Salem West Healthcare Center
Inspection history, citations, penalties and survey trends for this long-term care facility in Salem, Ohio.
- Location
- 2511 Bentley Drive, Salem, Ohio 44460
- CMS Provider Number
- 366096
- Inspections on file
- 26
- Latest survey
- December 12, 2025
- Citations (last 12 mo.)
- 9
Citation history
Health deficiencies cited at Salem West Healthcare Center during CMS and state inspections, most recent first.
A fire pull station behind the nurse's station was found to be inaccessible due to a wheeled cart of resident charts being parked in front of it. A resident raised concerns about shelving blocking the station, and an LPN confirmed the obstruction during observation. The issue was identified during a complaint investigation.
The facility did not properly identify or track a CNA as a suspected perpetrator in multiple abuse investigations, despite being aware of her involvement in incidents where she yelled at and acted aggressively toward two residents, including one with dementia. Staff reports and police involvement confirmed repeated concerns, but the facility failed to document the CNA in the required SRI tracking sections, contrary to policy.
A resident with cognitive impairment and multiple medical conditions was subjected to verbal abuse by a CNA, who threatened to take away the call light and spoke aggressively. The incident was witnessed and reported by a hospice aide, but facility leadership did not investigate, remove the CNA from resident care, or provide education as required by policy. The resident reported ongoing verbal abuse and lack of effective response from facility management.
A resident with cognitive impairment and multiple medical conditions was subjected to alleged verbal abuse by a CNA, including threats to remove her call light and aggressive language. The incident was reported by a hospice aide to the administrator, but no self-reported incident (SRI) was filed, no investigation was conducted, and the CNA continued working without intervention. The resident reported ongoing fear and discomfort, and facility policy requiring timely reporting and investigation of abuse was not followed.
A resident with impaired cognition and multiple diagnoses was subjected to verbal abuse by a CNA, who threatened to take away her call light. The incident was reported by a hospice aide to the Administrator, but no investigation was conducted, the CNA was not removed from resident care, and no SRI was initiated, contrary to facility policy. This failure to respond appropriately affected the resident and potentially all residents on the secure unit.
A resident in need of pain management did not receive safe and appropriate pain management services, resulting in a deficiency related to the facility's failure to meet the resident's needs.
Surveyors identified discrepancies between EHR and shower sheet documentation for four residents with complex medical and psychiatric conditions, including instances where showers and skin assessments were recorded as completed while a resident was hospitalized, and conflicting reasons for missed showers. The DON acknowledged the inconsistencies in documentation practices.
A resident with late onset Alzheimer's disease and a documented DNRCC-A order was found cyanotic and near arrest. Staff, including an LPN and RN, initiated CPR due to confusion about the DNRCC-A code status, providing chest compressions and respirations before stopping when the absence of a pulse and respirations was confirmed. The DON later acknowledged that staff misunderstood the advance directive and that CPR should not have been performed.
The facility did not ensure effective administration, resulting in inadequate staffing for timely incontinence care and meal assistance, incomplete CNA performance evaluations, an incomplete facility assessment, a resident call system with inaudible alerts, inconsistent water temperature monitoring, and missed scheduled therapeutic activities. These deficiencies were confirmed through staff interviews, observations, and record reviews.
A facility-wide assessment was found to be incomplete and inaccurate, missing required participant identification, QAPI review, and essential information on services, staffing, and emergency preparedness. Leadership interviews revealed inconsistencies regarding who completed the assessment, and the DON confirmed missing and incorrect data. These deficiencies had the potential to affect all residents.
Staff failed to follow hand hygiene protocols during incontinence care and feeding assistance for two residents, resulting in contamination of clean items and surfaces. Additionally, the facility's Water Management Program lacked required documentation, such as a flow diagram and written description of the water system, to minimize Legionella risk.
The facility did not provide enough nursing staff to meet residents' care needs, as confirmed by staff interviews, observations, and record reviews. Multiple residents requiring assistance with ADLs, incontinence care, and feeding were left unattended or received delayed care due to inadequate staffing. The facility's assessment was incomplete and did not address staffing based on resident acuity, resulting in unmet care needs and discrepancies between posted and actual staffing levels.
Surveyors found that call lights were not within reach for multiple residents, as confirmed by staff and resident council minutes, and that a resident with morbid obesity was not provided showers due to equipment limitations, despite expressing a preference for showers. Facility policies required resident-centered care and call light accessibility, but these were not consistently followed.
The facility did not provide scheduled therapeutic activities on the secured unit, with staff confirming that activities were frequently not held, especially after outings or during evening hours. Two residents with significant mental health and cognitive diagnoses were not provided with individualized or routine social activities as outlined in their care plans, leading to reports of isolation and lack of engagement.
The facility did not secure smoking materials for two residents, failed to consistently monitor and maintain safe water temperatures, and did not implement or document required fall prevention checks for a resident with cognitive and physical impairments. Staff interviews and record reviews confirmed these deficiencies, with missing documentation and policy violations identified.
The facility did not ensure that arbitration agreements were explained in a way that residents could understand before signing. Multiple residents with various medical conditions, most of whom were cognitively intact, reported not understanding the arbitration process or that they were waiving their right to court proceedings. The admissions process lacked documentation of resident understanding and did not include follow-up within the rescission period, affecting all residents who signed such agreements.
Surveyors found that two residents' bathrooms were unclean, with visible stool and strong odors, as confirmed by LPNs. Water temperatures in several rooms were consistently below required levels, with logs missing for multiple weeks and residents reporting discomfort during showers. The DPM confirmed both the inadequate water temperatures and the lack of consistent monitoring.
The facility did not ensure comprehensive care plans were developed with required interdisciplinary participation or timely updated for several residents with complex medical and psychiatric needs. Care conferences were not held or documented as required, and new fall prevention interventions were not promptly added to a resident's care plan after multiple falls, as confirmed by staff interviews and record reviews.
Multiple residents with significant physical or cognitive impairments did not receive timely assistance with ADLs, including showering and incontinence care. One resident dependent on staff for bathing was not included on the shower schedule and went over a week without a shower despite repeated requests. Other residents were found with saturated clothing and bedding due to delayed incontinence care, with CNAs unable to confirm when care was last provided and acknowledging checks should occur every two hours.
Staff failed to ensure the call system on the secured unit was audible, as observed when two residents activated their call lights and no sound was heard at the nurse's station due to the volume being turned down. An LPN confirmed the issue, and the Director of Plant Maintenance noted this had occurred before. This affected all residents on the secured unit, as it prevented reliable communication of needs to staff.
A resident who was cognitively intact and responsible for his own affairs reported that staff opened his mail without permission on several occasions. Staff interviews confirmed that mail was sometimes opened if it appeared to be insurance or a bill, and that mail was routinely reviewed by staff before being delivered, contrary to facility policy guaranteeing privacy in mail correspondence.
A DNR authorization form was found incomplete, missing key identifying information such as the resident's name, address, birthdate, and gender, and containing an illegible signature. The Administrator confirmed the form lacked necessary details and could not determine which resident it was for.
Two residents with cognitive impairment did not have their Medicare Non-Coverage Notices properly acknowledged by their representatives. In one case, a message was left for a representative but no signature was obtained, and in another, the resident with dementia signed the notice instead of the designated POA, despite being unable to understand the document.
A resident admitted with multiple medical conditions did not have required admission paperwork completed and signed until 28 days after admission, contrary to facility policy that mandates completion within 48 hours. The Administrator confirmed the delay and attributed it to the lack of a full-time admissions coordinator.
Surveyors found that three residents' MDS assessments were inaccurately coded, failing to reflect actual falls and oxygen therapy received during the assessment periods. Medical records, care plans, and treatment administration records showed discrepancies, and interviews with the MDS RN confirmed the errors.
A resident with severe cognitive impairment and a diagnosis of PTSD, anxiety, psychosis, and depression did not have a care plan addressing PTSD triggers or interventions. The care plan lacked input from the resident's representative, despite known triggers and behavioral symptoms. The DON confirmed the absence of a comprehensive PTSD care plan.
A resident with a feeding tube did not receive proper site care as ordered by the physician. Observation revealed a soiled, undated gauze dressing at the tube site, and both the resident and an LPN confirmed that the dressing had not been changed for several days, contrary to the care plan and physician orders.
Oxygen tubing for three residents with respiratory conditions was not changed weekly as required by physician orders and facility policy. Observations showed tubing dated beyond the weekly interval, and staff interviews confirmed knowledge of the requirement but failure to comply.
Two residents experienced significant medication errors: one did not receive prescribed Ativan for several nights due to an expired script and out-of-stock medication, while another was nearly given the wrong dose of Hydroxyzine when an RN failed to verify the correct medication card. These incidents highlight lapses in medication administration and verification by nursing staff.
A resident with dementia and impaired cognition had physician orders for blood work and urinalysis, but only the blood specimen was collected, and the urinalysis was not obtained. Both an LPN and the DON confirmed the omission and were unable to explain why the lab work was not completed as ordered.
A resident with severe cognitive impairment and total dependence for eating was fed by a CNA who stood over them throughout the meal, contrary to facility policy requiring care that promotes dignity. The CNA confirmed this was her usual practice, resulting in a failure to provide a dignified dining experience.
A resident with an indwelling urinary catheter was found with a catheter bag completely filled with urine, despite care plans and physician orders requiring regular catheter care and output documentation. An LPN confirmed the bag was overfilled and should have been emptied sooner to prevent backflow, and the DON was notified and observed the full bag.
The facility did not obtain or document weekly weights as ordered by physicians for two residents experiencing significant weight loss. Although weekly weights were marked as completed in the MAR, actual weight measurements were missing for several required dates, as confirmed by the RD and DON. This failure occurred despite facility policy requiring weights to be obtained as ordered.
A resident with severe cognitive impairment and a physician-ordered dysphagia advanced diet was served whole Brussel sprouts instead of the required chopped form. The error was identified when a family member feeding the resident questioned staff about the food's appropriateness, and staff confirmed the meal did not match the prescribed diet texture. Facility policy required meals to be prepared and verified according to individualized diet orders, but this was not followed.
The facility did not complete required quarterly or annual performance evaluations for several CNAs, as confirmed by a review of personnel files and an interview with the HR Manager. This failure had the potential to impact all residents, as regular evaluations are necessary to ensure proper care.
A resident who underwent ORIF surgery for a left femur fracture experienced unmanaged pain due to the facility's failure to implement a comprehensive pain management plan. Despite displaying signs of pain, such as restlessness and grimacing, the resident did not receive timely pain interventions or medications. The facility's pain management policy was not adhered to, resulting in prolonged periods of discomfort for the resident.
A resident with severe cognitive impairment and dementia was involved in an altercation with a state-tested nurse aide (STNA) who struck the resident after being hit. The resident had a history of dementia-related behaviors, and the facility's care plan included measures to manage these behaviors. Despite these interventions, the incident occurred, resulting in a small pink area on the resident's cheek. The facility's investigation substantiated the abuse, and the STNA was suspended and resigned. The incident highlighted a lapse in managing aggressive behaviors effectively.
The facility failed to provide timely pharmacy services, affecting two residents. One resident missed doses of antidepressants and antianxiety medications due to pharmacy delays, causing distress. Another resident did not receive prescribed medications for depression and constipation due to stock issues and ordering delays. The facility's policy required timely medication administration, which was not followed, leading to non-compliance.
A facility failed to implement proper infection control procedures for a resident with a feeding tube. The resident's care plan lacked enhanced barrier precautions (EBP), and a State tested Nurse Aide did not wear a gown during incontinence care. The facility's policy did not include EBP information, and the deficiency was found during a complaint investigation.
Fire Pull Station Obstructed by Chart Cart
Penalty
Summary
The facility failed to ensure that a fire pull station was visible and accessible in the event of an emergency. Review of the facility floor plan showed there were 14 fire pull stations in the building. During an interview, a resident expressed concern about shelving blocking the fire pull station located behind the nurse's station. Subsequent observation confirmed that a wheeled cart containing resident charts was parked in front of this fire pull station, making it inaccessible. An LPN verified at the time of observation that the fire pull station was obscured by the chart rack. This deficiency was identified during an investigation under Complaint Number 2606357.
Failure to Identify and Track Suspected Perpetrators in Abuse Investigations
Penalty
Summary
The facility failed to ensure that Self-Reported Incident (SRI) investigations were complete, specifically by not identifying suspected perpetrators (SP) in the SRI tracking section, despite being aware of the staff member involved. In two separate incidents involving two residents, a Certified Nursing Assistant (CNA) was named in the investigations for yelling at and raising her arm toward residents, one of whom had dementia and only spoke Spanish. The CNA was reported by other staff for aggressive behavior, including yelling at residents and demanding they speak English. Despite these reports and the CNA being named in multiple SRIs, the facility did not list her as an SP in the required tracking sections, even after being notified by the State agency to do so. Further review revealed that the same CNA was involved in several other SRIs, yet the facility continued to omit her from the SP tracking section. The facility's policy required accurate and timely reporting of all incidents and identification of those involved, but this was not followed. Interviews with staff confirmed the CNA's behavior and the lack of appropriate action or documentation by the facility. The deficiency affected two residents directly and had the potential to affect all residents on the secure unit.
Failure to Protect Resident from Verbal Abuse by CNA
Penalty
Summary
A deficiency occurred when a resident with multiple diagnoses, including bipolar disorder, schizoaffective disorder, and moderately impaired cognition, was subjected to verbal abuse by a certified nursing assistant (CNA). The incident was witnessed by a hospice aide, who reported that the CNA entered the resident's room and spoke to her in a loud, aggressive manner, telling her not to turn on her call light repeatedly and threatening to take the call light away. The hospice aide described the CNA as yelling and being verbally loud, which left the resident visibly upset and quiet after the interaction. Despite the report from the hospice aide and corroborating accounts from another CNA and the hospice director, the facility administrator did not initiate a self-reported incident (SRI) or conduct a formal investigation. The administrator did not interview the CNA involved, the resident, or other staff present during the incident. Furthermore, the CNA continued to work with residents after the event, and there was no documentation of any education or corrective action provided to the CNA regarding abuse or customer service. The resident herself reported to surveyors that she had experienced verbal abuse from the CNA on multiple occasions, including being yelled at and called obsessive compulsive. She stated she had reported these incidents to the DON and the ombudsman, but no effective action was taken, and she continued to be cared for by the same CNA. Facility policy required immediate reporting, investigation, and protective measures in response to allegations of abuse, but these procedures were not followed in this case.
Failure to Report and Investigate Alleged Verbal Abuse
Penalty
Summary
The facility failed to notify the State agency of an allegation of verbal abuse by a staff member towards a resident. The incident involved a resident with multiple diagnoses, including bipolar disorder, schizoaffective disorder, and moderately impaired cognition. On the date of the incident, a hospice aide reported to the facility administrator that a certified nursing assistant (CNA) had spoken loudly and aggressively to the resident, threatened to take away the resident's call light, and displayed behavior that upset the resident. The hospice aide also reported the incident to her own supervisor, and the hospice director confirmed that an occurrence was entered into their records. Despite being informed of the incident by both the hospice aide and another CNA, the facility administrator did not initiate a self-reported incident (SRI) or conduct an investigation. The administrator stated that after speaking with the hospice aide, she did not believe the incident was reportable and therefore did not notify the State agency. There was no documentation of the incident in the resident's medical record, and the administrator did not interview the CNA involved, the resident, or other staff present at the time. The CNA continued to work scheduled shifts and was not removed from resident care or provided with additional education regarding abuse or customer service. Interviews with the resident revealed that she felt verbally abused by the CNA, had reported previous incidents to the DON and ombudsman, and expressed fear and discomfort regarding the CNA's care. The resident described the CNA as yelling, intimidating, and making derogatory remarks about her preferences. The facility's policy required timely reporting and investigation of all alleged abuse, including immediate removal of accused staff from resident care, but these procedures were not followed in this case.
Failure to Investigate and Act on Allegation of Verbal Abuse
Penalty
Summary
The facility failed to thoroughly investigate and take immediate action following an allegation of verbal abuse by a staff member toward a resident. The incident involved a resident with multiple diagnoses, including bipolar disorder, schizoaffective disorder, and moderately impaired cognition, who was reported to have been yelled at and threatened by a CNA after repeatedly using her call light. The hospice aide present at the time reported the incident to the facility Administrator and her own supervisor, describing the CNA as speaking aggressively and threatening to take away the resident's call light. Despite this, there was no documentation of the incident in the resident's medical record or nursing notes. Interviews revealed that the CNA continued to work in the facility and was not removed from resident care duties following the allegation. The Administrator confirmed that she was aware of the report but did not initiate a Self-Reported Incident (SRI), did not interview the involved staff or resident, and did not conduct an investigation. The CNA was not provided with education regarding abuse or customer service, and no protective measures were implemented for the resident or other residents on the secure unit. Facility policy required immediate reporting, investigation, and protective actions in response to allegations of abuse, including removing the accused staff member from resident care areas and notifying appropriate authorities. However, these procedures were not followed. The failure to act on the allegation of verbal abuse affected one resident directly and had the potential to impact all residents on the secure unit.
Failure to Provide Safe and Appropriate Pain Management
Penalty
Summary
A resident who required pain management services did not receive safe and appropriate pain management. The report identifies a deficiency in the facility's provision of necessary pain management for a resident in need, but does not provide further details regarding the specific actions or omissions that led to this deficiency, nor does it include information about the resident's medical history or condition at the time.
Inaccurate Bathing Documentation and Recordkeeping
Penalty
Summary
The facility failed to ensure the accuracy of medical records regarding bathing for four residents reviewed for provision of showers. In several cases, there were discrepancies between the electronic health record (EHR) and the physical shower sheets or body/skin inspection forms. For example, one resident was documented in the EHR as not available for showers due to being hospitalized, yet shower sheets indicated that showers and skin assessments were completed during the same period. Another resident's EHR noted that showers were not attempted due to medical or safety concerns, while the shower sheets recorded that the resident refused showers, despite a separate area in the EHR to indicate refusals. Additionally, a resident reported that showers were not always offered according to the schedule, sometimes due to staffing issues. Other residents had similar inconsistencies, such as documentation in the EHR stating that showers were not attempted due to environmental limitations, while shower sheets indicated that showers were accepted on those dates. These discrepancies were identified during a complaint investigation and were confirmed through interviews with the Director of Nursing, who acknowledged the inconsistencies and the need for staff education on proper documentation. The affected residents had complex medical and psychiatric diagnoses and were dependent on staff for bathing and other activities of daily living.
Failure to Honor Resident's DNRCC-A Advance Directive
Penalty
Summary
Staff failed to honor a resident's documented code status regarding advance directives. The resident had a signed Do Not Resuscitate Comfort Care - Arrest (DNR CC-A) order, which specified that all interventions should cease at the point of cardiac or respiratory arrest, and no CPR should be performed. Despite this, when the resident was found cyanotic with a respiratory rate of three breaths per minute, staff initiated CPR, including chest compressions and respirations, before confirming the absence of a pulse and respirations. Interviews revealed that both the LPN and RN involved did not understand the meaning of the DNRCC-A order and proceeded with resuscitation efforts. The DON confirmed that staff were confused about the code status and that CPR should not have been initiated for a resident with a DNRCC-A order. The error was only recognized after emergency medical technicians arrived and confirmed the resident's DNR status.
Failure to Administer Facility Operations Effectively and Efficiently
Penalty
Summary
The facility failed to administer operations in a manner that enabled effective and efficient use of resources to attain or maintain the highest practicable well-being of each resident. Observations, record reviews, and staff interviews revealed multiple deficiencies, including inadequate staffing, incomplete performance evaluations, an incomplete facility assessment, malfunctioning resident call systems, inconsistent water temperature monitoring, and failure to provide scheduled therapeutic activities. The Administrator and Director of Nursing were found to lack effective systems to timely identify and correct these quality, care, and environmental concerns. Staffing issues were evident through direct care observations and interviews. Several residents were left in soiled clothing and bedding for extended periods, with staff confirming that incontinence care was not provided in a timely manner due to insufficient staffing. Residents were not assisted with meals promptly, and staff reported ongoing challenges in meeting care needs, including timely checks, showers, medication administration, and treatments. The facility's staffing plan and facility assessment were incomplete, lacking details on direct care staff assignments and failing to accurately reflect the facility's certified bed capacity. Performance evaluations for several CNAs were overdue, as confirmed by the Human Resource Manager. Environmental and activity-related deficiencies were also identified. The resident call system on the secured unit was found to have its volume turned down, preventing audible alerts for staff when residents required assistance. Water temperature monitoring was inconsistent, with some rooms having water that was too hot or too cold, and gaps in the temperature log indicated a lack of regular checks. Scheduled therapeutic activities, particularly in the evenings, were not provided as planned, with staff unaware of their responsibilities and key positions vacant, resulting in residents not receiving the activities listed on the facility calendar.
Incomplete and Inaccurate Facility Assessment with Missing Critical Resource Information
Penalty
Summary
The facility failed to develop a complete and accurate facility-wide assessment, as required, to determine the necessary resources for competent resident care during both routine operations and emergencies. The assessment lacked identification of required participants, was not reviewed with the QAPI committee, and contained numerous blank sections regarding essential services such as laboratory, x-ray, food, laundry, contracted services, and staff scheduling. Additionally, the certified bed capacity was incorrectly listed, and critical information regarding wound care, food service practices, spiritual programs, behavioral health, ancillary services, and staff schedules was missing. The staffing plan did not address the number of direct care staff needed for each shift or provide details on staff assignments, and the section on contracts and emergency preparedness was incomplete. Interviews with facility leadership revealed inconsistencies and lack of involvement in the assessment process. The Administrator initially stated she had no involvement in the assessment revision and could not identify the corporate staff member who completed it, but later claimed to have completed it herself with input from the DON, who denied participating. The DON also confirmed the presence of missing and incorrect information in the assessment. These deficiencies had the potential to affect all 64 residents in the facility.
Infection Control and Water Management Deficiencies
Penalty
Summary
The facility failed to maintain proper infection control practices, as evidenced by staff not adhering to hand hygiene protocols during care for two residents. In one instance, a CNA provided incontinence care to a resident with obesity and muscle weakness, handling soiled linens and performing resident care tasks without changing contaminated gloves or washing hands before touching clean items and leaving the room. The CNA also touched doors and other surfaces with soiled gloves before eventually returning to wash hands, confirming during interview that hand hygiene was not performed as required. The facility's policy specified that hand hygiene should be performed after contact with soiled items and before leaving a resident's room. Another deficiency was observed when a CNA assisted a resident with severe cognitive impairment and multiple medical conditions with eating, without performing hand hygiene upon entering the dining room or before providing feeding assistance. The CNA confirmed during interview that hand hygiene was not performed prior to assisting the resident. The facility's policy and CDC guidelines both require hand hygiene before resident contact and after exposure to potentially contaminated surfaces or items. Additionally, the facility's Water Management Program (WMP) for Legionella prevention was found lacking, as it did not include a flow diagram or written description of the building's water system. The Director of Plant Maintenance confirmed that no such documentation had been developed, and there was no evidence that all critical control points were being monitored. The facility's policy did not address the need for a flow diagram or text description, despite CDC guidance requiring these elements to identify areas where Legionella could grow and spread.
Failure to Provide Sufficient Nursing Staff to Meet Resident Care Needs
Penalty
Summary
The facility failed to provide sufficient nursing staff to meet the total care needs of all residents, as evidenced by multiple observations, interviews, and record reviews. The Payroll Based Journal (PBJ) Staffing Report indicated a one-star staffing rating, and the Facility Assessment (FA) was incomplete, lacking identification of contributors, QAPI review documentation, and a detailed staffing plan based on resident acuity. Staff interviews consistently reported inadequate staffing, with CNAs and nurses unable to complete timely resident care, including incontinence checks, medication administration, and assistance with activities of daily living (ADLs). Observations confirmed that actual staffing levels did not match posted schedules, and staff were often left to care for more residents than they could manage effectively. Several residents with significant care needs were directly affected by the staffing shortages. One resident, dependent on staff for toileting and hygiene, was found saturated with urine after not receiving incontinence care for several hours. Another resident, also incontinent and requiring assistance, was observed with a saturated brief and stale-smelling urine, with staff unable to recall the last time care was provided. A third resident with hemiplegia and significant weight loss was left unattended in the dining room, not receiving timely assistance with eating, despite care plans indicating the need for such support. Additionally, a resident with obesity and immobility was found lying in urine-soaked bedding, having not been changed since early morning, despite requests for assistance. Staff interviews corroborated these findings, with CNAs and nurses reporting that they were unable to meet residents' needs due to insufficient staffing. The Director of Nursing acknowledged that staffing levels met only the minimum required hours and did not align with the posted schedule or the actual needs of residents. The facility's own policy emphasized resident-centered care, but the lack of adequate staffing and incomplete facility assessment resulted in residents not receiving timely and appropriate care, particularly for those requiring frequent incontinence checks and assistance with meals and mobility.
Failure to Ensure Call Light Accessibility and Accommodate Shower Preferences
Penalty
Summary
Surveyors identified that the facility failed to ensure call lights were within reach for several residents and did not accommodate a resident's shower preference. Observations revealed that one resident's call light was draped over a light fixture and later found on the floor, both times out of reach. Another resident's call light was pinned to a privacy curtain, also not within reach. Staff present during these observations confirmed that call lights should always be accessible to residents. Resident council minutes from a previous month also documented concerns about call lights being left in inappropriate locations. A third resident, who was moderately cognitively impaired and required supervision for mobility, was observed lying in bed without a call light within reach. The call cord in this case was only about two feet long and could not be reached from the bed. Interviews with staff and the Ombudsman confirmed ongoing concerns about short emergency call cords in the secure unit, with some rooms having long cords and others short, without clear policy guidance on their use. Additionally, a resident with morbid obesity, who was dependent on staff for bathing, was not provided showers due to the facility's bariatric shower chair having a weight limit below the resident's current weight. The resident expressed a desire for showers, but staff indicated there was no safe way to provide one given the equipment limitations. The facility's policy stated that resident-centered care should meet physical needs, but there was no documentation in the care plan indicating the resident preferred only bed baths, nor was there evidence that the facility sought alternative solutions to accommodate the resident's shower preference.
Failure to Provide Scheduled Therapeutic Activities on Secured Unit
Penalty
Summary
The facility failed to provide scheduled therapeutic activities to residents on the secured unit, as observed and confirmed by staff interviews and record reviews. On the day in question, multiple scheduled activities listed on the activity calendar were not conducted, including morning and evening events. Certified Nursing Assistants (CNAs) working on the unit confirmed that no activities had taken place that morning or evening, and this was described as a frequent occurrence. The Activity Director stated that when outings occurred, the entire activity team would leave the facility, leaving only self-initiated activities available for residents. Additionally, activities scheduled after 5:00 P.M. were not being held due to staff vacancies and lack of awareness among new aides regarding their responsibilities. For one resident with diagnoses including bipolar disorder, schizoaffective disorder, and anxiety, the care plan indicated a preference for one-to-one activities and independent pursuits. However, documentation showed that one-to-one activities were rarely provided, and the resident reported that activity staff only delivered reading materials without engaging in actual one-to-one interaction. The Activity Director confirmed that there was no documentation of one-to-one activities being provided to this resident, despite the care plan interventions requiring such engagement. Another resident with multiple chronic conditions, including dementia and depression, was also affected by the lack of routine therapeutic activities for socialization. This resident reported feeling isolated and stated that no one had invited her to participate in activities, and observations confirmed that no activities were being held on the unit at the scheduled times. Staff interviews corroborated that scheduled activities were often not implemented on the secured unit, and the Activity Director acknowledged that activities were not being provided as scheduled, particularly after outings or during evening hours.
Failure to Secure Smoking Materials, Maintain Safe Water Temperatures, and Implement Fall Interventions
Penalty
Summary
The facility failed to ensure that smoking materials were secured when not in use for two residents who were identified as independent smokers. Both residents were found in possession of cigarettes and lighters, contrary to facility policy which requires staff to store smoking materials in a secured area and only provide them to residents upon request. Staff interviews confirmed that even independent smokers were not permitted to keep smoking materials in their possession, and both residents had to be reminded and have their materials confiscated. Additionally, the facility did not maintain safe water temperatures in resident areas. During an environmental tour, water temperatures in two residents' rooms were measured at 130 degrees Fahrenheit, which was verified as too hot by the Director of Plant Maintenance. Review of facility logs showed inconsistent documentation of weekly water temperature checks, with several weeks missing. Staff and residents reported that the water was very hot, requiring the addition of cold water to prevent burns. The facility also failed to implement and document fall prevention interventions for a resident with a history of falls and significant cognitive and physical impairments. After an unwitnessed fall, the care plan called for hourly checks during the night, but there was no documented evidence that these checks were completed. The DON confirmed that the required checks should have been performed but were not documented.
Failure to Adequately Explain Arbitration Agreements to Residents
Penalty
Summary
The facility failed to ensure that arbitration agreements were explained in a manner that residents could understand prior to signing. This deficiency was identified through medical record reviews, resident interviews, examination of signed arbitration agreements, and review of facility policy. Five residents who had signed arbitration agreements were interviewed, and all indicated a lack of understanding regarding the nature and implications of the agreement, including the waiver of their right to pursue litigation in court. The facility's process involved presenting the arbitration agreement as part of the admission paperwork, but there was no documentation that residents comprehended the agreement, nor was there follow-up within the 30-day rescission period to confirm understanding. Residents involved in the deficiency had varying medical conditions, including diabetes, obstructive sleep apnea, respiratory failure, morbid obesity, COPD, major depressive disorder, hypertension, GERD, bipolar disorder, anxiety disorder, acute kidney failure, and heart failure. Most residents were assessed as cognitively intact, with adequate hearing, vision, and the ability to express their wants and needs. Despite these capabilities, interviews revealed that residents did not know what arbitration was, did not understand that they were waiving their right to court proceedings, and some felt pressured to sign the agreement without adequate explanation. The facility's Mobile Admission Director acknowledged that while she would ask residents if they understood the arbitration agreement, there was no documentation of their understanding, nor was there a process to revisit the agreement within the rescission period. The facility's policy required that all questions regarding residency and agreements be answered before completion of the admission process, but this was not consistently followed in practice. As a result, the deficiency had the potential to affect all residents who had signed arbitration agreements, not just those interviewed.
Failure to Maintain Cleanliness and Adequate Water Temperatures
Penalty
Summary
The facility failed to maintain a clean and sanitary environment for multiple residents, as evidenced by observations of unclean bathrooms. In one instance, a resident's bathroom contained a large amount of black/green colored liquid stool on the toilet seat and in the bowl, which was confirmed by an LPN. In another case, a different resident's bathroom had dried stool on the toilet seat and inside the bowl, a heavy odor of stale urine, and a dark orange ring of residue around the base of the toilet, also confirmed by an LPN. Additionally, the facility did not ensure that water temperatures in resident rooms met the required standards for comfort and safety. Water temperature logs showed several weeks with missing records, and when temperatures were checked, they were consistently below the required range, with the highest readings being only lukewarm. The Director of Plant Maintenance confirmed both the insufficient water temperatures and the gaps in monitoring. Residents reported that the water was not warm enough for showers, and the facility's own policy required resident-centered care to meet physical needs, which was not met in these instances.
Failure to Develop and Document Comprehensive Care Plans and Timely Update Interventions
Penalty
Summary
The facility failed to develop and document comprehensive care plans in accordance with regulatory requirements for several residents. For one resident with multiple complex diagnoses, including ulcerative colitis, malnutrition, and cognitive impairment, there was no evidence of an interdisciplinary meeting involving the resident or their representative to develop a comprehensive care plan during their stay. The care plan was created without the required care conference, and the resident was not scheduled for a care conference before discharge. Staff interviews confirmed that care conferences were not held within the required timeframe for new admissions, as the facility scheduled them only within three months of admission, regardless of the resident's length of stay. For two other residents with significant psychiatric and medical conditions, there was no documented proof in the medical records that care plan meetings with the required participants were held within the past year. One resident reported never being invited to a care conference, and the facility's social service designee confirmed the absence of documentation for care conferences in the medical records. In another case, care plan meetings were not held at the required quarterly intervals, and when meetings did occur, there was no evidence that all required interdisciplinary team members were present. Additionally, the facility failed to timely update fall interventions in the care plan for a resident with a history of falls and multiple neurological and nutritional diagnoses. Despite several falls and the implementation of new interventions such as bed adjustments, fall mats, and non-skid footwear, these changes were not promptly reflected in the resident's care plan. The Director of Nursing confirmed that the care plan had not been updated as required following each fall event. Facility policy required resident and representative participation in care planning and timely updates to care plans as conditions changed, but these expectations were not met in the reviewed cases.
Failure to Provide Timely ADL and Incontinence Care
Penalty
Summary
The facility failed to provide necessary assistance with activities of daily living (ADLs) and timely incontinence care for multiple residents. One resident with multiple sclerosis, epilepsy, and partial quadriplegia was dependent on staff for showering and bathing, as documented in her care plan. Despite repeated requests to staff across several shifts, she did not receive a shower for over a week after moving rooms, as she was not included on the shower schedule. Certified Nursing Assistants (CNAs) confirmed the resident was not on the schedule and were unsure of the process for adding her, resulting in her continued lack of access to showering. Three other residents, all with significant physical or cognitive impairments and documented incontinence, did not receive timely incontinence care. One resident, dependent on staff for all ADLs and non-verbal, was found in a wheelchair with clothing and a lift pad saturated with urine after being up since the start of the shift, with staff unable to state when incontinence care was last provided. Another resident with dementia and incontinence was also found in a wheelchair with a saturated brief and stale-smelling urine, with staff again unable to confirm when care was last given. Both CNAs acknowledged residents should be checked for incontinence at least every two hours. A further resident, who was cognitively intact but dependent for mobility and toileting due to obesity and muscle weakness, was observed lying in bed with bedding and clothing saturated with urine and a strong foul odor. She reported not being checked or changed since early morning, despite requesting assistance at breakfast. The assigned CNA confirmed this was the first time the resident was checked during her shift and that assistance was delayed due to staffing constraints. Facility policy required residents to be checked every two hours, including during sleep, but this was not followed for these residents.
Failure to Maintain Audible Call System on Secured Unit
Penalty
Summary
The facility failed to ensure that all residents on the secured unit had access to a functioning call system that would audibly alert staff to their needs. During an environmental tour, it was observed that when the call light was pressed in two residents' rooms, the light outside the room illuminated, but no audible sound was emitted from the call system at the nurse's station. An LPN present at the nurse's station confirmed that the call system's volume had been turned down, preventing staff from hearing when a call light was activated. When the volume was increased, the system produced an audible alert as intended. The LPN verified that if the volume remained low or off, staff would not be audibly notified of any resident call lights on the unit. Further interview with the Director of Plant Maintenance revealed that he had previously noticed the call system units with the sound turned off or set too low to be heard by staff. Review of the facility's policy indicated that residents have the right to a method of communicating their needs to staff. This deficiency had the potential to affect all 13 residents living on the secured unit, as it compromised their ability to reliably alert staff for assistance.
Failure to Ensure Resident Privacy with Mail Correspondence
Penalty
Summary
The facility failed to ensure privacy for a resident regarding mail correspondence. A cognitively intact resident, who was his own responsible party, reported that staff had opened his mail on several occasions without his permission. During an interview, the Activity Director confirmed that staff opened the resident's mail if it appeared to be insurance or a bill. Further interviews with the Social Services Designee and the Business Office Manager revealed that mail was routinely reviewed by these staff members before being delivered to residents, and the Business Office Manager admitted to having opened some mail in the past. The facility's policy states that residents have the right to privacy in sending and receiving mail and email.
Incomplete DNR Authorization Form Lacks Resident Identification
Penalty
Summary
The facility failed to ensure that a do not resuscitate (DNR) authorization form was properly completed for a resident with multiple diagnoses, including congestive heart failure, chronic obstructive pulmonary disease, acute kidney failure, and major depressive disorder. Upon review of the resident's electronic health record, the DNR form was found to be missing essential identifying information such as the patient's name, address, birthdate, and gender. Additionally, the signature on the form was illegible, and there was no clear indication as to whom the authorization pertained. During an interview, the Administrator confirmed the absence of identifying information and was unable to determine which resident the form was intended for.
Failure to Obtain Proper Acknowledgment of Medicare Non-Coverage Notices for Cognitively Impaired Residents
Penalty
Summary
The facility failed to ensure that the Notice of Medicare Non-Coverage was properly acknowledged by the resident representative for residents with cognitive impairment. In one instance, a resident with dementia residing on a secured unit had a niece listed as their representative. The resident's medical record and MDS assessment confirmed impaired cognition. The Notice of Medicare Non-Coverage form indicated that a call was made to the niece and a message was left, but the form was not signed by the representative, and no further attempts were made to obtain acknowledgment or notify the representative of the right to appeal. In another case, a resident with dementia and cognitive deficits, also on a secured unit, had a grandson assigned as Power of Attorney (POA). The MDS assessment confirmed impaired cognition. The Notice of Medicare Non-Coverage form included a note that the POA had been contacted and the appeal process explained, but the resident, who was unable to understand due to dementia, signed the form instead of the POA. The staff member confirmed that the resident should not have signed and that the POA's signature was required to acknowledge notification of non-coverage and the right to appeal.
Failure to Complete Admission Paperwork Within Required Timeframe
Penalty
Summary
The facility failed to ensure that admission paperwork was completed and signed as required for one resident out of five reviewed for admission. Specifically, a resident with diagnoses including type two diabetes mellitus, obstructive sleep apnea, respiratory failure with hypoxia, anxiety disorder, and hypertension was admitted, and the admission Minimum Data Set (MDS) assessment indicated no cognitive impairment. However, review of the resident's admissions packet revealed that all required documents, such as the admissions agreement, responsible party agreement, assignment of benefits, and various consents, were signed 28 days after the resident's admission rather than at the time of admission. During an interview, the Administrator confirmed that the admissions paperwork was not completed at the time of admission and acknowledged that it should have been. The facility's policy requires that all admission paperwork be completed and signed within 48 hours of admission, with the Administrator signing off on the completed packet within the same timeframe. The Administrator also noted the absence of a full-time admissions coordinator, stating that the responsibility for completing admissions paperwork fell to either the Mobile Admissions Coordinator or the Administrator.
Inaccurate MDS Assessments for Multiple Residents
Penalty
Summary
The facility failed to ensure that Minimum Data Set (MDS) assessments accurately reflected the clinical status of three residents. For one resident with hemiplegia and cognitive impairment, the quarterly MDS assessment did not document two unwitnessed falls that occurred since the previous assessment, despite clear evidence in the medical record. For another resident with COPD and a history of pulmonary embolism, the MDS assessment failed to indicate that the resident was receiving oxygen therapy during the assessment reference period, even though physician orders, the treatment administration record, and the care plan all confirmed ongoing oxygen use. Similarly, a third resident with morbid obesity and dependence on supplemental oxygen was also not coded as receiving oxygen therapy on the MDS, despite continuous oxygen use documented in the medical record and care plan. Interviews with the MDS Registered Nurse confirmed that the MDS assessments for all three residents were incorrectly coded, as they did not accurately reflect the residents' actual care and clinical status during the assessment periods. The facility's policy on clinical documentation standards requires timely and accurate documentation of resident information, which was not followed in these cases. These inaccuracies were identified through record reviews, staff interviews, and policy review, affecting three out of 22 residents reviewed for MDS accuracy.
Failure to Develop Comprehensive PTSD Care Plan
Penalty
Summary
The facility failed to develop a comprehensive care plan addressing the diagnosis of Post-Traumatic Stress Disorder (PTSD) for a resident who was admitted with PTSD, anxiety, unspecified psychosis, and depression. The resident had severe cognitive impairment, as indicated by a BIMS score of 00, and exhibited verbal and physical behavioral symptoms directed at others one to three days per week. Despite these documented behaviors and the resident's history of PTSD, the care plan did not include any section to identify triggers or interventions specific to PTSD. The resident's wife, who is also the Power of Attorney, reported that she was not consulted to help develop a care plan for PTSD, even though she was aware of specific triggers such as loud noises, violence on television, and being handled. The Director of Nursing confirmed that a comprehensive care plan for PTSD was absent from the resident's medical record.
Failure to Provide Physician-Ordered Feeding Tube Site Care
Penalty
Summary
Resident #26, who had a history of surgical interventions of the digestive system and required a feeding tube, did not receive proper care of the feeding tube site as ordered by the physician. The care plan required checking the placement of the feeding tube and monitoring tube feedings, with a specific physician order to cleanse the feeding tube site with normal saline and apply drain gauze at bedtime. During observation, the resident's tube feeding site was found to have a soiled, undated gauze dressing. Interviews with both the resident and an LPN revealed that the dressing had last been changed several days prior, on the last day the LPN had worked with the resident, indicating that the dressing had not been changed as ordered.
Failure to Change Oxygen Tubing Weekly as Ordered
Penalty
Summary
The facility failed to ensure that oxygen tubing was changed weekly as required by physician orders and facility policy for three residents who were reviewed for respiratory care. Observations revealed that the oxygen tubing for these residents was not changed within the required weekly interval, with tubing dated nine days prior to the observation date. Interviews with a CNA confirmed awareness that tubing should be changed weekly, and the Director of Nursing also confirmed the expectation for weekly changes and proper dating of tubing. The affected residents had significant respiratory diagnoses, including chronic obstructive pulmonary disease (COPD), chronic respiratory failure, and dependence on supplemental oxygen. Physician orders and care plans for these residents specifically required weekly changes of oxygen tubing, and the facility's policy also mandated this practice. Despite these clear directives, the tubing was not changed as scheduled, and the deficiency was identified through direct observation, record review, and staff interviews.
Failure to Prevent Significant Medication Errors
Penalty
Summary
The facility failed to ensure that residents were free from significant medication errors, as evidenced by two separate incidents involving two residents. One resident with diagnoses of dementia and depression, and with intact cognition, did not receive her prescribed Ativan for several consecutive nights due to the medication being out of stock and the prescription having expired. Multiple progress notes documented the unavailability of the medication, communication with the pharmacy, and the need for a new prescription. Despite these issues being noted by various nursing staff, the resident went without her medication for at least four nights, and the issue was not promptly resolved. The resident herself reported not receiving her sleeping medication and experiencing difficulty sleeping as a result. In a separate incident, another resident with anxiety and dementia was almost administered the wrong dose and medication. During a medication pass, an RN obtained a 50 mg Hydroxyzine tablet from a medication card labeled for a different resident and added it to the medication cup for the intended resident, who was only prescribed 25 mg. The error was caught by a surveyor before administration, and the RN acknowledged not checking the name or dosage on the medication card prior to preparing the medication. These events demonstrate lapses in medication administration procedures and verification processes.
Failure to Complete Timely Laboratory Services per Physician Orders
Penalty
Summary
The facility failed to ensure that laboratory work was completed in a timely manner and according to physician orders for one resident. The resident, who had diagnoses including dementia, muscle weakness, and required personal care assistance, was noted to have impaired cognition. On a specified date, new physician orders were received for both blood work and a urinalysis. However, review of laboratory documentation showed that while the blood specimen was collected several days later, the urinalysis was not collected at all. During interviews, both the LPN and the Director of Nursing confirmed that the orders for blood and urine collection were in place, but the urinalysis had not been completed, and the LPN was unable to provide a reason for this omission.
Failure to Provide Dignified Dining Experience During Feeding Assistance
Penalty
Summary
A deficiency was identified when a certified nursing assistant (CNA) failed to provide a dignified dining experience for a resident with severe cognitive impairment and total dependence on staff for eating. The resident, who had diagnoses including muscle weakness, contractures, and a history of transient ischemic attack, required complete assistance with eating as documented in their care plan. During an observation in the dining room, the CNA was seen standing over the resident while feeding them and confirmed in an interview that she always stands while providing feeding assistance to residents. The facility's policy on routine resident care states that staff should provide care necessary for quality of life, promoting dignity and independence, including during eating and hydration. The CNA's practice of standing while feeding did not align with this policy and resulted in a failure to provide a dignified dining experience for the resident. This deficiency was identified during a review of records, observation, staff interview, and policy review.
Failure to Timely Empty Indwelling Urinary Catheter Bag
Penalty
Summary
A deficiency was identified when a resident with an indwelling urinary catheter was observed to have a catheter bag that was completely filled with urine. The resident required maximum assistance with toileting, had an indwelling catheter for urination, and was incontinent of bowel. The care plan specified that catheter care should be provided every shift and as needed, and physician orders required documentation of output every shift. However, there was no documented output prior to the afternoon of the day the deficiency was observed. During a morning observation, the resident was found sleeping in bed with a catheter bag containing approximately 2000 cc's of urine. An LPN confirmed the bag was full and acknowledged that catheter bags should be emptied before becoming full to prevent backflow. The DON was informed and observed the full bag at that time. This incident affected one of three residents observed for catheters, with a total of nine residents in the facility identified as having indwelling urinary catheters.
Failure to Obtain and Document Weekly Weights as Ordered
Penalty
Summary
The facility failed to ensure that weekly weights were obtained as ordered by physicians for two residents who were being monitored for nutritional status due to significant weight loss. For one resident with diagnoses including hemiplegia, dysphagia, cognitive impairment, depression, and severe protein calorie malnutrition, physician orders required weekly weights following a 14% weight loss over 180 days. Although weekly weights were signed off as completed in the Medication Administration Record (MAR), actual weight measurements were not documented for all required dates, and some weights were missing entirely from the medical record. This was confirmed by the Registered Dietitian. Similarly, another resident with Parkinson's disease, dementia, diabetes, anxiety disorder, and PTSD experienced a significant weight loss, prompting physician orders for weekly weights. The MAR indicated that weekly weights were signed off as completed, but actual weight measurements were only documented on two occasions, with no records for the other required dates. The Director of Nursing confirmed that weekly weights were not obtained as ordered. Facility policy required weights to be obtained monthly or as ordered by the physician, but this was not followed for these residents.
Failure to Provide Diet-Appropriate Food Texture for Resident with Dysphagia
Penalty
Summary
The facility failed to provide food in a form consistent with a dysphagia advanced diet for a resident with significant cognitive impairment and multiple diagnoses, including Parkinson's disease, dementia, and Alzheimer's disease. The resident had physician orders specifying a regular diet with dysphagia advanced texture, thin liquids, and specific fortified foods. The care plan included interventions to observe for signs of aspiration or dysphagia and to provide meals according to the diet order. Despite these orders and interventions, the resident was served whole Brussel sprouts instead of the required chopped Brussel sprouts, as indicated on both the facility's diet guide sheet and the resident's diet slip. During lunch, a family member feeding the resident noticed the whole Brussel sprouts and questioned staff about the appropriateness of the food, expressing difficulty in cutting the vegetable. Staff confirmed that the resident should have received chopped Brussel sprouts. Facility policy required that all meals be assembled according to individualized diet orders and that nursing staff verify meal accuracy before delivery. This deficiency was identified during a survey and affected one of six residents on a dysphagia advanced diet.
Failure to Conduct Required CNA Performance Evaluations
Penalty
Summary
The facility failed to conduct required performance evaluations for Certified Nursing Assistants (CNAs), as evidenced by a review of employee files. Personnel files for four CNAs showed no documentation of quarterly or annual performance evaluations, despite their respective hire dates indicating that such evaluations were due. This lapse was confirmed during an interview with the Human Resource Manager, who acknowledged the absence of performance evaluations in the files reviewed. This deficiency had the potential to affect all 64 residents residing in the facility, as regular performance evaluations are necessary to ensure that CNAs are meeting job expectations and providing appropriate care.
Failure in Timely Pain Management for Post-Surgical Resident
Penalty
Summary
The facility failed to provide timely and appropriate pain management for a resident who had undergone an open reduction and internal fixation (ORIF) surgery for a left femur fracture. Upon admission, the resident displayed signs of pain, including restlessness and agitation, but the facility did not develop or implement a comprehensive pain management plan. The admission physician's orders did not include any pain medications or interventions, and the baseline care plan only mentioned general pain assessments without specific actions. On multiple occasions, the resident exhibited signs of pain, such as grimacing, moaning, and restlessness, which were observed by staff and reported by a family member. Despite these observations, there was no documentation of pain interventions or communication with the physician regarding the resident's pain. The resident's pain was noted during therapy evaluations, but there was no evidence that this information was communicated to nursing staff or that any pain relief measures were taken. The resident was readmitted to the facility without an order for pain medication and continued to exhibit signs of acute pain. It was not until a telehealth encounter that an order for Acetaminophen was obtained, but the resident did not receive any doses of pain medication until much later. The facility's policy on pain management was not followed, as there was a lack of thorough pain assessment and treatment, leading to prolonged periods of unmanaged pain for the resident.
Failure to Prevent Staff-to-Resident Abuse
Penalty
Summary
The facility failed to prevent staff-to-resident physical abuse involving a resident with complex medical conditions, including severe cognitive impairment and dementia. The incident occurred when a state-tested nurse aide (STNA) reacted to being struck by the resident by striking the resident back. This resulted in a small pink area on the resident's left cheek, although the facility's investigation could not conclusively determine if the mark was directly caused by the STNA due to the resident's concurrent diagnosis of conjunctivitis. The resident involved had a history of dementia with behaviors, including striking toward staff, although it was noted that the resident had never made physical contact with staff before this incident. The resident's care plan included interventions for communication problems and mood and behavior issues, such as maintaining a consistent routine and providing a calm environment. Despite these measures, the incident occurred, highlighting a lapse in the facility's ability to manage aggressive behaviors effectively. The incident was reported promptly, with the Assistant Director of Nursing (ADON) being notified and taking immediate action to assess the resident and gather witness statements. The STNA involved was sent home pending investigation. The facility's investigation substantiated the abuse, and the STNA involved was suspended and subsequently resigned. The facility's policy on abuse, neglect, and misappropriation was in place, but the incident revealed a failure in its implementation, leading to the abuse of the resident.
Medication Administration Deficiency
Penalty
Summary
The facility failed to ensure timely pharmacy services for medication ordering, dispensing, acquiring, and administration, affecting two residents. Former Resident #58 had multiple diagnoses, including anxiety, depression, and PTSD, and was prescribed several medications, including antidepressants and antianxiety medications. However, there were multiple instances where these medications were not administered as ordered due to delays in receiving them from the pharmacy. The resident expressed concern and was upset about missing doses, and it was confirmed by an LPN that it was not uncommon for residents to miss doses due to medication delays. Resident #45, with diagnoses including depression and anxiety, also experienced issues with medication administration. The resident was prescribed Abilify for depression and a fiber laxative for constipation. However, the fiber laxative was not administered as the correct medication strength was not in stock, and the Abilify dose was missed because it was on order. An LPN confirmed the lack of the correct medication strength during a medication administration observation. The facility's policy on medication administration required medications to be given as ordered and within a specific timeframe, which was not adhered to in these cases. The deficiency was investigated under a specific complaint number, indicating non-compliance with the facility's medication administration policy.
Infection Control Deficiency in Resident Care
Penalty
Summary
The facility failed to implement proper infection control procedures for Resident #13, who was dependent on others for daily self-care and had multiple medical conditions, including a left femur fracture, Alzheimer's disease, and a feeding tube. The resident was admitted with a diagnosis of incontinence of bowel and bladder and received nutrition through a percutaneous endoscopic gastrostomy (PEG) tube. Despite these conditions, the care plan did not include enhanced barrier precautions (EBP), and there was no physician order for EBP. During an observation, a State tested Nurse Aide (STNA) did not wear a gown while providing incontinence care to Resident #13, who had a feeding tube. The STNA confirmed that she should have worn a gown due to the presence of the feeding tube. The facility's policy on standard precautions did not include information on EBP, and the facility's signage indicated that staff should wear a gown and gloves for high-contact resident care, including care involving feeding tubes. The deficiency was identified during a complaint investigation.
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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