The Laurels Of Kettering
Inspection history, citations, penalties and survey trends for this long-term care facility in Kettering, Ohio.
- Location
- 694 Isaac Prugh Way, Kettering, Ohio 45429
- CMS Provider Number
- 365773
- Inspections on file
- 30
- Latest survey
- March 17, 2026
- Citations (last 12 mo.)
- 1
Citation history
Health deficiencies cited at The Laurels Of Kettering during CMS and state inspections, most recent first.
A resident with type 2 DM and other comorbidities had physician orders for accu checks before meals and at bedtime, yet over multiple days experienced repeated, markedly elevated blood glucose readings (many above 350 mg/dl) without any documented nursing assessment or notification to the physician. The DON confirmed there were no notification parameters on the accu check order, no further assessment was performed, and the physician was not informed prior to the resident’s discharge. The physician later stated she had not been notified of the elevated readings and would have expected notification for blood glucose levels greater than 350 mg/dl, while American Diabetes Association information cited in the report defined hyperglycemia as blood sugar levels above 240 mg/dl.
The facility did not complete required discharge summaries, failed to provide bed hold notices when residents were transferred to the hospital, and did not notify the Ombudsman of resident discharges in a timely manner. These deficiencies were confirmed through record reviews and staff interviews, affecting several residents with complex medical needs.
A resident with orthopedic and post-surgical needs was given incorrect doses of oxycodone, with records showing administration of two tablets each of 10 mg and 5 mg at multiple times, contrary to physician orders and documentation on the MAR. The DON confirmed discrepancies between the Controlled Drug Record and the MAR, indicating a significant medication error.
Surveyors found that staff failed to follow infection control protocols during wound and peri care for three residents with pressure injuries. LPNs and a Unit Manager did not use required PPE such as gowns for Enhanced Barrier Precautions, and hand hygiene was not consistently performed after glove removal. Additionally, proper signage for EBP was missing in one case, despite facility policy requiring these measures for residents with wounds.
A resident with multiple medical conditions, including acute respiratory failure, requested a breathing treatment as per physician order, but the facility failed to administer it on the requested day. The medication was available in the emergency box, and the Director of Nursing confirmed the lack of documentation for the treatment. This incident was investigated under a complaint.
A resident with a history of muscle weakness and balance deficits fell and sustained a laceration after being left unattended by a CNA following toileting. The resident, who required substantial assistance, was left sitting on the side of the bed while the CNA sought additional help, leading to the fall. The facility's fall management policy was not adhered to, resulting in harm to the resident.
A facility failed to notify a resident's representative of a change in condition, specifically the development of a Stage II pressure ulcer. The resident had multiple medical conditions and required assistance with daily activities. The facility's policy mandates notification of significant health status changes, but documentation of such notification was absent.
The facility failed to ensure safe and orderly discharges for two residents, leading to deficiencies in the transfer and discharge process. One resident was transferred to the ER without proper documentation or information provided to the hospital. Another resident, after a fall, was transferred with incomplete information due to an EHR system failure. Additionally, there was no discharge summary for another resident, indicating non-compliance with the facility's policy.
The facility failed to complete a discharge recapitulation or summary for two residents upon their discharge. One resident, with multiple medical conditions, was cognitively intact and independent, while the other, with Alzheimer's and other health issues, was severely impaired and dependent on staff. The Director of Nursing confirmed the lack of required documentation, which was against the facility's policy.
A facility failed to assess and document a resident's pressure ulcer properly, neglecting weekly monitoring and ordered treatments. The resident, with multiple medical conditions, had a sacral wound that was not documented with necessary details from early August to mid-September. The facility's policy required detailed documentation and weekly evaluations, which were not followed.
A facility failed to follow physician orders for daily weights for a resident with acute respiratory failure, CHF, and other conditions. Despite orders to weigh the resident daily and notify the physician of significant weight changes, staff recorded weights on only a few days over several months. This deficiency was confirmed by the Administrator.
A resident with a feeding tube experienced significant weight fluctuations due to the facility's failure to monitor weights and implement nutritional recommendations. Despite a dietitian's suggestion to increase tube feeding, no physician's order was made, leading to a 19.8% weight loss. The facility did not follow its weight management policy, resulting in inadequate nutritional care.
The facility's medication error rate was 7.14%, exceeding the acceptable threshold of 5%. Two residents did not receive their prescribed medications due to unavailability, as confirmed by nursing staff. The facility's policy on timely and accurate medication administration was not followed.
The facility failed to follow proper infection control practices for two residents with orders for enhanced barrier precautions (EBP). One resident with a gastronomy tube and another with an ileostomy did not receive care with the required gowns, as observed with an STNA and an LPN. The facility's policy mandated the use of gowns and gloves for EBP, which was not adhered to in these cases.
The facility failed to maintain medication and treatment records during an internet outage, affecting five residents and potentially all 87 residents. The backup records were outdated and not printed due to a lack of paper, leading to missed documentation and medication administration. Staff interviews revealed a lack of awareness and adherence to the facility's policy for handling such disruptions.
A facility failed to administer medications as ordered due to an internet disruption, affecting several residents with conditions like diabetes and kidney disease. The backup plan, which involved printed MARs, was not executed due to a lack of paper, leading to significant medication errors. The DON was unaware of the medication administration disruption, and the facility's policies were not followed.
The facility failed to implement Enhanced Barrier Precautions (EBP) for residents with chronic wounds and indwelling medical devices, affecting 11 residents. Observations revealed a lack of visible EBP signs outside residents' rooms, and interviews confirmed the absence of necessary physician orders. This deficiency was documented under Complaint Number OH00154306, indicating noncompliance with the facility's EBP policy.
A resident with severely impaired cognition and multiple diagnoses had a skin tear on the left lower leg that was not timely identified or treated. The facility's policy required skin integrity evaluations and interventions for impaired skin, but a weekly skin assessment was missed due to a system error. An LPN later observed and treated the wound, but the delay led to a deficiency.
A resident with immobility and incontinence issues experienced a delay in receiving incontinence care at an LTC facility. Despite activating the call light and requesting assistance, the resident waited nearly an hour before receiving care. The facility's policy requires timely incontinence care, which was not adhered to, leading to a deficiency finding.
Failure to Assess and Report Critically Elevated Blood Glucose Levels
Penalty
Summary
The facility failed to assess and notify the physician regarding a resident’s persistently elevated blood glucose levels as ordered and expected. The resident was admitted with multiple diagnoses including type 2 diabetes mellitus, post-hemorrhagic stroke, congestive heart failure, depression, and anemia, and had intact cognition with a BIMS score of 15. Physician orders included accu checks before meals and at bedtime starting on 01/03/26. Blood glucose readings over several days showed repeated and significant elevations, including values of 403 mg/dl on the evening of 01/10/26; 195, 236, 326, and 376 mg/dl on 01/11/26; 353, 399, 277, and 373 mg/dl on 01/12/26; and 443 and 493 mg/dl on the morning and late morning of 01/13/26. Despite these elevated readings, the medical record contained no evidence of further assessment of the resident related to the high blood sugars and no documentation that the physician was notified. The DON confirmed there were no parameters on the accu check order specifying when to notify the physician, verified that no additional assessment was completed, and that the physician was not notified before the resident was discharged home with home health. The attending physician stated she had not been informed of the elevated blood glucose levels and that she would have expected notification for blood glucose levels greater than 350 mg/dl. Information from the American Diabetes Association cited in the report defined hyperglycemia as blood sugar levels above 240 mg/dl and noted that untreated hyperglycemia could lead to serious complications, including ketoacidosis.
Failure to Complete Discharge Documentation, Bed Hold Notices, and Ombudsman Notification
Penalty
Summary
The facility failed to complete required documentation and notifications related to resident discharges and transfers, affecting four residents reviewed for discharges. Specifically, the facility did not complete discharge summaries or recapitulations of residents' stays, did not provide bed hold notices when residents were transferred to the hospital, and failed to notify the Ombudsman of resident discharges in a timely manner. These deficiencies were identified through medical record reviews, staff interviews, and policy reviews. One resident with multiple chronic conditions, including COPD, diabetes, hypertensive heart disease, and kidney cancer, was discharged without a documented recapitulation of their stay, and the Ombudsman was not notified of the discharge. The discharge summary was signed after the resident had already left the facility. Another resident with end stage renal disease, atrial fibrillation, and major depressive disorder was sent to the hospital and subsequently discharged, but the Ombudsman was not notified until months later. A third resident with diabetes, peripheral vascular disease, and depression was discharged to another facility, and again, the Ombudsman notification was delayed. Additionally, a resident who was transferred to the hospital did not receive a bed hold notice, and there was no documentation of the bed hold offer or the resident or responsible party's decision in the medical record. Staff interviews confirmed these lapses, and policy reviews indicated that the facility's own procedures require timely discharge documentation, bed hold notifications, and Ombudsman notification, none of which were consistently followed in these cases.
Failure to Administer Medications as Ordered Resulting in Significant Medication Error
Penalty
Summary
A deficiency occurred when a resident with a history of orthopedic aftercare, left above the knee amputation, and joint surgery aftercare was not administered medications as ordered. The resident was cognitively intact and required supervision with activities of daily living. Physician orders specified that the resident should receive oxycodone 10 mg by mouth six times per day and oxycodone 5 mg by mouth every six hours as needed (PRN). On a specific date, the Medication Administration Record (MAR) documented that the resident received routine oxycodone as ordered, but there was no documentation supporting administration of the PRN oxycodone 5 mg. Further review of the Controlled Drug Record revealed that the resident actually received two tablets of oxycodone 10 mg and two tablets of oxycodone 5 mg at three different times that day, which did not match the physician's orders or the MAR documentation. The Director of Nursing confirmed that the records indicated the resident received incorrect doses of both oxycodone 10 mg and 5 mg, and that the MAR did not accurately reflect the administration of these medications. Facility policy required medications to be administered accurately and in accordance with physician orders, and for staff to record the dose, route, and time of administration on the MAR.
Failure to Maintain Infection Control During Wound and Peri Care
Penalty
Summary
Surveyors identified that the facility failed to maintain proper infection control measures during wound care and peri care for three residents. For one resident with a stage III pressure injury and excoriation in the peri-area, two LPNs did not don gowns as required for Enhanced Barrier Precautions (EBP) during wound care. Additionally, one LPN did not perform hand hygiene after removing soiled gloves following incontinence care and before proceeding with wound care. Both LPNs confirmed in interviews that they did not wear gowns or perform hand hygiene as required by facility policy. Another resident, who was cognitively impaired and dependent on staff for most activities of daily living, developed a stage III pressure ulcer in-house. During peri care, an LPN performed hand hygiene initially but did not wear a gown for EBP and failed to perform hand hygiene after removing gloves post-care. Both the LPN and another staff member confirmed in interviews that proper PPE and hand hygiene protocols were not followed. Facility policy requires hand hygiene before and after resident contact, after glove removal, and after contact with bodily fluids. A third resident, admitted with a stage III pressure ulcer, also did not receive care in accordance with EBP protocols. During wound care, both the LPN and the Unit Manager failed to use appropriate PPE, and there was no proper notification of EBP on the resident's room. The Unit Manager confirmed the lack of PPE use and signage. Facility policy mandates the use of EBP, including PPE and signage, for residents with wounds or indwelling devices to prevent the transmission of multi-drug resistant organisms.
Failure to Administer Medication as Ordered
Penalty
Summary
The facility failed to administer a medication as per a resident's request and physician order. Resident #65, who had multiple medical diagnoses including COVID-19, acute respiratory failure, and congestive heart failure, was dependent on staff for various activities and required oxygen. A physician order dated 12/04/24 prescribed ipratropium-albuterol inhalation solution to be administered every six hours as needed for shortness of breath. Despite the resident's request for a breathing treatment on 12/04/24, the Medication Administration Record (MAR) showed no documentation of the treatment being administered that day. The Director of Nursing confirmed that the medication was available in the facility's emergency box and that there was no documentation to support that the treatment was given as requested. The facility's policy on medication administration requires medications to be administered accurately and timely, in accordance with physician orders. The failure to administer the medication as ordered was investigated under Complaint Number OH00160573.
Resident Fall Due to Inadequate Supervision
Penalty
Summary
The facility failed to provide adequate supervision and assistance to a resident, resulting in a fall with injury. Resident #34, who required substantial assistance for transfers and toileting, was left unattended by a CNA after being assisted to the bedside commode. The resident, who was barefoot and had a history of muscle weakness and balance deficits, was left sitting on the side of the bed while the CNA left the room to seek additional help. During this time, the resident fell forward onto the floor, sustaining a laceration above her right eye that required stitches. The resident's medical history included heart failure, peripheral vascular disease, renal failure, diabetes, and septicemia. Despite these conditions, a fall risk assessment had not identified the resident as being at risk for falls, although the care plan noted a risk of falling due to decreased mobility. The care plan interventions included encouraging the resident to wear appropriate footwear and keeping the environment free of clutter, but these measures were not effectively implemented at the time of the incident. Interviews with staff and the resident revealed that the CNA had been aware of the resident's difficulty standing and the resident's expressed concern about falling. However, the CNA left the resident unattended on the side of the bed, leading to the fall. The facility's fall management policy emphasized the importance of identifying hazards and providing adequate supervision to minimize fall risks, but these protocols were not followed in this instance, resulting in harm to the resident.
Failure to Notify Resident Representative of Change in Condition
Penalty
Summary
The facility failed to notify the resident representative of a change in condition for a resident with multiple medical diagnoses, including left hemiparesis, congestive heart failure, diabetes mellitus, dementia, COPD, and anemia. The resident was admitted with moderate cognitive impairment and required assistance with daily activities. A physician order was issued to treat a sacrum wound, but the medical record lacked documentation of the wound's location, measurements, or description between two evaluations. The facility did not document any notification to the resident's representative about the development of a Stage II pressure ulcer. An interview with the Director of Nursing confirmed the absence of documentation regarding the notification of the resident's representative about the change in condition. The facility's policy on Notification of Change requires informing the resident, consulting with the resident's practitioner, and notifying the resident representative of significant changes in health status. This deficiency was identified during an investigation under a specific complaint number.
Deficiencies in Safe and Orderly Resident Discharges
Penalty
Summary
The facility failed to ensure safe and orderly discharges for two residents, resulting in deficiencies related to the transfer and discharge process. Resident #67, who had medical diagnoses including diabetes mellitus, hypertensive heart disease, and chronic obstructive pulmonary disease, was transferred to the emergency room for nausea and vomiting. However, there was no documentation of a change of condition assessment or transfer form, nor was there evidence that necessary information was provided to the hospital upon transfer. Resident #68, with diagnoses including infection due to an internal joint prosthesis and severe cognitive impairment, experienced a fall and was found unresponsive, leading to an emergency room transfer. Although a transfer form was completed, the hospital did not receive the resident's Advanced Directive information. The Director of Nursing confirmed that the facility's electronic health records system was down, preventing the staff from printing and sending necessary medical information. Additionally, there was no documentation of a discharge recapitulation of stay or discharge summary for Resident #70, indicating further non-compliance with the facility's transfer and discharge policy.
Failure to Complete Discharge Documentation for Two Residents
Penalty
Summary
The facility failed to ensure the completion of a discharge recapitulation of stay or discharge summary for two residents upon their discharge. Resident #66, who was admitted with diagnoses including multiple myeloma, lumbar spinal stenosis, hypertensive heart disease, and diabetes mellitus, was cognitively intact and independent in various activities of daily living. However, there was no documentation of a discharge recapitulation or summary prior to their discharge. Similarly, Resident #70, who had Alzheimer's disease, hypertensive heart disease, and a urinary tract infection, was severely cognitively impaired and dependent on staff for most activities. The medical record for this resident also lacked the necessary discharge documentation. The Director of Nursing confirmed the absence of discharge recapitulation or summary documentation for both residents. The facility's policy on transfer and discharge, revised shortly before these incidents, required comprehensive information to be provided to the receiving provider, including a discharge summary with a recapitulation of stay and a final summary of the resident's health status. This deficiency was identified during an investigation under Complaint Numbers OH00157511 and OH00157535.
Failure to Document and Treat Pressure Ulcer
Penalty
Summary
The facility failed to properly assess and document a resident's skin breakdown when it was first observed, and did not complete weekly monitoring or treatments as ordered. The resident, who had multiple medical diagnoses including left hemiparesis, congestive heart failure, diabetes mellitus, dementia, COPD, and anemia, was admitted with no noted skin issues. However, a wound/skin evaluation indicated a new wound on the sacrum, but lacked documentation of the wound's location, measurements, or description. This lack of documentation persisted from early August to mid-September. Additionally, the facility did not document the completion of ordered treatments for the sacrum wound on several occasions in August and September. The Director of Nursing confirmed the absence of documentation for wound assessments and treatments. The facility's policy on skin management required documentation of skin impairments, including location, measurements, and characteristics, as well as weekly evaluations until resolution, which was not adhered to in this case.
Failure to Follow Physician Orders for Daily Weights
Penalty
Summary
The facility failed to adhere to physician orders for obtaining daily weights for a resident diagnosed with acute respiratory failure with hypoxia, congestive heart failure, atrial fibrillation, and generalized anxiety disorder. The resident, who had intact cognition and was independent with eating but dependent on assistance for other activities, had a physician's order dated 05/11/24 to be weighed daily. The order also required notifying the physician if there was a weight gain greater than two and a half pounds in less than 24 hours or greater than five pounds in a week. Despite these orders, the facility staff did not obtain daily weights for the resident as required. In May 2024, weights were recorded on only four days, in June 2024 on twelve days, and in July 2024 on one day before the resident's discharge. The facility's policy on physician's orders, dated 10/10/23, was intended to provide clear direction in resident care, yet the staff did not comply with the order for daily weights. This deficiency was confirmed by the Administrator during an interview on 08/13/24.
Failure to Monitor and Implement Nutritional Recommendations
Penalty
Summary
The facility failed to properly monitor and manage the nutritional needs of a resident, leading to significant weight fluctuations. The resident, who had a history of type two diabetes mellitus, anxiety disorder, cerebral infarction, and larynx cancer, was admitted with a feeding tube due to an inability to tolerate food and fluids by mouth. The care plan required monthly weight monitoring and reporting of significant changes to the physician and dietitian. However, the facility did not adhere to these protocols. The resident's weight fluctuated significantly, with a notable gain followed by a substantial loss, yet no reweight was conducted to verify these changes. The dietitian recommended an increase in the resident's tube feeding to address the weight loss, but this recommendation was not implemented as there was no corresponding physician's order. The facility's policy on weight management required regular monitoring and intervention for significant weight changes, but these procedures were not followed. The resident experienced a 19.8% weight loss over a short period, which was not addressed in a timely manner, indicating a failure in the facility's nutritional management and monitoring processes.
Medication Error Rate Exceeds Acceptable Threshold
Penalty
Summary
The facility failed to maintain a medication error rate below five percent, with an observed error rate of 7.14% based on 28 medication opportunities and two errors. This deficiency affected two residents out of five reviewed for medication administration. Resident #22, who has diagnoses including type two diabetes mellitus, peripheral vascular disease, and anxiety disorder, did not receive their prescribed Refresh ophthalmic gel 1% eye drops because the medication was unavailable. This was confirmed by RN #30 during an interview. Similarly, Resident #68, with diagnoses including malignant melanoma of the skin, malignant neoplasm of the brain, and obstructive and reflux uropathy, did not receive their prescribed Pradaxa 150 mg due to the medication's unavailability. This was confirmed by LPN #20 during an interview. The facility's policy on medication administration, which requires medications to be administered accurately, safely, and within 60 minutes of the scheduled time, was not adhered to in these instances. This deficiency was investigated under Complaint Numbers OH00156756 and OH00156263.
Failure to Follow Enhanced Barrier Precautions
Penalty
Summary
The facility failed to adhere to proper infection control practices for residents with physician's orders for enhanced barrier precautions (EBP). Specifically, two residents were affected by this deficiency. Resident #9, who was admitted with diagnoses including hemiplegia, atrial fibrillation, and type two diabetes mellitus, had a physician's order for EBP due to the presence of a gastronomy tube. During observations, both a State tested Nurse Aide (STNA) and a Licensed Practical Nurse (LPN) were noted to perform hand hygiene and apply gloves but failed to don gowns while providing care to Resident #9, which was confirmed during interviews with the staff involved. Similarly, Resident #55, admitted with diagnoses including ileostomy status, chronic obstructive pulmonary disease, and congestive heart failure, had a physician's order for EBP related to a surgical incision and the presence of an ileostomy. An STNA was observed performing hand hygiene and applying gloves but did not wear a gown during ileostomy care for Resident #55, as confirmed in an interview. The facility's policy on EBP, dated 03/26/24, clearly indicated the use of personal protective equipment, including gowns and gloves, for residents under EBP, which was not followed in these instances.
Failure to Maintain Medication Records During Internet Outage
Penalty
Summary
The facility failed to ensure that medication administration records (MAR) and treatment administration records (TAR) were available during an internet service disruption, affecting five residents and potentially all 87 residents in the facility. On the day of the incident, there was no documentation for various medications and treatments for the affected residents, including insulin, probiotics, blood pressure medication, and nutritional supplements. The lack of documentation was due to the unavailability of the electronic medical records system, which was inaccessible because of the internet outage. Interviews with staff revealed that the backup MARs and TARs were outdated and not printed due to a lack of paper, leaving the facility without current paper records during the outage. The Licensed Practical Nurse (LPN) on duty did not administer medications during the outage, and the Director of Nursing (DON) was unaware of the disruption to medication and treatment administrations. The facility's policy required paper forms to be available during such disruptions, but this was not adhered to, resulting in the deficiency.
Medication Administration Failure Due to Internet Disruption
Penalty
Summary
The facility failed to ensure that residents were free from significant medication errors due to a disruption in internet service, which affected the administration of medications as per physician orders. On the day of the incident, the internet was not working, and the facility's electronic medical record system, Point Click Care, was inaccessible. The Director of Nursing (DON) was informed of the issue and attempted to resolve it by contacting the internet provider and IT department. However, the nurses were unable to access the electronic records and relied on their personal phone hotspots, which was not a reliable solution. The facility had a backup plan in place, which involved printing Medication Administration Records (MARs) and Treatment Administration Records (TARs) every weekend to be used in case of a power outage. These records were supposed to be stored in a black box at the receptionist's desk. However, the receptionist did not print the backup records the previous weekend due to a lack of paper, resulting in outdated backup documentation. Consequently, the residents did not receive their medications as ordered, and there was no documentation of blood glucose monitoring or insulin administration for several residents on the day of the incident. The deficiency affected five residents who had various medical conditions, including diabetes mellitus and chronic kidney disease. These residents did not receive their prescribed medications, such as insulin and other necessary treatments, at the scheduled times. The facility's policy on medication administration and electronic medical record disaster planning was not followed, leading to the failure in medication administration. This deficiency was investigated under Complaint Number OH00154306.
Failure to Implement Enhanced Barrier Precautions
Penalty
Summary
The facility failed to implement Enhanced Barrier Precautions (EBP) for residents with chronic wounds and/or indwelling medical devices, affecting 11 out of 23 residents reviewed. This deficiency was identified through observations, staff interviews, medical record reviews, and policy reviews. The facility's policy required EBP in addition to standard precautions for residents with chronic wounds, indwelling medical devices, and infection or colonization with Multi Drug Resistant Organisms (MDROs). Several residents, including those with stage IV pressure ulcers, unstageable pressure injuries, and indwelling devices such as PICC lines and feeding tubes, did not have appropriate physician orders for EBP. Observations revealed that these residents lacked visible signs indicating EBP outside their rooms. Interviews with the Director of Nursing (DON) and Licensed Practical Nurses (LPNs) confirmed the absence of EBP orders and signage, despite the residents' conditions necessitating such precautions. The deficiency was documented under Complaint Number OH00154306, highlighting the facility's noncompliance with its own EBP policy. The lack of EBP implementation for residents with chronic wounds and indwelling devices was a significant oversight, as verified by the DON and LPNs during the survey. This failure to adhere to established infection prevention protocols posed a risk to the health and safety of the affected residents.
Failure to Timely Identify and Treat Skin Tear
Penalty
Summary
The facility failed to timely identify and treat a skin tear on a resident's left lower leg. The resident, who was admitted with diagnoses including non-ischemic myocardial injury, rhabdomyolysis, chronic atrial fibrillation, stage III kidney disease, and chronic systolic heart failure, had severely impaired cognition and no documented skin conditions upon admission. However, during an observation and interview, an LPN verified that the resident had a dressing on her left lower leg dated a week prior, indicating a skin tear that had not been documented or treated in a timely manner. The facility's policy required all residents to be evaluated for skin integrity upon admission and for any impaired skin integrity to have appropriate interventions implemented. Despite this, the resident's weekly skin assessment was not completed as it did not flag in the system, leading to a delay in treatment. The LPN confirmed that the admission assessment noted no skin issues, and upon observation, the skin tear measured 2.0 cm by 1.0 cm. The LPN then cleansed the wound and applied appropriate dressings, but the delay in assessment and treatment constituted a deficiency.
Failure to Provide Timely Incontinence Care
Penalty
Summary
The facility failed to provide timely incontinence care for a resident, identified as Resident #61, who was incontinent of bowel and bladder due to immobility. The resident's care plan included interventions such as assisting with toileting upon request, providing disposable briefs, and checking during rounds for incontinence. Despite these interventions, the resident experienced a delay in receiving incontinence care. On the day of observation, the resident activated her call light at 9:20 A.M. and informed STNA #113 at 9:36 A.M. that she needed her brief changed due to an incontinent episode. However, STNA #113 did not provide the necessary care and instead deactivated the call light and left the room, stating that another aide would return to assist. The resident had to reactivate her call light at 10:32 A.M., and it was not until 10:33 A.M. that STNA #223 provided the required incontinence care. During an interview, STNA #113 confirmed that the resident had requested incontinence care at 9:36 A.M. and acknowledged that care was not provided until nearly an hour later. The facility's policy on Routine Resident Care, dated 03/07/23, mandates that incontinence care be provided timely according to each resident's needs. This deficiency was investigated under Complaint Numbers OH00155306 and OH00154306.
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.
Trusted data from CMS and state health departments
Every citation, penalty and Plan of Correction is sourced from public CMS records (latest release May 27, 2026) and official state health department websites — never guesswork.
Trusted by long-term care providers and associations.
