Scioto Rehabilitation & Care Center
Inspection history, citations, penalties and survey trends for this long-term care facility in Columbus, Ohio.
- Location
- 433 Obetz Road, Columbus, Ohio 43207
- CMS Provider Number
- 366259
- Inspections on file
- 43
- Latest survey
- March 10, 2026
- Citations (last 12 mo.)
- 18
Citation history
Health deficiencies cited at Scioto Rehabilitation & Care Center during CMS and state inspections, most recent first.
A resident with cognitive impairment and multiple medical conditions was involved in an incident where another resident became agitated and grabbed her shoulders. Although the resident, her representative, and an LPN confirmed the physical contact, facility documentation and the investigation failed to accurately reflect these accounts or include all relevant witness interviews, resulting in an incomplete abuse investigation.
A resident with an indwelling urinary catheter and multiple medical conditions was identified as being at risk for urinary tract infection, but there were no physician orders in place for catheter care, cleansing, or flushing. Staff interviews confirmed that catheter care is performed according to physician orders, but none had been entered for this resident, resulting in a failure to follow facility policy and established procedures.
A nurse administered Metoprolol to a resident with cardiac conditions without checking blood pressure or heart rate as required by the physician's order, resulting in a failure to ensure the medication was only given when necessary.
A CNA entered the room of a resident on contact precautions for an infection without wearing the required PPE, such as a gown and gloves, despite clear signage and available supplies. An LPN confirmed the resident's precaution status and the CNA's failure to comply with infection control protocols.
Multiple infection control lapses were observed, including dirty linen left on hallway floors, an LPN failing to clean a glucometer between resident uses, improper sterile technique during trach care by a respiratory therapist, and delayed or missing Enhanced Barrier Precautions for residents with wounds or tracheostomies. These deficiencies were confirmed through staff interviews, record reviews, and direct observation.
A resident with multiple chronic conditions was transferred to the hospital, but the facility did not notify the resident's POA as required by policy. The DON confirmed that the emergency contact was not informed of the transfer, despite the facility's procedures mandating such notification.
Surveyors found that a resident with CHF experienced significant weight gain without physician notification, despite clear orders and facility policy. Two other residents did not receive proper treatment for non-pressure skin alterations as ordered, including missed wound care and dressing changes. Nursing leadership confirmed these deficiencies.
The facility did not properly document or treat pressure ulcers for three residents, including failing to measure and stage wounds on admission, not updating wound care orders per wound nurse recommendations, delaying initiation of treatment, and not clarifying conflicting orders. Multiple wounds were not captured in admission assessments, and appropriate treatment orders were not established, as confirmed by the DON.
Two residents did not receive required fall prevention interventions, including proper placement of fall mats and use of two staff for Hoyer lift transfers. One resident's fall mats were not in place as ordered, and another resident experienced a fall when a CNA performed a mechanical lift transfer alone, contrary to policy. Additionally, a resident's bed was repeatedly observed not in the lowest position as required by the care plan.
A resident with multiple medical conditions and cognitive impairment did not receive Acetaminophen, Gabapentin, and Oxycodone as prescribed, due to discrepancies between hospital discharge orders and facility medication administration. The resident was given Acetaminophen more frequently than ordered and had conflicting Gabapentin orders, leading to confusion and improper dosing. The resident experienced a decline in condition, requiring transfer to the hospital, and staff interviews confirmed the medications were not administered per physician orders.
The facility did not ensure medical records were accurate and up-to-date for three residents, including failure to update code status after a resident transitioned to hospice, documenting care for a resident after discharge, and missing wound care notes from an outside consultant. The DON and Assistant DON confirmed these discrepancies during interviews.
The facility failed to provide meals as ordered and maintain proper food temperatures, affecting most residents. Observations revealed that cold foods were served above the acceptable temperature, and several residents did not receive the meals indicated on their meal tickets. A delay in food delivery led to inappropriate meal substitutions, which were not properly documented as per facility policy.
A resident with an NG tube for nutritional support did not receive proper care due to the facility's failure to reorder and document the verification of tube placement upon readmission. This oversight led to inadequate care, including an incident where the resident was found unresponsive and required emergency medical intervention. The Director of Nursing confirmed the absence of the necessary order in the resident's records.
The facility failed to implement a comprehensive pressure ulcer prevention program, resulting in harm to three residents. One resident developed a Stage III ulcer due to inadequate interventions, another developed an unstageable ulcer without an individualized prevention plan, and a third developed a Stage III ulcer due to malfunctioning equipment. Prescribed treatments were not consistently administered, contributing to skin breakdown.
The facility failed to maintain sanitary conditions in food storage and preparation areas, affecting 108 residents. Observations revealed sour-smelling liquid pools and dirty walls in the dietary department. Interviews confirmed a punctured hose in the three-compartment sink caused the leak, violating the facility's sanitation policy.
The facility failed to employ a qualified social worker despite having over 120 certified beds. SSD #320, introduced as the new social worker, had a Master's degree but had not passed the State licensing exam and was not licensed. The Administrator was aware of this at the time of hiring. The job description required a Bachelor's Degree, supervisory experience, and ACSW registration, which SSD #320 did not meet. This deficiency potentially affected all 109 residents.
The facility failed to maintain effective pest control in the kitchen, affecting 108 residents. Observations revealed standing pools of sour-smelling liquid and fruit flies in the dietary department. The Dietary Director confirmed the presence of fruit flies, and the facility's Sanitation policy requires areas to be clean and pest-free.
The facility failed to provide adequate supervision and ensure the functionality of safety devices for residents, leading to incidents such as unsupervised smoking and malfunctioning wanderguard alarms. A resident with hemiplegia was found smoking unsupervised, resulting in a burn, while another resident with dementia had smoking materials in his room and was not supervised. Additionally, wanderguard alarms for two residents at risk of elopement were not properly checked for functionality, highlighting deficiencies in the facility's safety protocols.
The facility failed to manage medications and medical supplies properly, with expired items found in the medication room and an unattended, unlocked medication cart on the 400 unit. An LPN confirmed the expired items and the unlocked cart, which was against the facility's policy.
The facility failed to maintain the dignity of two residents. One resident reported witnessing inappropriate behavior from another resident, and management's response was inadequate. Another resident was observed without clothing, with a soiled brief visible from the hallway, which was confirmed by an LPN. These incidents violated the facility's policy on resident rights, which emphasizes treating residents with dignity and respect.
The facility failed to provide timely access to social security benefits for a resident with intact cognition, who had been requesting access since March 2024. Additionally, another resident with cognitive impairment did not have a Power of Attorney or guardianship in place, and the facility was unaware of the guardianship process, lacking a Licensed Social Worker.
A facility failed to update a resident's code status from full code to DNR after admission to hospice services. Despite the resident's DPOA agreeing to the change and a DNR order being completed, the facility did not update the medical records to reflect this change, as confirmed by the ADON.
The facility failed to provide required written transfer notices and inform residents or their families of their rights regarding hospitalization for three residents. One resident was hospitalized multiple times with only one incomplete transfer notice documented. Another resident's transfer notices lacked essential information, and the resident's family confirmed not receiving any documentation. A third resident was transferred due to altered mental status without the necessary appeal information. The Administrator admitted to not completing transfer notices for all facility-initiated transfers.
The facility failed to provide bed hold notices to residents and their families during hospitalizations, affecting two residents with complex medical conditions. Despite the facility's policy, no written notices were given, depriving residents of the opportunity to make informed decisions about bed retention. Interviews confirmed the lack of communication, and the facility's Administrator admitted that bed hold notices were not completed or provided.
The facility failed to conduct accurate and timely assessments for residents, affecting their care. A resident with a wanderguard was incorrectly marked as not using alarms in the MDS, while another resident's significant weight change was inaccurately documented due to flawed calculation methods. Additionally, a resident's admission MDS was not completed within the required timeframe, indicating a lapse in adherence to assessment protocols.
The facility failed to complete accurate significant change MDS 3.0 assessments for two residents, affecting their care documentation. One resident admitted to hospice services had an MDS assessment that did not reflect their hospice status, confirmed by an MDS Nurse. Another resident with multiple diagnoses and hospice admission also lacked a significant change MDS assessment, verified by the IDON.
A resident with multiple medical conditions, including a cerebrovascular accident, did not receive timely assistance with meals due to staffing issues. The resident's breakfast tray remained untouched for over 30 minutes, contrary to the facility's policy on providing necessary ADL support.
The facility failed to monitor and address conditions for two residents. One resident experienced significant weight gain and edema without appropriate treatment or documentation, while another resident on anticoagulants had a bruise that was not documented or monitored. Interviews confirmed lapses in following facility policies for notifying changes in condition and documenting skin issues.
A resident with severe cognitive deficits and dependency on staff for ADLs was found to have long, thick, and curling toenails, indicating a lack of podiatry care. The Interim DON was unsure if the resident was offered podiatry services during the podiatrist's visit. A RN Wound Nurse later trimmed the resident's nails, confirming their condition.
The facility failed to monitor behaviors and side effects for two residents receiving psychotropic and anticoagulant medications. One resident was not monitored for side effects after being prescribed multiple psychotropic medications, and an AIMS was not completed. Another resident, at risk for abnormal bleeding due to anticoagulant therapy, was not monitored for side effects related to antidepressant and anticoagulant use. The facility's policy on medication management was not followed.
A facility failed to complete PT-INR tests timely for a resident with atrial fibrillation and other conditions, leading to missed or delayed anticoagulant medication. The contracted lab company did not consistently perform tests as scheduled, and the facility lacked a specific lab test policy, relying only on the lab contract.
A facility failed to maintain a complete and accurate medical record for a resident with severe cognitive deficits and multiple diagnoses. A room change that occurred while the resident was hospitalized was not documented, and there was no record of the reason for the change or notification to the resident's family. This deficiency was confirmed through staff interviews and medical record reviews.
The facility failed to follow infection control policies for two residents, leading to deficiencies in care. One resident did not receive ordered dressing changes for a nephrostomy site, and the nephrostomy bag was improperly managed. Another resident, requiring enhanced barrier precautions due to a PICC line, did not receive care with the necessary PPE, as a CNA failed to wear a gown during incontinence care. These lapses were identified through observations and interviews, indicating a significant deficiency in infection prevention practices.
A resident with a severe cognitive deficit was moved to a different room while admitted to a hospital, and the facility failed to notify the family of this change, as required by policy. The resident had a complex medical history, and the lack of documentation was confirmed by the Social Service Designee.
A facility failed to safely store smoking materials for a resident diagnosed with bipolar disorder, nicotine dependence, and anxiety disorder. Despite being an independent smoker, her care plan required smoking materials to be stored in a designated area. Observations revealed she kept cigarettes and lighters in her room, violating the facility's smoking policy. An LPN confirmed the presence of these items.
A resident with a history of falls sustained a fracture after stepping onto an unstable milk crate placed by facility staff during a bus transfer. Despite being assessed as low risk for falls, the resident experienced severe pain and swelling, leading to hospitalization. Interviews confirmed the inappropriate use of a milk crate as a transfer device, contributing to the fall and injury.
The facility failed to dispose of garbage and food waste properly, leaving soiled trays with uncovered food overnight in the dining room and kitchen. Staff interviews confirmed the absence of dietary staff after meal service led to this issue, which poses a risk of pest infestation. The facility's policy requires food waste to be disposed of in sealed containers, which was not followed.
Failure to Thoroughly Investigate Abuse Allegation
Penalty
Summary
The facility failed to thoroughly investigate an allegation of abuse involving a resident with multiple diagnoses, including dementia, Parkinson's disease, and mild cognitive impairment. The incident involved another resident who became agitated and grabbed the resident's shoulders, as confirmed by interviews with the resident, her representative, and an LPN who intervened. The resident reported a stress-induced headache following the incident, which was treated with a pain reliever. Documentation in the medical record and investigative documents did not accurately reflect the physical interaction, instead stating there was no evidence of physical contact. The investigation conducted by the facility was incomplete, as it did not include interviews with all relevant witnesses, specifically the resident's representative who was present during the incident. The DON stated she was unaware of any reports or documentation indicating physical contact and did not document her interview with the resident. The facility's policy requires a thorough investigation of all abuse allegations, including interviews and documentation, but these steps were not fully carried out in this case.
Failure to Implement Physician Orders for Catheter Care
Penalty
Summary
The facility failed to implement physician orders for the care of an indwelling urinary catheter for one resident. Record review showed that the resident was admitted with multiple diagnoses, including chronic obstructive pulmonary disorder, tracheostomy, obstructive sleep apnea, and muscle wasting. The resident was cognitively intact and required assistance with self-care activities. The care plan identified the resident as being at risk for urinary tract infection, but there were no physician orders in place for catheter care, cleansing, or flushing as of the date reviewed. Interviews with facility staff confirmed that catheter care is conducted according to physician orders in the system of record. However, both an LPN and the DON acknowledged that no such orders had been entered for this resident, despite the presence of an indwelling urinary catheter. The facility's policy on urinary catheter care emphasizes the importance of routine hygiene and regular emptying of the drainage bag to prevent catheter-associated urinary tract infections. The lack of physician orders for catheter care represented a failure to follow established procedures and contributed to the cited deficiency.
Failure to Monitor Vitals Before Administering Cardiovascular Medication
Penalty
Summary
A deficiency occurred when a registered nurse administered Metoprolol Tartrate 25 mg to a resident diagnosed with atherosclerotic heart disease, hypertension, and atrial fibrillation without first checking the resident's systolic blood pressure or heart rate as required by the physician's order. The order specifically directed that the medication should be held if the systolic blood pressure was less than 100 or the heart rate was less than 60. During observation of the medication administration, it was confirmed that the nurse did not perform these checks prior to giving the medication. The facility's policy on administering medications requires verification of the right resident, medication, dosage, time, and method, but does not specifically address the monitoring required by the physician's order in this case.
Failure to Follow Contact Precautions for Resident with Infection
Penalty
Summary
A deficiency was identified when a certified nursing assistant (CNA) entered the room of a resident who was on contact precautions for an infection without donning the required personal protective equipment (PPE), specifically a gown and gloves. The resident, admitted with a diagnosis of osteomyelitis, had a sign posted outside the room indicating contact precautions and a PPE cart was available at the door. Despite these measures, the CNA failed to follow proper transmission-based precautions as outlined in the facility's infection control policy, which adheres to CDC guidelines. This lapse was confirmed by a licensed practical nurse (LPN) who verified the resident's precaution status and the CNA's failure to use appropriate PPE.
Infection Control Deficiencies: Improper Linen Handling, Equipment Cleaning, and Precaution Implementation
Penalty
Summary
The facility failed to implement and maintain effective infection prevention and control measures, as evidenced by multiple observed deficiencies. Dirty bed linen was found piled on the hallway floor outside a resident's room, rather than being bagged and removed from the resident's room as required by infection control protocols. A CNA confirmed that this practice was not in accordance with facility policy, which mandates that soiled linen should not be placed on the floor to prevent the spread of infection. Additionally, an LPN was observed using a glucometer on multiple residents without cleaning it between uses. The LPN admitted to not disinfecting the device after each use, despite having access to approved disinfectant wipes in the medication cart. This failure to clean shared medical equipment between residents increases the risk of cross-contamination and infection transmission. Further deficiencies were noted in the performance of sterile procedures and the implementation of Enhanced Barrier Precautions (EBP). A respiratory therapist did not maintain sterile technique during trach care, including failing to perform hand hygiene, improperly donning sterile gloves, and contaminating sterile supplies. Several residents with wounds, tracheostomies, or other conditions requiring EBP did not have appropriate precautions or care plans in place upon admission, as confirmed by the DON. These lapses in infection control practices were identified through medical record review, staff interviews, and direct observation, affecting multiple residents and potentially placing all residents at risk.
Failure to Notify POA of Resident Hospital Transfer
Penalty
Summary
The facility failed to notify the Power of Attorney (POA) for a resident who was transferred to the hospital. The resident, who had diagnoses including chronic kidney disease stage 4, chronic obstructive pulmonary disease, chronic diastolic heart failure, and iron deficiency anemia, was admitted to the facility and later transferred to the hospital. The medical record indicated that the resident was cognitively intact, with a Brief Interview for Mental Status (BIMS) score of 13 out of 15, and required varying levels of assistance with activities of daily living. A review of the resident's closed record showed that the POA was listed as the emergency contact. However, documentation revealed that when the resident was transferred to the hospital, the POA was not notified as required by facility policy. This was confirmed during an interview with the Director of Nursing, who acknowledged that the notification should have occurred. The facility's policy, revised in May 2017, states that a nurse will notify the resident's representative when a transfer to the hospital is necessary.
Failure to Notify Physician of Weight Gain and Inadequate Treatment of Non-Pressure Skin Alterations
Penalty
Summary
The facility failed to notify the physician of significant weight gain in a resident with congestive heart failure, despite clear discharge instructions from the hospital and facility policy requiring such notification. The resident experienced a weight increase of over 10 pounds within a week, as documented in the weight log, but there was no evidence that the physician was informed at any point. The Director of Nursing confirmed that the required notification did not occur. Additionally, the facility did not ensure that non-pressure skin alterations were treated according to physician orders for two residents. One resident with bilateral lower leg stasis dermatitis did not receive the recommended ammonia lactate application and daily ace wrap, as suggested by the wound consultant, due to the absence of corresponding physician orders. The Assistant Director of Nursing verified that the correct treatment was not provided as recommended. Another resident with multiple surgical incisions did not have dressings changed daily as ordered by the physician. Observations revealed that dressings had not been changed for three days, and the resident confirmed that only one dressing change was refused, with no staff offering to change the dressings on other days. Facility policy required that wound treatments be implemented as ordered, but this was not followed.
Failure to Accurately Document and Treat Pressure Ulcers
Penalty
Summary
The facility failed to accurately document and treat pressure ulcers for three residents, resulting in deficiencies in pressure ulcer care. For one resident with multiple diagnoses including heart failure and pneumonia, the admission skin assessment did not include measurements or staging of a sacral pressure ulcer, and physician orders for wound care were not updated to reflect the wound nurse practitioner's recommendations. The Director of Nursing confirmed that the correct orders were not entered or administered, and that the admitting nurse did not properly assess the wound upon admission. Another resident was admitted with chronic ulcers and peripheral vascular disease, but no treatment orders were initiated until several days after admission. Additionally, there were conflicting physician orders for wound care on the left foot, which were not clarified. The Director of Nursing acknowledged the delay in initiating treatment and the presence of inconsistent orders for wound care. A third resident was admitted with a history of heart disease and a recent hip fracture. The admission assessment failed to capture multiple wounds, including a skin tear, surgical incision, and pressure injuries, and treatment orders were not put in place for these wounds. The Director of Nursing confirmed that the wounds were not documented on the admission assessment and that appropriate treatment orders were not established.
Failure to Implement Fall Prevention and Safe Transfer Protocols
Penalty
Summary
The facility failed to implement fall prevention interventions for two residents, resulting in deficiencies related to accident hazards and inadequate supervision. For one resident with orthopedic aftercare needs and a recent fracture, the care plan required fall mats to be placed on both sides of the bed while the resident was in bed. However, during observation, the fall mats were found against the wall and not in position as required, despite a physician order and care plan specifying their use. A registered nurse confirmed that the mats should have been in place while the resident was in bed. Another resident, who had diagnoses including acute respiratory failure and required a wheelchair for mobility, was dependent on staff for transfers and had a care plan specifying the use of a bed enabler, floor mat, and perimeter air mattress for fall prevention. The resident experienced a fall when a CNA attempted a Hoyer lift transfer alone, contrary to facility policy and the resident's care plan, which required two staff members for such transfers. The CNA reported that the resident became agitated while waiting for assistance, leading her to proceed alone, and the resident slipped out of the Hoyer lift pad and fell to the floor. The incident was witnessed and documented, and the resident later reported pain, prompting further medical evaluation. Additionally, repeated observations showed that the resident's bed was not kept in the lowest position as required by the care plan, and this was confirmed by a licensed nurse. Review of facility policies indicated that two staff members are required for mechanical lift transfers and that fall prevention interventions should be implemented based on assessment results. These failures affected two of three residents reviewed for accidents or falls.
Failure to Administer Medications as Ordered Results in Significant Medication Errors
Penalty
Summary
The facility failed to ensure that medications were administered as prescribed for a resident with multiple complex medical conditions, including chronic non-pressure ulcer, peripheral vascular disease, and cerebral infarction. Upon admission from the hospital, the resident had specific orders for Acetaminophen, Gabapentin, and Oxycodone, with detailed dosing schedules and indications for use. However, review of the medication administration records revealed discrepancies between the hospital discharge orders and the facility's transcription and administration of these medications. For example, Acetaminophen was administered more frequently than every 8 hours as ordered, and there were multiple, conflicting Gabapentin orders active at the same time, leading to confusion about the correct dosage and schedule. The resident, who had significant cognitive impairment and required daily administration of opioids, antiplatelets, and anticonvulsants, experienced a decline in condition during their stay. On one occasion, the resident was found to be non-responsive to commands, prompting assessment by a CNP and subsequent transfer to the emergency room. Hospital documentation indicated the resident was drowsy and had received pain medication earlier in the day, with Narcan administered for improvement. Interviews with facility staff, including the DON, confirmed that the medications were not transcribed or administered according to the hospital's orders, particularly regarding the timing and dosage of Acetaminophen and Gabapentin. Facility policy required medications to be administered in accordance with physician orders, including specified time frames, and for staff to consult with a physician if a dosage appeared inappropriate. Despite this, the facility did not ensure accurate transcription or administration of the resident's medications, resulting in significant medication errors. The deficiency was identified during a review of medical records, staff interviews, and hospital paperwork, and was confirmed by the DON.
Failure to Maintain Accurate and Complete Medical Records
Penalty
Summary
The facility failed to maintain accurate and up-to-date medical records for multiple residents, resulting in discrepancies regarding code status, wound care documentation, and charting after discharge. For one resident with diagnoses including acute respiratory failure and COPD, the medical record contained conflicting information about code status. While the physician order and care plan indicated full code status, the resident had transitioned to hospice care with a DNRCC order, which was not promptly or clearly reflected in the records. The Director of Nursing was unable to confirm the resident's current code status during the interview, and the updated DNRCC documentation was only later found uploaded in the record. Another resident, who had been admitted with chronic conditions and later discharged after a hospital transfer, had progress notes entered by nursing staff documenting vital signs and health status on days after the resident had already left the facility. The DON confirmed that these entries were inaccurate, as the resident was not present in the facility at the time the notes were made. A third resident with multiple chronic conditions and pressure ulcers was seen by an outside wound nurse practitioner, but the assessment and treatment recommendations from that visit were never received or uploaded into the resident's medical record. The Assistant DON verified that the documentation should have been included to ensure the record was complete and accurate. These failures affected three of the ten residents reviewed for accurate medical record information.
Failure to Provide Meals as Ordered and Maintain Proper Food Temperatures
Penalty
Summary
The facility failed to ensure that residents received meals as ordered and needed, affecting 105 out of 110 residents. During an observation of the kitchen, it was noted that meal temperatures were not within the required range, with cold foods such as mechanical texture ham sandwiches and regular texture ham sandwiches being served above the acceptable temperature of 41 degrees Fahrenheit. Additionally, several residents did not receive the meals as indicated on their meal tickets. For instance, residents who were supposed to receive tomato soup and crackers did not receive them, nor did they receive an appropriate substitution. Interviews with residents revealed dissatisfaction with meal substitutions and inaccuracies, such as receiving chocolate ice cream instead of sherbet or not receiving the coleslaw they were expecting. The kitchen manager confirmed that there was a delay in the food truck delivery, which led to the substitution of macaroni salad for tomato soup, a substitution deemed inappropriate. The facility's policy requires consultation with the director of food and nutrition services for menu substitutions and mandates that substitutions be recorded, which was not adhered to in this instance.
Failure to Ensure Proper NG Tube Care for Resident
Penalty
Summary
The facility failed to ensure proper care for a resident receiving nutritional support through a nasogastric (NG) tube. The resident, who had a history of heart failure, hemiplegia, hemiparesis, dysphasia, and gastrostomy status, was readmitted to the facility with an NG tube after a hospital stay. Despite the physician's order to check the NG tube placement before administering formula, medication, or flushing the tube, this order was not re-entered into the resident's medication administration record (MAR) or treatment administration records (TAR) upon readmission. This oversight led to the resident not receiving the necessary verification of tube placement before medication administration, as confirmed by the Director of Nursing (DON). The deficiency was further highlighted by an incident where the resident was found unresponsive in a wheelchair, leading to emergency medical intervention and hospitalization. Additionally, the resident experienced a clogged NG tube and an elevated blood glucose reading, which required physician intervention due to the absence of current orders for hyperglycemia management. The facility's failure to ensure the reordering and documentation of the NG tube placement verification order contributed to the inadequate care provided to the resident.
Failure to Implement Pressure Ulcer Prevention Program
Penalty
Summary
The facility failed to develop and implement a comprehensive and individualized pressure ulcer prevention program, resulting in actual harm to three residents. Resident #54, with moderate cognitive impairment and high risk for pressure ulcer development, developed a Stage II pressure ulcer on the right buttock that progressed to a Stage III ulcer due to inadequate interventions. The facility did not provide timely and individualized care, such as applying prescribed treatments after incontinence episodes, which contributed to the deterioration of the resident's condition. Resident #163, with severe cognitive impairment and dependent on staff for care, developed an unstageable pressure ulcer on the sacrum. Despite being at high risk for pressure ulcers, the facility failed to create and implement an individualized prevention plan. The resident's condition was not adequately monitored, and the pressure ulcer was not identified until it became unstageable, indicating a lack of proactive skin assessment and intervention. Resident #89, who had a history of pressure ulcers and was at high risk, developed a new Stage III pressure ulcer on the right ischium due to malfunctioning pressure-relieving equipment. The facility failed to ensure timely replacement and proper functioning of the air mattress, leading to the resident's skin coming into contact with the metal bed frame. Additionally, there were multiple instances where prescribed wound care treatments were not administered as ordered, further contributing to the resident's skin breakdown.
Unsanitary Food Storage and Preparation Conditions
Penalty
Summary
The facility failed to store and prepare food under sanitary conditions, affecting 108 of 109 residents, as one resident was not eating by mouth. Observations revealed two large pools of sour-smelling liquid on the dietary department floor, one near the skilled dining room door and another in the dish room area. Fruit flies were seen flying over these puddles. Additionally, the walls behind the three-compartment sink and the beverage dispenser were dirty with dried food and beverage stains. Interviews with the Dietary Director and Maintenance Director confirmed the unsanitary conditions. The Dietary Director acknowledged the presence of the pools of liquid and the dirty walls, while the Maintenance Director identified a punctured hose in the three-compartment sink as the source of the leak leading to the standing water. The facility's sanitation policy, last revised in 2008, mandates that all kitchen and dining areas be kept clean and free from insects, with regular cleaning schedules to prevent grime accumulation.
Facility Lacks Qualified Social Worker for Over 120 Beds
Penalty
Summary
The facility failed to ensure a qualified social worker was on staff, despite having over 120 certified beds, which is a requirement. The deficiency was identified through a review of Resident Council meeting minutes, staff interviews, and examination of the Social Services Designee (SSD) #320's credentials and work history. SSD #320, who was introduced as the facility's new social worker, had a Master's degree in Social Work but had not passed the State licensing board exam and was not a licensed social worker at the time of the survey. SSD #320 confirmed she would not retake the exam until January 2025 and had not been supervised by a licensed social worker in her previous roles. The facility's job description for the Director of Social Services required a minimum of a Bachelor's Degree in Social Work, two years of supervisory experience in a medical facility, and registration as an Academy of Certified Social Workers (ACSW) member in good standing with the National Association of Social Workers (NASW). However, SSD #320's resume did not indicate she met these requirements. The Administrator acknowledged hiring SSD #320 with the knowledge that she had not yet obtained a social work license, expecting her to pass the exam in the summer of 2024, which she did not. This oversight had the potential to affect all 109 residents in the facility.
Ineffective Pest Control in Kitchen
Penalty
Summary
The facility failed to maintain effective pest control in the kitchen, which had the potential to affect 108 of 109 residents, as one resident was not eating by mouth. Observations made on December 16, 2024, between 8:22 A.M. and 8:40 A.M. revealed standing pools of liquid, approximately three feet by three feet, on the dietary department floor next to the skilled dining room door and in the dish room area. These pools of liquid emitted a sour smell, and several fruit flies were observed flying over them. Additionally, fruit flies were seen on the clean silverware and dishes rack. An interview with the Dietary Director confirmed the presence of fruit flies in the dietary department. A review of the facility's Sanitation policy, dated 2001 and revised in October 2008, indicated that all kitchen and dining areas should be kept clean and free from pests such as rodents, roaches, flies, and other insects.
Inadequate Supervision and Safety Device Failures in LTC Facility
Penalty
Summary
The facility failed to ensure a safe environment free from accident hazards for several residents, as evidenced by inadequate supervision and malfunctioning safety devices. Resident #17, who had multiple medical conditions including hemiplegia and dependence on a wheelchair, was observed smoking unsupervised, resulting in a cigarette burn on his clothing. Despite the facility's smoking policy requiring assessments and supervision for residents who smoke, there were no documented smoking assessments for Resident #17, and the care plan inaccurately stated that he did not require supervision. Resident #56, with a history of multiple health issues including dementia and schizophrenia, was also found to be smoking unsupervised, with burn holes observed on his clothing and personal items. The facility's policy required that smoking materials be kept by staff and that residents be supervised while smoking, yet Resident #56 had smoking materials in his room and was not being supervised. No smoking assessments were documented for Resident #56, contrary to the facility's policy. Additionally, the facility failed to ensure the proper functioning of wanderguard alarms for Residents #27 and #87, both of whom were at risk for elopement. The wanderguard for Resident #27 was not checked for functionality as required, and staff were unable to locate the device needed to test it. Similarly, Resident #87, who had previously eloped, had a wanderguard that was not consistently verified for functionality. These lapses in safety measures and supervision highlight significant deficiencies in the facility's adherence to its own policies and procedures designed to prevent accidents and ensure resident safety.
Medication Management Deficiencies
Penalty
Summary
The facility failed to ensure that medications and medical supplies were properly managed, leading to potential risks for residents. During an observation in the medication room on the 100 unit, it was found that a box of vacutainers with 22-gauge needles was expired, and the reference number on the needles did not match the box. Additionally, prefilled sodium chloride syringes were also expired. A Licensed Practical Nurse (LPN) confirmed the presence of these expired items during a review of the medication storage room. On the 400 unit, an unlocked medication cart was observed unattended in the hallway, with no staff visible nearby. The LPN assigned to the cart was found at the nurse's station and later entered the medication storage room, leaving the cart unlocked and out of sight. The LPN confirmed that the cart was supposed to be locked when not in use or in direct sight. The Unit Manager confirmed the incident and provided education to the LPN regarding the facility's policy on medication storage.
Failure to Maintain Resident Dignity
Penalty
Summary
The facility failed to provide dignified living conditions for two residents, as observed in separate incidents. Resident #49, who has intact cognitive status, reported witnessing another resident exposing himself and engaging in inappropriate behavior from his room across the hallway. Despite reporting these incidents to management, Resident #49 was told to 'deal with it' and close her door, which she found undignified. The facility's policy on resident rights emphasizes the need for residents to be treated with courtesy, respect, and dignity, which was not upheld in this situation. In another incident, Resident #81, who has a severe cognitive deficit and is dependent on staff for activities of daily living, was observed lying in bed without clothing, with a soiled incontinence brief visible from the hallway. This was confirmed by a Licensed Practical Nurse. The facility's policy on resident rights was again not adhered to, as the resident was not treated with the dignity and respect outlined in the policy. These observations highlight a failure to maintain the dignity of residents as required by the facility's own policies.
Deficiencies in Resident Financial Access and Guardianship
Penalty
Summary
The facility failed to provide timely access to social security benefits for a resident with intact cognition, who had been requesting access since March 2024. The resident needed the funds to purchase preferred toiletry items. The facility lacked a Business Office Manager, and the Administrator was unsure how to assist the resident in obtaining a state identification card due to her transient status. The resident's social security benefits had stopped because the Social Security office was unaware of her location. Eventually, the Admissions Director assisted the resident in contacting Social Security to reroute her benefits to the facility. Another resident, with multiple diagnoses including cognitive impairment, did not have a Power of Attorney or guardianship in place. A volunteer guardian evaluated the resident but deemed guardianship unnecessary. The resident's Payee, who managed financial matters and appointments, informed the facility of the need for guardianship, but the facility lacked a Licensed Social Worker and was unaware of the guardianship process. The resident's primary care physician had not been involved in determining the need for guardianship.
Failure to Update Resident's Code Status
Penalty
Summary
The facility failed to ensure an accurate code status for a resident, leading to a deficiency in honoring the resident's right to request, refuse, and/or discontinue treatment. The resident, who had intact cognition at the time of admission, was initially documented as full code. However, upon admission to hospice services, a Do Not Resuscitate (DNR) order was completed, indicating a change in the resident's code status. Despite this, the facility did not update the resident's code status in the medical records, both in the hard chart and the electronic medical record, to reflect the DNR status. The Assistant Director of Nursing (ADON) confirmed that the resident's Durable Power of Attorney (DPOA) had agreed to the change in code status, and the hospice nurse had provided the DNR order to the physician for signing. However, the facility staff failed to review the admission paperwork and follow up to confirm the resident's code status change. The facility's policy required that a DNR form be completed and signed by the attending physician and placed in the front of the resident's medical record, which was not done in this case.
Failure to Provide Required Transfer Notices and Appeal Information
Penalty
Summary
The facility failed to provide written transfer notices and inform residents or their families of their rights regarding hospitalization for three residents. Resident #41, who had multiple chronic conditions, was hospitalized several times, but only one transfer notice was documented, which lacked essential information such as appeal rights and contact details. The Administrator confirmed that no other transfer notices were completed for Resident #41's hospitalizations, and the resident confirmed not receiving any transfer notice. Resident #76, diagnosed with various conditions including hemiplegia and diabetes, was hospitalized multiple times. Although some transfer notices were completed, they did not include required information like appeal rights or contact information. The Administrator admitted that the facility only submits transfer notices when a resident is discharged from the facility, and the resident's daughter confirmed the lack of written transfer documentation. Resident #106, with a history of osteomyelitis and diabetes, was transferred to a hospital due to altered mental status. The transfer report did not include necessary information about the right to appeal the transfer or contact details for the State entity and Ombudsman. The Administrator acknowledged that the facility did not complete transfer notices for all facility-initiated transfers, including emergency transfers, as required by federal regulation.
Failure to Provide Bed Hold Notices During Hospitalizations
Penalty
Summary
The facility failed to provide bed hold notices to inform residents or their families of their rights regarding the retention of their room and bed during hospitalizations. This deficiency was identified for two residents out of three reviewed for hospitalizations. Resident #41, who had multiple complex medical conditions including chronic respiratory failure and diabetes, was hospitalized several times throughout the year. Despite the facility's policy requiring written notice of bed hold rights at the time of transfer, the medical record for Resident #41 contained an undated and unsigned notice lacking essential information. Interviews with the interim Director of Nursing revealed that the notices were incomplete and could not be located, and Resident #41 expressed frustration over the lack of communication regarding her room reassignment during hospitalization. Similarly, Resident #76, who also had multiple health issues such as hemiplegia and chronic kidney disease, experienced several hospital stays without receiving any bed hold notices. An interview with Resident #76's daughter confirmed that the family did not receive any written documentation regarding bed hold rights. The facility's Administrator acknowledged that bed hold notices were not completed or provided to residents or families, which violated the terms of the Admissions Agreement and regulatory requirements. This omission deprived residents and their representatives of the opportunity to make informed decisions regarding care and bed retention during hospitalizations.
Inaccurate and Untimely Resident Assessments
Penalty
Summary
The facility failed to conduct accurate and timely assessments of residents' functional capacities, affecting multiple residents. Resident #27, who had a wanderguard in place due to elopement risk, was inaccurately assessed in the quarterly MDS as not using physical restraints or wander alarms, despite having an order and care plan for the wanderguard. MDS nurse #356 confirmed that the wanderguard was not considered a restraint, leading to the incorrect assessment marking. Resident #87 experienced a significant weight change that was not accurately documented in the MDS. The facility's process for calculating weight gain was flawed, as it used the lowest and highest weights within a month rather than following the RAI manual's instructions. Additionally, Resident #220's admission MDS was not completed within the required timeframe, as it was still in progress beyond the 14-day submission deadline. These deficiencies highlight the facility's failure to adhere to assessment protocols, potentially impacting resident care.
Failure to Complete Accurate Significant Change MDS Assessments
Penalty
Summary
The facility failed to complete accurate significant change Minimum Data Set (MDS) 3.0 assessments for two residents, affecting their care documentation. Resident #97, who was admitted to hospice services with a diagnosis of cerebral atherosclerosis, had an MDS assessment that did not reflect their hospice status. This oversight was confirmed by MDS Nurse #356, who acknowledged the inaccuracy of the assessment. Additionally, the facility lacked a specific MDS policy, relying instead on the Resident Assessment Instrument (RAI) guidelines, as confirmed by Regional Nurse #504. Similarly, Resident #163, who had multiple medical diagnoses and was admitted to hospice services, did not have a significant change MDS assessment completed to reflect this change. Despite a progress note indicating a hospice referral and subsequent admission, the MDS assessment failed to document the resident's hospice status. This deficiency was verified by the Interim Director of Nursing (IDON), who confirmed that the required significant change MDS assessment was not completed.
Failure to Assist Resident with Meals
Penalty
Summary
The facility failed to provide necessary assistance with meals to a resident, identified as Resident #163, who was unable to perform activities of daily living independently. The resident had a complex medical history, including conditions such as gastrostomy malfunction, asthma, chronic obstructive pulmonary disease, diabetes mellitus, chronic kidney disease, syncope, repeated falls, cerebrovascular accident with left-sided hemiplegia, anxiety disorder, dysphagia, aphasia, hypertension, and hypothyroidism. The resident's care plan indicated a need for extensive to dependent assistance with various activities, including eating, due to a self-care performance deficit related to a cerebrovascular accident. Despite these needs, the resident's breakfast tray was observed untouched for over 30 minutes, indicating a lack of timely assistance. The deficiency was further highlighted during an interview with a Certified Nursing Assistant (CNA), who confirmed that due to staffing cuts, there was insufficient time to assist the resident with meal setup promptly. The facility's policy on ADL support, which mandates providing necessary services to maintain or improve residents' ability to carry out daily activities, was not adhered to in this instance. This lapse in care resulted in the resident not receiving the required assistance with meals, as evidenced by the untouched breakfast tray and the resident's acknowledgment of hunger.
Failure to Monitor and Address Resident Conditions
Penalty
Summary
The facility failed to treat and monitor conditions for two residents according to professional standards of practice. Resident #85, who was admitted with diagnoses including chronic heart failure and chronic kidney disease, experienced a significant weight gain of 24.6 pounds over thirty days, indicative of edema. Despite the resident's complaints about discomfort from edema in his lower extremities, there were no physician orders for diuretics or treatments for edema. Interviews with the resident, an LPN, and a dietitian revealed that the weight gain and edema were not addressed with the physician or documented in the medical chart, contrary to the facility's policy requiring notification of significant changes in a resident's condition. Resident #87, admitted with conditions such as end-stage renal disease and atrial fibrillation, was on anticoagulant therapy. The care plan included monitoring for signs of abnormal bleeding, but there was no specific order for monitoring skin for bruising or bleeding. Observations revealed a bruise on the resident's forearm, which was not documented in the medical record or incident log. Interviews with nursing staff confirmed that there was no documentation of the bruise, and the facility lacked a comprehensive policy for monitoring non-pressure skin issues, focusing only on pressure ulcers.
Failure to Provide Podiatry Care
Penalty
Summary
The facility failed to ensure that a resident received appropriate podiatry care, as evidenced by the observation of the resident's toenails being long, thick, and curling over the toes. The resident, who had a severe cognitive deficit and was dependent on staff for activities of daily living, was observed during tracheostomy care with these toenail conditions. The Interim Director of Nursing was unsure if the resident was offered podiatry services during the contracted podiatrist's visit to the facility. Subsequently, a Registered Nurse Wound Nurse was observed trimming the resident's nails, confirming their long and thick condition.
Failure to Monitor Psychotropic and Anticoagulant Medication Side Effects
Penalty
Summary
The facility failed to monitor behaviors and side effects for two residents who were receiving psychotropic and anticoagulant medications. Resident #9, who had a complex medical history including major depressive disorder and anxiety, was not monitored for targeted behaviors or side effects after being prescribed multiple psychotropic medications, including an antipsychotic. The facility also did not complete an Abnormal Involuntary Movement Scale (AIMS) when the resident was started on the antipsychotic medication, which is necessary to measure involuntary movements that can develop as a side effect of long-term antipsychotic use. Resident #81, who had a severe cognitive deficit and was at risk for abnormal bleeding due to anticoagulant therapy, was also not monitored for behaviors or side effects related to the use of antidepressant and anticoagulant medications. The resident's medical record lacked evidence of monitoring for abnormal bleeding associated with the anticoagulant medication Enoxaparin Sodium. The facility's failure to document and monitor these aspects was verified by the Interim Director of Nursing. The facility's policy on antipsychotic medication use, which requires medications to be prescribed at the lowest possible dosage for the shortest period and subject to gradual dose reduction and review, was not adhered to. The lack of monitoring and documentation for both residents indicates a deficiency in the facility's adherence to its own policies and procedures regarding medication management and monitoring.
Failure to Timely Complete PT-INR Tests for Resident
Penalty
Summary
The facility failed to ensure timely completion of prothrombin time (PT) and international normalized ratio (INR) laboratory tests for a resident with a history of atrial fibrillation, heart failure, hypertension, hemiplegia, and venous thrombosis. The resident had a physician order for PT-INR tests every Monday and Thursday, but these tests were not completed as ordered on several occasions in November and December 2024. The medical record and progress notes indicated multiple instances where the tests were either not drawn or results were delayed, leading to missed or delayed administration of anticoagulant medication. Interviews with facility staff, including the Interim Director of Nursing (IDON), revealed that the contracted laboratory company failed to show up on scheduled days or did not complete all ordered tests. The facility did not have a specific lab test policy, relying solely on the contract with the lab company. The IDON confirmed the issues with the contracted lab and acknowledged the deficiency in completing the PT-INR tests as ordered by the physician.
Incomplete Medical Record Documentation for a Resident
Penalty
Summary
The facility failed to maintain a complete and accurate medical record for a resident, identified as Resident #81, among a sample of 29 residents. The resident had a complex medical history, including severe cognitive deficits and multiple diagnoses such as pneumonitis, bacteremia, metabolic encephalopathy, and severe sepsis, among others. The deficiency was identified through a review of the resident's medical records, which revealed a lack of documentation regarding a room change that occurred while the resident was admitted to an acute care hospital. Specifically, there was no record of the room change, the reason for the change, or notification to the resident's family. The issue was confirmed during an interview with the Social Service Designee, who verified the absence of documentation in the medical record. The resident had previously undergone several room changes, which were documented, but the most recent change was not recorded, indicating a lapse in maintaining accurate records. This oversight in documentation is a violation of the facility's responsibility to safeguard resident-identifiable information and maintain medical records according to accepted professional standards.
Infection Control Deficiencies in Resident Care
Penalty
Summary
The facility failed to adhere to infection control policies for two residents, leading to deficiencies in care. Resident #85, who was admitted with multiple diagnoses including chronic kidney disease and obstructive uropathy, had physician orders for daily dressing changes on a nephrostomy site. However, observations and interviews revealed that the nursing staff did not perform these dressing changes as ordered. The resident reported that the dressing was never applied, and observations confirmed the absence of a dressing on multiple occasions. Additionally, the nephrostomy bag was improperly managed, being placed in a plastic trash bag due to leakage, which was confirmed by the wound nurse. Resident #164, admitted with conditions such as osteomyelitis and a PICC line, required enhanced barrier precautions (EBP) due to the presence of the PICC line. The resident's care plan included specific interventions for infection control, such as wearing gloves and gowns during high-contact activities. However, during an observation of incontinence care, a CNA failed to wear the required gown, despite the presence of a PICC line and the need for EBP. This was verified by the CNA, who acknowledged not using the necessary personal protective equipment as ordered. The facility's policies on urinary catheter care and infection control were not followed, as evidenced by the lack of aseptic technique in managing the nephrostomy site and the failure to use appropriate PPE during resident care. These lapses in infection control practices were identified through observations, resident interviews, and staff interviews, highlighting a significant deficiency in the facility's adherence to its own infection prevention protocols.
Failure to Notify Family of Room Change
Penalty
Summary
The facility failed to notify a resident's family of a room change, which was a requirement according to the facility's policy. The resident, who had a severe cognitive deficit, was moved from room 307 bed A to 315 bed A while admitted to an acute care hospital. There was no documentation in the medical record regarding the room change, the reason for the change, or notification to the resident's family. The resident had a complex medical history, including conditions such as pneumonitis, bacteremia, severe sepsis, and a traumatic brain injury, among others. The facility's policy required that a nurse notify the resident's representative of any room assignment changes unless otherwise instructed by the resident. However, an interview with the Social Service Designee confirmed that there was no documented evidence of family notification for this room change. This deficiency was investigated under Complaint Number OH00160119.
Failure to Safely Store Smoking Materials
Penalty
Summary
The facility failed to ensure that smoking materials were stored safely, affecting one resident out of 22 who smoke in the facility. The resident, who was admitted with diagnoses including bipolar disorder, nicotine dependence, and anxiety disorder, was identified as an independent smoker, meaning she did not require supervision while smoking. However, her care plan specified that all smoking materials should be kept in a designated area. An observation revealed that the resident left her room with a cigarette and lighter in hand and exited into a secured courtyard. Further inspection of her room uncovered seven lighters and a pack of cigarettes, contrary to the facility's smoking policy, which prohibits independent smokers from keeping smoking items in their rooms. This was confirmed by an LPN during an interview.
Resident Injury Due to Unsafe Transfer Practices
Penalty
Summary
The facility failed to maintain a safe environment, resulting in a fall with injury for Resident #20. On 05/03/24, Resident #20, who had a history of falls and was at low risk for falls according to a recent assessment, sustained a fracture of the metatarsal bone and talus after stepping from a transportation bus onto an unstable milk crate placed by facility staff. This incident occurred despite the resident's care plan, which included interventions to mitigate fall risks due to her history of falls and medication use. Resident #20 was admitted to the facility with diagnoses including age-related osteoporosis, anemia, pain in the left hip, and a history of falls. She was discharged from physical therapy with safe functional mobility and could ambulate using a front-wheeled walker. However, during the incident, the resident experienced severe pain and swelling in her right foot and ankle, leading to hospitalization for evaluation and treatment of her injuries. Interviews with staff and the resident confirmed that the transport driver used a milk crate as a makeshift step, which was not an appropriate transfer device. The crate flipped, causing the resident to fall and sustain injuries. The facility's failure to ensure a safe transfer process and the use of inappropriate equipment directly contributed to the resident's fall and subsequent injury.
Improper Disposal of Food Waste
Penalty
Summary
The facility failed to ensure proper disposal of garbage and food waste, as observed during a survey. On the morning of June 17, 2024, ten soiled trays with uncovered food from the previous night's dinner were found in the main dining room. The trays contained various food items, including salad, potatoes, and a magic cup, with gnats present on some items. Additionally, 23 soiled trays dated June 16, 2024, were found in the kitchen area, containing uncovered foods such as hot dogs, salads, and hamburgers. Interviews with staff confirmed that the trays were left out overnight due to the absence of dietary staff after the final trays were returned. The Dietary Manager acknowledged that trays should not be left uncovered overnight due to the risk of pest issues. The Director of Maintenance and the Administrator also confirmed the potential risk of pest issues and the need for proper disposal of trays. The facility's Kitchen Cleanliness Policy requires food waste and garbage to be disposed of in sealed containers to maintain a pest-free environment, which was not adhered to in this instance.
Latest citations in Ohio
A resident with intact cognition receiving Medicare Part A skilled services for metabolic encephalopathy had services discontinued while benefit days remained, but the facility did not issue the required Skilled Nursing Facility Advance Beneficiary Notice (SNF ABN). The Social Services Director later confirmed that no SNF ABN was provided and reported she believed only a Notice of Medicare Non-Coverage (NOMNC) was needed when all skilled services were stopped. This practice conflicted with the facility’s written policy, which required SNF ABNs to be issued when extended care items or services were initiated, reduced, or terminated due to expected non-coverage by Medicare.
Surveyors identified that the facility exceeded the acceptable medication error rate when two residents with type 2 DM received insulin doses that were not administered according to orders or manufacturer instructions. In two separate observations, an LPN administered Novolog and another LPN administered insulin glargine and insulin lispro without priming the insulin pens, and the insulin lispro and Novolog were given after the residents had already consumed a significant portion of their breakfast meals, despite orders for administration before meals. Manufacturer information for both insulin products required priming before each injection to ensure accurate dosing, and facility policy required medications, including insulin, to be administered safely, timely, and in accordance with prescriber orders and specified time frames.
Surveyors found that the facility failed to document tray line food temperatures for multiple meals served from two dining room kitchenettes, despite having a “Trayline Taste & Temperature Log” and a policy requiring food to be stored, prepared, distributed, and served according to professional food safety standards. Review of logs showed repeated missing entries for breakfast, lunch, and dinner services in both the Harrison and McClellan dining areas, and the Senior Director of Culinary Services confirmed that temperatures had not been recorded for those meals, potentially affecting all residents receiving meals from those kitchenettes.
The facility failed to conduct and document required periodic care conferences for two residents, despite multiple comprehensive, quarterly, and significant change MDS assessments and a policy requiring periodic care conferences with resident and/or family participation. One resident with Parkinson’s disease, post-stroke hemiplegia, TIA, DMII, and depression had only two documented care conferences over a year, while another resident with aphasia, cerebrovascular disease, DMII, gait difficulty, coagulation defect, depression, and muscle weakness had no documented care conferences in the past year, aside from a declined invitation to the representative. The UCC confirmed that care conferences were expected to occur quarterly and that no additional documentation existed for either resident.
A resident with Alzheimer's disease and type II DM, who required extensive assistance with ADLs and was receiving scheduled Lantus and sliding-scale Humalog, experienced a severely elevated blood glucose level. The on-call provider was notified and ordered an additional dose of lispro insulin with a directive to recheck the blood glucose after administration. Nursing staff administered the extra insulin but did not document any follow-up blood glucose check, and the DON confirmed that this reevaluation was required by the facility's abnormal blood glucose policy and was not completed or documented.
A resident with Parkinson’s disease, dementia, and hypothyroidism was prescribed levothyroxine once daily along with other medications. A consultant pharmacist’s monthly drug regimen review recommended that levothyroxine be given in the morning on an empty stomach, 30–60 minutes before food, per manufacturer instructions. The medical record contained no documented physician response to this recommendation, and the MAR showed the drug scheduled for morning administration while the resident was observed eating breakfast and receiving the medication at the same time. An LPN confirmed administering levothyroxine during the meal, and the DON verified there was no documentation explaining whether or why the pharmacist’s recommendation was or was not followed, resulting in a failure to act on and document the identified irregularity.
A resident with severe cognitive impairment, multiple comorbidities, documented gait and balance abnormalities, and a high fall risk was care planned and assessed by therapy to require contact guard assistance and use of a gait belt for transfers and ambulation. While being assisted by a CNA from a recliner to the bathroom with a walker, the CNA did not apply a gait belt, even though the resident had a known tendency to lean backward when standing. As the CNA reached to open the bathroom door, the resident lost balance and fell backward, striking the back of the head, and was later found by an LPN without a gait belt in place, contrary to the facility’s gait belt policy and the resident’s assessed needs.
A resident with CKD stage five requiring peritoneal dialysis (PD) was admitted with pre-admission physician orders for three daily PD exchanges and monitoring for peritonitis (fever, abdominal pain, cloudy effluent), but these monitoring orders were not entered into the facility’s physician orders. The care plan referenced PD and general monitoring but did not specifically address peritonitis monitoring. Paper PD flowsheets showed incomplete and inconsistent documentation of exchanges and resident condition, including missing condition/comments for individual treatments and no record of one ordered PD exchange. The PD cycler flowsheet lacked effluent descriptions on multiple days. The PD nurse reported facility staff were expected to monitor effluent and symptoms, and the DON confirmed the absence of specific peritonitis monitoring orders, lack of an order for the PD cycler, and documentation gaps, despite a facility policy requiring ongoing assessment and monitoring for complications before, during, and after dialysis treatments.
A nurse was observed preparing multiple oral medications for a resident with depression, traumatic brain injury, anxiety, and impaired cognition by pushing tablets and capsules from unit-dose cards directly into her ungloved hand and then using her fingers to place them into a medication cup. In a follow-up interview, the RN confirmed this practice and acknowledged that the correct procedure is to dispense medications directly from the card into the cup, contrary to the facility’s medication administration policy requiring adherence to good nursing principles and practices.
A resident with Alzheimer’s disease, diabetes, anxiety, significant ADL dependence, and behavioral symptoms was observed seated in a chair positioned against the nursing station with a locked wheelchair placed directly in front, also against the nursing station, effectively restricting movement. An LPN confirmed both wheelchair wheels were locked and that it should not have been placed there, while a CNA stated she had positioned the wheelchair to prepare for lunch, was unable to complete the transfer, and left it in place, acknowledging this was wrong. This arrangement conflicted with the facility’s restraint policy, which prohibits physical restraints except when alternatives are ineffective for treating a medical symptom and defines restraints as devices adjacent to the body that cannot be easily removed and that restrict freedom of movement or access to the body.
Failure to Issue Required SNF ABN When Discontinuing Medicare Part A Services
Penalty
Summary
The deficiency involves the facility’s failure to issue a Skilled Nursing Facility Advance Beneficiary Notice (SNF ABN) when Medicare Part A services were discontinued for a resident who still had available benefit days. The resident was admitted with a diagnosis of metabolic encephalopathy and had intact cognition per the Minimum Data Set assessment. The facility’s own SNF Beneficiary Notification Review documented that Medicare Part A skilled services began on 02/11/26 and the last covered day was 03/11/26, and that the facility initiated discharge from Medicare Part A services before the resident’s benefit days were exhausted. Despite this, no SNF ABN was provided to the resident or the resident’s representative. During interviews, the Social Services Director stated that the SNF ABN was issued hours prior to the last covered day but, upon reviewing her files, confirmed that no SNF ABN had actually been issued for this resident. She further explained that she believed an SNF ABN was only required if one skilled service remained and that if all skilled services were being discontinued, only the Notice of Medicare Non-Coverage (NOMNC) needed to be issued. The Administrator, however, stated that a resident should always receive both a SNF ABN and a NOMNC when Medicare Part A services are discontinued and benefit days remain. Review of the facility’s written policy dated 03/28/23 showed that the facility was required to issue SNF ABNs for initiation, reduction, or termination of extended care items or services when Medicare payment was not expected, which did not occur in this case.
Plan Of Correction
This Plan of Correction is submitted as required under State and Federal law. This Plan of Correction does not constitute an admission on the part of the Facility that the findings cited are accurate, that the findings constitute a deficiency or that the scope and severity regarding the deficiency cited are correctly applied. Any changes to the Facility's policies and procedures should be inadmissible in any proceeding on that basis. Without admitting or denying the validity or the existence of the alleged noncompliance, the Facility submits this Plan of Correction with the intention that it be inadmissible by any third party in any civil or other action against the facility or any employee, agent, officer, director or shareholder of the Facility. The Facility is utilizing this Plan of Correction as its allegation of substantial compliance as of 05/29/2026 F-0582 Corrective action for resident/s: On 5/14/26 Resident #34 was informed of rights and responsibilities related to Advanced Beneficiary Notice and voiced understanding of information for future reference by administrator. Identification of other residents who may be affected: Any resident receiving skilled services from nursing or therapy services. The Administrator audited all residents who were discharged from skilled services in the past 30 days to ensure they were issued a Notice of Non-Coverage and Advanced Beneficiary Notice on 5/29/26. No non-compliance was noted. Measures for systemic change: On 5/14/2026 Business Office Manager, Director of Rehab, Minimum Data Set nurse, Director of Nursing and Social Services Director were educated on proper procedure of issuing of Notice Of Medicare Non Coverage and Advanced Beneficiary Notice by administrator. All upcoming discharges from skilled services will be reviewed weekly at Utilization Review meeting to ensure notices will be delivered timely. How Corrective Action will be monitored: Administrator or designee to complete audits of all residents being discharged from skilled services to ensure they were issued a Notice of Non-Coverage and Advanced Beneficiary. This audit will be completed weekly x 4 weeks, then monthly x 2 months. Corrective action will be initiated for any noted non-compliance. Audit findings will be reviewed as part of the monthly quality assurance process to determine the need for further monitoring. Date of Compliance 5/29/26
Insulin Administration Errors and Failure to Prime Insulin Pens
Penalty
Summary
The deficiency involves the facility’s failure to maintain a medication error rate below 5%, with surveyors identifying 3 errors out of 28 medication administration opportunities, resulting in a 10.71% error rate. For one resident with type 2 diabetes mellitus and moderate cognitive impairment, the physician’s order directed Novolog insulin 10 units via subcutaneous pen-injector to be given before meals. During an observed medication pass, the LPN administered 10 units of Novolog insulin without priming the pen and did so after the resident had already consumed approximately 50% of the breakfast meal. The LPN later confirmed she did not prime the pen and acknowledged that the insulin was ordered to be administered prior to meals. Manufacturer instructions for the Novolog FlexPen specified that an air shot (priming) must be performed before each injection to ensure proper dosing. Another resident, also diagnosed with type 2 diabetes mellitus and with intact cognition, had orders for insulin glargine 35 units subcutaneously twice daily and insulin lispro 20 units subcutaneously before meals, plus 12 units subcutaneously if blood glucose was between 251 mg/dL and 300 mg/dL. During an observed medication administration, an LPN administered 35 units of insulin glargine and 32 units of insulin lispro without priming the insulin pens and after the resident had consumed approximately 90% of the breakfast meal, despite orders for insulin lispro to be given before meals. The LPN later stated she could not remember if she had primed the pen and acknowledged that the insulin was ordered to be administered prior to meals. Manufacturer information for insulin lispro stated that the pen must be primed before each injection to confirm insulin delivery and remove air, and that failure to prime could result in too much or too little insulin. The DON confirmed the expectation that insulin be administered as ordered, including priming each pen with two units before dialing the prescribed dose, and facility policy required medications, including insulin, to be administered safely, timely, and in accordance with prescriber orders and required time frames.
Plan Of Correction
This Plan of Correction is submitted as required under State and Federal law. This Plan of Correction does not constitute an admission on the part of the Facility that the findings cited are accurate, that the findings constitute a deficiency or that the scope and severity regarding the deficiency cited are correctly applied. Any changes to the Facility's policies and procedures should be inadmissible in any proceeding on that basis. Without admitting or denying the validity or the existence of the alleged noncompliance, the Facility submits this Plan of Correction with the intention that it be inadmissible by any third party in any civil or other action against the facility or any employee, agent, officer, director or shareholder of the Facility. The Facility is utilizing this Plan of Correction as an allegation of substantial compliance as of 5/29/2026. F-0759 Corrective action for resident/s: Residents #21 and #22 were assessed and evaluated by nurse and Director of Nursing 5/14/26. Resident #21 and #22 both denied any adverse effects and none were noted upon assessment by the Director of Nursing on 5/14/2026. Notification made to physician on 5/14/2026. LPN # 2 competency Eval on insulin administration with the Director of Nursing completed 5/14/2026. Identification of other residents who may be affected: Diabetic residents on assignment of LPN #2/station 2 have the potential to be affected and were assessed by the DON/Designee on 5/14/26 and found to be within normal limits. Measures for systemic change: All Nurses were educated by the Director of Nursing on the steps for Insulin administration per competency, diabetes clinical protocol policy, Medication and treatment orders policy, administering medications policy, and Obtaining fingerstick Glucose Level policy On 5/14/2026. How Corrective Action will be monitored: Director of Nursing and Assistant Director of Nursing will complete insulin administration audits on 5 nurses. This audit will be completed weekly x 4 weeks, then monthly x 2 months. Corrective action will be initiated for any noted non-compliance. Audit findings will be reviewed as part of the monthly quality assurance process to determine the need for further monitoring. Date of Compliance: 5/29/2026
Failure to Document Tray Line Food Temperatures in Dining Room Kitchenettes
Penalty
Summary
The deficiency involves the facility’s failure to document tray line food temperatures for meals served from the Harrison and McClellan Dining Room kitchenettes, as required by professional standards for food service safety and the facility’s own policy. Review of the “Trayline Taste & Temperature Log” (revised September 2018) showed missing temperature documentation for multiple meals from the Harrison Dining Room kitchenette, including dinner on 03/30/26 and 03/31/26, lunch and dinner on 04/01/26 and 04/02/26, dinner on 04/07/26, and lunch and dinner on 04/08/26 and 04/10/26. The Senior Director of Culinary Services confirmed during interview that tray line food temperatures were not documented on the log for these meals. Similarly, review of the same log for the McClellan Dining Room kitchenette revealed that tray line food temperatures were not documented for dinner on 04/01/26, breakfast and lunch on 04/02/26, and lunch and dinner on 04/07/26. The Senior Director of Culinary Services also verified these omissions during interview. The facility census at the time was 27 residents, and the governing “Food and Nutrition” policy, approved on 09/07/21, stated that the facility must store, prepare, distribute, and serve food in accordance with professional standards for food service safety.
Plan Of Correction
F812 The facility will continue to ensure food temperatures are completed before meals are served for all residents. To ensure compliance with this standard the following measures have been taken: 1. Immediately 4/15/26 culinary supervisor #224 was re-educated by Dietary Manager to this standard and policy "Food and Nutrition" which includes documentation of food temperatures. 2. All dietary staff have been re-educated to the standard and policy "Food and Nutrition" during the month of April 2026. 3. Audits of food temperature documentation to be completed by Dietary Manager 4 x per week for 4 weeks then weekly for 4 weeks. 4. Administrator to validate audits/compliance and provide additional training as needed. Administrator will present to QAPI committee for ongoing monitoring and further direction.
Failure to Conduct and Document Required Care Conferences
Penalty
Summary
The deficiency involves the facility’s failure to complete and document comprehensive care conferences at required intervals in accordance with care plan regulations and facility policy. For one resident with Parkinson’s disease with dyskinesia, cognitive communication deficit, hemiplegia and hemiparesis following cerebral infarction, transient cerebral ischemic attack, type II diabetes mellitus, and major depressive disorder, the record showed multiple MDS assessments over a one-year period, including annual, quarterly, and significant change assessments. However, only two care conferences were documented during the last 12 months, despite the expectation that care conferences be conducted quarterly with the resident and family when possible. The Unit Care Coordinator confirmed that no additional care conference documentation existed for this resident beyond the notes dated 04/21/25 and 01/02/26. A second resident, with diagnoses including aphasia following cerebrovascular disease, cerebral infarction, type II diabetes mellitus, unsteadiness on feet, difficulty in walking, coagulation defect, depression, and muscle weakness, also had multiple MDS assessments completed over the review period, including quarterly and annual assessments. The record contained a note that a care conference was offered to the resident’s representative, who declined to attend, but there was no documentation of any care conferences for the most recent 12 months. The Unit Care Coordinator confirmed that no other care conference documentation was available for this resident. Facility policy stated that periodic care conferences involving the resident, family, and the interdisciplinary team are part of the care planning process, but the required periodic care conferences and corresponding documentation were not completed for these two residents.
Plan Of Correction
THIS PLAN OF CORRECTION SERVES AS BERKELEY SQUARE'S CREDIBLE ALLEGATION OF SUBSTANTIAL COMPLIANCE AS OF June 1, 2026. Without admitting or denying the validity or existence of the alleged deficiencies, Berkeley Square provides the following Plan of Correction: F657 The facility will continue to document completion of care conferences at the required intervals for all residents, including residents #04 & #15. To ensure compliance with this standard the following measures have be taken: 1. The social service designee and the inter- disciplinary team were re-educated by the administrator to the facility policy "Care Conference" on 4/29/26 and verbalized understanding. 2. Care conferences for resident #04 and resident #15 were conducted on or before 4/29/2026 by the interdisciplinary team. 3. Review of all other residents was conducted by the social service designee to validate and ensure that care conference schedule is up to date with timely care conferences scheduled for them on 4/15/2026. Audits of care conferences to be completed weekly for four weeks and then monthly after that by the social service designee. Documentation of the care conference including any identified concerns in the medical record. Administrator to validate audits/compliance and provide additional training as needed. Administrator will present results of these audits to QAPI committee for ongoing monitoring and further direction.
Failure to Reevaluate Blood Glucose After Treatment for Hyperglycemia
Penalty
Summary
The facility failed to ensure that a resident with diabetes received treatment in accordance with professional standards of practice when nursing staff did not reevaluate the resident's blood glucose after treatment for severe hyperglycemia. The resident, admitted with diagnoses including Alzheimer's disease, type II diabetes mellitus, and depression, had physician orders for Humalog insulin on a sliding scale before meals, Lantus insulin 25 units daily, and lisinopril 5 mg daily. The resident required extensive assistance with activities of daily living, including transfers, toileting hygiene, eating, and bathing. On the evening in question, the resident's blood glucose was documented as 532 mg/dL, and the on-call provider was notified. The provider gave a new order to administer an additional 8 units of lispro (Humalog) and to recheck the blood glucose in 30 minutes. The electronic medication administration record showed that the blood glucose of 532 mg/dL was obtained at 9:00 p.m. and that the additional 8 units of lispro were administered at 9:21 p.m. However, there was no documentation in the resident's chart that the blood glucose was rechecked after the additional insulin was given. In an interview, the DON confirmed there was no evidence of reevaluation and verified that, according to the facility's "Abnormal Blood Glucose Procedure" policy, the resident should have been reevaluated and that the evaluation step should have been included in the progress note documentation.
Plan Of Correction
F684 The facility will continue to ensure all residents, including #03, receive treatment in accordance with professional standards of practice and reevaluated for hyperglycemia. To ensure compliance with this standard the following measures have been taken: 1. The director of nursing assessed resident #03, reviewed documentation and orders and found no ill effects immediately 4/16/26. 2. All licensed nurses were re-educated to facility policy "Blood Glucose Monitoring" by the Director of Nursing/designee in April 2026. 3. Audits of like-residents that require blood sugar checks to be completed by the director of nursing/designee two times a week for 4 weeks and then monthly after that to validate correct follow through when there is abnormally high blood glucose result. The Administrator will bring results of these audits to the QAPI committee for ongoing monitoring and further direction.
Failure to Act on Pharmacist Drug Regimen Recommendation for Thyroid Medication
Penalty
Summary
The deficiency involves the facility’s failure to ensure that pharmacy recommendations from the monthly drug regimen review were acted upon and documented for a resident. The resident was admitted with diagnoses including Parkinson’s disease, dementia, and hypothyroidism, and had current physician orders for levothyroxine 150 mcg once daily, buspirone 50 mg twice daily, and losartan 100 mg once daily. A medication regimen review dated 11/25/2025 included a consultant pharmacist recommendation that levothyroxine be administered consistently in the morning on an empty stomach, at least 30–60 minutes before food, per manufacturer instructions. There was no specific physician response in the medical record to this recommendation, and the facility’s policy stated that consulting pharmacist reviews are sent to nursing and addressed with the primary care provider or consulting specialist for review and follow-up. Review of the resident’s medication administration record for April 2026 showed levothyroxine scheduled for 9:00 a.m. On observation, the resident was seen eating breakfast in the dining area at 8:03 a.m., and an LPN reported administering the levothyroxine 150 mcg to the resident while the resident was in the dining area eating breakfast. The DON confirmed there was no evidence in the resident’s medical record explaining why the consultant pharmacist’s recommendation from 11/25/2025 was or was not acted upon. This lack of documented physician review and action on the pharmacist’s identified irregularity constituted noncompliance with the drug regimen review requirements.
Plan Of Correction
F756 The facility will continue to ensure the pharmacy recommendations from the monthly drug regimen review by a licensed pharmacist are acted upon for all residents, including #08. To ensure compliance with this standard the following measures have been taken: 1. Resident #08 was assessed by the registered nurse and med review completed by 4/28/26. After review of resident's drug regime's, it was discovered that resident #8 had 2 separate medication recommendations on the same form, to be reviewed by two separate practitioners, pharmacy has been instructed and agreed to separate meds on individual forms. 2. Licensed nurses re-educated to facility policy "Drug Regimen Review" by Director of nursing/designee in April 2026 and no later than 5/8/26. Licensed nurses are responsible for ensuring the reviews and recommendations are given to the physician for timely review. 3. Review of all other current residents Drug Regimen orders completed by Director of nursing/designee on 4/16/26 to ensure recommendations were followed up on/reviewed by the physician and address concerns if needed. 4. Audit of drug regime recommendations, pharmacy recommendations, and physician follow up to be completed weekly for four weeks by the Director of nursing/designee. Administrator will present results of these audits to the QAPI committee for ongoing monitoring and further direction.
Failure to Use Required Gait Belt During Ambulation Resulting in Resident Fall
Penalty
Summary
The deficiency involves the facility’s failure to ensure that a required gait belt was used while assisting a high fall‑risk resident with ambulation, resulting in a fall with head injury. The resident had multiple diagnoses including metabolic encephalopathy, hypertension, osteoarthritis, muscle weakness, gait and mobility abnormalities, major depressive disorder, anxiety, and visual hallucinations. Admission and subsequent MDS and fall risk assessments documented that the resident was severely cognitively impaired, required moderate to maximal assistance with transfers and ambulation, could not independently come to a standing position, exhibited loss of balance while standing, used an assistive device, and had decreased muscle coordination. The resident had a history of falls prior to admission and was assessed as being at high, later moderate, risk for falls. The resident’s fall care plan identified her as at risk for falls and included interventions such as providing maximum to moderate assistance with transfers and walking short distances, use of a walker and wheelchair, and following the facility’s fall protocol. Therapy notes and care conference documentation indicated that the resident leaned backwards when standing, required contact guard to minimal assistance for bed mobility and transfers, and needed constant verbal cueing for safe sequencing during toilet transfers. The physical therapist confirmed that the resident was to use a gait belt with staff when ambulating, and the DON verified that therapy had assessed the resident as requiring contact guard assistance and a gait belt for ambulation and transfers. On the day of the incident, a CNA was assisting the resident from her recliner to the bathroom using a walker. The CNA walked beside the resident, providing guidance and support, and reported having a hand on the resident while assisting her. As they approached the bathroom door, the CNA reached for the doorknob to open it, and at that moment the resident began to lose her balance and fell backwards to the floor, striking the back of her head. The nurse who responded found the resident on her back at the foot of the bed with her feet near the bathroom, noted a red raised area on the back of the head, and documented that the resident was not wearing a gait belt and that the gait belt was on the dresser. In the facility’s investigative summary and in interviews, the CNA acknowledged that she did not have a gait belt on the resident while ambulating her, despite the resident’s assessed need for hands‑on assistance and gait belt use per facility policy and the resident’s care and therapy plans.
Failure to Implement PD Orders and Monitor Resident Receiving Peritoneal Dialysis
Penalty
Summary
The deficiency involves the facility’s failure to implement pre-admission physician orders for peritoneal dialysis (PD) and to provide ongoing monitoring for a resident with chronic kidney disease (CKD) stage five who required PD. Pre-admission orders dated 11/14/25 specified three daily PD exchanges at 6:00 A.M., 2:00 P.M., and 10:00 P.M., and directed staff to monitor for signs and symptoms of peritonitis, including fever, abdominal pain, and cloudy effluent. These monitoring orders were not entered into the facility’s physician orders. The resident’s care plan noted the need for PD and included general monitoring interventions (labs, signs of bleeding, bacteremia, septic shock, and significant vital sign changes), but did not specifically address the ordered monitoring for peritonitis. Review of PD documentation showed incomplete and inconsistent charting of treatments and resident condition. The paper peritoneal flowsheet had columns for time of PD and condition/comments, including instructions to call the nurse immediately for cloudy fluid, abdominal pain, or fever. However, the first entry on 11/15/26 at 2:00 P.M. only noted that the PD nurse completed the exchange, and the 10:00 P.M. entry that day had no condition/comment documentation. Subsequent days (11/16/25, 11/17/25, and 11/18/25) contained only one condition/comment entry per day rather than for each exchange, and there was no documentation that the 6:00 A.M. PD on 11/18/25 was completed. The PD cycler flowsheet starting 11/19/25 lacked any description of the effluent on multiple days. The PD nurse from the dialysis company stated facility staff were expected to monitor effluent for cloudiness and assess for abdominal pain and fever, and the DON confirmed there was no electronic physician order for peritonitis monitoring or for use of the PD cycler, that the paper charting did not allow for effluent description or symptom documentation for each treatment, and that PD was not documented at one ordered time. The facility’s dialysis policy required ongoing assessment and monitoring for complications before, during, and after treatments, which was not reflected in the documentation for this resident.
Improper Infection Control During Medication Administration
Penalty
Summary
Surveyors identified a deficiency in infection prevention and control related to medication administration for Resident #29. The resident was admitted on 02/28/14 with diagnoses including depression, traumatic brain injury, and anxiety, and had impaired cognition per a quarterly MDS assessment. During an observation on 03/25/26 at 6:58 A.M., RN #281 prepared the resident’s medications by removing an Amoxicillin-Pot Clavulanate tablet from the medication card and pushing it directly into her ungloved hand, then using her fingers to place the pill into a medication cup. The same process was observed for multiple other medications, including Escitalopram Oxalate, Furosemide, Sennosides, Lyrica, and Vitamin D, each being pushed from the card into the RN’s ungloved hand and then transferred by her fingers into the medication cup before administration to Resident #29. In a subsequent interview at 7:27 A.M. the same day, RN #281 confirmed she had placed each medication into her ungloved hands prior to administration and acknowledged that the proper procedure was to push the pills directly from the card into the medication cup. Review of the facility’s “Medication Administration – General guidelines” policy, revised 10/08/25, stated that medications are to be administered in accordance with good nursing principles and practices. This practice failure was cited as a deficiency under Complaint Number 2681777.
Improper Use of Wheelchair as a Physical Restraint
Penalty
Summary
Surveyors identified a deficiency related to the facility’s failure to ensure a resident was free from physical restraints. Resident #7, admitted with diagnoses including Alzheimer’s disease, diabetes mellitus, and anxiety disorder, was documented on a recent MDS as rarely understood and dependent for ADLs except eating. The resident ambulated independently on the unit without an assistive device and had documented verbal and other behaviors occurring one to three days during the look-back period. The care plan noted the resident had potential to be physically aggressive, chase staff, throw objects, and be combative with care, with interventions such as offering choices, administering medications as ordered, and intervening early when agitation occurred. During an observation and interview, Resident #7 was found sitting in a chair with the right arm of the chair positioned against the nursing station and a wheelchair placed directly in front of him. The left arm of the wheelchair was also against the nursing station, and both wheelchair wheels were locked, creating a barrier that appeared to restrain the resident, who was sleeping with his knees touching the locked wheelchair. An LPN confirmed both wheelchair wheels were locked and that the wheelchair should not have been placed in front of the resident. A CNA reported she had placed the wheelchair there in preparation to get the resident up for lunch, was unable to transfer him, and left the wheelchair in that position, acknowledging it was wrong to keep it there. The facility’s physical restraint policy stated that physical restraints are not used except when alternatives are not appropriate or effective for treating a medical symptom and defined physical restraints as any device attached or adjacent to the body that the individual cannot easily remove and that restricts freedom of movement or access to the body.
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