalty
Summary
The facility failed to ensure a complete and thorough investigation following an allegation of physical abuse involving two residents. Resident #2 alleged that Resident #3 attacked her in the dining room, resulting in scratches and bruises. The only witness, Resident #6, corroborated Resident #3's account that Resident #2 had instigated the altercation by attempting to remove Resident #3's oxygen tubing. The facility's investigation, led by the Director of Nursing (DON), concluded that the allegation was unsubstantiated and did not suspect abuse. However, the investigation was incomplete, lacking staff interviews, additional resident interviews, and proper documentation of the incident and injuries in the medical record. The DON did not notify the psychiatric providers of the involved residents, and there was no follow-up from psychiatry for either resident following the incident. Additionally, the facility failed to provide evidence of a 72-hour psychosocial evaluation for Resident #2, who expressed fear and tearfulness when reminded of the incident. The facility's abuse policy was not adequately followed, leading to a deficiency in ensuring resident safety and thorough investigation of abuse allegations.
Latest citations in Ohio
A resident with intact cognition receiving Medicare Part A skilled services for metabolic encephalopathy had services discontinued while benefit days remained, but the facility did not issue the required Skilled Nursing Facility Advance Beneficiary Notice (SNF ABN). The Social Services Director later confirmed that no SNF ABN was provided and reported she believed only a Notice of Medicare Non-Coverage (NOMNC) was needed when all skilled services were stopped. This practice conflicted with the facility’s written policy, which required SNF ABNs to be issued when extended care items or services were initiated, reduced, or terminated due to expected non-coverage by Medicare.
Surveyors identified that the facility exceeded the acceptable medication error rate when two residents with type 2 DM received insulin doses that were not administered according to orders or manufacturer instructions. In two separate observations, an LPN administered Novolog and another LPN administered insulin glargine and insulin lispro without priming the insulin pens, and the insulin lispro and Novolog were given after the residents had already consumed a significant portion of their breakfast meals, despite orders for administration before meals. Manufacturer information for both insulin products required priming before each injection to ensure accurate dosing, and facility policy required medications, including insulin, to be administered safely, timely, and in accordance with prescriber orders and specified time frames.
Surveyors found that the facility failed to document tray line food temperatures for multiple meals served from two dining room kitchenettes, despite having a “Trayline Taste & Temperature Log” and a policy requiring food to be stored, prepared, distributed, and served according to professional food safety standards. Review of logs showed repeated missing entries for breakfast, lunch, and dinner services in both the Harrison and McClellan dining areas, and the Senior Director of Culinary Services confirmed that temperatures had not been recorded for those meals, potentially affecting all residents receiving meals from those kitchenettes.
The facility failed to conduct and document required periodic care conferences for two residents, despite multiple comprehensive, quarterly, and significant change MDS assessments and a policy requiring periodic care conferences with resident and/or family participation. One resident with Parkinson’s disease, post-stroke hemiplegia, TIA, DMII, and depression had only two documented care conferences over a year, while another resident with aphasia, cerebrovascular disease, DMII, gait difficulty, coagulation defect, depression, and muscle weakness had no documented care conferences in the past year, aside from a declined invitation to the representative. The UCC confirmed that care conferences were expected to occur quarterly and that no additional documentation existed for either resident.
A resident with Alzheimer's disease and type II DM, who required extensive assistance with ADLs and was receiving scheduled Lantus and sliding-scale Humalog, experienced a severely elevated blood glucose level. The on-call provider was notified and ordered an additional dose of lispro insulin with a directive to recheck the blood glucose after administration. Nursing staff administered the extra insulin but did not document any follow-up blood glucose check, and the DON confirmed that this reevaluation was required by the facility's abnormal blood glucose policy and was not completed or documented.
A resident with Parkinson’s disease, dementia, and hypothyroidism was prescribed levothyroxine once daily along with other medications. A consultant pharmacist’s monthly drug regimen review recommended that levothyroxine be given in the morning on an empty stomach, 30–60 minutes before food, per manufacturer instructions. The medical record contained no documented physician response to this recommendation, and the MAR showed the drug scheduled for morning administration while the resident was observed eating breakfast and receiving the medication at the same time. An LPN confirmed administering levothyroxine during the meal, and the DON verified there was no documentation explaining whether or why the pharmacist’s recommendation was or was not followed, resulting in a failure to act on and document the identified irregularity.
A resident with severe cognitive impairment, multiple comorbidities, documented gait and balance abnormalities, and a high fall risk was care planned and assessed by therapy to require contact guard assistance and use of a gait belt for transfers and ambulation. While being assisted by a CNA from a recliner to the bathroom with a walker, the CNA did not apply a gait belt, even though the resident had a known tendency to lean backward when standing. As the CNA reached to open the bathroom door, the resident lost balance and fell backward, striking the back of the head, and was later found by an LPN without a gait belt in place, contrary to the facility’s gait belt policy and the resident’s assessed needs.
A resident with CKD stage five requiring peritoneal dialysis (PD) was admitted with pre-admission physician orders for three daily PD exchanges and monitoring for peritonitis (fever, abdominal pain, cloudy effluent), but these monitoring orders were not entered into the facility’s physician orders. The care plan referenced PD and general monitoring but did not specifically address peritonitis monitoring. Paper PD flowsheets showed incomplete and inconsistent documentation of exchanges and resident condition, including missing condition/comments for individual treatments and no record of one ordered PD exchange. The PD cycler flowsheet lacked effluent descriptions on multiple days. The PD nurse reported facility staff were expected to monitor effluent and symptoms, and the DON confirmed the absence of specific peritonitis monitoring orders, lack of an order for the PD cycler, and documentation gaps, despite a facility policy requiring ongoing assessment and monitoring for complications before, during, and after dialysis treatments.
A nurse was observed preparing multiple oral medications for a resident with depression, traumatic brain injury, anxiety, and impaired cognition by pushing tablets and capsules from unit-dose cards directly into her ungloved hand and then using her fingers to place them into a medication cup. In a follow-up interview, the RN confirmed this practice and acknowledged that the correct procedure is to dispense medications directly from the card into the cup, contrary to the facility’s medication administration policy requiring adherence to good nursing principles and practices.
A resident with Alzheimer’s disease, diabetes, anxiety, significant ADL dependence, and behavioral symptoms was observed seated in a chair positioned against the nursing station with a locked wheelchair placed directly in front, also against the nursing station, effectively restricting movement. An LPN confirmed both wheelchair wheels were locked and that it should not have been placed there, while a CNA stated she had positioned the wheelchair to prepare for lunch, was unable to complete the transfer, and left it in place, acknowledging this was wrong. This arrangement conflicted with the facility’s restraint policy, which prohibits physical restraints except when alternatives are ineffective for treating a medical symptom and defines restraints as devices adjacent to the body that cannot be easily removed and that restrict freedom of movement or access to the body.
Failure to Issue Required SNF ABN When Discontinuing Medicare Part A Services
Penalty
Summary
The deficiency involves the facility’s failure to issue a Skilled Nursing Facility Advance Beneficiary Notice (SNF ABN) when Medicare Part A services were discontinued for a resident who still had available benefit days. The resident was admitted with a diagnosis of metabolic encephalopathy and had intact cognition per the Minimum Data Set assessment. The facility’s own SNF Beneficiary Notification Review documented that Medicare Part A skilled services began on 02/11/26 and the last covered day was 03/11/26, and that the facility initiated discharge from Medicare Part A services before the resident’s benefit days were exhausted. Despite this, no SNF ABN was provided to the resident or the resident’s representative. During interviews, the Social Services Director stated that the SNF ABN was issued hours prior to the last covered day but, upon reviewing her files, confirmed that no SNF ABN had actually been issued for this resident. She further explained that she believed an SNF ABN was only required if one skilled service remained and that if all skilled services were being discontinued, only the Notice of Medicare Non-Coverage (NOMNC) needed to be issued. The Administrator, however, stated that a resident should always receive both a SNF ABN and a NOMNC when Medicare Part A services are discontinued and benefit days remain. Review of the facility’s written policy dated 03/28/23 showed that the facility was required to issue SNF ABNs for initiation, reduction, or termination of extended care items or services when Medicare payment was not expected, which did not occur in this case.
Plan Of Correction
This Plan of Correction is submitted as required under State and Federal law. This Plan of Correction does not constitute an admission on the part of the Facility that the findings cited are accurate, that the findings constitute a deficiency or that the scope and severity regarding the deficiency cited are correctly applied. Any changes to the Facility's policies and procedures should be inadmissible in any proceeding on that basis. Without admitting or denying the validity or the existence of the alleged noncompliance, the Facility submits this Plan of Correction with the intention that it be inadmissible by any third party in any civil or other action against the facility or any employee, agent, officer, director or shareholder of the Facility. The Facility is utilizing this Plan of Correction as its allegation of substantial compliance as of 05/29/2026 F-0582 Corrective action for resident/s: On 5/14/26 Resident #34 was informed of rights and responsibilities related to Advanced Beneficiary Notice and voiced understanding of information for future reference by administrator. Identification of other residents who may be affected: Any resident receiving skilled services from nursing or therapy services. The Administrator audited all residents who were discharged from skilled services in the past 30 days to ensure they were issued a Notice of Non-Coverage and Advanced Beneficiary Notice on 5/29/26. No non-compliance was noted. Measures for systemic change: On 5/14/2026 Business Office Manager, Director of Rehab, Minimum Data Set nurse, Director of Nursing and Social Services Director were educated on proper procedure of issuing of Notice Of Medicare Non Coverage and Advanced Beneficiary Notice by administrator. All upcoming discharges from skilled services will be reviewed weekly at Utilization Review meeting to ensure notices will be delivered timely. How Corrective Action will be monitored: Administrator or designee to complete audits of all residents being discharged from skilled services to ensure they were issued a Notice of Non-Coverage and Advanced Beneficiary. This audit will be completed weekly x 4 weeks, then monthly x 2 months. Corrective action will be initiated for any noted non-compliance. Audit findings will be reviewed as part of the monthly quality assurance process to determine the need for further monitoring. Date of Compliance 5/29/26
Insulin Administration Errors and Failure to Prime Insulin Pens
Penalty
Summary
The deficiency involves the facility’s failure to maintain a medication error rate below 5%, with surveyors identifying 3 errors out of 28 medication administration opportunities, resulting in a 10.71% error rate. For one resident with type 2 diabetes mellitus and moderate cognitive impairment, the physician’s order directed Novolog insulin 10 units via subcutaneous pen-injector to be given before meals. During an observed medication pass, the LPN administered 10 units of Novolog insulin without priming the pen and did so after the resident had already consumed approximately 50% of the breakfast meal. The LPN later confirmed she did not prime the pen and acknowledged that the insulin was ordered to be administered prior to meals. Manufacturer instructions for the Novolog FlexPen specified that an air shot (priming) must be performed before each injection to ensure proper dosing. Another resident, also diagnosed with type 2 diabetes mellitus and with intact cognition, had orders for insulin glargine 35 units subcutaneously twice daily and insulin lispro 20 units subcutaneously before meals, plus 12 units subcutaneously if blood glucose was between 251 mg/dL and 300 mg/dL. During an observed medication administration, an LPN administered 35 units of insulin glargine and 32 units of insulin lispro without priming the insulin pens and after the resident had consumed approximately 90% of the breakfast meal, despite orders for insulin lispro to be given before meals. The LPN later stated she could not remember if she had primed the pen and acknowledged that the insulin was ordered to be administered prior to meals. Manufacturer information for insulin lispro stated that the pen must be primed before each injection to confirm insulin delivery and remove air, and that failure to prime could result in too much or too little insulin. The DON confirmed the expectation that insulin be administered as ordered, including priming each pen with two units before dialing the prescribed dose, and facility policy required medications, including insulin, to be administered safely, timely, and in accordance with prescriber orders and required time frames.
Plan Of Correction
This Plan of Correction is submitted as required under State and Federal law. This Plan of Correction does not constitute an admission on the part of the Facility that the findings cited are accurate, that the findings constitute a deficiency or that the scope and severity regarding the deficiency cited are correctly applied. Any changes to the Facility's policies and procedures should be inadmissible in any proceeding on that basis. Without admitting or denying the validity or the existence of the alleged noncompliance, the Facility submits this Plan of Correction with the intention that it be inadmissible by any third party in any civil or other action against the facility or any employee, agent, officer, director or shareholder of the Facility. The Facility is utilizing this Plan of Correction as an allegation of substantial compliance as of 5/29/2026. F-0759 Corrective action for resident/s: Residents #21 and #22 were assessed and evaluated by nurse and Director of Nursing 5/14/26. Resident #21 and #22 both denied any adverse effects and none were noted upon assessment by the Director of Nursing on 5/14/2026. Notification made to physician on 5/14/2026. LPN # 2 competency Eval on insulin administration with the Director of Nursing completed 5/14/2026. Identification of other residents who may be affected: Diabetic residents on assignment of LPN #2/station 2 have the potential to be affected and were assessed by the DON/Designee on 5/14/26 and found to be within normal limits. Measures for systemic change: All Nurses were educated by the Director of Nursing on the steps for Insulin administration per competency, diabetes clinical protocol policy, Medication and treatment orders policy, administering medications policy, and Obtaining fingerstick Glucose Level policy On 5/14/2026. How Corrective Action will be monitored: Director of Nursing and Assistant Director of Nursing will complete insulin administration audits on 5 nurses. This audit will be completed weekly x 4 weeks, then monthly x 2 months. Corrective action will be initiated for any noted non-compliance. Audit findings will be reviewed as part of the monthly quality assurance process to determine the need for further monitoring. Date of Compliance: 5/29/2026
Failure to Document Tray Line Food Temperatures in Dining Room Kitchenettes
Penalty
Summary
The deficiency involves the facility’s failure to document tray line food temperatures for meals served from the Harrison and McClellan Dining Room kitchenettes, as required by professional standards for food service safety and the facility’s own policy. Review of the “Trayline Taste & Temperature Log” (revised September 2018) showed missing temperature documentation for multiple meals from the Harrison Dining Room kitchenette, including dinner on 03/30/26 and 03/31/26, lunch and dinner on 04/01/26 and 04/02/26, dinner on 04/07/26, and lunch and dinner on 04/08/26 and 04/10/26. The Senior Director of Culinary Services confirmed during interview that tray line food temperatures were not documented on the log for these meals. Similarly, review of the same log for the McClellan Dining Room kitchenette revealed that tray line food temperatures were not documented for dinner on 04/01/26, breakfast and lunch on 04/02/26, and lunch and dinner on 04/07/26. The Senior Director of Culinary Services also verified these omissions during interview. The facility census at the time was 27 residents, and the governing “Food and Nutrition” policy, approved on 09/07/21, stated that the facility must store, prepare, distribute, and serve food in accordance with professional standards for food service safety.
Plan Of Correction
F812 The facility will continue to ensure food temperatures are completed before meals are served for all residents. To ensure compliance with this standard the following measures have been taken: 1. Immediately 4/15/26 culinary supervisor #224 was re-educated by Dietary Manager to this standard and policy "Food and Nutrition" which includes documentation of food temperatures. 2. All dietary staff have been re-educated to the standard and policy "Food and Nutrition" during the month of April 2026. 3. Audits of food temperature documentation to be completed by Dietary Manager 4 x per week for 4 weeks then weekly for 4 weeks. 4. Administrator to validate audits/compliance and provide additional training as needed. Administrator will present to QAPI committee for ongoing monitoring and further direction.
Failure to Conduct and Document Required Care Conferences
Penalty
Summary
The deficiency involves the facility’s failure to complete and document comprehensive care conferences at required intervals in accordance with care plan regulations and facility policy. For one resident with Parkinson’s disease with dyskinesia, cognitive communication deficit, hemiplegia and hemiparesis following cerebral infarction, transient cerebral ischemic attack, type II diabetes mellitus, and major depressive disorder, the record showed multiple MDS assessments over a one-year period, including annual, quarterly, and significant change assessments. However, only two care conferences were documented during the last 12 months, despite the expectation that care conferences be conducted quarterly with the resident and family when possible. The Unit Care Coordinator confirmed that no additional care conference documentation existed for this resident beyond the notes dated 04/21/25 and 01/02/26. A second resident, with diagnoses including aphasia following cerebrovascular disease, cerebral infarction, type II diabetes mellitus, unsteadiness on feet, difficulty in walking, coagulation defect, depression, and muscle weakness, also had multiple MDS assessments completed over the review period, including quarterly and annual assessments. The record contained a note that a care conference was offered to the resident’s representative, who declined to attend, but there was no documentation of any care conferences for the most recent 12 months. The Unit Care Coordinator confirmed that no other care conference documentation was available for this resident. Facility policy stated that periodic care conferences involving the resident, family, and the interdisciplinary team are part of the care planning process, but the required periodic care conferences and corresponding documentation were not completed for these two residents.
Plan Of Correction
THIS PLAN OF CORRECTION SERVES AS BERKELEY SQUARE'S CREDIBLE ALLEGATION OF SUBSTANTIAL COMPLIANCE AS OF June 1, 2026. Without admitting or denying the validity or existence of the alleged deficiencies, Berkeley Square provides the following Plan of Correction: F657 The facility will continue to document completion of care conferences at the required intervals for all residents, including residents #04 & #15. To ensure compliance with this standard the following measures have be taken: 1. The social service designee and the inter- disciplinary team were re-educated by the administrator to the facility policy "Care Conference" on 4/29/26 and verbalized understanding. 2. Care conferences for resident #04 and resident #15 were conducted on or before 4/29/2026 by the interdisciplinary team. 3. Review of all other residents was conducted by the social service designee to validate and ensure that care conference schedule is up to date with timely care conferences scheduled for them on 4/15/2026. Audits of care conferences to be completed weekly for four weeks and then monthly after that by the social service designee. Documentation of the care conference including any identified concerns in the medical record. Administrator to validate audits/compliance and provide additional training as needed. Administrator will present results of these audits to QAPI committee for ongoing monitoring and further direction.
Failure to Reevaluate Blood Glucose After Treatment for Hyperglycemia
Penalty
Summary
The facility failed to ensure that a resident with diabetes received treatment in accordance with professional standards of practice when nursing staff did not reevaluate the resident's blood glucose after treatment for severe hyperglycemia. The resident, admitted with diagnoses including Alzheimer's disease, type II diabetes mellitus, and depression, had physician orders for Humalog insulin on a sliding scale before meals, Lantus insulin 25 units daily, and lisinopril 5 mg daily. The resident required extensive assistance with activities of daily living, including transfers, toileting hygiene, eating, and bathing. On the evening in question, the resident's blood glucose was documented as 532 mg/dL, and the on-call provider was notified. The provider gave a new order to administer an additional 8 units of lispro (Humalog) and to recheck the blood glucose in 30 minutes. The electronic medication administration record showed that the blood glucose of 532 mg/dL was obtained at 9:00 p.m. and that the additional 8 units of lispro were administered at 9:21 p.m. However, there was no documentation in the resident's chart that the blood glucose was rechecked after the additional insulin was given. In an interview, the DON confirmed there was no evidence of reevaluation and verified that, according to the facility's "Abnormal Blood Glucose Procedure" policy, the resident should have been reevaluated and that the evaluation step should have been included in the progress note documentation.
Plan Of Correction
F684 The facility will continue to ensure all residents, including #03, receive treatment in accordance with professional standards of practice and reevaluated for hyperglycemia. To ensure compliance with this standard the following measures have been taken: 1. The director of nursing assessed resident #03, reviewed documentation and orders and found no ill effects immediately 4/16/26. 2. All licensed nurses were re-educated to facility policy "Blood Glucose Monitoring" by the Director of Nursing/designee in April 2026. 3. Audits of like-residents that require blood sugar checks to be completed by the director of nursing/designee two times a week for 4 weeks and then monthly after that to validate correct follow through when there is abnormally high blood glucose result. The Administrator will bring results of these audits to the QAPI committee for ongoing monitoring and further direction.
Failure to Act on Pharmacist Drug Regimen Recommendation for Thyroid Medication
Penalty
Summary
The deficiency involves the facility’s failure to ensure that pharmacy recommendations from the monthly drug regimen review were acted upon and documented for a resident. The resident was admitted with diagnoses including Parkinson’s disease, dementia, and hypothyroidism, and had current physician orders for levothyroxine 150 mcg once daily, buspirone 50 mg twice daily, and losartan 100 mg once daily. A medication regimen review dated 11/25/2025 included a consultant pharmacist recommendation that levothyroxine be administered consistently in the morning on an empty stomach, at least 30–60 minutes before food, per manufacturer instructions. There was no specific physician response in the medical record to this recommendation, and the facility’s policy stated that consulting pharmacist reviews are sent to nursing and addressed with the primary care provider or consulting specialist for review and follow-up. Review of the resident’s medication administration record for April 2026 showed levothyroxine scheduled for 9:00 a.m. On observation, the resident was seen eating breakfast in the dining area at 8:03 a.m., and an LPN reported administering the levothyroxine 150 mcg to the resident while the resident was in the dining area eating breakfast. The DON confirmed there was no evidence in the resident’s medical record explaining why the consultant pharmacist’s recommendation from 11/25/2025 was or was not acted upon. This lack of documented physician review and action on the pharmacist’s identified irregularity constituted noncompliance with the drug regimen review requirements.
Plan Of Correction
F756 The facility will continue to ensure the pharmacy recommendations from the monthly drug regimen review by a licensed pharmacist are acted upon for all residents, including #08. To ensure compliance with this standard the following measures have been taken: 1. Resident #08 was assessed by the registered nurse and med review completed by 4/28/26. After review of resident's drug regime's, it was discovered that resident #8 had 2 separate medication recommendations on the same form, to be reviewed by two separate practitioners, pharmacy has been instructed and agreed to separate meds on individual forms. 2. Licensed nurses re-educated to facility policy "Drug Regimen Review" by Director of nursing/designee in April 2026 and no later than 5/8/26. Licensed nurses are responsible for ensuring the reviews and recommendations are given to the physician for timely review. 3. Review of all other current residents Drug Regimen orders completed by Director of nursing/designee on 4/16/26 to ensure recommendations were followed up on/reviewed by the physician and address concerns if needed. 4. Audit of drug regime recommendations, pharmacy recommendations, and physician follow up to be completed weekly for four weeks by the Director of nursing/designee. Administrator will present results of these audits to the QAPI committee for ongoing monitoring and further direction.
Failure to Use Required Gait Belt During Ambulation Resulting in Resident Fall
Penalty
Summary
The deficiency involves the facility’s failure to ensure that a required gait belt was used while assisting a high fall‑risk resident with ambulation, resulting in a fall with head injury. The resident had multiple diagnoses including metabolic encephalopathy, hypertension, osteoarthritis, muscle weakness, gait and mobility abnormalities, major depressive disorder, anxiety, and visual hallucinations. Admission and subsequent MDS and fall risk assessments documented that the resident was severely cognitively impaired, required moderate to maximal assistance with transfers and ambulation, could not independently come to a standing position, exhibited loss of balance while standing, used an assistive device, and had decreased muscle coordination. The resident had a history of falls prior to admission and was assessed as being at high, later moderate, risk for falls. The resident’s fall care plan identified her as at risk for falls and included interventions such as providing maximum to moderate assistance with transfers and walking short distances, use of a walker and wheelchair, and following the facility’s fall protocol. Therapy notes and care conference documentation indicated that the resident leaned backwards when standing, required contact guard to minimal assistance for bed mobility and transfers, and needed constant verbal cueing for safe sequencing during toilet transfers. The physical therapist confirmed that the resident was to use a gait belt with staff when ambulating, and the DON verified that therapy had assessed the resident as requiring contact guard assistance and a gait belt for ambulation and transfers. On the day of the incident, a CNA was assisting the resident from her recliner to the bathroom using a walker. The CNA walked beside the resident, providing guidance and support, and reported having a hand on the resident while assisting her. As they approached the bathroom door, the CNA reached for the doorknob to open it, and at that moment the resident began to lose her balance and fell backwards to the floor, striking the back of her head. The nurse who responded found the resident on her back at the foot of the bed with her feet near the bathroom, noted a red raised area on the back of the head, and documented that the resident was not wearing a gait belt and that the gait belt was on the dresser. In the facility’s investigative summary and in interviews, the CNA acknowledged that she did not have a gait belt on the resident while ambulating her, despite the resident’s assessed need for hands‑on assistance and gait belt use per facility policy and the resident’s care and therapy plans.
Failure to Implement PD Orders and Monitor Resident Receiving Peritoneal Dialysis
Penalty
Summary
The deficiency involves the facility’s failure to implement pre-admission physician orders for peritoneal dialysis (PD) and to provide ongoing monitoring for a resident with chronic kidney disease (CKD) stage five who required PD. Pre-admission orders dated 11/14/25 specified three daily PD exchanges at 6:00 A.M., 2:00 P.M., and 10:00 P.M., and directed staff to monitor for signs and symptoms of peritonitis, including fever, abdominal pain, and cloudy effluent. These monitoring orders were not entered into the facility’s physician orders. The resident’s care plan noted the need for PD and included general monitoring interventions (labs, signs of bleeding, bacteremia, septic shock, and significant vital sign changes), but did not specifically address the ordered monitoring for peritonitis. Review of PD documentation showed incomplete and inconsistent charting of treatments and resident condition. The paper peritoneal flowsheet had columns for time of PD and condition/comments, including instructions to call the nurse immediately for cloudy fluid, abdominal pain, or fever. However, the first entry on 11/15/26 at 2:00 P.M. only noted that the PD nurse completed the exchange, and the 10:00 P.M. entry that day had no condition/comment documentation. Subsequent days (11/16/25, 11/17/25, and 11/18/25) contained only one condition/comment entry per day rather than for each exchange, and there was no documentation that the 6:00 A.M. PD on 11/18/25 was completed. The PD cycler flowsheet starting 11/19/25 lacked any description of the effluent on multiple days. The PD nurse from the dialysis company stated facility staff were expected to monitor effluent for cloudiness and assess for abdominal pain and fever, and the DON confirmed there was no electronic physician order for peritonitis monitoring or for use of the PD cycler, that the paper charting did not allow for effluent description or symptom documentation for each treatment, and that PD was not documented at one ordered time. The facility’s dialysis policy required ongoing assessment and monitoring for complications before, during, and after treatments, which was not reflected in the documentation for this resident.
Improper Infection Control During Medication Administration
Penalty
Summary
Surveyors identified a deficiency in infection prevention and control related to medication administration for Resident #29. The resident was admitted on 02/28/14 with diagnoses including depression, traumatic brain injury, and anxiety, and had impaired cognition per a quarterly MDS assessment. During an observation on 03/25/26 at 6:58 A.M., RN #281 prepared the resident’s medications by removing an Amoxicillin-Pot Clavulanate tablet from the medication card and pushing it directly into her ungloved hand, then using her fingers to place the pill into a medication cup. The same process was observed for multiple other medications, including Escitalopram Oxalate, Furosemide, Sennosides, Lyrica, and Vitamin D, each being pushed from the card into the RN’s ungloved hand and then transferred by her fingers into the medication cup before administration to Resident #29. In a subsequent interview at 7:27 A.M. the same day, RN #281 confirmed she had placed each medication into her ungloved hands prior to administration and acknowledged that the proper procedure was to push the pills directly from the card into the medication cup. Review of the facility’s “Medication Administration – General guidelines” policy, revised 10/08/25, stated that medications are to be administered in accordance with good nursing principles and practices. This practice failure was cited as a deficiency under Complaint Number 2681777.
Improper Use of Wheelchair as a Physical Restraint
Penalty
Summary
Surveyors identified a deficiency related to the facility’s failure to ensure a resident was free from physical restraints. Resident #7, admitted with diagnoses including Alzheimer’s disease, diabetes mellitus, and anxiety disorder, was documented on a recent MDS as rarely understood and dependent for ADLs except eating. The resident ambulated independently on the unit without an assistive device and had documented verbal and other behaviors occurring one to three days during the look-back period. The care plan noted the resident had potential to be physically aggressive, chase staff, throw objects, and be combative with care, with interventions such as offering choices, administering medications as ordered, and intervening early when agitation occurred. During an observation and interview, Resident #7 was found sitting in a chair with the right arm of the chair positioned against the nursing station and a wheelchair placed directly in front of him. The left arm of the wheelchair was also against the nursing station, and both wheelchair wheels were locked, creating a barrier that appeared to restrain the resident, who was sleeping with his knees touching the locked wheelchair. An LPN confirmed both wheelchair wheels were locked and that the wheelchair should not have been placed in front of the resident. A CNA reported she had placed the wheelchair there in preparation to get the resident up for lunch, was unable to transfer him, and left the wheelchair in that position, acknowledging it was wrong to keep it there. The facility’s physical restraint policy stated that physical restraints are not used except when alternatives are not appropriate or effective for treating a medical symptom and defined physical restraints as any device attached or adjacent to the body that the individual cannot easily remove and that restricts freedom of movement or access to the body.
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