Sienna Skilled Nursing & Rehabilitation
Inspection history, citations, penalties and survey trends for this long-term care facility in Wintersville, Ohio.
- Location
- 250 Cadiz Road, Wintersville, Ohio 43953
- CMS Provider Number
- 366331
- Inspections on file
- 28
- Latest survey
- February 9, 2026
- Citations (last 12 mo.)
- 28
Citation history
Health deficiencies cited at Sienna Skilled Nursing & Rehabilitation during CMS and state inspections, most recent first.
The facility failed to consistently monitor and document food and drink serving temperatures for nearly all residents receiving meals from the kitchen. Review of temperature logs showed multiple meals and entire days with missing food and beverage temperature entries, including repeated omissions for dinner meals. The Dietary Manager acknowledged that staff sometimes wrote temperatures on separate sheets of paper instead of the official daily logs and that several of these sheets were incomplete, lacking milk or coffee temperatures. This practice did not comply with the facility’s policy requiring recording of hot and cold temperatures for all menu items at each meal service.
An RN left a medication cart unlocked and unattended while walking down the hall into a resident room and out of sight of the cart, despite facility policy requiring medication storage areas to remain locked when not in use or not attended by authorized staff. At the time, multiple cognitively impaired and independently mobile residents were present on the unit, creating a situation in which unauthorized individuals could have accessed medications.
The facility did not ensure reasonable access to medical records for a resident and family when they requested copies of PT/OT reports after discharge. The resident had multiple chronic conditions, severe cognitive impairment, and used mobility aids. Staff required the resident to appear in person to sign a release, would not accept a verbal request, and the daughter delayed the visit due to the resident’s limited mobility and weather. The daughter was reportedly told therapy records would cost $60–$80, leading the family not to obtain them. The facility’s fee schedule allowed high per-page and search fees, therapy records were controlled by a contracted provider with its own pricing, and facility staff could not provide clear cost information to the family, resulting in a lack of easy access to the requested records.
The facility failed to provide baseline care plan summaries to residents and/or their representatives and did not clearly base initial goals on admission orders. In one case, a resident with dementia had a care conference documented as including medication review and an offer of a care plan copy, but the resident’s POA reported no recall of medication discussion or receiving a copy, and there was no evidence a copy was given to the POA. In another case, a resident with multiple chronic conditions and high ADL dependence reported that medications and treatments were not reviewed, was not asked if she wanted a copy of the care plan, and was not asked about or provided compression hose previously used for edema. Staff confirmed that copies of baseline care plans were not routinely provided unless requested and that documentation did not show review of physician, medication, treatment, or dietary orders, and the facility policy did not address giving residents a copy of the baseline care plan.
A resident with multiple comorbidities, including CHF and diabetes, had documented bilateral lower extremity edema with cracking skin and clear drainage. A physician ordered daily compression stockings for edema management, but observations and interviews showed the resident was never provided compression hose and none were present in the room. The resident reported never being asked to wear them and described prior edema care at another facility. A CNA confirmed the absence of stockings and that the task did not appear in electronic charting, while an RN admitted signing the treatment record indicating stockings were applied when they were not.
A resident with COPD, heart failure, type 2 DM, and significant lower extremity edema had a physician order for daily compression stockings, yet staff repeatedly documented on the Treatment Administration Record that the stockings were on when the resident reported never having worn them and none were observed in the room. Surveyors observed the resident without compression hose, with edematous, reddened legs and scabs, while a CNA stated the task did not appear in electronic charting and an RN admitted signing the treatment sheet indicating the stockings were on when they were not, resulting in an inaccurate medical record.
A resident with multiple chronic conditions was not properly assessed or treated for a pressure ulcer. Staff failed to notify the physician or wound nurse in a timely manner, did not implement ordered pressure-relieving interventions, and did not complete comprehensive wound documentation. Inadequate and inconsistent assessments, along with delayed treatment, were observed, and facility policies for wound care and documentation were not followed.
Three residents with indwelling catheters did not receive timely and appropriate catheter care, including failure to monitor urinary output, delayed physician notification, and lack of proper catheter changes or irrigation. One resident experienced actual harm, requiring hospital transfer for a blocked catheter and pain management, while another developed a UTI due to delayed intervention. Facility staff did not consistently follow policy for monitoring and reporting catheter-related issues.
Facility staff failed to maintain clean and intact filters and vents on heating and cooling units in multiple resident rooms, with observations revealing dirt, dust, and missing or damaged filters. The Maintenance Director confirmed the lack of proper maintenance and difficulty obtaining parts, while the Housekeeping Supervisor acknowledged the absence of a cleaning schedule for the filters.
Two residents with diabetes and other chronic conditions did not receive podiatry services or appropriate foot care despite having signed consents on file. Family members and photographic evidence confirmed that both residents had long, thick, and untrimmed toenails, with one resident experiencing discomfort. The DON confirmed that the facility was unaware of the need for a physician's signature on podiatry consents, and the issue was compounded by the sudden departure of the social services designee.
A resident with a history of falls and multiple medical conditions did not have required fall prevention interventions in place, including a body pillow, a sign to request help, and a bed in the lowest position, as specified in the care plan. These items were missing following a recent room change, and the DON confirmed the interventions had not been implemented as directed.
A resident with multiple serious health conditions received morphine in a manner not consistent with hospice or physician orders, due to incorrect transcription and administration by nursing staff. Documentation on the MAR and narcotic control sheets showed discrepancies in timing and dosage, with some doses given more frequently than ordered and others not recorded. This resulted in the resident's drug regimen not being free from unnecessary medications.
The facility failed to serve food at safe and appetizing temperatures, affecting all 83 residents. Observations revealed that food was plated and served without maintaining proper temperatures, and residents reported dissatisfaction with the food's quality and temperature. The facility lacked policies on minimum holding temperatures, and the Dietary Manager confirmed the issue.
The facility failed to maintain sanitary conditions in the kitchen, affecting all 83 residents. Observations revealed dirty and greasy surfaces, cracked floors, and improperly stored food. During meal service, food was served at unsafe temperatures, and staff did not recognize the issue. The Dietary Manager confirmed the longstanding issues with cleanliness and equipment maintenance.
Failure to Consistently Monitor and Document Food and Drink Temperatures
Penalty
Summary
The facility failed to consistently monitor and document food and drink serving temperatures for all residents receiving nutrition from the kitchen, affecting all but one resident who did not receive nutrition from that source. During a kitchen tour, review of food temperature logs showed multiple missing entries: no coffee temperatures recorded for one dinner meal; no food or drink temperatures recorded for another dinner; no food or drink temperatures documented for breakfast and lunch on a subsequent day; no food or drink temperatures documented for an entire day; and repeated missing food and drink temperature entries for several dinner meals on additional days. In interview, the Dietary Manager confirmed there were days when food and drink temperatures were not recorded and reported finding seven separate sheets of paper with temperatures written on them that had not been transferred to the official daily logs, five of which were dated and four of which lacked milk or coffee temperatures. The facility’s undated Food Temperature Logs Policy required that temperatures of hot and cold items be recorded for all menu items for meal service, which was not followed, leading to the cited deficiency under the referenced complaint number. No additional resident-specific medical history or clinical condition at the time of the deficiency was provided in the report.
Unlocked and Unattended Medication Cart Accessible to Cognitively Impaired Residents
Penalty
Summary
The facility failed to ensure medications were stored to prevent access by unauthorized persons when a medication cart was left unlocked and unattended. During a tour on 02/05/26 at 7:52 A.M., an RN walked away from her medication cart, entered a resident room down the hall, and moved out of sight of the cart, leaving it unlocked. At 7:54 A.M., the RN returned to the cart and confirmed she had left it unlocked and unattended. The facility had identified 23 residents as cognitively impaired and independently mobile, and the unlocked cart was accessible in this environment. Review of the facility’s January 2025 Storage of Medication policy showed that only licensed nurses, pharmacy staff, and those lawfully authorized to administer medications were allowed access to medication carts, and that medication rooms, cabinets, and medication supplies should remain locked when not in use or when not attended by authorized personnel. The observed practice of leaving the medication cart unlocked and unattended was inconsistent with this policy and formed the basis of the cited deficiency, which was investigated under Complaint Number 2734445.
Failure to Ensure Reasonable Access and Fees for Resident Medical Records
Penalty
Summary
The facility failed to ensure ease of access for a resident and the resident’s family to obtain copies of the resident’s medical records, specifically therapy records. The resident, who had diagnoses including peripheral vascular disease, hypertensive heart disease without heart failure, encephalopathy, difficulty walking, dysphagia, atherosclerotic heart disease, kidney disease, alcohol abuse, and chronic peripheral disease, was severely impaired for daily decision making and used a wheelchair and front-wheeled walker for mobility. After discharge, the resident’s daughter requested physical and occupational therapy reports so home health could review what therapy had been provided. She was told the resident would need to come in person to sign a release form because the facility would not accept a verbal request, and the facility required a resident signature unless a power of attorney or other legal representative was in place. Due to the resident’s limited mobility and cold weather, the daughter did not bring him in to sign until a later date. The daughter reported being told by therapy staff that obtaining copies of the therapy records would cost approximately $60 to $80, and due to this reported cost, the family did not obtain the records. The facility’s fee schedule, based on the Ohio Revised Code and Consumer Price Index, allowed charges up to $3.88 per page for requests by a resident or resident representative, and for other requesters included an initial search fee of $23.94 plus up to $1.58 per page. The Administrator stated that therapy was provided by a contracted company using a different computer system and that this company set its own prices for records, which the Administrator did not know or verify for compliance, and that the facility used state fee requirements rather than federal. The Administrator also confirmed that the facility’s fee structure included additional fees for locating records and that verbal requests were not accepted. Medical Records staff indicated that requests required a signed release form, were routed through Quality Assurance and legal, and that the business office had a price sheet, but staff did not inform requesters of the cost. Corporate Business Office staff stated that charges were sometimes waived depending on page count and that the facility business office could not give residents or representatives a price, with therapy records handled separately by the third-party therapy agency.
Failure to Provide and Review Baseline Care Plan Summaries With Residents/Representatives
Penalty
Summary
The facility failed to provide a summary of baseline care plans to residents and/or their representatives and did not ensure that baseline care plans were clearly based on admission orders. For one resident with Alzheimer’s disease and dementia who was confused and oriented only to person, the medical record showed an admission assessment and a multidisciplinary care conference where staff documented that medications were discussed and that a copy of the plan of care was offered. However, the resident’s power of attorney (POA) reported not recalling any discussion of medications as part of the admission care conference and not being offered or given a copy of the baseline care plan. The Social Service Designee confirmed that the form only allowed staff to mark that a copy was offered to or received by the resident, that the resident was very confused with poor vision, and that there was no evidence a copy of the baseline care plan was provided to the POA. For another resident with multiple diagnoses including COPD, ventilator dependence, chronic respiratory failure, morbid obesity, heart failure, diabetes, and significant functional dependence, the multidisciplinary care conference form indicated that admission, goals, therapy, discharge, health, and code status were discussed, that the plan of care was reviewed, and that the resident was offered a copy of the plan of care. The form did not show that initial goals were based on admission orders or that physician orders, including dietary orders, were reviewed. The resident stated that medications and treatments were not reviewed at the conference, that she was not asked if she wanted a copy of the care plan, and that no one asked about or provided compression hose, which she had used at a prior facility for edema. The Social Service Designee verified that the facility did not provide copies of baseline care plans unless requested and that there was no documentation of physician orders, medications, treatments, or dietary orders being reviewed during the meeting. The facility’s care plan policy required resident or sponsor signatures to verify presence and review of the care plan but did not address providing a copy of the baseline care plan as required by regulation.
Failure to Implement Physician-Ordered Compression Stockings for Edema
Penalty
Summary
The facility failed to implement physician-ordered compression stockings for the treatment of edema for one resident. The resident was admitted with multiple diagnoses including COPD, hypertensive heart disease, type 2 diabetes, heart failure, weakness, and arthritis. A quarterly MDS showed the resident was independent in daily decision making but required substantial to maximum assistance with most ADLs. Weekly skin checks in early December documented bilateral leg cracking and clear drainage, and a subsequent health status note described bilateral lower extremities as edematous, hard, and with scant clear drainage. In response, a physician order was written for compression stockings to be applied in the morning and removed at bedtime daily for leg edema starting in December. Despite this order, surveyor observations and staff and resident interviews showed the intervention was not carried out. On observation, the resident’s lower legs were edematous, red, and had thin scabs, and the resident reported itching and scratching. The resident stated she had never worn compression hose at the facility, had not been asked about wearing them, and that at a prior facility her legs had been wrapped for edema. A CNA reported the resident was retaining a lot of fluid in her legs, had never been seen with compression stockings, that there were no stockings in the room, and that application of stockings did not appear in their electronic charting. The treatment record, however, was signed off indicating the stockings had been applied, and an RN acknowledged signing the treatment sheet for compression stockings when they had not actually been in place. This deficiency was cited under a complaint investigation.
Inaccurate Documentation of Compression Stocking Use for Edematous Legs
Penalty
Summary
The facility failed to maintain an accurate medical record for a resident with multiple chronic conditions, including COPD, hypertensive heart disease, type 2 diabetes, heart failure, and arthritis. The resident was admitted in late October and had a quarterly MDS showing dependence on staff for several ADLs. In early December, weekly skin checks and a health status note documented bilateral lower extremity edema, hardness, cracking, seeping clear liquid, and scant clear drainage. In response, a physician order dated 12/10/25 directed that compression stockings be applied in the morning and removed at bedtime daily and on night shift for leg edema. However, review of the Treatment Administration Record showed that staff documented the compression hose as being on for multiple days in January and the first days of February, despite the resident not being provided compression stockings during her stay. On the day of surveyor interviews and observations in February, the resident was observed without compression stockings, with edematous, red lower legs and thin scabs on the left lower shin, and reported itching and scratching. The resident stated she had never worn compression hose at the facility, no one had asked her about wearing them, and that at her previous facility her legs had been wrapped for edema. A CNA reported the resident was retaining a lot of fluid in her legs, had never seen the resident with compression stockings, noted there were none in the room, and that application of stockings did not appear in their electronic charting. Despite this, the Treatment Record for that day was signed off indicating the resident had compression stockings on. An RN confirmed she had signed the treatment sheet indicating the resident had compression stockings on when the resident did not, demonstrating inaccurate documentation in the medical record.
Failure to Accurately Assess and Timely Treat Pressure Ulcer
Penalty
Summary
The facility failed to ensure comprehensive and accurate pressure ulcer assessments, timely implementation of treatments, and adherence to pressure-relieving interventions as outlined in the care plan for a resident with multiple comorbidities, including a right femur fracture, chronic kidney disease, anemia, diabetes, protein-calorie malnutrition, dementia, heart disease, venous insufficiency, and a pressure ulcer. Upon re-admission, the resident was identified as having a suspected deep tissue injury on the sacrum, but there was no documented evidence that the physician was notified or that the wound nurse was consulted until more than a month later. Additionally, a pressure-reducing cushion was ordered, but observations revealed the resident was using an inadequate cushion, and staff confirmed it was not a proper pressure-relieving device. Medical record reviews showed inconsistent and incomplete documentation of the resident's skin condition. Weekly skin observations and skin grid assessments often lacked detailed descriptions of the wounds, including stage, drainage, odor, and other required characteristics. Several weekly pressure ulcer assessment forms were not completed, and the non-pressure forms used did not provide comprehensive information or proper staging. The resident's MDS assessment was also found to be inaccurate, failing to reflect the presence of a pressure ulcer on admission. There was a significant delay in implementing treatment for the sacral area, with no evidence of any treatment from the time the wound was identified until nearly two weeks later. The wound nurse did not assess the pressure ulcer until a telehealth visit was conducted, and the physician's progress notes did not mention or assess the pressure ulcer during the relevant period. Facility policy required prompt notification of the physician and responsible party, comprehensive documentation, and regular assessment, but these procedures were not followed as evidenced by the findings.
Failure to Provide Timely and Appropriate Urinary Catheter Care
Penalty
Summary
The facility failed to provide appropriate urinary catheter care and timely assessment for three residents with indwelling catheters, resulting in actual harm to one resident. One resident with multiple comorbidities, including chronic kidney disease and neuromuscular bladder dysfunction, experienced no urinary output for two days and minimal output on the third day. Despite documentation of blood in the Foley catheter and the resident's increasing pain, staff did not properly irrigate or change the catheter, nor did they notify the physician in a timely manner. The resident's wife repeatedly requested intervention, and the resident was eventually transferred to the hospital, where a blocked catheter was found, requiring replacement, continuous bladder irrigation, and pain management. Another resident with a history of neuromuscular bladder dysfunction and chronic kidney disease had a Foley catheter with milky, foul-smelling urine that was not promptly reported to the physician. The catheter bag was tinted, making urine assessment difficult, and the last documented assessment was nearly a month prior. The physician was not notified until after the urine was observed to be abnormal, and a urinalysis and culture were delayed. The resident was later found to have a urinary tract infection with specific bacteria identified, and antibiotic treatment was started only after the delay. A third resident with a suprapubic catheter and neuromuscular bladder dysfunction did not have current orders for regular catheter changes, irrigation, or equipment changes following a recent hospitalization. The resident's care plan and urology recommendations for monthly catheter changes were not reflected in current orders, and staff were unable to change the catheter as required, resulting in the resident being sent to the hospital. Facility policy required monitoring and reporting of catheter-related issues, but these were not consistently followed for the residents involved.
Failure to Maintain Clean and Functional Heating and Cooling Units
Penalty
Summary
The facility failed to maintain the heating and cooling units (PTACs) in a safe and clean condition in four out of five resident rooms observed. During an observation with the Maintenance Director, it was found that the PTAC filters and vents in rooms 101, 215, 303, and 412 were covered with dirt and dust, with some filters ripped or missing entirely. The Maintenance Director confirmed that each PTAC should have two filters to prevent the coils from becoming dirty and dusty, and acknowledged the difficulty in finding replacement parts due to the age of the units. The Housekeeping Supervisor stated there was no established cleaning schedule for the PTAC filters, although they should be cleaned weekly. An email from the Executive Director of Facilities Management clarified the function of the vent screens but did not address the lack of filter maintenance. These findings were confirmed during the survey and represent a failure to ensure a clean and safe environment for residents, staff, and the public.
Failure to Provide Podiatry Services and Foot Care
Penalty
Summary
The facility failed to provide appropriate foot care and ensure podiatry services for two residents with significant medical histories, including diabetes and end stage renal disease. In both cases, signed consents for podiatry services were present in the residents' records, but there was no evidence that either resident had been seen by a podiatrist during their stay. For one resident, family-provided photos and interviews confirmed that the resident's toenails were long, thick, brittle, and had buildup underneath, with dry, scaly skin present on both feet. The family reported that no foot or nail care had been performed since admission, despite the resident's enjoyment of such care prior to entering the facility. The Director of Nursing confirmed the lack of podiatry visits and noted that the facility was unaware that a physician's signature was required on the consent forms, partly due to the abrupt departure of the social services designee. In the second case, the resident's husband had requested podiatry services due to complaints of discomfort from long toenails, and was told the resident was on the list to be seen. However, the resident was not seen by the podiatrist, and subsequent review revealed that the necessary physician order had not been signed. The Director of Nursing again confirmed the absence of podiatry care and attributed the oversight to a lack of awareness regarding the need for a physician's signature and the recent loss of the social worker designee. Both cases were substantiated by medical record reviews, family interviews, and photographic evidence.
Failure to Implement Fall Prevention Interventions per Care Plan
Penalty
Summary
A deficiency was identified when a resident with a history of falls, cerebrovascular disease, diabetes, seizures, and an absent right great toe did not have fall prevention interventions in place as outlined in their care plan. The resident had experienced three falls over several months, each resulting in new interventions being added to the care plan, such as hanging a sign to ask for help, moving personal items within reach, and using a low bed. The care plan also specified that the bed should be in the lowest position when occupied, a body pillow should be placed on the right side of the bed, personal items should be within reach, and a visual reminder should be present to use the call light for assistance. During an observation of the resident's room with the DON, it was found that the required body pillow and sign were missing, and the bed was not in the low position as specified in the care plan. The DON acknowledged that the resident had recently changed rooms and that the body pillow and sign had not been transferred to the new room. Additionally, the DON stated that she did not believe the resident wanted the bed in the lowest position and intended to update the care plan, but at the time of observation, the interventions were not in place as required.
Failure to Ensure Drug Regimen Free from Unnecessary Medications Due to Improper Morphine Administration
Penalty
Summary
A deficiency occurred when a resident's drug regimen was not kept free from unnecessary medications, specifically regarding the administration of morphine that was not in accordance with hospice orders. The resident, who had multiple complex diagnoses including tracheostomy, respiratory failure, COPD, diabetes, and several cancers, was under hospice care and had orders for several medications, including morphine for pain and dyspnea. The original morphine order was for 5 mg every four hours as needed, which was later increased to 10 mg every two hours as needed, and then clarified to every four hours as needed. However, the medication administration records (MAR) and narcotic control sheets showed multiple discrepancies in the timing, dosage, and documentation of morphine administration. The review of records revealed that morphine was administered at intervals not consistent with either the original or clarified orders, with doses given as frequently as 20 to 40 minutes apart, and some doses not documented on the MAR or narcotic control sheets. There were also inconsistencies in the administration and documentation of other medications, such as lorazepam. The DON confirmed that the nurse had transcribed the hospice order incorrectly, entering every two hours as needed instead of every four hours as needed, and that morphine was not administered per either order. Additionally, a dose of morphine given shortly before the resident's death was not documented on the control sheet. Throughout the resident's final hours, progress notes indicated ongoing administration of morphine and lorazepam, with varying documentation of effectiveness and resident response. The resident was described as minimally responsive, with signs of pain and terminal restlessness, and ultimately expired with chronic hypoxic respiratory failure and malignancies listed as causes of death. The failure to ensure accurate transcription, administration, and documentation of medication orders, particularly for morphine, resulted in the resident receiving unnecessary drugs and doses not in accordance with hospice or physician orders.
Deficiency in Food Temperature and Quality
Penalty
Summary
The facility failed to ensure that food was prepared and served at an appetizing and safe temperature, affecting all 83 residents. During the lunch tray line observation, it was noted that the lids were off the chafing dishes, and the food was plated and sent to the dining room in an open-air cart. The dietary staff did not retake food temperatures halfway through the tray line, and the fish and tater tots were served at temperatures significantly below the industry standard of 135 degrees Fahrenheit. The dietary staff seemed unaware of the inadequate temperatures and continued to serve the food without reheating it. Interviews with residents revealed dissatisfaction with the food, citing it as cold, repetitive, and difficult to cut. Residents also expressed concerns about the quality and safety of the food, with some fearing it was undercooked. The facility's policies did not include minimum holding temperatures for food on the tray line, and the Dietary Manager confirmed the food holding temperatures did not meet industry standards. Resident Council minutes from January to March 2025 documented ongoing complaints about the food, including issues with temperature, repetition, and quality.
Facility Fails to Maintain Sanitary Kitchen Conditions
Penalty
Summary
The facility failed to maintain sanitary conditions in the kitchen, affecting all 83 residents. Observations revealed that the kitchen was in a state of disrepair and uncleanliness. The shelf above the cooktop and the top of the steamer were dirty with brown debris and a greasy, sticky film. The fronts of the refrigerators, freezers, and ovens were sticky and smeared with dried food. The Ansel system was dusty, and the floor was soiled and cracked with food debris around the appliances. The steam table had a thick lime buildup, and the knife block was dusty. Additionally, the reach-in refrigerator had rusting shelves, and there was an open, undated container of applesauce. The freezer contained unsealed hamburger patties, and the exit door wall was crumbling and rusty. The ceiling air vent was discolored, and the dumpster lid was broken. During the trayline observation, the fish and tater tots were served at temperatures below the safe threshold, with the fish at 128 degrees Fahrenheit and the tater tots at 122 degrees Fahrenheit. The staff member responsible for checking temperatures did not recognize these as too low and continued to serve the food. The Dietary Manager confirmed the findings, noting that the kitchen staff struggled to clean the old floors and that the damaged wall had been an issue for years. The manager also mentioned that the ovens and deep fryer were not used, and the steamer had issues with holding compression. The lime buildup on the steam table was attributed to water leakage.
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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