Taylor Springs Health Campus
Inspection history, citations, penalties and survey trends for this long-term care facility in Gahanna, Ohio.
- Location
- 748 Taylor Road, Gahanna, Ohio 43230
- CMS Provider Number
- 366480
- Inspections on file
- 16
- Latest survey
- April 28, 2025
- Citations (last 12 mo.)
- 0
Citation history
Health deficiencies cited at Taylor Springs Health Campus during CMS and state inspections, most recent first.
Two residents with significant upper extremity limitations and contracture risks did not receive timely, individualized interventions or care planning to address their range of motion (ROM) needs. Despite therapy assessments identifying ROM deficits and dependence on staff for care, neither resident had a care plan or ongoing services to maintain or improve ROM, and staff interviews confirmed a lack of interventions. The facility lacked a policy on ROM or therapy services, leading to actual harm including contracture development and pain.
The facility did not develop or implement comprehensive care plans for several residents with complex medical and psychiatric conditions, including those requiring continuous oxygen therapy, management of constipation and anemia, upper extremity contractures, and insomnia treated with Melatonin. Physician orders and direct observations confirmed the presence of these needs, but care plans were missing, and staff acknowledged the deficiencies.
A resident receiving enteral feedings was found to have dried tube feeding formula splattered across the walls, ceiling, personal items, and equipment in their room. The unsanitary condition resulted from formula spraying out during attempts to flush or unclog the gastrostomy tube, and the mess remained unaddressed for several days despite staff awareness.
A resident with multiple complex medical conditions, including hypoxemia and acute respiratory failure, was documented and observed to be receiving continuous oxygen therapy. However, the MDS assessment did not reflect the resident's oxygen use, and there was no care plan addressing this intervention. This inaccuracy was confirmed by an RN.
A resident admitted with diagnoses of mood disorder and anxiety disorder was not accurately identified on the PASRR screening, as these mental health conditions were omitted from the required section. This led to the resident being incorrectly determined as not needing further evaluation for serious mental illness.
Surveyors found that two residents' care plans were not revised to accurately reflect their current conditions. One resident's care plan included a pressure injury that was not present and lacked individualized non-pharmacological pain interventions, while another resident's care plan did not document the loss and replacement process of lower dentures, despite ongoing dental consults and resident reports.
Three residents who required staff assistance with ADLs did not consistently receive scheduled showers or routine nail care as required by their care plans and facility policy. One resident missed multiple scheduled showers over several months, another was observed with long and dirty nails on consecutive days, and a third received only one bath in a month despite being scheduled for twice-weekly showers. Staff interviews and documentation confirmed these deficiencies.
Two residents with significant mental health and cognitive needs did not receive individualized activities as required by their care plans. One resident missed several weeks of scheduled 1:1 activities, while another with severe cognitive impairment had limited group activity participation and was not accurately assessed for 1:1 attention, despite staff awareness of her needs and interests.
The facility failed to comprehensively assess and document pressure ulcers for two residents on admission and weekly thereafter, and did not implement timely interventions to prevent a new pressure ulcer in another resident. Incomplete wound assessments, delayed or inappropriate treatments, and lack of consistent repositioning contributed to the deficiencies, with staff citing inexperience and discomfort with wound staging as contributing factors.
A resident with multiple complex medical conditions was observed using a Bi-pap device with oxygen without a current physician order or documented monitoring. The care plan and MDS assessment did not address the use of Bi-pap or oxygen, and staff confirmed there was no active order for the device's settings or application.
A resident with multiple cardiac and neurological conditions received Metoprolol outside of physician-ordered parameters, as the medication was administered several times when the resident's pulse was below 60, contrary to the order to hold the medication under these circumstances. This was confirmed by the Regional Nurse.
A resident with a history of dental issues and multiple comorbidities experienced ongoing tooth pain and difficulty chewing, with staff documenting broken and missing teeth. Despite repeated requests and a care plan calling for dental coordination, the resident did not receive a dental exam or timely follow-up, and the facility failed to ensure access to both routine and emergency dental care as required by policy.
A resident with multiple medical conditions and intact cognition was prescribed a short course of cephalexin for cellulitis, but received three additional doses beyond what was ordered. The facility did not identify or address the over-administration during their antibiotic use review, despite having a policy requiring monitoring of antibiotic use.
A resident with severe cognitive impairment and physical dependency on staff for eating did not receive timely meal assistance. The resident was observed with an untouched meal for almost thirty minutes while only one CNA was available to assist multiple residents. The CNA confirmed the delay, attributing it to the high number of residents needing assistance.
A resident with severe cognitive impairment reported an unsubstantiated abuse incident to the police, but the LTC facility failed to report the allegation to management and the state agency in a timely manner, as required by their policy. The executive director was informed two days later, leading to a deficiency.
A resident with severe cognitive impairment and multiple diagnoses fell and sustained a wrist fracture. Despite severe pain and visible swelling, the facility failed to provide adequate pain management or timely medical intervention, resulting in over six hours of unmanaged pain.
A resident with severe cognitive impairment and a broken left wrist did not receive the required care as per emergency room instructions. The facility failed to document or implement orders for icing, elevating the wrist, and checking the skin under the splint, as confirmed by the DON.
A resident with severe cognitive impairment did not receive prescribed diazepam as ordered due to medication unavailability and discrepancies between the MAR and controlled drug use record. The DON confirmed the medication was not administered as documented.
The facility failed to maintain an accurate medical record for a controlled drug for a resident with severe cognitive impairment. The MAR indicated that all doses of diazepam were administered, but the controlled drug use record showed missing signatures for several doses. This discrepancy was confirmed by the DON, making the medical record inaccurate.
Failure to Implement Individualized ROM Interventions Resulting in Contractures
Penalty
Summary
The facility failed to timely develop and implement comprehensive and individualized interventions to address limitations in range of motion (ROM) and to prevent the onset or worsening of joint contractures for two residents. For one resident with a history of cerebrovascular accident, hemiplegia, and multiple comorbidities, occupational therapy (OT) assessments repeatedly identified limitations in left upper extremity ROM, including the wrist and fingers. Despite these findings and the resident's dependence on staff for activities of daily living, the care plan did not address the identified ROM limitations, risk for contractures, or include an individualized ROM program. After discharge from OT, there was no evidence of ongoing interventions or documentation of ROM services, and observations revealed the resident's arm was fixed in a contracted position, with no staff-provided ROM observed by the resident's spouse. Interviews with therapy and nursing staff confirmed that the resident had not been screened or evaluated by OT since discharge, and functional limitations were not reported by nursing staff. Another resident with a history of cerebellar stroke and contractures was referred to OT for declining upper extremity ROM and contracture prevention. After discharge from OT due to hospitalization, there was no evidence in the medical record of further therapy evaluation, ROM services, or interventions to prevent further decline in contractures for over a year. The resident was dependent on staff for care, had significant upper extremity contractures, and was not receiving any specialized therapies or restorative nursing programs. Interviews with nursing staff confirmed the absence of interventions or splints for the resident's upper extremities, and the resident reported not receiving ROM from staff and being unable to perform basic self-care tasks due to contractures. Both residents' care plans failed to address their upper extremity functional limitations and contracture risks, despite clear documentation of these issues in therapy assessments and resident interviews. The facility did not have a policy regarding ROM or therapy services, and there was no evidence of interdisciplinary planning or implementation of individualized interventions to maintain or improve ROM or prevent further decline. These failures resulted in actual harm, including deterioration in functional ability and pain for at least one resident.
Failure to Develop Comprehensive Care Plans for Resident Needs
Penalty
Summary
The facility failed to develop and implement comprehensive care plans to address the specific needs and conditions of several residents, as required by regulation. For one resident with multiple complex diagnoses, including metabolic encephalopathy, cerebrovascular accident, and acute respiratory failure, there was no care plan addressing the use of continuous oxygen therapy, despite physician orders and direct observation confirming ongoing oxygen use. The resident's Minimum Data Set (MDS) assessment also did not reflect oxygen use, and nursing staff confirmed the absence of a care plan for this intervention. Another resident with diagnoses such as acute respiratory failure, cerebral infarct, and obstructive sleep apnea was observed using a Bi-pap device with oxygen, and physician orders specified continuous oxygen therapy and related care. However, there was no care plan in place to address the resident's oxygen use, and the MDS assessment did not indicate oxygen therapy, despite documentation and observation to the contrary. Nursing staff confirmed the lack of a care plan for this resident's oxygen therapy. A third resident with a history of constipation, anemia, and contractures had active physician orders and was receiving medications for constipation and anemia, but there was no care plan addressing these conditions or the resident's significant upper extremity functional limitations and contractures. Additionally, a fourth resident with multiple psychiatric diagnoses and an order for nightly Melatonin for insomnia did not have a care plan addressing insomnia or the use of Melatonin, despite the order being in place for an extended period. Nursing staff responsible for care planning confirmed the absence of required care plans for these residents.
Failure to Maintain Clean and Sanitary Resident Room and Equipment
Penalty
Summary
A deficiency was identified when a resident's room and equipment were found to be unclean and unsanitary. The resident, who had diagnoses including anxiety disorder, depression, malnutrition, and adult failure to thrive, was receiving daily enteral feedings via a gastrostomy tube. Observations revealed a dried yellow substance, identified as tube feeding formula, splattered across the walls, ceiling, ceiling light, personal items, and television screen in the resident's room. The tube feeding pump pole and its base were also covered with the same dried substance. These findings were confirmed by an LPN, who acknowledged the extent of the splatter but was unaware of its cause at the time. Further interview with the resident indicated that the splattering occurred when nurses attempted to flush or unclog the gastrostomy tube, causing the formula to spray throughout the room. Despite the initial observation and verification by staff, a follow-up observation several days later found that the room and equipment remained in the same unsanitary condition, with the dried formula still present on multiple surfaces. The ongoing presence of the dried tube feeding formula was confirmed by another staff member during the subsequent observation.
Inaccurate MDS Coding for Oxygen Use
Penalty
Summary
The facility failed to ensure that a resident's Minimum Data Set (MDS) assessment was coded accurately regarding oxygen use. The resident, who had multiple complex diagnoses including metabolic encephalopathy, pneumonitis, cerebrovascular accident with right-sided hemiplegia, epilepsy, diabetes, dysphagia, anemia, hypoxemia, sepsis, severe malnutrition, hypertension, and acute respiratory failure with hypoxia, was admitted and readmitted with ongoing medical needs. Physician orders and the Treatment Administration Record (TAR) documented continuous oxygen use at two liters per nasal cannula, and direct observation confirmed the resident was receiving oxygen. However, the quarterly MDS assessment did not indicate the resident's use of oxygen, and there was no care plan addressing oxygen use. This discrepancy was confirmed by a registered nurse during an interview.
Failure to Accurately Complete PASRR for Mental Health Diagnoses
Penalty
Summary
The facility failed to ensure that the Preadmission Screening and Resident Review (PASRR) was completed accurately for a resident admitted with known mental health diagnoses. Upon review, the resident's medical record showed diagnoses of an unspecified (affective) mood disorder and anxiety disorder at the time of admission. However, the PASRR identification screen did not indicate these mental disorders, as required in Section E, despite them being listed among the mental disorders to be reported. As a result, the PASRR result notice concluded that the resident did not have indications of a serious mental illness and did not require a Level II evaluation for specialized services. The current Social Service Director confirmed that the PASRR was not accurate and did not reflect the resident's known mental illness diagnoses.
Care Plans Not Updated to Reflect Residents' Current Status
Penalty
Summary
The facility failed to ensure that comprehensive care plans were revised and accurately reflected the current status of two residents. For one resident with a history of constipation, fecal impaction, anemia, contractures, and cerebellar stroke, the care plan listed a pressure injury as a problem area, despite no evidence of a pressure injury in the medical record. Additionally, the care plan for pain management did not include individualized non-pharmacological interventions, and this omission was confirmed by the Regional MDS Coordinator. For another resident with dysphagia, diabetes mellitus, metabolic encephalopathy, and who was edentulous, the care plan only addressed the potential for mouth pain related to the use of top dentures. The care plan was not updated to reflect the loss of the lower denture and the ongoing process of obtaining a replacement, despite documentation in dental consults and resident interviews indicating the resident had been waiting for new lower dentures for approximately six months. The Regional Nurse confirmed that the care plan had not been revised to include these developments.
Failure to Provide Scheduled Showers and Nail Care for Dependent Residents
Penalty
Summary
The facility failed to provide routine nail care and scheduled showers for three residents who required staff assistance with activities of daily living (ADLs). For one resident with multiple diagnoses including dysphagia, aphasia, heart failure, and obesity, the care plan required staff assistance for ADLs and scheduled showers twice weekly. Documentation revealed that this resident missed several scheduled showers over a three-month period, with confirmation from the Regional MDS Coordinator that showers were not provided as scheduled. Another resident, with severe cognitive impairment and multiple complex medical conditions such as metabolic encephalopathy, sepsis, and Alzheimer's disease, required extensive staff assistance for self-care and mobility. The care plan specified nail care on shower days and as needed. Observations on two consecutive days found the resident's nails to be long and dirty with a brown substance underneath, and both an LPN and an RN confirmed the need for nail care at the time of observation. A third resident, who was cognitively intact but dependent on staff for functional abilities including bathing, received only one bath during a one-month period despite being scheduled for showers twice weekly. Review of documentation and interviews with the DON confirmed that there was no additional bath or refusal documentation for this resident. Facility policy required bathing at least twice a week unless otherwise specified by resident preference, but this was not adhered to for the residents involved.
Failure to Provide Individualized Activities for Residents
Penalty
Summary
The facility failed to provide appropriate activity programming to meet the individualized needs of two residents. One resident with major depressive disorder, anxiety, contractures, and a history of stroke was assessed to require weekly 1:1 meaningful activities, such as board games, music, and animal-related activities. However, documentation showed that this resident did not receive the required weekly 1:1 activity for a period of over three weeks. The Area Life Enrichment Director confirmed the absence of documentation and that the resident did not receive the scheduled activities during that time frame. Another resident with severe cognitive impairment, toxic encephalopathy, anxiety, and repeated falls was identified as being at risk for limited activity engagement. The care plan noted interests in sports and social interaction, and the resident expressed a desire for more social and sports-related activities. Despite this, activity logs indicated minimal participation in group activities, and the assessment inaccurately reflected the resident's engagement level. Staff interviews confirmed that the resident often required 1:1 attention, which was not properly documented or provided according to the assessment, and that family presence was incorrectly considered as a substitute for activity participation.
Failure to Assess, Document, and Prevent Pressure Ulcers
Penalty
Summary
The facility failed to ensure comprehensive assessment and documentation of pressure ulcers for two residents upon admission and on a weekly basis, as well as failed to implement interventions to prevent the development of a pressure ulcer for another resident. For one resident with multiple comorbidities including spinal stenosis, diabetes, and recent surgery, the initial wound assessments were incomplete, lacking proper staging, detailed descriptions, and consistent measurements. The wound nurse was reportedly inexperienced and uncomfortable with staging, resulting in delayed and inadequate documentation. Physician-ordered treatments were not implemented promptly, and wound care was not always appropriate for the stage of the ulcer. Another resident with a history of severe medical conditions and high risk for skin breakdown was admitted and readmitted with skin impairments, including abrasions and moisture-associated skin damage (MASD). The facility did not provide comprehensive assessments of these wounds, often omitting location, measurements, staging, and descriptions. Weekly wound observations were incomplete, and there was a consistent failure to determine whether wounds had improved, deteriorated, or remained unchanged. Documentation was insufficient, and the care plan interventions were not always based on thorough wound assessments. A third resident, who was at risk for pressure ulcers and required significant assistance with mobility and hygiene, developed a new pressure ulcer after admission. The facility did not implement timely interventions such as regular turning and repositioning, despite recommendations from a prior wound care consult. Documentation of the new ulcer lacked staging and pain assessment, and the care plan was not updated with new interventions until after the ulcer developed. Observations showed the resident frequently left in bed with the head elevated and expressing discomfort, with staff interviews confirming that repositioning was not consistently performed or documented.
Failure to Obtain Physician Order and Monitor Bi-pap Use
Penalty
Summary
The facility failed to obtain a current physician order and provide appropriate monitoring for a resident using a Bi-pap non-invasive ventilation device. The resident, who had multiple complex diagnoses including acute respiratory failure with hypoxia, obstructive sleep apnea, and other chronic conditions, was observed on two occasions using the Bi-pap machine with oxygen. However, review of the medical record showed that the only physician order for Bi-pap had been discontinued, and there was no active order specifying the settings, application, or monitoring requirements for the device. Additionally, the resident's care plan did not address the use of oxygen or Bi-pap, and the comprehensive MDS assessment did not indicate the use of these respiratory therapies. Further review of the resident's records revealed ongoing orders for oxygen therapy but none for Bi-pap after the previous order was discontinued. Interdisciplinary team notes indicated the resident was non-compliant with Bi-pap but would use nasal cannula oxygen. Despite this, direct observation confirmed the resident was using the Bi-pap device without a current physician order or documented monitoring. Interview with the regional nurse confirmed the absence of an order for the Bi-pap machine's use and monitoring.
Failure to Follow Physician Parameters for Antihypertensive Medication Administration
Penalty
Summary
The facility failed to ensure that a resident's antihypertensive medication, Metoprolol, was administered according to the physician's ordered parameters. The physician's order specified that Metoprolol 25 mg should be held if the resident's systolic blood pressure was less than 110 or if the heart rate was less than 60. Despite these instructions, the medication was administered on multiple occasions when the resident's pulse was below 60, including documented instances where the pulse was 58, 57, 52, 55, and 59. The resident had a medical history that included dysphagia, aphasia, dysarthria, atrial septal defect, asthma, atrial fibrillation, hypertensive urgency, hypertensive heart disease with heart failure, obesity, heart failure, and hyperlipidemia. The Regional Nurse confirmed that the medication was given outside the prescribed parameters.
Failure to Provide Timely Dental Services
Penalty
Summary
The facility failed to ensure that a resident received both emergent and routine dental care as required. The resident, who had a history of multiple medical conditions including dysphagia, aphasia, heart disease, and obesity, was identified in the care plan as having two broken teeth and difficulty chewing. Interventions in the care plan included coordinating dental care and monitoring for oral health issues. Despite these interventions, documentation showed that the resident continued to report tooth pain and difficulty chewing over several months. Nursing staff observed missing and broken teeth and offered pain medication, which the resident declined, and initiated a referral to a dentist. However, there was no documented evidence that the resident was actually seen by a dentist or that the facility followed up to secure a dental appointment. Further review revealed that the resident had not received a dental exam since early in the previous year, despite ongoing complaints of dental pain and visible oral health issues such as broken and missing teeth with obvious caries. Interviews confirmed that the resident had repeatedly requested to see a dentist and continued to experience pain when eating. The facility's policy required assistance in obtaining both routine and emergency dental care, including making appointments and arranging transportation, but these actions were not completed for this resident.
Failure to Administer Antibiotics as Ordered
Penalty
Summary
The facility failed to administer antibiotics as ordered for one resident. Medical record review showed that the resident was admitted with multiple diagnoses, including anxiety disorder, depression, psychotic disorder with delusions, contractures, and cerebellar stroke. The resident was cognitively intact according to the quarterly MDS assessment. A nurse practitioner evaluated the resident for right lower extremity edema and mild pain, diagnosed very mild cellulitis, and ordered a short course of cephalexin 500 mg three times a day. The electronic physician orders reflected this prescription. However, review of the medication administration record revealed that the resident received 18 doses of cephalexin instead of the 15 doses ordered, resulting in three additional doses being administered. The infection control log confirmed the resident met criteria for antibiotic treatment, but there was no evidence that the facility identified or addressed the administration of extra doses during their antibiotic use review. An interview with the regional nurse confirmed the over-administration. The facility's antibiotic stewardship policy required monitoring of antibiotic use to prevent unnecessary or inappropriate administration, but this was not followed in this instance.
Failure to Provide Timely Meal Assistance
Penalty
Summary
The facility failed to provide timely meal assistance to a resident who was dependent on staff for eating. Resident #44, who had diagnoses including dementia, osteoporosis, contracture of the left hand, and muscle weakness, was observed sitting in the dining room with a plate in front of her, untouched, for almost thirty minutes. The resident's comprehensive Minimum Data Set (MDS) assessment indicated severely impaired cognition and a dependency on staff for eating, with a diet order for a puree diet. During the observation, only one Certified Nursing Assistant (CNA) was present in the dining room, assisting three other residents who also required feeding assistance. Additional staff entered the dining room later, but no one assisted Resident #44 with her meal during the observation period. CNA #185 confirmed that Resident #44 was dependent on staff for eating and acknowledged the delay in assistance, citing the high number of residents needing help at meals. This deficiency was investigated under Complaint Numbers OH00162840 and OH00161491.
Failure to Timely Report Allegation of Abuse
Penalty
Summary
The facility failed to timely report an allegation of abuse involving a resident with severe cognitive impairment. The resident, who had diagnoses including gastro-esophageal reflux disease, hypertension, osteoporosis, and diverticulosis, reported to the police that a man had entered her room and had his way with her. The police found the complaint unsubstantiated and left. Despite the serious nature of the allegation, the incident was not reported to the executive director or the state agency until two days later. Interviews with facility staff revealed that the resident's confusion and agitation were noted on the night of the incident, and the resident's daughter was contacted. However, the staff did not notify management immediately, as required by the facility's policy. The executive director was only informed of the allegation two days later, at which point an SRI was initiated. The facility's policy mandates immediate reporting of such allegations, but this protocol was not followed, resulting in a deficiency.
Inadequate Pain Management for Resident Following Fall
Penalty
Summary
The facility failed to develop and implement an individualized, effective, and comprehensive pain management program for a resident who experienced pain following a fall. The resident, who had severe cognitive impairment and multiple diagnoses including a displaced bicondylar fracture of the right tibia and unspecified dementia, fell and sustained a closed fracture of the distal ends of the left radius and ulna. Despite the resident's complaints of severe pain and visible swelling, the facility did not provide adequate pain management or timely medical intervention. On the day of the fall, the resident was found on the floor with a swollen left wrist and reported pain rated at eight out of ten. The resident was given one dose of Hydrocodone-Acetaminophen, which was noted to be ineffective. However, no further pain medication or non-pharmacological interventions were provided, and the resident was not transferred to the emergency room until over six hours later. During this time, the resident continued to exhibit signs of pain, such as grimacing and guarding the injured wrist, but no additional assessments or follow-ups were conducted. Interviews with facility staff revealed a lack of communication and proper pain management protocols. The LPN caring for the resident did not document the pain scale, failed to administer additional pain medication, and did not contact the Certified Nurse Practitioner for further instructions. The Director of Nursing acknowledged the need for reeducation on pain management and proper assessment for residents with severe cognitive impairments. The facility's policy on pain observation and management was not followed, leading to inadequate care for the resident.
Failure to Provide Care for Broken Wrist
Penalty
Summary
The facility failed to provide appropriate care for a resident with a broken left wrist. The resident, who had severe cognitive impairment and required substantial assistance with daily activities, experienced an unwitnessed fall resulting in pain and swelling to the left wrist. An X-ray confirmed a closed fracture of the distal ends of the left radius and ulna. The emergency room discharge instructions included applying ice to the wrist, elevating it, and checking the skin under the splint daily. However, there was no documentation in the resident's chart indicating that these instructions were followed, nor were there any orders placed to ensure these care measures were implemented. The Director of Nursing confirmed that no orders were placed for the resident's wrist care as instructed by the emergency room. The progress notes from the date of the fall to the resident's discharge showed no evidence that the wrist was iced, elevated, or that the skin under the splint was checked. This deficiency was identified during a complaint investigation and represents non-compliance with the required standards of care.
Failure to Administer Medication as Ordered
Penalty
Summary
The facility failed to administer medication as ordered by the physician for one resident. The resident, who had severe cognitive impairment and required substantial assistance with daily activities, was prescribed diazepam to be administered three times a day for anxiety. However, the medication was unavailable for administration on multiple occasions, and there were discrepancies between the Medication Administration Record (MAR) and the controlled drug use record. Specifically, doses were signed off as administered on the MAR, but the controlled drug use record did not reflect these administrations, indicating that the medication was not given as prescribed. Interviews with the Director of Nursing (DON) confirmed that the diazepam tablets were not administered when documented as unavailable and that doses were not signed out on the controlled drug record form despite being marked as given on the MAR. This discrepancy led to the conclusion that the medication was not administered to the resident as ordered by the physician. The deficiency was identified during a complaint investigation and was verified through closed medical record review and staff interviews.
Failure to Maintain Accurate Medical Record for Controlled Drug
Penalty
Summary
The facility failed to maintain an accurate medical record for a controlled drug for one resident. The resident, who had severe cognitive impairment and required substantial assistance with daily activities, was prescribed diazepam for anxiety. The Medication Administration Record (MAR) indicated that all doses of diazepam were administered as prescribed. However, the controlled drug use record showed missing signatures for several doses, indicating that the medication may not have been administered as recorded in the MAR. This discrepancy was confirmed by the Director of Nursing during an interview, who verified that the doses were not signed out on the controlled drug record form, making the medical record inaccurate. The resident's medical history included a displaced bicondylar fracture of the right tibia, age-related osteoporosis, and unspecified dementia with behavioral disturbances. The resident was also taking antipsychotic, antianxiety, and opioid medications. The failure to accurately document the administration of diazepam raises concerns about the accuracy and reliability of the resident's medical records. This deficiency was identified during a review of the closed medical record and was part of an investigation under Complaint Number OH00152040.
Latest citations in Ohio
A resident with intact cognition receiving Medicare Part A skilled services for metabolic encephalopathy had services discontinued while benefit days remained, but the facility did not issue the required Skilled Nursing Facility Advance Beneficiary Notice (SNF ABN). The Social Services Director later confirmed that no SNF ABN was provided and reported she believed only a Notice of Medicare Non-Coverage (NOMNC) was needed when all skilled services were stopped. This practice conflicted with the facility’s written policy, which required SNF ABNs to be issued when extended care items or services were initiated, reduced, or terminated due to expected non-coverage by Medicare.
Surveyors identified that the facility exceeded the acceptable medication error rate when two residents with type 2 DM received insulin doses that were not administered according to orders or manufacturer instructions. In two separate observations, an LPN administered Novolog and another LPN administered insulin glargine and insulin lispro without priming the insulin pens, and the insulin lispro and Novolog were given after the residents had already consumed a significant portion of their breakfast meals, despite orders for administration before meals. Manufacturer information for both insulin products required priming before each injection to ensure accurate dosing, and facility policy required medications, including insulin, to be administered safely, timely, and in accordance with prescriber orders and specified time frames.
Surveyors found that the facility failed to document tray line food temperatures for multiple meals served from two dining room kitchenettes, despite having a “Trayline Taste & Temperature Log” and a policy requiring food to be stored, prepared, distributed, and served according to professional food safety standards. Review of logs showed repeated missing entries for breakfast, lunch, and dinner services in both the Harrison and McClellan dining areas, and the Senior Director of Culinary Services confirmed that temperatures had not been recorded for those meals, potentially affecting all residents receiving meals from those kitchenettes.
The facility failed to conduct and document required periodic care conferences for two residents, despite multiple comprehensive, quarterly, and significant change MDS assessments and a policy requiring periodic care conferences with resident and/or family participation. One resident with Parkinson’s disease, post-stroke hemiplegia, TIA, DMII, and depression had only two documented care conferences over a year, while another resident with aphasia, cerebrovascular disease, DMII, gait difficulty, coagulation defect, depression, and muscle weakness had no documented care conferences in the past year, aside from a declined invitation to the representative. The UCC confirmed that care conferences were expected to occur quarterly and that no additional documentation existed for either resident.
A resident with Alzheimer's disease and type II DM, who required extensive assistance with ADLs and was receiving scheduled Lantus and sliding-scale Humalog, experienced a severely elevated blood glucose level. The on-call provider was notified and ordered an additional dose of lispro insulin with a directive to recheck the blood glucose after administration. Nursing staff administered the extra insulin but did not document any follow-up blood glucose check, and the DON confirmed that this reevaluation was required by the facility's abnormal blood glucose policy and was not completed or documented.
A resident with Parkinson’s disease, dementia, and hypothyroidism was prescribed levothyroxine once daily along with other medications. A consultant pharmacist’s monthly drug regimen review recommended that levothyroxine be given in the morning on an empty stomach, 30–60 minutes before food, per manufacturer instructions. The medical record contained no documented physician response to this recommendation, and the MAR showed the drug scheduled for morning administration while the resident was observed eating breakfast and receiving the medication at the same time. An LPN confirmed administering levothyroxine during the meal, and the DON verified there was no documentation explaining whether or why the pharmacist’s recommendation was or was not followed, resulting in a failure to act on and document the identified irregularity.
A resident with severe cognitive impairment, multiple comorbidities, documented gait and balance abnormalities, and a high fall risk was care planned and assessed by therapy to require contact guard assistance and use of a gait belt for transfers and ambulation. While being assisted by a CNA from a recliner to the bathroom with a walker, the CNA did not apply a gait belt, even though the resident had a known tendency to lean backward when standing. As the CNA reached to open the bathroom door, the resident lost balance and fell backward, striking the back of the head, and was later found by an LPN without a gait belt in place, contrary to the facility’s gait belt policy and the resident’s assessed needs.
A resident with CKD stage five requiring peritoneal dialysis (PD) was admitted with pre-admission physician orders for three daily PD exchanges and monitoring for peritonitis (fever, abdominal pain, cloudy effluent), but these monitoring orders were not entered into the facility’s physician orders. The care plan referenced PD and general monitoring but did not specifically address peritonitis monitoring. Paper PD flowsheets showed incomplete and inconsistent documentation of exchanges and resident condition, including missing condition/comments for individual treatments and no record of one ordered PD exchange. The PD cycler flowsheet lacked effluent descriptions on multiple days. The PD nurse reported facility staff were expected to monitor effluent and symptoms, and the DON confirmed the absence of specific peritonitis monitoring orders, lack of an order for the PD cycler, and documentation gaps, despite a facility policy requiring ongoing assessment and monitoring for complications before, during, and after dialysis treatments.
A nurse was observed preparing multiple oral medications for a resident with depression, traumatic brain injury, anxiety, and impaired cognition by pushing tablets and capsules from unit-dose cards directly into her ungloved hand and then using her fingers to place them into a medication cup. In a follow-up interview, the RN confirmed this practice and acknowledged that the correct procedure is to dispense medications directly from the card into the cup, contrary to the facility’s medication administration policy requiring adherence to good nursing principles and practices.
A resident with Alzheimer’s disease, diabetes, anxiety, significant ADL dependence, and behavioral symptoms was observed seated in a chair positioned against the nursing station with a locked wheelchair placed directly in front, also against the nursing station, effectively restricting movement. An LPN confirmed both wheelchair wheels were locked and that it should not have been placed there, while a CNA stated she had positioned the wheelchair to prepare for lunch, was unable to complete the transfer, and left it in place, acknowledging this was wrong. This arrangement conflicted with the facility’s restraint policy, which prohibits physical restraints except when alternatives are ineffective for treating a medical symptom and defines restraints as devices adjacent to the body that cannot be easily removed and that restrict freedom of movement or access to the body.
Failure to Issue Required SNF ABN When Discontinuing Medicare Part A Services
Penalty
Summary
The deficiency involves the facility’s failure to issue a Skilled Nursing Facility Advance Beneficiary Notice (SNF ABN) when Medicare Part A services were discontinued for a resident who still had available benefit days. The resident was admitted with a diagnosis of metabolic encephalopathy and had intact cognition per the Minimum Data Set assessment. The facility’s own SNF Beneficiary Notification Review documented that Medicare Part A skilled services began on 02/11/26 and the last covered day was 03/11/26, and that the facility initiated discharge from Medicare Part A services before the resident’s benefit days were exhausted. Despite this, no SNF ABN was provided to the resident or the resident’s representative. During interviews, the Social Services Director stated that the SNF ABN was issued hours prior to the last covered day but, upon reviewing her files, confirmed that no SNF ABN had actually been issued for this resident. She further explained that she believed an SNF ABN was only required if one skilled service remained and that if all skilled services were being discontinued, only the Notice of Medicare Non-Coverage (NOMNC) needed to be issued. The Administrator, however, stated that a resident should always receive both a SNF ABN and a NOMNC when Medicare Part A services are discontinued and benefit days remain. Review of the facility’s written policy dated 03/28/23 showed that the facility was required to issue SNF ABNs for initiation, reduction, or termination of extended care items or services when Medicare payment was not expected, which did not occur in this case.
Plan Of Correction
This Plan of Correction is submitted as required under State and Federal law. This Plan of Correction does not constitute an admission on the part of the Facility that the findings cited are accurate, that the findings constitute a deficiency or that the scope and severity regarding the deficiency cited are correctly applied. Any changes to the Facility's policies and procedures should be inadmissible in any proceeding on that basis. Without admitting or denying the validity or the existence of the alleged noncompliance, the Facility submits this Plan of Correction with the intention that it be inadmissible by any third party in any civil or other action against the facility or any employee, agent, officer, director or shareholder of the Facility. The Facility is utilizing this Plan of Correction as its allegation of substantial compliance as of 05/29/2026 F-0582 Corrective action for resident/s: On 5/14/26 Resident #34 was informed of rights and responsibilities related to Advanced Beneficiary Notice and voiced understanding of information for future reference by administrator. Identification of other residents who may be affected: Any resident receiving skilled services from nursing or therapy services. The Administrator audited all residents who were discharged from skilled services in the past 30 days to ensure they were issued a Notice of Non-Coverage and Advanced Beneficiary Notice on 5/29/26. No non-compliance was noted. Measures for systemic change: On 5/14/2026 Business Office Manager, Director of Rehab, Minimum Data Set nurse, Director of Nursing and Social Services Director were educated on proper procedure of issuing of Notice Of Medicare Non Coverage and Advanced Beneficiary Notice by administrator. All upcoming discharges from skilled services will be reviewed weekly at Utilization Review meeting to ensure notices will be delivered timely. How Corrective Action will be monitored: Administrator or designee to complete audits of all residents being discharged from skilled services to ensure they were issued a Notice of Non-Coverage and Advanced Beneficiary. This audit will be completed weekly x 4 weeks, then monthly x 2 months. Corrective action will be initiated for any noted non-compliance. Audit findings will be reviewed as part of the monthly quality assurance process to determine the need for further monitoring. Date of Compliance 5/29/26
Insulin Administration Errors and Failure to Prime Insulin Pens
Penalty
Summary
The deficiency involves the facility’s failure to maintain a medication error rate below 5%, with surveyors identifying 3 errors out of 28 medication administration opportunities, resulting in a 10.71% error rate. For one resident with type 2 diabetes mellitus and moderate cognitive impairment, the physician’s order directed Novolog insulin 10 units via subcutaneous pen-injector to be given before meals. During an observed medication pass, the LPN administered 10 units of Novolog insulin without priming the pen and did so after the resident had already consumed approximately 50% of the breakfast meal. The LPN later confirmed she did not prime the pen and acknowledged that the insulin was ordered to be administered prior to meals. Manufacturer instructions for the Novolog FlexPen specified that an air shot (priming) must be performed before each injection to ensure proper dosing. Another resident, also diagnosed with type 2 diabetes mellitus and with intact cognition, had orders for insulin glargine 35 units subcutaneously twice daily and insulin lispro 20 units subcutaneously before meals, plus 12 units subcutaneously if blood glucose was between 251 mg/dL and 300 mg/dL. During an observed medication administration, an LPN administered 35 units of insulin glargine and 32 units of insulin lispro without priming the insulin pens and after the resident had consumed approximately 90% of the breakfast meal, despite orders for insulin lispro to be given before meals. The LPN later stated she could not remember if she had primed the pen and acknowledged that the insulin was ordered to be administered prior to meals. Manufacturer information for insulin lispro stated that the pen must be primed before each injection to confirm insulin delivery and remove air, and that failure to prime could result in too much or too little insulin. The DON confirmed the expectation that insulin be administered as ordered, including priming each pen with two units before dialing the prescribed dose, and facility policy required medications, including insulin, to be administered safely, timely, and in accordance with prescriber orders and required time frames.
Plan Of Correction
This Plan of Correction is submitted as required under State and Federal law. This Plan of Correction does not constitute an admission on the part of the Facility that the findings cited are accurate, that the findings constitute a deficiency or that the scope and severity regarding the deficiency cited are correctly applied. Any changes to the Facility's policies and procedures should be inadmissible in any proceeding on that basis. Without admitting or denying the validity or the existence of the alleged noncompliance, the Facility submits this Plan of Correction with the intention that it be inadmissible by any third party in any civil or other action against the facility or any employee, agent, officer, director or shareholder of the Facility. The Facility is utilizing this Plan of Correction as an allegation of substantial compliance as of 5/29/2026. F-0759 Corrective action for resident/s: Residents #21 and #22 were assessed and evaluated by nurse and Director of Nursing 5/14/26. Resident #21 and #22 both denied any adverse effects and none were noted upon assessment by the Director of Nursing on 5/14/2026. Notification made to physician on 5/14/2026. LPN # 2 competency Eval on insulin administration with the Director of Nursing completed 5/14/2026. Identification of other residents who may be affected: Diabetic residents on assignment of LPN #2/station 2 have the potential to be affected and were assessed by the DON/Designee on 5/14/26 and found to be within normal limits. Measures for systemic change: All Nurses were educated by the Director of Nursing on the steps for Insulin administration per competency, diabetes clinical protocol policy, Medication and treatment orders policy, administering medications policy, and Obtaining fingerstick Glucose Level policy On 5/14/2026. How Corrective Action will be monitored: Director of Nursing and Assistant Director of Nursing will complete insulin administration audits on 5 nurses. This audit will be completed weekly x 4 weeks, then monthly x 2 months. Corrective action will be initiated for any noted non-compliance. Audit findings will be reviewed as part of the monthly quality assurance process to determine the need for further monitoring. Date of Compliance: 5/29/2026
Failure to Document Tray Line Food Temperatures in Dining Room Kitchenettes
Penalty
Summary
The deficiency involves the facility’s failure to document tray line food temperatures for meals served from the Harrison and McClellan Dining Room kitchenettes, as required by professional standards for food service safety and the facility’s own policy. Review of the “Trayline Taste & Temperature Log” (revised September 2018) showed missing temperature documentation for multiple meals from the Harrison Dining Room kitchenette, including dinner on 03/30/26 and 03/31/26, lunch and dinner on 04/01/26 and 04/02/26, dinner on 04/07/26, and lunch and dinner on 04/08/26 and 04/10/26. The Senior Director of Culinary Services confirmed during interview that tray line food temperatures were not documented on the log for these meals. Similarly, review of the same log for the McClellan Dining Room kitchenette revealed that tray line food temperatures were not documented for dinner on 04/01/26, breakfast and lunch on 04/02/26, and lunch and dinner on 04/07/26. The Senior Director of Culinary Services also verified these omissions during interview. The facility census at the time was 27 residents, and the governing “Food and Nutrition” policy, approved on 09/07/21, stated that the facility must store, prepare, distribute, and serve food in accordance with professional standards for food service safety.
Plan Of Correction
F812 The facility will continue to ensure food temperatures are completed before meals are served for all residents. To ensure compliance with this standard the following measures have been taken: 1. Immediately 4/15/26 culinary supervisor #224 was re-educated by Dietary Manager to this standard and policy "Food and Nutrition" which includes documentation of food temperatures. 2. All dietary staff have been re-educated to the standard and policy "Food and Nutrition" during the month of April 2026. 3. Audits of food temperature documentation to be completed by Dietary Manager 4 x per week for 4 weeks then weekly for 4 weeks. 4. Administrator to validate audits/compliance and provide additional training as needed. Administrator will present to QAPI committee for ongoing monitoring and further direction.
Failure to Conduct and Document Required Care Conferences
Penalty
Summary
The deficiency involves the facility’s failure to complete and document comprehensive care conferences at required intervals in accordance with care plan regulations and facility policy. For one resident with Parkinson’s disease with dyskinesia, cognitive communication deficit, hemiplegia and hemiparesis following cerebral infarction, transient cerebral ischemic attack, type II diabetes mellitus, and major depressive disorder, the record showed multiple MDS assessments over a one-year period, including annual, quarterly, and significant change assessments. However, only two care conferences were documented during the last 12 months, despite the expectation that care conferences be conducted quarterly with the resident and family when possible. The Unit Care Coordinator confirmed that no additional care conference documentation existed for this resident beyond the notes dated 04/21/25 and 01/02/26. A second resident, with diagnoses including aphasia following cerebrovascular disease, cerebral infarction, type II diabetes mellitus, unsteadiness on feet, difficulty in walking, coagulation defect, depression, and muscle weakness, also had multiple MDS assessments completed over the review period, including quarterly and annual assessments. The record contained a note that a care conference was offered to the resident’s representative, who declined to attend, but there was no documentation of any care conferences for the most recent 12 months. The Unit Care Coordinator confirmed that no other care conference documentation was available for this resident. Facility policy stated that periodic care conferences involving the resident, family, and the interdisciplinary team are part of the care planning process, but the required periodic care conferences and corresponding documentation were not completed for these two residents.
Plan Of Correction
THIS PLAN OF CORRECTION SERVES AS BERKELEY SQUARE'S CREDIBLE ALLEGATION OF SUBSTANTIAL COMPLIANCE AS OF June 1, 2026. Without admitting or denying the validity or existence of the alleged deficiencies, Berkeley Square provides the following Plan of Correction: F657 The facility will continue to document completion of care conferences at the required intervals for all residents, including residents #04 & #15. To ensure compliance with this standard the following measures have be taken: 1. The social service designee and the inter- disciplinary team were re-educated by the administrator to the facility policy "Care Conference" on 4/29/26 and verbalized understanding. 2. Care conferences for resident #04 and resident #15 were conducted on or before 4/29/2026 by the interdisciplinary team. 3. Review of all other residents was conducted by the social service designee to validate and ensure that care conference schedule is up to date with timely care conferences scheduled for them on 4/15/2026. Audits of care conferences to be completed weekly for four weeks and then monthly after that by the social service designee. Documentation of the care conference including any identified concerns in the medical record. Administrator to validate audits/compliance and provide additional training as needed. Administrator will present results of these audits to QAPI committee for ongoing monitoring and further direction.
Failure to Reevaluate Blood Glucose After Treatment for Hyperglycemia
Penalty
Summary
The facility failed to ensure that a resident with diabetes received treatment in accordance with professional standards of practice when nursing staff did not reevaluate the resident's blood glucose after treatment for severe hyperglycemia. The resident, admitted with diagnoses including Alzheimer's disease, type II diabetes mellitus, and depression, had physician orders for Humalog insulin on a sliding scale before meals, Lantus insulin 25 units daily, and lisinopril 5 mg daily. The resident required extensive assistance with activities of daily living, including transfers, toileting hygiene, eating, and bathing. On the evening in question, the resident's blood glucose was documented as 532 mg/dL, and the on-call provider was notified. The provider gave a new order to administer an additional 8 units of lispro (Humalog) and to recheck the blood glucose in 30 minutes. The electronic medication administration record showed that the blood glucose of 532 mg/dL was obtained at 9:00 p.m. and that the additional 8 units of lispro were administered at 9:21 p.m. However, there was no documentation in the resident's chart that the blood glucose was rechecked after the additional insulin was given. In an interview, the DON confirmed there was no evidence of reevaluation and verified that, according to the facility's "Abnormal Blood Glucose Procedure" policy, the resident should have been reevaluated and that the evaluation step should have been included in the progress note documentation.
Plan Of Correction
F684 The facility will continue to ensure all residents, including #03, receive treatment in accordance with professional standards of practice and reevaluated for hyperglycemia. To ensure compliance with this standard the following measures have been taken: 1. The director of nursing assessed resident #03, reviewed documentation and orders and found no ill effects immediately 4/16/26. 2. All licensed nurses were re-educated to facility policy "Blood Glucose Monitoring" by the Director of Nursing/designee in April 2026. 3. Audits of like-residents that require blood sugar checks to be completed by the director of nursing/designee two times a week for 4 weeks and then monthly after that to validate correct follow through when there is abnormally high blood glucose result. The Administrator will bring results of these audits to the QAPI committee for ongoing monitoring and further direction.
Failure to Act on Pharmacist Drug Regimen Recommendation for Thyroid Medication
Penalty
Summary
The deficiency involves the facility’s failure to ensure that pharmacy recommendations from the monthly drug regimen review were acted upon and documented for a resident. The resident was admitted with diagnoses including Parkinson’s disease, dementia, and hypothyroidism, and had current physician orders for levothyroxine 150 mcg once daily, buspirone 50 mg twice daily, and losartan 100 mg once daily. A medication regimen review dated 11/25/2025 included a consultant pharmacist recommendation that levothyroxine be administered consistently in the morning on an empty stomach, at least 30–60 minutes before food, per manufacturer instructions. There was no specific physician response in the medical record to this recommendation, and the facility’s policy stated that consulting pharmacist reviews are sent to nursing and addressed with the primary care provider or consulting specialist for review and follow-up. Review of the resident’s medication administration record for April 2026 showed levothyroxine scheduled for 9:00 a.m. On observation, the resident was seen eating breakfast in the dining area at 8:03 a.m., and an LPN reported administering the levothyroxine 150 mcg to the resident while the resident was in the dining area eating breakfast. The DON confirmed there was no evidence in the resident’s medical record explaining why the consultant pharmacist’s recommendation from 11/25/2025 was or was not acted upon. This lack of documented physician review and action on the pharmacist’s identified irregularity constituted noncompliance with the drug regimen review requirements.
Plan Of Correction
F756 The facility will continue to ensure the pharmacy recommendations from the monthly drug regimen review by a licensed pharmacist are acted upon for all residents, including #08. To ensure compliance with this standard the following measures have been taken: 1. Resident #08 was assessed by the registered nurse and med review completed by 4/28/26. After review of resident's drug regime's, it was discovered that resident #8 had 2 separate medication recommendations on the same form, to be reviewed by two separate practitioners, pharmacy has been instructed and agreed to separate meds on individual forms. 2. Licensed nurses re-educated to facility policy "Drug Regimen Review" by Director of nursing/designee in April 2026 and no later than 5/8/26. Licensed nurses are responsible for ensuring the reviews and recommendations are given to the physician for timely review. 3. Review of all other current residents Drug Regimen orders completed by Director of nursing/designee on 4/16/26 to ensure recommendations were followed up on/reviewed by the physician and address concerns if needed. 4. Audit of drug regime recommendations, pharmacy recommendations, and physician follow up to be completed weekly for four weeks by the Director of nursing/designee. Administrator will present results of these audits to the QAPI committee for ongoing monitoring and further direction.
Failure to Use Required Gait Belt During Ambulation Resulting in Resident Fall
Penalty
Summary
The deficiency involves the facility’s failure to ensure that a required gait belt was used while assisting a high fall‑risk resident with ambulation, resulting in a fall with head injury. The resident had multiple diagnoses including metabolic encephalopathy, hypertension, osteoarthritis, muscle weakness, gait and mobility abnormalities, major depressive disorder, anxiety, and visual hallucinations. Admission and subsequent MDS and fall risk assessments documented that the resident was severely cognitively impaired, required moderate to maximal assistance with transfers and ambulation, could not independently come to a standing position, exhibited loss of balance while standing, used an assistive device, and had decreased muscle coordination. The resident had a history of falls prior to admission and was assessed as being at high, later moderate, risk for falls. The resident’s fall care plan identified her as at risk for falls and included interventions such as providing maximum to moderate assistance with transfers and walking short distances, use of a walker and wheelchair, and following the facility’s fall protocol. Therapy notes and care conference documentation indicated that the resident leaned backwards when standing, required contact guard to minimal assistance for bed mobility and transfers, and needed constant verbal cueing for safe sequencing during toilet transfers. The physical therapist confirmed that the resident was to use a gait belt with staff when ambulating, and the DON verified that therapy had assessed the resident as requiring contact guard assistance and a gait belt for ambulation and transfers. On the day of the incident, a CNA was assisting the resident from her recliner to the bathroom using a walker. The CNA walked beside the resident, providing guidance and support, and reported having a hand on the resident while assisting her. As they approached the bathroom door, the CNA reached for the doorknob to open it, and at that moment the resident began to lose her balance and fell backwards to the floor, striking the back of her head. The nurse who responded found the resident on her back at the foot of the bed with her feet near the bathroom, noted a red raised area on the back of the head, and documented that the resident was not wearing a gait belt and that the gait belt was on the dresser. In the facility’s investigative summary and in interviews, the CNA acknowledged that she did not have a gait belt on the resident while ambulating her, despite the resident’s assessed need for hands‑on assistance and gait belt use per facility policy and the resident’s care and therapy plans.
Failure to Implement PD Orders and Monitor Resident Receiving Peritoneal Dialysis
Penalty
Summary
The deficiency involves the facility’s failure to implement pre-admission physician orders for peritoneal dialysis (PD) and to provide ongoing monitoring for a resident with chronic kidney disease (CKD) stage five who required PD. Pre-admission orders dated 11/14/25 specified three daily PD exchanges at 6:00 A.M., 2:00 P.M., and 10:00 P.M., and directed staff to monitor for signs and symptoms of peritonitis, including fever, abdominal pain, and cloudy effluent. These monitoring orders were not entered into the facility’s physician orders. The resident’s care plan noted the need for PD and included general monitoring interventions (labs, signs of bleeding, bacteremia, septic shock, and significant vital sign changes), but did not specifically address the ordered monitoring for peritonitis. Review of PD documentation showed incomplete and inconsistent charting of treatments and resident condition. The paper peritoneal flowsheet had columns for time of PD and condition/comments, including instructions to call the nurse immediately for cloudy fluid, abdominal pain, or fever. However, the first entry on 11/15/26 at 2:00 P.M. only noted that the PD nurse completed the exchange, and the 10:00 P.M. entry that day had no condition/comment documentation. Subsequent days (11/16/25, 11/17/25, and 11/18/25) contained only one condition/comment entry per day rather than for each exchange, and there was no documentation that the 6:00 A.M. PD on 11/18/25 was completed. The PD cycler flowsheet starting 11/19/25 lacked any description of the effluent on multiple days. The PD nurse from the dialysis company stated facility staff were expected to monitor effluent for cloudiness and assess for abdominal pain and fever, and the DON confirmed there was no electronic physician order for peritonitis monitoring or for use of the PD cycler, that the paper charting did not allow for effluent description or symptom documentation for each treatment, and that PD was not documented at one ordered time. The facility’s dialysis policy required ongoing assessment and monitoring for complications before, during, and after treatments, which was not reflected in the documentation for this resident.
Improper Infection Control During Medication Administration
Penalty
Summary
Surveyors identified a deficiency in infection prevention and control related to medication administration for Resident #29. The resident was admitted on 02/28/14 with diagnoses including depression, traumatic brain injury, and anxiety, and had impaired cognition per a quarterly MDS assessment. During an observation on 03/25/26 at 6:58 A.M., RN #281 prepared the resident’s medications by removing an Amoxicillin-Pot Clavulanate tablet from the medication card and pushing it directly into her ungloved hand, then using her fingers to place the pill into a medication cup. The same process was observed for multiple other medications, including Escitalopram Oxalate, Furosemide, Sennosides, Lyrica, and Vitamin D, each being pushed from the card into the RN’s ungloved hand and then transferred by her fingers into the medication cup before administration to Resident #29. In a subsequent interview at 7:27 A.M. the same day, RN #281 confirmed she had placed each medication into her ungloved hands prior to administration and acknowledged that the proper procedure was to push the pills directly from the card into the medication cup. Review of the facility’s “Medication Administration – General guidelines” policy, revised 10/08/25, stated that medications are to be administered in accordance with good nursing principles and practices. This practice failure was cited as a deficiency under Complaint Number 2681777.
Improper Use of Wheelchair as a Physical Restraint
Penalty
Summary
Surveyors identified a deficiency related to the facility’s failure to ensure a resident was free from physical restraints. Resident #7, admitted with diagnoses including Alzheimer’s disease, diabetes mellitus, and anxiety disorder, was documented on a recent MDS as rarely understood and dependent for ADLs except eating. The resident ambulated independently on the unit without an assistive device and had documented verbal and other behaviors occurring one to three days during the look-back period. The care plan noted the resident had potential to be physically aggressive, chase staff, throw objects, and be combative with care, with interventions such as offering choices, administering medications as ordered, and intervening early when agitation occurred. During an observation and interview, Resident #7 was found sitting in a chair with the right arm of the chair positioned against the nursing station and a wheelchair placed directly in front of him. The left arm of the wheelchair was also against the nursing station, and both wheelchair wheels were locked, creating a barrier that appeared to restrain the resident, who was sleeping with his knees touching the locked wheelchair. An LPN confirmed both wheelchair wheels were locked and that the wheelchair should not have been placed in front of the resident. A CNA reported she had placed the wheelchair there in preparation to get the resident up for lunch, was unable to transfer him, and left the wheelchair in that position, acknowledging it was wrong to keep it there. The facility’s physical restraint policy stated that physical restraints are not used except when alternatives are not appropriate or effective for treating a medical symptom and defined physical restraints as any device attached or adjacent to the body that the individual cannot easily remove and that restricts freedom of movement or access to the body.
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