The Oaks Rehabilitation And Healthcare Center
Inspection history, citations, penalties and survey trends for this long-term care facility in Zanesville, Ohio.
- Location
- 3291 Northpointe Drive, Zanesville, Ohio 43701
- CMS Provider Number
- 366051
- Inspections on file
- 23
- Latest survey
- December 1, 2025
- Citations (last 12 mo.)
- 11
Citation history
Health deficiencies cited at The Oaks Rehabilitation And Healthcare Center during CMS and state inspections, most recent first.
A resident with hearing loss and cognitive impairment was not provided with timely family notification when their hearing aids went missing. Despite staff awareness and documentation lapses regarding the storage of the hearing aids, the family only learned of the issue after they raised the concern themselves. This deficiency was confirmed through record review and staff interviews.
A resident with a swallowing impairment and a physician order prohibiting straw use was provided with a cup containing a straw on two occasions. Although staff and family were aware of the restriction, a Business Office Manager unfamiliar with the resident's care plan placed the cup in the room, resulting in non-compliance with the prescribed diet order.
A facility failed to provide enough nursing staff, leading to multiple residents not receiving their medications on time, with some doses delayed by several hours or missed entirely. Night shifts were especially understaffed, with only one nurse covering a large number of residents, resulting in delayed call light responses, incomplete treatments, and poor hygiene care. Staff and family members reported residents being left in soiled conditions, not receiving required assistance, and a general decline in care quality due to heavy reliance on agency staff and open nursing positions.
The facility did not submit required direct care staffing data to CMS for a reporting period, as confirmed by review of PBJ Staffing Data and interviews with the CEO. The CEO indicated that a change of ownership and reliance on a contracted company contributed to the lack of submission, with no documentation available to verify that the data was sent. This affected all residents in the facility.
Medication carts were found unlocked and unattended, and medications were improperly stored and labeled, including pre-filled cups with only first names and room numbers and loose, unlabeled tablets in drawers. Staff confirmed these practices, which did not comply with facility policy requiring secure, properly labeled storage of all drugs and biologicals.
Two residents with dementia were involved in a physical altercation, resulting in one resident being pushed to the floor and complaining of arm pain. Staff failed to immediately report the abuse allegation to the administrator and state agency, and there was no prompt assessment by a nurse or timely notification of the resident's family or physician. Documentation of required monitoring was missing or delayed, leading to a deficiency in abuse reporting and investigation procedures.
A resident with severe cognitive impairment and significant physical limitations did not receive adequate oral hygiene assistance as required by their care plan. Despite documentation of daily oral care, dental assessments revealed heavy plaque, multiple decayed teeth, and gingivitis, with both family and staff reporting concerns about the frequency and quality of oral hygiene provided.
Staff failed to promptly assess and monitor a resident after a fall caused by another resident, with no immediate licensed nurse assessment, 15-minute checks, or vital signs documented, and the incident was not properly investigated until days later. In a separate case, another resident with heart failure and cirrhosis did not have daily weights consistently documented, and required provider notifications for significant weight gains were not made, despite physician orders. These lapses were confirmed through record review and interviews, highlighting failures in timely assessment, monitoring, and communication.
A resident with diabetes and other comorbidities did not receive a comprehensive assessment or timely treatment for a left great toe wound. Wound care orders were delayed, several days of treatment were missed, and updated wound care instructions were not promptly implemented, resulting in both old and new treatments being administered simultaneously. Documentation of wound assessments was incomplete, and the resident reported inconsistent care due to insufficient staffing.
A resident with fragile skin and multiple comorbidities experienced repeated skin tears when her legs struck unpadded wheelchair leg rests during transfers. Despite a care plan intervention to pad the leg rests, staff did not implement this measure, and both the resident and her family reported ongoing injuries. Staff and direct observation confirmed the absence of padding, and the DON acknowledged the intervention was not put in place, resulting in multiple injuries.
A resident with a history of recurrent UTIs and multiple comorbidities experienced a significant delay in receiving treatment for a symptomatic UTI. The delay was caused by issues with urine sample collection and lab processing, as well as slow communication with the infectious disease office, resulting in the resident not receiving antibiotics for over a week after symptoms began.
The facility experienced a medication error rate of 17.8% due to multiple incidents where two residents did not receive all prescribed medications as ordered. Errors included crushing an extended-release medication that should not be altered, omitting doses, and failing to provide medications due to unavailability. Staff also documented administration of medications that were not actually given, and did not follow facility policy for safe and timely medication administration.
Two residents experienced significant medication errors when prescribed medications were not administered as ordered. One resident missed multiple doses of Metoprolol for hypertension, with some doses signed as given despite the medication being unavailable, and pharmacy records showed unaccounted tablets. Another resident missed several doses of IV Ertapenem for a UTI, as confirmed by the MAR and infection tracking log. Staff interviews and record reviews highlighted failures in medication administration and documentation.
A resident with multiple medical conditions and feeding difficulties did not receive the ordered adaptive eating equipment, including a Kennedy cup and built-up utensils, during a meal. Despite physician orders and care plan interventions specifying these devices, the resident's tray was missing them, and this was confirmed by both the resident and an LPN. Facility policy requires provision of such adaptive devices for those who need them, but this was not followed.
A resident with multiple chronic conditions did not receive their prescribed Metoprolol due to pharmacy ordering issues and lack of availability, yet an LPN inaccurately documented on the MAR that the medication was administered on several occasions, with no indication in the progress notes that the medication was unavailable or not given.
Two CNAs did not use required PPE while transferring a resident on enhanced barrier precautions due to a cholecystostomy tube, despite clear signage and available equipment. Additionally, an LPN failed to perform hand hygiene and handled medications directly with her hands during administration to another resident, contrary to facility policy and infection control standards.
A facility failed to prevent falls and elopement in residents, leading to injuries and safety risks. A cognitively impaired resident fell and fractured her hip due to inadequate assistance and care planning. Another resident with exit-seeking behavior left a secured unit, as interventions were insufficient. A third resident experienced multiple falls without proper investigation or neurological checks. The facility's policies were not followed, resulting in harm and potential risks.
The facility failed to provide comprehensive care plans for several residents, including those with severe cognitive impairments and specific needs such as ADL assistance, wandering behaviors, and contractures. A resident with multiple diagnoses lacked a care plan for ADL needs, while another resident with Alzheimer's disease had no interventions for wandering. Additionally, a resident with major depressive disorder and dementia had no care plans for these conditions, and a resident with a hand contracture lacked a specific care plan for the condition.
A resident with severe cognitive impairment and dementia exhibited inappropriate behaviors, including wandering, aggression, and inappropriate sexual conduct. The facility failed to update the care plan with specific interventions, did not consistently notify the family or physician, and did not administer prescribed Lorazepam. Documentation lacked detail on interventions and tracking of behavior patterns, contributing to a deficiency in care.
The facility failed to provide appropriately textured pureed food for residents on a pureed diet. A Dining Services Assistant prepared pureed swiss steak, which was found to be gritty and required chewing, contrary to the facility's guidelines for smooth, pudding-like consistency. The Director of Food Services confirmed the inappropriate texture, highlighting a deficiency in food preparation for residents requiring a pureed diet.
The facility failed to follow proper hand hygiene and glove use during meal service and did not ensure food temperatures were checked before serving meals to residents in the Memory Care Unit. A DSA was observed using the same gloves throughout the meal service without changing them or performing hand hygiene, despite touching clothing and handling food items. The facility's policies on hand hygiene and glove use were not adhered to.
The facility failed to implement enhanced barrier precautions for four residents and did not follow contact isolation procedures for a resident with Cdiff. Observations revealed a lack of PPE and disposal measures, confirmed by staff and residents, indicating non-compliance with infection control protocols.
The facility did not report a potential abuse incident between two residents to the state agency. One resident with intact cognition slapped another resident with severe cognitive impairment after an attempted bite on a staff member. The incident was not documented or investigated further, contrary to the facility's policy requiring immediate reporting of suspected abuse.
A resident admitted with joint replacement surgery and other conditions did not have an initial care conference until 26 days after admission, despite being cognitively intact. The delay occurred because the conference was only scheduled after the resident's family requested it, contrary to the facility's protocol of holding such conferences within five days of admission.
A facility failed to provide a discharge summary for a resident transferred to an assisted living facility. The resident, with conditions such as hemiplegia and kidney disease, had an order for a hospital bed with side rails, which was not documented in the discharge planning form. The form also noted dialysis appointments but lacked caregiver information. The Executive Director confirmed the absence of a discharge summary.
A facility failed to adhere to a resident's bathing schedule and preferences. The resident, who required substantial assistance and was cognitively intact, was scheduled for evening baths twice a week but received fewer baths than scheduled over a six-week period. The resident expressed uncertainty about their bathing schedule, and the DON confirmed the discrepancy in documentation.
A resident admitted with a surgical wound required a wound vac, but the facility failed to ensure the supplies were received on time. Despite confirmation of the order, the delivery was delayed, leading to the use of wet to dry dressings instead. The resident and family expressed concerns, and the facility confirmed the delay and interim measures taken.
A resident with multiple medical conditions developed a pressure ulcer on her right heel and ankle, which was not timely identified or treated by the facility. Despite initial observations, there were delays in notifying healthcare providers, inconsistent documentation, and treatment changes. The facility failed to recognize a separate wound area and delayed necessary appointments and tests, leading to a decline in the resident's condition.
A resident with a Foley catheter did not have appropriate orders in place for catheter care, despite having a comprehensive care plan. The resident had multiple diagnoses and severely impaired cognition. Facility staff confirmed the absence of necessary orders, which should have been documented to guide care.
A resident with Parkinson's disease and other conditions experienced delays in the facility's response to pharmacy recommendations regarding medication use. Recommendations to reconsider certain medications were not reviewed or documented by the nurse practitioner until months later, as confirmed by the Administrator and DHS. The facility's procedures lacked a specified timeframe for addressing such recommendations.
A facility failed to justify the use of psychotropic medication for a resident with Parkinson's disease and psychosis. Despite the absence of documented behaviors such as delusions or hallucinations, an antipsychotic was prescribed based on staff reports. The facility could not provide supporting documentation for the diagnosis of psychosis prior to the medication prescription.
The facility failed to maintain accurate medical records for two residents, leading to deficiencies in care. One resident had inconsistencies in wound documentation and treatment orders, while another resident's medical record lacked documentation of a resident-to-resident altercation. These issues highlight a lapse in adherence to the facility's policy of maintaining complete and accurate records.
Failure to Notify Family of Missing Hearing Aids
Penalty
Summary
The facility failed to notify the family of a resident with hearing loss and impaired cognition when the resident's bilateral hearing aids went missing. The resident had a history of hearing loss, degenerative disease of the nervous system, seizures, and required assistance with personal care. Physician orders required that the hearing aids be checked every shift and stored in a medication cart each night. Documentation showed that the order to store the hearing aids was not completed from mid-October through November, and there were no progress notes referencing the missing hearing aids or family notification during this period. The resident's family was not informed of the missing hearing aids until they themselves reported the issue via a Resident Concern Form nearly two weeks after the aids were last seen. The facility's records confirmed that staff noticed the hearing aids were missing and searched for them, but failed to communicate this to the family in a timely manner. The deficiency was identified through record review and interviews, which verified the lack of timely family notification regarding the missing hearing aids.
Failure to Follow Physician-Ordered Diet Restrictions for Swallowing-Impaired Resident
Penalty
Summary
The facility failed to follow a physician's order regarding dietary restrictions for a resident with a swallowing impairment. The resident had a documented history of laryngeal/pharyngeal impairment and penetration of liquids when using a straw, leading to a specific physician order prohibiting the use of straws. Despite this, observations on two occasions revealed a cup with a straw filled with fresh ice water in the resident's room. A sign above the resident's bed clearly stated that no straws were to be used. Interviews confirmed that staff were aware of the no-straw restriction, and the family provided appropriate drinking cups for the resident. However, the Business Office Manager, who was assisting with distributing morning ice and water, was unaware of the restriction and placed the lidded cup with a straw in the resident's room. This oversight resulted in the resident not receiving care in accordance with the physician's order and established dietary restrictions.
Failure to Provide Adequate Nursing Staff Resulting in Delayed Medication Administration and Insufficient Supervision
Penalty
Summary
The facility failed to provide adequate nursing staff to meet the needs of all residents, resulting in multiple instances where residents did not receive their medications in a timely manner and lacked appropriate supervision. Several residents with complex medical histories, including psychiatric disorders, diabetes, heart failure, and mobility issues, reported not receiving their evening or bedtime medications until several hours after the scheduled administration times, with some medications being given as late as 2:00 or 3:00 A.M. instead of the ordered 8:00 or 9:00 P.M. In some cases, residents did not receive their medications at all, and staff interviews confirmed that agency nurses were unfamiliar with residents and unable to manage the workload effectively. Documentation audits and resident interviews corroborated these delays and omissions, with residents expressing concerns about trust in night shift staff and the impact on their health and well-being. The staffing shortages were particularly acute during night shifts, where there were documented occasions of only one licensed nurse being responsible for up to 91 residents across both the skilled nursing facility and the attached assisted living unit. Staff and residents reported that call lights went unanswered for extended periods, residents did not receive timely assistance with activities of daily living, and treatments and hygiene care were not consistently performed. Observations revealed that nurses were pre-setting medications to expedite administration due to being overwhelmed with responsibilities, and dietary staff were assisting with tasks outside their scope, such as delivering meal trays without ensuring they were within residents' reach. The facility's own assessment indicated that the number of licensed nurses and CNAs on duty was insufficient to meet the care needs of the resident population, and the assessment did not account for the staffing needs of the attached assisted living unit. Multiple complaints and concern logs documented issues with grooming, call light response, toileting, and medication administration. Family members and staff described residents being left in soiled conditions, not receiving two-person transfers as required, and experiencing a decline in care quality. The facility was relying heavily on agency staff and had several open nursing positions, contributing to inconsistent care and supervision.
Failure to Submit Required Staffing Data to CMS
Penalty
Summary
The facility failed to submit complete and accurate direct care staffing information to the Centers for Medicare and Medicaid Services (CMS) for the first quarter of 2025, as required. Review of the Payroll Based Journal (PBJ) Staffing Data Report showed that staffing data for the period from October 1st to December 31st, 2025, was not submitted, resulting in the facility receiving a one-star staff rating. During interviews, the Chief of Operation (CEO) confirmed there was no documented evidence that the required staffing data had been reported to CMS. The CEO explained that the facility underwent a change of ownership in December 2024, and it was the previous owner's responsibility to report the staffing data. The CEO also stated that the previous owner had sent the data to a contracted company, which was responsible for submitting it to CMS, but there was no documentation to confirm that this submission occurred. This deficiency had the potential to affect all 72 residents in the facility.
Medication Storage and Labeling Deficiencies
Penalty
Summary
Surveyors observed that medication carts on two separate halls were not properly secured and medications were not properly stored or labeled. On one hall, a medication cart was found unlocked and unattended between resident rooms, and an LPN confirmed leaving it in that state while attending to duties elsewhere. On another hall, three medication carts were inspected: one cart contained seven medication cups pre-filled with medications, labeled only with first names and room numbers, including two cups with the same first name but different room numbers. Additionally, two other carts contained numerous loose, unlabeled, and unpackaged tablets in various drawers. These findings were confirmed by staff present at the time of observation. Interviews with staff, including the DON, confirmed that medication carts should be locked when unsupervised, medications should not be pre-set, and all drugs must be stored in their original packaging with proper labeling. The facility's policy requires all drugs and biologicals to be stored securely, in their original containers, and properly labeled, with each resident's medications kept separate to prevent mixing. The observed practices did not comply with these requirements, affecting all residents on the 100 and 200 halls.
Failure to Timely Report and Investigate Resident-to-Resident Abuse
Penalty
Summary
The facility failed to ensure that all allegations of resident abuse were reported immediately to the administrator and the state survey agency, as required by policy and regulation. An incident occurred in which one resident, with a history of dementia and other medical conditions, pushed another resident, who also had significant cognitive impairment, to the floor after a verbal altercation. The event was witnessed by staff, and the resident who was pushed complained of arm pain, but there was no immediate assessment by a licensed nurse, and no documentation of vital signs or neurological checks as directed by the medication technician. Despite the facility's policy requiring immediate reporting of abuse allegations, the incident was not reported to the administrator or the state survey agency until four days after it occurred. Staff involved in the incident were unclear about their responsibilities for reporting, with some believing that the medication technician was a nurse and would handle the notification. The administrator and DON were not made aware of the incident until several days later, and there was confusion and lack of documentation regarding the required monitoring and assessment of the resident who was pushed. Medical record review confirmed that the resident who was pushed was not assessed by a nurse or had their family or physician notified until several days after the incident. The facility's investigation also revealed missing or undated documentation related to the required 15-minute checks and vital signs. The failure to report the incident in a timely manner and to follow established protocols for assessment and notification constituted a deficiency in the facility's abuse reporting procedures.
Failure to Provide Adequate Oral Hygiene to Dependent Resident
Penalty
Summary
A dependent resident with severe cognitive impairment, functional limitations, and a need for substantial assistance with activities of daily living, including oral hygiene, was not provided adequate oral care. The resident's care plan specified the need for daily oral hygiene assistance and monitoring for signs of dehydration and dental problems. Despite documentation indicating that oral care was being provided almost daily, multiple assessments and family concerns indicated otherwise. The resident's dental records showed a significant decline in oral health over several months. While earlier dental visits did not note any major concerns, a later assessment by the facility dentist identified multiple decayed teeth, heavy plaque, and poor oral hygiene, recommending increased staff assistance with daily oral care. An outside dental examination further confirmed extremely heavy plaque buildup, gingivitis, and pain, attributing these issues to inadequate home care. The resident's family also raised concerns about mouthwash not being used and reported that the dentist described the oral condition as a result of neglect. Interviews with staff and administration revealed that oral hygiene was not being performed as frequently as required, and there were ongoing concerns from families about the adequacy of oral care. Staff confirmed that oral hygiene was sometimes neglected, and the administrator was unable to explain the deterioration in the resident's oral health despite documentation of care. The deficiency was substantiated by direct observations, medical record reviews, and interviews, all indicating a failure to provide necessary assistance with oral hygiene to a dependent resident.
Failure to Timely Assess, Monitor, and Report Resident Condition Changes
Penalty
Summary
The facility failed to timely assess, monitor, and report significant changes in resident condition, specifically regarding a fall incident and weight gain. In one case, a resident with severe cognitive impairment was pushed to the floor by another resident. Staff present at the time did not ensure a licensed nurse assessed the resident immediately after the incident, nor were 15-minute checks, neurological assessments, or vital signs documented as directed. The incident was not discovered or properly investigated until four days later, and there was no evidence of a physical assessment by a licensed nurse until that time. The facility also lacked a clear policy or procedure for staff to follow when a fall occurs, and the Director of Nursing confirmed that education on documentation and notification was provided only during staff training or as needed for agency staff. In another case, a resident with multiple diagnoses, including heart failure and cirrhosis, had physician orders for daily weights and specific instructions to notify the provider if there was a two-pound weight gain in 24 hours or a five-pound gain in a week. The resident's medical record and treatment administration record showed several days where weights were not documented, and there was no evidence that the provider was notified when the resident experienced weight gains that met the criteria for notification. The resident reported difficulty finding working scales and required staff assistance to obtain weights, contradicting the DON's statement that the resident weighed himself. There was no documentation of weight refusals or provider notifications as required by the care plan and physician orders. These deficiencies were identified through medical record review, staff and resident interviews, and review of facility policies. The findings revealed lapses in timely assessment, monitoring, and communication regarding significant changes in resident condition, as well as a lack of clear procedures for staff to follow in the event of a fall or significant weight change.
Failure to Provide Comprehensive and Timely Foot Wound Care
Penalty
Summary
A resident with multiple complex medical conditions, including diabetes, heart failure, and venous insufficiency, was admitted with a wound on the left great toe. Upon admission, there was no comprehensive assessment of the wound's size or characteristics, and no wound assessment was documented from several days after admission until later in the month. The initial hospital order for wound care was not implemented until four days after admission, and subsequent treatment administration records showed multiple missed days where the prescribed wound care was not documented as completed. Additionally, when the wound clinic updated the treatment order, the new order was not initiated promptly, and the previous treatment was not discontinued, resulting in both treatments being administered concurrently for over two weeks. Wound evaluation notes repeatedly lacked documentation of the wound bed assessment, and the peri-wound appearance was consistently described as dry and flaky. Interviews with the resident revealed that wound care was not provided daily as ordered, and the resident reported insufficient staff to administer treatments in a timely manner. The Assistant Director of Nursing confirmed the lack of comprehensive assessment, delays in implementing treatment orders, missed documentation of treatments, and improper handling of updated wound care orders. The facility's wound nurse was absent during this period, and there was no evidence of weekly wound assessments until her return.
Failure to Implement Wheelchair Padding Results in Repeated Resident Injuries
Penalty
Summary
The facility failed to implement safety measures to prevent injuries for a resident with multiple medical conditions, including diabetes, respiratory failure, chronic kidney disease, heart failure, and dysphagia. Despite documented incidents of skin tears caused by the resident's legs coming into contact with the wheelchair leg rests during transfers, the intervention to pad the wheelchair leg rests was not put in place. The resident's care plan included padding the wheelchair leg piece and encouraging the use of long pants, but observations and interviews confirmed that the leg rests remained unpadded on both the old and new wheelchairs. Multiple staff members, including LPNs, CNAs, and the DON, verified that the intervention to pad the leg rests was not implemented, resulting in repeated skin tears for the resident. The resident and her daughter both reported ongoing injuries due to the lack of padding, and the daughter noted that even pool noodles brought from home to protect the bed frame were not used. Direct observation confirmed the absence of padding on the wheelchair leg rests, and the DON acknowledged that the failure to implement the intervention led to multiple injuries.
Delay in UTI Treatment Due to Lab and Communication Issues
Penalty
Summary
A deficiency was identified when a resident with a history of diabetes mellitus, chronic kidney disease, heart failure, and recurrent urinary tract infections (UTIs) experienced a delay in the treatment of a symptomatic UTI. The resident, who was cognitively intact and dependent for transfers with frequent incontinence, reported worsening burning and discomfort during urination. A nurse practitioner ordered a urine analysis, and a urine sample was collected via straight catheter. However, the initial sample was rejected by the hospital lab due to being in the wrong container, causing a delay as the sample had to be resent to another lab the following day. The urine culture results were received several days later and subsequently sent to the infectious disease office for review. Despite the resident's ongoing symptoms, including discomfort and pain with urination, no antibiotic treatment was initiated for over a week after the onset of symptoms. Interviews with the resident and her daughter confirmed the prolonged wait for treatment, and the Director of Nursing acknowledged the extended delay in both obtaining lab results and starting appropriate therapy.
Medication Error Rate Exceeds Acceptable Threshold Due to Administration and Availability Failures
Penalty
Summary
The facility failed to maintain a medication error rate below five percent, with five errors identified out of 28 opportunities, resulting in a 17.8% error rate. For one resident with multiple complex diagnoses, including bipolar disorder, hypertension, and a history of esophageal surgery, a medication technician crushed an extended-release Metoprolol tablet, which should not be crushed, and omitted two prescribed medications, Sertraline and Spironolactone, during a medication pass. The technician had signed off on the administration of all medications, but only 12 out of 14 pills were actually given. The resident confirmed that receiving the wrong medication was not uncommon, especially during night shifts, and that he preferred his medications crushed due to swallowing difficulties. Another resident with a history of cerebral infarction, heart failure, and hypertension did not receive the full prescribed dose of Amlodipine and missed several doses of Metoprolol due to the medication being unavailable for an extended period. The LPN administering the medication provided only one Amlodipine tablet instead of two and reported that Metoprolol had been out of stock since a specific date, with unsuccessful attempts to obtain it from the pharmacy and contingency box. The nurse practitioner was notified of the omission, and additional blood pressure monitoring was ordered, but no harm was noted from the missed doses at the time of review. Facility policy requires medications to be administered as prescribed and for staff to document administration on the medication administration record (MAR) after giving the medication. In both cases, staff failed to follow these procedures, either by not administering all prescribed medications, administering them incorrectly, or failing to ensure medication availability, leading to a medication error rate significantly above the acceptable threshold.
Significant Medication Errors Due to Missed and Unaccounted Doses
Penalty
Summary
The facility failed to ensure residents were free from significant medication errors, as evidenced by missed and unaccounted doses of prescribed medications for two residents. One resident with multiple complex diagnoses, including hypertension and heart failure, had several documented omissions of Metoprolol 100 mg, a medication ordered to be given twice daily. The Medication Administration Record showed multiple missed doses over a one-month period, with some doses signed as given when the medication was not available. Pharmacy records indicated that sufficient medication had been delivered, but tablets were unaccounted for, and staff interviews revealed confusion regarding the availability and administration of the medication. The Assistant Director of Nursing confirmed that tablets delivered were not used as intended, and the Director of Nursing could not verify administration for several dates, especially when agency staff were involved. Another resident, with diagnoses including diabetes, chronic kidney disease, and frequent urinary tract infections, did not receive four out of fourteen ordered doses of intravenous Ertapenem Sodium for a UTI. The Medication Administration Record and infection tracking log confirmed the missed doses. The Director of Nursing verified the omissions and noted the resident's ongoing issues with UTIs and involvement of an infectious disease physician. These findings were substantiated through medical record review, staff interviews, observation, and policy review, demonstrating a failure to administer medications as prescribed.
Failure to Provide Required Adaptive Eating Equipment During Meals
Penalty
Summary
The facility failed to ensure that all residents requiring assistive eating devices had them available during meal times. Specifically, one resident with diagnoses including diabetes mellitus, respiratory failure with hypoxia, chronic kidney disease, heart failure, dysphagia, and other feeding difficulties, and who had intact cognition, did not receive the ordered adaptive equipment during breakfast. Physician orders and the resident's care plan specified the use of a divided plate, Kennedy cup, and built-up utensils for all meals as tolerated. However, during observation, the resident's breakfast tray only included regular utensils and Styrofoam cups with a lid and straw, and lacked the required Kennedy cup and built-up utensils. The resident confirmed during interview that she preferred and found it easier to use the Kennedy cup and built-up utensils, as these helped her eat and drink without making a mess. Review of the meal ticket on the tray also indicated that adaptive equipment was to be provided. An LPN verified that the resident was supposed to have the Kennedy cup and built-up utensils for all meals, and acknowledged that these were missing from the breakfast tray. Facility policy requires that adaptive devices be provided for residents who need or request them, but this was not followed in this instance.
Failure to Accurately Document Medication Administration on MAR
Penalty
Summary
A deficiency occurred when a resident with multiple diagnoses, including cerebral infarction, chronic right heart failure, hypertension, and peripheral vascular disease, did not receive their prescribed Metoprolol 100 mg twice daily for hypertension. The medication was unavailable beginning on 05/24/25, and the LPN reported issues with reordering the medication from the pharmacy, including the need to discontinue and rewrite the order so it would be recognized by the pharmacy system. The LPN also stated that the contingency box did not contain the correct dosage, and the medication had not arrived despite follow-up calls to the pharmacy. Despite the medication not being administered, the LPN documented on the medication administration record (MAR) that the Metoprolol was given on several dates. There was no evidence in the resident's progress notes that the medication was unavailable or not administered. The facility's policy required appropriate documentation if a drug was withheld, refused, or given at a different time, but this was not followed, resulting in inaccurate documentation of medication administration.
Failure to Maintain Enhanced Barrier Precautions and Infection Control During Resident Care and Medication Administration
Penalty
Summary
Certified Nursing Assistants (CNAs) failed to follow enhanced barrier precautions (EBP) during the care of a resident with a cholecystostomy tube. The resident, who had multiple diagnoses including acute cholecystitis, acute renal failure, diabetes, and required assistance with personal care, was on EBP due to the presence of an indwelling device. Despite clear signage and the availability of personal protective equipment (PPE) outside the room, two CNAs transferred the resident using a Hoyer lift without wearing gloves or gowns. Both CNAs acknowledged during observation that they should have been wearing PPE, and the Director of Nursing (DON) confirmed this requirement based on the resident's EBP status. Additionally, an LPN failed to maintain infection control practices during medication administration for another resident. The LPN did not perform hand hygiene before administering medications and handled pills directly with her hands before placing them into a medication cup. This was observed and confirmed by the surveyor, and the LPN admitted to being new. The DON confirmed that medications should not be handled directly by hand and should be placed into the cup or on the lid. Facility policy requires staff to follow infection control procedures, including handwashing and proper technique, during medication administration.
Failure to Prevent Falls and Elopement in Residents
Penalty
Summary
The facility failed to provide appropriate assistance and follow care planned interventions for a resident, leading to a fall with injury. The resident, who was severely cognitively impaired, sustained a fall and fractured her left hip while ambulating without her walker and wearing inappropriate footwear. Despite being at high risk for falls, the care plan did not adequately address her assistance needs for dressing, applying footwear, or transfers from sit to stand. Staff failed to intervene appropriately when the resident was seen without shoes and a walker, resulting in her fall. Another resident, with a history of exit-seeking behavior and severe cognitive impairment, was able to leave a secured unit due to inadequate interventions. The resident had previously eloped and was found outside the facility, yet no exit-seeking event was documented for one of the incidents. The care plan called for assessing the need for a wander guard, but the facility policy did not allow for wander guards on memory care residents. The facility's response to the resident's ability to learn door codes was insufficient, as the code was not changed frequently enough to prevent further incidents. A third resident experienced multiple falls, some resulting in head injuries, but the facility failed to complete fall investigations and neurological checks as ordered. The resident, who had impaired cognition and required assistance with mobility, had falls that were either unwitnessed or witnessed without proper follow-up. The facility's policy required a thorough investigation and reassessment after falls, but these were not completed, leaving the resident at risk for further incidents.
Deficiencies in Comprehensive Care Planning
Penalty
Summary
The facility failed to ensure comprehensive care plans were in place for several residents, addressing their specific needs related to activities of daily living (ADL), wandering behaviors, and contractures. Resident #18, who had multiple diagnoses including multiple sclerosis and dementia, did not have a care plan specifying her ADL needs such as bed mobility, ambulation, and personal hygiene until a later date. This oversight was confirmed by the Campus Support Resident Assessment and MDS coordinator. Resident #59, diagnosed with Alzheimer's disease and dementia, was observed wandering the unit without a care plan addressing her wandering behavior. Her care plan also lacked details on her assistance needs for mobility, oral hygiene, and dressing. Despite being on a locked unit for safe wandering, the facility did not have specific interventions in place, as verified by the MDS coordinator. Resident #16, with diagnoses including major depressive disorder and unspecified dementia, did not have care plans for these conditions, which would include specific target behaviors and measurable interventions. The Director of Nursing and MDS Coordinator acknowledged the absence of these care plans. Additionally, Resident #40, who had severe cognitive impairment and a right hand contracture, did not have a care plan with interventions for the contracture, despite observations of the condition and the resident's spouse mentioning a brace at home. The MDS Coordinator confirmed the lack of a specific care plan for the contracture.
Deficiency in Dementia Care Documentation and Intervention
Penalty
Summary
The facility failed to appropriately document, revise, and implement care plans for a resident diagnosed with dementia, leading to a deficiency in addressing the resident's dementia-related behaviors. The resident, who had severe cognitive impairment and a history of Alzheimer's disease and dementia, exhibited behaviors such as wandering, inappropriate sexual behavior, and aggression towards other residents and staff. Despite these behaviors being documented in progress notes and behavior and mood events, the facility did not consistently notify the resident's family or physician, nor did they assess the other residents involved in these incidents. The facility's care plan for the resident was not updated to reflect new or specific interventions for the resident's behaviors. Interventions such as providing snacks, redirection, and activities were attempted but were often ineffective. The facility also failed to administer prescribed Lorazepam as needed for anxiety and agitation, despite the family agreeing to the order. The facility's documentation lacked thoroughness in detailing the interventions used or in place during each incident, and there was no evidence of tracking trends and patterns in the resident's behavior. Interviews with the Executive Director and Director of Health Services confirmed that the facility did not have policies related to dementia care and that the care plan was not updated to address the resident's behaviors adequately. The facility's failure to notify the family and physician of every incident, identify all residents involved in altercations, and document interventions and trends contributed to the deficiency in providing appropriate care for the resident with dementia.
Inappropriate Texture of Pureed Food for Residents
Penalty
Summary
The facility failed to ensure that pureed food items were prepared to an appropriate texture for residents on a pureed diet. During an observation, Dining Services Assistant (DSA) #123 was seen preparing pureed swiss steak for six residents who required a pureed diet. The process involved adding whole swiss steak patties to a blender, along with beef base and thickener. DSA #123 tasted the mixture and believed it was of the correct texture before transferring it to a serving container. However, upon tasting the pureed swiss steak, the surveyor found it to be gritty with small bits of fat that required chewing, which is not suitable for a pureed diet. The Director of Food Services (DFS) #159 confirmed the inappropriate texture upon tasting it as well. The facility's policy on pureed food guidelines, revised in 2012, specifies that pureed foods should be smooth, homogenous, and pudding-like, requiring very little chewing ability. The failure to adhere to these guidelines resulted in the preparation of food that was not safe for residents requiring a pureed diet.
Failure in Hand Hygiene and Food Temperature Monitoring
Penalty
Summary
The facility failed to adhere to proper hand hygiene and glove use during dinner meal service, as well as to ensure that food temperatures were taken before serving meals to residents in the Memory Care Unit. Observations revealed that the steam table in the kitchen was malfunctioning, and food temperatures were not checked before being delivered to the Memory Care Unit. Staff interviews confirmed that food temperatures were not taken by kitchen staff prior to delivery, which affected multiple residents, including those on specific dietary orders. Additionally, during the dinner meal service in the main dining room, a Dining Services Assistant (DSA) was observed not following hand hygiene protocols. The DSA did not change gloves or perform hand hygiene after touching clothing and continued to serve food with the same gloves, which were used to handle dinner rolls and other food items. The facility's policies on hand hygiene and glove use were not followed, as confirmed by the Director of Food Services and Assistant Director of Food Services.
Failure to Implement Infection Control Measures
Penalty
Summary
The facility failed to implement enhanced barrier precautions (EBP) for four residents, despite physician orders requiring such measures. Resident #58, who was admitted with orthopedic aftercare and dysphagia, had orders for enteral feeding and required EBP during high-contact care activities. However, observations revealed no EBP signs or personal protective equipment (PPE) in place, which was confirmed by the Director of Nursing (DON). Similarly, Resident #63, with a wound vacuum in place, and Resident #171, with an indwelling catheter, also lacked EBP signs and PPE, as verified by the DON and a Licensed Practical Nurse (LPN). Resident #371, with a sacral wound and orders for a wound vacuum, was also observed without EBP, despite orders for gown and glove use during high-contact care. The facility also failed to adhere to contact isolation precaution procedures for Resident #2, who was on contact isolation for Clostridioides difficile (Cdiff). Although a sign and PPE cabinet were present outside the resident's room, there were no disposal bins or red bags for used gowns inside or near the room. This was confirmed by both the resident and a Registered Nurse (RN), who acknowledged the absence of proper disposal containers. The facility's guidelines for contact precautions require the removal and disposal of gowns before leaving the resident's room, but these procedures were not followed. These deficiencies indicate a lack of adherence to infection prevention and control protocols, as evidenced by the absence of necessary PPE and disposal measures for residents requiring EBP and contact isolation. The observations and interviews with staff and residents highlight the facility's failure to implement and maintain appropriate infection control practices, potentially compromising resident safety and care quality.
Failure to Report Potential Abuse Incident
Penalty
Summary
The facility failed to report a potential abuse incident involving two residents to the state agency, as required by their policy. Resident #37, who had intact cognition, was involved in an altercation with Resident #35, who had severe cognitive impairment. The incident occurred when Resident #35 attempted to bite a staff member, prompting Resident #37 to slap Resident #35 on the right arm and scream at her. Both residents were separated following the incident, and Resident #35 was assessed and reported no pain. Despite the incident, the facility did not report it to the state agency or conduct any further investigation or documentation. The Executive Director confirmed that no incidents related to the altercation were reported to the state agency, and there was no additional investigation or documentation. The facility's policy mandates that any suspected abuse should be reported immediately to the Executive Director, who is responsible for notifying the state department of health and other relevant agencies.
Delayed Initial Care Conference for Resident
Penalty
Summary
The facility failed to conduct an initial care conference in a timely manner for a resident who was admitted with diagnoses including joint replacement surgery, osteoarthritis, pain, and anxiety. The resident was cognitively intact, as indicated by the Minimum Data Set (MDS). Despite the requirement for initial care conferences to be held within five days of admission, the care conference for this resident was not conducted until 26 days after admission, following a request from the resident's family. This delay was confirmed by the Director of Social Services during an interview.
Failure to Provide Discharge Summary
Penalty
Summary
The facility failed to provide a discharge summary for Resident #66 at the time of discharge to an assisted living facility. Resident #66 was admitted with diagnoses including hemiplegia, hemiparesis, kidney disease, and dependence on renal dialysis. An order was placed for a hospital bed with side rails, but this need was not documented in the discharge planning form. The form also noted dialysis appointments on Monday, Wednesday, and Friday, with transportation to be provided by the facility, but lacked caregiver information. The Executive Director confirmed that a discharge summary was not provided upon discharge.
Failure to Adhere to Resident's Bathing Schedule and Preferences
Penalty
Summary
The facility failed to provide a resident with bathing as scheduled and according to their preference. The resident, who was admitted with diagnoses including joint replacement surgery, osteoarthritis, pain, and anxiety, was cognitively intact and required substantial to maximal assistance for bathing. The resident was scheduled for evening baths twice a week, on Wednesdays and Saturdays. However, documentation from early May to mid-June showed the resident received only three showers, two bed baths, four partial bed baths, and refused bathing once. During an interview, the resident expressed uncertainty about their bathing schedule and stated they were not being bathed twice a week as expected. The Director of Nursing confirmed the documentation did not reflect the scheduled bathing frequency or the resident's preference for showers twice a week.
Delayed Delivery of Wound Vac Supplies
Penalty
Summary
The facility failed to ensure that a resident's wound vac and supplies were received prior to admission, affecting the resident's care. The resident, who was admitted with multiple medical diagnoses including sepsis and a surgical wound, required a wound vac for treatment. The medical record indicated that the wound vac order was placed and confirmed with the medical supply company, with an expected delivery on the day of admission. However, the delivery was delayed, and the facility was notified that the supplies would not arrive until the following day. Upon admission, the resident's wound was managed with a wet to dry dressing as a temporary measure until the wound vac could be applied. The hospital had discharged the resident with the understanding that the wound vac would be available at the facility, but due to the delay, the resident continued with the wet to dry dressing. The resident's sister and hospital staff were informed of the delay, and the facility confirmed the absence of the wound vac and supplies upon the resident's arrival. Interviews with the resident and the resident's sister revealed dissatisfaction with the facility's handling of the situation, as the resident was not supposed to be off the wound vac. The Executive Director confirmed the delay in receiving the necessary supplies and the use of wet to dry dressings in the interim. The facility did not follow up with the hospital after being notified of the delivery delay, contributing to the deficiency in care provided to the resident.
Failure to Timely Identify and Treat Pressure Ulcers
Penalty
Summary
The facility failed to timely identify, accurately assess, and treat a resident's pressure ulcer areas on her right heel and ankle. The resident, who had multiple medical diagnoses including Alzheimer's Disease and Type II Diabetes Mellitus, was initially noted to have a soft, spongy area on her right heel that was red/blue in color. Despite this observation, there was no immediate notification to the physician or Director of Health Services, and the initial treatment was not clearly indicated in the skin assessment. Over time, the wound progressed to an unstageable deep tissue injury, and there were significant gaps in documentation and treatment adjustments. The facility's Treatment Administration Record showed multiple changes in wound care orders, but there were inconsistencies in the application and documentation of these treatments. There were periods where no progress notes were documented, and the resident's wound was not reassessed for significant changes. When signs of a possible wound infection were noted, there was a delay in the resident being seen by a Certified Nurse Practitioner, and the wound culture results were not promptly communicated or acted upon. Additionally, the facility did not recognize a separate wound area on the resident's right lateral ankle, failing to initiate appropriate assessments and treatments for this area. The resident's appointments for wound consults and diagnostic tests were delayed, and there was a lack of coordination in managing the resident's care. The facility's policy required weekly documentation and reassessment of wounds, which was not consistently followed, contributing to the decline in the resident's condition.
Lack of Catheter Care Orders for Resident
Penalty
Summary
The facility failed to ensure that appropriate orders were in place for a resident who had a catheter. This deficiency was identified during a review of the medical records, which revealed that the resident, admitted with a Foley catheter, did not have any orders related to catheter care from the time of admission until the survey date. The resident had several diagnoses, including Parkinsonism, type two diabetes mellitus, chronic kidney disease stage four, anxiety disorder, and rheumatoid arthritis, and was noted to have severely impaired cognition. Despite the presence of a comprehensive care plan that included interventions for catheter care, such as maintaining a closed system and observing for complications, there were no formal physician's orders documented. Interviews with facility staff, including a Certified Resident Medication Assistant and the Executive Director, confirmed the absence of these necessary orders, which should have been in place to guide the care provided to the resident.
Delayed Response to Pharmacy Recommendations
Penalty
Summary
The facility failed to address pharmacy recommendations in a timely manner for a resident with multiple complex medical conditions, including Parkinson's disease and cognitive impairment. The resident was admitted with a range of diagnoses, and a pharmacy recommendation was made to reconsider the use of a specific medication not recommended for Parkinson's associated dementia. The recommendation suggested either a trial dose reduction or documentation of risk versus benefit if the medication was to continue. However, the progress note indicating the nurse practitioner's review of this recommendation was not recorded until two months later. A subsequent pharmacy recommendation was made regarding the resident's use of Olanzapine, suggesting a review due to its unsuitability for Parkinson's disease, with alternatives provided. Again, the progress note documenting the nurse practitioner's review was recorded more than a month after the recommendation. Interviews with the Administrator and Director of Health Services confirmed the delays in reviewing and documenting the pharmacy recommendations. The facility's Medication Regimen Review procedures lacked a specified timeframe for addressing pharmacy recommendations, contributing to the deficiency.
Failure to Justify Psychotropic Medication Use
Penalty
Summary
The facility failed to timely address pharmacy recommendations regarding the use of psychotropic medication for a resident. The resident, who was cognitively intact, had a complex medical history including Parkinson's disease, psychosis, and major depressive disorder. Despite the absence of documented behaviors such as delusions, hallucinations, or psychosis from July to November, an antipsychotic medication was prescribed in November based on staff reports of delusions. However, there was no supporting documentation in the medical records to justify the use of the medication. Interviews with staff confirmed that any resident behaviors should be documented in the medical records and reported to the nurse. The facility's administration could not provide documentation to support the diagnosis of psychosis prior to the prescription of the antipsychotic medication. This lack of documentation and failure to address pharmacy recommendations led to a deficiency in the facility's medication administration practices.
Inaccurate Medical Records for Two Residents
Penalty
Summary
The facility failed to maintain accurate medical records for two residents, leading to deficiencies in care. For Resident #9, the medical records showed inconsistencies in the documentation of a wound on the right heel. Initially identified as an unstageable deep tissue injury, the wound was later noted to have worsened, with discrepancies in measurements and classification between the facility's records and the wound clinic's assessment. Additionally, treatment orders were inaccurately documented for the left heel, despite the wound being on the right heel, and these errors persisted until they were corrected on June 20, 2024. Resident #48's medical records were incomplete, as an incident involving a resident-to-resident altercation was not documented. Despite the altercation occurring on April 22, 2024, there was no record of the event in Resident #48's medical file. This omission was confirmed during an interview with the Executive Director, highlighting a failure to adhere to the facility's policy of maintaining a complete and ongoing resident record. The facility's policy, which mandates the creation and maintenance of a complete, timely, and accurate medical record for each resident, was not followed in these cases. The deficiencies in documentation for both residents indicate a lapse in the facility's adherence to its own guidelines, affecting the quality of care provided to the residents involved.
Latest citations in Ohio
A resident with intact cognition receiving Medicare Part A skilled services for metabolic encephalopathy had services discontinued while benefit days remained, but the facility did not issue the required Skilled Nursing Facility Advance Beneficiary Notice (SNF ABN). The Social Services Director later confirmed that no SNF ABN was provided and reported she believed only a Notice of Medicare Non-Coverage (NOMNC) was needed when all skilled services were stopped. This practice conflicted with the facility’s written policy, which required SNF ABNs to be issued when extended care items or services were initiated, reduced, or terminated due to expected non-coverage by Medicare.
Surveyors identified that the facility exceeded the acceptable medication error rate when two residents with type 2 DM received insulin doses that were not administered according to orders or manufacturer instructions. In two separate observations, an LPN administered Novolog and another LPN administered insulin glargine and insulin lispro without priming the insulin pens, and the insulin lispro and Novolog were given after the residents had already consumed a significant portion of their breakfast meals, despite orders for administration before meals. Manufacturer information for both insulin products required priming before each injection to ensure accurate dosing, and facility policy required medications, including insulin, to be administered safely, timely, and in accordance with prescriber orders and specified time frames.
Surveyors found that the facility failed to document tray line food temperatures for multiple meals served from two dining room kitchenettes, despite having a “Trayline Taste & Temperature Log” and a policy requiring food to be stored, prepared, distributed, and served according to professional food safety standards. Review of logs showed repeated missing entries for breakfast, lunch, and dinner services in both the Harrison and McClellan dining areas, and the Senior Director of Culinary Services confirmed that temperatures had not been recorded for those meals, potentially affecting all residents receiving meals from those kitchenettes.
The facility failed to conduct and document required periodic care conferences for two residents, despite multiple comprehensive, quarterly, and significant change MDS assessments and a policy requiring periodic care conferences with resident and/or family participation. One resident with Parkinson’s disease, post-stroke hemiplegia, TIA, DMII, and depression had only two documented care conferences over a year, while another resident with aphasia, cerebrovascular disease, DMII, gait difficulty, coagulation defect, depression, and muscle weakness had no documented care conferences in the past year, aside from a declined invitation to the representative. The UCC confirmed that care conferences were expected to occur quarterly and that no additional documentation existed for either resident.
A resident with Alzheimer's disease and type II DM, who required extensive assistance with ADLs and was receiving scheduled Lantus and sliding-scale Humalog, experienced a severely elevated blood glucose level. The on-call provider was notified and ordered an additional dose of lispro insulin with a directive to recheck the blood glucose after administration. Nursing staff administered the extra insulin but did not document any follow-up blood glucose check, and the DON confirmed that this reevaluation was required by the facility's abnormal blood glucose policy and was not completed or documented.
A resident with Parkinson’s disease, dementia, and hypothyroidism was prescribed levothyroxine once daily along with other medications. A consultant pharmacist’s monthly drug regimen review recommended that levothyroxine be given in the morning on an empty stomach, 30–60 minutes before food, per manufacturer instructions. The medical record contained no documented physician response to this recommendation, and the MAR showed the drug scheduled for morning administration while the resident was observed eating breakfast and receiving the medication at the same time. An LPN confirmed administering levothyroxine during the meal, and the DON verified there was no documentation explaining whether or why the pharmacist’s recommendation was or was not followed, resulting in a failure to act on and document the identified irregularity.
A resident with severe cognitive impairment, multiple comorbidities, documented gait and balance abnormalities, and a high fall risk was care planned and assessed by therapy to require contact guard assistance and use of a gait belt for transfers and ambulation. While being assisted by a CNA from a recliner to the bathroom with a walker, the CNA did not apply a gait belt, even though the resident had a known tendency to lean backward when standing. As the CNA reached to open the bathroom door, the resident lost balance and fell backward, striking the back of the head, and was later found by an LPN without a gait belt in place, contrary to the facility’s gait belt policy and the resident’s assessed needs.
A resident with CKD stage five requiring peritoneal dialysis (PD) was admitted with pre-admission physician orders for three daily PD exchanges and monitoring for peritonitis (fever, abdominal pain, cloudy effluent), but these monitoring orders were not entered into the facility’s physician orders. The care plan referenced PD and general monitoring but did not specifically address peritonitis monitoring. Paper PD flowsheets showed incomplete and inconsistent documentation of exchanges and resident condition, including missing condition/comments for individual treatments and no record of one ordered PD exchange. The PD cycler flowsheet lacked effluent descriptions on multiple days. The PD nurse reported facility staff were expected to monitor effluent and symptoms, and the DON confirmed the absence of specific peritonitis monitoring orders, lack of an order for the PD cycler, and documentation gaps, despite a facility policy requiring ongoing assessment and monitoring for complications before, during, and after dialysis treatments.
A nurse was observed preparing multiple oral medications for a resident with depression, traumatic brain injury, anxiety, and impaired cognition by pushing tablets and capsules from unit-dose cards directly into her ungloved hand and then using her fingers to place them into a medication cup. In a follow-up interview, the RN confirmed this practice and acknowledged that the correct procedure is to dispense medications directly from the card into the cup, contrary to the facility’s medication administration policy requiring adherence to good nursing principles and practices.
A resident with Alzheimer’s disease, diabetes, anxiety, significant ADL dependence, and behavioral symptoms was observed seated in a chair positioned against the nursing station with a locked wheelchair placed directly in front, also against the nursing station, effectively restricting movement. An LPN confirmed both wheelchair wheels were locked and that it should not have been placed there, while a CNA stated she had positioned the wheelchair to prepare for lunch, was unable to complete the transfer, and left it in place, acknowledging this was wrong. This arrangement conflicted with the facility’s restraint policy, which prohibits physical restraints except when alternatives are ineffective for treating a medical symptom and defines restraints as devices adjacent to the body that cannot be easily removed and that restrict freedom of movement or access to the body.
Failure to Issue Required SNF ABN When Discontinuing Medicare Part A Services
Penalty
Summary
The deficiency involves the facility’s failure to issue a Skilled Nursing Facility Advance Beneficiary Notice (SNF ABN) when Medicare Part A services were discontinued for a resident who still had available benefit days. The resident was admitted with a diagnosis of metabolic encephalopathy and had intact cognition per the Minimum Data Set assessment. The facility’s own SNF Beneficiary Notification Review documented that Medicare Part A skilled services began on 02/11/26 and the last covered day was 03/11/26, and that the facility initiated discharge from Medicare Part A services before the resident’s benefit days were exhausted. Despite this, no SNF ABN was provided to the resident or the resident’s representative. During interviews, the Social Services Director stated that the SNF ABN was issued hours prior to the last covered day but, upon reviewing her files, confirmed that no SNF ABN had actually been issued for this resident. She further explained that she believed an SNF ABN was only required if one skilled service remained and that if all skilled services were being discontinued, only the Notice of Medicare Non-Coverage (NOMNC) needed to be issued. The Administrator, however, stated that a resident should always receive both a SNF ABN and a NOMNC when Medicare Part A services are discontinued and benefit days remain. Review of the facility’s written policy dated 03/28/23 showed that the facility was required to issue SNF ABNs for initiation, reduction, or termination of extended care items or services when Medicare payment was not expected, which did not occur in this case.
Plan Of Correction
This Plan of Correction is submitted as required under State and Federal law. This Plan of Correction does not constitute an admission on the part of the Facility that the findings cited are accurate, that the findings constitute a deficiency or that the scope and severity regarding the deficiency cited are correctly applied. Any changes to the Facility's policies and procedures should be inadmissible in any proceeding on that basis. Without admitting or denying the validity or the existence of the alleged noncompliance, the Facility submits this Plan of Correction with the intention that it be inadmissible by any third party in any civil or other action against the facility or any employee, agent, officer, director or shareholder of the Facility. The Facility is utilizing this Plan of Correction as its allegation of substantial compliance as of 05/29/2026 F-0582 Corrective action for resident/s: On 5/14/26 Resident #34 was informed of rights and responsibilities related to Advanced Beneficiary Notice and voiced understanding of information for future reference by administrator. Identification of other residents who may be affected: Any resident receiving skilled services from nursing or therapy services. The Administrator audited all residents who were discharged from skilled services in the past 30 days to ensure they were issued a Notice of Non-Coverage and Advanced Beneficiary Notice on 5/29/26. No non-compliance was noted. Measures for systemic change: On 5/14/2026 Business Office Manager, Director of Rehab, Minimum Data Set nurse, Director of Nursing and Social Services Director were educated on proper procedure of issuing of Notice Of Medicare Non Coverage and Advanced Beneficiary Notice by administrator. All upcoming discharges from skilled services will be reviewed weekly at Utilization Review meeting to ensure notices will be delivered timely. How Corrective Action will be monitored: Administrator or designee to complete audits of all residents being discharged from skilled services to ensure they were issued a Notice of Non-Coverage and Advanced Beneficiary. This audit will be completed weekly x 4 weeks, then monthly x 2 months. Corrective action will be initiated for any noted non-compliance. Audit findings will be reviewed as part of the monthly quality assurance process to determine the need for further monitoring. Date of Compliance 5/29/26
Insulin Administration Errors and Failure to Prime Insulin Pens
Penalty
Summary
The deficiency involves the facility’s failure to maintain a medication error rate below 5%, with surveyors identifying 3 errors out of 28 medication administration opportunities, resulting in a 10.71% error rate. For one resident with type 2 diabetes mellitus and moderate cognitive impairment, the physician’s order directed Novolog insulin 10 units via subcutaneous pen-injector to be given before meals. During an observed medication pass, the LPN administered 10 units of Novolog insulin without priming the pen and did so after the resident had already consumed approximately 50% of the breakfast meal. The LPN later confirmed she did not prime the pen and acknowledged that the insulin was ordered to be administered prior to meals. Manufacturer instructions for the Novolog FlexPen specified that an air shot (priming) must be performed before each injection to ensure proper dosing. Another resident, also diagnosed with type 2 diabetes mellitus and with intact cognition, had orders for insulin glargine 35 units subcutaneously twice daily and insulin lispro 20 units subcutaneously before meals, plus 12 units subcutaneously if blood glucose was between 251 mg/dL and 300 mg/dL. During an observed medication administration, an LPN administered 35 units of insulin glargine and 32 units of insulin lispro without priming the insulin pens and after the resident had consumed approximately 90% of the breakfast meal, despite orders for insulin lispro to be given before meals. The LPN later stated she could not remember if she had primed the pen and acknowledged that the insulin was ordered to be administered prior to meals. Manufacturer information for insulin lispro stated that the pen must be primed before each injection to confirm insulin delivery and remove air, and that failure to prime could result in too much or too little insulin. The DON confirmed the expectation that insulin be administered as ordered, including priming each pen with two units before dialing the prescribed dose, and facility policy required medications, including insulin, to be administered safely, timely, and in accordance with prescriber orders and required time frames.
Plan Of Correction
This Plan of Correction is submitted as required under State and Federal law. This Plan of Correction does not constitute an admission on the part of the Facility that the findings cited are accurate, that the findings constitute a deficiency or that the scope and severity regarding the deficiency cited are correctly applied. Any changes to the Facility's policies and procedures should be inadmissible in any proceeding on that basis. Without admitting or denying the validity or the existence of the alleged noncompliance, the Facility submits this Plan of Correction with the intention that it be inadmissible by any third party in any civil or other action against the facility or any employee, agent, officer, director or shareholder of the Facility. The Facility is utilizing this Plan of Correction as an allegation of substantial compliance as of 5/29/2026. F-0759 Corrective action for resident/s: Residents #21 and #22 were assessed and evaluated by nurse and Director of Nursing 5/14/26. Resident #21 and #22 both denied any adverse effects and none were noted upon assessment by the Director of Nursing on 5/14/2026. Notification made to physician on 5/14/2026. LPN # 2 competency Eval on insulin administration with the Director of Nursing completed 5/14/2026. Identification of other residents who may be affected: Diabetic residents on assignment of LPN #2/station 2 have the potential to be affected and were assessed by the DON/Designee on 5/14/26 and found to be within normal limits. Measures for systemic change: All Nurses were educated by the Director of Nursing on the steps for Insulin administration per competency, diabetes clinical protocol policy, Medication and treatment orders policy, administering medications policy, and Obtaining fingerstick Glucose Level policy On 5/14/2026. How Corrective Action will be monitored: Director of Nursing and Assistant Director of Nursing will complete insulin administration audits on 5 nurses. This audit will be completed weekly x 4 weeks, then monthly x 2 months. Corrective action will be initiated for any noted non-compliance. Audit findings will be reviewed as part of the monthly quality assurance process to determine the need for further monitoring. Date of Compliance: 5/29/2026
Failure to Document Tray Line Food Temperatures in Dining Room Kitchenettes
Penalty
Summary
The deficiency involves the facility’s failure to document tray line food temperatures for meals served from the Harrison and McClellan Dining Room kitchenettes, as required by professional standards for food service safety and the facility’s own policy. Review of the “Trayline Taste & Temperature Log” (revised September 2018) showed missing temperature documentation for multiple meals from the Harrison Dining Room kitchenette, including dinner on 03/30/26 and 03/31/26, lunch and dinner on 04/01/26 and 04/02/26, dinner on 04/07/26, and lunch and dinner on 04/08/26 and 04/10/26. The Senior Director of Culinary Services confirmed during interview that tray line food temperatures were not documented on the log for these meals. Similarly, review of the same log for the McClellan Dining Room kitchenette revealed that tray line food temperatures were not documented for dinner on 04/01/26, breakfast and lunch on 04/02/26, and lunch and dinner on 04/07/26. The Senior Director of Culinary Services also verified these omissions during interview. The facility census at the time was 27 residents, and the governing “Food and Nutrition” policy, approved on 09/07/21, stated that the facility must store, prepare, distribute, and serve food in accordance with professional standards for food service safety.
Plan Of Correction
F812 The facility will continue to ensure food temperatures are completed before meals are served for all residents. To ensure compliance with this standard the following measures have been taken: 1. Immediately 4/15/26 culinary supervisor #224 was re-educated by Dietary Manager to this standard and policy "Food and Nutrition" which includes documentation of food temperatures. 2. All dietary staff have been re-educated to the standard and policy "Food and Nutrition" during the month of April 2026. 3. Audits of food temperature documentation to be completed by Dietary Manager 4 x per week for 4 weeks then weekly for 4 weeks. 4. Administrator to validate audits/compliance and provide additional training as needed. Administrator will present to QAPI committee for ongoing monitoring and further direction.
Failure to Conduct and Document Required Care Conferences
Penalty
Summary
The deficiency involves the facility’s failure to complete and document comprehensive care conferences at required intervals in accordance with care plan regulations and facility policy. For one resident with Parkinson’s disease with dyskinesia, cognitive communication deficit, hemiplegia and hemiparesis following cerebral infarction, transient cerebral ischemic attack, type II diabetes mellitus, and major depressive disorder, the record showed multiple MDS assessments over a one-year period, including annual, quarterly, and significant change assessments. However, only two care conferences were documented during the last 12 months, despite the expectation that care conferences be conducted quarterly with the resident and family when possible. The Unit Care Coordinator confirmed that no additional care conference documentation existed for this resident beyond the notes dated 04/21/25 and 01/02/26. A second resident, with diagnoses including aphasia following cerebrovascular disease, cerebral infarction, type II diabetes mellitus, unsteadiness on feet, difficulty in walking, coagulation defect, depression, and muscle weakness, also had multiple MDS assessments completed over the review period, including quarterly and annual assessments. The record contained a note that a care conference was offered to the resident’s representative, who declined to attend, but there was no documentation of any care conferences for the most recent 12 months. The Unit Care Coordinator confirmed that no other care conference documentation was available for this resident. Facility policy stated that periodic care conferences involving the resident, family, and the interdisciplinary team are part of the care planning process, but the required periodic care conferences and corresponding documentation were not completed for these two residents.
Plan Of Correction
THIS PLAN OF CORRECTION SERVES AS BERKELEY SQUARE'S CREDIBLE ALLEGATION OF SUBSTANTIAL COMPLIANCE AS OF June 1, 2026. Without admitting or denying the validity or existence of the alleged deficiencies, Berkeley Square provides the following Plan of Correction: F657 The facility will continue to document completion of care conferences at the required intervals for all residents, including residents #04 & #15. To ensure compliance with this standard the following measures have be taken: 1. The social service designee and the inter- disciplinary team were re-educated by the administrator to the facility policy "Care Conference" on 4/29/26 and verbalized understanding. 2. Care conferences for resident #04 and resident #15 were conducted on or before 4/29/2026 by the interdisciplinary team. 3. Review of all other residents was conducted by the social service designee to validate and ensure that care conference schedule is up to date with timely care conferences scheduled for them on 4/15/2026. Audits of care conferences to be completed weekly for four weeks and then monthly after that by the social service designee. Documentation of the care conference including any identified concerns in the medical record. Administrator to validate audits/compliance and provide additional training as needed. Administrator will present results of these audits to QAPI committee for ongoing monitoring and further direction.
Failure to Reevaluate Blood Glucose After Treatment for Hyperglycemia
Penalty
Summary
The facility failed to ensure that a resident with diabetes received treatment in accordance with professional standards of practice when nursing staff did not reevaluate the resident's blood glucose after treatment for severe hyperglycemia. The resident, admitted with diagnoses including Alzheimer's disease, type II diabetes mellitus, and depression, had physician orders for Humalog insulin on a sliding scale before meals, Lantus insulin 25 units daily, and lisinopril 5 mg daily. The resident required extensive assistance with activities of daily living, including transfers, toileting hygiene, eating, and bathing. On the evening in question, the resident's blood glucose was documented as 532 mg/dL, and the on-call provider was notified. The provider gave a new order to administer an additional 8 units of lispro (Humalog) and to recheck the blood glucose in 30 minutes. The electronic medication administration record showed that the blood glucose of 532 mg/dL was obtained at 9:00 p.m. and that the additional 8 units of lispro were administered at 9:21 p.m. However, there was no documentation in the resident's chart that the blood glucose was rechecked after the additional insulin was given. In an interview, the DON confirmed there was no evidence of reevaluation and verified that, according to the facility's "Abnormal Blood Glucose Procedure" policy, the resident should have been reevaluated and that the evaluation step should have been included in the progress note documentation.
Plan Of Correction
F684 The facility will continue to ensure all residents, including #03, receive treatment in accordance with professional standards of practice and reevaluated for hyperglycemia. To ensure compliance with this standard the following measures have been taken: 1. The director of nursing assessed resident #03, reviewed documentation and orders and found no ill effects immediately 4/16/26. 2. All licensed nurses were re-educated to facility policy "Blood Glucose Monitoring" by the Director of Nursing/designee in April 2026. 3. Audits of like-residents that require blood sugar checks to be completed by the director of nursing/designee two times a week for 4 weeks and then monthly after that to validate correct follow through when there is abnormally high blood glucose result. The Administrator will bring results of these audits to the QAPI committee for ongoing monitoring and further direction.
Failure to Act on Pharmacist Drug Regimen Recommendation for Thyroid Medication
Penalty
Summary
The deficiency involves the facility’s failure to ensure that pharmacy recommendations from the monthly drug regimen review were acted upon and documented for a resident. The resident was admitted with diagnoses including Parkinson’s disease, dementia, and hypothyroidism, and had current physician orders for levothyroxine 150 mcg once daily, buspirone 50 mg twice daily, and losartan 100 mg once daily. A medication regimen review dated 11/25/2025 included a consultant pharmacist recommendation that levothyroxine be administered consistently in the morning on an empty stomach, at least 30–60 minutes before food, per manufacturer instructions. There was no specific physician response in the medical record to this recommendation, and the facility’s policy stated that consulting pharmacist reviews are sent to nursing and addressed with the primary care provider or consulting specialist for review and follow-up. Review of the resident’s medication administration record for April 2026 showed levothyroxine scheduled for 9:00 a.m. On observation, the resident was seen eating breakfast in the dining area at 8:03 a.m., and an LPN reported administering the levothyroxine 150 mcg to the resident while the resident was in the dining area eating breakfast. The DON confirmed there was no evidence in the resident’s medical record explaining why the consultant pharmacist’s recommendation from 11/25/2025 was or was not acted upon. This lack of documented physician review and action on the pharmacist’s identified irregularity constituted noncompliance with the drug regimen review requirements.
Plan Of Correction
F756 The facility will continue to ensure the pharmacy recommendations from the monthly drug regimen review by a licensed pharmacist are acted upon for all residents, including #08. To ensure compliance with this standard the following measures have been taken: 1. Resident #08 was assessed by the registered nurse and med review completed by 4/28/26. After review of resident's drug regime's, it was discovered that resident #8 had 2 separate medication recommendations on the same form, to be reviewed by two separate practitioners, pharmacy has been instructed and agreed to separate meds on individual forms. 2. Licensed nurses re-educated to facility policy "Drug Regimen Review" by Director of nursing/designee in April 2026 and no later than 5/8/26. Licensed nurses are responsible for ensuring the reviews and recommendations are given to the physician for timely review. 3. Review of all other current residents Drug Regimen orders completed by Director of nursing/designee on 4/16/26 to ensure recommendations were followed up on/reviewed by the physician and address concerns if needed. 4. Audit of drug regime recommendations, pharmacy recommendations, and physician follow up to be completed weekly for four weeks by the Director of nursing/designee. Administrator will present results of these audits to the QAPI committee for ongoing monitoring and further direction.
Failure to Use Required Gait Belt During Ambulation Resulting in Resident Fall
Penalty
Summary
The deficiency involves the facility’s failure to ensure that a required gait belt was used while assisting a high fall‑risk resident with ambulation, resulting in a fall with head injury. The resident had multiple diagnoses including metabolic encephalopathy, hypertension, osteoarthritis, muscle weakness, gait and mobility abnormalities, major depressive disorder, anxiety, and visual hallucinations. Admission and subsequent MDS and fall risk assessments documented that the resident was severely cognitively impaired, required moderate to maximal assistance with transfers and ambulation, could not independently come to a standing position, exhibited loss of balance while standing, used an assistive device, and had decreased muscle coordination. The resident had a history of falls prior to admission and was assessed as being at high, later moderate, risk for falls. The resident’s fall care plan identified her as at risk for falls and included interventions such as providing maximum to moderate assistance with transfers and walking short distances, use of a walker and wheelchair, and following the facility’s fall protocol. Therapy notes and care conference documentation indicated that the resident leaned backwards when standing, required contact guard to minimal assistance for bed mobility and transfers, and needed constant verbal cueing for safe sequencing during toilet transfers. The physical therapist confirmed that the resident was to use a gait belt with staff when ambulating, and the DON verified that therapy had assessed the resident as requiring contact guard assistance and a gait belt for ambulation and transfers. On the day of the incident, a CNA was assisting the resident from her recliner to the bathroom using a walker. The CNA walked beside the resident, providing guidance and support, and reported having a hand on the resident while assisting her. As they approached the bathroom door, the CNA reached for the doorknob to open it, and at that moment the resident began to lose her balance and fell backwards to the floor, striking the back of her head. The nurse who responded found the resident on her back at the foot of the bed with her feet near the bathroom, noted a red raised area on the back of the head, and documented that the resident was not wearing a gait belt and that the gait belt was on the dresser. In the facility’s investigative summary and in interviews, the CNA acknowledged that she did not have a gait belt on the resident while ambulating her, despite the resident’s assessed need for hands‑on assistance and gait belt use per facility policy and the resident’s care and therapy plans.
Failure to Implement PD Orders and Monitor Resident Receiving Peritoneal Dialysis
Penalty
Summary
The deficiency involves the facility’s failure to implement pre-admission physician orders for peritoneal dialysis (PD) and to provide ongoing monitoring for a resident with chronic kidney disease (CKD) stage five who required PD. Pre-admission orders dated 11/14/25 specified three daily PD exchanges at 6:00 A.M., 2:00 P.M., and 10:00 P.M., and directed staff to monitor for signs and symptoms of peritonitis, including fever, abdominal pain, and cloudy effluent. These monitoring orders were not entered into the facility’s physician orders. The resident’s care plan noted the need for PD and included general monitoring interventions (labs, signs of bleeding, bacteremia, septic shock, and significant vital sign changes), but did not specifically address the ordered monitoring for peritonitis. Review of PD documentation showed incomplete and inconsistent charting of treatments and resident condition. The paper peritoneal flowsheet had columns for time of PD and condition/comments, including instructions to call the nurse immediately for cloudy fluid, abdominal pain, or fever. However, the first entry on 11/15/26 at 2:00 P.M. only noted that the PD nurse completed the exchange, and the 10:00 P.M. entry that day had no condition/comment documentation. Subsequent days (11/16/25, 11/17/25, and 11/18/25) contained only one condition/comment entry per day rather than for each exchange, and there was no documentation that the 6:00 A.M. PD on 11/18/25 was completed. The PD cycler flowsheet starting 11/19/25 lacked any description of the effluent on multiple days. The PD nurse from the dialysis company stated facility staff were expected to monitor effluent for cloudiness and assess for abdominal pain and fever, and the DON confirmed there was no electronic physician order for peritonitis monitoring or for use of the PD cycler, that the paper charting did not allow for effluent description or symptom documentation for each treatment, and that PD was not documented at one ordered time. The facility’s dialysis policy required ongoing assessment and monitoring for complications before, during, and after treatments, which was not reflected in the documentation for this resident.
Improper Infection Control During Medication Administration
Penalty
Summary
Surveyors identified a deficiency in infection prevention and control related to medication administration for Resident #29. The resident was admitted on 02/28/14 with diagnoses including depression, traumatic brain injury, and anxiety, and had impaired cognition per a quarterly MDS assessment. During an observation on 03/25/26 at 6:58 A.M., RN #281 prepared the resident’s medications by removing an Amoxicillin-Pot Clavulanate tablet from the medication card and pushing it directly into her ungloved hand, then using her fingers to place the pill into a medication cup. The same process was observed for multiple other medications, including Escitalopram Oxalate, Furosemide, Sennosides, Lyrica, and Vitamin D, each being pushed from the card into the RN’s ungloved hand and then transferred by her fingers into the medication cup before administration to Resident #29. In a subsequent interview at 7:27 A.M. the same day, RN #281 confirmed she had placed each medication into her ungloved hands prior to administration and acknowledged that the proper procedure was to push the pills directly from the card into the medication cup. Review of the facility’s “Medication Administration – General guidelines” policy, revised 10/08/25, stated that medications are to be administered in accordance with good nursing principles and practices. This practice failure was cited as a deficiency under Complaint Number 2681777.
Improper Use of Wheelchair as a Physical Restraint
Penalty
Summary
Surveyors identified a deficiency related to the facility’s failure to ensure a resident was free from physical restraints. Resident #7, admitted with diagnoses including Alzheimer’s disease, diabetes mellitus, and anxiety disorder, was documented on a recent MDS as rarely understood and dependent for ADLs except eating. The resident ambulated independently on the unit without an assistive device and had documented verbal and other behaviors occurring one to three days during the look-back period. The care plan noted the resident had potential to be physically aggressive, chase staff, throw objects, and be combative with care, with interventions such as offering choices, administering medications as ordered, and intervening early when agitation occurred. During an observation and interview, Resident #7 was found sitting in a chair with the right arm of the chair positioned against the nursing station and a wheelchair placed directly in front of him. The left arm of the wheelchair was also against the nursing station, and both wheelchair wheels were locked, creating a barrier that appeared to restrain the resident, who was sleeping with his knees touching the locked wheelchair. An LPN confirmed both wheelchair wheels were locked and that the wheelchair should not have been placed in front of the resident. A CNA reported she had placed the wheelchair there in preparation to get the resident up for lunch, was unable to transfer him, and left the wheelchair in that position, acknowledging it was wrong to keep it there. The facility’s physical restraint policy stated that physical restraints are not used except when alternatives are not appropriate or effective for treating a medical symptom and defined physical restraints as any device attached or adjacent to the body that the individual cannot easily remove and that restricts freedom of movement or access to the body.
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