The Laurels Of Walden Park
Inspection history, citations, penalties and survey trends for this long-term care facility in Columbus, Ohio.
- Location
- 5700 Karl Road, Columbus, Ohio 43229
- CMS Provider Number
- 365379
- Inspections on file
- 48
- Latest survey
- October 9, 2025
- Citations (last 12 mo.)
- 42
Citation history
Health deficiencies cited at The Laurels Of Walden Park during CMS and state inspections, most recent first.
Surveyors found that two residents with complex medical conditions did not receive weekly comprehensive wound assessments, and appropriate skin interventions were not consistently implemented. One resident's MASD was not assessed weekly as required, while another resident's pressure ulcer was not offloaded and the air mattress was set incorrectly for their weight. Documentation of wound status was inconsistent, and wounds were not always accurately classified, as confirmed by interviews with nursing staff and review of facility policy.
A resident with significant mobility impairments and a history of falls was left sitting unattended on the side of the bed by a CNA, despite care plan interventions requiring supervision and use of a Hoyer lift for transfers. The resident slipped and fell between the bed and dialysis chair, sustaining superficial skin tears. This incident was confirmed by record review, fall investigation, and DON interview, and was not in accordance with the facility's fall management policy.
A resident did not receive appropriate care for existing pressure ulcers, and the facility failed to implement effective interventions to prevent new ulcers from developing. Observations and record reviews showed lapses in assessment, monitoring, and treatment, with necessary preventive measures not consistently applied.
The facility did not maintain an effective pest control program, resulting in daily sightings of gnats, roaches, and flies in resident rooms and common areas. Multiple residents and staff confirmed the ongoing pest presence, and direct observations documented pests on surfaces and equipment. In one case, a resident with a tracheostomy was found to have fly larvae in the stoma, requiring hospital transfer.
The facility did not ensure that advance directives, such as DNR orders, were readily available to staff and EMS for several residents with significant medical conditions. In one case, a resident with a DNR order experienced a medical emergency, but staff could not provide the required documentation, resulting in unwanted resuscitation efforts. Similar documentation gaps were found for other residents, with missing signed DNR forms in both electronic records and code status binders, as confirmed by staff interviews and record reviews.
Several dependent residents with complex medical needs did not receive adequate personal hygiene care, including shaving and nail care, as required by facility policy. Observations and interviews revealed that staff did not consistently offer or provide these services, and residents or their families reported unmet requests for assistance with grooming.
Two residents experienced ongoing issues with a loose, leaking sink faucet and a separated baseboard exposing a dark surface in their shared room. Despite repeated notifications to staff and adherence to facility policy requiring maintenance of a safe and clean environment, the problems were not addressed, resulting in a deficiency.
The facility did not timely report multiple incidents of physical and verbal abuse, as well as injuries of unknown origin, to the State Survey Agency as required by policy. In several cases involving residents with cognitive impairment and complex medical histories, allegations of abuse were either reported late or not reported at all, despite clear documentation of the incidents and facility policy mandating prompt notification.
The facility did not promptly or thoroughly investigate multiple allegations of verbal and physical abuse, as well as injuries of unknown origin, affecting several residents with cognitive impairments and complex medical histories. Required investigations were delayed or not conducted, and there was no evidence of proper follow-up or staff interviews as outlined in facility policy.
Two residents with contractures did not receive their physician-ordered splint devices as required. Despite clear orders and care plan interventions for the use of a palm protector and a c-roll splint, observations over several days showed that neither device was applied. Staff interviews revealed confusion about responsibility for applying the devices, and facility policy regarding splint use was not followed.
The facility failed to prevent accidents and secure hazards for residents, including not thoroughly investigating a fall that resulted in a hip fracture, not ensuring proper footwear to prevent slips, and not securing smoking materials for a resident assessed as unsafe to smoke. These deficiencies involved inadequate supervision, incomplete care plan updates, and failure to follow facility safety policies.
A resident with severe cognitive impairment and total dependence on staff for tracheostomy care was found with fly larvae at the tracheostomy site, requiring hospital evaluation and removal of the infestation. Documentation showed tracheostomy care was signed off as completed, but surveyors observed ongoing fly presence in the unit and noted the facility's policy lacked guidance for such infestations.
A resident with chronic pain conditions received scheduled Tramadol, but staff failed to document pain assessments or evaluate the effectiveness of the medication as required by the care plan and facility policy. Nursing staff confirmed the absence of pain scale documentation and monitoring, despite established procedures for pain management.
The facility did not identify PTSD triggers in the care plan for a resident with a known PTSD diagnosis and failed to assess another resident for PTSD despite recent traumatic experiences. Two residents were affected, and the facility's policy requiring trauma-informed care and identification of triggers was not followed.
A resident with a chronic wound and an active order for Enhanced Barrier Precautions (EBP) received incontinence care from a CNA who wore gloves but failed to wear a gown, despite posted EBP signage and facility policy requiring both for high-contact care activities. The CNA confirmed not following the gown requirement during the care.
A resident receiving anticoagulant therapy, with a care plan indicating risk for bleeding and bruising, was found to have multiple bruises that had not been identified or monitored by nursing staff. The RN assigned to the resident was unaware of the bruising, and there was no documentation of monitoring for bruising in the medical record, despite the resident's known risk factors.
A resident with complex medical needs experienced a significant weight gain over a short period, but staff failed to assess, document, or investigate the change as required by facility policy. The dietitian did not notice the weight change when entering data, and the DON indicated that monitoring was the dietitian's responsibility. No reweigh or assessment was completed, and the resident was later hospitalized following a change in condition.
A resident with multiple chronic conditions did not receive prescribed Brimonidine eye drops twice daily as ordered, due to the facility's failure to properly reconcile and verify medication orders upon readmission. Despite clear indications in the hospital discharge summary and prior orders, the medication was administered only once daily, and staff interviews confirmed the error and the resident's awareness of the issue.
A resident with multiple diagnoses, including schizophrenia and dementia, was prescribed Paliperidone, but staff failed to document daily monitoring for antipsychotic side effects as required by the care plan and facility policy. Interviews with the DON and ADON confirmed the lack of required documentation, and this deficiency was identified during a complaint investigation, potentially affecting other residents on antipsychotic medications.
A resident with a history of traumatic brain injury was physically assaulted by a visitor on the smoking patio, resulting in a laceration and swelling. The facility's investigation was incomplete, and neurological checks were not conducted at proper intervals. The incident highlights a failure to ensure a safe environment as per the facility's abuse prohibition policy.
A resident with a history of traumatic brain injury and other conditions was physically assaulted by a visitor in the smoking area, resulting in a fractured nose. The facility's investigation was incomplete as it failed to include a statement from another resident who witnessed the incident. Despite the incident's severity, the facility unsubstantiated the allegation, citing unpredictability of the event.
A resident experienced harm due to the facility's failure to address a low potassium level, resulting in an acute change in condition. The resident's lab results indicating hypokalemia were not reviewed, leading to shortness of breath, bradycardia, and eventual hospitalization for ventricular tachycardia. Interviews revealed a lack of communication and follow-up on lab results, contributing to the deficiency.
A resident with chronic conditions had a BMP ordered post-hospital discharge, revealing low potassium levels. The facility failed to notify the physician or fax results to the cardiologist. Staff interviews confirmed the oversight, and the facility's policy on notifying practitioners of significant changes was not followed.
A resident with severe cognitive impairment and multiple medical conditions left the facility without staff knowledge and was found intoxicated by law enforcement. The facility failed to investigate the incident, as confirmed by interviews with an LPN and the DON, who acknowledged the lack of documentation and investigation into the resident's unauthorized departure.
A resident with multiple medical conditions, including quadriplegia and chronic respiratory failure, missed a scheduled appointment with Ohio Health Neuroscience due to the facility's failure to record the appointment and arrange transport. Despite the resident's full cognitive capacity, the oversight was only discovered when the resident's wife informed the facility, leading to a deficiency finding.
Failure to Complete Weekly Wound Assessments and Ensure Proper Skin Interventions
Penalty
Summary
The facility failed to ensure that weekly comprehensive wound assessments were completed, appropriate skin interventions were in place, and wounds were accurately classified for two residents reviewed for wounds. For one resident with multiple complex diagnoses, including chronic kidney disease, malnutrition, and dependence on dialysis, the initial assessment upon admission identified excoriation and Moisture Associated Skin Damage (MASD) to several areas. Although the care plan included weekly head-to-toe skin assessments and specific interventions, there was no documented weekly comprehensive assessment of the MASD until nearly a month after admission. Interviews with the wound nurse and DON confirmed that weekly assessments should have been performed and documented. Another resident with a history of end-stage renal disease, severe malnutrition, bilateral lower limb amputation, and other comorbidities was admitted with a stage III pressure injury and later developed an unstageable pressure ulcer to the left below-knee amputation site. The care plan required weekly skin assessments, offloading, and use of pressure-relieving devices. However, observations revealed the resident's wound was not offloaded, and the air mattress was set incorrectly for the resident's weight, providing no effective offloading. Documentation inconsistencies were also identified, with the DON confirming that an LPN had been documenting wounds incorrectly or not at all, and the wound was later reclassified as vascular in origin by a wound nurse practitioner. Review of facility policy indicated that residents with wounds or at risk for skin compromise should receive ongoing monitoring, evaluation, and appropriate documentation of skin impairments until resolved. The deficiencies were identified through observation, record review, and staff interviews, and were cited under a complaint investigation and as a recite to the annual survey.
Resident Left Unattended Resulting in Fall
Penalty
Summary
A deficiency occurred when a resident with multiple complex medical conditions, including chronic kidney disease, impaired mobility, and a history of falls, was left unattended sitting on the side of the bed while preparing for dialysis. The resident required one-person assistance with transfers and ambulation, had a documented fear of falling, and was identified as being at high risk for falls due to factors such as medication effects, impaired vision, unsteady gait, and pain. The care plan specifically included interventions such as not leaving the resident unattended in the bathroom or at the bedside, using a Hoyer lift for transfers, and keeping the call light within reach. Despite these documented interventions, the resident was left alone by a CNA, resulting in the resident slipping off the bed and being found on the floor between the bed and dialysis chair with two superficial skin tears. The incident was confirmed through record review, fall investigation, and interview with the DON, who verified that the resident was left unsupervised, contrary to the care plan and facility policy. The facility's fall management policy required identification of hazards and implementation of interventions to minimize falls, which was not followed in this instance.
Failure to Provide and Prevent Pressure Ulcer Care
Penalty
Summary
The facility failed to provide appropriate care for pressure ulcers and did not implement effective measures to prevent the development of new ulcers. This deficiency was identified through observations and record reviews that indicated lapses in the assessment, monitoring, and treatment of pressure ulcers for residents at risk. The report notes that necessary interventions to prevent skin breakdown were not consistently applied, and existing pressure ulcers were not managed according to established protocols.
Failure to Maintain Effective Pest Control Program
Penalty
Summary
The facility failed to maintain an effective pest control program, resulting in the presence of gnats, roaches, house flies, and fruit flies throughout the building. Multiple residents reported daily encounters with gnats and roaches in their rooms, with direct observations confirming the presence of these pests on privacy curtains, tray tables, and side tables. Staff interviews corroborated the ongoing issue, with both nursing and housekeeping personnel acknowledging the daily presence of live pests in resident rooms and common areas. Additionally, a roach was observed crawling in a hallway, and a significant number of gnats were seen in a resident's room during maintenance staff observation. In the tracheostomy unit, multiple observations documented house flies and fruit flies flying around and landing on various surfaces. One resident, whose room was adjacent to an exit door leading outside, was found to have a tracheostomy and stoma infested with fly larvae, necessitating hospital transfer. The facility's policy stated an environment free of pests would be provided, but the ongoing pest infestation affected several residents and had the potential to impact all residents in the facility.
Failure to Ensure Advance Directives Are Accessible to Staff and EMS
Penalty
Summary
The facility failed to ensure that residents' advance directives were readily accessible to staff and Emergency Medical Services (EMS) personnel, as evidenced by observations, interviews, and record reviews. In several cases, residents had documented wishes regarding resuscitation and code status, but the necessary paperwork, such as signed Do Not Resuscitate (DNR) forms, was either missing from the electronic health record or not available in the code status binders at the nurses' stations. This deficiency affected four residents who had varying degrees of cognitive impairment and significant medical histories, including dementia, atrial fibrillation, chronic obstructive pulmonary disease, and congestive heart failure. One resident with severe cognitive impairment and a DNR order experienced a critical event where EMS was called due to low oxygen saturation. When EMS arrived, staff were unable to provide a valid, physician-signed DNR form, resulting in the initiation of CPR and transport to the hospital, contrary to the resident's documented wishes. The resident was revived at the hospital, and only after family confirmation was care de-escalated, and the resident passed away. Interviews with nursing staff confirmed the absence of the required DNR documentation at the time of the emergency. For other residents, reviews of their medical records and code status binders revealed similar issues: either the signed DNR paperwork was not present in the electronic health record or not available in the code status book at the nurses' stations. Staff interviews confirmed that the required documentation was missing, and facility policy required that copies of all advance directives be placed in the medical record and, if applicable, a DNR order be obtained from the physician. The lack of accessible advance directive documentation directly impacted the facility's ability to honor residents' wishes regarding life-sustaining treatment.
Failure to Provide Adequate Personal Hygiene for Dependent Residents
Penalty
Summary
The facility failed to provide adequate care and services for personal hygiene to residents who were dependent on staff for activities of daily living (ADLs). Multiple residents with significant medical conditions, including surgical amputation, chronic obstructive pulmonary disease, multiple sclerosis, contractures, dementia, and hemiplegia, were observed to have unmet hygiene needs. These included unshaven facial hair, long and untrimmed fingernails, and dirty contracted hands, despite being fully dependent on staff for these tasks. One resident with intact cognition and dependency for grooming was observed with a long, untrimmed mustache and beard, and reported that staff had not offered to shave or trim his facial hair, though he expressed a desire for this care. Another resident with a contracted hand and multiple sclerosis had long fingernails resting against her palm and reported repeatedly asking staff to trim her nails, but the care was not provided. Staff confirmed that this resident did not refuse grooming or care. A third resident, dependent on staff for personal hygiene due to cognitive impairment, was observed with a long beard and no documentation of refusal of care. The resident’s family member also confirmed the need for daily shaving. Additionally, a resident with diabetes, contractures, and hemiplegia was observed with long, dirty fingernails on a contracted hand. Staff confirmed the presence of debris and a yeast-like odor, and that the hand required cleaning and trimming. Facility policy required daily personal hygiene, including nail care and shaving, but documentation and observations indicated these standards were not met for several dependent residents.
Failure to Maintain Safe and Homelike Resident Environment
Penalty
Summary
The facility failed to maintain a safe, clean, and homelike environment in the rooms of two residents. Record review and interviews revealed that one resident's sink faucet had been loose and leaking since March, and both the resident and their guardian had notified the facility of the issue, but it was never repaired. Observations over several days confirmed the faucet remained loose and dripping. Additionally, the baseboard behind the toilet in the same room was separated from the wall, exposing a dark brown and black surface underneath. Both the resident and their roommate reported the ongoing issues with the sink to the facility, but no repairs had been made. Staff interviews confirmed awareness of the loose and leaking sink faucet, though the RN was not aware of the separated baseboard. Maintenance workers and housekeeping staff acknowledged the problems, with housekeeping stating she had reported the issues to her supervisor. Facility policy requires housekeeping to report repair needs to maintenance and affirms residents' rights to a safe, clean, and comfortable environment. Despite these policies, the facility did not address the reported maintenance issues in a timely manner, resulting in a deficiency affecting the residents' living conditions.
Failure to Timely Report Allegations of Abuse and Injuries of Unknown Origin
Penalty
Summary
The facility failed to timely report allegations of physical and verbal abuse, as well as injuries of unknown origin, to the State Survey Agency as required. For one resident with severe cognitive impairment and multiple medical conditions, an incident occurred where the resident was found with a bleeding nose and alleged being punched. Although an assessment and room change were completed, no Self-Reported Incident (SRI) was filed for this physical abuse allegation. Additionally, when the same resident was later found with facial bruising, skin tears, and injuries of unknown origin, no SRI was submitted for this event either. The Administrator confirmed that these incidents were not reported until approximately eight months later, following discussion during the survey. Another resident with moderately impaired cognition and multiple diagnoses was subjected to verbal abuse by another resident, which resulted in emotional distress. The SRI for this incident was filed three days after the event, rather than within the required timeframe. A subsequent incident of verbal abuse by the same resident was not reported at all. The facility's policy requires that allegations of abuse or serious injury be reported to state or federal agencies within two hours, and all other allegations within 24 hours, but these requirements were not met in the cases reviewed.
Failure to Investigate Allegations of Abuse and Injuries of Unknown Origin
Penalty
Summary
The facility failed to ensure that allegations of verbal and physical abuse, as well as injuries of unknown origin, were thoroughly investigated for three residents. In one instance, a resident with moderately impaired cognition was verbally abused by another resident, resulting in emotional distress. The facility did not initiate an investigation into this incident until three days after it occurred, and failed to investigate a subsequent similar incident involving the same residents. The Administrator confirmed that the required investigations were either delayed or not conducted at all. Another resident with severe cognitive impairment and multiple medical diagnoses experienced physical aggression and later sustained injuries of unknown origin. Although these incidents were documented in nursing notes and discussed in interdisciplinary team meetings, the facility did not initiate any formal investigations to determine the cause or identify responsible parties. There was no evidence of staff interviews, injury assessments of other residents, or follow-up actions consistent with a proper abuse investigation, as required by the facility's own policy.
Failure to Provide Physician-Ordered Splint Devices for Residents with Contractures
Penalty
Summary
The facility failed to provide physician-ordered splint devices to residents with contractures, as evidenced by the care of two residents reviewed for range of motion. One resident, with diagnoses including paralytic syndrome, polyneuropathy, and contracture of the right hand and wrist, had a physician order and care plan intervention for a right palm protector to be applied daily for up to eight hours. Despite this, multiple observations over several days showed the resident was not wearing the palm protector. Interviews with nursing staff and CNAs revealed confusion and lack of clarity regarding responsibility for applying the device, with none of the interviewed staff having applied the palm protector as ordered. Another resident, diagnosed with contracture of the left hand and elbow as well as hemiplegia and hemiparalysis, had an active physician order and care plan for a left c-roll splint to be applied for six hours daily. Observations on multiple occasions found the resident in bed with contracted extremities and no splint or device in place. Staff interviews confirmed the resident had not had the splint applied during the observed period. Facility policy indicated that splints and braces are to be used to enhance mobility and maintain alignment, but these were not provided as ordered for the residents in question.
Failure to Prevent Accidents and Secure Hazards for Residents
Penalty
Summary
The facility failed to ensure a safe environment free from accident hazards and did not provide adequate supervision to prevent accidents for several residents. In one instance, a resident with Alzheimer's disease, dementia, and osteopenia, who was at high risk for falls, experienced a fall in her room after turning off the lights. The fall resulted in a right hip fracture. The facility's fall investigation did not include staff interviews to determine the root cause or other contributing factors, and the care plan was not updated to reflect the use of a walker and wheelchair as interventions after the resident returned from the hospital. The intervention to maintain adequate lighting was not new and had been in place prior to the fall, but the investigation did not address why the resident was able to turn off the lights or if additional measures were needed. Another resident with dementia, unsteadiness, and muscle weakness experienced a fall attributed to worn non-skid socks that lacked sufficient grip. The facility provided these socks, which were shared and cleaned between residents, but staff did not routinely check their condition before use. The only immediate intervention after the fall was replacing the socks with a new pair. The care plan did not address the need for routine inspection or replacement of facility-provided footwear, and the fall investigation did not identify or implement additional preventive measures. A third resident, who was cognitively intact but had bilateral above-knee amputations and muscle wasting, was assessed as unsafe to smoke and required supervision. Despite this, the resident was observed with two lighters within reach at the bedside, contrary to the facility's smoking policy, which required all smoking paraphernalia to be maintained by staff and locked away. Staff interviews confirmed that even safe smokers were not permitted to keep lighters or smoking materials on their person, and the policy required staff to secure all such items. The presence of lighters at the bedside represented a failure to follow the facility's own safety protocols.
Failure to Provide Adequate Respiratory Care Resulting in Tracheostomy Site Infestation
Penalty
Summary
A resident with acute and chronic respiratory failure, hemiplegia, hemiparesis, and who was ventilator dependent with a tracheostomy, was found to have multiple fly larvae (maggots) in and on the tracheostomy site. The resident was totally dependent on staff for all care, including tracheostomy care, which was ordered to be performed every 12 hours with skin checks under the tracheostomy ties on each shift. Documentation in the Treatment Administration Record indicated that tracheostomy care was completed and signed off by various respiratory therapists. However, a nursing note documented the discovery of the larvae, and the resident was subsequently sent to the emergency room, where the infestation was removed. Hospital records confirmed the presence and removal of three larvae, with no further intervention required. Observations during the survey revealed multiple house flies and fruit flies present in the tracheostomy unit, landing on various surfaces. The resident's room was located next to an exit door leading outside, which staff had frequently used prior to the incident. The facility's policy on tracheostomy suctioning did not contain information on care required for fly larvae infestation. Interviews confirmed the infestation and the presence of flies in the unit, but attempts to interview the staff directly involved at the time of the incident were unsuccessful.
Failure to Monitor Effectiveness of Scheduled Opioid Pain Medication
Penalty
Summary
The facility failed to consistently evaluate the effectiveness of regularly scheduled opioid pain medication for a resident with chronic pain conditions, including fibromyalgia and polyarthritis. The resident had a physician's order for Tramadol 50 mg twice daily for pain management, and the care plan required evaluation of the medication's effectiveness, review of compliance, symptom alleviation, dosing schedules, resident satisfaction, and impact on functional ability and cognition. However, review of the medication administration record, treatment administration record, and progress notes revealed no documentation of pain scale assessments or evaluation of the medication's effectiveness during the specified period. Interviews with nursing staff confirmed that there was no pain scale or documentation of pain assessment or medication effectiveness for this resident, despite facility policy requiring such monitoring for residents identified with pain. The facility's pain management policy specified the use of a consistent pain scale, regular re-evaluation, and documentation of pain monitoring, but these procedures were not followed for the resident receiving scheduled Tramadol.
Failure to Identify and Address PTSD Triggers and Assess for Trauma
Penalty
Summary
The facility failed to provide trauma-informed and culturally competent care for two residents with significant histories of trauma and mental health concerns. For one resident with diagnoses including PTSD, anxiety disorder, and depression, the care plan did not include specific PTSD triggers, despite documentation in the social services evaluation that identified triggers such as people, thoughts, and feelings. The care plan only addressed general interventions for mood and anxiety but omitted the individualized triggers that could help staff avoid re-traumatization. This omission was confirmed by the social worker during an interview. For another resident with a history of recent traumatic events, including the loss of a child to suicide and a recent bilateral leg amputation, there was no assessment for PTSD upon admission or during the resident's stay. The resident expressed feelings of sadness and depression and requested to speak with someone, but the social service designee was unaware of the resident's traumatic loss and confirmed that no PTSD assessment had been completed. The facility's policy requires trauma to be identified and addressed in the care plan, including triggers and interventions, but this was not done for these residents.
Failure to Follow Enhanced Barrier Precautions During Resident Care
Penalty
Summary
Staff failed to follow Enhanced Barrier Precautions (EBP) as required for a resident with a chronic wound. The resident, who had a diagnosis of chronic obstructive pulmonary disease and an active physician order for EBP due to a chronic wound, was observed receiving incontinence care from a Certified Nursing Assistant (CNA) who wore gloves but did not don a gown, despite clear signage outside the resident's room indicating the need for both gloves and a gown during high-contact care activities. The CNA confirmed during interview that he did not wear a gown while providing care, contrary to the posted EBP requirements. Facility policy and CDC guidance both specify that gloves and gowns must be worn during high-contact care for residents on EBP, particularly those with chronic wounds. Observations confirmed that the required EBP signage was present and visible outside the resident's room, outlining the need for gloves and gowns during specific care activities. Despite these clear instructions and policies, the staff member did not adhere to the EBP protocol during care provision.
Failure to Monitor Bruising in Resident on Anticoagulant
Penalty
Summary
A resident with diagnoses including end stage renal disease, anemia, and heart failure was admitted to the facility and was receiving Apixaban, an anticoagulant, as ordered by her physician. The resident's care plan identified her as being at risk for hematological alterations due to anemia and anticoagulant side effects, with interventions to administer medications as ordered and observe for side effects such as bruising. Despite these interventions, observations revealed maroon, gray-brown, and yellow bruising on the resident's bilateral forearms and lower right extremity. The assigned RN was unaware of the bruising until it was pointed out during the survey, despite the resident being on anticoagulant therapy. Further review and interviews with the DON and wound nurse confirmed there was no documented evidence of monitoring the resident's bruising in the medical record. This lack of monitoring and documentation for bruising in a resident on anticoagulant medication constituted the deficiency identified during the survey.
Failure to Assess and Investigate Significant Weight Gain
Penalty
Summary
A resident with multiple complex medical conditions, including chronic respiratory failure, end stage renal disease, and dysphagia, was identified as being at risk for nutritional decline according to their care plan. The care plan required observation and evaluation of weight and weight changes. The resident experienced a significant weight gain of 7.6% in less than 30 days, increasing from 169.1 lbs to 181.9 lbs. Despite this notable change, there was no documentation in the progress notes acknowledging, identifying, or assessing the weight gain during the period reviewed. Interviews revealed that the dietitian entered the resident's weight into the system but did not notice the significant change at the time, and confirmed that no assessment or documentation of the weight gain occurred. The DON stated that the dietitian was responsible for monitoring weekly weights, not the nursing staff. Facility policy required reweighs within 48 to 72 hours for significant weight changes, but this was not done. The resident was later sent to the hospital due to a change in condition, but there was no evidence that the significant weight gain was investigated or addressed prior to this event.
Failure to Reconcile Medication Orders Leads to Incorrect Eye Drop Administration
Penalty
Summary
The facility failed to properly reconcile a resident's medication orders upon readmission, resulting in the resident not receiving prescribed eye drops as ordered by the physician. Specifically, the resident, who had a complex medical history including end stage renal disease, kidney transplant, congestive heart failure, and glaucoma, was supposed to receive Brimonidine Tartrate Ophthalmic Solution 0.2% one drop in each eye twice daily. Prior to hospitalization, this was the established order, and the hospital after visit summary (AVS) also indicated continuation of this regimen. However, upon readmission, the facility entered an order for the medication to be administered only once daily, and this was how it was given from 04/01/25 to 04/09/25. Interviews with the resident and an LPN confirmed the discrepancy between the intended twice-daily dosing and the once-daily administration. The resident reported awareness of the change and expressed concern that the facility was not following the correct regimen. The LPN acknowledged that the AVS contained conflicting instructions but that the check marks for morning and evening administration indicated the medication should have continued twice daily. Facility policy and the nurse admission checklist required verification and reconciliation of orders with the physician and pharmacy, but this process was not properly followed, resulting in the medication error.
Failure to Monitor and Document Antipsychotic Side Effects
Penalty
Summary
The facility failed to monitor and document the side effects of antipsychotic medication for a resident diagnosed with conditions including cerebrovascular disease, schizophrenia, hypothyroidism, dementia, and drug-induced dyskinesia. The resident was prescribed Paliperidone, an antipsychotic, and her care plan included interventions to observe and report side effects such as sedation, headaches, dizziness, and other symptoms. However, a review of the resident’s medical record, including medication and treatment administration records from January through April 2025, revealed no documented evidence of daily monitoring for antipsychotic side effects as required by the care plan and facility policy. Interviews with the DON and ADON confirmed that daily documentation of side effect monitoring for antipsychotic medications was expected and should be present in the medical record, but was missing for this resident. The facility’s policy on behavior management also emphasized the importance of describing behaviors that could indicate medication side effects. This deficiency was identified during a complaint investigation and had the potential to affect other residents receiving antipsychotic medications.
Failure to Protect Resident from Physical Abuse
Penalty
Summary
The facility failed to protect a resident from physical abuse, resulting in a deficiency. Resident #145, who had a history of traumatic brain injury and other medical conditions, was involved in an altercation with a visitor on the smoking patio. The resident, who had intact cognition and required minimal assistance with activities of daily living, was struck twice on the right upper eye by the visitor, leading to a laceration and swelling. Despite the resident's refusal to file a police report, the facility proceeded with reporting the incident to the authorities. The facility's investigation into the incident revealed that the altercation occurred over a lighter, and the visitor was identified as the aggressor. The Smoking Aide, who was present at the time, confirmed that the visitor continued to assault the resident even after he fell from his wheelchair. The facility's response included escorting the visitor out and notifying the police. However, the facility's investigation was incomplete as it did not include an interview with another resident who was present during the incident. Additionally, the facility failed to conduct neurological checks on Resident #145 at the proper intervals following the incident. The resident was later seen in the emergency department, where a CT scan revealed an age-indeterminate nasal fracture, and the resident was treated for pain and swelling. The facility's policy on abuse prohibition emphasizes the responsibility of staff to ensure a safe environment, which was not upheld in this case.
Incomplete Investigation of Physical Abuse Allegation
Penalty
Summary
The facility failed to conduct a thorough investigation of an allegation of physical abuse involving a resident, identified as Resident #145. The incident occurred when Resident #145 was struck twice on the right upper eye by a family member of another resident while outside in the smoking area. The resident sustained an injury to the right upper eye, which was treated on-site, and later complained of nose pain, leading to a hospital visit where a fractured nose was diagnosed. Despite the severity of the incident, the facility's investigation was incomplete as it did not include an interview or written statement from another resident, Resident #69, who was present during the incident. Resident #145 had a medical history that included a fracture of nasal bones, hemiplegia, a history of traumatic brain injury, difficulty in walking, seizures, and a mental disorder. The resident was noted to have intact cognition and required minimal assistance for activities of daily living. The incident was reported to the police, and the alleged perpetrator was escorted out of the building and not allowed to return. However, the facility unsubstantiated the allegation, claiming they could not have predicted the event. The facility's policy on abuse prohibition requires interviews with any witnesses to incidents, but this was not fully adhered to in this case. The Smoking Aide, who witnessed the incident, confirmed that the alleged perpetrator was the aggressor and that Resident #145 was injured during the altercation. The Administrator acknowledged the oversight in not obtaining a statement from Resident #69, who was also a witness. This deficiency was investigated under Complaint Number OH00161880.
Failure to Address Hypokalemia Leads to Resident Harm
Penalty
Summary
The facility failed to provide adequate, timely, and necessary care to a resident, leading to an acute change in condition due to hypokalemia. The resident's laboratory results on 10/25/24 indicated a low potassium level of 3.0 mmol/L, which was not reviewed or addressed by the facility staff. This oversight resulted in the resident experiencing shortness of breath and requiring supplemental oxygen by 10/28/24. By 10/30/24, the resident's heart rate was significantly low, and the resident reported that his automated implanted cardioverter defibrillator (AICD) had alarmed. On 10/31/24, the resident exhibited a change in condition, including an irregular pulse, generalized weakness, and signs of delirium. The resident was transferred to a local emergency department, where he was diagnosed with chest pain and ventricular tachycardia (VT), requiring multiple defibrillations. The hospital records indicated that the VT was likely precipitated by significant hypokalemia, with a potassium level of 2.6 mmol/ml upon arrival at the emergency department. The resident was admitted to the hospital and did not return to the facility. Interviews with facility staff revealed a lack of communication and follow-up regarding the resident's laboratory results. The registered nurse and unit manager were unaware of the need to notify the physician or fax the results to the cardiologist. The director of nursing confirmed that the BMP results were not reviewed, and the facility's policy on notification of change was not followed. This deficiency was investigated under Complaint Number OH00159685.
Failure to Notify Physician of Abnormal Lab Results
Penalty
Summary
The facility failed to ensure timely notification to the physician or Certified Nurse Practitioner (CNP) of abnormal laboratory values for a resident. The resident, who had multiple chronic conditions including heart failure, diabetes, and kidney disease, was discharged from the hospital with instructions for outpatient testing, including a Basic Metabolic Panel (BMP). The BMP was ordered and collected as scheduled, revealing a low potassium level. However, there was no evidence that the physician was notified of these results, nor were they faxed to the resident's cardiologist as instructed. Interviews with facility staff, including a Registered Nurse, Unit Manager, and the Director of Nursing, confirmed that the abnormal lab results were not communicated to the appropriate medical personnel. The Unit Manager indicated that the order for the BMP likely originated from the hospital, and the in-house provider was not aware to check for the results. The facility's policy on 'Notification of change' requires informing the resident and consulting with the resident's practitioner when there is a significant change in status, which was not adhered to in this case.
Failure to Investigate Resident's Unauthorized Departure and Intoxication
Penalty
Summary
The facility failed to appropriately investigate an incident involving a resident with severe cognitive impairment who had an unwitnessed fall and later left the facility without staff knowledge. The resident, who had multiple complex medical conditions including vascular dementia and depression, was found by local law enforcement near a liquor store, appearing intoxicated, and was subsequently taken to a hospital for treatment. Despite the resident's absence being noted during a neurological check, there was no documentation indicating that the facility was aware of his departure or had conducted an investigation into the incident. Interviews with staff revealed that the LPN on duty did not know the resident was out of the facility until notified by the hospital. The Director of Nursing confirmed that no investigation was conducted to determine when or how the resident left, nor were any staff or the resident interviewed to gather information about the incident. This lack of investigation and documentation represents a deficiency in the facility's responsibility to ensure resident safety and supervision.
Missed Medical Appointment for Resident
Penalty
Summary
The facility failed to ensure that Resident #11 attended a scheduled medical appointment, resulting in a deficiency. Resident #11, who was admitted with diagnoses including demyelinating disease of the central nervous system, chronic respiratory failure with hypoxia, tracheostomy status, and quadriplegia, was assessed to require total dependence on all aspects of care. Despite having a Brief Interview for Mental Status (BIMS) score of 15 out of 15, indicating no cognitive impairment, the resident missed an appointment with Ohio Health Neuroscience. The appointment was scheduled for 08/21/24 at 10:00 A.M., but there was no record of it being entered into the medical record, nor was transport arranged by the facility. The resident's wife informed the facility of the missed appointment, which she rescheduled, and the Director of Nursing confirmed the oversight.
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A resident with intact cognition receiving Medicare Part A skilled services for metabolic encephalopathy had services discontinued while benefit days remained, but the facility did not issue the required Skilled Nursing Facility Advance Beneficiary Notice (SNF ABN). The Social Services Director later confirmed that no SNF ABN was provided and reported she believed only a Notice of Medicare Non-Coverage (NOMNC) was needed when all skilled services were stopped. This practice conflicted with the facility’s written policy, which required SNF ABNs to be issued when extended care items or services were initiated, reduced, or terminated due to expected non-coverage by Medicare.
Surveyors identified that the facility exceeded the acceptable medication error rate when two residents with type 2 DM received insulin doses that were not administered according to orders or manufacturer instructions. In two separate observations, an LPN administered Novolog and another LPN administered insulin glargine and insulin lispro without priming the insulin pens, and the insulin lispro and Novolog were given after the residents had already consumed a significant portion of their breakfast meals, despite orders for administration before meals. Manufacturer information for both insulin products required priming before each injection to ensure accurate dosing, and facility policy required medications, including insulin, to be administered safely, timely, and in accordance with prescriber orders and specified time frames.
Surveyors found that the facility failed to document tray line food temperatures for multiple meals served from two dining room kitchenettes, despite having a “Trayline Taste & Temperature Log” and a policy requiring food to be stored, prepared, distributed, and served according to professional food safety standards. Review of logs showed repeated missing entries for breakfast, lunch, and dinner services in both the Harrison and McClellan dining areas, and the Senior Director of Culinary Services confirmed that temperatures had not been recorded for those meals, potentially affecting all residents receiving meals from those kitchenettes.
The facility failed to conduct and document required periodic care conferences for two residents, despite multiple comprehensive, quarterly, and significant change MDS assessments and a policy requiring periodic care conferences with resident and/or family participation. One resident with Parkinson’s disease, post-stroke hemiplegia, TIA, DMII, and depression had only two documented care conferences over a year, while another resident with aphasia, cerebrovascular disease, DMII, gait difficulty, coagulation defect, depression, and muscle weakness had no documented care conferences in the past year, aside from a declined invitation to the representative. The UCC confirmed that care conferences were expected to occur quarterly and that no additional documentation existed for either resident.
A resident with Alzheimer's disease and type II DM, who required extensive assistance with ADLs and was receiving scheduled Lantus and sliding-scale Humalog, experienced a severely elevated blood glucose level. The on-call provider was notified and ordered an additional dose of lispro insulin with a directive to recheck the blood glucose after administration. Nursing staff administered the extra insulin but did not document any follow-up blood glucose check, and the DON confirmed that this reevaluation was required by the facility's abnormal blood glucose policy and was not completed or documented.
A resident with Parkinson’s disease, dementia, and hypothyroidism was prescribed levothyroxine once daily along with other medications. A consultant pharmacist’s monthly drug regimen review recommended that levothyroxine be given in the morning on an empty stomach, 30–60 minutes before food, per manufacturer instructions. The medical record contained no documented physician response to this recommendation, and the MAR showed the drug scheduled for morning administration while the resident was observed eating breakfast and receiving the medication at the same time. An LPN confirmed administering levothyroxine during the meal, and the DON verified there was no documentation explaining whether or why the pharmacist’s recommendation was or was not followed, resulting in a failure to act on and document the identified irregularity.
A resident with severe cognitive impairment, multiple comorbidities, documented gait and balance abnormalities, and a high fall risk was care planned and assessed by therapy to require contact guard assistance and use of a gait belt for transfers and ambulation. While being assisted by a CNA from a recliner to the bathroom with a walker, the CNA did not apply a gait belt, even though the resident had a known tendency to lean backward when standing. As the CNA reached to open the bathroom door, the resident lost balance and fell backward, striking the back of the head, and was later found by an LPN without a gait belt in place, contrary to the facility’s gait belt policy and the resident’s assessed needs.
A resident with CKD stage five requiring peritoneal dialysis (PD) was admitted with pre-admission physician orders for three daily PD exchanges and monitoring for peritonitis (fever, abdominal pain, cloudy effluent), but these monitoring orders were not entered into the facility’s physician orders. The care plan referenced PD and general monitoring but did not specifically address peritonitis monitoring. Paper PD flowsheets showed incomplete and inconsistent documentation of exchanges and resident condition, including missing condition/comments for individual treatments and no record of one ordered PD exchange. The PD cycler flowsheet lacked effluent descriptions on multiple days. The PD nurse reported facility staff were expected to monitor effluent and symptoms, and the DON confirmed the absence of specific peritonitis monitoring orders, lack of an order for the PD cycler, and documentation gaps, despite a facility policy requiring ongoing assessment and monitoring for complications before, during, and after dialysis treatments.
A nurse was observed preparing multiple oral medications for a resident with depression, traumatic brain injury, anxiety, and impaired cognition by pushing tablets and capsules from unit-dose cards directly into her ungloved hand and then using her fingers to place them into a medication cup. In a follow-up interview, the RN confirmed this practice and acknowledged that the correct procedure is to dispense medications directly from the card into the cup, contrary to the facility’s medication administration policy requiring adherence to good nursing principles and practices.
A resident with Alzheimer’s disease, diabetes, anxiety, significant ADL dependence, and behavioral symptoms was observed seated in a chair positioned against the nursing station with a locked wheelchair placed directly in front, also against the nursing station, effectively restricting movement. An LPN confirmed both wheelchair wheels were locked and that it should not have been placed there, while a CNA stated she had positioned the wheelchair to prepare for lunch, was unable to complete the transfer, and left it in place, acknowledging this was wrong. This arrangement conflicted with the facility’s restraint policy, which prohibits physical restraints except when alternatives are ineffective for treating a medical symptom and defines restraints as devices adjacent to the body that cannot be easily removed and that restrict freedom of movement or access to the body.
Failure to Issue Required SNF ABN When Discontinuing Medicare Part A Services
Penalty
Summary
The deficiency involves the facility’s failure to issue a Skilled Nursing Facility Advance Beneficiary Notice (SNF ABN) when Medicare Part A services were discontinued for a resident who still had available benefit days. The resident was admitted with a diagnosis of metabolic encephalopathy and had intact cognition per the Minimum Data Set assessment. The facility’s own SNF Beneficiary Notification Review documented that Medicare Part A skilled services began on 02/11/26 and the last covered day was 03/11/26, and that the facility initiated discharge from Medicare Part A services before the resident’s benefit days were exhausted. Despite this, no SNF ABN was provided to the resident or the resident’s representative. During interviews, the Social Services Director stated that the SNF ABN was issued hours prior to the last covered day but, upon reviewing her files, confirmed that no SNF ABN had actually been issued for this resident. She further explained that she believed an SNF ABN was only required if one skilled service remained and that if all skilled services were being discontinued, only the Notice of Medicare Non-Coverage (NOMNC) needed to be issued. The Administrator, however, stated that a resident should always receive both a SNF ABN and a NOMNC when Medicare Part A services are discontinued and benefit days remain. Review of the facility’s written policy dated 03/28/23 showed that the facility was required to issue SNF ABNs for initiation, reduction, or termination of extended care items or services when Medicare payment was not expected, which did not occur in this case.
Plan Of Correction
This Plan of Correction is submitted as required under State and Federal law. This Plan of Correction does not constitute an admission on the part of the Facility that the findings cited are accurate, that the findings constitute a deficiency or that the scope and severity regarding the deficiency cited are correctly applied. Any changes to the Facility's policies and procedures should be inadmissible in any proceeding on that basis. Without admitting or denying the validity or the existence of the alleged noncompliance, the Facility submits this Plan of Correction with the intention that it be inadmissible by any third party in any civil or other action against the facility or any employee, agent, officer, director or shareholder of the Facility. The Facility is utilizing this Plan of Correction as its allegation of substantial compliance as of 05/29/2026 F-0582 Corrective action for resident/s: On 5/14/26 Resident #34 was informed of rights and responsibilities related to Advanced Beneficiary Notice and voiced understanding of information for future reference by administrator. Identification of other residents who may be affected: Any resident receiving skilled services from nursing or therapy services. The Administrator audited all residents who were discharged from skilled services in the past 30 days to ensure they were issued a Notice of Non-Coverage and Advanced Beneficiary Notice on 5/29/26. No non-compliance was noted. Measures for systemic change: On 5/14/2026 Business Office Manager, Director of Rehab, Minimum Data Set nurse, Director of Nursing and Social Services Director were educated on proper procedure of issuing of Notice Of Medicare Non Coverage and Advanced Beneficiary Notice by administrator. All upcoming discharges from skilled services will be reviewed weekly at Utilization Review meeting to ensure notices will be delivered timely. How Corrective Action will be monitored: Administrator or designee to complete audits of all residents being discharged from skilled services to ensure they were issued a Notice of Non-Coverage and Advanced Beneficiary. This audit will be completed weekly x 4 weeks, then monthly x 2 months. Corrective action will be initiated for any noted non-compliance. Audit findings will be reviewed as part of the monthly quality assurance process to determine the need for further monitoring. Date of Compliance 5/29/26
Insulin Administration Errors and Failure to Prime Insulin Pens
Penalty
Summary
The deficiency involves the facility’s failure to maintain a medication error rate below 5%, with surveyors identifying 3 errors out of 28 medication administration opportunities, resulting in a 10.71% error rate. For one resident with type 2 diabetes mellitus and moderate cognitive impairment, the physician’s order directed Novolog insulin 10 units via subcutaneous pen-injector to be given before meals. During an observed medication pass, the LPN administered 10 units of Novolog insulin without priming the pen and did so after the resident had already consumed approximately 50% of the breakfast meal. The LPN later confirmed she did not prime the pen and acknowledged that the insulin was ordered to be administered prior to meals. Manufacturer instructions for the Novolog FlexPen specified that an air shot (priming) must be performed before each injection to ensure proper dosing. Another resident, also diagnosed with type 2 diabetes mellitus and with intact cognition, had orders for insulin glargine 35 units subcutaneously twice daily and insulin lispro 20 units subcutaneously before meals, plus 12 units subcutaneously if blood glucose was between 251 mg/dL and 300 mg/dL. During an observed medication administration, an LPN administered 35 units of insulin glargine and 32 units of insulin lispro without priming the insulin pens and after the resident had consumed approximately 90% of the breakfast meal, despite orders for insulin lispro to be given before meals. The LPN later stated she could not remember if she had primed the pen and acknowledged that the insulin was ordered to be administered prior to meals. Manufacturer information for insulin lispro stated that the pen must be primed before each injection to confirm insulin delivery and remove air, and that failure to prime could result in too much or too little insulin. The DON confirmed the expectation that insulin be administered as ordered, including priming each pen with two units before dialing the prescribed dose, and facility policy required medications, including insulin, to be administered safely, timely, and in accordance with prescriber orders and required time frames.
Plan Of Correction
This Plan of Correction is submitted as required under State and Federal law. This Plan of Correction does not constitute an admission on the part of the Facility that the findings cited are accurate, that the findings constitute a deficiency or that the scope and severity regarding the deficiency cited are correctly applied. Any changes to the Facility's policies and procedures should be inadmissible in any proceeding on that basis. Without admitting or denying the validity or the existence of the alleged noncompliance, the Facility submits this Plan of Correction with the intention that it be inadmissible by any third party in any civil or other action against the facility or any employee, agent, officer, director or shareholder of the Facility. The Facility is utilizing this Plan of Correction as an allegation of substantial compliance as of 5/29/2026. F-0759 Corrective action for resident/s: Residents #21 and #22 were assessed and evaluated by nurse and Director of Nursing 5/14/26. Resident #21 and #22 both denied any adverse effects and none were noted upon assessment by the Director of Nursing on 5/14/2026. Notification made to physician on 5/14/2026. LPN # 2 competency Eval on insulin administration with the Director of Nursing completed 5/14/2026. Identification of other residents who may be affected: Diabetic residents on assignment of LPN #2/station 2 have the potential to be affected and were assessed by the DON/Designee on 5/14/26 and found to be within normal limits. Measures for systemic change: All Nurses were educated by the Director of Nursing on the steps for Insulin administration per competency, diabetes clinical protocol policy, Medication and treatment orders policy, administering medications policy, and Obtaining fingerstick Glucose Level policy On 5/14/2026. How Corrective Action will be monitored: Director of Nursing and Assistant Director of Nursing will complete insulin administration audits on 5 nurses. This audit will be completed weekly x 4 weeks, then monthly x 2 months. Corrective action will be initiated for any noted non-compliance. Audit findings will be reviewed as part of the monthly quality assurance process to determine the need for further monitoring. Date of Compliance: 5/29/2026
Failure to Document Tray Line Food Temperatures in Dining Room Kitchenettes
Penalty
Summary
The deficiency involves the facility’s failure to document tray line food temperatures for meals served from the Harrison and McClellan Dining Room kitchenettes, as required by professional standards for food service safety and the facility’s own policy. Review of the “Trayline Taste & Temperature Log” (revised September 2018) showed missing temperature documentation for multiple meals from the Harrison Dining Room kitchenette, including dinner on 03/30/26 and 03/31/26, lunch and dinner on 04/01/26 and 04/02/26, dinner on 04/07/26, and lunch and dinner on 04/08/26 and 04/10/26. The Senior Director of Culinary Services confirmed during interview that tray line food temperatures were not documented on the log for these meals. Similarly, review of the same log for the McClellan Dining Room kitchenette revealed that tray line food temperatures were not documented for dinner on 04/01/26, breakfast and lunch on 04/02/26, and lunch and dinner on 04/07/26. The Senior Director of Culinary Services also verified these omissions during interview. The facility census at the time was 27 residents, and the governing “Food and Nutrition” policy, approved on 09/07/21, stated that the facility must store, prepare, distribute, and serve food in accordance with professional standards for food service safety.
Plan Of Correction
F812 The facility will continue to ensure food temperatures are completed before meals are served for all residents. To ensure compliance with this standard the following measures have been taken: 1. Immediately 4/15/26 culinary supervisor #224 was re-educated by Dietary Manager to this standard and policy "Food and Nutrition" which includes documentation of food temperatures. 2. All dietary staff have been re-educated to the standard and policy "Food and Nutrition" during the month of April 2026. 3. Audits of food temperature documentation to be completed by Dietary Manager 4 x per week for 4 weeks then weekly for 4 weeks. 4. Administrator to validate audits/compliance and provide additional training as needed. Administrator will present to QAPI committee for ongoing monitoring and further direction.
Failure to Conduct and Document Required Care Conferences
Penalty
Summary
The deficiency involves the facility’s failure to complete and document comprehensive care conferences at required intervals in accordance with care plan regulations and facility policy. For one resident with Parkinson’s disease with dyskinesia, cognitive communication deficit, hemiplegia and hemiparesis following cerebral infarction, transient cerebral ischemic attack, type II diabetes mellitus, and major depressive disorder, the record showed multiple MDS assessments over a one-year period, including annual, quarterly, and significant change assessments. However, only two care conferences were documented during the last 12 months, despite the expectation that care conferences be conducted quarterly with the resident and family when possible. The Unit Care Coordinator confirmed that no additional care conference documentation existed for this resident beyond the notes dated 04/21/25 and 01/02/26. A second resident, with diagnoses including aphasia following cerebrovascular disease, cerebral infarction, type II diabetes mellitus, unsteadiness on feet, difficulty in walking, coagulation defect, depression, and muscle weakness, also had multiple MDS assessments completed over the review period, including quarterly and annual assessments. The record contained a note that a care conference was offered to the resident’s representative, who declined to attend, but there was no documentation of any care conferences for the most recent 12 months. The Unit Care Coordinator confirmed that no other care conference documentation was available for this resident. Facility policy stated that periodic care conferences involving the resident, family, and the interdisciplinary team are part of the care planning process, but the required periodic care conferences and corresponding documentation were not completed for these two residents.
Plan Of Correction
THIS PLAN OF CORRECTION SERVES AS BERKELEY SQUARE'S CREDIBLE ALLEGATION OF SUBSTANTIAL COMPLIANCE AS OF June 1, 2026. Without admitting or denying the validity or existence of the alleged deficiencies, Berkeley Square provides the following Plan of Correction: F657 The facility will continue to document completion of care conferences at the required intervals for all residents, including residents #04 & #15. To ensure compliance with this standard the following measures have be taken: 1. The social service designee and the inter- disciplinary team were re-educated by the administrator to the facility policy "Care Conference" on 4/29/26 and verbalized understanding. 2. Care conferences for resident #04 and resident #15 were conducted on or before 4/29/2026 by the interdisciplinary team. 3. Review of all other residents was conducted by the social service designee to validate and ensure that care conference schedule is up to date with timely care conferences scheduled for them on 4/15/2026. Audits of care conferences to be completed weekly for four weeks and then monthly after that by the social service designee. Documentation of the care conference including any identified concerns in the medical record. Administrator to validate audits/compliance and provide additional training as needed. Administrator will present results of these audits to QAPI committee for ongoing monitoring and further direction.
Failure to Reevaluate Blood Glucose After Treatment for Hyperglycemia
Penalty
Summary
The facility failed to ensure that a resident with diabetes received treatment in accordance with professional standards of practice when nursing staff did not reevaluate the resident's blood glucose after treatment for severe hyperglycemia. The resident, admitted with diagnoses including Alzheimer's disease, type II diabetes mellitus, and depression, had physician orders for Humalog insulin on a sliding scale before meals, Lantus insulin 25 units daily, and lisinopril 5 mg daily. The resident required extensive assistance with activities of daily living, including transfers, toileting hygiene, eating, and bathing. On the evening in question, the resident's blood glucose was documented as 532 mg/dL, and the on-call provider was notified. The provider gave a new order to administer an additional 8 units of lispro (Humalog) and to recheck the blood glucose in 30 minutes. The electronic medication administration record showed that the blood glucose of 532 mg/dL was obtained at 9:00 p.m. and that the additional 8 units of lispro were administered at 9:21 p.m. However, there was no documentation in the resident's chart that the blood glucose was rechecked after the additional insulin was given. In an interview, the DON confirmed there was no evidence of reevaluation and verified that, according to the facility's "Abnormal Blood Glucose Procedure" policy, the resident should have been reevaluated and that the evaluation step should have been included in the progress note documentation.
Plan Of Correction
F684 The facility will continue to ensure all residents, including #03, receive treatment in accordance with professional standards of practice and reevaluated for hyperglycemia. To ensure compliance with this standard the following measures have been taken: 1. The director of nursing assessed resident #03, reviewed documentation and orders and found no ill effects immediately 4/16/26. 2. All licensed nurses were re-educated to facility policy "Blood Glucose Monitoring" by the Director of Nursing/designee in April 2026. 3. Audits of like-residents that require blood sugar checks to be completed by the director of nursing/designee two times a week for 4 weeks and then monthly after that to validate correct follow through when there is abnormally high blood glucose result. The Administrator will bring results of these audits to the QAPI committee for ongoing monitoring and further direction.
Failure to Act on Pharmacist Drug Regimen Recommendation for Thyroid Medication
Penalty
Summary
The deficiency involves the facility’s failure to ensure that pharmacy recommendations from the monthly drug regimen review were acted upon and documented for a resident. The resident was admitted with diagnoses including Parkinson’s disease, dementia, and hypothyroidism, and had current physician orders for levothyroxine 150 mcg once daily, buspirone 50 mg twice daily, and losartan 100 mg once daily. A medication regimen review dated 11/25/2025 included a consultant pharmacist recommendation that levothyroxine be administered consistently in the morning on an empty stomach, at least 30–60 minutes before food, per manufacturer instructions. There was no specific physician response in the medical record to this recommendation, and the facility’s policy stated that consulting pharmacist reviews are sent to nursing and addressed with the primary care provider or consulting specialist for review and follow-up. Review of the resident’s medication administration record for April 2026 showed levothyroxine scheduled for 9:00 a.m. On observation, the resident was seen eating breakfast in the dining area at 8:03 a.m., and an LPN reported administering the levothyroxine 150 mcg to the resident while the resident was in the dining area eating breakfast. The DON confirmed there was no evidence in the resident’s medical record explaining why the consultant pharmacist’s recommendation from 11/25/2025 was or was not acted upon. This lack of documented physician review and action on the pharmacist’s identified irregularity constituted noncompliance with the drug regimen review requirements.
Plan Of Correction
F756 The facility will continue to ensure the pharmacy recommendations from the monthly drug regimen review by a licensed pharmacist are acted upon for all residents, including #08. To ensure compliance with this standard the following measures have been taken: 1. Resident #08 was assessed by the registered nurse and med review completed by 4/28/26. After review of resident's drug regime's, it was discovered that resident #8 had 2 separate medication recommendations on the same form, to be reviewed by two separate practitioners, pharmacy has been instructed and agreed to separate meds on individual forms. 2. Licensed nurses re-educated to facility policy "Drug Regimen Review" by Director of nursing/designee in April 2026 and no later than 5/8/26. Licensed nurses are responsible for ensuring the reviews and recommendations are given to the physician for timely review. 3. Review of all other current residents Drug Regimen orders completed by Director of nursing/designee on 4/16/26 to ensure recommendations were followed up on/reviewed by the physician and address concerns if needed. 4. Audit of drug regime recommendations, pharmacy recommendations, and physician follow up to be completed weekly for four weeks by the Director of nursing/designee. Administrator will present results of these audits to the QAPI committee for ongoing monitoring and further direction.
Failure to Use Required Gait Belt During Ambulation Resulting in Resident Fall
Penalty
Summary
The deficiency involves the facility’s failure to ensure that a required gait belt was used while assisting a high fall‑risk resident with ambulation, resulting in a fall with head injury. The resident had multiple diagnoses including metabolic encephalopathy, hypertension, osteoarthritis, muscle weakness, gait and mobility abnormalities, major depressive disorder, anxiety, and visual hallucinations. Admission and subsequent MDS and fall risk assessments documented that the resident was severely cognitively impaired, required moderate to maximal assistance with transfers and ambulation, could not independently come to a standing position, exhibited loss of balance while standing, used an assistive device, and had decreased muscle coordination. The resident had a history of falls prior to admission and was assessed as being at high, later moderate, risk for falls. The resident’s fall care plan identified her as at risk for falls and included interventions such as providing maximum to moderate assistance with transfers and walking short distances, use of a walker and wheelchair, and following the facility’s fall protocol. Therapy notes and care conference documentation indicated that the resident leaned backwards when standing, required contact guard to minimal assistance for bed mobility and transfers, and needed constant verbal cueing for safe sequencing during toilet transfers. The physical therapist confirmed that the resident was to use a gait belt with staff when ambulating, and the DON verified that therapy had assessed the resident as requiring contact guard assistance and a gait belt for ambulation and transfers. On the day of the incident, a CNA was assisting the resident from her recliner to the bathroom using a walker. The CNA walked beside the resident, providing guidance and support, and reported having a hand on the resident while assisting her. As they approached the bathroom door, the CNA reached for the doorknob to open it, and at that moment the resident began to lose her balance and fell backwards to the floor, striking the back of her head. The nurse who responded found the resident on her back at the foot of the bed with her feet near the bathroom, noted a red raised area on the back of the head, and documented that the resident was not wearing a gait belt and that the gait belt was on the dresser. In the facility’s investigative summary and in interviews, the CNA acknowledged that she did not have a gait belt on the resident while ambulating her, despite the resident’s assessed need for hands‑on assistance and gait belt use per facility policy and the resident’s care and therapy plans.
Failure to Implement PD Orders and Monitor Resident Receiving Peritoneal Dialysis
Penalty
Summary
The deficiency involves the facility’s failure to implement pre-admission physician orders for peritoneal dialysis (PD) and to provide ongoing monitoring for a resident with chronic kidney disease (CKD) stage five who required PD. Pre-admission orders dated 11/14/25 specified three daily PD exchanges at 6:00 A.M., 2:00 P.M., and 10:00 P.M., and directed staff to monitor for signs and symptoms of peritonitis, including fever, abdominal pain, and cloudy effluent. These monitoring orders were not entered into the facility’s physician orders. The resident’s care plan noted the need for PD and included general monitoring interventions (labs, signs of bleeding, bacteremia, septic shock, and significant vital sign changes), but did not specifically address the ordered monitoring for peritonitis. Review of PD documentation showed incomplete and inconsistent charting of treatments and resident condition. The paper peritoneal flowsheet had columns for time of PD and condition/comments, including instructions to call the nurse immediately for cloudy fluid, abdominal pain, or fever. However, the first entry on 11/15/26 at 2:00 P.M. only noted that the PD nurse completed the exchange, and the 10:00 P.M. entry that day had no condition/comment documentation. Subsequent days (11/16/25, 11/17/25, and 11/18/25) contained only one condition/comment entry per day rather than for each exchange, and there was no documentation that the 6:00 A.M. PD on 11/18/25 was completed. The PD cycler flowsheet starting 11/19/25 lacked any description of the effluent on multiple days. The PD nurse from the dialysis company stated facility staff were expected to monitor effluent for cloudiness and assess for abdominal pain and fever, and the DON confirmed there was no electronic physician order for peritonitis monitoring or for use of the PD cycler, that the paper charting did not allow for effluent description or symptom documentation for each treatment, and that PD was not documented at one ordered time. The facility’s dialysis policy required ongoing assessment and monitoring for complications before, during, and after treatments, which was not reflected in the documentation for this resident.
Improper Infection Control During Medication Administration
Penalty
Summary
Surveyors identified a deficiency in infection prevention and control related to medication administration for Resident #29. The resident was admitted on 02/28/14 with diagnoses including depression, traumatic brain injury, and anxiety, and had impaired cognition per a quarterly MDS assessment. During an observation on 03/25/26 at 6:58 A.M., RN #281 prepared the resident’s medications by removing an Amoxicillin-Pot Clavulanate tablet from the medication card and pushing it directly into her ungloved hand, then using her fingers to place the pill into a medication cup. The same process was observed for multiple other medications, including Escitalopram Oxalate, Furosemide, Sennosides, Lyrica, and Vitamin D, each being pushed from the card into the RN’s ungloved hand and then transferred by her fingers into the medication cup before administration to Resident #29. In a subsequent interview at 7:27 A.M. the same day, RN #281 confirmed she had placed each medication into her ungloved hands prior to administration and acknowledged that the proper procedure was to push the pills directly from the card into the medication cup. Review of the facility’s “Medication Administration – General guidelines” policy, revised 10/08/25, stated that medications are to be administered in accordance with good nursing principles and practices. This practice failure was cited as a deficiency under Complaint Number 2681777.
Improper Use of Wheelchair as a Physical Restraint
Penalty
Summary
Surveyors identified a deficiency related to the facility’s failure to ensure a resident was free from physical restraints. Resident #7, admitted with diagnoses including Alzheimer’s disease, diabetes mellitus, and anxiety disorder, was documented on a recent MDS as rarely understood and dependent for ADLs except eating. The resident ambulated independently on the unit without an assistive device and had documented verbal and other behaviors occurring one to three days during the look-back period. The care plan noted the resident had potential to be physically aggressive, chase staff, throw objects, and be combative with care, with interventions such as offering choices, administering medications as ordered, and intervening early when agitation occurred. During an observation and interview, Resident #7 was found sitting in a chair with the right arm of the chair positioned against the nursing station and a wheelchair placed directly in front of him. The left arm of the wheelchair was also against the nursing station, and both wheelchair wheels were locked, creating a barrier that appeared to restrain the resident, who was sleeping with his knees touching the locked wheelchair. An LPN confirmed both wheelchair wheels were locked and that the wheelchair should not have been placed in front of the resident. A CNA reported she had placed the wheelchair there in preparation to get the resident up for lunch, was unable to transfer him, and left the wheelchair in that position, acknowledging it was wrong to keep it there. The facility’s physical restraint policy stated that physical restraints are not used except when alternatives are not appropriate or effective for treating a medical symptom and defined physical restraints as any device attached or adjacent to the body that the individual cannot easily remove and that restricts freedom of movement or access to the body.
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