Steubenville Country Club Manor
Inspection history, citations, penalties and survey trends for this long-term care facility in Steubenville, Ohio.
- Location
- 575 Lovers Lane, Steubenville, Ohio 43953
- CMS Provider Number
- 366241
- Inspections on file
- 27
- Latest survey
- February 28, 2025
- Citations (last 12 mo.)
- 0
Citation history
Health deficiencies cited at Steubenville Country Club Manor during CMS and state inspections, most recent first.
A facility failed to ensure accurate recording of a resident's advanced directives. The resident's hard copy chart indicated a DNR-CCA directive, but this was not reflected in the EMR, where staff typically check for such information. Interviews with staff confirmed this inconsistency, which was against the facility's policy requiring directives to be in both the EMR and hard copy records.
A facility failed to accurately complete a PASRR for a resident upon admission. The resident's PASRR omitted diagnoses of bipolar disorder and PTSD, only indicating mood disorder and severe anxiety disorders. This was confirmed by an Admissions Coordinator interview.
A facility failed to monitor a resident's blood pressure before administering midodrine, an anti-hypotensive medication, as per the physician's order. The resident had a history of falls, subdural hematoma, craniotomy, cerebrovascular accident, hypotension, and hypertension. The medication was to be held if the systolic blood pressure was ≥150 mmHg, but the Medication Administration Record showed no evidence of monitoring. This was confirmed by the DON.
The facility failed to maintain complete and accurate documentation of showers for two residents, affecting their medical records. One resident, with multiple health conditions, had only one shower documented over a month despite a care plan for regular showers. Another resident, with mental health diagnoses, also had insufficient shower documentation. Interviews revealed that the transition to electronic records and staff forgetfulness contributed to the issue.
The facility failed to conduct assessments for proper antibiotic use for three residents, leading to the administration of antibiotics without documented justification. An LPN confirmed the absence of assessments, despite the facility's policy requiring the use of the McGeer Criteria for Infection Surveillance.
A facility failed to offer influenza and pneumococcal vaccines to a newly admitted resident with multiple diagnoses, as their policy only addressed annual vaccine offerings and not new admissions. An LPN confirmed the oversight, and the facility's vaccine policies lacked guidance for new admissions.
A facility failed to offer a COVID-19 vaccine to a newly admitted resident, who had no documented evidence of vaccination or declination. The resident's medical record lacked any vaccine information, and the facility's policy did not address offering vaccines to new admissions after the annual clinic. An LPN confirmed the oversight.
The facility failed to respond timely to residents' call lights, affecting four residents. Observations showed call lights left unanswered for extended periods, with residents reporting delays of up to an hour. Staff interviews revealed confusion over assignments and a lack of responsiveness, with an LPN noting that the issue was not due to staffing shortages but rather staff ignoring call lights. The DON acknowledged the problem, attributing it to staff congregating in one area.
The facility failed to honor the bathing preferences of three residents who were dependent on staff for assistance. A resident reported never receiving a shower since admission, despite her preference, and the DON confirmed the lack of documentation for her showers. Another resident's records did not specify the type of bath received, and the DON confirmed missing documentation for scheduled showers. Staff interviews revealed that bathing preferences were not honored due to time constraints.
The facility failed to ensure nursing assistants received required training before providing direct care, affecting all 46 residents. A nurse aide in training performed duties without formal training, and several nursing assistants were hired without being on the nurse aide registry or enrolled in training programs. The facility believed they had four months to enroll aides in classes, but some worked longer without enrollment.
The facility failed to maintain secure infection control records and did not investigate a resident's elopement incidents. The previous DON kept records on personal devices, leaving no retrievable data. Additionally, the facility did not follow up on elopement incidents, and the door alarm system was found to be non-functional.
The facility failed to maintain infection control logs and implement proper hand hygiene and PPE use, affecting two residents. An LPN used bare hands to handle medication, and another LPN did not follow hand hygiene or gown protocols during PEG tube care. Facility policies on hand hygiene and enhanced barrier precautions were not adhered to, leading to non-compliance with infection control standards.
The facility did not have a qualified Infection Preventionist (IP) after the Director of Nursing (DON), who was also the IP, left the facility. A Registered Nurse confirmed that no other staff member had the necessary training to fulfill the IP role, potentially affecting all 46 residents.
The facility failed to consistently implement restorative nursing programs for four residents, impacting their range of motion maintenance. A resident with COPD and heart disease rarely received the prescribed ROM exercises, while another with heart disease and dementia experienced inconsistent shoulder exercises. Two other residents with various conditions also faced irregular program delivery. A restorative aide reported being frequently reassigned, affecting program implementation.
The facility failed to act on pharmacy recommendations for four residents, leading to unaddressed medication use issues. A resident was prescribed risperidone without a supporting diagnosis, while another lacked scheduled TSH levels for hypothyroidism. Two residents on insulin had no A1c levels scheduled, despite pharmacy recommendations. The RN could not locate pharmacy reviews for the past six months, resulting in unaddressed recommendations.
The facility failed to properly label and store medications, affecting multiple residents. Observations revealed opened insulin vials without dates, an earwax solution not discarded after use, an unlabeled inhaler, and topical creams stored with oral medications. Staff confirmed that creams should be stored separately, highlighting non-compliance with medication storage policies.
The facility failed to maintain accurate medical records, affecting several residents. A resident was found outside unsupervised, with no documentation of the incident. There were also inconsistencies in documenting bathing and bladder care. Additionally, medication administration records were incomplete, with reports of nurses signing off on medications they did not administer. Another resident's records lacked documentation for bathing and toileting assistance, despite orders for hourly checks. Staff interviews suggested these were documentation issues.
A facility failed to consistently implement a stop sign across a resident's room to deter wandering residents, despite it being part of the care plan for a resident with dementia. Observations showed the stop sign was not properly positioned, and staff, including an LPN, did not address its placement, even though another wandering resident was present.
A resident with dementia and a history of wandering was found outside the facility unaccompanied by staff. Despite being assessed as a high risk for elopement, the facility failed to notify the resident's family and physician, as required by policy. The incident was not documented in the nursing notes, and the responsible RN did not recall making the necessary notifications.
A resident with a history of falls and multiple medical conditions experienced several unwitnessed falls, and the facility failed to complete the required neurological checks. Despite the protocol for 72-hour monitoring, checks were either not initiated or not completed as required, indicating a lapse in providing appropriate care.
The facility failed to implement effective elopement interventions and ensure the proper functioning of safety devices, affecting two residents. One resident, at high risk for wandering, lacked a care plan until after multiple elopement incidents. Another resident, at high risk for falls, experienced multiple falls without new interventions. The facility's policies on elopement and fall prevention were not effectively implemented, contributing to these deficiencies.
A facility failed to ensure adequate indications for the use of risperidone in a resident with multiple diagnoses, including dementia. The RN confirmed that dementia was not an acceptable indication for risperidone, and there was no documentation justifying its continued use. A black box warning on risperidone highlighted increased risks for elderly residents with dementia-related psychosis.
Inconsistent Recording of Advanced Directives
Penalty
Summary
The facility failed to ensure that advanced directives were accurately and consistently recorded in the medical records for Resident #30. This resident, who was admitted with multiple diagnoses including Alzheimer's Disease, dementia, and malignant melanoma, had a documented advanced directive of Do Not Resuscitate Comfort Care - Arrest (DNR-CCA) in their hard copy chart, signed by a physician. However, this directive was not recorded in the Electronic Medical Record (EMR) in the demographic section, where staff typically look for such information. Interviews with facility staff, including an LPN and the Assistant Director of Nursing, confirmed that the standard procedure was to check the EMR for a resident's code status, and if not found there, to refer to the hard chart. The facility's policy on Advanced Directives, last reviewed in June 2024, stated that all advance directive documents should be located in both the EMR and the resident's medical record for easy retrieval by staff. The inconsistency between the hard copy chart and the EMR led to a deficiency in maintaining accurate and accessible records of the resident's advanced directives.
Incomplete PASRR Assessment for Resident
Penalty
Summary
The facility failed to ensure that the Pre-Admission Screening and Resident Review (PASRR) was completed accurately for a resident upon admission. The resident, who was admitted with diagnoses including diabetes mellitus, adjustment disorder with mixed anxiety and depressed mood, bipolar disorder, and post-traumatic stress disorder, had a PASRR completed that only indicated mood disorder and panic or other severe anxiety disorders. The PASRR did not reflect the resident's full mental health diagnoses, specifically omitting bipolar disorder and post-traumatic stress disorder. This discrepancy was confirmed during an interview with the Admissions Coordinator, who acknowledged that the PASRR did not include all current mental health diagnoses.
Failure to Monitor Blood Pressure Before Administering Hypotensive Medication
Penalty
Summary
The facility failed to ensure that a resident's blood pressure was monitored prior to the administration of hypotensive medication, as per the physician's order. The resident, who had a history of falls with subdural hematoma and craniotomy, cerebrovascular accident, hypotension, and hypertension, was prescribed midodrine, an anti-hypotensive medication, with specific parameters to hold the medication if the systolic blood pressure was greater than or equal to 150 mmHg. However, a review of the Medication Administration Record (MAR) showed that the medication was administered as ordered without evidence of the required blood pressure monitoring. This deficiency was confirmed during an interview with the Director of Nursing, who verified that the resident's blood pressure was not monitored prior to the administration of midodrine.
Incomplete Documentation of Resident Showers
Penalty
Summary
The facility failed to ensure that the medical records for two residents were complete and accurate, specifically regarding the documentation of showers provided. Resident #28, who has multiple diagnoses including malignant neoplasms and requires assistance with activities of daily living, had a care plan indicating showers were to be provided every Monday, Wednesday, and Friday night. However, the documentation from 01/12/25 to 02/12/25 showed only one shower was recorded as completed. Interviews with the Director of Nursing and CNAs revealed that showers were not consistently documented, and the transition from paper to electronic medical records contributed to this oversight. Similarly, Resident #8, who has diagnoses including diabetes mellitus and bipolar disorder, also required staff assistance with showers. The records indicated only one shower was documented in the prior 30 days, despite the resident expressing a preference for three showers a week. The Director of Nursing confirmed the lack of accurate documentation for showers provided to residents. The facility's shower policy requires documentation of each shower or refusal, but this was not adhered to, leading to incomplete records.
Failure to Conduct Antibiotic Use Assessments
Penalty
Summary
The facility failed to ensure that an assessment for proper indication of antibiotic use was completed prior to administering antibiotic medications to residents. This deficiency affected three residents out of five reviewed for medications, with a facility census of 42. The medical records of the affected residents revealed multiple instances of antibiotic use without documented assessments to determine the appropriate indication for their use. For example, Resident #7 was administered antibiotics such as doxycycline, Bactrim DS, cephalexin, and ciprofloxacin for various infections, but there was no evidence of any assessment completed to justify their use. Similarly, Resident #8 and Resident #10 were also given antibiotics for conditions like urinary tract infections, cellulitis, and pneumonia without documented assessments. The facility's infection preventionist, an LPN who started in December 2024, confirmed that no antibiotic assessments were completed for the affected residents during the specified dates. The facility's policy on the Antibiotic Stewardship Program, dated May 2024, required nurses to ensure that infections met the McGeer Guidelines by using the McGeer Criteria for Infection Surveillance Checklist. However, the previous infection preventionist and administrative nursing staff left no antibiotic assessments, leading to the deficiency. The LPN verified that the facility utilized the McGeer Criteria to determine appropriate use of antibiotics, but the required assessments were not conducted for the residents in question.
Failure to Offer Vaccines to New Admission
Penalty
Summary
The facility failed to ensure that a resident was offered influenza and pneumococcal vaccines after admission, affecting one of five residents reviewed for vaccines. The resident, who was admitted with diagnoses including diabetes mellitus, adjustment disorder with mixed anxiety and depressed mood, bipolar disorder, and post-traumatic stress disorder, had no evidence of vaccines administered or any declination documented in their medical record. An interview with an LPN revealed that the facility's policy was to offer vaccines annually, but it did not address new admissions after the annual vaccine clinic. The facility's policies for influenza and pneumococcal vaccines, both dated March 2021, lacked instructions for offering vaccines to new admissions.
Failure to Offer COVID-19 Vaccine to New Admission
Penalty
Summary
The facility failed to ensure that a resident was offered COVID-19 vaccines after admission, affecting one of five residents reviewed for vaccines. The resident, who was admitted with diagnoses including diabetes mellitus, adjustment disorder with mixed anxiety and depressed mood, bipolar disorder, and post-traumatic stress disorder, had no evidence of any vaccines administered, including COVID-19, in their medical record. Additionally, there was no documentation of any declination of the vaccine. The facility's policy on COVID-19 vaccination did not include instructions for offering or reviewing vaccines for new admissions after the annual vaccine clinic. An interview with an LPN confirmed that the resident was not reviewed or offered the COVID-19 vaccine following their admission.
Failure to Respond Timely to Call Lights
Penalty
Summary
The facility failed to ensure the timely response to residents' call lights, affecting four residents out of 41. Observations revealed that call lights were left unanswered for extended periods, with one resident's call light remaining activated for eight minutes while staff walked by without responding. Another resident's call light was not answered for 21 minutes. Interviews with residents confirmed that call lights were often not answered promptly, with reports of waiting times ranging from 30 minutes to an hour. One resident, who suffers from chronic pain, expressed the need to activate her call light in advance to manage her pain medication schedule due to anticipated delays. Staff interviews indicated confusion over assignments and a lack of responsiveness to call lights. An STNA reported uncertainty about unit assignments due to a missing assignment sheet, leading to staff moving between units. An LPN confirmed that the issue was not due to staffing shortages but rather staff ignoring call lights or refusing to provide care to certain residents. The Director of Nursing acknowledged the ongoing issue of untimely responses to call lights, attributing it to staff congregating in one area rather than a lack of staff, as the facility had adequate staffing levels on the day of observation.
Failure to Honor Resident Bathing Preferences
Penalty
Summary
The facility failed to honor the bathing preferences of three residents who were dependent on staff for assistance with activities of daily living. Resident #9, who was paraplegic and had multiple medical conditions, reported never having received a shower since her admission, despite her preference for one. The Director of Nursing (DON) confirmed the absence of documented evidence that Resident #9 received showers as per her preference. Similarly, Resident #22, who had hemiplegia and other significant health issues, was scheduled for showers on specific days, but the records did not specify the type of bath received, and the DON confirmed the lack of documentation for the scheduled showers. Resident #22's wife also expressed concerns about the care provided due to her husband's inappropriate behaviors. Resident #43, who had a history of cerebral infarctions and other health issues, was also dependent on staff for bathing. The records indicated that the resident received some form of bath on certain dates, but the type of bath was not specified, and the DON confirmed the lack of documentation for the resident's shower preferences. Interviews with State Tested Nurse's Aides (STNAs) and a Licensed Practical Nurse (LPN) revealed that resident bathing preferences were not being honored due to time constraints, with staff reporting insufficient time to complete scheduled showers. This deficiency was investigated under Complaint Number OH00157827.
Failure to Ensure Proper Training for Nursing Assistants
Penalty
Summary
The facility failed to ensure that nursing assistants received the required training before providing direct care to residents, potentially affecting all 46 residents. Employee #145, a nurse aide in training, had not started formal training classes but was performing duties equivalent to a state-tested nursing assistant, including helping with meals, providing showers, and incontinence care. Despite having previous experience in a group home, Employee #145 had not received dementia training or training on handling aggressive behaviors. The Human Resource employee confirmed that Employee #145 was not enrolled in classes and was functioning as a state-tested nursing assistant based on the Administrator's instructions. Additionally, the facility hired several nursing assistants who were not on the nurse aide registry at the time of hire and were not enrolled in nurse aide registry classes or nursing school. These employees, including STNA #155, STNA #120, and STNA #110, had their skills checked off on orientation checklists despite not being registered or enrolled in training programs. The Human Resource employee verified that the facility believed they had four months to enroll aides in classes, and some employees had worked longer than four months without being enrolled in the NATCEP program, as the Administrator decided the timing of enrollment.
Deficiencies in Record-Keeping and Elopement Investigation
Penalty
Summary
The facility failed to maintain secure and accessible records, specifically infection control surveillance logs, which were not available since February 2024. The previous Director of Nursing (DON) had kept these records on her personal devices, and upon her departure, the records were not retrievable. The current staff, including the Administrator and RN #100, were unable to locate any documentation or evaluations of infection data, indicating a lack of proper record-keeping and oversight. Additionally, the facility did not adequately investigate incidents of elopement involving a resident who left the facility on two occasions. The staff could not find any investigation or witness statements regarding these incidents. The Administrator believed the previous DON had handled the situation, but no follow-up was conducted. An inspection revealed that the door alarm system was not functioning properly, as no sound was heard when the door was opened, and the Administrator could not verify when the alarm was last checked or monitored.
Infection Control and PPE Deficiencies
Penalty
Summary
The facility failed to maintain proper infection control surveillance and implement appropriate hand hygiene and use of personal protective equipment (PPE) during care procedures, affecting two residents and potentially impacting all residents. During an entrance conference, the Administrator was unable to provide infection control surveillance logs for the past three months, as the previous infection control preventionist, RN #200, had left the facility and deleted records from her personal device. RN #100 attempted to gather information from other sources but could not find records beyond February 2024, and there was no evidence of trend evaluation or action taken based on infection data. During medication administration, an LPN dropped pills on a cart and used bare hands to pick up some of them before administering the medication to a resident. This action was acknowledged as inappropriate by the LPN. Additionally, another LPN failed to perform hand hygiene and did not don a gown while administering a water flush through a resident's PEG tube, despite the facility's policy requiring enhanced barrier precautions for such procedures. The LPN confirmed that her typical practice did not include wearing a gown for feeding tube care. The facility's policies on hand hygiene and enhanced barrier precautions were not followed, as evidenced by the observations of staff not washing hands before direct resident care and not wearing gowns during high-contact activities. These deficiencies were identified during a survey and were part of a complaint investigation, highlighting non-compliance with infection control standards.
Lack of Qualified Infection Preventionist
Penalty
Summary
The facility failed to ensure that a qualified individual was designated as the Infection Preventionist (IP) responsible for the infection prevention and control program. During the entrance conference, the Administrator reported that the Director of Nursing (DON), who was also assigned as the facility's IP, had their last day of employment on 05/15/24. Subsequently, on 05/21/24, a Registered Nurse (RN) confirmed that no other staff member had completed the specialized training required to serve as the IP. This deficiency had the potential to affect all 46 residents in the facility.
Inconsistent Implementation of Restorative Nursing Programs
Penalty
Summary
The facility failed to provide restorative nursing services as per program instructions to maintain the range of motion for four residents. Resident #10, diagnosed with conditions such as COPD, diabetes, and heart disease, was on a restorative nursing program for bilateral lower extremity active range of motion. However, the program was not consistently offered or documented, with records showing minimal engagement and no refusals documented. Resident #10 confirmed that staff rarely offered the ROM exercise program. Resident #9, with diagnoses including heart disease and dementia, was on an active range of motion program for the right shoulder. The program required cues and encouragement from staff, but records indicated inconsistent implementation, with only one day showing the program was conducted twice as required. Resident #9 expressed that STNAs did not consistently perform the exercise program, except during therapy sessions. Resident #2, diagnosed with COPD and osteoarthritis, was on a restorative program for both lower extremities and transfers. The program was not implemented as written, with records showing limited engagement. Similarly, Resident #42, with dementia and Alzheimer's, was on a passive range of motion and transfer program, which was also inconsistently provided. Restorative Aide #175 reported being frequently reassigned to floor duties, impacting her ability to perform restorative programs, and noted that other aides did not take responsibility for these programs.
Failure to Act on Pharmacy Recommendations for Medication Use
Penalty
Summary
The facility failed to ensure timely action on pharmacy recommendations for medication use, affecting four residents. Resident #13's medical record lacked a diagnosis to justify the use of risperidone, an antipsychotic medication, despite being prescribed for behaviors. The pharmacy review indicated the need for a diagnosis, but no physician response was documented. Resident #13 was under psychiatric care, but there was no documentation supporting the use of risperidone or its benefits outweighing the risks. Resident #40 was prescribed synthroid for hypothyroidism, but no Thyroid Stimulating Hormone (TSH) level was scheduled or obtained since the pharmacy recommendation. Resident #34, with diabetes and severe dementia, was receiving insulin without an A1c level scheduled, as noted in the pharmacy review. Similarly, Resident #10, also on insulin, had no A1c level scheduled since the pharmacy recommendation. The facility's RN was unable to locate pharmacy reviews for the past six months, leading to unaddressed recommendations and missing lab orders.
Improper Medication Labeling and Storage
Penalty
Summary
The facility failed to ensure proper labeling and storage of medications, affecting five residents. During an observation of the medication cart, it was found that a resident had two bottles of opened Humalog insulin without a date indicating when they were opened. The nurse stated that the insulin vials were transferred with the resident from another facility, and she was unaware of how long they had been opened. According to Medscape, open vials of Humalog insulin can be used for up to 28 days. Another resident had an earwax removal solution that was opened and labeled for a limited time, but it was not discarded after the order was fulfilled. Additionally, an inhaler was found in the medication cart with only the last name of a resident and no label, as the box with the label was sent with the resident upon discharge. Furthermore, during another observation, it was verified that several residents' topical creams were stored with oral medications, contrary to the facility's policy. The nurse confirmed that creams should be stored in the treatment cart, not with medications. This deficiency was investigated under a specific complaint number.
Inaccurate Medical Records and Documentation Issues
Penalty
Summary
The facility failed to ensure the accuracy and completeness of medical records, affecting three known residents and potentially impacting all residents. For Resident #18, there was a lack of documentation regarding an incident where the resident was found outside without supervision, despite having a wander guard. Additionally, there were inconsistencies in documenting bathing and bladder care, with several days lacking entries. Interviews with staff suggested these were documentation issues rather than failures in care. The report also highlighted issues with medication administration documentation. An LPN mentioned hearing about day shift nurses administering night shift medications, which was corroborated by an RN who admitted to signing off on medications she did not administer. This practice was against the facility's Medication Administration policy, which requires nurses to sign the Medication Administration Record (MAR) only after administering medications. For Resident #47, there was a lack of documentation for bathing and toileting assistance during the last 30 days of their stay. Despite having orders for hourly incontinence checks, records were incomplete, and there was no documentation of bathing for extended periods. Interviews with staff indicated these were believed to be documentation issues, but the records did not specify the type of care provided. This deficiency was part of a broader investigation under specific complaint numbers.
Failure to Implement Stop Sign for Resident's Room
Penalty
Summary
The facility failed to implement a stop sign across a resident's room to deter wandering residents from entering, affecting a resident with dementia and cognitive communication deficit. The care plan for this resident, initiated in January 2014, included the use of a stop sign to prevent wandering residents from entering her room. Despite the care plan's directive, observations on multiple occasions revealed that the stop sign was not properly positioned across the door. The resident was assessed as severely cognitively impaired but was able to make herself understood and understand others. On several occasions, the stop sign was observed not being used as intended. Staff members, including a State Tested Nursing Assistant and a Licensed Practical Nurse, acknowledged the purpose of the stop sign but did not ensure it was in place. The stop sign was initially implemented to prevent another resident, who no longer resided at the facility, from entering the room. However, another wandering resident was present in the facility, yet the stop sign was still not consistently used. Staff members, including three unidentified staff and an LPN, passed by the room without addressing the stop sign's placement.
Failure to Notify Family and Physician of Resident Elopement
Penalty
Summary
The facility failed to notify the family and physician of Resident #18 when she was found outside the facility unaccompanied by staff. Resident #18, who had a history of wandering and was assessed as a high risk for elopement, was discovered outside the building by housekeeping staff. Despite being found without injuries, there was no documentation of notification to the resident's family or physician, as required by the facility's elopement policy. Resident #18 had multiple diagnoses, including dementia with agitation and major depressive disorder, and was assessed as severely cognitively impaired. The incident report from the night of the event indicated that the resident was confused about place and time, yet ambulatory without assistance. The responsible RN on duty did not recall notifying the physician or family, although the administrator was informed via text. The lack of documentation and notification represents a deficiency in the facility's adherence to its policies.
Failure to Complete Neurological Checks After Falls
Penalty
Summary
The facility failed to ensure that neurological checks were completed after unwitnessed falls for a resident with a history of falling and multiple medical conditions, including right-sided paralysis and hypertension. The resident experienced several falls, and the facility's protocol required neurological checks to be conducted following such incidents. However, the documentation revealed that these checks were either not initiated or not completed as required. For instance, after a fall on January 19, 2024, neurological checks were only documented between 6:00 P.M. and 7:00 P.M., failing to meet the 72-hour monitoring requirement. Further incidents on February 19, 2024, and May 2, 2024, also showed deficiencies in the completion of neurological checks. On February 19, checks were initiated but not continued for the full 72 hours, and on May 2, there was no record of checks being initiated at all. These lapses in following the facility's post-fall monitoring protocol indicate a failure to provide appropriate treatment and care according to the resident's needs and the physician's orders.
Failure to Implement Elopement and Fall Prevention Measures
Penalty
Summary
The facility failed to implement effective elopement interventions and ensure the proper functioning of wanderguards and exit doors, affecting two residents. Resident #18, diagnosed with dementia and other conditions, was assessed as a high risk for wandering but lacked a care plan or interventions until after multiple elopement incidents. Despite being identified as a high risk in December 2023, no documented actions were taken until March 2024, when Resident #18 was found outside the facility twice. The facility's failure to monitor the wanderguard's functionality and the exit doors' alarms contributed to these incidents. Additionally, the facility did not maintain a comprehensive fall prevention program for Resident #13, who had a history of falls and was at high risk. Despite physician orders for the bed to remain in the lowest position, observations revealed the bed was often raised, increasing the risk of falls. Multiple falls occurred without post-fall evaluations or new interventions being implemented. The facility's lack of consistent monitoring and intervention for Resident #13's fall risk was evident in repeated incidents, including a fall in the bathroom where the resident was left unattended. The facility's policies on elopement and fall prevention were not effectively implemented, as evidenced by the lack of documentation, investigation, and monitoring of interventions for both residents. The absence of a coordinated response to the identified risks and the failure to ensure the functionality of safety devices contributed to the deficiencies noted in the report.
Inadequate Indication for Psychotropic Medication Use
Penalty
Summary
The facility failed to ensure that a resident had adequate indications for the use of a psychotropic medication, specifically risperidone. The medical record review revealed that the resident had multiple diagnoses, including hemiplegia, rhabdomyolysis, heart failure, and dementia, among others. A physician had ordered risperidone for the resident, but the Registered Nurse (RN) confirmed that dementia was not an acceptable indication for its use. The RN also noted that a gradual dose reduction had been attempted unsuccessfully, but there was no documentation to justify the continued use of risperidone, indicating that the benefits outweighed the risks. Further review of risperidone information on Medscape highlighted a black box warning against its use in elderly residents with dementia-related psychosis due to an increased risk of death, primarily from cardiovascular or infectious causes. Additionally, the risk of orthostatic hypotension was noted to be higher in the elderly with the use of risperidone. This deficiency affected one resident out of five whose medications were reviewed, in a facility with a census of 46.
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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