The Pavilion Rehabilitation And Nursing Center
Inspection history, citations, penalties and survey trends for this long-term care facility in North Royalton, Ohio.
- Location
- 13900 Bennett Road, North Royalton, Ohio 44133
- CMS Provider Number
- 366158
- Inspections on file
- 41
- Latest survey
- February 19, 2025
- Citations (last 12 mo.)
- 0
Citation history
Health deficiencies cited at The Pavilion Rehabilitation And Nursing Center during CMS and state inspections, most recent first.
A facility failed to provide adequate supervision when nursing staff were found sleeping during their shifts, affecting residents at high risk for elopement. Residents with dementia and schizophrenia diagnoses, requiring close supervision, were left unsupervised on the 100 and 300 halls. The incident was observed by the Administrator and RDCS during unannounced rounds, highlighting a significant lapse in resident safety.
A facility failed to provide appropriate dementia care for a resident with dementia and behavioral disturbances. The resident, identified as an elopement risk, displayed wandering behaviors. A CNA, unfamiliar to the resident, attempted to redirect the resident during sundowning, leading to agitation. To prevent altercations, the CNA blocked the resident's access to certain areas with chairs, constituting involuntary seclusion, which violated the facility's policy on abuse and neglect.
The facility failed to maintain a clean and safe environment, affecting all residents. Observations included an active ceiling leak, blocked air vents, rusted shower chairs, and missing privacy curtains. Electrical outlet covers were off or loose, and moldy food was found in the dining room fridge. Walls and furniture were stained and damaged, and wheelchairs lacked padding. Handrails were chipped, and overbed lights lacked covers.
A facility failed to ensure accurate documentation of a resident's advance directive preferences. Despite the resident's wish for a DNRCC status, records showed conflicting information, with electronic orders indicating a full code status. The resident confirmed his preference for DNRCC, and the DON acknowledged the discrepancies.
A facility failed to complete the required MDS 3.0 assessments for a resident who left against medical advice and returned the same day. The resident, with conditions including paraplegia and opioid dependence, did not have the necessary discharge and entry assessments completed, as confirmed by the MDS nurse.
The facility failed to complete timely PASRR assessments for two residents with mental disorders or intellectual disabilities. One resident was readmitted without a PASRR assessment after leaving against medical advice, while another remained beyond a 30-day exemption period without a full assessment. These lapses were confirmed by facility staff.
A facility failed to update a resident's care plan to address wandering behaviors and potential elopement risk. The resident, with schizophrenia and cognitive delay, was identified as high risk for elopement but lacked a care plan for these issues. An incident occurred where the resident wandered off during a smoke break, leading to the implementation of a wanderguard and frequent checks, which were not reflected in the care plan.
The facility did not implement pharmacy recommendations for two residents, affecting medication management. A resident's Hydroxyzine dose was not reduced, and necessary blood tests and medication timing adjustments were not made. Another resident's Diphenhydramine was not discontinued despite agreement. The DON confirmed these lapses.
A resident with a history of antiphospholipid syndrome and lupus received Warfarin without proper monitoring of INR levels, leading to a significant medication error. The facility failed to report elevated INR results in a timely manner, resulting in continued Warfarin administration despite the risk of excessive anticoagulation. The resident expressed concerns about the lack of communication regarding her INR levels, and the DON confirmed that Warfarin should have been held until INR values normalized.
The facility failed to properly store Methadone, a Schedule 2 medication, for two residents. Observations revealed that the Methadone was kept in black boxes inside medication carts that were not permanently affixed or separately locked. In one case, the box was not fully closed, allowing access without unlocking. The facility's medication storage policy lacked specific guidelines for storing controlled medications.
The facility failed to maintain accurate and complete medical records for two residents regarding laboratory findings. One resident, with dementia and schizophrenia, lacked recorded Depakote lab results after a specific date, while another resident, with cognitive deficits and hypertension, was missing Valproic Acid lab results. An LPN confirmed these omissions and retrieved the missing results from the lab website.
The facility failed to maintain a safe and clean environment, with issues such as dirty and worn carpets, chipped paint, and cracked showers observed in various areas. A broken window in the common area and unpainted wall patches were also noted. The Administrator confirmed these findings, and the resident complaint log indicated multiple housekeeping issues.
A resident with a traumatic brain injury and hemiplegia was found smoking in their room, against the facility's policy allowing smoking only in designated outdoor areas. Despite having intact cognition, the resident was non-receptive to re-education and continued to smoke indoors. Observations showed cigarette butts and a lighter on the windowsill, with the window partially open and the screen torn. The care plan noted behavior issues but lacked interventions to address them.
The facility failed to provide sufficient dietary staff, affecting meal service for all 49 residents. Staffing inconsistencies and a lack of pay incentives led to nurse aides filling in without proper protocols, causing meal delays. The Dietary Manager's absence was not covered, resulting in a cook working double shifts.
The facility's kitchen was found to be unsanitary, with debris and grime on the floor, improperly stored food items, and ice buildup in the freezer. Observations included undated and unsealed food items, food debris under cooler shelving, and a bug in the dry storage area. The Regional Culinary Director confirmed these issues, which violated the facility's food storage policy.
The facility failed to maintain its commercial laundry machines, affecting all 49 residents. The large Unimac machine lost power due to wiring issues, and the small machine was out of service until repaired. Without a backup, the maintenance supervisor transported laundry to a sister facility. Staff noted delays in returning residents' clothing, and the Administrator was unaware of the small machine's repair needs. A review indicated the slab under the large machine was unstable, prompting a replacement recommendation.
The facility failed to maintain an adequate supply of clean towels and washcloths, affecting 31 residents. Observations revealed empty linen rooms, and staff confirmed the shortage, impacting resident care, including missed shower days. Budget constraints and lack of established par levels contributed to the deficiency.
A resident and their POA were denied access to personal records, including government-issued documents, despite a signed release request. The facility lacked a procedure for handling resident information, leading to misplacement of documents and an open misappropriation case. The resident had intact cognition and requested the documents prior to discharge, but the administrator did not comply.
The facility failed to maintain kitchen cleanliness and proper food storage. Observations revealed grease buildup on the oven hood suppression system and improperly stored food items in the walk-in refrigerator and freezer, including undated and uncovered items. These findings were confirmed by a cook during the tour.
The facility failed to maintain the laundry area in a clean, safe, and sanitary condition, with lint-covered areas behind washers, a poorly maintained dryer ventilation system, and significantly water-stained ceiling tiles. These issues were confirmed by the Laundry Director.
The facility failed to conduct annual performance reviews for STNAs as required, affecting one of two personnel files reviewed and potentially impacting all 43 residents. This was confirmed during an interview with the HRD.
Inadequate Supervision Due to Sleeping Staff
Penalty
Summary
The facility failed to provide appropriate supervision to residents, as nursing staff were found sleeping during their shifts. This incident affected three residents identified as high risk for elopement, residing on the 100 and 300 halls, and had the potential to affect all residents on these halls. The residents involved had various diagnoses, including dementia, schizophrenia, and cognitive impairments, which increased their risk of elopement and required close supervision. Resident #44, residing on the 300-hall, had a history of attempts to leave the facility unattended and was identified as an elopement risk. The resident had a wanderguard device to alert staff if an exit was attempted. Similarly, Resident #8, residing on the 100-hall, was also at high risk for elopement due to being ambulatory and disoriented. Both residents required interventions such as reorientation and supervision to prevent wandering and potential elopement. On the night of the incident, CNAs assigned to the 100 and 300 halls were found sleeping, leaving the residents unsupervised. The facility's Administrator and Regional Director of Clinical Services observed the sleeping staff during unannounced rounds. This lack of supervision posed a significant risk to the residents, particularly those identified as high risk for elopement, as they were left without the necessary oversight to ensure their safety.
Inappropriate Dementia Care and Involuntary Seclusion
Penalty
Summary
The facility failed to provide appropriate dementia care for a resident diagnosed with dementia with behavioral disturbance, anxiety disorder, cognitive communication deficit, and schizophrenia. The resident, who was identified as an elopement risk and wanderer, displayed wandering behaviors and had a history of attempting to leave the facility unattended. The care plan for the resident included interventions such as offering pleasant diversions and structured activities to distract from wandering, but these measures were not effectively implemented. An incident occurred where a Certified Nurse Aide (CNA) was assigned to care for the resident, despite being new and unfamiliar to the resident. During the evening, the resident began to exhibit sundowning behaviors, including disrobing and attempting to enter other residents' rooms. The CNA and a Registered Nurse (RN) attempted to redirect the resident using calm voices and physical guidance, but the resident became agitated and attempted to hit the staff. In an effort to prevent altercations with other residents, the CNA placed chairs to block the resident's access to certain areas, which was later identified as involuntary seclusion. The facility's policy on abuse, neglect, and exploitation prohibits involuntary seclusion, which is defined as confining a resident against their will. The Regional Director of Operations confirmed that the CNA's actions of obstructing an area with chairs constituted involuntary seclusion. This deficiency was investigated under a specific complaint number, indicating non-compliance with the facility's policies and procedures for dementia care.
Facility Fails to Maintain Clean and Safe Environment
Penalty
Summary
The facility failed to maintain a clean, sanitary, and well-maintained environment, which had the potential to affect all 43 residents. During an environmental tour, several deficiencies were observed, including an active ceiling leak in the first-floor common area, noticeable scratches on the floor in a resident's room, and a blocked air vent covered with industrial tape. Additionally, a shower chair was found to be significantly rusted, and some rooms lacked privacy curtains. Electrical outlet covers were either off or loose, and cobwebs were present on a ceiling. A shower head was observed to leak water continuously, and the dining room walls were stained and scuffed. Moldy food was found in the common use fridge, and tables were in poor condition, with one held together by duct tape. Further observations included torn non-skid strips, stained blankets and bed sheets, and crumbling wall areas around heating/AC units. A geriatric chair contained food crumbs, and a room had numerous brown dots of an unknown substance. Wallpaper was falling off in several rooms, and a patched wall was not properly finished. Wheelchairs lacked padding, and a large red stain was noted on a floor. Handrails throughout the facility were chipped and scratched, and overbed lights lacked covers. Several rooms had extremely scuffed and scratched walls, and bathroom walls were also in poor condition.
Inconsistent Documentation of Advance Directives
Penalty
Summary
The facility failed to ensure that a resident's advance directive orders and information were accurately documented throughout the medical record. This deficiency was identified during a review of the records for a resident who was admitted with diagnoses including alcohol dependence, schizoaffective disorder, bipolar disorder, and cocaine abuse. The resident was cognitively intact and receiving hospice services. Despite the resident's expressed desire to have a DNRCC (do not resuscitate comfort care) status, inconsistencies were found in the medical records. The electronic physician's orders and care plan indicated a full code status, while the hard medical chart contained conflicting information, including a signed DNRCC form. Interviews with the resident confirmed his wish to maintain the DNRCC status, and the Director of Nursing verified the discrepancies in the resident's code status documentation. The facility's policy on advanced directives requires that the plan of care be consistent with the resident's documented treatment preferences. However, the failure to ensure accurate and consistent documentation of the resident's advance directive preferences throughout the medical record led to this deficiency.
Failure to Complete MDS Assessment for Resident Discharge
Penalty
Summary
The facility failed to complete a Minimum Data Set (MDS) 3.0 assessment as required when a resident self-initiated discharge from the facility. This deficiency affected one resident who was admitted with diagnoses including paraplegia, bipolar disorder, opioid dependence, and drug-induced constipation. The resident left the facility against medical advice and was administered methadone prior to departure. The resident later returned to the facility from a local hospital via ambulance on the same day. Upon review, it was found that the required discharge return not anticipated assessment and the subsequent entry assessment were not completed for the resident. An interview with the MDS nurse confirmed that these assessments were not conducted as required. The facility's policy and the Resident Assessment Instrument (RAI) manual specify that an OBRA Discharge assessment should be completed for unplanned discharges, such as when a resident leaves against medical advice, but this was not adhered to in this case.
Failure to Complete Timely PASRR Assessments for Residents
Penalty
Summary
The facility failed to ensure a valid Pre Admission Screen and Resident Review (PASRR) was completed timely for two residents, affecting their compliance with federal requirements. Resident #14, who was admitted with diagnoses including paraplegia, bipolar disorder, opioid dependence, and drug-induced constipation, did not have a PASRR assessment completed upon readmission to the facility after leaving against medical advice. This oversight was confirmed by the MDS Nurse, indicating a lapse in the required assessment process for residents with mental disorders or intellectual disabilities. Similarly, Resident #27, admitted with bipolar disorder, anxiety disorder, and opioid dependence, was initially exempt from PASRR requirements due to a hospital exemption for a stay of less than 30 days. However, the resident remained in the facility beyond the 30-day exemption period without a full PASRR assessment being conducted. This was verified by the Social Service Designee, highlighting a failure to adhere to the necessary assessment timeline for residents requiring extended care.
Failure to Update Care Plan for Wandering and Elopement Risk
Penalty
Summary
The facility failed to update the care plan for Resident #148 to address her wandering behaviors and potential for elopement. Resident #148, who was admitted with schizophrenia and cognitive delay, was identified as being at high risk for elopement due to her ambulatory status and mental health condition. Despite this, her care plan did not include measures for wandering or elopement prevention. This oversight was noted during a review of her medical records and care plan. An incident occurred where Resident #148 wandered off the patio during a supervised smoke break, necessitating staff intervention to redirect her back inside. Following this event, a wanderguard was placed on her ankle, and staff were instructed to check on her every 15 minutes. However, these measures were not reflected in her care plan. The Regional Director of Clinical Services confirmed the absence of a care plan addressing these risks, highlighting a deficiency in the facility's care planning process for this resident.
Failure to Implement Pharmacy Recommendations for Residents
Penalty
Summary
The facility failed to act on pharmacy recommendations for two residents, leading to deficiencies in medication management. For Resident #36, the pharmacy recommended a dose reduction of Hydroxyzine, blood level monitoring for magnesium and thyroid hormones, and a change in administration times for Levothyroxine and magnesium to prevent absorption interference. Despite these recommendations being agreed upon and signed by the nurse practitioner or physician, there was no evidence that the necessary actions were taken, such as ordering or drawing the recommended blood levels, reducing the Hydroxyzine dose, or adjusting the medication administration times. Similarly, for Resident #11, the pharmacy recommended discontinuing Diphenhydramine, which was agreed upon by the nurse practitioner. However, the medication was not discontinued as recommended. The Director of Nursing confirmed these findings during interviews, indicating a lapse in following through with accepted pharmacy recommendations, affecting the quality of care provided to the residents.
Failure to Monitor INR Levels Before Warfarin Administration
Penalty
Summary
The facility failed to appropriately monitor and report relevant lab values before administering Warfarin to a resident, leading to a significant medication error. The resident, who had a history of antiphospholipid syndrome, systemic lupus, and venous thrombosis, was on a regimen that required regular INR lab draws to monitor Warfarin effectiveness. Despite an active order for INR lab draws every Monday, Wednesday, and Friday, and the requirement to report these results to the medical provider, the INR result from 01/03/25 was not communicated to the practitioner until 01/05/25. During this period, the resident continued to receive Warfarin, even though the INR value was above the therapeutic range, indicating a risk of excessive anticoagulation. The resident expressed concern about the lack of communication regarding her INR levels and the continued administration of Warfarin despite elevated INR values. The Assistant Director of Nursing, who administered the Warfarin on 01/03/25, assumed the INR was within acceptable limits due to a lack of reported concerns from the previous shift. The Director of Nursing confirmed that Warfarin should have been held from 01/03/25 until the INR returned to normal limits. This oversight placed the resident at risk for complications associated with excessive anticoagulation.
Improper Storage of Controlled Medications
Penalty
Summary
The facility failed to ensure that controlled medications were stored in a separately locked and permanently affixed compartment, affecting two residents who were prescribed Methadone, a Schedule 2 medication with a high potential for abuse. During an observation of medication administration for one resident, it was noted that the Methadone was stored in a black box inside the medication cart that was not permanently affixed or separately locked. The box's lid, which was supposed to lock automatically, was not fully closed, allowing the nurse to remove the Methadone without unlocking it. This was confirmed by an LPN present at the time. In another instance, the Methadone for a second resident was observed to be stored in a similar locked black box that was also not permanently affixed to the cart. This finding was confirmed by another LPN. The facility's medication storage policy, dated 2001, did not specify how controlled medications should be stored, contributing to the deficiency.
Inaccurate and Incomplete Medical Records for Laboratory Findings
Penalty
Summary
The facility failed to maintain accurate and complete medical records for two residents, specifically regarding laboratory findings. Resident #11, who was admitted with diagnoses of dementia, schizophrenia, and insomnia, had a physician order for a Depakote laboratory test dated 09/26/24. However, upon review, there were no laboratory results recorded in the resident's medical record after 07/11/24. This discrepancy was confirmed during an interview with an LPN, who subsequently accessed the laboratory website to retrieve and print the missing results for the resident's medical record. Similarly, Resident #24, admitted with diagnoses including cognitive communication deficit, dementia, and hypertension, had a physician's order for Valproic Acid laboratory testing every three months. The review of the resident's medical record revealed an absence of laboratory results after 07/09/24. This was verified by the same LPN, who then logged onto the laboratory company's website to print the missing results, which should have been included in the resident's paper chart. These omissions in maintaining up-to-date laboratory results in the residents' medical records highlight a deficiency in the facility's record-keeping practices.
Environmental Deficiencies in Facility
Penalty
Summary
The facility failed to maintain a safe, functional, sanitary, and comfortable environment for its residents, as evidenced by multiple observations during a tour with the Administrator. The elevator, a primary means of transport for residents, had a dirty and worn carpet. The 100 wing had a buildup of dirt along the baseboards, and several resident rooms had issues such as chipped paint, dirt and debris buildup, and dust accumulation. Specific rooms had additional problems, such as cracked showers, bubbled carpets posing trip hazards, and rusted door jams with peeling paint. These deficiencies were confirmed by the Administrator during the observations. Further issues were noted, including a broken window in the common area covered with plywood, which had not been repaired for a week. The 100 hall had multiple unpainted wall patches. The resident Concern/Complaint log revealed multiple complaints about housekeeping and room cleanliness. The facility's policy on maintaining a homelike environment emphasized cleanliness and order, which was not upheld. These deficiencies were identified during the investigation of several complaint numbers.
Inadequate Supervision and Unsafe Smoking Practices
Penalty
Summary
The facility failed to ensure adequate supervision and safe maintenance of smoking materials for a resident identified as a smoker. The resident, who had a traumatic brain injury and hemiplegia, was found to have been smoking in their room, contrary to the facility's smoking policy which permits smoking only in designated outdoor areas. Despite having intact cognition and requiring only setup assistance for personal hygiene, the resident was non-receptive to re-education on the smoking policy and continued to smoke in their room. Observations revealed that the resident had a small plate used as an ashtray with cigarette butts and a lighter on the windowsill, with the window partially open and the screen torn. The resident admitted to smoking in the room and refused to turn in cigarettes, despite being previously caught and educated on the policy. The care plan for the resident noted behavior problems related to hiding cigarettes and smoking in the room but lacked interventions to address these behaviors. This deficiency was identified during a complaint investigation.
Insufficient Dietary Staffing Leads to Delayed Meal Service
Penalty
Summary
The facility failed to provide sufficient support personnel to effectively carry out the functions of food and nutrition services, potentially affecting all 49 residents receiving meals from the kitchen. The facility's assessment indicated that food and nutrition services were overseen by a full-time dietary manager and a contracted dietitian, with a staffing plan that included one full-time dietary manager, a part-time dietitian, five full-time food service workers, and three part-time food service workers. However, the dietary services schedule revealed inconsistencies in staffing, with fewer part-time employees scheduled than planned. Interviews with residents indicated delays in meal service, with breakfast being served late on some days. Further interviews revealed that dietary staff did not stay over to the next shift due to a lack of pay incentives, leading to nurse aides working in the kitchen without adhering to all food production protocols. The Regional Culinary Director confirmed that nurse aides filled in when the dietary department was short-staffed. Additionally, the Dietary Manager was off for six weeks due to surgery, and the facility did not adjust the schedule to cover her absence, resulting in a cook working double shifts. The facility's policy stated that adequate staffing should be provided to meet the needs of the resident population, but this was not adhered to, leading to the identified deficiency.
Kitchen Sanitation and Food Storage Deficiencies
Penalty
Summary
The facility failed to maintain a clean and sanitary kitchen environment, which had the potential to affect all 49 residents receiving meals. During an initial kitchen tour, several issues were observed, including debris and grime on the kitchen floor, and improperly stored food items in the dry food storage area. Specific concerns included opened and undated bread, confection sugar not sealed or dated, and a box of sugar stored in an open cardboard box with a scoop inside. Additionally, chicken gravy packets were undated, and a 50-pound bag of long grain rice was unsealed with a scoop stored inside. The dry food storage floor also had dried onion peel debris with a bug crawling through it. Further observations revealed food debris under the shelving in the dairy walk-in cooler and a thin layer of ice buildup on the freezer floor, with a large buildup of ice on the ceiling. Undated open plastic bags of country fried steak and hush puppies were also found in the freezer. The Regional Culinary Director confirmed these areas of concern at the time of observation. The facility's policy on food storage, which was undated, stated that food should be stored and prepared according to professional standards to prevent contamination, using metal or plastic containers with tight-fitting covers for bulk foods, and all containers must be accurately labeled.
Facility Fails to Maintain Safe Laundry Equipment
Penalty
Summary
The facility failed to maintain its commercial laundry machines in safe operating condition, affecting all 49 residents. On June 13, 2024, the large Unimac commercial laundry machine lost power and stopped working due to wiring issues, as advised by a repair technician. The small Unimac commercial washing machine was also out of service until June 14, 2024, when it was repaired. However, the facility had no backup commercial laundry machine available, leading to the maintenance supervisor transporting soiled laundry to a sister facility for cleaning. The Director of Maintenance confirmed that the small machine had been out of use since January 2024 due to a missing part, and the large machine was not in use following the technician's advice. Interviews with staff revealed that the Director of Nursing noted delays in returning residents' clothing due to the broken washing machine. The Administrator was unaware of the small machine's repair needs at the time. A review of the facility's sales and security agreement indicated that the slab under the large machine was moving and had come free, prompting a recommendation to replace the machine. The facility's maintenance policy, dated December 2009, stated that maintenance service would be provided to all areas of the building, grounds, and equipment. This deficiency was investigated under Complaint Number OH00154970.
Inadequate Linen Supply Affects Resident Care
Penalty
Summary
The facility failed to ensure an adequate supply of clean towels and washcloths for resident care, affecting 31 out of 49 residents. During an environmental tour, it was observed that the clean linen rooms on units 200 and 300 were inadequately stocked, with unit 200 having no clean towels or washcloths and unit 300 having only a few available. Interviews with staff, including a Regional Director, State Tested Nurse Assistants, and a Registered Nurse, confirmed the shortage of linens, which impacted resident care, including missed shower days. A resident reported feeling terrible about missing a shower due to the lack of available towels. The Laundry Aid mentioned that budget constraints limited the ordering of necessary linens, and the Central Supply Supervisor noted that supplies were ordered only as needed without established par levels. The Housekeeping Supervisor stated that linen par levels should be double the resident census, but orders required corporate approval. The facility's policy emphasized providing a safe, clean, and homelike environment, which includes maintaining adequate linen supplies, but this was not adhered to, leading to the identified deficiency.
Failure to Provide Resident Access to Personal Records
Penalty
Summary
The facility failed to ensure that a resident and their legal representative had access to personal records upon request, affecting one resident out of four reviewed for resident rights. The resident, who had intact cognition, was admitted with multiple medical diagnoses and had appointed a family member as their Power of Attorney (POA). Despite a signed request for the release of health information, the facility did not provide the resident's personal documents, including a birth certificate, social security card, state identification card, and military discharge papers, which were reportedly held in the former social worker's office. The resident and their POA requested these documents prior to discharge, but the facility's administrator refused to provide them. Interviews revealed that the facility lacked a standard procedure for receiving and storing resident information, leading to the misplacement of important documents. The Ombudsman reported an open misappropriation case against the facility due to the missing documents and poor communication with the resident's family member. The former social worker confirmed that the documents were to be returned upon request, but the administrator did not comply. The facility's policy stated that resident records should be safeguarded and released upon a written request, which was not honored in this case.
Failure to Maintain Kitchen Cleanliness and Proper Food Storage
Penalty
Summary
The facility failed to maintain the kitchen in a clean and sanitary manner and did not ensure that foods were stored to prevent contamination and spoilage. During a tour of the kitchen, it was observed that the oven hood suppression system was coated in a layer of brown and black grease, and the grease collection area was coated in thick, chunky grease. In the walk-in refrigerator, several food items were found to be improperly stored: lettuce was significantly brown and past its best buy date, a bag of carrots was opened and past its best buy date, a bag of pepperoni was open and undated, and various other food items were undated and uncovered. In the walk-in freezer, a bag of omelettes and a bag of cream puffs were open and undated. These findings were confirmed by a cook during the tour. The facility's policy on food storage, which was undated, stated that food should be stored, prepared, and transported at appropriate temperatures and by methods designed to prevent contamination.
Laundry Area Maintenance Deficiency
Penalty
Summary
The facility failed to maintain the laundry area in a clean, safe, and sanitary condition, potentially affecting all 43 residents. Observations revealed that the area behind two industrial-sized washers was covered in lint, and the power cords were encased in lint debris. Additionally, a household-sized dryer had a ventilation system held together with dry wall spackle. The ceiling tiles in the laundry room were significantly water-stained, with one tile above the clean linen area being brown in color and sagging down multiple inches. These findings were confirmed by the Laundry Director during the observation.
Failure to Conduct Annual Performance Reviews for STNAs
Penalty
Summary
The facility failed to ensure that state tested nurse aides (STNAs) received a performance review at least every 12 months as required. This deficiency was identified during a review of personnel files and staff interviews. Specifically, the personnel file for STNA #201, who was hired on 07/01/22, lacked evidence of a performance review completed every 12 months. This issue was confirmed during an interview with the Human Resource Director (HRD) on 05/13/24. The deficiency had the potential to affect all 43 residents residing in the facility, as it was found in one of two STNA personnel files reviewed that were employed for more than one year at the facility.
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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