Smithville Western Care Center
Inspection history, citations, penalties and survey trends for this long-term care facility in Wooster, Ohio.
- Location
- 4110 East Smithville Western Road, Wooster, Ohio 44691
- CMS Provider Number
- 365317
- Inspections on file
- 22
- Latest survey
- April 28, 2025
- Citations (last 12 mo.)
- 0
Citation history
Health deficiencies cited at Smithville Western Care Center during CMS and state inspections, most recent first.
The facility did not maintain accurate and complete records for controlled medications, including discrepancies between drug removal, administration documentation, and physician orders. In several cases, controlled drugs were signed out after orders had expired, not properly documented as administered or wasted, and required signatures were missing, involving multiple residents with complex medical needs. These actions did not comply with facility policy for controlled substance management.
A resident with multiple medical conditions was placed in a room with a non-functioning heater, resulting in an uncomfortably cold environment. Despite repeated complaints to staff and maintenance tickets being submitted, the only immediate intervention was providing an extra blanket, and the resident was not offered a room change until after the weekend when maintenance staff returned. The facility failed to maintain required temperature standards, impacting the resident's comfort and well-being.
A resident with a history of respiratory issues expressed concerns about having pneumonia and requested a chest x-ray, but the facility did not facilitate this due to the resident's body habitus and did not send him to the hospital. The resident was not examined by the physician during his stay, leading to dissatisfaction with the facility's handling of his health concerns. This situation highlights a failure to support the resident's right to self-determination in medical care.
A resident with multiple health conditions was involved in a verbal altercation with an LPN, during which the LPN allegedly recorded the conversation without proper consent. The incident, which involved yelling and racial slurs, was reported by a CNA who witnessed the event. The facility's policy prohibits the use of personal devices during work, and the LPN was reprimanded for the privacy violation.
The facility failed to follow physician's orders for insulin management in a diabetic resident, leading to improper administration without prior blood sugar checks. Additionally, another resident's open abdominal wound was not properly evaluated or treated, despite existing skin conditions. These deficiencies highlight lapses in the facility's adherence to care protocols.
A resident experienced severe symptoms and deterioration due to the facility's failure to provide timely and adequate care, including lack of physician notification for abnormal lab results and medication issues. The resident was admitted to the hospital with severe dehydration, malnutrition, and an abnormal TSH level. Additionally, two other residents were affected by the facility's failure to ensure continuity of care and timely assessment.
The facility failed to ensure residents were seen by their physician every 30 days for the first 90 days post-admission, affecting four residents. Despite being seen by a nurse practitioner, these residents, with serious health conditions, did not meet with their assigned physician as required. Interviews confirmed the lack of physician visits.
A resident with a history of acute ischemia and other conditions had abnormal lab results that were not communicated to the physician or NP, despite facility policy requiring such notifications. The resident's sodium and creatinine levels were concerning, but the physician was unaware and unable to take corrective action.
The facility failed to maintain a clean kitchen and proper food storage, affecting all 90 residents. Observations revealed a scoop in oats, molded cucumbers, unlabeled and undated food items, and expired juices. The deep fryer and surrounding areas were unclean, with oil and food debris. Additional cleanliness issues included food build-up on ovens, greasy floors, and dust-covered fans. Facility policies on sanitation and food handling were not followed.
The facility did not properly dispose of garbage and refuse, potentially affecting all 90 residents. An observation of the outside trash area revealed plastic wrappers, gloves, plastic spoons, and cigarette butts on the ground around the dumpsters. This was confirmed by the Dining Services Director. The facility's policy required the area to be free from debris, with employees responsible for maintaining cleanliness.
The facility failed to employ a full-time, qualified social worker, affecting 90 residents. The Social Services Designee lacked the required qualifications, and the Activities Director, identified as handling social services, had no relevant experience. The Administrator confirmed that neither were Licensed Social Workers (LSWs), and oversight was provided by a Corporate Social Services Designee who was also not an LSW.
The facility failed to maintain a pest-free kitchen, with drain flies observed in the dish machine area. Despite the Dining Services Director's awareness, no action was taken for two weeks. The Maintenance Director was unaware of the issue until later, and pest control reports showed no treatment for drain flies. The facility's policy required contacting pest control services when issues arise.
A facility failed to store medications safely when an RN left a medication cup unsupervised on a cart in the memory care unit. A cognitively impaired resident was near the cart, and the RN acknowledged the risk of the resident taking the medications. The facility's policy requires medications to be stored in a locked cart or area until use.
The facility failed to maintain a clean and safe environment for residents, with issues such as exposed wiring, damaged walls, and unsanitary bathrooms affecting multiple rooms. Observations revealed widespread deficiencies, including closet doors off track, dusty light fixtures, and missing heating unit covers. The Director of Maintenance confirmed these findings and acknowledged the need for further cleaning and repairs.
The facility did not ensure that authorizations for managing resident funds were witnessed by a non-facility affiliated individual, affecting three residents. The absence of required witness signatures was confirmed by the Business Office Manager.
A facility failed to convey a resident's funds within the required 30-day timeframe after the resident was discharged to a hospital and subsequently expired. The Business Office Manager confirmed the delay, with checks being dispersed to the state and a funeral home beyond the stipulated period.
The facility failed to provide written transfer notices to residents and/or their representatives during hospital transfers. Two residents with significant medical conditions were affected, with transfer notices communicated only over the phone. The Administrator and Social Services Designee confirmed the lack of written notices.
A resident with severe cognitive impairment and muscle weakness was found with long, thick, and curling toenails, indicating a lack of necessary toenail care. Despite the evident need, there was no documentation of an assessment or referral for podiatry services. The DON and an RN confirmed the oversight, and podiatry was only notified after the surveyor's observation.
The facility failed to implement fall interventions for two residents, leading to deficiencies in accident prevention. A resident with hemiplegia fell and fractured her arm due to inadequate supervision, and staff moved her despite pain complaints. Another resident experienced two falls despite requiring two-person assistance, with no confirmation of intervention implementation. The facility's fall investigations lacked thoroughness and communication.
A resident with insomnia and other health issues experienced unnecessary increases in Trazodone dosage due to unresolved environmental disturbances caused by a roommate. Despite staff awareness of the issue, there was a lack of follow-up and communication, leading to medication adjustments without addressing the root cause.
The facility failed to maintain accurate documentation for a resident's mattress orders and care conferences for two residents. A resident's TAR inaccurately showed completion of LAL mattress orders, while interviews revealed uncertainty about the mattress switch. Care conference records for two residents were incorrect, with one resident's meeting documented inaccurately and another's meeting not occurring as recorded. These discrepancies were confirmed by staff interviews.
The facility failed to provide timely liability notices to a resident, who was discharged with diagnoses including Alzheimer's disease, dementia, and COVID-19. The Notice of Medicare Non-Coverage (NOMNC) was signed on the same day the skilled services ended, not providing the required 48-hour notice for an appeal. This was confirmed by the Admissions Director.
Failure to Maintain Accurate and Complete Controlled Drug Records
Penalty
Summary
The facility failed to ensure and maintain accurate and complete drug records for multiple residents, as evidenced by discrepancies between controlled drug records, medication administration records (MAR), and physician orders. For one resident with Alzheimer's dementia and anxiety, Ativan was removed from secured storage and signed out by a nurse after the order had been discontinued, with no documentation in the MAR or medical record indicating administration or a valid order. Additionally, for the same resident, Norco was documented as administered in the MAR, but the controlled drug record indicated it was not given, as the count remained accurate. Another resident with paraplegia and chronic pain had Oxycodone signed out from secured storage after the order had expired, with no documentation in the MAR or medical record to support administration or a valid order. For a resident admitted to hospice with a history of cerebral infarction, the controlled drug record for morphine sulfate did not include the drug name or directions for use, and there were inconsistencies between the controlled drug record and the MAR regarding the times and documentation of administration. A further resident with toxic encephalopathy had Hydrocodone-Acetaminophen signed out twice on the same day, with a handwritten note indicating the medication was wasted, but without the required second nurse signature to verify the waste. The MAR indicated the medication was administered, but the documentation did not meet policy requirements. The facility's policy requires immediate and complete documentation of controlled substance administration and proper witnessing and documentation of wasted doses, which was not followed in these cases.
Resident Exposed to Uncomfortable Room Temperature Due to Inoperative Heating
Penalty
Summary
A deficiency occurred when a resident was admitted to a room that did not maintain a comfortable temperature, as required by facility policy. The resident, who had diagnoses including diabetes mellitus, depression, and anxiety disorder and was cognitively intact, reported that the room was cold and lacked heat. Despite informing staff of the issue, the only immediate action taken was to provide an extra blanket. The resident's family also experienced the cold during visits, and maintenance staff confirmed that the baseboard heater in the room was not functioning due to a failed thermocouple. Maintenance was not available over the weekend, and the resident was not offered a room change during this period, despite ongoing complaints about the cold temperature. Staff interviews confirmed that nursing staff submitted maintenance tickets regarding the room temperature, but no further action was taken to address the resident's comfort until after the weekend, when maintenance returned and the resident was moved to a different room. The facility's policy requires maintaining room temperatures between 71 and 81 degrees Fahrenheit, but this standard was not met for the resident during their stay in the affected room. The deficiency was identified through interviews, record reviews, and weather history, and it was determined that the resident's right to a safe, clean, comfortable, and homelike environment was not honored.
Failure to Support Resident's Self-Determination in Medical Care
Penalty
Summary
The facility failed to ensure that a resident, who was cognitively intact, was fully informed and able to direct his own medical care. The resident, who had a history of pneumonia, acute respiratory failure, and other serious health conditions, expressed concerns about his respiratory status and requested a chest x-ray to confirm his condition. Despite his requests and the presence of symptoms such as a cough and fluctuating oxygen saturation levels, the facility did not facilitate a chest x-ray due to the resident's body habitus and did not send him to the hospital for further evaluation. The resident's progress notes indicated that he repeatedly expressed concerns about having pneumonia and requested medical interventions similar to those he received in a hospital setting. However, the facility's physician did not examine or communicate with the resident from the time of his admission until he was eventually sent to the hospital. The Director of Nursing confirmed that the physician did not order a chest x-ray and instructed the nurses not to send the resident to the hospital, despite the resident's persistent requests and concerns. Interviews with the resident and a family member revealed dissatisfaction with the facility's handling of the situation, particularly regarding the lack of a chest x-ray and the perceived lack of responsiveness to the resident's health concerns. The facility's policy on resident rights emphasizes the importance of supporting resident self-determination and choice in their healthcare, which was not upheld in this case. This deficiency was investigated under a specific complaint number, indicating non-compliance with resident rights.
Privacy Violation Due to Unauthorized Recording
Penalty
Summary
The facility failed to maintain the privacy of a resident, identified as Resident #88, during an incident involving a Licensed Practical Nurse (LPN) and other staff members. Resident #88, who had a history of paraplegia, type two diabetes mellitus with diabetic neuropathy, morbid obesity, bipolar disorder, and anxiety disorder, was involved in a heated verbal exchange with LPN #204. During this altercation, it was alleged that LPN #204 recorded the conversation with Resident #88 without proper consent, although LPN #204 claimed that Resident #88 had given permission. The incident was reported by a Certified Nursing Assistant (CNA) who witnessed the altercation and alleged that another CNA was also recording the incident. The altercation occurred in Resident #88's room, where the resident was reportedly yelling at LPN #204 and using racial slurs. The LPN allegedly recorded the conversation on her cell phone, which was left on the treatment cart. Witnesses reported that the recording was played at the nurses' station, although it did not contain any identifying information. The incident was reported to the Unit Manager, who intervened to calm the situation but did not witness any abuse. The Director of Nursing (DON) confirmed that the LPN was reprimanded for recording the resident, and staff were educated on the facility's cell phone use policy. Resident #88 expressed dissatisfaction with the facility, citing multiple arguments with LPN #204 and feeling overwhelmed and stressed by the situation. The resident claimed that the recording was made without consent and that the incident caused significant distress, leading to a transfer to another facility. The facility's policy on the use of personal handheld devices prohibits their use during working time unless authorized for business purposes, and the incident was investigated as a potential violation of this policy.
Failure in Insulin Management and Wound Care
Penalty
Summary
The facility failed to adhere to physician's orders for the management of diabetes in Resident #81, leading to improper insulin administration. Resident #81, who has a history of type one diabetes mellitus with hyperglycemia and type two diabetes mellitus with hypoglycemia, was supposed to have blood sugar levels checked before insulin administration. However, on 10/03/24, insulin was administered without checking blood sugar levels, and both scheduled and sliding scale insulin doses were given simultaneously, contrary to the physician's orders. This mismanagement was confirmed by the Director of Nursing and the Licensed Practical Nurse involved, who acknowledged the deviation from the prescribed insulin administration schedule. Additionally, the facility failed to evaluate and treat an open area on Resident #86's abdominal fold. Resident #86, who was admitted with conditions including pneumonia and type two diabetes mellitus with hyperglycemia, had an open, reddened area on the right lower abdominal fold that was not properly assessed or treated from 12/11/24 to 12/15/24. Despite the presence of a chronic skin condition noted in a weekly skin check, there were no treatment orders or documentation of care for this area. Interviews with Resident #86 and nursing staff revealed that the area was not consistently monitored or treated, and the facility's policy for wound management was not followed. These deficiencies highlight the facility's failure to provide appropriate treatment and care according to physician's orders and resident needs. The lack of adherence to insulin administration protocols and inadequate wound care management for the residents involved demonstrates a significant lapse in the facility's quality of care practices.
Failure to Provide Timely and Adequate Care for Resident
Penalty
Summary
The facility failed to provide timely and adequate care for Resident #78, who was admitted following a hospitalization for acute ischemia of the small intestine, septic shock, and gastroenteritis. Despite exhibiting symptoms such as increased nausea, vomiting, diarrhea, and abdominal pain between 09/05/24 and 09/18/24, the facility did not update the physician on the resident's change in condition, including abnormal laboratory values and meal refusals. The resident's thyroid stimulating hormone (TSH) level was significantly elevated, and the physician, unaware of the resident's current levothyroxine treatment, ordered a lower dose, exacerbating the resident's condition. From 09/24/24 to 10/09/24, Resident #78 continued to experience severe symptoms, including nausea, vomiting, diarrhea, abdominal pain, decreased appetite, and weight loss, without adequate intervention or physician notification. The resident's laboratory results on 09/24/24 showed abnormal sodium, potassium, and creatinine levels, yet there was no evidence of physician notification. The resident's condition deteriorated, leading to a transfer to the emergency room on 10/09/24, where she was diagnosed with severe dehydration, malnutrition, and an abnormal TSH level, requiring hospitalization. Additionally, the facility failed to ensure continuity of care for Resident #25, who missed scheduled appointments, and did not assess Resident #71 in a timely manner for elevated blood sugar. These failures affected three residents out of the twelve reviewed for changes in condition and continuity of care, indicating systemic issues in the facility's management of resident care and communication with healthcare providers.
Removal Plan
- Resident #78 was transferred to the emergency room and did not return to the facility.
- The DON conducted a whole house audit to ensure all resident labs in the last 30 days had documented evidence of physician notification.
- The DON conducted a whole house audit to ensure any resident who refused meals in the last 72 hours had physician and registered dietitian (RD) notification and documentation.
- The DON educated Registered Dietitian (RD) #613 on communicating meal refusals with the facility nursing management.
- Licensed Practical Nurse (LPN) #578/Unit Manager conducted a whole house audit for all resident's nursing progress notes from the previous 72 hours to ensure any change in condition had proper notification and documentation.
- The DON educated all nurses on the proper process for reporting labs, observing new orders and ensuring appropriate documentation of all notifications and new orders. The education also included current medications related to lab values should be relayed to the physician at the time of notification.
- The DON completed verbal education to all facility physicians and nurse practitioners regarding verifying the current dose of any medication related to a lab value before changing the dose.
- The DON completed education for all nurses on notification of change in condition policy and recognizing signs and symptoms of a change in condition.
- Registered Nurse (RN) #583/Unit Manager conducted a whole house audit for all residents ordered levothyroxine to ensure labs within the last 30 days were managed appropriately. All orders were verified for accuracy. Any concerns were addressed and documented.
- Physician #600, who was the Medical Director, was notified of the concern related to Resident #78 and notified of the facility current corrective action plan.
- An ad hoc Quality Assurance Performance Improvement (QAPI) meeting was held with the Administrator, DON, RDO #606, VPO #612, RCRN #605, LPN #593/Minimum Data Set Nurse, RN #583/Unit Manager, LPN #578/Unit Manager, and with Physician #600 via telephone. Discussion included requirements of visits, labs, notifications, communication, current orders, and resident conditions.
- The DON/designee would audit all labs for results, notifications and documentation every business day for four weeks then randomly thereafter for a total of two months. Quality Assurance (QA) would review the results of the audits weekly.
- The DON/designee would audit all nurses' notes for a change in condition and proper notification and documentation each business day for four weeks, then randomly thereafter for a total of two months. QA would review the results of the audits weekly.
- The DON/designee would audit meal intakes on five residents each business day for four weeks, then randomly thereafter for a total of two months. QA would review the results weekly.
- The DON/designee would audit four residents on Levothyroxine each week to check for notification of physician as warranted, if new orders were reviewed and were appropriate, documentation of labs, new order notification to family, and if any needed follow up was completed immediately for four weeks, then randomly thereafter for a total of two months. QA would review the results weekly.
Failure to Ensure Timely Physician Visits for Residents
Penalty
Summary
The facility failed to ensure that residents were seen by their physician at least once every 30 days for the first 90 days following admission, affecting four out of seven residents reviewed. Resident #9, admitted with serious conditions such as necrotizing fasciitis and sepsis, was not seen by his physician during his stay, although he was seen by a nurse practitioner and external specialists. Interviews confirmed that the resident had not met with his assigned physician at the facility. Similarly, Resident #10, with diagnoses including diabetes mellitus and chronic kidney disease, was not seen by her physician during her stay, only by a nurse practitioner. Resident #78, who had acute ischemia and other serious health issues, was also not seen by her physician before being discharged to the hospital. Resident #84, with chronic obstructive pulmonary disease and lung cancer, was only seen by her physician once, just before being discharged to the hospital, and not within the required 30 days of admission. Interviews with facility staff verified these deficiencies in physician visits.
Failure to Notify Physician of Abnormal Lab Results
Penalty
Summary
The facility failed to notify the physician and/or nurse practitioner of abnormal lab results for a resident, which was a deficiency identified during a survey. The resident, who had a history of acute ischemia of the small intestine, infectious gastroenteritis, and other conditions, was admitted to the facility from the hospital. The resident's lab results on multiple occasions showed abnormal sodium and creatinine levels, indicating potential health concerns that required medical attention. Despite the abnormal lab results, there was no evidence that the resident's physician or nurse practitioner was notified of these results, particularly the lab results from September 24, 2024, which showed low sodium and potassium levels and high creatinine levels. Interviews with the Director of Nursing and the physician confirmed that the physician was not aware of these abnormal results, and if notified, would have taken corrective actions such as ordering oral potassium and additional IV fluids. The facility's policy on Notification of Change in Resident Condition required that significant changes in a resident's status be communicated to the physician and other relevant parties. However, this policy was not followed in the case of the resident's abnormal lab results, leading to a deficiency being cited during the survey. This deficiency was investigated under a specific complaint number.
Sanitation and Food Storage Deficiencies in Kitchen
Penalty
Summary
The facility failed to maintain a clean and sanitary kitchen area and ensure proper food storage, which had the potential to affect all 90 residents receiving meals. During an observation, a plastic storage container with oats was found with a scoop resting on top inside the container. In the walk-in refrigerator, a box of cucumbers contained two molded cucumbers touching non-molded ones, and there were several unlabeled and undated items, including a quarter-full pan of tomato soup and a pitcher of red juice. Additionally, pitchers of grape juice and sweet tea were dated beyond the facility's seven-day storage policy. The deep fryer had dark oil with food debris, and the surrounding area was unclean, with oil build-up and food debris on the floor and equipment. Further observations revealed significant cleanliness issues in the kitchen, including food build-up on ovens, dark grease on the flat top grill, and food debris on the clean side of the dish machine. The dish machine area had greasy and slippery floors, dust-covered fans, and dirty trash cans. The ceilings in the kitchen and dish machine areas had dust build-up around lights and air vents. A hand sink next to the coffee machine was found with significant food debris. The facility's policies on sanitation and food handling, as well as food stock rotation, were not adhered to, as confirmed by the Dining Services Director.
Improper Disposal of Garbage and Refuse
Penalty
Summary
The facility failed to ensure proper disposal of garbage and refuse, which had the potential to affect all 90 residents. During an observation of the outside trash area, it was noted that there were various plastic wrappers, gloves, plastic spoons, and cigarette butts on the ground surrounding the dumpsters. This observation was confirmed through an interview with the Dining Services Director. The facility's policy, dated January 2022, stated that the area around the dumpsters should be free from debris and that each employee was responsible for maintaining cleanliness in this area.
Facility Lacks Qualified Full-Time Social Worker
Penalty
Summary
The facility failed to employ a full-time, qualified social worker, which had the potential to affect all 90 residents. The facility, with 127 certified and licensed beds, had a Social Services Designee (SSD) who did not meet the qualifications outlined in the job description. SSD #611, hired on 03/28/21, had attended college but did not earn a degree and had no documented history of long-term care experience. The job description required two years of experience in long-term care and preferred a Licensed Social Worker (LSW). Additionally, the Activities Director (AD) #502, who was identified as handling social services, had a degree in healthcare administration but no social services experience. Interviews with the Administrator revealed that SSD #611 had moved to a corporate position, and AD #502 was training to fill the social services role. SSD #611 continued to assist the facility twice weekly, with Corporate Social Services Designee (CSSD) #902 providing oversight and assistance once every week or every other week. LSW #900 from a sister facility initially assisted once a week but now only helped as needed. The Administrator confirmed that neither AD #502 nor SSD #611 were LSWs or held a related degree, and CSSD #902, who oversaw the Social Services Department, was also not an LSW.
Failure to Address Drain Flies in Kitchen
Penalty
Summary
The facility failed to maintain a kitchen area free of pests, specifically drain flies, which had the potential to affect all 90 residents who received meals from the kitchen. During an observation of the kitchen with the Dining Services Director (DSD), large amounts of drain flies were noted in the dish machine area, seen on the walls and equipment, and flying around. The DSD confirmed the presence of the drain flies and indicated that maintenance was supposed to address the issue, but no action had been taken for two weeks. The Maintenance Director (MD) later revealed he was unaware of the issue until after the observation. A review of pest control service inspection reports from January to June showed that the kitchen had not been treated for drain flies. The facility's pest control policy stated that the pest control company would be contacted and appropriate services provided when an issue arises.
Unsafe Medication Storage in Memory Care Unit
Penalty
Summary
The facility failed to store medications in a safe manner, as observed during a medication administration on the secured memory care unit. A registered nurse (RN) placed medications for another resident in a medication cup and left it unsupervised on the medication cart. This occurred while Resident #79, who was severely cognitively impaired and used a walker/wheelchair for mobility, was standing near the cart. The RN left the medications unattended while entering another resident's room to assess their blood sugar, leaving the medication cart out of view and without any staff present to monitor Resident #79. The facility's policy, revised in August 2021, requires that medications be stored in a locked medication cart or locked overflow area until ready for use. However, the RN confirmed during an interview that she left the medication cup unsupervised, acknowledging that Resident #79 could have taken the medications. This incident affected Resident #79 and had the potential to affect nine additional residents who were independently mobile and cognitively impaired, residing on the memory care unit.
Facility Fails to Maintain Clean and Safe Environment
Penalty
Summary
The facility failed to maintain residents' rooms in a clean and sanitary manner, affecting ten residents. Observations revealed several issues, including closet doors hanging off the track, black markings and gashes on walls, exposed wiring on bed remotes, and missing covers on heating units. Additionally, light fixtures were covered with heavy dust and dead bugs, and call light panels were not affixed to the wall. These deficiencies were observed in multiple rooms, indicating a widespread issue with the physical environment. Interviews with the Director of Maintenance (DOM) confirmed these findings. The DOM verified that some repairs were made, such as covering exposed wiring with tape and placing a cover on a heating unit, but acknowledged that further cleaning and repairs were needed. Additional observations with the DOM revealed unsanitary conditions in residents' bathrooms, including cracked floor tiles, missing light covers, and dirty walls and baseboards. The DOM confirmed these issues and stated that further cleaning and repairs were necessary.
Failure to Obtain Non-Facility Witness for Resident Fund Authorizations
Penalty
Summary
The facility failed to ensure that authorizations for managing resident funds were attested to by a witness not affiliated with the facility, affecting three residents out of five reviewed. Specifically, the authorizations for Residents #10, #34, and #57 lacked the required non-facility affiliated witness signatures. These authorizations were dated 02/15/24, 07/17/23, and 08/30/22, respectively. This deficiency was confirmed during an interview with the Business Office Manager, who verified the absence of the necessary witness signatures for all three residents.
Delayed Conveyance of Resident Funds Post-Discharge
Penalty
Summary
The facility failed to ensure timely conveyance of resident funds upon discharge, affecting one resident. The resident was admitted and later readmitted to the facility before being discharged to a hospital, where they subsequently expired. A review of the resident's fund records showed that checks were dispersed to the state and a funeral home, but not within the required 30-day timeframe post-discharge. This was confirmed during an interview with the Business Office Manager, who acknowledged the delay in conveying the funds.
Failure to Provide Written Transfer Notices
Penalty
Summary
The facility failed to provide written transfer notices to residents and/or their representatives when transferring residents to the hospital. This deficiency affected two residents, one with chronic obstructive pulmonary disease, chronic respiratory failure with hypoxia, chronic diastolic heart failure, and muscle weakness, and another with diabetes mellitus, end-stage renal disease, atrial fibrillation, hypoxemia, metabolic encephalopathy, and lobar pneumonia. The medical records for these residents showed multiple hospital transfers, but there was no evidence of written transfer notices being provided. Interviews with the facility's Administrator and Social Services Designee confirmed that transfer notices were communicated over the phone but not provided in writing. The Administrator acknowledged that social services were responsible for the transfer and discharge notices, but there was uncertainty about whether written notices were given. The Social Services Designee admitted to not providing written transfer/discharge notices to the residents or their responsible parties.
Failure to Provide Toenail Care for Cognitively Impaired Resident
Penalty
Summary
The facility failed to provide necessary toenail care for a resident who was severely cognitively impaired and required substantial assistance with personal hygiene. The resident, who had been admitted with diagnoses including unspecified dementia and muscle weakness, was observed with very long, thick, and curling toenails. Despite the evident need for toenail care, there was no documentation in the resident's medical record indicating an assessment or referral for podiatry services. Interviews with the Director of Nursing (DON) and a Registered Nurse (RN) confirmed the lack of action regarding the resident's toenail care. The DON acknowledged that the toenails were too thick and long for staff to manage and that there was no record of the resident being assessed for podiatry needs or referred for such services. It was only after the surveyor's observation that podiatry was notified of the resident's need for toenail care, indicating a delay in addressing the resident's personal care needs.
Failure to Implement Fall Interventions and Procedures
Penalty
Summary
The facility failed to implement all fall interventions for two residents, leading to deficiencies in accident prevention and supervision. Resident #41, who was at high risk for falls due to conditions such as hemiplegia and vascular dementia, experienced a fall in the dining room, resulting in a fracture of the right humerus. Despite being identified as requiring two-person assistance for transfers, Resident #41 was observed independently ambulating without staff intervention, indicating a lack of adherence to the prescribed fall prevention measures. Additionally, the facility did not follow proper procedures after Resident #41's fall, as staff moved the resident despite complaints of pain, contrary to the facility's policy of not moving residents after a fall until assessed to prevent further injury. The Director of Nursing confirmed that the resident should not have been moved and that the physician should have been notified immediately. Resident #45, who required maximal assistance with ADLs, experienced two falls within a short period. The first fall occurred while being assisted to bed, and the second fall happened during a transfer to bed, despite a new intervention requiring two-person assistance with a front-wheeled walker. The facility's fall investigation did not confirm whether this intervention was in place during the second fall, and there was no statement from the aide involved, indicating a lack of thorough investigation and communication of new interventions to staff.
Failure to Address Environmental Factors Led to Unnecessary Medication Increase
Penalty
Summary
The facility failed to ensure that a resident's drug regimen was free from unnecessary medication increases. Resident #74, who had diagnoses including end-stage renal disease, depression, insomnia, and anxiety disorder, experienced an increase in Trazodone dosage from 50 mg to 100 mg over a period of time. This increase was ordered by a Psychiatric Nurse Practitioner (PNP) in response to the resident's complaints of sleep disturbances, which were attributed to noise and disturbances caused by a roommate. Despite the resident's reports and a nurse's note indicating the issue, there was no evidence of follow-up action to address the environmental factors affecting the resident's sleep. Interviews with staff revealed a lack of communication and awareness regarding the resident's situation. The Registered Nurse (RN) was aware of the resident's dissatisfaction with the roommate and noted that a room change could be easily arranged. However, the Administrator was unaware of the issue, and the Unit Manager believed the situation had been resolved. The Director of Nursing (DON) and the Unit Manager were unaware of the reasons for the medication increases, despite the DON being aware of the increase itself. This lack of coordination and follow-up contributed to the unnecessary medication increase for Resident #74.
Inaccurate Documentation in Medical Records and Care Conferences
Penalty
Summary
The facility failed to ensure accurate documentation on the Treatment Administration Record (TAR) for a resident with quadriplegia, polyneuropathy, and morbid obesity. The resident was dependent on staff for mobility and had orders for a low air loss (LAL) mattress, which were signed off as completed from early June to late June. However, there was no evidence of when the resident was switched from a LAL mattress to a bariatric mattress, and interviews with staff revealed uncertainty about the exact timing of the switch. The Director of Nursing confirmed the orders were inaccurately signed off as completed. Additionally, the facility failed to ensure accurate care conference documentation for two residents. One resident with severe cognitive impairment had care conference documentation indicating meetings were held on two separate dates, but both were documented as occurring at the same time, which was verified as incorrect by the Director of Nursing. Another resident's care plan meeting was documented as having occurred with specific attendees, but interviews revealed that the meeting did not take place as documented, and the resident's daughter, who was supposed to be involved, denied any participation. The inaccuracies in documentation affected three residents in total, highlighting a failure in maintaining accurate medical records and care conference documentation. The discrepancies were confirmed through interviews with staff, including the Director of Nursing, who acknowledged the errors in documentation and the lack of proper record-keeping for the residents involved.
Failure to Provide Timely Liability Notices
Penalty
Summary
The facility failed to ensure proper liability notices were received timely for Resident #104. The resident, who had diagnoses including Alzheimer's disease, dementia, and COVID-19, was discharged on [DATE]. The Notice of Medicare Non-Coverage (NOMNC) indicated that skilled services would end on 02/19/24, with the option to appeal no later than noon of the day before the effective date. However, the NOMNC was signed and dated by the resident on 02/19/24, not providing the required 48-hour notice for an appeal. This was confirmed by the Admissions Director, who acknowledged the late issuance of the NOMNC. This deficiency was investigated under Complaint Number OH00152123.
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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