Summit Acres Nursing Home
Inspection history, citations, penalties and survey trends for this long-term care facility in Caldwell, Ohio.
- Location
- 44565 Sunset Road, Caldwell, Ohio 43724
- CMS Provider Number
- 365612
- Inspections on file
- 41
- Latest survey
- March 19, 2026
- Citations (last 12 mo.)
- 3
Citation history
Health deficiencies cited at Summit Acres Nursing Home during CMS and state inspections, most recent first.
Surveyors identified widespread environmental deficiencies, including a persistent musty/mildew odor in a main hallway, dust and debris along hallway edges, and trash and disposable items on floors in some resident rooms. Multiple hallways and units had chipped and peeled paint where tape had been used to hang items, with some areas poorly repainted in mismatched colors, and numerous doors and door jambs were scuffed and scraped. One resident’s shared bathroom was found with an overfilled trash can containing an incontinent brief, floor debris, a towel placed under a raised toilet seat, dried residue on the floor, and feces splatter on the raised seat and inside the commode. Housekeeping was limited to two day-shift staff with no evening or night coverage; while a housekeeper felt staffing was adequate, a CNA, an RN, and the Maintenance Director reported that housekeeping struggled to keep up, with some residents stating their rooms had not been cleaned for weeks. The Maintenance Director also acknowledged a roof leak near the hallway with the musty odor and recognized the need for cleaning and repair of walls, doors, and FRP surfaces.
Two residents experienced verbal abuse from staff, including a CNA who repeatedly argued with and upset a resident with chronic pain, and a Dietary Coordinator who yelled and used profanity toward another resident during a dispute over a meal. Staff and resident interviews confirmed that both residents were subjected to unprofessional and disrespectful conduct, contrary to facility policy.
A facility failed to conduct a thorough investigation into an alleged verbal abuse incident involving a resident with muscle dystrophy and intact cognition. The incident involved a verbal altercation with a Dietary Coordinator, who used profanity in the presence of other residents and family members. The facility's investigation did not include interviews with additional residents or family members who may have witnessed the event, resulting in an incomplete investigation as required by policy.
The facility did not document all infections on its tracking log, failed to identify a pattern of MRSA infections, and did not provide staff education on infection control. A resident with a UTI was not included on the infection log, and another resident with open wounds did not receive care under enhanced barrier precautions, with staff not using required PPE during wound care. These lapses affected multiple residents and had the potential to impact the entire facility.
A resident with severe cognitive impairment was spoken to disrespectfully and forcefully guided to her room by a CNA, while two other residents were fed in bed by CNAs who stood over them rather than sitting at eye level, contrary to facility policy. Staff interviews confirmed these actions were not in line with promoting resident dignity.
A resident dependent on staff for incontinence care experienced neglect when a CNA repeatedly failed to provide timely assistance, turned off call lights without delivering care, and left the resident in a saturated brief. Multiple staff observed this CNA neglecting several residents, failing to respond to call lights, and spending extended periods away from her duties. The facility's investigation did not include interviews or assessments of all potentially affected residents or staff, contrary to policy requirements.
A resident with multiple psychiatric and medical diagnoses, including PTSD and bipolar disorder, was not accurately assessed on the MDS 3.0, as these diagnoses were omitted despite the resident receiving psychotropic medications and reporting ongoing symptoms. The MDS nurse initially failed to code these diagnoses, believing they were not active or medicated, but later confirmed the assessment was inaccurate after review.
A resident with multiple mental health diagnoses, including PTSD, was admitted without accurate completion of the PASARR screening. The PASARR form failed to document the PTSD diagnosis and did not list prescribed psychotropic medications, as confirmed by facility staff interviews.
Three residents did not receive care in accordance with their assessed needs: one did not receive dental services or denture replacement despite documented need and consent; another, at risk for pressure ulcers, did not have required heel offloading interventions implemented; and a third, with a PTSD diagnosis, lacked a care plan addressing trauma-informed care due to incomplete assessment and staff unawareness.
The facility did not timely update care plans to reflect changes in residents' dental status and non-compliance with skin impairment interventions, and failed to conduct care conferences following significant change MDS assessments. Staff were unaware of current resident conditions, and required care plan revisions and care conferences were not completed as per facility policy.
A resident with multiple comorbidities and high dependence on staff developed skin tears and painful calluses on both heels. The facility did not promptly assess, document, or treat a skin tear on the right arm, and failed to monitor or record the development of calluses, despite the resident and family expressing concerns. Facility policy did not require documentation of wound assessments, contributing to the deficiency.
A resident with hemiplegia and limited ROM did not receive timely contracture management after occupational therapy was discontinued without a restorative nursing program in place. Although a palm guard was ordered and eventually received, therapy did not reevaluate the resident, resulting in a lapse in appropriate care.
A resident dependent on hemodialysis did not have consistent or complete communication between the facility and the dialysis center, as required by facility policy. Over a 30-day period, documentation from the dialysis center was missing or incomplete for more than half of the resident's dialysis treatments, and staff reported frequent issues obtaining necessary treatment information.
A resident with PTSD and multiple comorbidities did not receive trauma-informed care, as the facility failed to complete a trauma-informed care observation on admission and did not include PTSD-related interventions in the care plan. The resident continued to experience triggers and flashbacks, and staff were unaware of the PTSD diagnosis due to the missing assessment.
A resident with anxiety and depression did not consistently receive scheduled doses of Xanax on time, with 20 out of 82 doses administered late over a three-week period. The resident reported increased anxiety due to the inconsistent timing, and an LPN confirmed delays in administration, citing unfamiliarity with the unit and workload. Facility policy required medications to be given within 60 minutes of the scheduled time, but this was not followed.
A resident with iron deficiency anemia and other conditions continued to receive ferrous sulfate despite a pharmacy recommendation and physician agreement to discontinue the medication after a normal CBC. Miscommunication and misinterpretation between the physician and DON led to the ongoing administration of the unnecessary drug.
Surveyors found that opened insulin pens for three residents were not dated when opened, as confirmed by an LPN and an RN during interviews. Facility policy requires nurses to label medications with the date opened, but this procedure was not followed for the insulin pens observed in two medication carts.
A resident with significant medical needs and a broken lower denture, who had consented to receive dental services, did not receive any dental care or evaluation during their stay. The facility's records showed no evidence of dental visits or attempts to arrange for denture replacement, and staff interviews confirmed a lack of awareness and action regarding the resident's dental needs.
Two residents were treated with antibiotics for UTIs without meeting established clinical criteria, as documented in the infection control log. In both cases, antibiotics were continued despite the absence of urinalysis or culture to confirm infection, and the DON confirmed that the nurse practitioner instructed staff to continue the antibiotics even after it was determined that criteria were not met.
Two residents did not receive timely assistance with incontinence and nail care. One resident with severe cognitive impairment was left in urine-soaked clothing for extended periods, despite staff protocols for regular checks. Another resident, dependent on staff for personal hygiene, had a broken fingernail and dirty nails for several days before staff addressed the issue.
Multiple residents at risk for or with pressure ulcers did not receive consistent or comprehensive pressure ulcer prevention and care. One resident's Stage III heel ulcer was not fully assessed in weekly documentation, another resident did not have prescribed heel offloading interventions implemented, and a third resident did not consistently receive required pressure-relieving devices in bed or chair. Staff interviews and observations confirmed lapses in following care plans and facility policy.
The facility failed to protect a resident from sexual abuse by a CNA who allowed inappropriate touching, and another resident from neglect, who was left on a bedpan for 14 hours, resulting in skin breakdown. Despite reports to the Administrator, no immediate action was taken, and the facility's investigation did not adequately address the neglect. The facility's policy on abuse and neglect was not effectively implemented.
The facility failed to report allegations of staff-to-resident sexual abuse and resident neglect to the State survey agency. One resident was reportedly allowed by a CNA to engage in inappropriate touching, which was not properly investigated or reported by the Administrator. Another resident was left on a bedpan for an extended period, resulting in skin breakdown, but this neglect was not reported to the State. The facility's internal investigation focused on the resulting pressure ulcer rather than the neglect itself.
A facility failed to investigate an allegation of sexually inappropriate behavior between a resident with dementia and a CNA. The resident, known for inappropriate touching, allegedly fondled the CNA's breasts, which she allowed, rationalizing it as excitement for the resident. Despite multiple staff reports, the Administrator did not conduct a thorough investigation or report the incident, violating the facility's abuse policy.
A resident with dementia and impaired mobility was left on a bedpan for approximately 14 hours, leading to the development of pressure ulcers. Despite being at risk for skin breakdown, the resident's care plan for frequent turning and incontinence care was not followed. Staff interviews revealed a failure to adhere to the facility's policy of checking and changing residents every two hours, resulting in the progression of a Stage I pressure ulcer to Stage II.
Three residents in an LTC facility did not receive showers per their preferences due to staff shortages and scheduling issues. One resident, with end-stage renal disease, had only two bed baths in three weeks. Another resident, with multiple fractures, received only a few showers over two months, despite being scheduled for three times a week. A third resident, dependent on oxygen, reported staff often failed to return for scheduled showers. Documentation inconsistencies and inaccurate audits were noted.
A resident with severe cognitive impairment and a history of wandering exited a secured unit unsupervised after being mistaken for a visitor by staff members. Despite being identified as an elopement risk, the resident was allowed to leave the facility by a cook, an LPN, and a receptionist who did not recognize him. The resident was later found outside with injuries, including a skin tear and bruising. The incident was compounded by the absence of a care plan addressing the resident's elopement risk, despite documented attempts to exit the building. Staff confusion and lack of proper identification protocols contributed to the breach in supervision.
The facility failed to accommodate a family's request to install an electronic monitoring device in a resident's room due to high installation costs and specific corporate policies. The resident had multiple diagnoses, including dementia, and the family was concerned about overmedication. Despite the request, no camera was installed, and the family decided not to pursue it due to the expense.
The facility failed to ensure the confidentiality of a resident's medical record. A computer monitor on a medication cart was observed displaying the resident's confidential health information without any staff member present. The Regional DON confirmed the breach and locked the screen. The facility's policy emphasizes the protection of clinical information in compliance with HIPAA requirements.
A resident with Alzheimer's disease eloped from a secure unit due to staff mistaking them for a visitor. The resident exited the facility, fell, and sustained minor injuries. The facility's investigation was incomplete, with key details missing and safety measures not followed.
The facility failed to provide necessary assistance with showers and nail care to residents dependent on staff, affecting their personal hygiene and well-being. Despite scheduled bathing times, residents did not receive regular showers, and their nails were not properly trimmed, indicating non-compliance with the facility's care policies.
A facility failed to ensure a resident with cerebral palsy and diabetes was seen by an audiologist despite family requests and documented hearing concerns. The resident's care plan did not specifically address hearing issues, and there was no evidence of an audiology consult in the medical record. The resident was not seen during two visits by the facility's contracted audiologist, and an appointment was only made after the deficiency was identified.
A resident with diabetes did not receive routine foot care, leading to an infection and ingrown toenail. The resident's last podiatry exam was several months prior, and two subsequent appointments were canceled. Staff interviews confirmed the resident should have been seen every nine to ten weeks.
A facility failed to ensure a resident's CPAP mask was properly cleaned, despite the resident's diagnoses requiring its use. Observation and staff interviews confirmed the presence of dried substances on the mask and a lack of proper cleaning documentation, contrary to manufacturer instructions.
The facility failed to implement physician orders for a gradual dose reduction of Zyprexa and did not document a rationale for extending the PRN use of Xanax beyond 14 days for a resident with dementia, alcohol abuse, and anxiety disorder. These deficiencies were confirmed by the Regional Nurse Consultant during a review.
Environmental Sanitation and Maintenance Deficiencies Throughout Facility
Penalty
Summary
The deficiency involves the facility’s failure to maintain a sanitary, clean, and homelike environment throughout the building, affecting all resident care areas. During an environmental tour of all four units, surveyors noted a distinct musty/mildew odor in the hallway connecting the independent living section to Home B Short hall, despite no visible mold, mildew, or recent water damage. The building appeared older and outdated, with vinyl wood-look flooring and FRP boarding on the lower half of the walls. Dust and debris were observed along the edge of the wall on Home B Long near a resident room, and debris such as wrappers, paper, and disposable gloves were seen on floors in some resident rooms, indicating inadequate routine cleaning. Surveyors observed multiple areas of chipped and peeled paint throughout the facility. On Home B Long, chipped paint was noted outside several resident rooms where adhesive tape had been applied and removed, leaving white areas that did not match the rest of the wall. Some of these areas had been painted over without patching and with a different color paint, resulting in a mismatched appearance. Similar peeled or chipped paint was observed outside rooms on Unit 1, Unit 2, and the secured memory care unit, including areas where tape removal had stripped paint and around a wall-mounted computer near the dining/lounge area. Multiple door jambs and doors were scuffed and scraped and in need of repainting, and the FRP boarding on Home B halls was noted to have scuff marks that required cleaning. In a resident-specific observation, a shared bathroom used by one resident was found to be unclean. The trash can was overfilled, with an incontinent brief protruding over the top, and a toilet paper roll wrapper was on the floor next to the trash can. A folded towel was on the floor under the front leg of a raised toilet seat, with unclear purpose, and dried white sediment was visible on the floor in front of and to the right of the toilet. The raised toilet seat and inside of the commode had feces splatter all around them. The resident reported that housekeeping staff swept and mopped her room about once a week and felt that was enough to keep things tidy. Staff interviews revealed differing views on housekeeping adequacy: a housekeeper stated there were typically two housekeepers on day shift only and felt staffing was adequate, while the Maintenance Director, a CNA, and an RN all indicated that housekeeping struggled to keep up, that there were not enough housekeepers, and that residents sometimes reported their rooms had not been cleaned for a couple of weeks. The Maintenance Director also acknowledged ongoing roof leak issues near the area with the musty odor and recognized the need for wall and door repairs and cleaning, but these environmental issues remained uncorrected at the time of the follow-up observation.
Failure to Protect Residents from Verbal Abuse by Staff
Penalty
Summary
The facility failed to ensure that residents were free from verbal abuse, as evidenced by incidents involving two residents. In the first case, a resident with a diagnosis of malignant neoplasm of the brain and chronic pain reported repeated upsetting interactions with a CNA. The resident stated that the CNA would enter her room multiple times, engage in arguments, and make statements such as questioning if the resident's brain was working. Witness statements from staff corroborated that the resident became visibly upset and was shaking after these encounters. The CNA admitted to explaining medication schedules to the resident but denied any intent to antagonize her, while other staff intervened to remove the CNA from the situation when the resident became distressed. In the second case, a resident with autosomal dominant limb girdle muscle dystrophy and intact cognition was involved in a verbal altercation with the Dietary Coordinator (DC). The DC was reported to have yelled and used profanity towards the resident after the resident insulted her regarding a missing lunch tray. Multiple staff witnesses confirmed hearing the DC use profane language both in the resident's room and in common areas, with the DC admitting to telling the resident to "shut up" after reaching her "boiling point." The resident later confirmed being very angry at being told to "shut the f*ck up" by a staff member, although he stated he was "over it" at the time of interview. Facility policy review indicated that residents are to be treated with respect, kindness, and dignity, and that abuse, including verbal abuse, is not tolerated. Despite investigations determining that there was no willful intent to harm in either case, the actions and statements of staff members resulted in residents experiencing distress and being subjected to unprofessional conduct. The deficiency was substantiated based on direct observations, resident and staff interviews, and review of facility documentation.
Failure to Thoroughly Investigate Alleged Verbal Abuse Incident
Penalty
Summary
The facility failed to thoroughly investigate an allegation of verbal abuse involving a resident with autosomal dominant limb girdle muscle dystrophy and intact cognition. The incident began when the resident complained about a missing lunch tray, leading to a verbal altercation with the Dietary Coordinator (DC). Witnesses reported that both the resident and the DC exchanged profanities, with the DC telling the resident to "shut up" and continuing to use profanity while walking through the hallway, where other residents and family members were present. The facility's investigation concluded that the allegation of verbal abuse was unsubstantiated due to a lack of willful intent to harm the resident, although the DC was terminated for unprofessional conduct. However, the investigation did not include interviews with additional residents or family members who may have witnessed the DC's behavior in the hallway and dining area, despite staff statements indicating their presence during the incident. The investigation relied primarily on statements from staff directly involved or present during the altercation. Facility policy requires that all allegations of abuse be thoroughly investigated, including interviews with the resident, the accused, all witnesses, and potentially other residents and staff who may have been in close contact or present during the incident. In this case, the failure to interview additional residents or family members who were in the vicinity of the incident resulted in an incomplete investigation, as required by facility policy.
Failure to Track Infections, Identify Trends, and Implement Enhanced Barrier Precautions
Penalty
Summary
The facility failed to ensure comprehensive infection prevention and control practices were implemented and maintained. Specifically, the infection control tracking log for one unit in March 2025 did not include all infections that occurred, and the Infection Preventionist did not identify or act upon a trend of Methicillin-Resistant Staphylococcus Aureus (MRSA) infections. Three out of five infections on the unit involved MRSA, all of which were healthcare-associated, but the DON did not recognize this as a trend or provide staff education on hand hygiene, wound care, or contact isolation precautions, despite facility policy requiring tracking and trending of infections. Additionally, a resident with a urinary tract infection (UTI) was treated with antibiotics after a positive urine culture for proteus mirabilis, but this infection was not documented on the infection control log. The DON confirmed the omission during an interview, acknowledging that the infection should have been recorded according to facility procedures. Furthermore, another resident with open wounds on the buttocks did not have a care plan for enhanced barrier precautions, and staff did not follow CDC-recommended enhanced barrier precautions during wound care. Observation confirmed that gloves and gowns were not used during high-contact care activities, contrary to both facility policy and CDC guidance. These failures had the potential to affect all residents in the facility, which had a census of 84 at the time.
Failure to Ensure Resident Dignity During Care and Meal Assistance
Penalty
Summary
The facility failed to honor residents' rights to dignity and respect in multiple instances. One resident with severe cognitive impairment and a history of behavioral symptoms was subjected to undignified treatment by a CNA, who was observed forcefully guiding the resident out of another room, telling her to "stay in your damn room," and slamming the door. This incident was witnessed by other staff, and interviews confirmed that the language and manner used were not respectful or dignified, regardless of the resident's cognitive status. Additionally, two residents were not provided with a dignified dining experience during meal assistance. Certified Nursing Assistants were observed standing over these residents while feeding them in bed, rather than sitting at eye level as required by facility policy. The CNAs admitted that standing was for their own convenience and not for the benefit of the residents. They also acknowledged that they had not been trained to sit while feeding and recognized that standing over residents during feeding is a dignity issue. The facility's own policy specifies that staff should be seated next to residents and engage with them during meals to promote dignity. The observations and staff interviews confirmed that this policy was not followed, resulting in a failure to provide a dignified environment for the affected residents.
Failure to Prevent and Investigate Resident Neglect
Penalty
Summary
A resident with multiple medical conditions, including cardiac arrhythmia, heart failure, muscle weakness, and reduced mobility, was dependent on staff for all activities of daily living, including toileting and personal hygiene. The resident was always incontinent of urine and bowel and required two-person assistance for transfers and incontinence care. On the date in question, the resident reported that his call light was not answered in a timely manner, and when a staff member did respond, she turned off the call light without providing the requested incontinence care, stating she would return but did not. The resident had to activate his call light multiple times before eventually receiving care from other staff members, by which time his incontinence brief was saturated and nearly disintegrated. Multiple staff statements corroborated that the agency CNA assigned to the resident's unit repeatedly failed to respond to call lights, turned off call lights without providing care, and spent extended periods away from her assigned duties, including being outside and in the activity room. Other CNAs reported that this staff member neglected not only the resident in question but also other residents on the unit, resulting in unmet care needs and emotional distress. One resident was reportedly dropped during a transfer, and several residents were left without proper nighttime care due to the lack of assistance from the agency CNA. The facility's investigation was incomplete, as it focused solely on the initial resident who reported neglect and did not include interviews or assessments of other potentially affected residents or all staff involved. The LPN on duty was informed of the concerns late in the shift but did not address them with the agency CNA or review the written statements provided by staff. The facility's policy required thorough investigation of all allegations of neglect, including interviewing all involved parties and assessing all potentially affected residents, but these steps were not fully carried out.
Inaccurate MDS Assessment for Resident with Psychiatric Diagnoses
Penalty
Summary
The facility failed to ensure an accurate Minimum Data Set (MDS) 3.0 assessment for one resident. The resident, who had a history of acute and chronic respiratory failure with hypoxia, type 2 diabetes, bipolar disorder, depression, PTSD, adjustment disorder with depressed mood, and ADHD, reported ongoing PTSD symptoms including nightmares, paranoia, and flashbacks. During interviews, the resident stated that staff had not questioned her about her PTSD. Review of her comprehensive MDS assessment showed that PTSD and bipolar disorder were not identified as diagnoses. The MDS nurse explained that these diagnoses were not coded because the resident was not believed to be on medications for them and only active diagnoses with medications are coded. However, review of physician's orders confirmed the resident was receiving psychotropic medications, including Cymbalta and Zoloft, as well as Melatonin. The MDS nurse later confirmed the assessment was not accurate.
Incomplete PASARR Documentation for Mental Health Diagnoses
Penalty
Summary
The facility failed to ensure that the Preadmission Screening and Resident Review (PASARR) was completed accurately for one resident upon admission. Medical record review showed that the resident had multiple diagnoses, including acute and chronic respiratory failure, type 2 diabetes, bipolar disorder, depression, post-traumatic stress disorder (PTSD), adjustment disorder with depressed mood, and attention-deficit hyperactivity disorder. However, the PASARR form did not include the diagnosis of PTSD or identify the psychotropic medications prescribed to the resident. This omission was confirmed during interviews with the social worker and the regional director of social services and activities, both of whom verified that the PASARR was inaccurate and incomplete regarding the resident's PTSD diagnosis and psychotropic medication use.
Failure to Implement and Develop Comprehensive Care Plans for Dental, Skin, and PTSD Needs
Penalty
Summary
The facility failed to provide necessary dental services to a resident who was admitted with moderate protein-calorie malnutrition, stroke history, failure to thrive, and legal blindness. Despite being covered under Medicaid and having a care plan that included dental evaluation and treatment, there was no evidence in the medical record that the resident had been seen by a dentist since admission. The resident expressed interest in obtaining new dentures, as his lower dentures were broken and not present at the facility, but no attempts to arrange dental services or replace the dentures were documented. Staff interviews confirmed a lack of awareness regarding the resident's denture status and the absence of dental care provided. Another resident, with a history of stroke, muscle weakness, and impaired mobility, was identified as being at risk for pressure ulcers. The care plan included interventions to offload the resident's heels to prevent skin breakdown. However, multiple observations revealed that the resident's heels were not offloaded while in bed, and no pillows or devices were used for this purpose. Staff interviews indicated a lack of implementation of the care plan intervention, with CNAs unaware or not following the directive to offload the resident's heels, despite having access to the care plan instructions. A third resident, admitted with multiple diagnoses including PTSD, did not have a care plan or interventions addressing PTSD, despite facility policy requiring trauma-informed care planning. The social worker confirmed that a trauma-informed care observation was not completed upon the resident's readmission, and the diagnosis of PTSD was not addressed in the care plan. This omission was attributed to a lack of awareness of the resident's diagnosis at the time of readmission.
Failure to Timely Update Care Plans and Conduct Care Conferences
Penalty
Summary
The facility failed to ensure timely completion of care conferences following significant change Minimum Data Set (MDS) assessments and did not revise care plans to accurately reflect residents' current conditions and interventions. For one resident, the care plan was not updated to reflect the acquisition and use of dentures, despite dental consults and the resident's own report confirming full upper and lower dentures. Staff interviews revealed confusion about the resident's dental status, with some staff unaware of the presence of dentures, and the care plan still indicating the resident was edentulous. Another resident experienced a significant change in condition, as documented by a completed MDS assessment, but there was no evidence that a care conference was held in a timely manner. The only care conference on record was the initial one completed at admission, with no subsequent conferences documented until a month after the significant change assessment. The facility's own policy requires care conferences to be held quarterly or upon significant changes, but this was not followed. Additionally, a third resident with a history of multiple skin tears had a care plan that included the use of geri-sleeves as an intervention. However, the resident was observed without geri-sleeves, and staff reported that the resident refused the intervention, leading to its removal from charting. Despite this, the care plan was not revised to address the resident's non-compliance with the intervention, and there was no documentation of alternative measures or updates to the care plan to reflect the resident's current status.
Failure to Assess and Treat Skin Integrity Concerns
Penalty
Summary
The facility failed to comprehensively assess and provide appropriate treatment for a resident with multiple skin integrity concerns. The resident, who had a history of cardiac arrhythmia, heart failure, reduced mobility, and was dependent on staff for most activities of daily living, experienced several skin tears and the development of calluses on both heels. Documentation showed that a skin tear to the left arm was promptly treated and recorded, but a skin tear to the right arm was not identified, assessed, or treated according to physician orders until several days after it was first observed. Progress notes and observations indicated that a dressing was present on the right arm before an official order was entered, and there was no evidence of a skin assessment or documentation for this injury until later. Additionally, the resident developed callused areas on both heels, which were observed to be painful and, in one case, starting to flake. These areas were not documented or assessed in the medical record, and staff interviews revealed that calluses were not routinely monitored or recorded. The resident and family expressed concerns about the frequency of skin tears and the lack of aggressive treatment for the heel calluses. The wound nurse and visiting wound NP were eventually involved, and orders for skin prep were updated, but there was no initial comprehensive assessment or documentation of these areas. Facility policy required the use of professional standards of practice for skin integrity issues, including obtaining physician orders and reviewing care plans, but did not specify documentation requirements for wound assessments. The lack of timely assessment, documentation, and treatment for the right arm skin tear and bilateral heel calluses constituted a failure to provide care and treatment according to physician orders and the resident's needs.
Failure to Provide Timely Contracture Management for Resident with Limited ROM
Penalty
Summary
A resident with a history of hemiplegia, hemiparesis, weakness, dysphagia, difficulty walking, pain, and adult failure to thrive was identified as having a range of motion (ROM) limitation on one side and was dependent on staff for transfers. The resident received occupational therapy, during which a palm guard was trialed and tolerated, and further assessment for splinting and palm pad was indicated. Upon discharge from therapy, no recommendations were made for a restorative nursing program for ROM, despite the resident's ongoing needs. Occupational therapy staff reported that therapy was discontinued due to the unavailability of a palm guard, which was subsequently ordered, but therapy did not reevaluate the resident after the device arrived. As a result, timely contracture management was not provided for the resident.
Failure to Ensure Consistent Communication with Dialysis Center
Penalty
Summary
The facility failed to ensure consistent communication with the dialysis center for a resident who required hemodialysis. The resident, who had end stage renal disease, chronic kidney disease Stage V, and was dependent on hemodialysis, had physician's orders to receive dialysis three times a week. The care plan specified coordination with the dialysis center and required the center to forward dialysis treatment notes to the facility. However, review of the resident's records over a 30-day period showed that out of 13 dialysis treatments, only six treatment sheets were available, and several of those were incomplete. Seven treatment dates had no documentation at all, and among the available sheets, key sections such as medications administered, new orders, and any problems during treatment were often left blank. Staff interviews confirmed that the dialysis center frequently failed to send back completed treatment sheets, and when documentation was received, it was often limited to pre- and post-dialysis weights and vital signs. The facility staff had to search the resident's belongings for any paperwork and sometimes had to call the dialysis center to request missing information. The facility's policy required comprehensive monitoring and communication with the dialysis center, including receiving reports after each dialysis visit, but this was not consistently followed.
Failure to Provide Trauma-Informed Care for Resident with PTSD
Penalty
Summary
The facility failed to provide trauma-informed care and culturally competent services for a resident with a diagnosis of post-traumatic stress disorder (PTSD). The resident, who had a history of acute and chronic respiratory failure, type 2 diabetes, bipolar disorder, depression, adjustment disorder, and ADHD, reported ongoing triggers and flashbacks related to a past car accident, specifically noting sensitivity to loud noises. Record review showed that the resident's comprehensive care plan did not include any interventions or plans addressing PTSD. Staff interviews revealed that a trauma-informed care observation, which is typically completed on admission to identify triggers and inform the care plan, was not conducted for the resident upon their most recent admission. The social worker was unaware of the resident's PTSD diagnosis due to the lack of this assessment, and the care plan was not updated to reflect the resident's needs.
Failure to Administer Anti-Anxiety Medication as Ordered
Penalty
Summary
A resident with diagnoses of anxiety disorder and major depressive disorder was admitted to the facility with a physician's order for Xanax 0.5 mg by mouth four times daily at specific times. Review of the medication administration history over a three-week period revealed that 20 out of 82 scheduled doses were administered late, with some doses given up to several hours after the scheduled time. The medication administration record included comments indicating the late administration, and the facility's policy required medications to be administered within 60 minutes of the scheduled time unless otherwise specified by the prescriber. The resident reported receiving his anti-anxiety medication inconsistently and often late, which led to increased anxiety and distress. An LPN confirmed administering the medication late and was unaware of the required administration window. The nurse cited unfamiliarity with the unit and workload as contributing factors to the delays. The facility's policies and drug reference resources emphasized the importance of timely administration and even distribution of doses, but these were not consistently followed for this resident.
Failure to Discontinue Unnecessary Medication Following Pharmacy and Physician Recommendations
Penalty
Summary
A deficiency occurred when the facility failed to implement a pharmacy recommendation and corresponding physician order regarding a resident's medication regimen. The resident, who had diagnoses including iron deficiency anemia, weakness, fibromyalgia, and Parkinson's disease, had been receiving ferrous sulfate 325 mg daily since 2023. A pharmacy review recommended discontinuing the ferrous sulfate after a normal complete blood count (CBC) was documented. The physician agreed with this recommendation and also noted to discontinue monthly CBC monitoring. However, a handwritten note from the DON indicated a misunderstanding, stating the resident was not on monthly CBCs and that the issue would be readdressed. Despite the physician's agreement to discontinue ferrous sulfate, medical record review showed that the medication was not discontinued and continued to be administered. The resident's orders and medication administration records confirmed ongoing administration of ferrous sulfate. Interviews with the physician and DON revealed miscommunication and misinterpretation of the pharmacy recommendation and physician's intent, resulting in the continued use of an unnecessary medication.
Insulin Pens Not Dated When Opened
Penalty
Summary
Surveyors observed that insulin pens stored in two medication carts were not dated when opened, as required by facility policy. Specifically, opened Lantus long-acting insulin pens for three residents and an Insulin Lispro pen for one resident were found without open dates, despite being dispensed on earlier dates. Licensed nursing staff, including an LPN and an RN, confirmed during interviews that the insulin pens in their respective medication carts were not dated upon opening. Review of the facility's medication storage policy indicated that nurses are required to place a date opened sticker on medications and record the date opened, which was not followed in these instances.
Failure to Provide Dental Services for Resident with Broken Denture
Penalty
Summary
A resident with a history of moderate protein-calorie malnutrition, stroke, adult failure to thrive, and legal blindness was admitted to the facility and was covered under Medicaid. Upon admission, the resident had an upper denture in fair condition and was noted to have lower dentures that were not brought to the facility due to being broken. The resident was cognitively intact, required assistance with oral hygiene, and had a care plan in place to address dental/oral status, including the need for dental evaluation and treatment as needed. The resident consented to receive dental services, as documented in the ancillary services consent form. Despite these documented needs and consent, there was no evidence in the medical record that the resident had been seen by a dentist since admission, nor were there any progress notes indicating attempts to arrange dental services to replace the broken lower denture. The contracted dental provider had visited the facility, but the resident was not seen during these visits. Interviews with staff confirmed a lack of awareness regarding the resident's denture status, and the DON confirmed that no dental services had been provided to the resident during their stay.
Failure to Adhere to Antibiotic Stewardship Protocols for UTI Treatment
Penalty
Summary
The facility failed to ensure that residents were not treated with antibiotics for urinary tract infections (UTIs) unless they met established criteria for treatment. In two cases, residents were administered antibiotics despite not meeting McGeer's criteria, which are standardized definitions used for surveillance of healthcare-associated infections in long-term care facilities. The infection control log indicated that for both residents, the criteria for initiating antibiotic therapy were not met, and no urinalysis with culture and sensitivity was performed to confirm the presence of a UTI. For one resident with a history of chronic UTIs, Levofloxacin was prescribed by her urologist, and the antibiotic course was continued even after it was determined that she did not meet the criteria for treatment. The DON, who also served as the Infection Preventionist, confirmed that the nurse practitioner and attending physician did not question the need for the antibiotic, and the nurse practitioner instructed staff to continue the antibiotic as ordered, despite the lack of supporting clinical evidence. In the second case, a resident in the memory care unit received Macrobid for a suspected UTI, but again did not meet the criteria for treatment and did not have a urinalysis performed. The resident was experiencing urinary retention and had an indwelling catheter placed, but no other symptoms were documented. The DON acknowledged that urinary retention could be due to other causes and was unable to provide documentation supporting the necessity of the antibiotic. The nurse practitioner was aware of the situation and directed that the antibiotic be continued, even though the resident did not meet McGeer's criteria.
Failure to Provide Timely Incontinence and Nail Care
Penalty
Summary
The facility failed to provide timely incontinence care and nail care for two residents. One resident with severe cognitive impairment, dementia, and multiple comorbidities was observed to be frequently incontinent of urine. On several occasions, the resident was seen sitting in urine-soaked clothing for extended periods, including a visible wet stain on her pants that remained for nearly an hour. Staff interviews confirmed that the resident was to be checked and changed at least every two hours, but observations indicated lapses in this routine, with the resident remaining unattended and unchanged for significant periods. Another resident, dependent on staff for personal hygiene due to conditions such as Parkinson's disease and weakness, was observed with a broken fingernail and a brown substance under all her nails. The broken nail had been present for several days, and the resident expressed dissatisfaction with her nail care. Staff acknowledged the issue, with one CNA stating discomfort in trimming the nail due to its condition, and subsequently began cleaning the resident's nails only after the issue was brought to their attention. Facility policy required regular cleaning and maintenance of nails, which was not followed in this instance.
Failure to Implement and Document Pressure Ulcer Prevention and Care Interventions
Penalty
Summary
The facility failed to implement and document appropriate pressure ulcer prevention and care interventions for multiple residents at risk for or with existing pressure ulcers. For one resident with a history of stroke, hemiplegia, diabetes, and reduced mobility, the facility did not comprehensively assess a right heel pressure ulcer. Weekly wound assessments repeatedly omitted depth measurements for a Stage III ulcer, and the last two assessments did not include staging. The wound nurse, who was not wound certified, acknowledged these omissions and inconsistencies in the wound documentation, despite the presence of a care plan and physician orders for wound care. Another resident, who was dependent on staff for bed mobility and transfers and identified as at risk for pressure ulcers, did not have prescribed heel offloading interventions implemented. Observations over several days showed the resident's heels in direct contact with the mattress, with no pillows or offloading devices in use, despite care plan instructions to encourage or assist with heel offloading. Interviews with CNAs and LPNs confirmed that the intervention was not being carried out, and staff were unaware of the care plan requirements or had not attempted to implement them. A third resident, identified as high risk for pressure ulcers due to multiple comorbidities and reduced mobility, did not consistently receive pressure-relieving devices as specified in the care plan. The resident and family reported inconsistent use of heel offloading pillows and absence of a pressure-relieving cushion in the recliner, where the resident spent most of his time. Observations confirmed the lack of required devices in the resident's room and chair, and staff interviews revealed uncertainty about the location and use of these devices. The facility's policy required identification of at-risk residents and implementation of interventions such as floating heels and use of pressure-relieving devices, but these were not consistently followed.
Failure to Protect Residents from Abuse and Neglect
Penalty
Summary
The facility failed to protect a resident from staff-to-resident sexual abuse and another resident from neglect. The first incident involved a resident with a history of traumatic brain injury, dementia, and severe cognitive impairment, who was reportedly allowed by a CNA to engage in inappropriate sexual behavior. Multiple staff members reported that the CNA permitted the resident to fondle her breasts, rationalizing it as a way to calm the resident. Despite being reported to the facility's Administrator, no immediate action was taken, and the CNA continued to work without any apparent intervention. The second incident involved a resident with Lewy Body dementia and Alzheimer's disease, who was left on a bedpan for approximately 14 hours, resulting in skin breakdown and the development of a pressure ulcer. The resident was dependent on staff for toileting and mobility, and the neglect occurred due to a failure in performing regular checks and changes. Staff interviews revealed that the resident was placed on the bedpan during the afternoon shift and was not attended to until the night shift, leading to the skin issues. The facility's investigation into the neglect incident included obtaining statements from involved staff, conducting a body assessment of the resident, and performing a skin sweep of all residents. However, the investigation did not address the potential neglect aspect of the incident, and no self-reporting incidents were submitted to the state agency regarding the neglect. The facility's policy on abuse and neglect was not effectively implemented, as evidenced by the lack of timely reporting and investigation of these incidents.
Failure to Report Abuse and Neglect
Penalty
Summary
The facility failed to report allegations of staff-to-resident sexual abuse and resident neglect to the State survey agency as required. This involved two residents, one of whom was reportedly allowed by a CNA to engage in inappropriate touching. Multiple staff members were aware of the situation, and it was reported to the facility's Administrator. However, the Administrator did not take appropriate action to investigate or report the incident to the State, as required by the facility's policy. The first resident involved had a history of behavioral issues and was dependent on staff for all activities of daily living. Despite this, a CNA reportedly allowed the resident to engage in inappropriate touching, rationalizing it as a form of excitement for the resident. This behavior was reported by other staff members to the Administrator, who failed to investigate or report the incident properly. The Administrator claimed to have addressed the issue with the staff involved but did not follow through with a formal investigation or report to the State. The second resident was left on a bedpan for an extended period, resulting in skin breakdown and the development of pressure ulcers. Staff interviews revealed that the resident was left on the bedpan due to a lack of proper rounds and care checks. Although the facility conducted an internal investigation and provided education to staff, they failed to report the incident as neglect to the State survey agency. The facility's investigation focused on the development of the pressure ulcer rather than the neglect that led to it.
Failure to Investigate Alleged Sexual Abuse
Penalty
Summary
The facility failed to recognize and investigate an allegation of sexually inappropriate behavior between a resident and a staff member as potential sexual abuse. The incident involved a resident with a history of traumatic brain injury, dementia, and behavioral disturbances, who was known to exhibit inappropriate touching of female staff. Despite this, the facility did not document any sexually related behaviors in the resident's progress notes. Multiple staff members reported that a Certified Nursing Assistant (CNA) allowed the resident to fondle her breasts, rationalizing it as a form of excitement for the resident. Interviews with various staff members revealed that the CNA in question, who was responsible for training new aides, allegedly permitted the resident to engage in inappropriate touching. Several aides reported hearing the CNA make comments about allowing the resident to touch her until he became erect. Despite these reports, the facility's Administrator, who was responsible for investigating abuse allegations, did not take appropriate action. The Administrator was informed of the situation but did not conduct a thorough investigation or report the incident to the relevant authorities. The facility's policy required immediate reporting and investigation of abuse allegations, but this protocol was not followed. The Administrator claimed to have been informed only of a minor incident involving the resident brushing against an aide's breast, and he did not perceive it as abuse. Consequently, no self-reporting incidents or investigations were completed regarding the allegations involving the resident and the CNA. This lack of action and failure to adhere to the facility's abuse policy resulted in a deficiency in handling potential abuse cases.
Resident Left on Bedpan for Extended Period Develops Pressure Ulcers
Penalty
Summary
The facility failed to provide adequate care to prevent the development of a pressure ulcer in a resident who was admitted without any skin breakdown. The resident, who had diagnoses including Lewy Body dementia and Alzheimer's disease, was dependent on staff for toileting hygiene, bed mobility, and transfers. Despite being at risk for pressure ulcers due to impaired mobility, cognition, and incontinence, the resident developed a pressure ulcer after being left on a bedpan for an extended period. The incident occurred when the resident was left on a bedpan for approximately 14 hours, resulting in excoriation and pressure ulcers on the buttocks. Staff interviews revealed that the resident was placed on the bedpan during the afternoon shift and was not removed until the night shift, leading to the development of a Stage I pressure ulcer that later progressed to Stage II. The resident's care plan required frequent turning and positioning, as well as incontinence care, but these interventions were not adequately followed. Interviews with staff members indicated a lack of adherence to the facility's policy of checking and changing residents every two hours. The resident was not checked on during the afternoon and night shifts, and the staff failed to remove the resident from the bedpan in a timely manner. This oversight led to the development of pressure ulcers, which were later identified and treated by the facility.
Failure to Provide Scheduled Showers to Dependent Residents
Penalty
Summary
The facility failed to ensure that dependent residents received showers according to their preferences, affecting three residents. Resident #17, who was admitted with multiple diagnoses including end-stage renal disease and diabetes, was dependent on staff for bathing. Despite being scheduled for showers three times a week, there was no documented evidence that Resident #17 received a complete bed bath on numerous occasions. The resident reported having only two bed baths during a three-week stay, one of which was prompted by a family member's insistence. Resident #70, admitted with a complex medical history including multiple fractures and injuries, also depended on staff for bathing. The resident expressed concerns about not receiving showers, citing staff shortages as the reason given by facility staff. Despite being scheduled for showers three times a week, documentation showed that Resident #70 received only a few showers over a two-month period. The facility's audits were found to be inaccurate, with discrepancies between documented showers and actual care provided. Resident #52, with diagnoses including heart failure and respiratory failure, required assistance with bathing due to oxygen dependency. The resident reported that staff often promised to return for showers but failed to do so, leaving her without a shower for several days. Documentation revealed inconsistencies in the recorded showers, with several scheduled showers not being provided. The facility's policy emphasized the importance of cleanliness and skin observation, yet the lack of adherence to scheduled bathing routines for these residents highlighted a significant deficiency in care.
Supervision Deficiency Leads to Resident Elopement and Injury
Penalty
Summary
The report details a significant deficiency in a nursing home's supervision that resulted in a resident, identified as an elopement risk, leaving the secured unit and the facility unsupervised. Resident #74, who had severe cognitive impairment and a history of wandering, was able to exit the secured unit after being mistaken for a visitor by staff members. Despite being actively exit-seeking and displaying behaviors indicating a high risk of elopement, Resident #74 was allowed to leave the facility by a cook, a licensed practical nurse, and a receptionist who did not recognize him as a resident. This lack of proper identification and supervision led to Resident #74 being found outside the facility with injuries, including a skin tear and bruising, likely sustained during a fall. The deficiency was exacerbated by the failure to have a care plan in place addressing Resident #74's high risk for elopement upon admission, despite clear indications of his propensity to wander and attempt to leave the facility. Nursing notes documented multiple instances of Resident #74 attempting to exit the building, with staff providing minimal interventions or redirection. The facility's inadequate response to these behaviors, coupled with the lack of a comprehensive care plan tailored to address the resident's elopement risk, contributed to the incident where Resident #74 eloped from the facility. The investigation revealed a series of oversights and missteps by staff members, including the failure to verify Resident #74's identity as a resident before allowing him to exit the secured unit. Statements from involved staff members highlighted the confusion surrounding Resident #74's status, with multiple individuals mistaking him for a visitor due to his appearance and demeanor. The lack of proper communication, identification protocols, and awareness of the resident's elopement risk collectively led to the breach in supervision that allowed Resident #74 to leave the facility unattended, posing a serious risk to his safety and well-being.
Failure to Accommodate Request for Electronic Monitoring Device
Penalty
Summary
The facility failed to reasonably accommodate the request of a resident's family to install an electronic monitoring device in the resident's room. The resident, who had diagnoses including dementia, hypertension, cardiac arrhythmia, anxiety, and depression, was admitted to the facility and had a care plan that included monitoring for cognitive loss and behaviors. The resident's family, who held power of attorney, requested a camera to monitor the resident's sleep due to concerns about overmedication and excessive sleeping. Despite the request, no camera was installed in the resident's room, which was observed to be a double occupancy room without a roommate. The facility's policy required the use of a specific camera and installation by a designated company, which resulted in an estimated cost of $700 to $900 for installation, despite the camera itself costing only $50 to $55. The family expressed concerns about the high cost and decided not to pursue the installation due to the expense. The facility's administrator confirmed that the corporation had specific requirements for cameras and installation, and that the facility did not profit from the installation costs. The administrator also indicated that the family had not made a final decision on proceeding with the camera installation. Interviews with the ombudsman and the regional nurse consultant revealed that the corporation's policies and procedures for camera installation were seen as obstacles by the family. The ombudsman noted that only one camera had been installed in any of the corporation's facilities, and the regional nurse consultant confirmed that the corporation chose a specific camera to meet policy requirements. The facility's policy stated that the authorized person was responsible for all costs associated with the electronic monitoring device, including installation, maintenance, and removal, and that only authorized facility personnel could install the devices.
Confidentiality Breach of Resident's Medical Record
Penalty
Summary
The facility failed to ensure the confidentiality of Resident #16's medical record. An observation revealed that a computer monitor on top of a medication cart was displaying Resident #16's confidential health information without any staff member present. This incident was confirmed by the Regional Director of Nursing, who subsequently locked the screen. The facility's policy mandates the use of an electronic medical records system and emphasizes the protection of clinical information in compliance with HIPAA requirements.
Failure to Investigate Resident Elopement
Penalty
Summary
The facility failed to ensure a thorough investigation was completed regarding a resident elopement, affecting one resident of two reviewed for accidents. Resident #74, who had Alzheimer's disease, anxiety, and depression, was admitted to a secure unit due to a high risk for elopement. Despite this, Resident #74 managed to exit the secure unit and the facility, resulting in a fall and minor injuries. The incident was not thoroughly investigated, with key details such as the exact location and duration of the resident's absence remaining unclear. On the day of the incident, Resident #74 was mistaken for a visitor by multiple staff members, including a cook, an LPN, and a receptionist, who allowed the resident to exit the secure unit and the facility. The resident was later found outside by a visitor, who reported the situation to the receptionist. The facility's investigation revealed that the staff members involved did not verify whether the individual was a resident or a visitor, leading to the elopement. Additionally, the facility's elopement binders did not contain Resident #74's information, and the doors to the smoking patio, which should have been alarmed, were not. Interviews with staff and the resident's responsible party highlighted inconsistencies and gaps in the investigation. The facility's policy on abuse, mistreatment, neglect, and exploitation was not followed, as the investigation did not include interviews with all relevant witnesses or a thorough review of the incident. The facility's failure to conduct a comprehensive investigation and ensure proper safety measures contributed to the resident's elopement and subsequent injuries.
Failure to Provide Adequate Personal Care
Penalty
Summary
The facility failed to provide necessary assistance with personal care, specifically showers and nail care, to residents who were dependent on staff for these activities. Resident #26, who had diagnoses including cerebral palsy and adult-onset diabetes mellitus, was scheduled for showers twice a week but had not received a shower since 04/17/24. Observations revealed that her fingernails were long and in need of trimming, despite her preference for short nails. Interviews with staff confirmed that the resident's nails were not trimmed as required, and there was confusion about whether the resident, being diabetic, should have her nails trimmed by a nurse or another designated person. The facility's policy on nail care was not followed, leading to the resident's unmet needs for personal care. Resident #236, who had diagnoses including hemiplegia, morbid obesity, and arthritis, was also dependent on staff for showers. She was scheduled to receive showers twice a week but had only been documented as receiving one shower and one bed bath since her admission. Interviews with the Assistant Director of Nursing (ADON) and the resident confirmed the lack of regular bathing activities. The facility did not have a specific policy for bathing activities, contributing to the inconsistency in providing necessary personal care. Resident #41, who had cognitive impairment and other diagnoses such as dementia and schizophrenia, was scheduled for baths twice a week. Despite documentation indicating that the resident had been bathed and had her nails cleaned and trimmed on multiple occasions, observations revealed that her fingernails were long, jagged, and had a dark substance underneath. Interviews confirmed the resident's nails were not properly maintained, indicating a failure to adhere to the facility's policy on nail care. This lack of proper personal care affected the resident's overall well-being and hygiene.
Failure to Ensure Resident Access to Audiology Services
Penalty
Summary
The facility failed to ensure a resident was seen by an audiologist as requested by the resident and her family. Resident #26, who had diagnoses including cerebral palsy and adult-onset diabetes mellitus, was admitted to the facility and later transitioned to Medicaid coverage. Despite a consent form signed by the resident's niece, the form did not indicate whether the resident should receive ancillary services. The resident's medical record showed no evidence of an audiology consult, even though the family had expressed concerns about her hearing and requested an audiologist referral. The resident's care plan included interventions for impaired communication but did not specifically address hearing issues. The resident's progress notes indicated that the family reported hearing problems after the resident was taken off a ventilator in the hospital. Despite the family's request for an audiologist referral, there was no documentation of the resident being seen by an audiologist. The facility's contracted audiologist visited the facility on two occasions, but the resident was not seen during these visits. An interview with a Licensed Social Worker confirmed the resident had not been seen by an audiologist and that an appointment was finally made for the resident to be seen by an outside audiologist after the deficiency was identified.
Failure to Provide Routine Foot Care
Penalty
Summary
The facility failed to ensure that residents received routine, preventative foot care, specifically affecting a resident with multiple health conditions including diabetes mellitus. The resident's care plan included monitoring for potential foot ulcers, but the last podiatry examination was conducted several months prior. Two subsequent podiatry appointments were canceled due to time constraints, and there was no documentation indicating the resident refused care. The resident complained of pain and infection in the right great toe, which was confirmed by observation and medical review to be due to untrimmed toenails. Interviews with staff and the physician revealed that the resident should have been seen every nine to ten weeks due to his diabetes diagnosis. The physician confirmed that the infection and ingrown toenail were likely caused by the lack of routine foot care. The facility's policy stated that the Social Services Department was responsible for ensuring residents received necessary ancillary services, but this was not followed, leading to the resident's condition worsening.
Failure to Properly Clean CPAP Mask
Penalty
Summary
The facility failed to ensure that a resident's continuous positive airway pressure (CPAP) mask was properly cleaned. Resident #8, who was admitted with diagnoses including acute respiratory failure, diabetes mellitus, chronic obstructive pulmonary disease (COPD) with exacerbation, emphysema, sleep apnea, and anxiety disorder, reported that their CPAP mask was dirty and not cleaned. Observation confirmed the presence of dried substances on the inside of the mask. The facility's policy required CPAP equipment to be cleaned by night shift nurses, but there was no documentation to verify that the mask had been cleaned as recommended by the manufacturer. Interviews with staff, including a Licensed Practical Nurse (LPN) and a Regional Nurse, confirmed the lack of proper cleaning and documentation. The manufacturer's instructions specified that the mask should be disassembled and cleaned daily and after each use, with specific steps for rinsing, brushing, and air drying the components. However, the facility's records only indicated that the resident was to wear the full face mask at bedtime, with no mention of the required cleaning procedures. This deficiency affected one out of three residents reviewed for respiratory care in a facility with a census of 85.
Failure to Implement Physician Orders and Document Rationale for Extended PRN Psychotropic Medication Use
Penalty
Summary
The facility failed to implement physician orders following a pharmacy recommendation for a gradual dose reduction of Zyprexa for a resident with dementia, alcohol abuse, and anxiety disorder. Despite the physician's order to decrease and eventually discontinue the medication, the resident continued to receive the original dosage. This oversight was confirmed by the Regional Nurse during a review of the medical record. Additionally, the facility did not provide a rationale for extending the as-needed use of Xanax beyond the recommended 14 days for the same resident. The physician extended the duration to 90 days without documenting the necessary justification in the medical record. This failure was also verified by the Regional Nurse Consultant during the review.
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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