Timberland Ridge Nursing & Rehabilitation
Inspection history, citations, penalties and survey trends for this long-term care facility in Fairlawn, Ohio.
- Location
- 3558 Ridgewood Road, Fairlawn, Ohio 44333
- CMS Provider Number
- 366479
- Inspections on file
- 25
- Latest survey
- January 22, 2026
- Citations (last 12 mo.)
- 27
Citation history
Health deficiencies cited at Timberland Ridge Nursing & Rehabilitation during CMS and state inspections, most recent first.
Surveyors found that medications were not securely stored or properly administered. An LPN left an unlocked medication cart unattended in a hallway with multiple labeled medication cups containing pills for several residents, having preset doses in advance rather than preparing and administering them one resident at a time. On the memory care unit, an LPN left a cup with nine medications on a bedside table for a severely cognitively impaired resident to take without supervision, despite the DON’s statement that no residents were authorized to self-administer and that staff were required to remain with residents until medications were taken.
Two cognitively intact, fully incontinent residents who depended on staff for toileting hygiene reported and were observed to experience long delays in incontinence care, including remaining in urine and feces for extended periods. Staff CNAs described checking and changing residents only three to four times in a 12‑hour shift and stated they were not allowed to perform patient care, including changing briefs, during meal service, causing residents to wait through mealtimes. One resident was found with a saturated brief, deep redness of the peri area and buttocks, and pain during cleansing, while another was observed saturated with stool and urine, with redness on the buttocks and thighs, after her call light had been on and her request to be changed was disputed by a CNA. An RN confirmed CNAs were occupied feeding residents, and the DON later stated residents were supposed to be checked and changed every two hours and as needed and that staff were allowed to change residents during meals.
A resident with severe cognitive impairment and a history of pressure ulcers developed extensive skin breakdown, including open wounds and bleeding, due to the facility's failure to consistently perform and document required skin assessments and interventions. Staff did not effectively communicate or report changes in the resident's skin condition, and a malfunctioning low air loss mattress was not promptly addressed, leading to delayed identification and treatment of skin impairments.
A resident at risk for falls, requiring substantial assistance, was not provided with care planned interventions during a transfer using a sit-to-stand lift, resulting in a fall. The CNA did not ensure proper hand placement or secure the safety belt, and the resident's concerns were ignored. After the incident, vital signs and pain assessments were not completed, and documentation was lacking, contrary to facility policy.
A resident with significant care needs was found wearing two saturated incontinence briefs and lying on a wet blanket, with redness noted on the skin. A CNA provided care but failed to follow infection control protocols, including handling soiled items without a plastic bag and touching clean surfaces with soiled gloves. The DON confirmed these lapses and that the use of two briefs was inappropriate.
A resident with diabetes and obesity did not receive a scheduled dose of Zepbound because the medication was not available at the facility when needed. The delay occurred due to insurance prior authorization issues, requiring administrative approval before the pharmacy could dispense the medication. There was a lack of clarity among staff regarding responsibility for ensuring the medication was available for timely administration.
Three medication errors were observed, resulting in a 12% error rate. Errors included an LPN administering insulin without priming the pen as required, and two residents missing scheduled doses of inhaled and topical medications because the medications were not available and needed to be reordered from the pharmacy. These deficiencies were confirmed through observation, record review, and staff interviews.
A resident with Parkinson's Disease and anxiety did not receive prescribed alprazolam for anxiety because the medication order was not processed and the pharmacy never received a valid prescription. Despite multiple attempts by the pharmacy to contact the prescriber and observable signs of anxiety in the resident, the medication was not administered due to communication failures among staff and unclear on-call physician coverage.
A resident with moderate cognitive impairment and multiple chronic conditions experienced significant unplanned weight loss and dehydration due to the facility's failure to monitor weight, record fluid intake, and implement timely interventions for decreased meal intake. Despite care plan requirements for assistance and monitoring, the resident did not consistently receive needed support, leading to hospitalization for dehydration.
A resident with multiple complex medical conditions developed a vascular wound on the left calf, but wound care was not initiated or ordered for three days after identification. During this period, no wound treatments were documented, and the resident later required hospital transfer due to acute medical issues. Facility staff confirmed the lack of timely wound care, which was inconsistent with facility policy.
A resident with severe cognitive impairment and multiple mobility issues was admitted with several pressure ulcers and subsequently developed additional blisters while in the facility. For three days, there were no physician orders or wound care provided for the resident's sacrum, right ankle, or left ankle wounds, as confirmed by record review and staff interview.
A resident with multiple medical conditions was not provided timely podiatry care due to a delay in obtaining consent for auxiliary services and a lack of awareness among staff. The resident was observed with long, thickened, yellow toenails, and staff interviews confirmed there was no specific policy for podiatry services, resulting in the resident missing needed foot care.
A resident with dementia and a history of falls experienced a delay in receiving appropriate care after a fall resulting in a fractured femur. Despite a STAT x-ray order, the x-ray was conducted 17 hours later, delaying the diagnosis and transfer to the hospital. The facility's policy for timely response to changes in condition was not followed.
A resident with SIADH did not receive a physician-ordered urea sodium oral packet due to the medication being consistently unavailable from the pharmacy. Despite multiple notes indicating the medication was on order or out of stock, there was no documentation of the physician being informed. Interviews confirmed the resident never received the treatment, highlighting a failure in medication administration policy adherence.
Unsecured Medications and Improper Self-Administration Practices
Penalty
Summary
The deficiency involves the facility’s failure to securely store and properly administer medications in accordance with professional standards and facility policy. During observation on the west hall, an unlocked medication cart was found unattended with eight medication cups containing pills on top of the cart, each cup labeled with letters corresponding to resident names. LPN #300 acknowledged she had preset 11:00 A.M. medications for multiple residents, written their names on the cups, and left the cart and medications unsupervised in the hallway while she was in a resident’s room. She confirmed the specific number of pills preset for each identified resident. The DON later stated that nurses should not preset medications and that medications were to be prepared and administered at the same time, one resident at a time. A second deficiency was identified on the memory care unit involving a resident with dementia who was assessed as severely cognitively impaired on a recent MDS and resided on the Memory Care Unit. Observation revealed this resident lying in bed with the door open and a bedside table in front of her, on which there was a medication cup containing nine medications of various pill sizes and capsules, with no staff present nearby. LPN #302 confirmed she had completed her medication pass and had left the medications in the resident’s room for the resident to self-administer, stating the resident preferred not to be supervised when taking pills. The DON later confirmed that no residents in the facility were authorized to self-administer medications and that this resident, given her severe cognitive impairment, would not be appropriate for self-administration, and that nursing staff were required to remain with residents until all medications were taken.
Failure to Provide Timely Incontinence Care Due to Meal-Time Restrictions and Inadequate Rounding
Penalty
Summary
The deficiency involves the facility’s failure to provide timely toileting hygiene and incontinence care to residents who were dependent on staff, resulting in residents remaining in urine and feces for extended periods. One resident, admitted with a fracture of the right femur, muscle weakness, and a need for assistance with personal care, was documented as cognitively intact, frequently incontinent of bowel and bladder, and dependent on staff for toileting hygiene. Her care plan identified complete incontinence with an intervention to provide incontinence care as needed. She reported that staff sometimes did not change her when she was incontinent and made her wait long periods. She described an incident where, after she had an accidental bowel movement, a CNA told her it was mealtime and she would have to wait until after the meal to be changed. On a subsequent observation, this resident was found lying in bed and reported she was wet with urine and had not yet been checked or changed that day, despite CNAs starting their shift at 6:00 A.M. Her primary CNA stated she had not yet checked the resident for incontinence and that she typically did her first rounds after breakfast, then again before lunch, for a total of about four checks in a 12‑hour shift. During observed incontinence care, the resident’s brief was saturated with urine, her peri area and buttocks were deep red, and she cried out in pain when the area was cleansed. Another CNA reported she routinely checked and changed residents only three times in a 12‑hour shift. Multiple staff, including CNAs and an LPN, stated they were not allowed to perform patient care, including changing residents, during meal service from the time the meal cart arrived until trays were picked up, and one CNA confirmed she had required a resident to wait to be changed during a prior mealtime because of this rule. A second cognitively intact resident, always incontinent of bowel and bladder and dependent on staff for toileting hygiene, also had a care plan indicating complete incontinence with interventions to provide incontinence care as needed. She reported that she had requested to be changed about an hour earlier after having a bowel movement, and that the CNA told her she would change her before bringing meal trays. Later, she stated she still had not been changed, her call light remained on, and she expressed being upset about having to sit in her bowel movement. The charge nurse confirmed both CNAs were feeding other residents and that it took a long time for staff to provide care. When the CNAs arrived, one CNA denied the earlier request, rolling her eyes, while the resident firmly restated that she had asked to be changed. Observation of peri care revealed the resident was saturated with urine and stool in the peri area, with a large bowel movement present and redness on the buttocks and thighs. The CNA wiped from the buttocks up through the vaginal area, revealing heavy stool with each wipe, and confirmed she only wiped the front twice in this manner. The DON later stated that staff were allowed to change residents during meals and that residents were to be checked and changed every two hours and as needed.
Failure to Implement and Monitor Skin Integrity Interventions
Penalty
Summary
A deficiency occurred when the facility failed to implement care planned interventions and timely identify and treat skin impairments for a resident with severe cognitive impairment, cerebral palsy, and a history of pressure ulcers. The resident was dependent on staff for all activities of daily living, including incontinence care, and had orders for regular skin checks and the application of moisture barrier ointment. Despite these orders, documentation and staff interviews revealed that skin assessments were not consistently performed, and the resident's skin condition was not properly monitored or reported. Observations showed that the resident developed extensive skin breakdown, including large reddened areas, open wounds, and bleeding on the lower back, buttocks, and hips. Multiple staff members, including CNAs and LPNs, either did not notice or did not report the worsening skin condition, and some were unsure if the required interventions had been completed. The low air loss mattress, intended to prevent pressure injuries, was found to be malfunctioning with a low pressure warning, but there was no indication of how long it had been inoperable or if it had been reported or addressed in a timely manner. Interviews with staff revealed a lack of communication and documentation regarding the resident's skin condition. CNAs reported seeing redness and applying barrier cream but often did not inform the nurse, assuming the nurse was already aware. Nurses admitted to checking off treatments and skin checks on the Treatment Administration Record without actually assessing the resident's skin, relying on CNAs to report any issues. The facility's policy required reporting of skin breakdown, but this was not consistently followed, resulting in delayed identification and treatment of the resident's skin impairments.
Failure to Implement Fall Prevention Interventions and Timely Post-Fall Assessment
Penalty
Summary
A deficiency occurred when the facility failed to implement care planned interventions and did not complete a comprehensive fall evaluation in a timely manner for a resident identified as being at risk for falls. The resident, who had diagnoses including sepsis, obesity, and type 2 diabetes with diabetic neuropathy, required substantial to maximal assistance for transfers and personal care. Despite being cognitively intact and having no upper or lower extremity impairment, the resident's care plan included specific interventions such as education on proper hand placement during sit-to-stand transfers, encouragement to use assistive devices properly, and provision of rest periods. However, these interventions were not followed during a transfer using a sit-to-stand lift, resulting in the resident sliding out of the lift and being lowered to the floor by a CNA. Following the incident, the resident reported that the CNA was impatient and did not ensure her hands were correctly placed on the lift, nor was the safety belt properly secured. The resident expressed that she communicated her concerns during the transfer but was ignored, leading to her sliding out of the lift, hitting her knee, and experiencing pain and anxiety. Observations after the fall revealed a reddened area on her right knee and missing artificial fingernails, consistent with her account of the incident. The resident also stated that her vital signs were not checked, she was not asked about pain, and she did not receive prompt attention or medication for her pain and anxiety. A review of the medical record and facility documentation showed no evidence that vital signs were checked at the time of the fall, no comprehensive pain assessment was completed, and no physical assessment was documented in the progress notes. Additionally, the fall investigation lacked staff witness statements and a statement from the resident. The facility's policy required prompt medical attention, assessment for injuries, and documentation of pertinent data following a fall, but these procedures were not followed in this case.
Failure to Provide Timely Incontinence Care and Maintain Infection Control
Penalty
Summary
Staff failed to provide timely and appropriate incontinence care for a resident with a history of urinary tract infection, diabetes mellitus, and hemiplegia. The resident, who required substantial to maximal assistance with toileting and was frequently incontinent, was observed wearing two saturated incontinence briefs and lying on a wet blanket used as a chux pad. The blanket was wet with urine, and dried urine was noted around the edges. During incontinence care, redness was observed on the resident's buttocks and sacral area. The CNA providing care acknowledged that the resident had not been changed in a long time and confirmed the use of two briefs, which was not in accordance with facility policy. Additionally, the CNA failed to follow proper infection control procedures by removing soiled briefs and the wet chux pad and placing them on the floor without a plastic bag. The CNA continued to touch the resident's closet door, clean bed linens, pillow, and door handle while still wearing soiled gloves, only removing the gloves after leaving the room. The DON confirmed these actions and that the resident should not have been wearing two incontinence briefs. Facility policy required proper hand hygiene and glove use after each incontinent episode, which was not followed in this instance.
Failure to Provide Timely Administration of Ordered Medication Due to Ordering and Authorization Delays
Penalty
Summary
The facility failed to ensure that a resident's physician orders for Zepbound, a medication prescribed for diabetes management and weight loss, were followed and that the medication was available for administration as scheduled. The resident, who was cognitively intact and had diagnoses including class III obesity and type 2 diabetes with neuropathy, did not receive her ordered Zepbound injection on the scheduled day. The medication administration record confirmed the dose was missed, and the resident reported to staff that she had not received her shot within the expected timeframe. Staff interviews revealed that the medication was not present in the facility at the time it was due, and it was still on order. Further investigation showed that the delay was due to issues with insurance prior authorization, requiring administrative approval before the pharmacy could dispense the medication. The pharmacy confirmed that a refill request was received, but the medication was not covered by insurance, prompting them to contact the facility for approval. The administrator authorized the medication after being contacted by the pharmacy, but there was a lack of clarity regarding who was responsible for ensuring the medication was available for timely administration. This resulted in the resident missing a scheduled dose of her prescribed medication.
Medication Error Rate Exceeds Five Percent Due to Administration and Availability Failures
Penalty
Summary
The facility failed to maintain a medication error rate below five percent, as required, resulting in a 12% error rate with three errors observed in 25 opportunities. For one resident with diabetes, an LPN administered insulin using a FlexPen without priming it as directed by the manufacturer’s instructions, despite the resident’s care plan and physician order specifying insulin administration per sliding scale. The LPN confirmed not priming the pen, and the DON stated that priming is necessary before dialing the dose. Additionally, two residents missed scheduled doses of their prescribed medications due to unavailability. One resident with COPD and heart failure did not receive a scheduled dose of a bronchodilator inhaler because the medication was not available on the medication cart, and the LPN confirmed it needed to be reordered from the pharmacy. Another resident with Alzheimer’s disease and pain management needs missed a scheduled dose of topical capsaicin cream for pain relief, also due to the medication not being available and requiring reorder. These incidents were observed during medication administration and confirmed by staff interviews and record reviews.
Failure to Administer Ordered Anxiety Medication Due to Communication and Order Processing Breakdown
Penalty
Summary
A deficiency occurred when a resident with Parkinson's Disease and anxiety was admitted to the facility with a physician's order for alprazolam (Xanax) 0.25 mg to be given every 12 hours as needed for anxiety. Despite this order, the medication was never administered during the resident's stay. Review of the Medication Administration Record confirmed that alprazolam was not given, and pharmacy records indicated that the prescription was never filled because the pharmacy did not receive a valid prescription from the physician. The pharmacy attempted to contact the physician multiple times without success, and there were no notes indicating that facility nurses called the pharmacy about the medication. Staff interviews revealed confusion and lack of communication regarding the medication order. The LPN who admitted the resident stated that the night shift nurse was supposed to complete the admission process and was unsure if the medication was ordered or filled. The LPN also noted that during the weekend in question, staff were unable to reach the nurse practitioner or physicians, which was unusual and led to a post-incident meeting. The DON, who was not employed at the time, confirmed that alprazolam was available in the facility's starter supply and could have been administered with proper authorization, but could not explain why the medication was not filled or administered. The facility's policy required medications to be dispensed only upon receipt of a clear, complete order signed by an authorized prescriber. In this case, the lack of a valid prescription and the inability to contact the prescriber resulted in the resident not receiving the ordered medication for anxiety. The situation was further complicated by family involvement, visitor disruptions, and the resident's observable anxiety symptoms, but the core issue remained the failure to ensure the resident was free from significant medication errors due to breakdowns in communication and order processing.
Failure to Implement Effective Nutrition and Hydration Plan Resulting in Harm
Penalty
Summary
The facility failed to develop and implement a comprehensive, individualized, and effective nutrition and hydration plan for a resident with moderate cognitive impairment, resulting in significant weight loss and dehydration. The resident, who had diagnoses including dementia, hemiplegia, diabetes, and other chronic conditions, was at moderate risk for malnutrition and required cues and assistance with eating. Despite care plan interventions to monitor and provide hydration, the facility did not ensure ongoing weight monitoring or implement adequate interventions in response to the resident's decreased meal intake. The resident experienced a severe weight loss of 17.3 pounds (8.3%) in two weeks and was subsequently hospitalized for altered mental status secondary to dehydration, requiring intravenous fluids. Medical record review revealed that the facility did not obtain an admission weight for the resident upon readmission and failed to record fluid intake amounts for the entire month of September. There was no evidence that the diet technician was notified of the resident's decreased meal intake, and no updates or new interventions were made to the care plan during the period of declining intake. Observations showed that fluids were not consistently within the resident's reach, and interviews with staff and family members indicated that the resident's meals were often left on the bedside table without adequate assistance, despite the resident's need for help with feeding. The facility's own weight monitoring policy required weekly weights for four weeks after admission and prompt reporting of significant weight changes, but these protocols were not followed. The resident's significant weight loss and decreased intake were not addressed in a timely manner, and the lack of proper monitoring and intervention led to actual harm, as evidenced by the resident's hospitalization for dehydration. Interviews confirmed that staff were aware of the resident's declining intake but did not take appropriate action to notify the diet technician or update the care plan.
Failure to Provide Timely Wound Care for Resident
Penalty
Summary
A resident with a history of paraplegia, chronic respiratory failure, osteomyelitis, and major depressive disorder was admitted and later readmitted to the facility. The resident developed a vascular wound on the rear left calf, which was first identified during a skin assessment. Despite the care plan indicating that wound treatments should be provided per physician orders, there was no evidence that any wound care was initiated or ordered for three days following the identification of the wound. Medical records, including the Medication Administration Record (MAR) and Treatment Administration Record (TAR), confirmed that no wound care was provided during this period. Subsequently, the resident experienced a significant change in condition, including tachycardia and hypotension, leading to transfer to the emergency room. Hospital documentation noted the presence of the left lower extremity wound with cellulitis, as well as additional pressure injuries acquired during hospitalization. Facility staff interviews confirmed that no wound care orders were placed or treatments completed for the wound during the initial three-day period. The facility's policy required necessary care and treatment to prevent and manage pressure injuries, which was not followed in this instance.
Failure to Obtain Orders and Provide Wound Care for Pressure Ulcers
Penalty
Summary
The facility failed to obtain physician orders and provide wound care for a resident with multiple pressure ulcers. The resident was admitted with several wounds, including a stage one sacrum pressure ulcer, a right ankle deep tissue injury, and a left ankle stage three pressure ulcer. Additionally, two blisters on the plantar surfaces of the feet were identified as acquired in the facility. Review of the resident's medical record, medication administration records, and treatment administration records revealed that there were no physician orders or wound care provided for the sacrum, right ankle, or left ankle wounds for three consecutive days following admission. Interview with the wound nurse confirmed that wound care orders or treatments were not in place for these pressure wounds during the specified period. The facility's skin assessment policy required necessary care to prevent and treat pressure injuries, but this was not followed for the resident in question. The deficiency was identified during a complaint investigation and affected one resident with severe cognitive impairment and multiple mobility-related diagnoses.
Failure to Provide Timely Podiatry Services
Penalty
Summary
A deficiency was identified when a resident did not receive timely podiatry services. The resident, who had diagnoses including muscle weakness, vascular dementia, and epilepsy, was observed to have long, thickened, yellow toenails on both great toes. Review of the medical record showed that although the resident was readmitted to the facility, a consent for auxiliary services, including podiatry, was not obtained until several weeks later. During this period, the resident did not receive podiatry care, and the need for such services was not recognized until a care conference was held. Interviews with facility staff confirmed that there was no specific policy in place for podiatry services, and the social services designee was unaware of the resident's need for podiatry until the care conference. The podiatrist's last visit to the facility occurred prior to the consent being obtained, and the next scheduled visit was after the deficiency was identified. The lack of timely consent and absence of a clear process for arranging podiatry services led to the resident not receiving necessary foot care.
Delayed Response to Resident's Fall and Fracture
Penalty
Summary
The facility failed to provide appropriate and timely care to a resident after a fall that resulted in a fracture. The resident, who was admitted with diagnoses including dementia, repeated falls, and arthritis, was found on the floor by a registered nurse. The resident complained of hip pain and was unable to move her right leg. The nurse notified the nurse practitioner, who ordered a STAT hip x-ray. However, the x-ray was not conducted until approximately 17 hours later, delaying the diagnosis of a fractured femur and the resident's transfer to the hospital for surgery. The delay in obtaining the x-ray and subsequent treatment was a significant oversight, as the facility's policy defines a change of condition to include life-threatening conditions such as broken bones. Interviews with the nurse practitioner and registered nurse revealed a lack of awareness regarding the delay in the x-ray, and the resident was found to be in more pain and soiled the following morning. The deficiency was identified during a complaint investigation, highlighting the facility's failure to adhere to its policy for timely response to a change in a resident's condition.
Failure to Administer Physician-Ordered Medication for SIADH
Penalty
Summary
The facility failed to provide a physician-ordered treatment for a resident diagnosed with Syndrome of Inappropriate Secretion of Antidiuretic Hormone (SIADH). The resident, who had multiple diagnoses including normal pressure hydrocephalus, chronic obstructive pulmonary disease, and depression, was prescribed a urea sodium oral packet to manage low sodium levels associated with SIADH. Despite the order being in place from late May to early July, the medication was never obtained from the pharmacy and thus never administered to the resident. Throughout the period, multiple medication administration notes indicated that the urea sodium oral packet was either on order or out of stock, yet there was no documentation of the physician being notified about the unavailability of the medication. Interviews with the Director of Nursing, the physician, and a nurse practitioner confirmed that the resident did not receive the prescribed treatment and that there was no record of communication with the physician regarding this issue. The facility's policy on medication administration was not adhered to, resulting in a deficiency as investigated under a specific complaint number.
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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