Sapphire Rehabilitation And Care Center
Inspection history, citations, penalties and survey trends for this long-term care facility in Columbus, Ohio.
- Location
- 1605 Northwest Professional Plaza, Columbus, Ohio 43220
- CMS Provider Number
- 365950
- Inspections on file
- 36
- Latest survey
- March 19, 2026
- Citations (last 12 mo.)
- 68 (2 serious)
Citation history
Health deficiencies cited at Sapphire Rehabilitation And Care Center during CMS and state inspections, most recent first.
A resident with intact cognition and multiple medical diagnoses requested a COVID-19 vaccine, for which a provider order was obtained and entered. On the scheduled administration date, an LPN documented the vaccine as not available on the MAR, and the vaccine was never given. The resident reported being told the vaccine was on back order and was only offered the option to obtain it at a local pharmacy, which she declined. The ADON stated nurses are expected to confirm vaccine orders with the pharmacy, while pharmacy staff reported the vaccine was in stock but could not be released because the facility failed to submit the required vaccine request form, resulting in noncompliance with the facility’s vaccination policy.
A cognitively intact resident with multiple chronic conditions, including CHF, renal insufficiency, DM, and depression, received a 30‑day discharge notice signed by the Administrator, with discharge planned to a homeless shelter. Although the resident reported receiving the discharge letter, there was no documentation that the Office of the State Long-Term Care Ombudsman was provided a copy of the notice, and the Administrator confirmed he could not produce evidence of such notification. This failure to notify the Ombudsman regarding the resident’s discharge was identified during a complaint investigation.
The facility did not ensure food was served at appropriate temperatures, as multiple residents reported consistently receiving cold meals. Observations confirmed that food temperatures dropped significantly between the tray line and delivery to residents, with the Dietary Manager noting a lack of adequate warming carts. Resident Council minutes also reflected ongoing concerns about food temperature.
Staff did not maintain a clean kitchen environment, with about 15 ceiling tiles covered in a black dusty substance and thick dust on ceiling vents above food prep and cooking areas. The Dietary Manager confirmed the issue and stated there was no set cleaning schedule for these areas, potentially affecting all residents receiving meals.
A resident with multiple chronic conditions was unable to reliably use the call system in the bathroom due to a known malfunction, resulting in staff providing a handheld bell as an alternative. Facility staff confirmed that a specific issue with the bathroom call system prevented signals from reaching the nurses' station, and resident council minutes documented ongoing concerns about call light response.
Surveyors found that the facility failed to provide a clean, safe, and comfortable environment, with issues such as exposed drywall, exposed wires, unsanitary conditions including dried feces, and multiple areas with temperatures below the required minimum. Staff confirmed these environmental problems, and maintenance logs indicated unresolved heating issues despite previous repair attempts.
Several residents requiring assistance with ADLs did not receive timely care due to a shortage of towels and washcloths, leading families to supply their own linens. In addition, a resident with severe cognitive impairment was observed attempting to eat a foil lid from a juice container, despite staff being aware of the need to remove such lids for residents with low cognition. Staff and resident council confirmed ongoing issues with linen shortages and inadequate supervision during meals.
Surveyors found that most exterior lights were not functioning, leaving areas around the building and parking lots unlit at night. Additionally, a sitting room intended for resident use was used to store hazardous maintenance supplies, including caulk and paint stripper, with the room left unlocked and accessible. Staff confirmed these conditions, which did not meet facility policies for safety and secure storage.
A resident with multiple chronic conditions and requiring ADL assistance did not have their family's request for an electronic monitoring device in their room accommodated. The facility initiated contact with the roommate's guardian for consent but did not follow up after receiving no response, and no further action or documentation was found. Facility policy supports resident rights to electronic monitoring, but the request was not fulfilled.
A resident with severe cognitive impairment did not have access to a working bedside phone, requiring her to use the nurse's station for family calls. Staff were unaware of alternative private phone options, and the facility's policy for private phone access was not effectively communicated or implemented, resulting in a lack of privacy for the resident's phone communication.
A medication error rate of 10 percent was identified when an LPN was unable to administer three prescribed medications to a resident with multiple chronic conditions because the medications were not available in the facility. The LPN confirmed that medication unavailability is a frequent issue, resulting in missed doses and non-compliance with facility policy.
A resident with moderate cognitive impairment and multiple diagnoses was found with medications left at the bedside by an LPN, despite lacking a physician order for self-administration or for medications to be left at bedside. Facility policy requires such an order and assessment, which was not present in this instance.
A cognitively impaired resident with a history of wandering and high elopement risk left the facility twice without staff knowledge. On both occasions, the resident was found by police outside the facility, with the second incident resulting in the resident being missing for over 17 hours. Despite documented risk factors and family concerns, the care plan lacked interventions for elopement, required safety checks were not performed or documented, and incidents were not reported as required.
A resident with multiple medical and psychosocial issues, including alcohol abuse and homelessness, was discharged without evidence of a safe destination or continuity of care. The resident repeatedly left the facility unsupervised, and there was no documentation of mental health or substance abuse services being offered. Staff failed to update care plans, notify responsible parties, or coordinate with community resources, resulting in the resident being found homeless, malnourished, and expressing suicidal ideation after discharge.
The facility did not provide required written bed hold or transfer/discharge notices to three residents with complex medical needs when they were transferred to the hospital, nor did it notify the ombudsman of these discharges. The DON confirmed that documentation of these notifications was not available, and one resident reported only receiving a verbal notice about bed hold duration.
A resident with dementia and a history of wandering was physically assaulted by another resident with behavioral issues after repeatedly entering the latter's room. Despite care plans and staff redirection, the interventions in place failed to prevent the incident, resulting in facial injuries that required hospital treatment. The facility did not implement additional preventive measures until after the event, and those measures were not consistently maintained.
A resident with a tracheostomy and a history of respiratory failure experienced acute respiratory distress and did not receive appropriate emergency respiratory interventions, including suctioning, as-needed nebulizer treatment, changing the inner cannula, or Ambu bag ventilation. Staff failed to provide continuous bedside support, and no CPR was initiated prior to EMS arrival. The resident was found in cardiac arrest by EMS and was later pronounced deceased.
A resident's room was found cluttered with medical supplies and personal items, making the environment non-homelike and hindering furniture usability. The resident, with multiple medical conditions, did not require all the items present, as confirmed by their family. Facility staff acknowledged the issue, which violated the facility's policy for maintaining a homelike environment.
The facility failed to provide adequate bathing and nail care for residents unable to perform these tasks independently. A resident with multiple health issues received only two showers in January, with no prior documentation of bathing. Another resident, despite requests, did not receive nail care, and a third resident reported inconsistent bathing assistance. The facility's policy required assistance with ADLs, which was not followed.
Two residents did not receive physical therapy as ordered, with therapy provided inconsistently due to staffing issues. Despite physician orders for therapy five times weekly, therapy was only provided two to four times weekly. Facility staff acknowledged the lack of therapy documentation and insufficient staffing to meet residents' needs.
A facility failed to monitor a resident's COVID-19 infection. The resident, with a complex medical history, initially tested negative but later tested positive after a change in condition. The facility's infection logs did not include this positive test, contrary to their policy requiring infection monitoring and reporting. This was confirmed by a regional nurse.
A resident with a history of stroke sustained a foot injury in a motorized wheelchair accident. The facility treated the wound, but the resident later felt lightheaded, prompting her guardian to request hospital evaluation. The facility failed to notify the guardian in a timely manner, as required by policy, leading to a deficiency finding.
A resident with multiple diagnoses, including dehiscence of amputation stump and peripheral vascular disease, missed a follow-up appointment with an orthopedic physician due to the RN's oversight in completing necessary assessments and updating medical orders. The resident's initial appointment was rescheduled due to a COVID-positive status, but the rescheduled appointment was also missed, and no new appointment was made until the orthopedic office called to inform the facility.
A resident fell during a transfer using a Hoyer lift due to improper handling by staff, including not opening the lift's legs for balance and leaving the wheels unlocked. The resident did not sustain any apparent injuries, and the incident was documented and investigated.
The facility failed to ensure proper hand hygiene after glove removal and did not implement Enhanced Barrier Precautions during wound care for a resident with a surgical wound. The LPN did not wear a gown and changed gloves multiple times without performing hand hygiene, contrary to facility policy.
Failure to Provide Requested COVID-19 Vaccination Due to Breakdown in Ordering Process
Penalty
Summary
The deficiency involves the facility’s failure to administer a requested SARS-CoV-2 (COVID-19) vaccination to a cognitively intact resident after a provider order was obtained. The resident, admitted with diagnoses including asthma, malnutrition, and vertigo, had previously received four COVID-19 vaccinations, the last in late October 2024. On 12/30/25, the resident requested another COVID-19 vaccination, and the nurse practitioner issued an order on 12/31/25 for a Comirnaty 30 mcg/0.3 mL intramuscular dose. The order was entered with an end date of 01/08/26. On 01/07/26, an LPN documented the vaccine on the MAR as “Med Not Available” and did not administer it. Review of the January and February 2026 MARs showed no evidence that the vaccine was ever given. The resident later developed a cough and was transferred to the hospital after independently calling EMS; she reported being hospitalized for eight days with COVID-19 and double pneumonia. During interview, the resident stated she had been told she would receive the vaccine on 01/07/26 but did not, and was informed it was on back order, with the only alternative offered being to go to a local pharmacy, which she declined due to cold weather. The LPN unit manager did not recall the request but confirmed placing and revising the vaccine order. The LPN who signed the MAR as “Med Not Available” stated the pharmacy required paperwork before sending the vaccine and that she notified someone at the facility, though she could not recall whom. The ADON stated nurses should call the pharmacy to confirm vaccine orders and provide needed information. Pharmacy staff reported the COVID-19 vaccine was not on back order and had been available throughout the relevant months, but the facility had not submitted the required vaccine request form, so the pharmacy could not release the vaccine. Facility policy required that residents be offered influenza, pneumonia, and COVID vaccines unless contraindicated or already vaccinated.
Failure to Notify Ombudsman of Resident Discharge Notice
Penalty
Summary
The deficiency involves the facility’s failure to provide a copy of a 30‑day discharge notice to the Office of the State Long-Term Care Ombudsman for a resident being discharged. The resident, who had diagnoses including heart failure, renal insufficiency, diabetes mellitus, and depression, was cognitively intact and independent with eating, toileting, bathing, and personal hygiene per an MDS 3.0 assessment. The medical record showed the resident was admitted on an unspecified date and received a 30‑day discharge notice dated 12/29/25, with an effective discharge date of 01/28/26, signed by the Administrator. There was no documentation that the Ombudsman’s office was notified or provided a copy of this discharge notice. During an interview on 01/28/26, the resident reported receiving a letter stating she was being discharged that day to a homeless shelter, and in a separate interview the same day, the Administrator confirmed he could not provide any evidence that the Ombudsman had been notified of the discharge notice. This omission was identified as an incidental finding during a complaint investigation.
Failure to Serve Food at Safe and Palatable Temperatures
Penalty
Summary
The facility failed to ensure that food was served at palatable and safe temperatures for all 108 residents receiving meals from the kitchen. Multiple residents reported that their food was never served hot, with several stating it was always cold. Observations during lunch meal service showed that while food temperatures on the tray line were above 165°F, the temperatures dropped significantly by the time food reached residents, with turkey at 112°F, mashed potatoes at 110°F, and vegetables at 71°F. The Dietary Manager confirmed that the food was lukewarm and attributed the issue to an insufficient number of warming food carts. Resident Council meeting minutes from the previous month also documented ongoing resident concerns about food temperature.
Unsanitary Kitchen Conditions Due to Unclean Ceiling Tiles and Vents
Penalty
Summary
Facility staff failed to maintain a clean and sanitary kitchen area, as evidenced by the presence of approximately 15 ceiling tiles covered with a black dusty substance and a thick layer of dust on the ceiling vents located above food preparation and cooking areas. During an observation with the Dietary Manager, it was confirmed that the black substance could not be removed despite attempts with a microfiber cloth, and the dust on the vents was also acknowledged. The Dietary Manager stated there was no set cleaning schedule for the ceiling or vents. Review of facility policy indicated that residents are to be provided with a safe, clean, and comfortable environment. This deficiency had the potential to affect all 108 residents who received meals from the kitchen.
Failure to Maintain Functional Call System in Resident Bathrooms
Penalty
Summary
The facility failed to ensure that resident call systems were functioning properly in bathrooms and bathing areas, as evidenced by the experience of one resident who reported that her call light was not answered on multiple occasions. The resident, who had multiple diagnoses including chronic respiratory failure, diabetes, dementia, and other serious conditions, stated that staff provided her with a handheld bell due to the malfunctioning call system. Medical record review and interviews confirmed that the resident required assistance with activities of daily living and had ongoing health concerns. Observation and interviews with facility staff, including the Administrator and Maintenance Director, revealed a known issue with the call system in double rooms with shared bathrooms. Specifically, if a metal lever or switch in the bathroom was left partially engaged, the call light above the resident's bed would illuminate but would not send a signal to the nurses' station or outside the room. Review of Resident Council meeting minutes also documented ongoing resident concerns about call light response. There was no facility policy specifically addressing call lights, though staff were expected to respond in a timely manner.
Failure to Maintain Clean, Safe, and Comfortable Environment
Penalty
Summary
Surveyors identified multiple failures by the facility to maintain a safe, clean, and homelike environment for residents, as evidenced by direct observations, resident and staff interviews, and review of maintenance logs and facility policy. Specific deficiencies included rooms with holes exposing drywall, exposed wires hanging from walls, and unsanitary conditions such as dried feces on floors, walls, and privacy curtains. Several rooms and common areas were found to be below the required minimum temperature, with one resident reporting it was freezing in her room despite the thermostat being set to a high temperature. Maintenance checks confirmed that the actual room temperature was significantly lower than the thermostat setting, and the furnace in that room was not operational. Additional temperature checks throughout the facility revealed that multiple areas, including resident rooms, hallways, and activity spaces, were below the facility's stated minimum temperature requirement. Staff interviews corroborated the environmental issues, with both maintenance and housekeeping supervisors acknowledging the problems. Maintenance logs showed that heating issues had been previously identified and marked as resolved, but subsequent observations indicated ongoing problems. Facility policy required a homelike environment with comfortable temperatures and cleanliness, but these standards were not met in the affected areas. The deficiency affected all ten residents reviewed for environmental conditions, with a total facility census of 108.
Failure to Provide Adequate ADL Assistance and Supplies
Penalty
Summary
The facility failed to ensure that residents who required assistance with activities of daily living (ADLs) received appropriate care and supervision, and did not provide staff with the necessary supplies to deliver timely ADL care. Three residents were affected by these deficiencies. One resident with dementia, chronic pain, and mobility issues reported that her family had to purchase bath towels and washcloths because the facility did not have enough linens to provide showers or baths when requested. Another resident with hemiplegia and heart failure also reported that his family had to supply towels and washcloths due to the facility's shortage, which resulted in missed showers or baths. Observations of the facility's linen storage rooms on multiple occasions revealed insufficient quantities of towels and washcloths, and both housekeeping and laundry staff confirmed that there were not enough linens to meet residents' needs in a timely manner. Resident council minutes also documented complaints about the lack of washcloths and towels, particularly on weekends. Additionally, a resident with severe cognitive impairment and a history of dementia and schizoaffective disorder was observed attempting to eat a foil lid from a juice container while in bed with a meal tray. Staff interviews confirmed that this resident required assistance with eating and that the foil lid should have been removed due to the resident's cognitive status. Despite staff education on this issue, further observation showed that the resident continued to receive meal trays with the foil lid attached. These findings demonstrate a failure to provide adequate assistance and supervision for ADLs, as well as a lack of necessary supplies to ensure timely and safe care.
Failure to Maintain Outdoor Lighting and Secure Hazardous Materials
Penalty
Summary
The facility failed to maintain adequate outdoor lighting and proper storage of hazardous maintenance equipment and supplies. Observations revealed that most exterior lights, including those around the building, employee parking lot, and visitor parking area, were not functioning, leaving large areas unlit during nighttime hours. Only two of six lights in the visitor parking area were operational, and even those had only partial illumination. Staff interviews confirmed that the lack of functioning exterior lighting was a safety issue, particularly in the dark. Additionally, a sitting room adjacent to the activity area was found to be used for storage of maintenance equipment, including hazardous materials such as caulk and paint stripper, which were labeled with warnings. The room was unlocked and propped open, making these hazardous materials easily accessible to residents. Staff confirmed that the room, originally intended as a comfortable space for residents, had become a storage area with hazardous items within reach. Facility policies required hazardous materials to be stored securely and for the environment to be safe and homelike, but these standards were not met.
Failure to Accommodate Resident Request for Electronic Monitoring Device
Penalty
Summary
The facility failed to accommodate a resident's preference to have an electronic monitoring device (camera) placed in their room. The resident, who had multiple diagnoses including chronic respiratory failure with hypoxia, type II diabetes mellitus, dementia, heart failure, depression, chronic kidney disease, weakness, and cancer, required assistance with activities of daily living. The resident's family requested the placement of an electronic monitoring device, and the facility's Social Service Designee sent an email to the guardian of the resident's roommate requesting consent for the device. However, there was no evidence of a response from the roommate's guardian, nor was there any further documented correspondence or follow-up regarding the request. Observation of the resident's room confirmed that no electronic monitoring device was present. Interviews with facility staff, including the Social Service Designee and the current Administrator, revealed that the previous Administrator had been handling the situation, but no additional documentation or communication could be found. Review of the facility's policy indicated that residents have the right to use electronic monitoring devices in their rooms, but the facility did not provide evidence that it had reasonably accommodated the resident's or family's request.
Failure to Ensure Resident Privacy and Access for Telephone Communication
Penalty
Summary
Facility staff failed to ensure that a resident had privacy and reasonable access to telephone communication. Observation revealed that the resident's bedside phone was not plugged in and the phone jack did not have service, a situation that had persisted for several months according to the roommate. The resident, who had severe cognitive impairment and was rarely understood, was unable to be interviewed, but it was confirmed that she had a guardian and a family member involved in her care. When the resident received calls from her family, she had to go to the nurse's station to communicate, as her room phone was nonfunctional and lacked a cord to connect to the outlet. Staff interviews showed inconsistent knowledge about the availability of alternative phones for private use, with some LPNs unaware of any facility-provided cell phone and unable to locate one. The Unit Manager and Administrator were not aware that the resident's phone was unusable or that not all room phones had service. Facility policy required reasonable access to phones in a private area, but staff were not aware of the designated private phone options in the Social Services or Business Office. This resulted in the resident not having private access to phone communication as required.
Medication Error Rate Exceeds Acceptable Threshold Due to Unavailable Medications
Penalty
Summary
The facility failed to maintain a medication error rate below five percent, as required, with three medication errors occurring out of 30 observed opportunities, resulting in a 10 percent error rate. During medication administration for one resident with diagnoses including rhabdomyolysis, type II diabetes mellitus, and hypertension, it was observed that three prescribed medications—Mucinex 600 mg, Fluticasone Propionate nasal spray, and glipizide 5 mg—were not administered as ordered due to the medications not being available in the facility. The LPN responsible for administering the medications confirmed that the medications were not given because they were not on hand and stated that this issue occurs frequently. Facility policy requires verification of the right medication, dose, time, and route before administration, but the lack of medication supply prevented compliance with these requirements.
Medications Improperly Left at Bedside Without Physician Order
Penalty
Summary
The facility failed to ensure that medications were properly stored in accordance with professional standards. During observation, a resident with vascular dementia, cerebral infarction, and hypertension was found to have several medications left in a medicine cup on his bedside table. The resident, who had moderate cognitive impairment and required minimal assistance with activities of daily living, stated he did not know how long the medications had been there and that nurses often left his medications at the bedside for him to take. Review of the medical record and physician orders confirmed there was no order for the resident to self-administer medications or for medications to be left at the bedside. An LPN acknowledged preparing and leaving the medications on the bedside table and confirmed the absence of an order for self-administration. Facility policy requires that residents may only self-administer medications if the physician and care planning team determine it is safe, which had not occurred in this case.
Failure to Prevent Elopement of Cognitively Impaired Resident
Penalty
Summary
A cognitively impaired resident, identified as high risk for elopement, was able to leave the facility on two separate occasions without staff knowledge. The first incident occurred when the resident, who had a history of wandering, confusion, and impaired decision-making, was found by police 0.5 miles from the facility after staff were unaware of his absence until contacted by law enforcement. The resident's medical record indicated a high elopement risk score, documented episodes of wandering, and family concerns about his tendency to leave, yet no interventions or care plan addressing elopement risk were in place at the time. Following the first elopement, the resident was returned to the facility and placed on one-to-one supervision, but there was no physician order for this intervention, and the resident was returned to a non-secured unit. Documentation revealed that cognitive assessments were not completed upon his return, and the care plan still lacked interventions for elopement risk. The facility also failed to submit a Self-Reported Incident (SRI) related to this event, and the incident was not documented in the facility's incident/accident log. A second elopement occurred when the resident, who was supposed to be on 15-minute checks, left the facility again and was missing for over 17 hours before being found by police 2.6 miles away. There was no documented evidence that the required 15-minute checks were performed, and staff interviews confirmed that checks were not consistently documented or performed as ordered. The facility did not report this elopement to the state health department, and the incident was again omitted from the SRI and incident/accident log. The lack of timely and appropriate interventions, failure to follow physician orders, and inadequate documentation contributed to the deficiency.
Removal Plan
- The facility initiated a search for Resident #10.
- The facility initiated a head count, and all residents were accounted for except for Resident #10.
- The facility administrator notified the police of Resident #10's absence.
- The police requested assistance from another police department who had access to a device with thermal capabilities.
- The Bureau of Criminal Investigations was contacted and a silver alert was completed and sent out statewide.
- The Sheriff's Office was notified and assisted with the search for Resident #10.
- The facility conducted an AD HOC Quality Assurance and Performance Improvement (QAPI) meeting.
- Resident #10 was found and transported to a hospital for an evaluation.
- The facility reviewed and updated the elopement policy to reflect clearer definitions on elopement, more concise instructions to staff on reporting elopement, investigation procedures, and notification to appropriate agencies and medical staff.
- Resident #10's care plan was updated to reflect resident now resides on the secured unit.
- The facility staff completed a whole house head count as part of the facility's daily audits of residents. All residents were accounted for.
- Resident #10 was placed on the facility secured unit.
- Resident #10 was assessed by the facility nurse with no significant injuries. The assessment revealed two open areas on the right foot assessed as abrasions.
- A whole house audit of all residents was completed to ensure all residents were accurately assessed for elopement risk and no new residents were identified as being high risk for elopement. All residents who were previously identified as being high risks had their care plans reviewed for accuracy and no inaccuracies were found.
- Facility Unit Manager initiated education on the facility elopement policy which included one Registered Nurse, four Licensed Practical Nurses, and two Certified Nursing Assistants.
- The facility continued education for all staff on the facility elopement policy. Five Licensed Practical Nurses, two Certified Nursing Assistants were educated in person. Director of Nursing and the Administrator were educated on the facility Elopement Policy. Medical Director and Certified Nurse Practitioner were educated on the Elopement Policy via the telephone.
- Sixteen Licensed Practical Nurses, thirty Certified Nursing Assistants, three Activity Employees, eight Housekeepers, ten Dietary Staff, four Office Staff, twenty-one Therapists, five Speech Therapists, and one Maintenance Director were educated on the facility Elopement Policy via the telephone.
- Two Registered Nurses, eleven Licensed Practical Nurses, twenty-seven Certified Nursing Assistants, three Dietary Staff, four Housekeeping Staff, two Office Staff, seven Therapists, and one Maintenance Staff were educated in person on the facility Elopement Policy.
- All residents who were assessed as a high risk for elopement had their care plans reviewed for accuracy and updated as necessary. No inaccuracies were found.
- The facility checked the elopement binders and verified they reflected the status of the residents in the facility. No changes were identified.
- The facility reviewed the Brief Interview for Mental Status (BIMS) for residents who were deemed at high risk for elopement to ensure the assessments were accurate. There were no changes made to the resident's assessments.
- The facility completed a second check of all Elopement Risk Assessments and Elopement Care Plans for Accuracy.
- One Licensed Practical Nurse, one Certified Nursing Assistant and one Office Staff member were educated on the facility Elopement Policy.
- No staff will be permitted to work at the facility who have not received and reviewed the updated facility Elopement Policy. Facility education on the Elopement Policy will be ongoing.
- All new hired employees will be educated on the facility Elopement Policy as part of the general orientation.
- Elopement drills and head counts were completed at various times/shifts. Staff knowledge and review of the drill was completed. The Administrator reviewed and verified no actual elopements occurred.
- The facility's Interdisciplinary Team members reviewed elopement care plans to ensure interventions were in place. No identified concerns were noted.
- The facility will complete weekly elopement drills with the drills rotating between day and night shift to ensure each shift will have at least four elopement drills. Drills will be done monthly and randomly thereafter.
- The facility will conduct head counts daily as part of their midnight census procedure which ensures that all residents are accounted for daily.
- All new residents will be assessed by the facility nursing staff and follow up completed to ensure proper assessments and interventions are in place for residents deemed to be high risk for elopement.
- Telephone interviews with staff verified they all had received education on the policies/procedures for elopement. All staff had knowledge of how to respond to an elopement situation. Staff reported there had been no elopements. The LNHA verified he had continued on-going training/education/drills for all staff on elopement policies/procedures.
- Review of the audits revealed elopement drills were completed successfully and on-going monitoring continued.
- The facility denied any further elopements.
Failure to Ensure Safe Discharge and Continuity of Care for Resident with Complex Needs
Penalty
Summary
The facility failed to develop and implement an effective discharge planning process that ensured the safety and total care needs of a resident with multiple complex medical and psychosocial issues. The resident, who had diagnoses including alcohol abuse, malnutrition, chronic illnesses, and a history of homelessness, was discharged without evidence of a safe location to go or continuity of care post-discharge. The medical record review showed repeated instances where the resident left the facility unsupervised, often without signing out, and there were no new interventions or care plan updates to address these behaviors or ensure the resident's safety during leaves of absence. Despite the resident's known risk factors, including substance abuse and mental health concerns, there was no documentation of mental health or substance abuse services being offered or provided during the resident's stay. The facility's documentation revealed that the resident frequently left the premises, sometimes being found in unsafe situations such as in the street or at bus stops, and on several occasions required staff or police intervention to return. There was no evidence of comprehensive assessment or follow-up regarding the resident's ability to safely leave the facility, nor was there documentation of communication with the resident's physician or responsible party when the resident left. The care plan for anticipated discharge was not followed, and there was no evidence of social service follow-up or coordination with community resources, even after the resident expressed uncertainty about his housing situation and demonstrated ongoing psychosocial distress. After leaving the facility, the resident was found homeless, malnourished, and expressing suicidal ideation, leading to multiple hospital admissions. Interviews with facility staff confirmed a lack of notification to appropriate authorities or support services when the resident left and did not return. The facility's own investigation was minimal, with no staff or resident statements obtained, and the documentation did not support that the resident had requested to leave against medical advice. The facility's policies regarding leave of absence and discharge were not effectively implemented, and the resident's medical and psychosocial needs were not met at the time of discharge.
Removal Plan
- LNHA and the DON were educated on the facility's discharge against medical advice (AMA) and leave of absence (LOA) policies.
- An audit was completed by LNHA of current residents with plans to discharge to the community to ensure discharge planning was in progress and discharge plans were accurately recorded in each resident's record.
- SSD and LNHA were educated by RDCS on ensuring support for residents' psychosocial well-being and providing assistance with discharge needs and requests.
- SSD will complete new admission care conferences which will include screening assessments such as the PHQ-9 depression screening tool.
- The DON provided education to the facility's interdisciplinary team (IDT) and licensed nurses on the facility's policies on discharge AMA and LOA policies.
- A Quality Assurance Performance Improvement (QAPI) meeting was held, including completion of a root cause analysis of the event and development of a plan of correction.
- MDS Nurse completed an audit of in-house residents with the diagnosis or history of substance abuse or polysubstance abuse.
- The DON provided one-on-one education to residents with a substance abuse or polysubstance abuse history on the facility's leave of absences policy.
- Ad hoc education will be provided on an ongoing basis by RDCS or Regional Nurse for any staff member who is not correctly implementing the AMA and/or LOA policies on an as-needed basis.
- Newly hired nurses will be trained on the facility's discharge AMA and LOA policies upon hire by the DON or designee.
- The DON or designee will provide education to agency staff nurses on the facility's discharge AMA and LOA procedures prior to the agency nurse being able to accept the assignment at the facility.
- LNHA or designee will audit discharges to ensure documentation supports a safe discharge, including a discharge plan that meets the residents' behavioral and psychosocial needs.
- The results of ongoing audits will be reviewed by the facility's QAPI committee to determine if additional audits or education is needed.
- At Utilization Review (UR) meetings, LNHA or designee will discuss upcoming resident discharges and safe discharge planning.
Failure to Provide Required Bed Hold and Transfer/Discharge Notices
Penalty
Summary
The facility failed to provide required bed hold notices and transfer/discharge notifications to residents or their representatives when residents were transferred to the hospital. Specifically, three residents with various medical conditions, including diabetes, chronic kidney disease, Alzheimer's disease, peripheral vascular disease, and osteomyelitis, were transferred or discharged without documentation that they or their representatives received written bed hold or transfer/discharge notices. In addition, there was no documentation that the ombudsman was notified of these transfers or discharges as required. Interviews with the Director of Nursing confirmed the absence of this documentation for all three residents reviewed. Medical record reviews revealed that one resident with severely impaired cognition and another who was cognitively intact did not receive the required notifications upon transfer to the hospital. Another resident, who was readmitted after a hospital stay, also did not receive a formal bed hold notification, despite being verbally informed of a nine-day bed hold. Facility policies reviewed indicated that written notification should be provided prior to transfers, but this was not followed in these cases.
Failure to Prevent Resident-to-Resident Physical Abuse Resulting in Injury
Penalty
Summary
The facility failed to protect a resident from physical abuse, resulting in actual harm. One resident with dementia and a history of wandering into other residents' rooms was repeatedly redirected by staff but continued to enter other rooms, including that of another resident with a known behavior problem involving hitting others. Despite care plans identifying these behaviors and interventions such as redirection and staff intervention, the measures in place were not effective in preventing the incident. On the day of the incident, a resident reported to an LPN that an assault was occurring. The LPN found the resident with dementia in another resident's room, bleeding from the face after being punched. The resident who committed the assault admitted to hitting the other resident due to frustration over repeated intrusions into his room. The injured resident required hospital treatment for facial bruising and a laceration above the left eye, which required sutures. Prior to the incident, the injured resident had no facial injuries. Both residents involved had documented behavioral issues and cognitive impairments, with care plans outlining interventions to address these risks. However, the interventions were not sufficient to prevent the assault. The facility did not implement additional interventions, such as a stop sign on the door, until after the incident had occurred. Observations after the incident revealed that the stop sign intervention was not consistently maintained.
Failure to Provide Emergency Respiratory Support to Resident with Tracheostomy
Penalty
Summary
A deficiency occurred when a resident with a tracheostomy, who had a history of acute respiratory failure with hypoxia and hypercapnia, bacterial pneumonia, morbid obesity, and tracheostomy status, experienced respiratory distress and did not receive appropriate respiratory support as ordered and required by their condition. The resident was admitted with a full code status and had physician orders for tracheostomy care every shift and as needed, continuous supplemental oxygen via trach, and as-needed nebulizer treatments for shortness of breath. The care plan failed to identify a plan for respiratory or tracheostomy care. On the day of the incident, the resident requested suctioning due to difficulty clearing secretions, which was performed by a nurse with assistance from another nurse. After suctioning, the resident requested to be changed and, during repositioning, began to complain of shortness of breath and showed signs of acute respiratory distress, including labored breathing and cyanosis. The oxygen flow was increased, but the resident showed no improvement. The nurse left the room to call 911 and prepare paperwork for transfer, while another nurse was to remain at the bedside. However, when EMS arrived, the resident was found alone, without supplemental oxygen, and in cardiac arrest. No CPR was being performed by staff prior to EMS arrival, and EMS personnel immediately initiated resuscitation efforts. Interviews and documentation revealed that during the emergency, staff did not administer the as-needed nebulizer treatment, did not attempt further suctioning, did not change the inner trach cannula, and did not use an Ambu bag to provide breaths. The resident's oxygen saturation had dropped to critically low levels, and the resident ultimately lost consciousness, lost respirations, and lost pulse, and was later pronounced deceased in the emergency room. The deficiency affected one of two residents reviewed for tracheostomy care.
Failure to Maintain a Homelike Environment for a Resident
Penalty
Summary
The facility failed to maintain a homelike environment for Resident #13, as observed during a survey. Resident #13, who has multiple medical conditions including dysphasia, muscle disorder, mobility abnormalities, diabetes with a foot ulcer, respiratory failure, and dependence on renal dialysis, was found to have their room cluttered with medical supplies and personal items. During an interview and observation, it was noted that the resident's furniture was covered with medical supplies, pillows, wound vacuum care supplies, gloves, incontinence briefs, and blankets, forming a pile three feet high. The resident's family member confirmed that the resident did not have current orders for a wound vacuum and did not require the excessive number of pillows present. Further observations and interviews with a Certified Nurse Aide (CNA) and a Regional Nurse confirmed that the cluttered state of the resident's room did not appear homelike and hindered the usability of the furniture for guests. The facility's policy, dated February 2021, mandates that residents should be provided with a safe, clean, comfortable, and homelike environment, which was not adhered to in this case. This deficiency was investigated under Complaint Number OH00162784.
Failure to Provide Adequate Bathing and Nail Care
Penalty
Summary
The facility failed to provide adequate assistance with bathing and nail care for residents who were unable to perform these activities independently. Resident #102, who had multiple diagnoses including diabetes and end-stage renal disease, was documented to have received only two showers during a 19-day stay in January 2025, with no evidence of bathing in the preceding months of November and December 2024. This lack of documentation and care was confirmed by Regional Nurse #200. Resident #13, who had conditions such as dysphasia and diabetes with a foot ulcer, was provided showers on specific dates in February 2025, but there was no documentation of nail care being performed. Despite requests from the resident and her family for assistance with nail trimming, the facility staff did not provide the necessary care. Observations confirmed that Resident #13's nails were long and untrimmed, and the resident expressed difficulty in getting staff assistance for nail care. Resident #21, with diagnoses including chronic respiratory failure and heart disease, was documented to have received showers only four times over two months, with one refusal noted. The resident reported inconsistent bathing assistance, and Regional Nurse #200 confirmed the lack of consistent documentation and care. The facility's policy required assistance with activities of daily living, including bathing and grooming, for residents unable to perform these tasks independently, which was not adhered to in these cases.
Failure to Provide Ordered Physical Therapy Services
Penalty
Summary
The facility failed to provide physical therapy as ordered for two residents, leading to a deficiency in specialized rehabilitative services. Resident #13, who was admitted with multiple diagnoses including dysphasia, muscle disorder, and diabetes with a foot ulcer, had physician orders for physical therapy five times weekly. However, there were no therapy notes or assessments for several months, and therapy was inconsistently provided only two to three times weekly. Interviews with the resident and family confirmed the lack of consistent therapy services, and facility staff acknowledged the absence of therapy documentation during the ordered period. Similarly, Resident #102, admitted with conditions such as amputation, diabetes, and heart failure, was also ordered physical therapy five times weekly. Despite this, therapy was provided only two to four times weekly, as confirmed by therapy notes. Interviews with the resident's family and facility staff revealed concerns about insufficient therapy staffing, which affected the delivery of ordered services. The facility's therapy manager admitted that the facility was understaffed and unable to meet the therapy needs of all residents, including Resident #102. The facility's policy on specialized rehabilitative services mandates providing therapy upon physician orders until goals are met. However, the facility's failure to adhere to these orders resulted in non-compliance, as evidenced by the lack of therapy documentation and inconsistent service delivery for both residents. This deficiency was investigated under a specific complaint number, highlighting the facility's inability to provide the required rehabilitative services as per their policy.
Failure to Monitor COVID-19 Infection
Penalty
Summary
The facility failed to adequately monitor COVID-19 infections, specifically affecting one resident out of three reviewed for COVID-19 infections. The resident, who was cognitively intact, had a medical history including amputation of the right foot, diabetes, muscle disorder, end-stage renal disease, epilepsy, and heart failure. The resident was evaluated for a transfer to an assisted living facility and initially tested negative for COVID-19. However, following a family concern about a change in condition, a subsequent COVID-19 test was ordered, which returned positive. Despite this, the facility's infection logs did not include or review the resident's positive COVID-19 test as part of their infection control surveillance program. This was confirmed by a regional nurse who acknowledged the lack of evidence related to monitoring or tracking the resident's COVID-19 infection. The facility's policy required that infections be monitored and reported, but this was not adhered to in this case.
Failure to Timely Notify Guardian of Resident's Condition Change
Penalty
Summary
The facility failed to timely notify a resident's guardian following a change in the resident's condition, which is a deficiency in the facility's protocol for notification. The incident involved a resident who had hemiparesis and hemiplegia following a stroke, and who was cognitively intact. The resident sustained a wound to her left foot after jamming her toes into a door while using a motorized wheelchair. The wound was initially treated by the facility staff, but the resident later felt lightheaded and confused, prompting her guardian to request hospital evaluation, where six stitches were required. The facility's records indicated that the nurse on duty attempted to notify the resident's guardian by leaving a voicemail approximately 5.5 hours after the incident. However, the guardian reported not receiving timely notification and had to visit the facility to learn about the injury. The guardian found the resident feeling lightheaded and requested hospital evaluation. The facility's investigation into the incident revealed inconsistencies in the documentation and verbal accounts of the notification process. The facility's policy required timely notification of the resident's representative following an incident that could require medical intervention. The investigation concluded that the guardian was not notified in a timely manner, as required by the facility's policy. The nurse involved could not provide evidence of the call made to the guardian, and the facility's records did not support the nurse's claim of timely notification.
Failure to Ensure Follow-Up Appointments for Resident
Penalty
Summary
The facility failed to ensure follow-up appointments were implemented as scheduled and/or ordered for Resident #36. The resident, who was admitted with diagnoses including dehiscence of amputation stump, peripheral vascular disease, and acquired absence of the right leg below the knee, had a follow-up appointment with an orthopedic physician scheduled for two weeks after a hospital visit. This appointment was initially scheduled for February 20th, 2024, but was canceled and rescheduled for February 27th, 2024, due to the resident's COVID-positive status. However, the resident missed the rescheduled appointment on February 27th, 2024, and no new appointment was scheduled until March 19th, 2024, after the orthopedic office called to inform the facility of the missed appointment. The failure to attend the follow-up appointment was due to the RN's oversight in not completing the necessary assessments and failing to update the medical orders and inform the transportation department or the orthopedic office about the resident's status. Resident #36's quarterly Minimum Data Set (MDS) assessment indicated an intact cognition for daily decision-making abilities, although the resident displayed disorganized thinking and inattention. The resident required partial to moderate assistance for personal care and had a venous and/or arterial ulcer and a surgical wound. The RN responsible for the resident admitted to failing to complete the necessary assessments and update the medical orders, which led to the missed follow-up appointment. This deficiency was investigated under Complaint Number OH00153996.
Failure to Ensure Safety During Mechanical Lift Transfer
Penalty
Summary
The facility failed to ensure safety measures were in place during mechanical lift transfers, resulting in a fall involving Resident #108. The resident, who had diagnoses including contracture of the ankles, lack of coordination, muscle spasms, and dependence on enabling machines and devices, was being transferred from her bed to a chair using a Hoyer lift. During the transfer, the Hoyer lift tipped over, causing the resident to fall to the floor. The incident occurred because the Hoyer lift's legs were not properly opened to ensure balance, and the wheels were unlocked, which led to instability when the lift was moved over oxygen tubing. The fall assessment for Resident #108 indicated a low risk for falls, and her quarterly Minimum Data Set (MDS) assessment showed she had intact cognition and was dependent on staff for all transfers. During the incident, two State Tested Nursing Assistants (STNAs) were involved in the transfer. One STNA was guiding the Hoyer lift, while the other was waiting by the chair. The guiding STNA let go of the Hoyer lift handles to move the oxygen tubing, which caused the lift to tip over. The resident landed on the floor but did not sustain any apparent injuries. The incident was documented in a fall investigation report, and witness statements from the involved STNAs confirmed the sequence of events. The resident was assessed for injuries immediately after the fall, and vital signs were taken, all of which were within normal limits. An X-ray later confirmed no fractures. The deficiency was identified during a survey and was subsequently corrected by the facility through staff education and re-training on the proper use of the Hoyer lift.
Failure to Implement Proper Hand Hygiene and Enhanced Barrier Precautions
Penalty
Summary
The facility failed to ensure proper hand hygiene after glove removal and did not implement Enhanced Barrier Precautions during wound care and dressing change for Resident #36. The resident, who had a dehiscence of an amputated stump and required assistance with personal care, was observed to be in Enhanced Barrier Precautions due to having a wound. During the dressing change, the LPN did not wear a gown, which was required for this type of isolation, and changed gloves multiple times without performing hand hygiene as per facility policy. The LPN confirmed that she did not complete hand hygiene between glove changes and believed that gown and gloves were only required when assisting the resident to the bathroom, not during dressing/wound care. The medical record review revealed that Resident #36 had an intact cognition for daily decision-making abilities and had a venous and/or arterial ulcer and a surgical wound. The physician's orders required specific wound care procedures, including cleansing the surgical site and applying Triad cream. The facility's policies on hand hygiene and Enhanced Barrier Precautions were not followed, leading to the observed deficiencies. This non-compliance was investigated under Complaint Number OH00153996.
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A resident with intact cognition receiving Medicare Part A skilled services for metabolic encephalopathy had services discontinued while benefit days remained, but the facility did not issue the required Skilled Nursing Facility Advance Beneficiary Notice (SNF ABN). The Social Services Director later confirmed that no SNF ABN was provided and reported she believed only a Notice of Medicare Non-Coverage (NOMNC) was needed when all skilled services were stopped. This practice conflicted with the facility’s written policy, which required SNF ABNs to be issued when extended care items or services were initiated, reduced, or terminated due to expected non-coverage by Medicare.
Surveyors identified that the facility exceeded the acceptable medication error rate when two residents with type 2 DM received insulin doses that were not administered according to orders or manufacturer instructions. In two separate observations, an LPN administered Novolog and another LPN administered insulin glargine and insulin lispro without priming the insulin pens, and the insulin lispro and Novolog were given after the residents had already consumed a significant portion of their breakfast meals, despite orders for administration before meals. Manufacturer information for both insulin products required priming before each injection to ensure accurate dosing, and facility policy required medications, including insulin, to be administered safely, timely, and in accordance with prescriber orders and specified time frames.
Surveyors found that the facility failed to document tray line food temperatures for multiple meals served from two dining room kitchenettes, despite having a “Trayline Taste & Temperature Log” and a policy requiring food to be stored, prepared, distributed, and served according to professional food safety standards. Review of logs showed repeated missing entries for breakfast, lunch, and dinner services in both the Harrison and McClellan dining areas, and the Senior Director of Culinary Services confirmed that temperatures had not been recorded for those meals, potentially affecting all residents receiving meals from those kitchenettes.
The facility failed to conduct and document required periodic care conferences for two residents, despite multiple comprehensive, quarterly, and significant change MDS assessments and a policy requiring periodic care conferences with resident and/or family participation. One resident with Parkinson’s disease, post-stroke hemiplegia, TIA, DMII, and depression had only two documented care conferences over a year, while another resident with aphasia, cerebrovascular disease, DMII, gait difficulty, coagulation defect, depression, and muscle weakness had no documented care conferences in the past year, aside from a declined invitation to the representative. The UCC confirmed that care conferences were expected to occur quarterly and that no additional documentation existed for either resident.
A resident with Alzheimer's disease and type II DM, who required extensive assistance with ADLs and was receiving scheduled Lantus and sliding-scale Humalog, experienced a severely elevated blood glucose level. The on-call provider was notified and ordered an additional dose of lispro insulin with a directive to recheck the blood glucose after administration. Nursing staff administered the extra insulin but did not document any follow-up blood glucose check, and the DON confirmed that this reevaluation was required by the facility's abnormal blood glucose policy and was not completed or documented.
A resident with Parkinson’s disease, dementia, and hypothyroidism was prescribed levothyroxine once daily along with other medications. A consultant pharmacist’s monthly drug regimen review recommended that levothyroxine be given in the morning on an empty stomach, 30–60 minutes before food, per manufacturer instructions. The medical record contained no documented physician response to this recommendation, and the MAR showed the drug scheduled for morning administration while the resident was observed eating breakfast and receiving the medication at the same time. An LPN confirmed administering levothyroxine during the meal, and the DON verified there was no documentation explaining whether or why the pharmacist’s recommendation was or was not followed, resulting in a failure to act on and document the identified irregularity.
A resident with severe cognitive impairment, multiple comorbidities, documented gait and balance abnormalities, and a high fall risk was care planned and assessed by therapy to require contact guard assistance and use of a gait belt for transfers and ambulation. While being assisted by a CNA from a recliner to the bathroom with a walker, the CNA did not apply a gait belt, even though the resident had a known tendency to lean backward when standing. As the CNA reached to open the bathroom door, the resident lost balance and fell backward, striking the back of the head, and was later found by an LPN without a gait belt in place, contrary to the facility’s gait belt policy and the resident’s assessed needs.
A resident with 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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