Tallmadge Health & Rehab Center
Inspection history, citations, penalties and survey trends for this long-term care facility in Tallmadge, Ohio.
- Location
- 619 Northwest Avenue, Tallmadge, Ohio 44278
- CMS Provider Number
- 366487
- Inspections on file
- 27
- Latest survey
- March 19, 2026
- Citations (last 12 mo.)
- 6
Citation history
Health deficiencies cited at Tallmadge Health & Rehab Center during CMS and state inspections, most recent first.
Surveyors found that staff failed to accurately and timely document both controlled and routine medications. A resident receiving PRN tramadol had doses recorded on the narcotic log that were not entered on the EMAR. Another resident with leukemia and chronic pain had PRN oxycodone signed out on the narcotic log at a time not aligned with scheduled passes and with no corresponding PRN entry on the EMAR. In addition, an LPN administered ordered antihypertensive, anticoagulant, cardiac, and GI medications to a resident with multiple comorbidities but did not document these doses in the EMAR for more than two hours after administration, despite facility policy requiring proper documentation of all and PRN medications.
An LPN was found to be preparing medications ahead of time by placing pills into multiple medication cups, stacking them, and leaving them unlabeled on the med cart during night shift passes on two halls. Photographs showed numerous cups with pills stacked and unlabeled, as well as multiple empty, unlabeled cups lined up on the cart. Two residents reported that a night-shift nurse routinely prepared and stacked medications in this manner. The DON confirmed the contents of the photos, and the pharmacist and facility policy both specified that medications should not be prefilled, stacked, or unlabeled and must be prepared for only one resident at a time. This practice had the potential to affect all residents on the involved halls.
Surveyors found that facility staff failed to remain awake during scheduled working hours, with multiple instances of employees sleeping on night shift in common areas and hallways. Personnel records documented disciplinary actions and terminations for a dietary aide and a CNA who were observed asleep by HR and a midnight RN supervisor. Several residents and a confidential individual reported that staff sleep during night shift. The facility’s Employee Handbook identifies sleeping on the premises during working hours as a critical offense warranting immediate discharge.
A resident with multiple complex medical conditions was readmitted after a hospital stay, but did not receive timely assessment or care for a J-tube site. The required admission assessment was incomplete for several days, and there were no orders or documentation for feeding tube site care or monitoring until three days after readmission. Staff confirmed that routine care should have been in place, and facility policy requiring daily monitoring and prompt assessment was not followed.
A resident admitted with a history of skin breakdown did not receive appropriate assessment or wound care, despite clear risk factors and physician orders for pressure ulcer prevention. Facility staff failed to document or implement necessary interventions, and the resident was later hospitalized with multiple advanced pressure injuries, including an unstageable sacral wound with necrotizing infection. Staff interviews and records revealed inconsistent documentation, lack of awareness, and failure to follow pressure injury prevention protocols.
A resident with multiple complex medical conditions did not receive proper care for his ostomy and enteral feeding tubes, resulting in significant skin irritation, leakage of gastric and fecal contents onto his body and environment, and lack of appropriate monitoring and intervention by nursing staff. Documentation and staff interviews revealed missed or undocumented care, failure to recognize and report skin breakdown, and confusion among staff regarding care responsibilities.
Multiple residents and a family member reported that meals and beverages were frequently served cold and unappetizing, with some residents stating the food tasted bad or made them nauseous. Observations confirmed that food temperatures dropped significantly before reaching residents, and the food service manager acknowledged the issue. Facility records also documented ongoing concerns about food temperature and palatability.
A resident's room refrigerator was found to contain multiple expired and moldy food items, including dressings, jam, and cheese, during an observation with the Administrator. Despite facility policy requiring daily checks and proper labeling and dating of food, these procedures were not followed, leading to unsanitary conditions.
Multiple residents reported and were observed experiencing disrespectful and undignified treatment by staff, including unfriendly interactions, lack of assistance with personal care, belittling comments, and staff wearing ear buds while working. Residents felt intimidated, rushed, and that their privacy was compromised, with concerns raised about staff not responding promptly to call lights and not engaging respectfully during care.
A resident with a history of traumatic subdural hemorrhage, PTSD, anxiety, and dementia was admitted with moderate cognitive impairment, but the PASARR completed after admission did not include these diagnoses. The Social Service Designee confirmed the omission of these conditions in the screening.
A CNA transferred a resident with severe cognitive impairment and multiple medical conditions using a mechanical lift without the required assistance of a second staff member, despite physician orders and facility policy mandating two staff for all such transfers. Video evidence confirmed the transfer was performed by only one staff member.
A resident with complex medical needs did not have a baseline weight established or weekly weights consistently obtained as required by facility policy and physician orders. This failure led to an inability to accurately monitor for significant weight loss, despite the resident being at increased nutritional risk and reporting recent weight loss. Staff interviews confirmed inconsistent weight documentation due to staffing issues.
A resident with end stage renal disease requiring regular dialysis did not have dialysis communication forms completed before and after each treatment as required, with several forms missing over a two-month period. Additionally, when the resident refused dialysis, the LPN's documentation did not indicate that the physician was notified. The DON confirmed these omissions and the facility's expectations for proper documentation and communication.
Pharmacy recommendations for two residents were not timely reviewed or addressed by the provider. One resident did not receive recommended lab work to monitor kidney function for over a month, and another resident's medication regimen involving two antidepressants was not reviewed or adjusted as recommended by the pharmacy. The DON and Administrator confirmed these lapses.
A resident with multiple serious diagnoses, including osteomyelitis and quadriplegia, had physician orders for regular IV site observation and dressing changes. Despite MAR entries indicating that dressing changes were performed as ordered, direct observation found the dressing had not been changed as documented, and staff confirmed the discrepancy between records and actual care provided.
An LPN failed to follow infection control protocols during a wound dressing change for a resident with multiple medical conditions, including placing dressings on soiled linens, using non-disinfected scissors, and not performing hand hygiene or changing gloves between wound sites.
A resident with multiple comorbidities received Macrobid for an extended period after returning from the hospital, despite the discharge order specifying a one-day course for UTI treatment. Due to the lack of an end date on the order, staff continued the antibiotic and later updated it to prophylactic use without supporting documentation or physician awareness, resulting in inappropriate administration.
Two residents, including the resident council president, reported that their ongoing concerns about care, staff treatment, housekeeping, and food quality were repeatedly brought to the attention of the Administrator and DON without resolution. After complaints were made, staff members involved reportedly ignored the residents, and a letter signed by multiple residents was sent to the corporate office, which confirmed that management was not taking the issues seriously. Staff interviews indicated that outcomes of these concerns were not communicated or resolved.
A resident with multiple medical conditions experienced repeated emotional distress due to a CNA's dismissive and unsupportive behavior during toileting assistance. Despite reports from the resident and her family, the CNA was not immediately removed from resident care during the investigation, as required by facility policy. Additionally, reference checks were not completed for eight newly hired staff members before they began working with residents, contrary to facility procedures.
Two residents did not receive care as ordered, including lack of monitoring and documentation for a biliary drain after hospital readmission, and failure to apply TED hose and complete weekly skin checks as prescribed. Staff inaccurately documented that treatments were provided, and care plans did not address all medical devices in use.
A resident with a midline IV for treatment of osteomyelitis, respiratory failure, and quadriplegia did not have dressing changes performed as ordered, despite documentation in the MAR and TAR indicating otherwise. Observation found the dressing was overdue for change and there was dried blood at the site. The care plan lacked documentation for the midline, and the DON confirmed inaccurate documentation and failure to update the care plan.
The facility did not return unused medications to the pharmacy or destroy controlled substances within required timeframes after residents were discharged or deceased, as observed with several medication cards and confirmed by staff interviews and record reviews. Additionally, a resident with diabetes did not receive their prescribed Ozempic injections as ordered, with discrepancies noted in medication administration and availability. These failures were identified through interviews, observations, and review of facility policies and state regulations.
A resident with bladder cancer and impaired cognition received intravenous antibiotics despite worsening kidney function, as indicated by lab results. The pharmacy recommended a lower dose, and the NP advised staff to follow these recommendations and contact infectious disease for further orders. However, there was no documentation that infectious disease was contacted or provided orders, and the resident continued on the higher antibiotic dose. Staff interviews confirmed the lack of follow-up and missing specialty orders.
A resident admitted for post-operative care did not receive prescribed pain medication due to access issues with the facility's emergency supply system. Despite the resident's severe pain and repeated requests for relief, the LPN on duty was unable to administer the medication. The resident's pain was not properly assessed or documented, leading to a call to emergency services and subsequent rehospitalization. The facility's pain management policy was not followed, resulting in harm to the resident.
The facility failed to ensure proper hand hygiene and infection control during incontinence care for two residents. Video footage showed multiple STNAs using soiled gloves to touch residents and their belongings without washing hands. Additionally, soiled items were improperly disposed of on the floor. These actions violated the facility's hand hygiene policy, affecting the quality of care for residents with severe cognitive impairment and other health conditions.
A resident with severe cognitive impairment and no natural teeth reported missing dentures, but the facility failed to refer them for dental services in a timely manner. Despite the facility's policy to refer residents within three days, the process was delayed due to a lack of communication among staff, resulting in non-compliance.
A resident was not appropriately secured during a wheelchair transport to a dentist appointment, resulting in the resident hitting her head. The transport driver moved the van without re-securing the resident, causing the wheelchair to tip backward. The resident was admitted to the hospital for a head injury, although imaging revealed no acute issues. The driver was terminated following the incident.
A resident with a Stage IV pressure ulcer did not receive prescribed pain medication before wound care, resulting in significant pain during the procedure. The nurse did not verify if the medication was administered, and the resident expressed pain rated at eight out of ten. The Director of Nursing confirmed that the staff should have checked and waited for the medication to take effect before proceeding.
A resident with severe sepsis, bacteremia, diabetes, and chronic kidney disease experienced a delay in UTI treatment. Despite a positive culture reported on 03/16/24, antibiotic treatment was not initiated until 03/18/24. The resident's care plan and progress notes did not adequately address the UTI, leading to a deficiency.
Failure to Accurately and Timely Document Controlled and Routine Medications
Penalty
Summary
Surveyors identified a failure to maintain accurate and timely medication records for controlled substances and other medications, including discrepancies between the EMAR and the facility’s narcotic log, and failure to document medications at the time of administration. One resident with arthritis and chronic pain had a PRN tramadol 50 mg order for moderate to severe pain every eight hours; the EMAR showed multiple administrations during the month, while the narcotic log for the same period showed additional tramadol doses that were not documented on the EMAR. Another resident with leukemia and chronic pain had orders for scheduled oxycodone 5 mg twice daily and PRN oxycodone 5 mg every 24 hours; the EMAR for the review period showed no PRN oxycodone administrations, but the paper narcotic log showed an oxycodone dose signed out at a time that did not correspond to the scheduled AM or PM medication passes and was not documented as PRN on the EMAR. In both cases, the DON confirmed that controlled substances should be documented on both the EMAR and the narcotic log. Surveyors also observed a failure to document routine medications at the time of administration for another resident admitted with multiple diagnoses including peripheral vascular disease, partial foot amputation, stroke, liver disease, and chronic kidney disease. This resident had orders for amlodipine 10 mg daily, apixaban 2.5 mg daily, metoprolol 25 mg twice daily, and pantoprazole 40 mg daily. During a medication pass, an LPN administered these medications but did not sign them as given in the EMAR at the time of administration. More than two hours later, the EMAR still did not show documentation of the morning medications, and the LPN was observed sitting at the nurse’s station talking with coworkers rather than charting. The LPN verified that the medications administered earlier remained undocumented. Facility policy required staff to document administration of controlled substances in accordance with law, document when medications are given, and document PRN medications on appropriate forms.
Improper Prefilling and Labeling of Medication Cups During Night Shift Med Passes
Penalty
Summary
The deficiency involves the facility’s failure to ensure medications were stored, prepared, and administered in accordance with professional standards and facility policy. Photographs reviewed by surveyors showed one image with fourteen medication cups containing pills, stacked on top of each other and unlabeled, and a second image with nine empty, unlabeled medication cups lined up on a medication cart. These photos were associated with an LPN’s medication passes on two different halls during the night shift. The DON, upon viewing the photos, confirmed that the cups in both images were unlabeled and, in the first image, stacked with pills already placed in them. Interviews with two residents indicated that an LPN on the night shift was preparing medications ahead of time without labeling the cups and stacking them. An interview with a confidential individual confirmed that the photographs were taken during the identified LPN’s medication passes on the 100 and 200 halls. The facility’s pharmacist stated that medications are not to be prefilled ahead of time, stacked, or left unlabeled, and that medications are to be administered one resident at a time. Review of the facility’s “General Dose Preparation and Medication Administration Policy” likewise showed that staff are to prepare medications for only one resident at a time. This conduct had the potential to affect all 47 residents residing on the 100 and 200 halls and was cited under a complaint investigation.
Staff Found Sleeping on Duty During Night Shift
Penalty
Summary
The deficiency involves the facility’s failure to ensure staff remained awake during scheduled working hours, as required to effectively meet the needs of all 81 residents. Personnel records showed that a dietary aide was terminated following a disciplinary action dated 12/19/25 for sleeping on the job in the main lobby. A written statement signed by Human Resources and the Administrator documented that the HR staff member found the dietary aide asleep in the lobby, brought in the Administrator as a witness, and then woke the aide, who apologized and stated he had not slept well the previous night. Multiple interviews supported that staff slept during night shift, including interviews with two residents and a confidential individual who reported witnessing staff sleeping at night. The DON and Administrator confirmed that the dietary aide had been found sleeping and was terminated. A second staff member, a CNA, was also found sleeping while on duty. Review of the CNA’s personnel file showed a disciplinary action dated 12/30/25 for termination due to sleeping in the hallway. Interviews again corroborated that staff slept on night shift, including statements from a resident and a confidential individual. A midnight RN supervisor confirmed that the CNA was found asleep at 1:32 A.M. on 12/30/25, and the DON confirmed the CNA was found sleeping, suspended, and would be terminated. Review of the Employee Handbook dated 01/01/24 showed that sleeping on the community’s premises during scheduled working hours is listed as a critical offense that is considered serious in nature and results in immediate discharge. The survey determined that the facility failed to ensure staff were awake at all times, with the potential to affect all residents.
Failure to Assess and Monitor Feeding Tube Site After Readmission
Penalty
Summary
The facility failed to ensure proper assessment, monitoring, and care of a resident's gastric tube following readmission. The resident, who had multiple complex medical conditions including chronic respiratory failure, end stage renal disease, and a history of gastrostomy infection, was readmitted after a hospital stay. Upon readmission, the required assessment was not completed in a timely manner, with the gastrointestinal section, including information on the gastric tube, left incomplete for several days. There was no evidence in the medical record of any orders or documentation for feeding tube site care, monitoring, or assessment during this period. Observations and interviews confirmed that the resident's J-tube site was not being properly managed. The site was observed to have dark brown drainage with granules, and the resident reported that the site had been in that condition since returning from the hospital. Staff interviews revealed that no orders for J-tube site care were present until three days after readmission, and that routine care for the site should have been in place. The facility's own policies required daily monitoring and documentation of enteral tube sites, as well as prompt initiation of admission and readmission assessments, but these were not followed. Multiple staff members, including the DON, ADON, and LPNs, confirmed the lack of timely assessment and absence of orders for J-tube care in the days following the resident's readmission. The deficiency was substantiated by review of the medical record, which showed no documentation of site care or monitoring until several days after the resident's return. The failure to promptly assess and provide care for the feeding tube site was in direct violation of facility policy and physician expectations.
Failure to Identify and Treat Pressure Ulcers Resulting in Harm
Penalty
Summary
The facility failed to develop and implement a comprehensive and individualized pressure ulcer program for a resident who was admitted with a history of skin breakdown. Upon admission, the resident's prior hospital records indicated an active coccyx pressure injury, but the facility's admission observation did not identify any skin alterations or document the existing wound. The care plan noted the resident was at high risk for pressure ulcers but did not include specific interventions or ongoing treatment for the known coccyx injury. Weekly and shift-based skin assessments were either not completed or not documented as required, and there was no evidence that the facility recognized or treated the resident's pressure injuries during their stay. Despite physician orders for pressure-reducing interventions such as floating heels, use of pressure-reducing cushions and mattresses, and regular turning and repositioning, there was no documentation that these interventions were carried out. Nursing and aide documentation was inconsistent, with aides noting open areas and dressings on the resident's buttock, while nursing records failed to acknowledge any wounds. The resident, who was dependent on staff for most activities of daily living and was incontinent, was not consistently assessed or provided with necessary wound care. Reports from the resident's spouse and staff interviews indicated that the resident was not changed in a timely manner and did not receive consistent care, further contributing to the lack of wound management. The deficiency resulted in actual harm when the resident was transferred to the hospital due to a change in condition and was found to have multiple pressure injuries, including an unstageable sacral wound with necrotizing soft tissue infection, and additional pressure injuries to the right buttock, heel, and upper posterior right leg. Hospital records confirmed the presence and progression of these wounds, which were not identified or treated by the facility. Interviews with facility staff revealed a lack of awareness and documentation regarding the resident's wounds, and a failure to follow the facility's own policy for pressure injury prevention and treatment.
Failure to Provide Proper Ostomy and Tube Feeding Care
Penalty
Summary
A resident with complex medical needs, including acute and chronic respiratory failure, Rett's syndrome, seizure disorder, and dependence for all activities of daily living, did not receive proper care and assistance in managing his ostomy and tube feeding requirements. The resident was dependent on staff for all care, had a colostomy, a G-tube and J-tube, and required regular monitoring and maintenance of these devices as per physician orders and facility policy. Documentation and observation revealed that required care, such as changing the colostomy skin barrier appliance and bag when detached, applying prescribed ointments for skin irritation, and conducting weekly skin checks, was either not performed or not documented as completed. There was also a lack of evidence that staff monitored and reported changes in the resident's stoma site and peristomal skin as ordered. On one occasion, the resident was found by EMS covered in tube feeding formula and feces, with the ostomy bag detached and not replaced, and gastric contents leaking onto his skin, clothing, and bedding. The hospital emergency department documented that the resident arrived with an unattached ostomy bag, significant skin irritation, and evidence of medical neglect. The resident's abdominal area and perineal region were extremely red and irritated, and the hospital diagnosed candida dermatitis, irritant contact dermatitis, and leaking PEG tube. Facility staff failed to recognize, report, or treat the resident's skin breakdown and did not notify the nurse practitioner of the resident's condition. Further observations in the facility revealed the resident left alone in his room with a strong odor present, a large puddle of gastric contents on the floor, and his clothing and wheelchair saturated with drainage from a leaking tube. Staff interviews indicated confusion about who was responsible for the resident's care and a lack of awareness or follow-through regarding the resident's skin condition and tube management. Facility policy required competent nursing staff to provide routine ostomy and enteral tube care, including monitoring for signs of irritation and leakage, but these standards were not met for this resident.
Failure to Serve Palatable and Properly Tempered Meals
Penalty
Summary
The facility failed to ensure that meals provided to residents were palatable and served at an appetizing temperature, as required by policy. Multiple residents reported that their food and beverages were frequently served cold, with some stating that the food tasted bad or was unappetizing. Specific complaints included cold coffee, repetitive meals, and food that made some residents feel nauseous. One resident noted that concerns had been brought to management during care conferences, but no changes had been made. A family member also observed that food was sometimes not hot and did not look appealing. Direct observations during meal service confirmed that food temperatures dropped significantly between preparation and service, with test trays showing items such as oatmeal, eggs, and omelets being served at temperatures well below initial preparation levels. The food service manager acknowledged that the food was not as warm or as firm as preferred. Review of facility food committee meeting minutes and policy further confirmed ongoing concerns about food temperature and palatability, affecting the majority of residents receiving meals from the facility.
Expired and Moldy Food Found in Resident Refrigerator
Penalty
Summary
The facility failed to maintain resident refrigerators in a safe and sanitary condition, as evidenced by the presence of expired and moldy food items in a resident's room refrigerator. During an observation with the Administrator, multiple food items were found to be expired, including bottles of Italian, honey mustard, and ranch dressings, as well as a bottle of strawberry jam. Additionally, an opened bag of shredded cheddar cheese appeared moldy and contained liquid, and an open, undated chunk of Swiss cheese was visibly moldy. The Administrator confirmed these findings at the time of observation. Prior to this observation, resident council meeting minutes documented concerns about items in resident refrigerators not being labeled or dated, and the need for food to be discarded after three days. Facility policy required that foods in resident refrigerators be labeled, dated, and checked daily by designated employees, with refrigerators kept clean and in working order. Despite these policies and prior discussions with residents, the facility did not ensure that staff consistently monitored and maintained the cleanliness and safety of resident refrigerators, resulting in the deficiency.
Failure to Ensure Resident Dignity and Respect
Penalty
Summary
The facility failed to ensure residents were treated with dignity and respect, as evidenced by multiple complaints and observations involving four residents. Residents reported that staff were immature, untrained, and lacked compassion, with specific concerns about staff being unfriendly, not engaging in small talk, and talking down to residents and their families. Some residents in wheelchairs felt belittled, and staff, particularly nursing and CNAs, were described as intimidating. Residents also expressed concerns about staff wearing ear buds while working, which they felt was rude and potentially a privacy issue. During a resident council meeting, additional concerns were raised about staff entering rooms without greeting residents respectfully and nurses not responding to call lights promptly. One resident with type one diabetes, obesity, Asperger's syndrome, and PTSD, who was cognitively intact and required assistance with personal care, reported that a CNA did not assist her properly with toileting and made negative comments about her abilities, causing her to feel neglected and hurt. Another resident with acute and chronic respiratory failure, tracheostomy, and limited mobility, also cognitively intact, reported that a CNA was rude and did not speak kindly during care. The CNA admitted to working quickly due to split assignments and acknowledged that residents felt rushed and like a burden, especially when staffing was short. A third resident, newly admitted with a trimalleolar fracture, diabetes, COPD, and major depressive disorder, described being belittled and mentally abused by a CNA who became upset when the resident needed frequent assistance due to illness. The CNA told the resident she would not be able to help until after her lunch break and displayed behavior that frightened the resident. Observations also confirmed that staff, including CNAs, RNs, and LPNs, were seen wearing ear buds while on duty, and a resident reported that staff sometimes talked on the phone while in their rooms, which was perceived as disrespectful and a privacy concern.
Incomplete PASARR Screening for Mental Disorders and Intellectual Disabilities
Penalty
Summary
The facility failed to ensure that a Preadmission Screening and Resident Review (PASARR) was accurately completed for Resident #56 upon admission. The resident, who had diagnoses including traumatic subdural hemorrhage without loss of consciousness, Post Traumatic Stress Disorder (PTSD), anxiety, and dementia, was admitted with moderate cognitive impairment. Upon review, it was found that the PASARR completed the day after admission did not include the resident's diagnoses of PTSD, anxiety, or dementia. The Social Service Designee confirmed that the PASARR was completed without including these diagnoses, as there was no previous PASARR record available at the time of admission.
Failure to Follow Two-Person Mechanical Lift Protocol
Penalty
Summary
A deficiency occurred when a certified nursing assistant (CNA) transferred a resident with severe cognitive impairment, chronic obstructive pulmonary disease (COPD), Alzheimer's disease, and type 2 diabetes mellitus using a mechanical lift without the required assistance of a second staff member. The resident's physician orders and care plan both specified that all transfers were to be performed with a mechanical lift and the assistance of two staff members. Video evidence submitted to the Ohio Department of Health showed the CNA conducting the transfer alone, contrary to facility policy and the resident's care plan. The facility administrator confirmed that the transfer was performed unsafely by only one staff member.
Failure to Establish Baseline Weight and Monitor Nutrition
Penalty
Summary
The facility failed to establish a baseline weight for a resident with multiple medical conditions, including hemiplegia, vertebral fracture, and dysphagia, as required by facility policy and physician orders. The resident was admitted with orders to obtain a weight upon admission and weekly for four weeks, but the medical record showed inconsistent documentation of weights, with significant gaps between recorded measurements. The resident's care plan identified increased nutritional and hydration risk and called for close monitoring of weight, intake, and related factors. Despite these interventions, the facility did not consistently obtain or document the required weights. Interviews with facility staff, including two dietitians, confirmed that the baseline weight and subsequent weekly weights were not consistently obtained due to staffing issues. The lack of a baseline weight made it impossible for the dietitian to determine if the resident had experienced a true weight loss. Facility policy required weights to be obtained upon admission, weekly for four weeks, and monthly thereafter, but this protocol was not followed for the resident in question. The resident reported significant recent weight loss, which was corroborated by the recorded weights, indicating a 10.95 percent loss over a short period.
Failure to Complete Dialysis Communication Forms and Notify Physician of Refusal
Penalty
Summary
The facility failed to ensure that dialysis communication forms were consistently completed before and after dialysis treatments for a resident with end stage renal disease who was dependent on dialysis. Medical record review showed that the required communication forms were missing for several treatment dates in February and March, despite physician orders specifying monitoring and communication of post-dialysis weights. Additionally, when the resident refused dialysis on one occasion, the progress note did not document that the physician was notified of the refusal. The Director of Nursing confirmed that the dialysis communication forms were incomplete and acknowledged the expectation for these forms to be filled out for each treatment, as well as for physician notification in the event of a refusal.
Failure to Timely Address Pharmacy Recommendations for Medication Management
Penalty
Summary
The facility failed to ensure that pharmacy recommendations were reviewed and addressed by the provider in a timely manner for two residents. For one resident with diabetes and congestive heart failure, the pharmacy recommended monitoring blood work to assess kidney function, but the required lab work was not completed until over a month after the recommendation was made. The DON confirmed the delay between the pharmacy's recommendation and the completion of the lab work. For another resident with end stage renal disease, generalized anxiety disorder, and major depressive disorder, the pharmacy identified that the resident was receiving two antidepressants and recommended reducing one of the medications with the goal of discontinuation. However, there was no evidence that the physician addressed this recommendation. The Administrator confirmed that the pharmacy's recommendation was not acted upon.
Failure to Accurately Document IV Dressing Changes
Penalty
Summary
The facility failed to ensure accurate documentation regarding a resident's midline intravenous (IV) dressing changes. Review of the resident's medical records showed physician orders requiring the IV site to be observed every shift and the dressing to be changed every seven days and as needed. However, the Medication Administration Record (MAR) indicated that IV dressing changes were documented on multiple dates, while direct observation revealed the dressing was last changed on a much earlier date, with the dressing still dated and dried blood present at the site. The LPN confirmed the dressing date and the required frequency for changes, and the Director of Nursing acknowledged that the MAR included documentation of dressing changes that had not actually been performed. The resident involved had diagnoses including osteomyelitis, respiratory failure, and quadriplegia, and was dependent on staff for personal care.
Infection Control Lapses During Wound Care
Penalty
Summary
During a wound dressing change for a resident with osteomyelitis, respiratory failure, and quadriplegia, an LPN failed to maintain effective infection control measures. The LPN placed foam dressings and calcium alginate directly onto soiled bed linens and used scissors from her pocket to cut the dressings without disinfecting them beforehand. The same scissors were used to open additional wound dressing packaging, and the dressings were again placed on soiled linens. The LPN did not change gloves or perform hand hygiene after cleansing the resident's leg wound or before applying a clean dressing. The resident's right leg was also placed onto soiled bed linens during the procedure. These actions were confirmed by the LPN during an interview and were not in accordance with the facility's clean dressing change policy, which requires avoiding direct contamination of materials and supplies.
Failure to Ensure Appropriate Antibiotic Administration Following UTI
Penalty
Summary
A resident with a history of traumatic subdural hemorrhage, type 2 diabetes mellitus, urinary tract infection (UTI), and stage three chronic kidney disease was admitted to the facility with moderately impaired cognition. After a hospitalization, the resident returned with a hospital discharge order for Macrobid 100 mg to be administered twice daily for one day for treatment of a UTI. However, the facility entered the order without an end date, resulting in the antibiotic being administered daily from 01/30/25 through 03/19/25. During medication reviews, the infection preventionist assumed the ongoing order was for prophylactic use and updated the order accordingly, despite no documentation supporting this indication. The DON later confirmed that the antibiotic was administered incorrectly and that the physician was unaware of the original hospital order's intended duration. There was no evidence in the progress notes explaining the rationale for prophylactic use, and the physician stated she would not have ordered it as such without specific recommendation from the hospital.
Failure to Address Resident Council Concerns
Penalty
Summary
The facility failed to address resident concerns in a manner that provided resolution, as evidenced by interviews, record reviews, and correspondence. One resident, who served as the president of the resident council, reported that he and other residents had repeatedly expressed concerns about their care to both the Administrator and the DON, but these concerns were not addressed and no changes were observed. The resident also stated that after voicing complaints, the Administrator would inform the staff members involved, resulting in those staff members ignoring him and not assisting with his care. A resident council meeting further confirmed that several residents had ongoing unresolved concerns related to laundry, maintenance, nursing, and administration. A review of a letter sent to the corporate office, authored and signed by multiple residents, detailed issues including staff treatment, housekeeping, food quality, and nursing care. The corporate office acknowledged receipt of these concerns and noted that management at the facility was not taking the issues seriously. Interviews with staff, including an LPN, revealed that while residents were encouraged to discuss their concerns with administration, staff were often unaware of any outcomes or resolutions. This deficiency was identified during an investigation under a specific complaint number and affected at least two residents out of the four reviewed for concerns.
Failure to Remove Accused Staff and Complete Reference Checks
Penalty
Summary
The facility failed to implement its abuse policy by not immediately removing a staff member accused of emotional abuse during an investigation. A cognitively intact resident with multiple medical conditions, including diabetes, obesity, Asperger's syndrome, and PTSD, reported repeated instances of a CNA being verbally dismissive and unsupportive when she requested assistance with toileting. The resident expressed fear and distress, sometimes resulting in incontinence due to her reluctance to seek help. The resident's brother corroborated these concerns, stating he witnessed the CNA making inappropriate comments and observed her sitting at the nurse's station on her phone instead of assisting the resident. The incident was reported to nursing staff and management, but the CNA continued to work in the facility during the investigation, contrary to facility policy, which requires immediate removal of accused staff from resident care areas. Additionally, the facility failed to complete reference checks for eight newly hired staff members, including CNAs, a nurse, an admissions coordinator, a laundry aide, and a respiratory director. Personnel file reviews confirmed that reference checks were not obtained prior to employment, despite facility policy stating that references from two prior employers should generally be attempted for each applicant. The human resources coordinator verified that these checks were not completed before the staff began working with residents. These deficiencies were identified through interviews, medical record reviews, personnel file reviews, and policy reviews. The failures had the potential to affect all residents in the facility, which had a census of 85 at the time of the survey.
Failure to Follow Physician Orders for Biliary Drain and TED Hose Application
Penalty
Summary
The facility failed to provide appropriate treatment and care according to physician orders and resident needs for two residents. One resident with a biliary drain did not have a care plan addressing the drain and, following a hospital readmission, had no active orders for monitoring the drain site or recording its output. Documentation showed that after the resident returned from the hospital, there was no evidence of monitoring or documentation related to the biliary drain, despite previous orders requiring twice-daily monitoring and output documentation. The resident's family observed issues with the drain, including unchanged drainage and unclean tubing, and reported pain at the site, which led to the resident being sent to the hospital for further evaluation. Another resident with a history of chronic conditions, including congestive heart failure and peripheral vascular disease, had physician orders for daily application and nightly removal of TED hose (compression stockings), as well as weekly skin checks. Observations and interviews revealed that the resident was not wearing the TED hose as ordered, and the resident reported that staff had not offered to put them on for some time. The Medication Administration Record and Treatment Administration Record inaccurately indicated that the TED hose were applied as ordered, and staff confirmed this was an error. Additionally, weekly skin checks were not completed as ordered. Facility policy required that anti-embolic stockings be applied according to provider orders, and that monitoring and documentation be performed as directed. The failures identified included lack of care planning, failure to follow physician orders for monitoring and documentation, and inaccurate recordkeeping regarding the application of prescribed treatments.
Failure to Ensure Accurate IV Dressing Changes and Documentation
Penalty
Summary
A deficiency occurred when a resident with a history of osteomyelitis, respiratory failure, and quadriplegia did not receive midline intravenous access site dressing changes as ordered by the physician. The physician's order specified that the midline dressing should be changed every seven days and as needed, with the site observed every shift. However, observation revealed that the dressing on the resident's left upper arm was dated over three weeks prior, and there was dried blood around the insertion site. Despite this, the Medication Administration Record (MAR) and Treatment Administration Record (TAR) documented that dressing changes had been completed on multiple dates within the month. Further review showed that the resident's care plan did not include any documentation related to the midline intravenous access. Interviews with facility staff confirmed that the dressing had not been changed according to the schedule, and that inaccurate documentation had been entered into the MAR and TAR. The Director of Nursing acknowledged that nurses should not document treatments that were not performed and confirmed the care plan had not been updated since the midline was placed.
Failure to Timely Return and Destroy Medications; Missed Routine Medication Administration
Penalty
Summary
The facility failed to ensure timely return of medications to the pharmacy following resident discharge and did not destroy unused narcotics within the required timeframe. Observations and interviews revealed that several medication cards, including controlled substances such as oxycodone, morphine, and lorazepam, remained in the facility after residents had either been discharged or had passed away. The Director of Nursing (DON) initially stated that unused medications were sent back to the pharmacy twice weekly and denied the presence of unused narcotics, but subsequent observations and interviews confirmed that unused narcotics had not been destroyed promptly. Review of facility policy and Ohio Revised Code indicated that controlled substances should be destroyed within ten days of removal from storage, and medications eligible for return should be sent back within 48 hours or as soon as practicably possible. Additionally, the facility failed to ensure that a resident with diabetes received routine medication as ordered by the physician. The resident was prescribed Ozempic, to be administered once weekly, but did not receive the medication as scheduled. The resident reported not receiving the medication on the correct day and expressed concerns that the medication may have been taken for unauthorized use. Review of the Medication Administration Record (MAR) and pharmacy delivery slips confirmed discrepancies in the administration and availability of the medication, with documentation showing a dose was given prior to the medication being delivered and subsequent doses missed due to unavailability. These deficiencies affected the residents directly involved and had the potential to impact all residents in the facility. The facility census at the time was 85, and the failures were identified through interviews, observations, record reviews, and policy reviews, as well as a review of relevant state regulations.
Failure to Ensure Timely Infectious Disease Follow-Up for Antibiotic Management
Penalty
Summary
The facility failed to ensure appropriate follow-up with a specialty physician regarding an antibiotic regimen for a resident diagnosed with bladder cancer who was receiving chemotherapy. The resident had impaired cognition and was receiving intravenous Cefazolin, with orders to follow up with infectious disease and to fax laboratory results weekly. Laboratory results indicated worsening kidney function, with elevated BUN and creatinine levels and decreased GFR. The pharmacy notified staff of the need to adjust the antibiotic dosage due to declining kidney function and recommended a lower dose. The nurse practitioner advised staff to follow pharmacy recommendations and to contact infectious disease for further orders, but the orders were not changed at that time, and the information was passed to the oncoming nurse. Subsequent progress notes documented that the antibiotic was placed on hold due to abnormal kidney function, and the pharmacy again recommended a lower dose. The nurse practitioner reiterated that laboratory results should be faxed to infectious disease, as they were responsible for managing the antibiotics, and instructed staff to follow pharmacy recommendations until infectious disease provided orders. However, there was no documentation that the infectious disease physician was contacted or provided orders, and the resident continued to receive the higher dose of Cefazolin. Interviews with staff and the administrator confirmed the lack of infectious disease orders and follow-up, resulting in a failure to ensure the resident's drug regimen was free from unnecessary drugs.
Failure in Pain Management Leads to Resident Rehospitalization
Penalty
Summary
The facility failed to provide adequate pain management for a resident admitted for post-operative care following surgery for perforated diverticulitis. The resident, who had undergone a sigmoid colectomy and had an abdominal wound requiring dressing changes, was discharged from the hospital with a prescription for Oxycodone to manage pain. However, upon admission to the facility, the resident did not receive the prescribed pain medication due to issues with accessing the medication from the facility's emergency supply system. The resident experienced severe pain throughout the night, which was not addressed by the nursing staff. Despite the resident's repeated requests for pain relief and the CNA's reports of the resident's distress, the LPN on duty was unable to administer the prescribed medication due to a lack of access to the Omnicell system, which required two nurses to retrieve medication. The resident's pain was not properly assessed or documented, and the situation was not escalated to the Director of Nursing for resolution. As a result of the facility's failure to manage the resident's pain, the resident called emergency services multiple times and was eventually transferred back to the hospital. The resident's wife was also involved in attempting to secure pain relief for her husband, but the situation was not resolved before the resident was readmitted to the hospital. The facility's policy on pain management, which required a comprehensive assessment and timely administration of pain medication, was not followed, leading to actual harm to the resident.
Inadequate Hand Hygiene and Infection Control During Incontinence Care
Penalty
Summary
The facility failed to ensure proper hand hygiene and infection control practices during incontinence care for two residents, affecting their overall care quality. Resident #81, with severe cognitive impairment and multiple health conditions, was observed through video footage installed by her representative. The footage revealed that several State Tested Nursing Assistants (STNAs) consistently failed to perform hand hygiene after providing incontinence care. They used soiled gloves to touch the resident, her personal items, and the environment, and improperly disposed of soiled items by placing them on the floor. The video evidence, reviewed with the Administrator and Director of Nursing (DON), showed repeated instances of STNAs #90, #91, #92, #93, #94, #95, #96, #97, and #98 neglecting hand hygiene protocols. These staff members were seen using soiled gloves to handle the resident's bed linens, personal items, and even assist with feeding, without changing gloves or washing hands. Additionally, some STNAs placed soiled incontinence briefs and wipes directly on the floor, further compromising infection control standards. Resident #52, who required assistance with toileting and hygiene, was also affected by similar lapses in infection control. During an observation, STNA #98 performed incontinence care without removing soiled gloves or performing hand hygiene afterward. This STNA then proceeded to handle the resident's bed remote, linens, and call light with contaminated gloves. The facility's policy on hand hygiene, which emphasizes the importance of hand cleaning before and after resident contact, was not adhered to, leading to these deficiencies.
Failure to Timely Refer Resident for Dental Services
Penalty
Summary
The facility failed to timely refer a resident for dental services after the resident's dentures went missing. The resident, who was severely cognitively impaired and edentulous, reported the missing dentures to the nursing staff. Despite the resident's report and a search conducted by staff and family, the dentures were not found. The Director of Nursing was unaware of the missing dentures, and the Assistant Director of Nursing assumed the social worker would handle the issue. However, the Director of Social Services was not informed of the missing dentures until several days later. The facility's policy required that residents with lost or damaged dentures be referred for dental services within three days. However, this policy was not followed, as the referral process for the resident's dental services did not begin until after the Director of Social Services was informed. The delay in addressing the resident's need for dental services was a result of a lack of communication and awareness among the facility's staff, leading to non-compliance with the facility's dental services policy.
Failure to Secure Resident During Transport
Penalty
Summary
The facility failed to ensure that a resident was appropriately secured during a wheelchair transport, resulting in an unsafe transfer. The incident involved a resident who was being transported to a dentist appointment via a facility van. The transport driver initially secured the resident in her wheelchair but, upon realizing he was in the wrong driveway, moved the van without re-securing the resident. This caused the resident's wheelchair to tip backward, and she reported hitting her head on the van door. The resident was subsequently admitted to the hospital for a head injury, although imaging revealed no acute intracranial process or hemorrhage. The resident involved had a medical history that included muscle weakness, essential hypertension, and acute kidney failure. At the time of the incident, the resident exhibited intact cognition. The transport driver admitted to not securing the resident during the short move between driveways and was terminated following the incident. The facility conducted an investigation and found that the transport driver had been educated on safe transport procedures but failed to follow them in this instance.
Failure to Provide Pain Management During Wound Care
Penalty
Summary
The facility failed to provide appropriate pain management for a resident with a Stage IV pressure ulcer during wound care. On the specified date, a registered nurse proceeded with the wound care without verifying if the resident had received the prescribed narcotic pain medication, despite the resident expressing pain and inquiring about the medication. The resident experienced significant pain during the procedure, rated at an eight out of ten, and displayed facial grimacing. The medical record confirmed that the resident had not been given the ordered Oxycodone prior to the wound care, and the nurse admitted to not checking the Medication Administration Record (MAR) before proceeding with the treatment. The resident's care plan included interventions for pain management, such as administering medications per physician orders and monitoring pain levels. However, these interventions were not followed during the incident. The Director of Nursing confirmed that the staff should have checked if the pain medication had been administered and waited for it to take effect before proceeding with the wound care. The facility's policy on pain management emphasized the importance of assessing and managing pain to ensure residents' well-being, which was not adhered to in this case.
Failure to Timely Treat UTI
Penalty
Summary
The facility failed to timely treat a urinary tract infection (UTI) for a resident, leading to a deficiency. The resident, who was admitted with severe sepsis, bacteremia, diabetes mellitus type two, and stage four chronic kidney disease, had a urinalysis on 03/12/24, and the culture results were reported on 03/16/24, indicating Escherichia Coli growth. Despite the positive culture, the facility did not initiate antibiotic treatment until 03/18/24, two days after receiving the culture results. The resident's care plan included monitoring lab work due to the risk of dehydration and other complications, but this was not adequately followed in a timely manner. The resident's Medication Administration Record confirmed that the antibiotic treatment was administered from 03/18/24 through 03/25/24. However, the progress notes from 03/12/24 through 03/25/24 did not address the resident's UTI, symptoms, testing, or antibiotic use. The Director of Nursing confirmed the delay in treatment but could not provide a reason for it. This deficiency was investigated under Complaint Number OH00152563.
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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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