Three Meadows Post Acute
Inspection history, citations, penalties and survey trends for this long-term care facility in Perrysburg, Ohio.
- Location
- 10540 Fremont Pike Rd, Perrysburg, Ohio 43551
- CMS Provider Number
- 365535
- Inspections on file
- 38
- Latest survey
- March 12, 2026
- Citations (last 12 mo.)
- 13 (1 serious)
Citation history
Health deficiencies cited at Three Meadows Post Acute during CMS and state inspections, most recent first.
Surveyors found that medication carts on two different floors were left unattended and unlocked near nurses’ stations on separate occasions, and LPNs on each floor confirmed the carts had been left in this condition. The facility’s written policy required all medications to be stored in locked compartments, but this was not followed, creating a situation in which medications on the first and second floors were not secured for the majority of residents, excluding those on a secured memory care unit.
An unattended medication cart laptop at the nurses’ station was left open to a cognitively intact resident’s electronic record, displaying PHI including the resident’s photo, name, gender, room number, date of birth, code status, allergies, and recent vital signs. The cart and laptop were unattended in a common area, allowing anyone passing by to view the information. An LPN confirmed the laptop was left open with visible PHI, despite a facility policy assigning staff responsibility to prevent unauthorized disclosure of PHI.
Two residents receiving high-contact care did not have appropriate infection prevention measures followed. One resident with multiple chronic conditions and a foot wound had wound care performed by an LPN who began care without a gown and later changed gloves without performing hand hygiene, despite EBP and wound care orders requiring gown, gloves, and hand hygiene. Another resident with an indwelling urinary catheter and bowel incontinence received catheter and perineal care from two CNAs who did not perform hand hygiene before donning PPE, during glove changes, or after removing gowns and gloves, contrary to facility hand hygiene and catheter care policies.
A resident on hospice with multiple diagnoses, including hearing loss, had documented moderate hearing difficulty and a care plan addressing hearing deficits, and later signed consent requesting an audiology consultation due to a new hearing deficit and decreased responsiveness. Despite this, the resident was never scheduled or seen by an audiologist for an extended period, could not hear normal conversation, and reported having no hearing aids or ear evaluation since admission. Facility leadership and the LSW confirmed the resident was omitted from the audiology list, missed a scheduled visit, and was affected by provider issues that left her without timely access to audiology services.
A resident with multiple neuro and psychiatric diagnoses, a history of repeated falls, and intact cognition was care-planned as a fall risk with interventions including assisted transfers, room arrangement for safe transfers, and non-skid strips between the bed and bedside commode. After the resident was found on the floor, staff initiated neuro checks per protocol, but documentation showed the ordered frequency (q15 min, then q30 min, then hourly, then each shift) was not followed, as confirmed by the DON. Later observation and interviews revealed that non-skid strips were not present next to the bed or commode despite being a care-planned intervention, and both the resident and rehab leadership confirmed that skid strips were expected and beneficial for safe transfers.
A resident with COPD, respiratory failure, OSA, and heart failure required oxygen therapy and CPAP support, but the facility did not ensure that provider orders were accurately obtained and followed. The care plan called for continuous oxygen at 2 L/min, while NP documentation specified PRN oxygen to maintain O2 saturation above 90% and use of CPAP during sleep, yet the medical record contained only a continuous oxygen order and no PRN oxygen or CPAP orders. The resident was not using CPAP for a period due to a broken mask, and although the DON reported frequent refusals, there was no documentation of these refusals. The NP and DON both could not account for the origin of the continuous oxygen order, and the facility’s oxygen and CPAP/BiPAP policies were not consistently implemented for this resident.
A resident with COPD, respiratory failure, CHF, CKD stage 3, and dysphagia, who required continuous O2 and extensive assistance with ADLs, had a physician order for daily Fluticasone Furoate-Vilanterol inhalation for COPD. During a medication pass observation, surveyors found that the ordered inhaler was not available, and an LPN confirmed its absence. This failure occurred despite a facility policy requiring medications to be administered in accordance with prescriber orders and time frames.
A resident with multiple comorbidities and severe cognitive impairment developed an unstageable pressure ulcer beneath an ankle monitoring device due to lack of timely assessment, inadequate monitoring, and failure to implement physician-ordered interventions. The wound deteriorated, with delayed wound culture and vascular consult, and incomplete documentation of care. The resident was ultimately hospitalized with severe complications, including infection and amputation.
A resident with severe cognitive impairment and multiple comorbidities experienced a change in condition, leading to new physician orders for diagnostic tests and IV fluids. While the family was informed of some new orders and pending consults, there was no documentation that the resident's representative was notified of x-ray results, nor that the physician was informed when IV fluids were not administered as ordered. An LPN confirmed the lack of documentation for both the unsuccessful IV attempt and physician notification.
A resident with a surgical wound did not receive wound care as ordered by the physician, despite documentation indicating otherwise. The resident reported that the dressing change was missed and had to request dressing changes for her PICC line. Observation confirmed the wound dressing was not changed as scheduled, and the ADON verified the lapse in care and documentation.
A resident with a history of constipation and multiple comorbidities went six days without a documented bowel movement, despite being at risk and having physician orders for bowel medications. The facility did not accurately document bowel movements, failed to follow its bowel management protocol, and did not ensure timely assessment or physician notification, as confirmed by staff interviews and record review.
Two residents experienced incomplete and inaccurate medical documentation related to the use of ankle monitors and compression stockings. Staff documented checks and interventions that were not performed as ordered, failed to record refusals of care, and were unaware of how to properly check device function. Family and staff interviews confirmed discrepancies between documentation and actual care provided, including a wound caused by an ankle monitor and frequent refusal of compression stockings.
Two nurses provided wound care to a resident with multiple complex medical conditions without donning gowns, despite clear signage and facility policy requiring enhanced barrier precautions (EBPs) for high contact care. Both nurses confirmed their awareness of the requirement but did not follow it, resulting in direct contact between their uniforms and the resident during treatment.
A resident with multiple comorbidities and existing wounds developed a new, facility-acquired unstageable pressure ulcer on the heel due to the lack of documented shift skin checks and failure to assess skin under offloading boots, despite care plan interventions. The wound progressed and required surgical debridement, with no evidence of ongoing assessment or adjustment of interventions by staff or nursing leadership.
A resident who was dependent on staff for most activities of daily living and had multiple medical conditions was found to have their call light out of reach, both on the floor and after being repositioned by CNAs. Staff confirmed the call light was not accessible to the resident during these observations, indicating a failure to reasonably accommodate the resident's needs.
Two residents with multiple chronic conditions were found to have unclean room environments, including spilled popcorn, trash, and sticky floors, which persisted for several hours and caused discomfort to the residents. Both residents, who were cognitively intact, expressed their dissatisfaction, and an LPN confirmed the observations.
A resident with anxiety and depression was prescribed and administered both antidepressant and antianxiety medications, but there was no evidence that staff monitored for behaviors, efficacy, or adverse effects as required by facility policy. Staff and administrative interviews confirmed the lack of documentation and monitoring for these psychotropic medications.
A resident with multiple medical conditions and a documented goal to return home was not kept informed or involved in discharge planning, resulting in a lack of coordination and communication about their discharge status. The resident was listed as a permanent placement without being notified, and the medical record lacked documentation of ongoing involvement or updates regarding discharge planning.
A resident with dementia, impaired mobility, and a history of falls was care planned to require two staff for bed mobility and toileting. Despite this, a CNA provided incontinence care alone, resulting in the resident rolling off the bed and sustaining a skin tear. Facility staff confirmed that two-person assistance was required, but this intervention was not followed.
A resident with end-stage renal disease and multiple comorbidities required regular dialysis, but the facility did not ensure that communication forms were fully completed by the dialysis center on several occasions. There was no documentation that staff contacted the dialysis center to obtain the missing information or to check on the resident's status during treatments, despite a contractual requirement for documented collaboration and communication.
Multiple residents received medications outside of prescribed time frames, and one resident did not receive a scheduled dose due to medication unavailability. Staff confirmed that medications were not administered as ordered, resulting in a medication error rate significantly above acceptable standards.
Surveyors observed that medications were not administered as ordered or within the required time frames for three residents. In two cases, a nurse gave medications for conditions such as Parkinson's disease, hypertension, and depression outside the scheduled times. In another case, an LPN omitted a scheduled dose of Sacubitril-Valsartan because it was not available, administering only the remaining medications. Facility policy requires medications to be given within one hour of the prescribed time, which was not followed.
Two residents on pureed diets, including one with dysphagia and another in a vegetative state, were served pureed pears that were thin, watery, and contained chunks, contrary to the facility's diet manual requiring smooth and lump-free pureed foods. The dietary aide did not measure added liquid, and the dietary director confirmed the texture was inappropriate.
A CNA served a meal tray to a resident by placing it on an overbed table that also held a urinal containing urine. The CNA did not notice the urinal before placing the tray, resulting in a failure to maintain sanitary meal service standards.
A resident's medications, including Atorvastatin, Cranberry, and Gabapentin, were improperly left at the bedside by nursing staff, contrary to the facility's medication storage policy. The resident reported that medications were sometimes left on her table if she was sleeping, particularly by the night nurse for early morning doses. This incident was confirmed through observation and interviews, highlighting a failure to adhere to safe and secure medication storage practices.
A resident with a complex medical history received Metoprolol Succinate for hypertension despite their SBP being below the prescribed threshold. The medication was administered twice against physician orders, which required it to be given only if SBP was above 130. This error was confirmed by hospice staff and the DON, indicating non-compliance with the facility's medication administration policy.
A resident with quadriplegia and other conditions was transferred using a mechanical lift by a single STNA, contrary to the care plan and facility policy requiring two staff members. The incident was confirmed through observations and interviews with the involved parties.
A facility failed to provide timely incontinence care for a dependent resident with severe cognitive impairment and multiple diagnoses. The resident had not been checked or changed for incontinence since the start of the shift, despite the facility's policy requiring checks every two hours. The delay was attributed to high demand from other residents needing assistance.
A facility failed to provide timely incontinence care for a resident with severe cognitive impairment and multiple medical conditions due to inadequate staffing. The resident was found with a saturated incontinence brief and dried stool on the skin, having not been checked or changed for over five hours.
Unattended and Unlocked Medication Carts on Multiple Floors
Penalty
Summary
The facility failed to ensure medications were stored in locked compartments as required by facility policy and professional standards. During a complaint investigation, surveyors observed an unattended and unlocked medication cart next to the first-floor nurses’ station on 03/10/26 at 10:30 A.M., and the LPN present at that time confirmed the cart had been left unattended and unlocked. On the following day, 03/11/26 at 12:00 P.M., surveyors again observed an unattended and unlocked medication cart next to the second-floor nurses’ station, and the LPN on duty confirmed that this cart was also unattended and unlocked. The facility’s written policy, “Medication Labeling and Storage” dated February 2023, stated that all medications would be stored in locked compartments. This deficiency had the potential to affect all residents on the first and second floors, excluding 13 residents identified as residing on the secured memory care unit. These observations and staff confirmations demonstrated that the facility did not follow its own policy or accepted professional principles for secure medication storage, resulting in medication carts being left unlocked and unattended on two separate floors during the survey period.
Unattended Laptop Exposed Resident PHI at Nurses’ Station
Penalty
Summary
The deficiency involved a failure to keep a resident’s protected health information (PHI) private and confidential when an unattended medication cart laptop was left open and visible in a common area. The resident involved had multiple medical diagnoses including respiratory failure, heart disease, atrial fibrillation, pulmonary hypertension, peripheral venous insufficiency, a history of falling, and transient ischemic attacks, and was cognitively intact, used a wheelchair, and required maximal to dependent assistance with ADLs per a recent MDS assessment. During observation at the second-floor nurses’ station, surveyors noted the laptop on the medication cart was left open to the landing page for this resident, displaying PHI such as the resident’s photo, name, gender, room number, date of birth, code status, allergies, and most recent vital signs, and the cart and laptop were unattended, making the information viewable to anyone passing by. An LPN confirmed that the laptop was unattended and that PHI for the resident was visible, and review of the facility’s PHI policy showed that facility personnel were responsible for preventing unauthorized disclosure of PHI; this issue was identified as an incidental finding during a complaint investigation.
Failure to Follow Enhanced Barrier Precautions and Hand Hygiene During High-Contact Care
Penalty
Summary
The deficiency involves the facility’s failure to follow its infection prevention and control program, specifically enhanced barrier precautions (EBP) and hand hygiene, during high-contact care for two residents. For one resident with multiple chronic conditions, including stage four chronic kidney disease, osteoporosis, GERD, dysphagia, cognitive communication deficit, and muscle wasting, the quarterly MDS showed cognitive impairment and a need for maximal to dependent assistance with mobility, transfers, and ADLs. Physician orders required EBP for high-contact care, including dressing changes, and nightly wound care to a right foot digit. During observed wound care, an LPN began care by removing the resident’s sock without wearing a gown, left the room, then returned with a gown and gloves. The LPN removed the sock, then removed and replaced gloves without performing hand hygiene, and continued wound care. The LPN confirmed she started wound care without a gown and did not perform hand hygiene after glove removal, and was unsure if she should have, despite facility policies requiring hand hygiene during wound care after glove removal and use of gown and gloves for high-contact care under EBP. For a second resident admitted with traumatic subdural hemorrhage, malignant neoplasm of the right kidney, hypovolemic shock, syncope, and a history of falls, the admission MDS showed cognitive intactness and a need for moderate to maximal assistance with ADLs and maximal assistance for transfers. The resident had an indwelling urinary catheter for urinary retention, was bowel incontinent, and was dependent for toileting hygiene and catheter cleansing. Physician orders required EBP for high-contact care and catheter care every shift. During observed catheter care and perineal hygiene, two CNAs did not perform hand hygiene before donning gowns and gloves. One CNA changed gloves during catheter care without performing hand hygiene, and at the end of care the other CNA removed her gown and gloves and left the room without performing hand hygiene. Both CNAs confirmed they did not perform hand hygiene before, during, or after providing catheter care, despite facility policies requiring handwashing before and after perineal hygiene and immediately after glove removal.
Failure to Provide Timely Audiology Services for Resident With Hearing Deficit
Penalty
Summary
The facility failed to ensure timely access to audiology services for a hospice resident with documented hearing loss and identified hearing concerns. The resident was admitted with multiple diagnoses, including unspecified hearing loss, and an MDS showing moderate difficulty hearing while remaining cognitively intact. Her care plan included interventions for a hearing deficit, such as getting her attention before speaking, facing her in good light, and minimizing background noise. An ancillary services consent form, signed several months after admission, documented a request for an audiological consultation due to a new hearing deficit and decreased responsiveness. The hospice agreement sample indicated that the facility was responsible for providing facility services at the same level of care as before hospice election and in compliance with applicable regulations. Despite the documented need and consent for audiology services, the resident was not seen by an audiologist during her stay up to the time of the survey. Observation showed she could not hear an introduction from the foot of the bed, appeared frustrated, and stated she could not hear unless someone came very close and spoke loudly. She reported she did not have hearing aids, had not seen anyone about her ears since admission, and knew she needed her ears checked before getting help for her hearing. The Administrator, DON, and LSW confirmed the resident had not been seen by an audiologist, explaining she was not placed on the list when first admitted, was omitted from the March audiology schedule after signing consent, and that there were subsequent issues with the provider not having an audiologist in the area while the facility transitioned to a new provider.
Failure to Complete Post-Fall Neuro Checks and Implement Care-Planned Fall Interventions
Penalty
Summary
The deficiency involves the facility’s failure to complete ordered post-fall neurological assessments and to implement care-planned fall interventions for a resident at risk for falls. The resident had multiple diagnoses including neuroleptic-induced Parkinsonism, hemiplegia and hemiparesis after cerebral infarction, bipolar disorder, anxiety disorder, repeated falls, adrenocortical insufficiency, and chronic kidney disease stage 3B, and had intact cognition with a BIMS score of 14. The care plan identified the resident as at risk for falls related to altered mental status, use of antidepressant and antipsychotic medications, history of falls, unsteady gait, poor safety awareness, and noncompliance, with interventions such as assisting with all transfers and mobility, arranging the room for ease of transfers, and placing non-skid strips between the bed and the bedside commode. After the resident was found on the floor on 11/23/25, staff assisted the resident to a chair, educated the resident on call light use and not ambulating without assistance, and initiated neurological checks per protocol. However, review of the neurological check documentation showed that the ordered schedule of every 15 minutes for one hour, every 30 minutes for two hours, every hour for two hours, and then every shift for 72 hours was not followed. On 11/23/25, checks were not completed every 15 minutes as required and were only documented at 1:30 p.m., 1:45 p.m., and 2:10 p.m., and subsequent checks were not completed every 30 minutes, but instead at 3:00 p.m., 5:00 p.m., 9:00 p.m., and 11:00 p.m. The DON confirmed that staff did not follow the neurological check protocol. In addition, observation of the resident’s room revealed there were no skid strips next to the bed leading to the bedside commode, despite the care plan intervention for non-skid strips between the bed and commode. The resident reported that skid strips helped prevent slipping during transfers and that none had been in place since a bedside mat was removed on 01/30/25. The Director of Rehabilitation stated that skid strips should be in front of the bedside commode and directly next to the bed, and the DON verified that no skid strips were present, indicating that the care-planned fall prevention intervention was not implemented.
Failure to Follow Orders for Oxygen Therapy and CPAP Use
Penalty
Summary
The deficiency involves the facility’s failure to follow physician and NP orders for oxygen therapy and CPAP use for a resident with significant respiratory and cardiac conditions. The resident had diagnoses including acute and chronic respiratory failure with hypoxia and hypercapnia, COPD, congestive heart failure, chronic kidney disease, and dysphagia, and required continuous oxygen per the care plan at 2 L/min via nasal cannula. The care plan also included interventions such as educating the resident on keeping oxygen on at the prescribed setting, maintaining the head of bed elevated, and reporting signs of hypoxia. However, documentation and orders were inconsistent with the NP’s stated intent that oxygen should be used on an as-needed basis to maintain oxygen saturation above 90%, not as continuous oxygen. Pulmonology after-visit documentation indicated the resident had OSA and was to resume CPAP at 15 cm H2O when available, noting the resident had been more short of breath at night while not on oxygen and that the CPAP machine had malfunctioned and a new machine had been ordered months earlier. Despite this, there were no physician orders in the record from November through February for CPAP at 15 cm H2O, and the resident was not using CPAP as ordered by the pulmonologist. The resident reported not using the CPAP because the mask was broken, although a new mask was later obtained, and the DON confirmed the resident had a CPAP machine but the face mask was broken and being replaced. The DON also stated the resident frequently refused CPAP, but there was no documentation of refusals in the record. NP progress notes on multiple dates documented that the resident should wear CPAP at night and with naps, and that staff should monitor oxygen saturation and provide oxygen at 2 L/min as needed to keep saturation above 90%. The NP stated that staff sometimes requested oxygen for the resident and she would give verbal orders for PRN oxygen at 2 L/min for shortness of breath or oxygen saturation below 90%. However, review of physician orders for December, January, and February showed only an order for continuous oxygen at 2 L/min and no PRN oxygen order matching the NP’s plan. Both the DON and NP were unsure of the origin of the continuous oxygen order dated in late November, and the facility’s own policies required verification of a physician order for oxygen administration and outlined procedures for CPAP/BiPAP support that were not reflected in the documented orders and implementation for this resident.
Ordered COPD Inhaler Not Available for Resident
Penalty
Summary
Surveyors identified a deficiency in the facility’s failure to ensure that prescribed medication was available for a resident. The resident, admitted on 02/17/22, had diagnoses including acute respiratory failure with hypercapnia, acute and chronic respiratory failure with hypoxia, COPD, acute on chronic diastolic congestive heart failure, chronic kidney disease stage three, and dysphagia. A quarterly MDS dated 01/23/26 documented that the resident had intact cognition, was dependent on staff for ADLs and eating, used a motorized wheelchair, required a mechanical lift for transfers, and was frequently incontinent of bowel and bladder. The plan of care dated 12/01/25 indicated the resident required continuous oxygen related to acute respiratory failure, COPD, pneumonia, and shortness of breath while lying flat, with interventions including administering oxygen at 2 L/min, educating the resident on oxygen use and settings, maintaining the head of bed elevated, and reporting signs of hypoxia. Review of physician’s orders for February 2026 showed that on 02/05/26 the resident had an order for Fluticasone Furoate-Vilanterol Inhalation Aerosol Powder Breath Activated 100-25 mcg per actuation, one puff inhaled orally once daily for COPD. During observation of medication administration on 02/17/26 at 9:41 A.M., surveyors found that the facility did not have the resident’s ordered Fluticasone Furoate-Vilanterol inhaler available. An interview with an LPN confirmed that the inhaler was not available for the resident. Facility policy titled “Administering Medications” dated 04/2019 stated that medications are to be administered in accordance with prescriber orders, including any required time frame. The lack of availability of the ordered inhaler constituted non-compliance with this policy and with the requirement to provide pharmaceutical services to meet each resident’s needs.
Failure to Prevent and Manage Pressure Ulcer Resulting in Severe Harm
Penalty
Summary
A deficiency occurred when the facility failed to provide timely assessment, ongoing monitoring, and appropriate interventions to prevent the development of a pressure ulcer for a resident with arterial and venous insufficiency who was identified as being at risk for pressure ulcers. The resident, who had severe cognitive impairment, immobility, and multiple comorbidities including diabetes and peripheral vascular disease, was found with an unstageable pressure ulcer on the right malleolus beneath an ankle monitoring device. There was no immediate wound assessment, no documentation of interventions regarding skin monitoring under the ankle monitor, and no evidence that the ankle monitor had been removed. The care plan did not include interventions to monitor the skin under the ankle monitor, and physician orders for the device did not specify skin checks. The wound was not accurately assessed or measured at the time it was discovered, and there was no documentation of family or physician notification. Following the identification of the pressure ulcer, there was a lack of timely and appropriate follow-up. The wound was not assessed by a physician on the day it was found, and wound care orders were not initiated until the following day. There was no documentation that the dietitian was notified or that the resident's nutritional status was reassessed in response to the new wound. As the wound deteriorated, recommended interventions such as the use of offloading heel boots were not documented as being implemented, and a wound culture was delayed. Orders for a vascular consult and laboratory testing were not promptly carried out, and there was no documentation that the physician was notified when intravenous fluids were not administered as ordered. The resident's wound continued to worsen, showing signs of infection, and ultimately required hospitalization. The resident was admitted to the hospital with a wound infection, septic arthritis, osteomyelitis, and severe hypoglycemia. Hospital records indicated the need for intravenous antibiotics, wound debridement, negative pressure wound therapy, and ultimately an above-the-knee amputation. Throughout the period leading up to hospitalization, there were multiple missed opportunities for timely intervention, monitoring, and communication among staff, providers, and family. Documentation was incomplete regarding the implementation of physician orders, wound care interventions, and monitoring of medical devices in contact with the resident's skin.
Removal Plan
- The Administrator immediately notified Physician #600, the Interim Medical Director.
- Unit Manager Licensed Practical Nurse (UMLPN) #108 conducted a thorough assessment on Resident #05 with no adverse effects noted.
- Registered Dietitian (RD) #100 completed a nutritional reassessment for Resident #05 and updated nutritional interventions by adding an additional nutritional supplement with all meals.
- The DON and UMLPN #108 reviewed Resident #05's wound care regimen to ensure it was updated per current physician orders.
- UMLPN #108 reviewed and evaluated Resident #05's medical devices (heel boot) for proper fit and skin protection measures.
- The DON implemented an enhanced turning and repositioning schedule for Resident #05 with documentation every two hours.
- The DON and ADON #114 reviewed Resident #05's pressure redistribution surfaces as indicated by the current risk assessment.
- The DON reviewed Resident #05's current skin care plan.
- The ADON #114 reviewed the Certified Nursing Assistant's charting documentation tasks to ensure accuracy.
- The DON/designee conducted audits for all residents to identify those at risk for pressure ulcer development, with focus on residents with ankle monitoring devices or other medical devices in contact with skin. Each identified at risk resident received immediate reassessment of current interventions and implementation of enhanced monitoring protocols.
- The DON identified one current resident (#51) with an ankle monitoring device and implemented skin monitoring checks each shift.
- The DON/designee identified 33 residents with medical devices and implemented enhanced orders for skin monitoring each shift.
- The DON/designee identified 10 residents with existing pressure ulcers or a history of pressure ulcers and implemented enhanced skin monitoring orders for nurses to complete visual skin checks on shower/bath day along with a daily comprehensive skin evaluation.
- The DON/designee identified 14 residents with vascular insufficiency or other circulatory conditions and implemented enhanced monitoring orders for nurses to complete visual skin checks on shower/bed bath day.
- The DON/designee identified 34 residents at moderate to high risk of skin breakdown and implemented enhanced monitoring orders for nurses to complete visual skin checks on shower/bed bath day.
- The DON, the Administrator, and ADON #114 conducted a root cause analysis identifying contributing factors including: insufficient knowledge of ankle monitoring skin monitoring protocols, lack of standardized skin inspection procedures for medical devices, insufficient communication systems for reporting skin changes, and absence of structured investigation process for new pressure ulcers.
- The DON/designee started education for all nurses and certified nursing assistants on pressure ulcer prevention, medical device skin safety, skin and wound assessment and documentation training with emphasis on timely reporting. Nurses were also re-educated on implementation of physician orders. Education to be completed.
- The Administrator and ADON #114 reeducated RD #100 on the position job description and the importance of reassessing residents with skin integrity changes.
- The DON/designee implemented enhanced monitoring orders for nurses to complete visual skin checks on all residents on their shower/bed bath day. All new admissions will be evaluated to determine if they qualify for this classification.
- The DON/designee implemented a standardized pressure ulcer investigation form and process.
- The DON/designee implemented weekly wound care rounds with wound team participation.
- The Administrator and the Quality Assurance Team reviewed policies on medical devices with skin integrity, lab procedures and policies, and clinical documentation.
- The Administrator and Medical Director implemented new best practices on A Guide to Device Skin Inspection.
- The DON reviewed the new admission checklist and updated it to include obtaining physician orders for skin monitoring for new admissions with medical devices. The new admission checklist was implemented and put into effect.
- The Administrator notified MD #602 of Immediate Jeopardy.
- UMLPN #108 conducted a thorough skin assessment on Resident #51 with no adverse effects noted.
- The Administrator reeducated UMLPN #102 on job duties, manager role, chart review, wound care, accurate order entry, complete investigation, and follow through on all job duties.
- The facility held an ad hoc Quality Assurance and Performance Improvement (QAPI) meeting with the Administrator, Infection Preventionist/ADON #114, UMLPN #108, UMLPN #102, and Medical Director.
- The Administrator and Medical Director reviewed policies for laboratory procedures and clinical documentation. The reviewed policies were acceptable with no changes needed.
- RD #100 reviewed all residents with skin integrity changes for nutritional intervention needs.
- The Administrator/designee educated all staff on new best practices A Guide to Device Skin Inspection. Education was completed.
- The Administrator/Designee educated all nurses on laboratory communication and documentation. Education was completed.
- The DON/designee conducted a review of all residents with medical devices for skin integrity documentation. Ongoing monitoring will occur daily for five days, then five residents weekly for four weeks, then two residents monthly for two months with a completion date.
- Unit Managers/designee performed an audit of physician order implementation timeframes on all residents with new orders or order changes. Audits will continue daily for five days, then audit five residents weekly for four weeks, then audit two residents monthly for two months with a completion date.
- The DON/designee will audit random resident medical records to ensure pressure ulcer prevention interventions and skin assessments are in place as ordered. Audits by the DON/designee will continue with five random resident medical records per week for one month, then two random resident records per week for two months with a completion date.
- The DON/designee will conduct weekly audits on wound dressing changes to ensure timely treatments on five random residents for four weeks, then for five random residents monthly for two months with a completion date.
- All systemic changes would be reviewed monthly for three months by the Quality Assurance (QA) Team. The DON/designee would report monitoring plan results to the QAPI committee monthly. The QAPI committee would monitor on an ongoing basis until sustained compliance was achieved with quarterly reviews to assess effectiveness and make necessary adjustment to the monitoring plan frequency on demonstrated compliance rates.
- Staff who were not educated would not be scheduled to work until the education was completed.
Failure to Notify Resident Representative and Physician of Change in Condition and Treatment
Penalty
Summary
The facility failed to ensure that a resident's representative and physician were notified of changes in the resident's condition. Specifically, for a resident with multiple complex diagnoses including severe cognitive impairment, Alzheimer's disease, diabetes, and a history of falls and pressure ulcers, there was a documented decline in appetite, muscle tremors, and an elevated heart rate. The on-call physician was notified and ordered an EKG, x-ray, and laboratory tests. The x-ray was completed, and the family was later updated on the new orders and the resident's refusal of labs, as well as pending consults and potential IV fluid orders. However, there was no documentation that the resident's representative was notified of the x-ray results. Additionally, although a verbal order was given to start IV fluids and the resident agreed to the treatment, there was no documentation that the IV fluids were administered or that the physician was notified of the failure to administer them. The unit manager LPN confirmed the lack of documentation regarding both the unsuccessful IV attempt and physician notification. Facility policy required prompt notification of the attending physician for changes in treatment needs, but this was not followed in this instance.
Failure to Provide Surgical Wound Care per Physician Orders
Penalty
Summary
The facility failed to provide surgical wound care according to physician orders for one resident with a surgical wound. The resident had an order for wound care to the right upper quadrant mid abdomen, which included cleansing, applying skin prep, antibacterial dressing, and foam, to be changed three times per week on specific days and as needed. Documentation in the Treatment Administration Record indicated that wound care was completed on a specific date, but both resident interview and direct observation revealed that the dressing had not been changed as ordered. The dressing was found to be dated several days prior, and the resident reported that the nurse did not return to complete the dressing change after being asked. Additionally, the resident stated that she had to request weekly for her PICC line dressing to be changed, or it would not have been done. Review of nurses' notes showed no documentation that the resident refused wound care during the relevant period. The Assistant Director of Nursing confirmed that the wound dressing had not been changed as documented. Facility policy required wound care to be provided per physician orders and for the date and time of care to be documented in the medical record, which was not followed in this instance.
Failure to Follow Bowel Management Protocol and Timely Assessment
Penalty
Summary
The facility failed to ensure accurate documentation and appropriate follow-up for a resident with a known history of constipation who did not have a bowel movement for more than three days. Despite the resident being at risk for constipation due to decreased mobility and frequent pain medication use, there was no documentation that the bowel protocol was followed when the resident went six days without a bowel movement. The resident's care plan included interventions such as administering medications per physician orders and monitoring for complications of constipation, but the medical record showed that the resident frequently refused prescribed bowel medications, and there was no evidence of additional interventions or education regarding these refusals. Certified Nursing Assistants documented the absence of bowel movements, and the facility's electronic medical record system triggered alerts for no bowel movement over several days. However, there was no documentation that the physician or nurse practitioner was notified as required by facility policy, nor was there evidence of a timely nursing assessment, such as checking bowel sounds or providing additional interventions. Staff interviews confirmed that the process for tracking and responding to residents without bowel movements was not consistently followed, and there was confusion among staff regarding whether the resident had been placed on the no bowel movement list and whether appropriate notifications had occurred. The resident experienced a decline in condition, including increased pain, drooling, and greenish phlegm, which led to a nurse practitioner evaluation and subsequent hospital transfer. Hospital records did not indicate a bowel blockage, but the facility's failure to document bowel movements accurately, follow the bowel management protocol, and ensure timely assessment and notification contributed to the deficiency identified during the survey.
Incomplete and Inaccurate Medical Documentation for Resident Monitoring Devices and Interventions
Penalty
Summary
The facility failed to ensure that medical documentation was complete and accurate for two residents, which had the potential to affect all residents. For one resident with multiple complex diagnoses, including severe cognitive impairment and a history of falls, there were inconsistencies and omissions in the documentation of ankle monitor placement and compression stocking use. Physician orders specified the ankle monitor should be placed on the left ankle and checked for function and placement, but staff documented checks on the left leg while the device was actually on the right leg. There was no documentation of the device being moved, and staff were unaware of the conflicting orders. Additionally, staff documented daily application and removal of compression stockings, but interviews revealed the resident frequently refused them, and there was no documentation of these refusals. Family and staff interviews confirmed the resident often did not wear the stockings and that the ankle monitor caused a wound on the right ankle, which was not reflected in the records. For another resident with dementia and other chronic conditions, the care plan and physician orders required staff to check the placement and function of an ankle monitor on the right ankle every shift. However, review of the Treatment Administration Record showed missed documentation on several shifts. Furthermore, an LPN admitted to documenting that the function and placement of the ankle monitor were checked without actually knowing how to check the device's function. The device used to check the monitor's function was found without batteries, and the LPN was instructed on its use only after the deficiency was identified. Facility policy required that all services provided, progress toward care plan goals, and changes in condition be documented objectively, completely, and accurately in the medical record. Despite this, there were clear lapses in documentation, including failure to record refusals of care, inaccurate reporting of device placement, and incomplete or inaccurate documentation of required monitoring. These deficiencies were confirmed through record review, staff and family interviews, and direct observation.
Failure to Maintain Enhanced Barrier Precautions During Wound Care
Penalty
Summary
The facility failed to maintain enhanced barrier precautions (EBPs) during wound care for one resident who was identified as requiring these precautions. Observation revealed that two nurses provided wound care to a resident with multiple complex medical conditions, including an above-the-knee amputation, unstageable pressure ulcers, and a history of Methicillin susceptible Staphylococcus aureus infection. Despite a sign posted outside the resident's door indicating the need for gown and gloves during high contact care, both nurses did not don gowns while performing wound care. Their uniform tops came into direct contact with the resident during repositioning and treatment. Interviews with the involved nurses confirmed their awareness that the resident required EBPs during wound care and acknowledged that they had not worn gowns as required. Review of the facility's policy, revised in March 2024, specified that EBPs, including the use of gowns and gloves, are necessary during high contact care activities such as wound care to reduce the transmission of multidrug-resistant organisms. The failure to follow these precautions was identified through observation, record review, staff interviews, and policy review.
Failure to Provide Timely Pressure Ulcer Assessment and Prevention
Penalty
Summary
The facility failed to provide timely assessment, monitoring, and interventions to prevent the development of a pressure ulcer in a resident who was assessed at moderate risk for pressure ulcer development. The resident was admitted with multiple complex medical conditions, including a stage four sacral pressure ulcer, diabetes mellitus type II, congestive heart failure, and vascular ulcers. The care plan included interventions such as skin checks each shift, offloading of heels, use of heel suspension boots, and pressure redistribution mattresses. However, there was no documented evidence that skin checks were completed each shift as required by the care plan. Despite the presence of heel protector boots, the resident developed a new, in-house acquired unstageable pressure ulcer on the left lateral heel. The wound was first noted as a blister and later progressed to a stage three pressure ulcer requiring surgical debridement and ongoing wound care. There was no documentation of ongoing assessments to determine the causative factors of the wound or to evaluate the need for changes in pressure reduction interventions. Staff interviews confirmed that no further evaluation occurred to determine the origin of the wound, and there was no evidence that the skin under the offloading boots was assessed each shift. The Director of Nursing confirmed that the required skin assessments were not documented, and the resident was not assessed as high risk for pressure ulcer development despite significant risk factors and existing wounds. The facility's clinical protocol required monitoring and physician guidance when wounds were not healing or new wounds developed, but this was not followed in the case of this resident.
Call Light Accessibility Not Ensured for Dependent Resident
Penalty
Summary
A deficiency was identified when a resident with diagnoses of venous insufficiency, multiple sclerosis, and osteoporosis, who was cognitively intact but dependent on staff for toileting, bathing, dressing, and required substantial assistance for personal hygiene, was observed to have their call light lying on the floor out of reach. Further observation showed that after a CNA attached the call light to the resident's bed sheet near her right arm, the resident was still unable to reach it. Both CNAs involved confirmed during interviews that the call light was not accessible to the resident at the time of observation. These findings demonstrate that the facility failed to ensure the call light was within reach for a resident who was dependent on staff for most activities of daily living, resulting in a lack of reasonable accommodation for the resident's needs and preferences.
Failure to Maintain Clean and Comfortable Resident Rooms
Penalty
Summary
The facility failed to maintain a clean and comfortable environment for its residents, as evidenced by observations in the rooms of two residents. In the first instance, a resident with diagnoses including acute kidney failure, asthma, hypertensive heart and chronic kidney disease, type II diabetes, and anxiety, who was cognitively intact, was found to have a cup with popcorn spilled all over the floor of her room. The popcorn remained on the floor for several hours, and the resident expressed that the mess bothered her and she wanted it cleaned up. This was confirmed by an LPN Manager during an interview. In the second instance, another cognitively intact resident with hypertensive chronic kidney disease, iron deficiency anemia, anxiety, major depressive disorder, and weakness was observed to have a sticky floor in his room. Later observations revealed bloody tissues, a mustard packet, a cotton swab, and pieces of pretzels on the floor, with the stickiness persisting. The resident stated that the trash and sticky floor were bothersome, especially when guests visited. The LPN Manager verified the presence of trash and the sticky condition of the floor during an interview.
Failure to Monitor Psychotropic Medication Use and Effects
Penalty
Summary
The facility failed to ensure that a resident receiving psychotropic medications was properly monitored for behaviors, adverse effects, and efficacy. Medical record review showed that the resident, who had diagnoses including anxiety, depression, and hypertension, was prescribed and administered both antidepressant and antianxiety medications. The care plan required monitoring and documentation of side effects and effectiveness for these medications. However, there was no evidence in the medical record that the resident was monitored for behaviors during a specific period, and no documentation was found regarding monitoring for efficacy or adverse consequences related to the medications at any time. Further review of the medication administration records confirmed that the resident consistently received the prescribed psychotropic medications over several months. Interviews with facility staff, including the Administrator, verified the lack of documentation and monitoring for both efficacy and adverse effects, as well as the absence of behavioral monitoring until a certain date. Facility policies required such monitoring, but these were not followed in this case.
Failure to Involve Resident in Discharge Planning and Communication
Penalty
Summary
The facility failed to provide ongoing assistance and coordination, with resident involvement, in developing discharge goals and plans for discharge for one resident. The medical record showed that the resident was admitted with multiple diagnoses, including atrial fibrillation, venous insufficiency, major depressive disorder, hypertension, dysphagia, and a right artificial hip joint. The resident was cognitively intact, used a wheelchair, was independent with activities of daily living, and was at risk for pressure ulcers but had no skin breakdown. Initial assessments and quarterly reviews documented a discharge goal of returning home, and the resident had an apartment being held for this purpose. However, a nursing plan of care later documented the resident as a permanent placement, and a physical therapy discharge summary listed the discharge destination as LTC, with no documentation that the resident was informed of this change. Interviews revealed that the resident was not informed about the change in discharge plans and had limited contact with social services regarding discharge planning. The social worker, upon assuming the role, was told the resident was staying long-term, but later learned from the resident that he still intended to return to the community. The medical record lacked documentation of resident involvement or updates regarding discharge planning, and there were no further instructions to staff or evidence that the resident was informed about the recommendation for long-term placement.
Failure to Provide Required Staff Assistance During Care Leads to Resident Fall
Penalty
Summary
The facility failed to provide adequate staff assistance and implement fall prevention interventions during care for a resident with a history of repeated falls, dementia, impaired mobility, and incontinence. The resident was assessed as requiring substantial/maximal assistance for bed mobility and was care planned to need two staff members for bed mobility and toileting. Despite these documented needs, a CNA provided incontinence care alone, during which the resident rolled off the bed and sustained a skin tear. The CNA stated she believed the resident could roll independently and was unaware of the requirement for two-person assistance, which was confirmed as necessary by the LPN Unit Manager and the Director of Nursing. Observations further revealed that, on another occasion, a CNA again provided incontinence care to the resident alone, despite the care plan specifying two-person assistance. The facility's policies defined substantial/maximal assistance as requiring more than half the effort from the helper, including lifting or holding the trunk or limbs. The failure to follow the care plan and provide the required level of assistance directly led to the resident's fall and injury.
Failure to Ensure Effective Communication with Dialysis Center
Penalty
Summary
The facility failed to ensure effective communication and documentation between its staff and the dialysis center for a resident who required regular dialysis treatments. Medical record review showed that the resident, who had end-stage renal disease, heart failure, type II diabetes mellitus, hypertension, and was dependent on renal dialysis, was admitted to the facility and had physician orders for dialysis three times a week. The resident was cognitively intact and assessed to receive dialysis. However, review of the dialysis communication forms over a two-month period revealed that, on multiple occasions, the section of the form to be completed by the dialysis center was left blank. Further review of both electronic and paper medical records indicated there was no evidence that the facility staff contacted the dialysis center to have the forms completed or to inquire about the resident's status during dialysis on those dates. An interview with the DON confirmed that the dialysis center had not completed their portion of the communication forms and that there was no documentation of attempts by facility staff to communicate with the dialysis center. The facility's contract with the dialysis provider required documented evidence of collaboration and communication, which was not present in these instances.
Medication Administration Errors and Timing Deficiencies
Penalty
Summary
The facility failed to ensure medications were administered as ordered by the physician and within prescribed time frames, resulting in a medication error rate of 42.86%. During observation, a registered nurse administered medications to a resident with Parkinson's disease, depression, heart failure, hypertension, and arthritic pain outside of the prescribed time frames. The medications included Carbidopa-Levodopa, divalproex, Sacubitril-Valsartan, Hydralazine, and Tylenol, all of which had specific scheduled times that were not adhered to during administration. Additionally, another resident with hypertension, constipation, anticoagulation needs, memory impairment, and mood disorder received medications such as diltiazem, Docusil, apixaban, memantine, risperidone, and Sildenafil outside of the prescribed time frames. In a separate incident, a licensed practical nurse omitted the administration of Sacubitril-Valsartan for a resident with hypertension because the medication was not available. Staff interviews confirmed that medications were not given within the required time frames, and the facility's policy required medications to be administered within one hour of the prescribed time unless otherwise specified.
Failure to Administer Medications as Ordered and Within Prescribed Time Frames
Penalty
Summary
The facility failed to ensure that medications were administered as ordered and within prescribed time frames, resulting in significant medication errors for three residents. Observations revealed that a registered nurse administered medications to one resident over an hour after the scheduled time, including treatments for Parkinson's disease, depression, heart failure, and hypertension. Another resident received multiple medications, such as antihypertensives, anticoagulants, antipsychotics, and vasodilators, also outside the prescribed time frames. In both cases, the nurse confirmed that the medications were not given within the required time windows as specified in the physician orders and the medication administration record (MAR). Additionally, a licensed practical nurse was observed omitting a scheduled dose of Sacubitril-Valsartan for a resident because the medication was not available at the time of administration. The nurse proceeded to administer the remaining medications and confirmed that the omitted medication needed to be reordered. Facility policy requires medications to be administered within one hour of the prescribed time unless otherwise specified, but this was not followed in the observed instances.
Failure to Provide Properly Textured Pureed Foods
Penalty
Summary
The facility failed to ensure that pureed food items were prepared with the appropriate texture for residents requiring a pureed diet. Specifically, two residents with significant medical needs—one with dysphagia and anorexia, and another in a persistent vegetative state due to Alzheimer's disease—were identified as receiving pureed diets. Observations revealed that a dietary aide prepared pureed pears by adding an unmeasured amount of apple juice, resulting in a product that was thin, watery, and contained chunks, rather than being smooth and homogenous as required by the facility's diet manual. Further review and interviews confirmed that the texture of the pureed pears was inappropriate for residents on a pureed diet. The dietary director acknowledged that the pears did not meet the required consistency, as they were both too thin and contained lumps. The facility's diet manual specifies that pureed foods should be smooth, cohesive, and free of lumps, but these standards were not met during the preparation and serving of the pureed pears.
Meal Tray Served on Contaminated Surface
Penalty
Summary
A deficiency occurred when a Certified Nurse Aide (CNA) delivered a meal tray to a resident and placed it on an overbed table that already contained a urinal filled with urine. The resident, who had a history of anxiety, repeated falls, and required assistance with personal care, was cognitively intact and able to eat independently according to the most recent assessment. The CNA confirmed during an interview that she did not notice the urinal on the table before placing the meal tray there. This event was directly observed by surveyors during meal service.
Improper Medication Storage at Bedside
Penalty
Summary
The facility failed to properly store medications, affecting a resident who was reviewed for medications left at the bedside. The resident, who was admitted with diagnoses including hyperlipidemia, polyneuropathy, and a history of urinary tract infection, had physician orders for Cranberry, Atorvastatin, and Gabapentin. These medications were scheduled to be administered at specific times throughout the day. However, the resident reported that nurses sometimes left medications on her table if she was sleeping, particularly the night nurse for early morning medications. An observation confirmed that a plastic medication cup containing three pills was left on the resident's overbed table while she was sleeping. The medications were identified as Atorvastatin, Cranberry, and Gabapentin. The facility's policy on medication storage requires that medications be stored safely and securely, but this was not adhered to in this instance. The deficiency was investigated under a specific complaint number, indicating non-compliance with the facility's medication storage policy.
Significant Medication Error Due to Non-compliance with Physician Orders
Penalty
Summary
The facility failed to administer blood pressure medication in accordance with physician orders, resulting in a significant medication error for one resident. The resident, who had a complex medical history including cardiomyopathy, congestive heart failure, and hypertension, was prescribed Metoprolol Succinate 25 mg to be given as needed for systolic blood pressure (SBP) above 130. However, the medication was administered on two occasions when the resident's SBP was below the prescribed threshold, specifically at 115 and 119. Interviews with hospice staff and the Director of Nursing confirmed that the physician's orders were not followed, as the medication should have been withheld when the SBP was below 130. The facility's medication administration policy requires adherence to prescriber orders, which was not observed in this case. This deficiency was identified during a complaint investigation and affected one of the five sampled residents, highlighting a lapse in medication administration practices.
Failure to Follow Mechanical Lift Transfer Protocol
Penalty
Summary
The facility failed to ensure a resident was safely transferred using a mechanical lift per the care plan and facility policy. Resident #48, who has diagnoses including quadriplegia, polyneuropathy, epilepsy, and contractures, was observed being transferred by a single State tested Nurse Aide (STNA) using a mechanical lift, despite the care plan and facility policy requiring two staff members for such transfers. The incident occurred when STNA #90 wheeled Resident #48 out of the resident's room while suspended in a sling attached to a mechanical lift, and proceeded to transfer the resident to a wheelchair in the hallway without the assistance of a second staff member. Interviews with STNA #90, Resident #48, and the Administrator confirmed that the transfer was conducted by only one staff member, contrary to the facility's policy and the resident's care plan. The facility policy, dated 11/30/23, explicitly states that mechanical lift transfers require the assistance of two individuals to ensure safety. This deficiency was identified during the course of a complaint investigation and affected one resident observed for a mechanical lift transfer.
Failure to Provide Timely Incontinence Care
Penalty
Summary
The facility failed to ensure timely incontinence care for a dependent resident, identified as Resident #41, who was severely cognitively impaired and dependent on staff for activities of daily living. The resident, who had multiple diagnoses including hemiplegia, hemiparesis, and dementia, was observed to have a saturated incontinence brief with both urine and stool. The incontinence care was delayed, as the resident had not been checked or changed since the beginning of the shift at 6:00 A.M., despite the facility's policy requiring residents to be checked and changed every two hours. The State tested Nurse Aide (STNA) #90 confirmed that the resident had not been checked or changed for incontinence since the start of the shift, citing the high demand of other residents needing assistance as a reason for the delay. During the observation, STNA #90 performed incontinence care by cleaning the resident's perineum and buttocks, removing the soiled brief, and applying a clean one. The resident expressed that it had been a long while since they were last checked and changed. The facility's policy on Activities of Daily Living, dated 06/08/22, emphasized the importance of providing necessary support to maintain residents' ADL functions and dignity. However, the facility's failure to adhere to this policy resulted in inadequate incontinence care for Resident #41, as documented in the complaint investigation under Complaint Number OH00151587.
Inadequate Staffing Leads to Delayed Incontinence Care
Penalty
Summary
The facility failed to ensure adequate staffing to provide timely incontinence care for a resident with severe cognitive impairment and multiple medical conditions. Resident #41, who was dependent on staff for activities of daily living and at risk for pressure ulcers, was observed with a saturated incontinence brief and dried stool on the skin. The resident had not been checked or changed for incontinence since the beginning of the shift at 6:00 A.M., despite facility policy requiring checks every two hours. An interview with the State tested Nurse Aide (STNA) revealed that due to insufficient staffing, she was unable to attend to all residents in a timely manner. The STNA confirmed that Resident #41 had not been checked or changed for over five hours, as she had to assist five other residents with getting out of bed. This deficiency was corroborated by the facility's policy on activities of daily living, which mandates support to maintain residents' current level of assistance and promote dignity.
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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