Trotwood Health & Rehab Llc
Inspection history, citations, penalties and survey trends for this long-term care facility in Dayton, Ohio.
- Location
- 4911 Covenant House Drive, Dayton, Ohio 45426
- CMS Provider Number
- 365364
- Inspections on file
- 55
- Latest survey
- December 22, 2025
- Citations (last 12 mo.)
- 10
Citation history
Health deficiencies cited at Trotwood Health & Rehab Llc during CMS and state inspections, most recent first.
The facility did not maintain comfortable air temperatures in common areas, with multiple locations such as hallways, dining room, and chapel recorded well below policy standards. Residents were observed bundled in coats and blankets, and the main boiler system was found to be permanently shut off. While PTAC units were installed in resident rooms, some were not functioning properly, and common areas remained inadequately heated.
Several residents expressed a desire to eat in the dining room, but the facility failed to provide a comfortable environment due to inadequate heating. Temperatures in the dining room and other common areas were consistently low, as the main boiler was non-functional and auxiliary heaters were insufficient. As a result, all meals were served in residents' rooms, and residents' choices regarding dining location were not supported.
The facility did not ensure its Activities Program was overseen by a qualified Activities Director, as the staff member in the role lacked required certification or training and was originally hired for social services. Resident Council meetings were facilitated by an Activities Aid, and management was not kept informed of resident concerns from these meetings.
The facility did not maintain its boiler in working condition, resulting in low temperatures throughout common areas such as hallways, dining rooms, and lounges. Residents were observed bundled in coats and blankets, and auxiliary heaters were used but were often ineffective. While PTAC units were installed in resident rooms, common areas remained inadequately heated, and staff confirmed ongoing temperature issues and equipment malfunctions.
The facility did not maintain safe and comfortable temperatures, with some rooms exceeding 81°F due to a broken air conditioning system, and failed to provide hot water for bathing and hygiene in several halls. Residents reported significant discomfort, and staff confirmed that both the air conditioning and hot water issues had persisted for weeks without resolution.
The facility did not obtain food from approved sources and failed to follow professional standards for storing, preparing, distributing, and serving food.
Several residents reported that their heating/air conditioning units were not working, and observations confirmed that multiple rooms had non-functioning or inadequate units. The maintenance supervisor initially stated all units were operational, but later confirmed the deficiencies. Facility policy required prompt repairs, but the issue persisted from a previous survey.
A resident with multiple chronic conditions and cognitive intactness was not treated with dignity and respect when a CNA repeatedly yelled at her to take a shower and to get off the phone, disregarding her request to shower later. The incident was reported to the Administrator, who did not follow up with the resident, and the CNA later confirmed her actions.
A resident with multiple chronic conditions and a history of pain reported high pain levels on multiple occasions but did not receive any pain medication or documented non-pharmacological interventions, despite physician orders and a care plan addressing pain management. The DON confirmed the resident had not received pain medication since admission and that pain management interventions were not implemented.
Two residents did not receive medications as ordered: one was given an antihypertensive without required blood pressure monitoring, and another was left without prescribed pain medication for several days due to delays in reordering and delivery. Staff confirmed these lapses, and documentation showed the facility did not follow its own medication administration policy.
Multiple areas of the facility, including a resident's room and common spaces, were found in disrepair, with issues such as a large hole in a resident's wall, damaged cabinetry, broken trim, and chipped paint. Residents and staff confirmed these conditions had persisted for months without repair, and the administrator acknowledged the lack of action and absence of a policy regarding the physical environment.
The facility failed to maintain a clean and homelike environment, with non-functioning and dirty shower rooms and a sticky floor in a resident's room. The 500-hallway shower room, used by all residents, had non-functioning stalls and debris, while the 200-hall shower room had stagnant water and water damage. A resident's room had a sticky floor, possibly due to improper cleaning. These conditions were confirmed by staff.
The facility exceeded the acceptable medication error rate, with errors affecting two residents. An LPN administered Pyridium without an active order to one resident and failed to administer Linagliptin as ordered to another. Both residents were cognitively intact and required assistance with daily activities.
A resident was found with several bottles of medication improperly stored in their room, contrary to the facility's policy requiring safe and secure storage. The resident, who was cognitively intact and dependent on staff for medication administration, had multiple medical conditions. The facility's policy mandates nursing staff to maintain proper medication storage, which was not followed in this case.
A resident with severe cognitive impairment experienced inadequate room temperature due to incomplete installation of new heating units. The room was recorded at 66°F, below the facility's policy threshold, with staff confirming the issue and reliance on hallway heaters. The facility's policy indicated a higher risk for hypothermia at such temperatures.
A resident did not receive prescribed Oxycodone due to a supply issue, as the pharmacy awaited a new prescription. The resident, with chronic pain and other health conditions, was cognitively intact and required assistance with mobility. The facility's policy mandates medications be administered as prescribed, which was not followed in this case.
The facility exceeded the acceptable medication error rate, reaching 6.6%, due to incorrect administration of medications to a resident. An LPN administered Magnesium Oxide 400 mg and Folic Acid 400 mcg instead of the prescribed Magnesium Hydroxide oral suspension and Folic Acid 1 mg. The correct medication was available but not used, violating the facility's medication administration policy.
The facility failed to maintain comfortable air temperatures in the secure behavioral unit, with room temperatures ranging from 43.6 F to 55 F. Despite operational heaters, the temperatures were below the facility's policy range of 71-81 degrees F, potentially affecting 13 residents. A resident noted it was cold, and the issue was confirmed by the Maintenance Director and Administrator.
A facility failed to assist a resident with medical appointments, affecting their follow-up care after an aortic aneurysm repair. The resident, with chronic conditions, had an appointment rescheduled without proper documentation or communication. The cardiologist's office confirmed a no-show, and the facility's administration acknowledged the lack of documentation.
Two residents experienced medication administration and documentation failures. One resident did not receive the correct dosage of Clonazepam due to transcription errors and lack of medication availability. Another resident had inconsistencies in oxycodone documentation and unavailability of methocarbamol due to improper refill requests and documentation. Interviews confirmed these deficiencies, highlighting failures in medication management.
The facility did not ensure RN supervision for eight consecutive hours daily, as required. A review of the nursing schedule showed no RN was scheduled on a specific day, and the DON confirmed this absence. This had the potential to affect all 52 residents in the facility.
The facility failed to provide a clean, safe, and comfortable environment for residents, with issues such as dirty floors, excessively warm rooms, leaking ceilings, and poorly maintained outdoor areas. These conditions were confirmed by staff and residents, highlighting ongoing environmental deficiencies.
The facility failed to prevent residents from accessing hazardous items like knives, razors, and smoking materials, and did not provide adequate supervision for smokers. Several residents, including those with cognitive impairments, were found with smoking materials and other dangerous items, unsupervised, contrary to the facility's policy. This deficiency affected residents who required supervision and secure storage of smoking materials.
The facility failed to maintain proper sanitizer levels in the dishwasher, affecting 51 residents. The Dietary Supervisor confirmed the sanitizer had been at 0 ppm for weeks, despite needing 50 ppm for safe use. The issue was due to an empty sanitizer bucket, with no records of when it was last ordered or opened.
The facility failed to implement Enhanced Barrier Precautions (EBP) for residents with wounds and indwelling medical devices, affecting five residents. A resident with an unstageable vascular ulcer and another with a feeding tube lacked EBP orders and appropriate signage or PPE. Another resident with vascular ulcers and a resident with an indwelling catheter also did not have EBP orders or PPE available. The facility's policy required EBP for such conditions, but it was not followed.
The facility did not ensure that residents were offered pneumococcal and influenza vaccinations, as there was no documentation in the medical records of five residents regarding the receipt or refusal of these vaccines. This issue was confirmed by the Administrator, affecting all residents reviewed for vaccinations.
The facility failed to maintain the dignity and privacy of two residents. A resident with an indwelling catheter had a full urinary Foley bag visible from the hallway without a dignity cover. Another resident, who required assistance for ADLs, was observed in a common area with her hospital gown untied, exposing her back and buttocks. Despite acknowledgment by staff, the exposure continued, violating the facility's Residents Rights policy.
The facility failed to prevent resident-to-resident sexual abuse involving two residents with cognitive impairments and a resident with a history of inappropriate sexual behavior. Despite the incidents, the facility did not notify law enforcement or conduct thorough investigations, and insufficient supervision measures were in place.
A facility failed to implement its abuse policy during a verbal altercation between a resident and an STNA. The incident involved derogatory language and aggressive behavior by the STNA, witnessed by an RN who attempted to intervene but did not effectively remove the STNA or protect the resident. The facility's policy required immediate removal of staff suspected of abuse, which was not followed, leading to a deficiency finding.
A facility failed to investigate allegations of sexual abuse involving a cognitively impaired resident with a court-appointed guardian. The resident was found in a compromising situation with another resident, but no immediate investigation or notification to the guardian or police was made. Staff interviews revealed a pattern of neglect in addressing similar incidents, and the facility's policy on immediate reporting and investigation was not followed.
The facility failed to conduct quarterly care conferences for three residents, including one with cognitive impairment and a court-appointed guardian. Despite requests, no conferences were held for one resident since 2022, and others had only one or two conferences over a year. The facility did not adhere to its policy requiring notification and documentation of care conferences.
A facility failed to administer dietary supplements as ordered for a resident with multiple health conditions, including malnutrition. The resident was supposed to receive Boost three times daily, but the MAR showed missed doses on two occasions. The DON confirmed the gaps in documentation and administration, leading to a deficiency finding.
A resident with multiple diagnoses, including COPD and anxiety disorder, did not receive medications as ordered on several occasions. The MAR lacked documentation for the administration of various medications, including Celebrex, Aspirin, and Seroquel, on specific dates. The DON confirmed the absence of documentation, which is against the facility's medication administration policy.
A resident with a history of constipation and other medical conditions did not receive a KUB x-ray as ordered by a physician, despite experiencing abdominal pain and lack of bowel movement for several days. The facility's medical records lacked documentation of the x-ray or any rationale for its omission, as confirmed by the DON.
A facility failed to document the transfer of a resident to the hospital in their medical records. The resident, with multiple diagnoses including a fracture and major depressive disorder, was missing from their room during a survey. The DON confirmed the resident was sent to the hospital days earlier, but this was not recorded in the medical record.
The facility failed to provide functioning call lights for three residents, affecting their ability to summon assistance. A resident with schizophrenia and dementia was found without a call light cord, while another with severe cognitive impairment had a non-functional call light. A third resident with Huntington's disease also lacked a working call light. Staff confirmed these deficiencies, which were noted in previous surveys.
A resident experienced a significant weight loss over a six-month period, but the facility failed to notify the physician as required by their policy. The resident's weight decreased from 179.6 pounds to 151.4 pounds, amounting to a 15.7% weight loss. Despite a dietary recommendation for supplements, there was no documentation of physician notification, confirmed by the DON. The facility's policy mandates physician notification for significant weight changes.
A resident with a history of visual loss and other medical conditions did not receive necessary vision services due to a failure in scheduling and communication within the facility. Despite a physician's order for an ophthalmology referral, the resident's appointment was canceled and not rescheduled, leaving her without needed eye care.
Two residents did not receive necessary follow-up dental care. One resident needed fillings replaced but had not seen a dentist since admission, while another required dental extractions and dentures, which were not addressed. The Social Service Designee and DON were unaware of these needs, despite facility policy requiring timely dental services.
The facility failed to maintain a comfortable and clean environment, with the 100 Hall experiencing uncomfortably warm temperatures at 85.5°F, potentially affecting 11 residents. Despite the presence of portable air conditioning units, the temperature remained high. Additionally, the 500 Hall had a pervasive urine odor, confirmed by an LPN, potentially affecting 10 residents. These issues were part of ongoing noncompliance from a previous survey.
A resident with multiple medical conditions, including impaired cognition and vision, was found to have a call light placed out of reach and not within their line of vision. The resident confirmed the inability to reach the call light, and an LPN verified the lack of alternative means for the resident to notify staff. This was contrary to the facility's policy, which requires call lights to be within reach to ensure timely response to residents' needs.
The facility failed to implement its smoking policy, leading to a deficiency in supervising and securing smoking materials for residents. A resident with multiple medical diagnoses was not assessed for smoking upon admission and was found smoking in his room, causing a small fire. Another resident was observed storing cigarette packs in her walker, contrary to the policy requiring secure storage of smoking materials. The facility's policy mandates evaluations and secure storage, which were not adhered to, resulting in the deficiency.
The facility failed to ensure proper medication administration for two residents, as their May 2024 MARs lacked documentation confirming that prescribed medications were given as ordered. One resident, who was cognitively intact, did not receive several medications on a specific day, while another resident with moderately impaired cognition and requiring assistance also missed multiple medications. The DON confirmed these discrepancies, which violated the facility's medication administration policy.
A medication administration error occurred in an LTC facility, resulting in a 6.66% error rate. An LPN failed to apply a Lidocaine patch and administer MiraLAX to a resident with a history of cerebral infarction and other conditions. This was confirmed through observation and staff interview.
A resident with severe cognitive impairment and multiple medical conditions was readmitted to the facility and required lab work, which was not obtained as ordered. The lab was unable to collect an adequate sample, and there was no follow-up to ensure the tests were completed. The resident was later sent to the hospital due to a change in condition, where further medical interventions were necessary.
The facility failed to maintain a functioning call light system for two residents, one with impaired cognition and vision, and another who was cognitively intact. Both residents were unable to alert staff for assistance due to non-functioning call lights, which were confirmed by staff observations.
A resident with multiple medical diagnoses and moderate cognitive impairment, identified as a high risk for elopement, managed to leave the facility by asking a visitor for a ride. The incident occurred when the nurse responsible for one-on-one supervision left the resident unattended. The resident was found and returned without injuries.
The facility failed to ensure proper disposal of medications after a resident with multiple medical diagnoses was discharged to the hospital and did not return. There was no documentation related to the disposition of the resident's medications, and the facility lacked a policy for medication disposal upon discharge. The DON confirmed the absence of documentation and policy.
A resident with moderate cognitive impairment reported that his call light had not worked for a few weeks. Observations confirmed the malfunction, and staff interviews revealed that maintenance was aware but had not received recent work orders. The resident did not have an alternate device to notify staff, contrary to facility policy.
The facility failed to maintain the 200 Hall shower, affecting one resident directly and potentially impacting nine others, with issues including a missing shower head, poor water pressure, and black substances on the ceiling tiles and grout. Additionally, a leaking roof on the 500 Hall had the potential to affect ten residents, with water leaking onto the hallway floor without any wet floor signs to caution staff or residents.
Failure to Maintain Safe and Comfortable Air Temperatures in Common Areas
Penalty
Summary
The facility failed to maintain air temperatures within comfortable ranges in multiple common areas, affecting all 33 residents. Observations revealed that temperatures in the main entrance, administration offices, dining room, hallways, chapel, and common gathering rooms were consistently below the facility's policy range of 71-81 degrees Fahrenheit, with some areas as low as 48.5 degrees Fahrenheit. Residents were observed wearing winter coats, sweatshirts, hats, and blankets in an attempt to stay warm. The Secured Behavioral Unit and other common areas also had low temperatures, and portable heaters were either insufficient or malfunctioning. The main boiler system, which provided heat to these areas, was found to be permanently shut off and non-functional, with exposed wires in the boiler room. Interviews with the Maintenance Director and Administrator confirmed the ongoing low temperatures and the non-functioning boiler. The facility had installed PTAC units in resident rooms, allowing residents to control their own room temperatures, but these units were not always working correctly, as evidenced by discrepancies between thermometer readings and PTAC displays. The Administrator acknowledged that common areas were not prioritized for heating, and the dining room had been closed for at least two years due to the boiler issue. Facility policy required maintaining safe and comfortable temperatures in all resident rooms and areas, but this was not achieved in the common spaces.
Failure to Accommodate Resident Dining Preferences Due to Inadequate Heating
Penalty
Summary
The facility failed to accommodate residents' preferences to eat in the dining room due to inadequate heating in common areas, including the dining room itself. Observations revealed that the temperatures in these areas, measured by the Maintenance Director using a hand-held infrared thermometer, ranged from 51.2 to 56.5 degrees Fahrenheit. The boiler responsible for heating these spaces was found to be non-functional and had been permanently shut off, with exposed wires visible in the boiler room. Auxiliary heaters were present but insufficient to make the dining room comfortable for regular use. Staff interviews confirmed that the dining room had not been used for meals or activities for two years, except for a single event where additional heaters were used. Resident interviews indicated a clear desire to eat in the dining room if the temperature were comfortable. One resident, who was cognitively intact and independent with eating, specifically expressed enjoyment in dining in the communal space but cited the cold as a deterrent. Other residents echoed this sentiment. The Administrator acknowledged that the dining room and other common areas had not been prioritized for heating due to cost concerns and stated that the focus was on maintaining resident room temperatures. As a result, all meals were served in residents' rooms, and the facility did not support or facilitate resident choice regarding dining location.
Unqualified Activities Director Oversight
Penalty
Summary
The facility failed to ensure that its Activities Program was directed by a qualified Activities Director (AD). Record review showed that the AD did not sign attendance forms for several Resident Council meetings, and these meetings were instead facilitated and signed by an Activities Aid (AA). Interviews revealed that the DON was unaware of any concerns from these meetings and did not know if the AD met the required qualifications. The AA stated she had only recently been informed of her responsibility to share meeting minutes with management. Personnel file review indicated that the individual serving as AD was originally hired as social services staff and lacked documentation of certification or appropriate training for the AD role. The AD confirmed in an interview that she did not meet the qualifications for the position and had not enrolled in the necessary program due to a change in facility ownership. This deficiency had the potential to affect 32 residents interested in or participating in activities.
Failure to Maintain Safe and Functional Heating in Common Areas
Penalty
Summary
The facility failed to maintain essential mechanical equipment, specifically the boiler, in a functional and safe operating condition, which resulted in inadequate heating throughout multiple common areas and resident-accessible spaces. Observations revealed that temperatures in the main entrance, administration offices, dining room, hallways, chapel, and common gathering rooms were significantly below the facility's policy requirement of 71-81 degrees Fahrenheit, with recorded temperatures ranging from 48.5 to 61.6 degrees Fahrenheit. Residents were observed wearing winter coats, sweatshirts, hats, and blankets to keep warm while ambulating or self-propelling in these areas. The boiler was found to be permanently shut off with exposed wires, and auxiliary heaters were being used as supplemental heat sources, some of which were not functioning properly. Interviews with the Maintenance Director and Administrator confirmed the non-functional status of the boiler and the ongoing low temperatures in the affected areas. The facility had installed PTAC units in resident rooms, allowing residents to control their room temperatures, but did not address heating in the common areas linked to the non-functional boiler. Discrepancies were noted between actual room temperatures and those displayed on PTAC units, with some units requiring frequent resets. The dining room had been closed for at least two years due to the lack of heat, and the Administrator stated that heating common areas was not a priority as they believed it did not affect resident care.
Failure to Maintain Safe and Comfortable Environmental Conditions
Penalty
Summary
The facility failed to maintain comfortable and safe environmental conditions for its residents, specifically regarding air temperature and access to hot water. On the 400 and 500 halls, the air conditioning system was inoperable, resulting in room temperatures exceeding 81 degrees Fahrenheit, with specific readings as high as 83.3 degrees. Residents reported discomfort due to the heat, with some removing clothing or opening windows to cope. Staff interviews confirmed the air conditioning had been nonfunctional for several weeks, and the facility's own policy required immediate action to maintain temperatures within the 71 to 81 degrees Fahrenheit range, which was not followed. Additionally, residents on the 100, 200, and 300 halls did not have access to hot water in their rooms or shower areas. Water temperatures in resident sinks and shower rooms were measured between 65.0 and 73.5 degrees Fahrenheit, which was insufficient for bathing and personal hygiene. Residents reported being unable to wash up or take bed baths, and the issue had persisted for several weeks. Despite obtaining an estimate for hot water heater replacement, there was no evidence that the facility had taken action to repair the hot water system.
Non-Compliance with Food Procurement and Handling Standards
Penalty
Summary
The facility failed to procure food from approved or satisfactory sources and did not store, prepare, distribute, or serve food in accordance with professional standards. This deficiency was identified during the survey process, indicating non-compliance with established food safety and handling requirements. No additional details regarding specific residents, staff, or observed events are provided in the report.
Failure to Maintain Properly Functioning Heating and Air Conditioning Units
Penalty
Summary
The facility failed to maintain a comfortable and home-like environment by not ensuring that heating and air conditioning units in several resident rooms were properly functioning. Multiple residents reported that the heating/air conditioning units in their rooms were not working. Specifically, five residents voiced complaints about non-functioning units. During interviews, the maintenance supervisor initially stated that all units were working and that residents could control them in their rooms. However, subsequent observations and interviews with the maintenance supervisor confirmed that the units in four residents' rooms were not functioning properly, and the unit in another resident's room was working but not blowing strong enough and required repair. A review of the facility's Room Temperatures policy indicated that air conditioning repairs or modifications should be completed as soon as possible. The deficiency was identified through resident and staff interviews, direct observation, and policy review. This issue was found to be ongoing from a previous survey, indicating that the problem had not been resolved since it was first identified.
Resident Not Treated with Dignity and Respect During Shower Assistance
Penalty
Summary
A deficiency was identified when a resident with chronic obstructive pulmonary disease, edema, post-traumatic stress disorder, and hypertension, who was cognitively intact and required supervision for all activities of daily living, reported being treated without dignity and respect by a Certified Nursing Assistant (CNA). The resident stated that while on the phone, the CNA repeatedly insisted that she take a shower immediately, disregarding the resident's request to shower later. The CNA returned and began yelling at the resident to take a shower and to get off the phone, stating that the phone call was not important. The resident reported this incident to the Administrator, who told her he would speak with her later but did not follow up. Further interviews confirmed the CNA's actions, as the CNA admitted to yelling at the resident from a distance and telling her to hang up the phone, expressing disbelief in the importance of the call. The Administrator stated he was unaware of the specific accusations and did not address the resident's concerns at the time. The care plan for the resident included interventions to approach and speak to her in a calm voice due to her anxiety and depression, which were not followed during the incident.
Failure to Provide Adequate Pain Management
Penalty
Summary
A resident with multiple complex medical conditions, including quadriplegia, polyneuropathy, a history of a displaced bimalleolar fracture, hypertension, type 2 diabetes, and COPD, was admitted to the facility and identified as being at risk for pain. The resident's care plan included interventions such as administering medication as ordered, monitoring for pain every shift, and notifying the physician as needed. Physician orders were in place for acetaminophen as needed for pain and a daily aspirin, though the DON later clarified that the aspirin was not intended for pain management. Despite these orders, documentation showed that the resident reported significant pain levels of 7 and 8 out of 10 on two consecutive days, but did not receive any pain medication on those occasions. Further review of the medical record and interviews confirmed that the resident had not received any pain medication since admission, and there was no documentation of non-pharmacological pain interventions being offered or implemented. The DON acknowledged these findings and confirmed the lack of pain management provided, despite the resident's ongoing pain and an upcoming appointment at a pain clinic. The facility's pain assessment and management policy required staff to identify pain and develop interventions to meet the resident's goals, but these steps were not followed in this case.
Failure to Administer and Reorder Medications as Prescribed
Penalty
Summary
The facility failed to ensure that medications were administered as ordered for two residents. For one resident with a history of chronic obstructive pulmonary disease, hypertension, and other conditions, there was a physician's order to administer Olmesartan Medoxomil 20 mg daily, with instructions to hold the medication if the systolic blood pressure was 100 or less. Despite this, the medication was administered on multiple occasions without documentation of the resident's blood pressure at the time of administration. The Director of Nursing confirmed that blood pressures were not monitored when the medication was given, contrary to the physician's order and care plan interventions. Another resident, with diagnoses including right lower quadrant pain and schizoaffective disorder, had a physician's order for Norco 5-325 mg every six hours for pain. The resident's medical record and progress notes indicated that the Norco was not available for administration for several days, resulting in the resident receiving Tylenol instead, which was documented as ineffective for pain relief on at least one occasion. Staff notes repeatedly indicated that the Norco was on order or awaiting delivery, and the controlled drug record showed the last dose was administered several days prior. Nursing staff confirmed the resident had been without the prescribed pain medication for a week, and the nurse practitioner was unaware of the medication's unavailability. Facility policy required medications to be administered in a safe and timely manner as prescribed. The failure to monitor blood pressure prior to administering antihypertensive medication and the lack of timely reordering and availability of prescribed pain medication for the residents constituted non-compliance with pharmaceutical service requirements. These deficiencies were identified through medical record review, staff interviews, and policy review.
Failure to Maintain Safe and Homelike Physical Environment
Penalty
Summary
The facility failed to maintain the building and furnishings in good repair, affecting multiple residents, including one with chronic obstructive pulmonary disease and bipolar disorder who required assistance with activities of daily living. Observations revealed a large hole in the wall of this resident's room, which had been present since admission and had not been repaired despite requests. The resident and staff confirmed the ongoing disrepair, and the administrator acknowledged the damage was caused by a power wheelchair. Additional observations identified significant deterioration in common areas, including a built-in buffet cabinet in the resident lounge with missing baseboards, chipped wood, scuff marks, and cracked drawers. Staff noted the cabinets appeared moldy and had been in poor condition for several months. The walls and doors in the 300 and 400 halls also showed broken trim, chipped paint, and scuffing. Residents and staff confirmed the poor state of repair, and the administrator admitted repairs were not prioritized, stating that damage would likely recur. The facility did not have a policy regarding the physical environment.
Facility Fails to Maintain Clean and Homelike Environment
Penalty
Summary
The facility failed to maintain a clean and homelike environment, as evidenced by the condition of the shower rooms and the floor in a resident's room. Observations revealed that the 500-hallway shower room, the only one used by all residents, had non-functioning stalls, dirt, debris, and trash scattered on the floor, and lights containing what appeared to be bugs. Additionally, the 200-hall shower room was found to be in disrepair, with a foot of stagnant water covering the floor, water pouring from the ceiling, and brown stains and black dotted substances on the walls and ceiling. The Maintenance Supervisor confirmed these conditions and noted that the bathroom was filled with various chairs and debris, with the water turned off. Resident #36, who was cognitively impaired and required assistance with daily activities, was affected by the facility's failure to maintain cleanliness. During a medication pass, an LPN observed that her shoes were sticking to the floor in the resident's room, making a loud noise. This was confirmed by a Regional Nurse, who suggested that the stickiness might be due to the chemical cleaner used. The facility's cleaning checklist required proper cleaning and disinfection of floors, which was not adhered to in this case.
Medication Administration Errors Exceed Acceptable Rate
Penalty
Summary
The facility failed to administer medications according to physician orders, resulting in a medication error rate of 6.45%, which exceeds the acceptable threshold of 5%. This deficiency affected two residents. Resident #40, who was cognitively intact and required assistance with various activities of daily living, was administered Pyridium 100 mg by an LPN despite having no active order for this medication. The LPN confirmed the absence of an active order, and the Regional Nurse verified that the medication should not have been administered. Resident #47, also cognitively intact and requiring assistance with daily activities, had a physician's order for Linagliptin 5 mg to be administered for diabetes management at 8:00 A.M. However, the LPN failed to administer this medication during the scheduled time. The LPN later confirmed the omission. The facility's policy on medication administration, which mandates that medications be administered as prescribed, was not followed in these instances.
Medication Storage Deficiency
Penalty
Summary
The facility failed to ensure medications were stored in a safe manner, affecting one resident. During an observation and interview, it was found that the resident had several bottles of medication in his room, including milk thistle, St. John's Wort, zinc, B vitamins, and soy lecithin. These medications were not stored in accordance with the facility's policy, which requires all drugs and biologicals to be stored in a safe, secure, and orderly manner. The resident, who was cognitively intact and dependent on staff for medication administration, had a range of medical conditions including alcohol dependence withdrawal, emphysema, anxiety disorder, major depressive disorder, and others. The facility's policy, dated 2001, mandates that nursing staff are responsible for maintaining medication storage, but this was not adhered to in this instance, leading to the deficiency.
Inadequate Room Temperature for Resident
Penalty
Summary
The facility failed to ensure a comfortable environment for a resident, identified as Resident #46, who was affected by inadequate room temperature. The resident, who was severely cognitively impaired with a BIMS score of three, required supervision and assistance with daily activities. During an observation, the temperature in the resident's room was recorded at 66 degrees Fahrenheit, which was below the facility's policy threshold of 71 degrees for implementing procedures to prevent hypothermia. The facility's heating system was not fully operational due to incomplete installation of new heating and air conditioning units, which were not yet connected to the outdoor condenser. Interviews with facility staff, including a Housekeeping Technician and a Certified Nurse Aide, confirmed the issue with the room temperature and the reliance on hallway heaters to warm resident rooms. The Administrator verified the room temperature with a laser thermometer and acknowledged the deficiency. The facility's policy on extreme cold indicated a higher risk for hypothermia when temperatures dropped below 65 degrees for four consecutive hours, highlighting the potential risk to the resident's safety and comfort.
Medication Administration Deficiency
Penalty
Summary
The facility failed to ensure medications were administered as ordered for Resident #44, who was affected by this deficiency. Resident #44, admitted on 08/24/21, had diagnoses including chronic obstructive pulmonary disease, heart disease, delusional disorder, and chronic pain. The resident was cognitively intact with a BIMS score of 15 and required extensive assistance for bed mobility and toileting hygiene. The plan of care indicated a risk for pain related to muscle spasm, post-procedural pain, and chronic pain, with interventions to administer medication as ordered. However, on 02/19/25, Resident #44 did not receive the prescribed Oxycodone Hcl 5 mg at 9:00 A.M. and 9:00 P.M. The deficiency occurred because the facility ran out of the Oxycodone supply, and the pharmacy was awaiting a new prescription script. The LPN documented the situation in a progress note, and the provider was made aware. The Director of Nursing confirmed that the new prescription was ordered timely, but the emergency drug kit supply could not be used to administer the pain medication on that day. The facility's policy on medication administration, dated 01/2018, states that medications should be administered as prescribed, which was not adhered to in this instance.
Medication Error Rate Exceeds 5%
Penalty
Summary
The facility failed to maintain a medication error rate below 5%, resulting in a 6.6% error rate during the survey. This deficiency was identified through record reviews, observations, and staff interviews. Specifically, the error involved Resident #44, who was prescribed Magnesium Hydroxide oral suspension and Folic Acid 1 mg tablet. However, the resident was administered Magnesium Oxide 400 mg in tablet form and Folic Acid 400 mcg in pill form, which did not align with the physician's orders. The incident was observed when LPN #288 administered the incorrect medications to Resident #44. Upon interview, LPN #288 confirmed the administration of the wrong form and dosage of medications. Further observation with the Director of Nursing revealed that the correct Magnesium Hydroxide oral suspension was available in the medication cart but was not used. The facility's policy on medication administration, which requires medications to be administered as prescribed, was not followed, leading to this deficiency.
Failure to Maintain Comfortable Room Temperatures
Penalty
Summary
The facility failed to maintain air temperatures within comfortable ranges for residents residing on the secure behavioral unit (100 hall). During an observation conducted on January 21, 2025, from 4:16 P.M. to 4:30 P.M., it was noted that the air temperatures in the unit were below 71 degrees Fahrenheit. Specific room temperatures were recorded, with one room at 43.6 degrees F, another at 55 degrees F, and a third at 51.1 degrees F. The temperatures in all 12 rooms on the unit ranged from 43.6 F to 55 F. Two portable heating units were present in the hallway, but residents were observed in the unit without any visible signs of distress. Interviews with the Maintenance Director (MD) and the Administrator confirmed that the air temperatures were not at comfortable levels. The MD stated that the resident room heaters were operational but unable to keep up with the current low outside temperatures. A resident expressed that it was cold in the unit. The facility's policy, revised in July 2020, mandates maintaining room temperatures between 71-81 degrees F. This deficiency was investigated under Complaint Number OH00161777 and had the potential to affect 13 residents residing on the secure behavioral unit.
Failure to Assist Resident with Medical Appointments
Penalty
Summary
The facility failed to provide medically-related social services by not assisting a resident with their medical appointments. Resident #21, who has diagnoses including chronic obstructive pulmonary disease, chronic pain, hypertension, and depression, was affected by this deficiency. The resident had intact cognition and required assistance with daily activities. The facility did not document the resident's medical appointments on 10/17/24 and 10/28/24 in the progress notes, which were crucial for the resident's follow-up care after an aortic aneurysm repair. Interviews revealed that the resident attended the appointment on 10/17/24, but the appointment on 10/28/24 was rescheduled to 11/04/24 without proper documentation or communication. The transportation staff confirmed the appointment was scheduled but canceled without a documented reason. The cardiologist's office confirmed the resident was a no-show for the 10/28/24 appointment, and the facility's administration acknowledged the lack of documentation and could not explain the cancellation. This deficiency was investigated under Complaint Number OH00159497.
Medication Administration and Documentation Failures
Penalty
Summary
The facility failed to ensure medications were administered according to physician orders, accurately documented, and reordered as necessary, affecting two residents. Resident #52, who was admitted with multiple diagnoses including anxiety and schizophrenia, had an order for Clonazepam that was not transcribed correctly. The facility's medication administration record showed discrepancies in the dosage and frequency of administration, with the resident not receiving the prescribed doses. Interviews with the Director of Nursing (DON) and the pharmacist confirmed these errors, and the facility did not utilize the emergency box to provide the medication when it was unavailable. Resident #21, admitted with conditions such as chronic pain and depression, had orders for oxycodone and methocarbamol. The facility's records showed inconsistencies in the documentation of oxycodone administration, with more tablets signed out than documented as given. Additionally, methocarbamol was not available, and there was a lack of documentation for its administration. Interviews revealed that the facility did not request refills or document insurance issues properly, leading to the unavailability of the medication. The facility's policy on medication errors defines such errors as deviations from physician orders and documentation standards. The deficiencies were identified during a complaint investigation, highlighting failures in medication management and documentation processes. The facility's staff, including the DON and corporate RN, verified the discrepancies and acknowledged the lack of proper documentation and medication availability.
Failure to Ensure RN Supervision for Required Hours
Penalty
Summary
The facility failed to ensure the supervision by a Registered Nurse (RN) for eight consecutive hours daily, which is a requirement. This deficiency was identified through a review of the nursing schedule dated June 16, 2024, which revealed that no RN was scheduled for that day. An interview with the Director of Nursing (DON) on July 17, 2024, confirmed that the facility did not have an RN on duty on June 16, 2024. This failure had the potential to affect all 52 residents residing in the facility.
Facility Fails to Maintain Safe and Clean Environment
Penalty
Summary
The facility failed to maintain a clean, safe, and comfortable environment for its residents, as evidenced by several observations and interviews. In the secured Memory Care Unit, the floors were found to be dirty, with 80% of the laminate wood stained black and littered with food crumbs, soda cans, and other debris. This was confirmed by a State Tested Nursing Assistant (STNA) who verified the poor environmental conditions. In another instance, a resident's room was observed to be excessively warm, with temperatures reaching 85 degrees Fahrenheit despite attempts to adjust the thermostat. The resident reported discomfort due to the heat, and a Housekeeping Assistant confirmed the room's temperature was above the recommended range. Additionally, the common area between two halls had multiple buckets and trash cans collecting water from leaking ceilings, which had been an ongoing issue for several months, as confirmed by a Licensed Practical Nurse (LPN) and the Maintenance Supervisor. The outdoor environment of the facility was also found to be poorly maintained, with overgrown landscaping, decaying tree branches, and debris such as empty plastic bottles and fabric pieces scattered across the patio area. This made it difficult for residents to navigate the pathways, as confirmed by a resident and an STNA. The facility's administrator acknowledged the poor conditions and the need for a safe and homelike environment. The facility's housekeeping policy indicated that residents should receive regular housekeeping services, which were evidently not being provided. This deficiency was a repeat issue from previous complaint surveys.
Failure to Supervise Smoking and Control Hazardous Items
Penalty
Summary
The facility failed to ensure that residents did not have access to potentially dangerous items such as knives, razors, and smoking materials, and did not provide adequate supervision for residents who smoked. This deficiency affected several residents, including those with cognitive impairments and those who required supervision while smoking. For instance, Resident #50, who had intact cognition and was independently mobile, was observed lighting a cigarette for Resident #29, who had moderately impaired cognition and required supervision. Both residents were unsupervised on the smoking patio, contrary to the facility's policy. Resident #48, who had severely impaired cognition and was independently mobile, was found with cigarettes in his walker basket, despite the care plan indicating that smoking items should be stored at the nurse's station and that the resident required supervision while smoking. Similarly, Resident #107, who had a history of suicidal ideation and required partial assistance for transfers, was found with a large pocketknife, razors, and a carton of cigarettes in his drawer, which he was not supposed to have access to. This resident also expressed feelings of depression and had been consulted for psychiatric services. Additionally, Resident #21, who was cognitively intact, was observed smoking outside the designated area with a lighter, despite being a supervised smoker. The resident claimed to have had the lighter since admission, and the Director of Nursing confirmed that the resident was not supposed to have a lighter without supervision. These incidents highlight the facility's failure to adhere to its smoking policy, which mandates supervision for residents with supervised smoking privileges and secure storage of smoking materials.
Dishwasher Sanitization Failure
Penalty
Summary
The facility failed to ensure the dishwasher was functioning properly to clean and sanitize dishes, which had the potential to affect 51 of the 52 residents. The Dietary Supervisor (DS) confirmed that the sanitizer concentration levels in the dishwasher had been reading 0 parts per million (ppm) for a few weeks, despite the requirement for a safe level of 50 ppm. The dishwasher continued to be used during this period, and the issue was not addressed until a service technician was called. The technician confirmed that the sanitizer bucket was empty, which was the cause of the 0 ppm reading. The sanitizer bucket had a delivery date of several months prior, and there was no record of when it was opened or when the sanitizer was last ordered. The DS was unable to provide invoices or documentation regarding the ordering of sanitizer, and the staff member responsible for managing kitchen chemicals was unavailable. This lack of oversight and documentation contributed to the deficiency, as the facility did not maintain the necessary supplies to ensure proper sanitation of dishes.
Failure to Implement Enhanced Barrier Precautions
Penalty
Summary
The facility failed to implement Enhanced Barrier Precautions (EBP) for residents with wounds and indwelling medical devices, affecting five residents. Resident #14, with an unstageable vascular ulcer, had no physician orders for EBP, and there was no signage or personal protective equipment (PPE) outside the resident's room. Similarly, Resident #15, who had a feeding tube, also lacked EBP orders and appropriate signage or PPE outside the room. Registered Nurse #368 confirmed the absence of necessary precautions for both residents. Resident #28, with vascular ulcers on both lower extremities, also did not have physician orders for EBP, and there was no notification or PPE outside the room. The same issue was observed for Resident #33, who had an indwelling catheter and was a carrier of methicillin-resistant Staphylococcus aureus. Despite the care plan indicating the need for EBP, there were no orders or PPE available. The Director of Nursing confirmed that both Residents #16 and #33 should have been placed in EBP due to their conditions. The facility's policy on Enhanced Barrier Precautions, dated April 1, 2024, stated that EBP should be used to prevent the transmission of multidrug-resistant organisms and protect patients with chronic wounds and indwelling devices. The policy required physician orders for EBP to be reflected in the resident's medical record. However, the facility did not adhere to this policy, resulting in the deficiency noted during the survey.
Failure to Document Vaccination Offers
Penalty
Summary
The facility failed to ensure that residents were offered pneumococcal and influenza vaccinations, as evidenced by the lack of documentation in the medical records of five residents. The medical records for these residents did not include any information regarding the receipt or refusal of the vaccines. This deficiency was confirmed during an interview with the Administrator, who acknowledged the absence of documentation for the vaccinations in question. The facility's census at the time was 52 residents, and the deficiency affected all five residents reviewed for vaccinations.
Failure to Maintain Resident Dignity and Privacy
Penalty
Summary
The facility failed to ensure residents were treated with dignity and respect, affecting two residents. Resident #33, who was cognitively intact with a BIMS score of 15, had an indwelling catheter due to obstructive and reflux uropathy. During an observation, it was noted that Resident #33's urinary Foley bag was very full and visible from the hallway, without a dignity bag covering it. This was confirmed by a State tested Nursing Assistant (STNA), indicating a lack of privacy and dignity for the resident. Resident #17, who was cognitively impaired with a BIMS score of 10 and required substantial assistance for ADLs, was observed seated in a wheelchair at the nurse's station with her hospital gown untied, exposing her back and buttocks. Despite being in a common area where other residents were passing by, the resident remained exposed for a period of time. An LPN acknowledged the situation and indicated that an aide would assist the resident, but the exposure continued during further observation. This incident demonstrated a failure to maintain the resident's dignity and respect as outlined in the facility's Residents Rights document.
Inadequate Supervision Leads to Resident-to-Resident Sexual Abuse
Penalty
Summary
The facility failed to provide adequate supervision to prevent resident-to-resident sexual abuse, affecting two residents. Resident #29, who was cognitively impaired and had a court-appointed guardian, was involved in a sexual incident with another resident, #42. Despite the resident's inability to consent, the facility did not notify the police or conduct a thorough investigation. The Director of Nursing acknowledged the resident's mental capacity was akin to that of a young child, yet the facility did not implement sufficient measures to prevent further incidents. Resident #42, who was cognitively intact, had a history of inappropriate sexual behavior and was involved in multiple incidents with Resident #29. The facility's response to these incidents was inadequate, as there was no documented evidence of an investigation or notification to law enforcement. The facility's plan of care for Resident #42 included interventions such as staff redirection and 15-minute checks, but these measures were insufficient to prevent the incidents. Another resident, #43, who had severe cognitive impairment, was also involved in a sexual incident with Resident #42. The facility failed to provide increased supervision or implement safety measures following the incident. Despite the resident's history of wandering into other residents' rooms, the facility did not place her on one-on-one observation. The facility's policy on abuse and neglect was not followed, as incidents were not reported or documented appropriately, leading to a deficiency in protecting residents from abuse.
Failure to Implement Abuse Policy During Staff-to-Resident Verbal Abuse Incident
Penalty
Summary
The facility failed to timely implement their abuse policy during an incident involving staff-to-resident verbal abuse. The incident involved Resident #18, who was cognitively intact and had a history of verbal behaviors and occasionally rejecting care. The situation arose when State tested Nurse Aide (STNA) #360 entered the room shared by Resident #18 and Resident #46 to provide care. Resident #18 became upset with the noise and interaction, leading to a verbal altercation between her and STNA #360. The altercation escalated with both parties exchanging derogatory language, and STNA #360 pushing Resident #18's wheelchair aggressively. Registered Nurse (RN) #406 witnessed the incident and attempted to intervene by asking STNA #360 to leave the room. However, STNA #360 refused to comply and continued to engage in verbal abuse towards Resident #18. Despite RN #406's efforts to de-escalate the situation and educate STNA #360 on professional conduct, the STNA was not receptive and continued to threaten Resident #18. RN #406 did not promptly remove Resident #18 from the room or take further action to ensure STNA #360 left the premises, failing to protect the resident from continued abuse. The facility's policy on abuse, neglect, exploitation, and misappropriation of resident property required immediate removal of any staff member accused or suspected of abuse. However, this policy was not effectively implemented during the incident, as evidenced by the continued presence and actions of STNA #360. The deficiency was identified during a complaint investigation, highlighting the facility's non-compliance with its own policies and procedures designed to protect residents from abuse.
Failure to Investigate Allegations of Sexual Abuse
Penalty
Summary
The facility failed to thoroughly investigate allegations of sexual abuse involving Resident #29, who was identified as having cognitive impairments and a court-appointed guardian due to incompetence. The incident in question occurred when Resident #42 was found in Resident #29's room, and Resident #29 was attempting to give oral sex to Resident #42. Despite the serious nature of the incident, there was no documented evidence that the resident's guardian or physician was notified, nor was there an investigation initiated immediately as required by the facility's policy. Interviews with staff revealed a pattern of neglect in addressing similar incidents involving Resident #29. The Social Services Designee (SSD) provided Resident #29 with a guide on sexual consent, despite the guardian's explicit instructions against any sexual contact. The State Tested Nursing Assistant (STNA) reported multiple sexual encounters involving Resident #29 with other residents, which were not properly investigated. The Director of Nursing (DON) acknowledged the lack of police notification and proper investigation following the incident, admitting that Resident #29 had the mental capacity of a young child and could not consent to sexual activities. The facility's policy mandates immediate reporting and investigation of all incidents and allegations of abuse, yet this was not adhered to in the case of Resident #29. The Administrator confirmed that allegations of sexual abuse should be investigated immediately, with law enforcement and guardians notified, but this protocol was not followed. The deficiency was investigated under Complaint Number OH00155040, highlighting a significant lapse in the facility's duty to protect its residents and ensure their safety.
Failure to Conduct Quarterly Care Conferences
Penalty
Summary
The facility failed to hold quarterly care conferences with residents and/or their representatives, affecting three residents. Resident #29, who has multiple diagnoses including cognitive impairment, had not had a care conference since March 2022, despite having a court-appointed guardian who requested conferences multiple times. The guardian was unaware of the resident's plan of care due to the lack of communication from the facility. Social Services Designee #376 confirmed that no care conferences had been scheduled or conducted for Resident #29 since she began working at the facility six months prior. Resident #49, who is cognitively intact, had only one documented care conference from March 2023 to July 2024, despite the requirement for quarterly conferences. Similarly, Resident #51, with moderately impaired cognition, had care conferences documented only twice between September 2023 and July 2024. The facility's policy requires social services to notify residents or their representatives about care conferences and maintain records of such notices, which was not adhered to in these cases.
Failure to Administer Dietary Supplements as Ordered
Penalty
Summary
The facility failed to ensure that dietary supplements were administered according to the physician's order for a resident. The medical record review and staff interview revealed that a resident, who had been admitted with multiple diagnoses including acute gastroenteritis, colitis, PTSD, major depressive disorder, cerebral infarction, adult failure to thrive, colon cancer, diabetes mellitus, emphysema, and mild protein-calorie malnutrition, was affected by this deficiency. The resident was ordered to receive Boost, an oral supplement, three times a day starting from June 2, 2024. However, the Medication Administration Record (MAR) indicated that the resident did not receive the Boost as ordered on two occasions on June 3, 2024, and once on June 7, 2024. The Director of Nursing (DON) confirmed during an interview that there were gaps in the MAR for the administration of Boost on the specified dates, and there were no progress notes documenting the administration of the supplement on those days. This lack of documentation and administration of the dietary supplement as per the physician's order led to the deficiency being identified. The deficiency was investigated under Complaint Number OH00154796, affecting one of the two residents reviewed for nutrition in a facility with a census of 52.
Failure to Administer Medications as Ordered
Penalty
Summary
The facility failed to ensure that a resident received medications as ordered, affecting one of four residents reviewed for pain. The resident, who had intact cognition, was admitted with multiple diagnoses including COPD, hypertension, pain, anxiety disorder, and major depressive disorder. The physician orders for the resident included medications such as Celebrex, Aspirin, folic acid, omeprazole, multivitamins, thiamine, metoprolol, Seroquel, Norco, promethazine, and lorazepam. However, the Medication Administration Record (MAR) for June 2024 showed no documentation that these medications were administered on specific dates, namely 06/19/24, 06/25/24, and 06/28/24. The Director of Nursing confirmed the absence of documentation for the administration of these medications on the specified dates. The facility's policy on medication administration requires that medications be administered as prescribed and documented immediately after administration. If a medication is withheld, refused, or not available, it should be documented on the MAR with an explanatory note in the medical record. This deficiency was investigated under a complaint and is a recite to previous complaint surveys.
Failure to Provide Timely Radiology Services
Penalty
Summary
The facility failed to provide timely radiology services as per the physician's order for a resident experiencing constipation. Resident #107, who had a medical history including a humerus fracture, major depressive disorder, and age-related osteoporosis, was admitted with intact cognition and required moderate assistance for transfers. The resident's last recorded bowel movement was on 07/04/24, and by 07/08/24, the resident complained of lower abdominal pain and had not had a bowel movement in five days. The physician was notified and ordered a KUB x-ray on 07/09/24 to assess the situation. Despite the physician's order, the medical record for Resident #107 did not include documentation of the KUB x-ray being completed or any results from such an x-ray. An interview with the resident on 07/08/24 confirmed the absence of a bowel movement for six days, despite receiving medications to promote bowel movements, and the resident reported stomach cramping. The Director of Nursing confirmed on 07/15/24 that the KUB x-ray was not completed and there was no documentation explaining the rationale for this omission.
Failure to Document Resident Transfer to Hospital
Penalty
Summary
The facility failed to ensure that the medical records of a resident adequately reflected their status, specifically in the case of a resident who was reviewed for constipation. The resident, who had a range of diagnoses including a right humerus fracture, major depressive disorder, and age-related osteoporosis, was admitted on an unspecified date and discharged on another unspecified date. The Minimum Data Set (MDS) assessment indicated that the resident had intact cognition and required partial/moderate staff assistance for transfers. On a specific date, the resident was observed to be missing from their room and could not be located by the surveyor. Upon reviewing the medical records, it was found that there was no documentation of the resident's location. An interview with the Director of Nursing (DON) revealed that the resident had been sent to the hospital several days prior and had not returned, but this transfer was not documented in the medical record, which the DON confirmed should have been done.
Deficiency in Call Light Functionality for Residents
Penalty
Summary
The facility failed to ensure that residents had functioning call lights, affecting three residents. Resident #2, who was admitted with diagnoses including schizophrenia, dementia, chronic pulmonary disease, and delusional disorder, was observed without a call light cord in their room, making it impossible to summon assistance or turn off the sounding call light. Despite being cognitively intact and requiring supervision for various activities, the resident's care plan emphasized the need for a call light within reach due to fall risk. Interviews with staff confirmed the absence of a functional call light or alternative means for the resident to summon help. Similarly, Resident #53, with severe cognitive impairment and diagnoses including schizoaffective bipolar disorder and anxiety disorder, was found with a call light cord wrapped around the call light box, rendering it non-functional. The resident's care plan also highlighted the necessity of having a call light within reach due to fall risk. Additionally, Resident #47, who was severely cognitively impaired and diagnosed with Huntington's disease, mood disorder, anxiety disorder, and dementia, was observed with a non-functional call light cord wrapped around the box on the wall. Staff interviews confirmed the lack of functional call lights for these residents, which was a recurring issue noted in previous complaint surveys.
Failure to Notify Physician of Significant Weight Loss
Penalty
Summary
The facility failed to notify the physician of a significant weight loss experienced by a resident, which is a requirement according to the facility's policy. The medical record review for the resident, who had multiple diagnoses including type two diabetes, emphysema, and congestive heart failure, showed a significant weight loss over a six-month period. The resident's weight decreased from 179.6 pounds to 151.4 pounds, amounting to a 15.7% weight loss in six months and an 11.9% weight loss in three months. Despite this significant change, there was no documentation indicating that the physician was informed of the weight loss. The dietary progress note for the resident recommended a house supplement twice per day due to the significant weight loss, but again, there was no documentation of physician notification. An interview with the Director of Nursing confirmed the lack of documentation regarding physician notification. The facility's policy, dated January 11, 2020, clearly states that a nurse should notify the physician of any significant change in a resident's status, including unplanned significant weight loss, defined as a loss of 5% in 30 days or 10% in 180 days. This oversight represents a failure to adhere to the facility's notification policy.
Failure to Provide Vision Services
Penalty
Summary
The facility failed to provide necessary vision services to a resident, which was identified during a survey. The resident, who has a medical history including type two diabetes, unspecified visual loss, chronic obstructive pulmonary disease, and chronic kidney disease, was admitted with a physician's order for a referral to an ophthalmologist due to decreased vision. Despite this order being in place since March, the resident had not been seen by an eye doctor by July, and the appointment that was supposed to occur six months prior was canceled and never rescheduled. The resident confirmed her vision was impaired and she was going blind, and she needed new prescription glasses. The facility's policy on Ancillary Services, which includes coordinating vision services, was not followed in this case. The Social Service Designee was unaware of the resident's referral for ophthalmology, indicating a breakdown in communication and coordination within the facility. The resident's care plan included interventions to obtain eye exam consultations, but these were not executed, leading to the deficiency in maintaining the resident's vision care.
Failure to Provide Follow-Up Dental Care
Penalty
Summary
The facility failed to ensure residents received follow-up care after dental visits, affecting two residents. Resident #46, who has type two diabetes, visual loss, chronic obstructive pulmonary disease, and chronic kidney disease, was admitted with a care plan that included arranging for dental care. Despite this, the resident confirmed needing dental fillings that had fallen out and had not been seen by a dentist since admission. The Social Service Designee was unaware of the resident's dental concerns, confirming the lack of follow-up care. Resident #49, with diagnoses including morbid obesity, asthma, and heart failure, was examined by the facility dentist, who recommended dental extractions and possibly dentures. However, the resident reported experiencing gum pain and confirmed that the extractions had not been performed. The Social Service Designee admitted to not reviewing the dentist's notes, and the Director of Nursing was also unaware of the recommendations for dental extractions and dentures. The facility's policy stated that they assist residents in obtaining timely dental services, which was not adhered to in these cases.
Facility Fails to Maintain Comfortable Environment
Penalty
Summary
The facility failed to provide a comfortable, clean, and homelike environment for its residents, as evidenced by two main issues observed during the survey. On the 100 Hall, the air temperature was found to be uncomfortably warm, with a recorded temperature of 85.5 degrees Fahrenheit. This was confirmed by Maintenance staff, who noted the presence of portable air conditioning units intended to maintain comfortable temperatures. Despite the warm conditions, residents were observed walking in the hallways and rooms without appearing to be in distress. However, the high temperature had the potential to affect 11 residents residing on this hall. Additionally, the 500 Hall was noted to have a pervasive urine odor, which was confirmed by an LPN who stated that the hall usually had a strong urine smell. This odor issue had the potential to affect 10 residents residing on the 500 Hall. These deficiencies were investigated under Complaint Number OH00154503 and were noted as ongoing noncompliance from a previous survey dated April 11, 2024.
Call Light Accessibility Deficiency
Penalty
Summary
The facility failed to ensure that the call light was within reach for a resident, identified as Resident #47, which was a deficiency noted during a survey. Resident #47 had a medical history that included diabetes mellitus with chronic kidney disease, chronic obstructive pulmonary disease (COPD), depression, and dementia with behavioral disturbances. The resident's quarterly Minimum Data Set (MDS) assessment indicated moderately impaired cognition, substantial assistance needed for toilet hygiene, bathing, and bed mobility, and highly impaired vision. During an observation and interview, it was found that the call light was placed on the headboard of the resident's bed, out of reach and not within the resident's line of vision. The resident confirmed the inability to reach the call light and mentioned that it did not work. An interview with LPN #277 confirmed the call light was not accessible to Resident #47 and that there were no alternative means for the resident to notify staff if assistance was needed. The facility's policy, dated December 2020, stated that call lights should be within the resident's reach before staff leave the room, to ensure timely response to residents' needs. This deficiency was investigated under Complaint Numbers OH00154373 and OH00153975, indicating non-compliance with the facility's policy regarding call light accessibility.
Failure to Implement Smoking Policy and Secure Smoking Materials
Penalty
Summary
The facility failed to implement its smoking policy, resulting in a deficiency related to the supervision and security of smoking materials for residents. Resident #51, who was admitted with multiple medical diagnoses including paraplegia and schizoaffective disorder, was not assessed for smoking upon admission. Despite being identified as a supervised smoker, Resident #51 was found smoking in his room, leading to a fire incident. The resident's smoking materials were not properly secured, as evidenced by the fire alarm activation and subsequent discovery of smoke in the resident's room. The resident admitted to smoking in the room and was found with a lit cigarette that caused a small fire on the bed linen. Additionally, Resident #46, who was also identified as a supervised smoker, was observed storing cigarette packs in the basket of her walker, contrary to the facility's smoking policy. The policy required that all smoking materials be stored in a designated secure area by the facility staff. This observation was confirmed by Maintenance staff, indicating a lapse in the enforcement of the smoking policy for Resident #46 as well. The facility's smoking policy, revised in November 2022, mandates that residents be evaluated upon admission and routinely to determine their ability to smoke safely. The policy also stipulates that smoking is only permitted in designated areas and that all smoking materials should be secured by the facility. The failure to adhere to these policies resulted in the deficiency, affecting the safety and supervision of residents who smoke.
Medication Administration Deficiency
Penalty
Summary
The facility failed to ensure that residents were free from significant medication errors, affecting two residents. Resident #23, who was cognitively intact and independent in most activities, had multiple physician orders for medications including Celebrex, Elavil, melatonin, metoprolol, Seroquel, and Norco. However, the May 2024 Medication Administration Record (MAR) lacked documentation to confirm that these medications were administered as ordered on May 8, 2024. Similarly, Resident #47, who had moderately impaired cognition and required substantial assistance, had physician orders for various medications such as dorzolamide-timolol ophthalmic solution, fluticasone-salmeterol inhaler, carvedilol, pregabalin, and others. The MAR for May 2024 did not contain documentation to support that these medications were administered as ordered on May 21, 2024. The Director of Nursing confirmed the lack of documentation for both residents. The facility's policy on medication administration, revised in November 2018, stated that medications should be administered as prescribed, which was not adhered to in these cases.
Medication Administration Error in LTC Facility
Penalty
Summary
The facility failed to ensure that medications were administered as ordered, resulting in a medication error rate of 6.66%, which is above the acceptable threshold of 5%. This deficiency was identified during a review of medical records, observations, and staff interviews. Specifically, the error involved Resident #53, who was observed not receiving the Lidocaine patch and MiraLAX as prescribed. The resident had a history of cerebral infarction, right-sided hemiparesis, paranoid schizophrenia, and bipolar disorder, and was noted to have moderate cognitive impairment. During an observation on June 5, 2024, at 8:15 A.M., LPN #229 was seen administering medications to Resident #53 but failed to apply the Lidocaine patch and administer MiraLAX. This was confirmed in an interview with LPN #229 shortly after the observation, where the nurse acknowledged the oversight. The facility census at the time was 55, and this incident was part of a complaint investigation under Complaint Number OH00153942.
Failure to Obtain Ordered Lab Work for Resident
Penalty
Summary
The facility failed to obtain laboratory work as ordered for a resident, which was identified during a review of medical records, staff interviews, and policy review. The resident, who had severe cognitive impairment and required substantial assistance for daily activities, was readmitted to the facility from the hospital and was lethargic and not eating well. A physician ordered blood work, including a comprehensive metabolic panel, complete blood count, and thyroid stimulating hormone test, on April 30, 2024. However, the lab was unable to obtain an adequate sample on the first attempt, and there was no documentation to support that the lab work was redrawn as ordered. Interviews with the Director of Nursing (DON) and the Administrator confirmed that the medical record did not contain documentation of the lab work being completed. The DON was unaware that the nurse was supposed to call the lab to schedule a redraw. The resident was later sent back to the hospital due to a change in medical condition and poor intake, where emergency guardianship was obtained, and a gastrointestinal tube was inserted for enteral nutrition. The facility's policy required staff to process test requisitions and arrange for tests, which was not followed in this case.
Call Light System Malfunction
Penalty
Summary
The facility failed to ensure the proper functioning of the call light system, affecting two residents. Resident #47, who has medical diagnoses including diabetes mellitus with chronic kidney disease, COPD, depression, and dementia with behavioral disturbances, was found to have a call light that was not within reach or in her line of vision. Despite pressing the call light button, the signal box outside her room did not indicate activation, leaving her without a means to notify staff for assistance. This was confirmed by an LPN who observed the malfunction. Similarly, Resident #23, with medical conditions such as COPD, hypertension, convulsions, anxiety, liver disease, and depression, reported that the call light in his room had not been working for a long time. Observations confirmed that pressing the call light button did not activate the signal box inside or outside his room, and there was no alternative means for him to alert staff. An RN confirmed the malfunction. The facility's policy requires that non-functioning call lights be replaced with alternative devices until repaired, which was not adhered to in these cases.
Failure to Prevent Elopement of High-Risk Resident
Penalty
Summary
The facility failed to provide adequate interventions and supervision to prevent the elopement of a resident assessed as being at high risk for elopement. Resident #26, who had medical diagnoses including chronic obstructive pulmonary disease, schizoaffective disorder, spinal stenosis, psychosis, and mild neurocognitive disorder, was admitted to the facility and assessed as having moderate cognitive impairment and delusions. Despite being identified as a flight risk and placed on one-on-one observation, Resident #26 managed to elope from the facility by asking a visitor for a ride to a nearby store/gas station. The incident occurred when the nurse responsible for the one-on-one supervision left the resident unattended for a short period of time. The elopement was immediately identified by the staff, and the Director of Nursing (DON), Assistant Director of Nursing (ADON), and Administrator were notified. The police and the resident's family were also informed. The Administrator located Resident #26 at the store/gas station and returned her to the facility without any injuries or negative effects. The facility's policy on elopement, which mandates individualized care plans for residents at risk of elopement, was not adequately followed, leading to this incident.
Failure to Document Medication Disposal After Resident Discharge
Penalty
Summary
The facility failed to ensure proper disposal of medications after a resident was discharged to the hospital and did not return. This deficiency affected one resident who had multiple medical diagnoses, including pneumonia, severe protein calorie malnutrition, HIV, Hepatitis C, and asthma. The resident was discharged to the hospital and did not return to the facility, but there was no documentation related to the disposition of the resident's medications upon discharge. The resident had several physician orders for medications, which were administered as prescribed, but often refused by the resident. However, there was no record of what happened to these medications after the resident's discharge. Interviews with the Director of Nursing (DON) revealed that the facility's protocol was to send medications back to the pharmacy and destroy narcotics with two licensed nurses when a resident is discharged and does not return. Despite this, the DON confirmed that there was no documentation to support that the resident's medications were sent back to the pharmacy or destroyed. Additionally, the facility did not have a policy for the disposition of a resident's medications upon discharge. This deficiency was investigated under a specific complaint number and represents ongoing noncompliance from a previous survey.
Failure to Ensure Functioning Call Light for Resident
Penalty
Summary
The facility failed to ensure that a resident's call light was functioning properly, affecting one resident out of the three reviewed for call lights. The resident, who had moderate cognitive impairment and required supervision with various activities, reported that his call light had not worked for a few weeks. Observations confirmed that while the call light indication box in the resident's room signaled the call light was on, the light outside the room did not turn on, and there was no sound alerting staff. The resident also did not have an alternate device to notify staff of his needs. Interviews with staff confirmed the malfunctioning call light and revealed that maintenance was aware of the issue but had not received any recent work orders for repair. The Director of Nursing acknowledged the problem and mentioned that a new call light system was to be installed soon. The facility's policy stated that if a resident's call light was not functioning, it should be replaced with an alternative device until repaired, which was not done in this case.
Facility Fails to Maintain Shower and Address Roof Leak
Penalty
Summary
The facility failed to ensure the 200 Hall shower was in good working condition for resident use, affecting one resident directly and potentially impacting nine others. Observations revealed the shower head was missing, the water pressure was poor, and there were multiple areas of a black substance on the ceiling tiles and grout. Interviews with staff and residents confirmed these issues, with one resident stating that the shower had been in disrepair for a while and that staff offered an alternative shower location, which was often difficult to access due to high usage. Resident Council Meeting minutes from January and March 2024 also documented residents' concerns about the shower's functionality and cleanliness. Additionally, the facility failed to address a leaking roof on the 500 Hall, which had the potential to affect ten residents. Observations showed water leaking from the ceiling onto the hallway floor, collected in a large trash can, a small bucket, and a large white towel, without any wet floor signs to caution staff or residents. The Director of Nursing confirmed the leak and the absence of warning signs. The facility census was 50 at the time of the survey, and the issues were investigated under Complaint Number OH00151636.
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A resident with intact cognition receiving Medicare Part A skilled services for metabolic encephalopathy had services discontinued while benefit days remained, but the facility did not issue the required Skilled Nursing Facility Advance Beneficiary Notice (SNF ABN). The Social Services Director later confirmed that no SNF ABN was provided and reported she believed only a Notice of Medicare Non-Coverage (NOMNC) was needed when all skilled services were stopped. This practice conflicted with the facility’s written policy, which required SNF ABNs to be issued when extended care items or services were initiated, reduced, or terminated due to expected non-coverage by Medicare.
Surveyors identified that the facility exceeded the acceptable medication error rate when two residents with type 2 DM received insulin doses that were not administered according to orders or manufacturer instructions. In two separate observations, an LPN administered Novolog and another LPN administered insulin glargine and insulin lispro without priming the insulin pens, and the insulin lispro and Novolog were given after the residents had already consumed a significant portion of their breakfast meals, despite orders for administration before meals. Manufacturer information for both insulin products required priming before each injection to ensure accurate dosing, and facility policy required medications, including insulin, to be administered safely, timely, and in accordance with prescriber orders and specified time frames.
Surveyors found that the facility failed to document tray line food temperatures for multiple meals served from two dining room kitchenettes, despite having a “Trayline Taste & Temperature Log” and a policy requiring food to be stored, prepared, distributed, and served according to professional food safety standards. Review of logs showed repeated missing entries for breakfast, lunch, and dinner services in both the Harrison and McClellan dining areas, and the Senior Director of Culinary Services confirmed that temperatures had not been recorded for those meals, potentially affecting all residents receiving meals from those kitchenettes.
The facility failed to conduct and document required periodic care conferences for two residents, despite multiple comprehensive, quarterly, and significant change MDS assessments and a policy requiring periodic care conferences with resident and/or family participation. One resident with Parkinson’s disease, post-stroke hemiplegia, TIA, DMII, and depression had only two documented care conferences over a year, while another resident with aphasia, cerebrovascular disease, DMII, gait difficulty, coagulation defect, depression, and muscle weakness had no documented care conferences in the past year, aside from a declined invitation to the representative. The UCC confirmed that care conferences were expected to occur quarterly and that no additional documentation existed for either resident.
A resident with Alzheimer's disease and type II DM, who required extensive assistance with ADLs and was receiving scheduled Lantus and sliding-scale Humalog, experienced a severely elevated blood glucose level. The on-call provider was notified and ordered an additional dose of lispro insulin with a directive to recheck the blood glucose after administration. Nursing staff administered the extra insulin but did not document any follow-up blood glucose check, and the DON confirmed that this reevaluation was required by the facility's abnormal blood glucose policy and was not completed or documented.
A resident with Parkinson’s disease, dementia, and hypothyroidism was prescribed levothyroxine once daily along with other medications. A consultant pharmacist’s monthly drug regimen review recommended that levothyroxine be given in the morning on an empty stomach, 30–60 minutes before food, per manufacturer instructions. The medical record contained no documented physician response to this recommendation, and the MAR showed the drug scheduled for morning administration while the resident was observed eating breakfast and receiving the medication at the same time. An LPN confirmed administering levothyroxine during the meal, and the DON verified there was no documentation explaining whether or why the pharmacist’s recommendation was or was not followed, resulting in a failure to act on and document the identified irregularity.
A resident with severe cognitive impairment, multiple comorbidities, documented gait and balance abnormalities, and a high fall risk was care planned and assessed by therapy to require contact guard assistance and use of a gait belt for transfers and ambulation. While being assisted by a CNA from a recliner to the bathroom with a walker, the CNA did not apply a gait belt, even though the resident had a known tendency to lean backward when standing. As the CNA reached to open the bathroom door, the resident lost balance and fell backward, striking the back of the head, and was later found by an LPN without a gait belt in place, contrary to the facility’s gait belt policy and the resident’s assessed needs.
A resident with CKD stage five requiring peritoneal dialysis (PD) was admitted with pre-admission physician orders for three daily PD exchanges and monitoring for peritonitis (fever, abdominal pain, cloudy effluent), but these monitoring orders were not entered into the facility’s physician orders. The care plan referenced PD and general monitoring but did not specifically address peritonitis monitoring. Paper PD flowsheets showed incomplete and inconsistent documentation of exchanges and resident condition, including missing condition/comments for individual treatments and no record of one ordered PD exchange. The PD cycler flowsheet lacked effluent descriptions on multiple days. The PD nurse reported facility staff were expected to monitor effluent and symptoms, and the DON confirmed the absence of specific peritonitis monitoring orders, lack of an order for the PD cycler, and documentation gaps, despite a facility policy requiring ongoing assessment and monitoring for complications before, during, and after dialysis treatments.
A nurse was observed preparing multiple oral medications for a resident with depression, traumatic brain injury, anxiety, and impaired cognition by pushing tablets and capsules from unit-dose cards directly into her ungloved hand and then using her fingers to place them into a medication cup. In a follow-up interview, the RN confirmed this practice and acknowledged that the correct procedure is to dispense medications directly from the card into the cup, contrary to the facility’s medication administration policy requiring adherence to good nursing principles and practices.
A resident with Alzheimer’s disease, diabetes, anxiety, significant ADL dependence, and behavioral symptoms was observed seated in a chair positioned against the nursing station with a locked wheelchair placed directly in front, also against the nursing station, effectively restricting movement. An LPN confirmed both wheelchair wheels were locked and that it should not have been placed there, while a CNA stated she had positioned the wheelchair to prepare for lunch, was unable to complete the transfer, and left it in place, acknowledging this was wrong. This arrangement conflicted with the facility’s restraint policy, which prohibits physical restraints except when alternatives are ineffective for treating a medical symptom and defines restraints as devices adjacent to the body that cannot be easily removed and that restrict freedom of movement or access to the body.
Failure to Issue Required SNF ABN When Discontinuing Medicare Part A Services
Penalty
Summary
The deficiency involves the facility’s failure to issue a Skilled Nursing Facility Advance Beneficiary Notice (SNF ABN) when Medicare Part A services were discontinued for a resident who still had available benefit days. The resident was admitted with a diagnosis of metabolic encephalopathy and had intact cognition per the Minimum Data Set assessment. The facility’s own SNF Beneficiary Notification Review documented that Medicare Part A skilled services began on 02/11/26 and the last covered day was 03/11/26, and that the facility initiated discharge from Medicare Part A services before the resident’s benefit days were exhausted. Despite this, no SNF ABN was provided to the resident or the resident’s representative. During interviews, the Social Services Director stated that the SNF ABN was issued hours prior to the last covered day but, upon reviewing her files, confirmed that no SNF ABN had actually been issued for this resident. She further explained that she believed an SNF ABN was only required if one skilled service remained and that if all skilled services were being discontinued, only the Notice of Medicare Non-Coverage (NOMNC) needed to be issued. The Administrator, however, stated that a resident should always receive both a SNF ABN and a NOMNC when Medicare Part A services are discontinued and benefit days remain. Review of the facility’s written policy dated 03/28/23 showed that the facility was required to issue SNF ABNs for initiation, reduction, or termination of extended care items or services when Medicare payment was not expected, which did not occur in this case.
Plan Of Correction
This Plan of Correction is submitted as required under State and Federal law. This Plan of Correction does not constitute an admission on the part of the Facility that the findings cited are accurate, that the findings constitute a deficiency or that the scope and severity regarding the deficiency cited are correctly applied. Any changes to the Facility's policies and procedures should be inadmissible in any proceeding on that basis. Without admitting or denying the validity or the existence of the alleged noncompliance, the Facility submits this Plan of Correction with the intention that it be inadmissible by any third party in any civil or other action against the facility or any employee, agent, officer, director or shareholder of the Facility. The Facility is utilizing this Plan of Correction as its allegation of substantial compliance as of 05/29/2026 F-0582 Corrective action for resident/s: On 5/14/26 Resident #34 was informed of rights and responsibilities related to Advanced Beneficiary Notice and voiced understanding of information for future reference by administrator. Identification of other residents who may be affected: Any resident receiving skilled services from nursing or therapy services. The Administrator audited all residents who were discharged from skilled services in the past 30 days to ensure they were issued a Notice of Non-Coverage and Advanced Beneficiary Notice on 5/29/26. No non-compliance was noted. Measures for systemic change: On 5/14/2026 Business Office Manager, Director of Rehab, Minimum Data Set nurse, Director of Nursing and Social Services Director were educated on proper procedure of issuing of Notice Of Medicare Non Coverage and Advanced Beneficiary Notice by administrator. All upcoming discharges from skilled services will be reviewed weekly at Utilization Review meeting to ensure notices will be delivered timely. How Corrective Action will be monitored: Administrator or designee to complete audits of all residents being discharged from skilled services to ensure they were issued a Notice of Non-Coverage and Advanced Beneficiary. This audit will be completed weekly x 4 weeks, then monthly x 2 months. Corrective action will be initiated for any noted non-compliance. Audit findings will be reviewed as part of the monthly quality assurance process to determine the need for further monitoring. Date of Compliance 5/29/26
Insulin Administration Errors and Failure to Prime Insulin Pens
Penalty
Summary
The deficiency involves the facility’s failure to maintain a medication error rate below 5%, with surveyors identifying 3 errors out of 28 medication administration opportunities, resulting in a 10.71% error rate. For one resident with type 2 diabetes mellitus and moderate cognitive impairment, the physician’s order directed Novolog insulin 10 units via subcutaneous pen-injector to be given before meals. During an observed medication pass, the LPN administered 10 units of Novolog insulin without priming the pen and did so after the resident had already consumed approximately 50% of the breakfast meal. The LPN later confirmed she did not prime the pen and acknowledged that the insulin was ordered to be administered prior to meals. Manufacturer instructions for the Novolog FlexPen specified that an air shot (priming) must be performed before each injection to ensure proper dosing. Another resident, also diagnosed with type 2 diabetes mellitus and with intact cognition, had orders for insulin glargine 35 units subcutaneously twice daily and insulin lispro 20 units subcutaneously before meals, plus 12 units subcutaneously if blood glucose was between 251 mg/dL and 300 mg/dL. During an observed medication administration, an LPN administered 35 units of insulin glargine and 32 units of insulin lispro without priming the insulin pens and after the resident had consumed approximately 90% of the breakfast meal, despite orders for insulin lispro to be given before meals. The LPN later stated she could not remember if she had primed the pen and acknowledged that the insulin was ordered to be administered prior to meals. Manufacturer information for insulin lispro stated that the pen must be primed before each injection to confirm insulin delivery and remove air, and that failure to prime could result in too much or too little insulin. The DON confirmed the expectation that insulin be administered as ordered, including priming each pen with two units before dialing the prescribed dose, and facility policy required medications, including insulin, to be administered safely, timely, and in accordance with prescriber orders and required time frames.
Plan Of Correction
This Plan of Correction is submitted as required under State and Federal law. This Plan of Correction does not constitute an admission on the part of the Facility that the findings cited are accurate, that the findings constitute a deficiency or that the scope and severity regarding the deficiency cited are correctly applied. Any changes to the Facility's policies and procedures should be inadmissible in any proceeding on that basis. Without admitting or denying the validity or the existence of the alleged noncompliance, the Facility submits this Plan of Correction with the intention that it be inadmissible by any third party in any civil or other action against the facility or any employee, agent, officer, director or shareholder of the Facility. The Facility is utilizing this Plan of Correction as an allegation of substantial compliance as of 5/29/2026. F-0759 Corrective action for resident/s: Residents #21 and #22 were assessed and evaluated by nurse and Director of Nursing 5/14/26. Resident #21 and #22 both denied any adverse effects and none were noted upon assessment by the Director of Nursing on 5/14/2026. Notification made to physician on 5/14/2026. LPN # 2 competency Eval on insulin administration with the Director of Nursing completed 5/14/2026. Identification of other residents who may be affected: Diabetic residents on assignment of LPN #2/station 2 have the potential to be affected and were assessed by the DON/Designee on 5/14/26 and found to be within normal limits. Measures for systemic change: All Nurses were educated by the Director of Nursing on the steps for Insulin administration per competency, diabetes clinical protocol policy, Medication and treatment orders policy, administering medications policy, and Obtaining fingerstick Glucose Level policy On 5/14/2026. How Corrective Action will be monitored: Director of Nursing and Assistant Director of Nursing will complete insulin administration audits on 5 nurses. This audit will be completed weekly x 4 weeks, then monthly x 2 months. Corrective action will be initiated for any noted non-compliance. Audit findings will be reviewed as part of the monthly quality assurance process to determine the need for further monitoring. Date of Compliance: 5/29/2026
Failure to Document Tray Line Food Temperatures in Dining Room Kitchenettes
Penalty
Summary
The deficiency involves the facility’s failure to document tray line food temperatures for meals served from the Harrison and McClellan Dining Room kitchenettes, as required by professional standards for food service safety and the facility’s own policy. Review of the “Trayline Taste & Temperature Log” (revised September 2018) showed missing temperature documentation for multiple meals from the Harrison Dining Room kitchenette, including dinner on 03/30/26 and 03/31/26, lunch and dinner on 04/01/26 and 04/02/26, dinner on 04/07/26, and lunch and dinner on 04/08/26 and 04/10/26. The Senior Director of Culinary Services confirmed during interview that tray line food temperatures were not documented on the log for these meals. Similarly, review of the same log for the McClellan Dining Room kitchenette revealed that tray line food temperatures were not documented for dinner on 04/01/26, breakfast and lunch on 04/02/26, and lunch and dinner on 04/07/26. The Senior Director of Culinary Services also verified these omissions during interview. The facility census at the time was 27 residents, and the governing “Food and Nutrition” policy, approved on 09/07/21, stated that the facility must store, prepare, distribute, and serve food in accordance with professional standards for food service safety.
Plan Of Correction
F812 The facility will continue to ensure food temperatures are completed before meals are served for all residents. To ensure compliance with this standard the following measures have been taken: 1. Immediately 4/15/26 culinary supervisor #224 was re-educated by Dietary Manager to this standard and policy "Food and Nutrition" which includes documentation of food temperatures. 2. All dietary staff have been re-educated to the standard and policy "Food and Nutrition" during the month of April 2026. 3. Audits of food temperature documentation to be completed by Dietary Manager 4 x per week for 4 weeks then weekly for 4 weeks. 4. Administrator to validate audits/compliance and provide additional training as needed. Administrator will present to QAPI committee for ongoing monitoring and further direction.
Failure to Conduct and Document Required Care Conferences
Penalty
Summary
The deficiency involves the facility’s failure to complete and document comprehensive care conferences at required intervals in accordance with care plan regulations and facility policy. For one resident with Parkinson’s disease with dyskinesia, cognitive communication deficit, hemiplegia and hemiparesis following cerebral infarction, transient cerebral ischemic attack, type II diabetes mellitus, and major depressive disorder, the record showed multiple MDS assessments over a one-year period, including annual, quarterly, and significant change assessments. However, only two care conferences were documented during the last 12 months, despite the expectation that care conferences be conducted quarterly with the resident and family when possible. The Unit Care Coordinator confirmed that no additional care conference documentation existed for this resident beyond the notes dated 04/21/25 and 01/02/26. A second resident, with diagnoses including aphasia following cerebrovascular disease, cerebral infarction, type II diabetes mellitus, unsteadiness on feet, difficulty in walking, coagulation defect, depression, and muscle weakness, also had multiple MDS assessments completed over the review period, including quarterly and annual assessments. The record contained a note that a care conference was offered to the resident’s representative, who declined to attend, but there was no documentation of any care conferences for the most recent 12 months. The Unit Care Coordinator confirmed that no other care conference documentation was available for this resident. Facility policy stated that periodic care conferences involving the resident, family, and the interdisciplinary team are part of the care planning process, but the required periodic care conferences and corresponding documentation were not completed for these two residents.
Plan Of Correction
THIS PLAN OF CORRECTION SERVES AS BERKELEY SQUARE'S CREDIBLE ALLEGATION OF SUBSTANTIAL COMPLIANCE AS OF June 1, 2026. Without admitting or denying the validity or existence of the alleged deficiencies, Berkeley Square provides the following Plan of Correction: F657 The facility will continue to document completion of care conferences at the required intervals for all residents, including residents #04 & #15. To ensure compliance with this standard the following measures have be taken: 1. The social service designee and the inter- disciplinary team were re-educated by the administrator to the facility policy "Care Conference" on 4/29/26 and verbalized understanding. 2. Care conferences for resident #04 and resident #15 were conducted on or before 4/29/2026 by the interdisciplinary team. 3. Review of all other residents was conducted by the social service designee to validate and ensure that care conference schedule is up to date with timely care conferences scheduled for them on 4/15/2026. Audits of care conferences to be completed weekly for four weeks and then monthly after that by the social service designee. Documentation of the care conference including any identified concerns in the medical record. Administrator to validate audits/compliance and provide additional training as needed. Administrator will present results of these audits to QAPI committee for ongoing monitoring and further direction.
Failure to Reevaluate Blood Glucose After Treatment for Hyperglycemia
Penalty
Summary
The facility failed to ensure that a resident with diabetes received treatment in accordance with professional standards of practice when nursing staff did not reevaluate the resident's blood glucose after treatment for severe hyperglycemia. The resident, admitted with diagnoses including Alzheimer's disease, type II diabetes mellitus, and depression, had physician orders for Humalog insulin on a sliding scale before meals, Lantus insulin 25 units daily, and lisinopril 5 mg daily. The resident required extensive assistance with activities of daily living, including transfers, toileting hygiene, eating, and bathing. On the evening in question, the resident's blood glucose was documented as 532 mg/dL, and the on-call provider was notified. The provider gave a new order to administer an additional 8 units of lispro (Humalog) and to recheck the blood glucose in 30 minutes. The electronic medication administration record showed that the blood glucose of 532 mg/dL was obtained at 9:00 p.m. and that the additional 8 units of lispro were administered at 9:21 p.m. However, there was no documentation in the resident's chart that the blood glucose was rechecked after the additional insulin was given. In an interview, the DON confirmed there was no evidence of reevaluation and verified that, according to the facility's "Abnormal Blood Glucose Procedure" policy, the resident should have been reevaluated and that the evaluation step should have been included in the progress note documentation.
Plan Of Correction
F684 The facility will continue to ensure all residents, including #03, receive treatment in accordance with professional standards of practice and reevaluated for hyperglycemia. To ensure compliance with this standard the following measures have been taken: 1. The director of nursing assessed resident #03, reviewed documentation and orders and found no ill effects immediately 4/16/26. 2. All licensed nurses were re-educated to facility policy "Blood Glucose Monitoring" by the Director of Nursing/designee in April 2026. 3. Audits of like-residents that require blood sugar checks to be completed by the director of nursing/designee two times a week for 4 weeks and then monthly after that to validate correct follow through when there is abnormally high blood glucose result. The Administrator will bring results of these audits to the QAPI committee for ongoing monitoring and further direction.
Failure to Act on Pharmacist Drug Regimen Recommendation for Thyroid Medication
Penalty
Summary
The deficiency involves the facility’s failure to ensure that pharmacy recommendations from the monthly drug regimen review were acted upon and documented for a resident. The resident was admitted with diagnoses including Parkinson’s disease, dementia, and hypothyroidism, and had current physician orders for levothyroxine 150 mcg once daily, buspirone 50 mg twice daily, and losartan 100 mg once daily. A medication regimen review dated 11/25/2025 included a consultant pharmacist recommendation that levothyroxine be administered consistently in the morning on an empty stomach, at least 30–60 minutes before food, per manufacturer instructions. There was no specific physician response in the medical record to this recommendation, and the facility’s policy stated that consulting pharmacist reviews are sent to nursing and addressed with the primary care provider or consulting specialist for review and follow-up. Review of the resident’s medication administration record for April 2026 showed levothyroxine scheduled for 9:00 a.m. On observation, the resident was seen eating breakfast in the dining area at 8:03 a.m., and an LPN reported administering the levothyroxine 150 mcg to the resident while the resident was in the dining area eating breakfast. The DON confirmed there was no evidence in the resident’s medical record explaining why the consultant pharmacist’s recommendation from 11/25/2025 was or was not acted upon. This lack of documented physician review and action on the pharmacist’s identified irregularity constituted noncompliance with the drug regimen review requirements.
Plan Of Correction
F756 The facility will continue to ensure the pharmacy recommendations from the monthly drug regimen review by a licensed pharmacist are acted upon for all residents, including #08. To ensure compliance with this standard the following measures have been taken: 1. Resident #08 was assessed by the registered nurse and med review completed by 4/28/26. After review of resident's drug regime's, it was discovered that resident #8 had 2 separate medication recommendations on the same form, to be reviewed by two separate practitioners, pharmacy has been instructed and agreed to separate meds on individual forms. 2. Licensed nurses re-educated to facility policy "Drug Regimen Review" by Director of nursing/designee in April 2026 and no later than 5/8/26. Licensed nurses are responsible for ensuring the reviews and recommendations are given to the physician for timely review. 3. Review of all other current residents Drug Regimen orders completed by Director of nursing/designee on 4/16/26 to ensure recommendations were followed up on/reviewed by the physician and address concerns if needed. 4. Audit of drug regime recommendations, pharmacy recommendations, and physician follow up to be completed weekly for four weeks by the Director of nursing/designee. Administrator will present results of these audits to the QAPI committee for ongoing monitoring and further direction.
Failure to Use Required Gait Belt During Ambulation Resulting in Resident Fall
Penalty
Summary
The deficiency involves the facility’s failure to ensure that a required gait belt was used while assisting a high fall‑risk resident with ambulation, resulting in a fall with head injury. The resident had multiple diagnoses including metabolic encephalopathy, hypertension, osteoarthritis, muscle weakness, gait and mobility abnormalities, major depressive disorder, anxiety, and visual hallucinations. Admission and subsequent MDS and fall risk assessments documented that the resident was severely cognitively impaired, required moderate to maximal assistance with transfers and ambulation, could not independently come to a standing position, exhibited loss of balance while standing, used an assistive device, and had decreased muscle coordination. The resident had a history of falls prior to admission and was assessed as being at high, later moderate, risk for falls. The resident’s fall care plan identified her as at risk for falls and included interventions such as providing maximum to moderate assistance with transfers and walking short distances, use of a walker and wheelchair, and following the facility’s fall protocol. Therapy notes and care conference documentation indicated that the resident leaned backwards when standing, required contact guard to minimal assistance for bed mobility and transfers, and needed constant verbal cueing for safe sequencing during toilet transfers. The physical therapist confirmed that the resident was to use a gait belt with staff when ambulating, and the DON verified that therapy had assessed the resident as requiring contact guard assistance and a gait belt for ambulation and transfers. On the day of the incident, a CNA was assisting the resident from her recliner to the bathroom using a walker. The CNA walked beside the resident, providing guidance and support, and reported having a hand on the resident while assisting her. As they approached the bathroom door, the CNA reached for the doorknob to open it, and at that moment the resident began to lose her balance and fell backwards to the floor, striking the back of her head. The nurse who responded found the resident on her back at the foot of the bed with her feet near the bathroom, noted a red raised area on the back of the head, and documented that the resident was not wearing a gait belt and that the gait belt was on the dresser. In the facility’s investigative summary and in interviews, the CNA acknowledged that she did not have a gait belt on the resident while ambulating her, despite the resident’s assessed need for hands‑on assistance and gait belt use per facility policy and the resident’s care and therapy plans.
Failure to Implement PD Orders and Monitor Resident Receiving Peritoneal Dialysis
Penalty
Summary
The deficiency involves the facility’s failure to implement pre-admission physician orders for peritoneal dialysis (PD) and to provide ongoing monitoring for a resident with chronic kidney disease (CKD) stage five who required PD. Pre-admission orders dated 11/14/25 specified three daily PD exchanges at 6:00 A.M., 2:00 P.M., and 10:00 P.M., and directed staff to monitor for signs and symptoms of peritonitis, including fever, abdominal pain, and cloudy effluent. These monitoring orders were not entered into the facility’s physician orders. The resident’s care plan noted the need for PD and included general monitoring interventions (labs, signs of bleeding, bacteremia, septic shock, and significant vital sign changes), but did not specifically address the ordered monitoring for peritonitis. Review of PD documentation showed incomplete and inconsistent charting of treatments and resident condition. The paper peritoneal flowsheet had columns for time of PD and condition/comments, including instructions to call the nurse immediately for cloudy fluid, abdominal pain, or fever. However, the first entry on 11/15/26 at 2:00 P.M. only noted that the PD nurse completed the exchange, and the 10:00 P.M. entry that day had no condition/comment documentation. Subsequent days (11/16/25, 11/17/25, and 11/18/25) contained only one condition/comment entry per day rather than for each exchange, and there was no documentation that the 6:00 A.M. PD on 11/18/25 was completed. The PD cycler flowsheet starting 11/19/25 lacked any description of the effluent on multiple days. The PD nurse from the dialysis company stated facility staff were expected to monitor effluent for cloudiness and assess for abdominal pain and fever, and the DON confirmed there was no electronic physician order for peritonitis monitoring or for use of the PD cycler, that the paper charting did not allow for effluent description or symptom documentation for each treatment, and that PD was not documented at one ordered time. The facility’s dialysis policy required ongoing assessment and monitoring for complications before, during, and after treatments, which was not reflected in the documentation for this resident.
Improper Infection Control During Medication Administration
Penalty
Summary
Surveyors identified a deficiency in infection prevention and control related to medication administration for Resident #29. The resident was admitted on 02/28/14 with diagnoses including depression, traumatic brain injury, and anxiety, and had impaired cognition per a quarterly MDS assessment. During an observation on 03/25/26 at 6:58 A.M., RN #281 prepared the resident’s medications by removing an Amoxicillin-Pot Clavulanate tablet from the medication card and pushing it directly into her ungloved hand, then using her fingers to place the pill into a medication cup. The same process was observed for multiple other medications, including Escitalopram Oxalate, Furosemide, Sennosides, Lyrica, and Vitamin D, each being pushed from the card into the RN’s ungloved hand and then transferred by her fingers into the medication cup before administration to Resident #29. In a subsequent interview at 7:27 A.M. the same day, RN #281 confirmed she had placed each medication into her ungloved hands prior to administration and acknowledged that the proper procedure was to push the pills directly from the card into the medication cup. Review of the facility’s “Medication Administration – General guidelines” policy, revised 10/08/25, stated that medications are to be administered in accordance with good nursing principles and practices. This practice failure was cited as a deficiency under Complaint Number 2681777.
Improper Use of Wheelchair as a Physical Restraint
Penalty
Summary
Surveyors identified a deficiency related to the facility’s failure to ensure a resident was free from physical restraints. Resident #7, admitted with diagnoses including Alzheimer’s disease, diabetes mellitus, and anxiety disorder, was documented on a recent MDS as rarely understood and dependent for ADLs except eating. The resident ambulated independently on the unit without an assistive device and had documented verbal and other behaviors occurring one to three days during the look-back period. The care plan noted the resident had potential to be physically aggressive, chase staff, throw objects, and be combative with care, with interventions such as offering choices, administering medications as ordered, and intervening early when agitation occurred. During an observation and interview, Resident #7 was found sitting in a chair with the right arm of the chair positioned against the nursing station and a wheelchair placed directly in front of him. The left arm of the wheelchair was also against the nursing station, and both wheelchair wheels were locked, creating a barrier that appeared to restrain the resident, who was sleeping with his knees touching the locked wheelchair. An LPN confirmed both wheelchair wheels were locked and that the wheelchair should not have been placed in front of the resident. A CNA reported she had placed the wheelchair there in preparation to get the resident up for lunch, was unable to transfer him, and left the wheelchair in that position, acknowledging it was wrong to keep it there. The facility’s physical restraint policy stated that physical restraints are not used except when alternatives are not appropriate or effective for treating a medical symptom and defined physical restraints as any device attached or adjacent to the body that the individual cannot easily remove and that restricts freedom of movement or access to the body.
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