Troy Rehabilitation And Healthcare Center
Inspection history, citations, penalties and survey trends for this long-term care facility in Troy, Ohio.
- Location
- 512 Crescent Drive, Troy, Ohio 45373
- CMS Provider Number
- 365278
- Inspections on file
- 40
- Latest survey
- March 24, 2025
- Citations (last 12 mo.)
- 0
Citation history
Health deficiencies cited at Troy Rehabilitation And Healthcare Center during CMS and state inspections, most recent first.
A facility failed to re-admit a resident after hospitalization, despite being informed of the return. The resident, with dementia and behavioral issues, was refused re-entry by the Admissions Coordinator due to a lack of notification and updated information. The resident was returned to the hospital without a discharge notice, and the facility lacked a re-admission policy.
A facility failed to provide a pressure redistribution cushion for a resident with pressure ulcers, as required by the care plan. The resident, with severe cognitive impairment and multiple health conditions, returned from dialysis without the necessary cushion in the chair. Staff interviews revealed a lack of awareness and implementation of the care plan intervention, affecting the resident's wound care.
The facility failed to implement its water management policy and respond to local health department recommendations to remediate their water system for Legionella. A resident tested positive for Legionnaire's disease, and the facility did not conduct appropriate water testing or follow their policy for suspected cases. Despite multiple communications from the health department, the facility did not comply promptly, affecting all 128 residents.
A resident experienced harm due to the facility's failure to reconcile medications after hospital re-admission, resulting in the abrupt discontinuation of Keppra, an anticonvulsant. This led to seizure activity and re-hospitalization. The facility staff were unaware of the epilepsy diagnosis and the 30-day order for Keppra, and there was a lack of communication and access to hospital records, contributing to the oversight.
The facility failed to ensure a safe and clean environment in several resident rooms. Issues included an adhesive fly paper strip with dead insects, a broken heater with a pillow on it, and structural gaps allowing bugs to enter. The Maintenance Director was unaware of these issues, which had not been reported, and confirmed that the facility was in the process of updates.
A resident with cognitive intactness and mobility impairments was not provided privacy during toileting due to a broken toilet in their room, leading them to use a shower room with a door that did not close properly. Staff confirmed the ongoing issue, which compromised the resident's dignity and privacy.
The facility failed to accurately code MDS assessments for three residents, leading to discrepancies in medical records. A resident using an APAP device was inaccurately recorded as not using oxygen, while another receiving daily oxygen therapy was not documented as such. Additionally, a resident with pressure ulcers was not recorded as having a pressure reduction cushion, despite its presence. These inaccuracies were confirmed by staff interviews.
The facility failed to update care plans for two residents, leading to deficiencies in bathing assistance and pressure ulcer prevention. One resident, with quadriplegia, was not adequately supervised during showers, despite being a fall risk. Another resident, at risk for pressure ulcers, had a pressure-reducing cushion in use, but it was not documented in the care plan as recommended by the Wound Nurse Practitioner.
Two residents in a facility were not provided with necessary assistance for activities of daily living (ADLs), leading to deficiencies in care. One resident, with quadriplegia, was left alone in the shower room despite being a fall risk, while another resident, requiring assistance with toileting, was found alone in the shower room attempting to exit without help. Staff interviews confirmed these lapses in supervision and adherence to care plans.
A facility failed to complete pressure ulcer treatments as ordered for a resident with multiple stage 2 pressure ulcers. Despite being cognitively intact and requiring assistance with daily activities, the resident's prescribed wound care was not fully administered on specific dates. Interviews with LPNs confirmed the treatments were not completed due to time constraints, highlighting a deficiency in care.
A resident at risk for falls due to dementia and other conditions did not have proper interventions in place, as their bed was not in the lowest position and a fall mat was not correctly placed. An LPN confirmed these deficiencies, and the DON acknowledged the lack of low beds in the facility, contrary to the facility's fall prevention policy.
The facility failed to provide proper indwelling catheter care for two residents, with one lacking adequate indication for catheter use and another missing documentation of catheter output. An LPN noted a diagnosis without supporting documentation, and the facility lacked a policy on catheter use reasons. The Administrator confirmed missing output records, violating the facility's urinary catheter care policy.
A facility failed to ensure physician orders were in place for a resident's respiratory care. The resident, with chronic obstructive pulmonary disease and chronic respiratory failure, was observed using an APAP device without a corresponding physician order. An order existed for oxygen via nasal cannula, but the resident used a nose piece. The Unit Manager confirmed the absence of orders and incorrect oxygen administration route, contrary to the facility's policy requiring documented hypoxia or a physician's order.
A facility failed to administer medications as ordered, resulting in a 10% error rate. Two residents were affected: one received incorrect dosages of Ferrous Gluconate and Magnesium Glycinate, and did not receive the ordered Calcium due to stock issues; another received a lower dose of Vitamin D than prescribed. An LPN confirmed the errors, which violated the facility's medication administration policy.
A resident with severe cognitive impairment, indicated by a BIMS score of four and a diagnosis of vascular dementia, was asked to sign an arbitration agreement without the presence of a family member or legal representative. Facility staff did not check the resident's cognitive status before obtaining the signature, relying instead on verbal confirmation of understanding. The resident was unable to demonstrate an understanding of the agreement.
A facility failed to maintain infection control protocols for a resident's indwelling urinary catheter. The resident, with a history of urinary tract infection and other conditions, had a care plan requiring the drainage bag to be below bladder level. However, the catheter bag and tubing were found on the floor, contrary to facility policy. An LPN confirmed this breach of protocol.
A facility failed to store medications safely, as two medications were found on a resident's overbed table. An LPN confirmed the medications, Flomax and gemfibrozil, were supposed to be administered the previous evening. The facility's policy requires safe and secure storage of all drugs, which was not followed in this case.
The facility failed to maintain cleanliness and sanitation in two residents' rooms. An oxygen concentrator was found with dried white substance, and another room had debris including food particles and trash on the floor. These conditions were confirmed by staff, violating the facility's policy for maintaining a clean environment.
Facility Fails to Re-admit Resident After Hospitalization
Penalty
Summary
The facility failed to permit a resident to return after hospitalization, violating the bed-hold policy. Resident #137, who had been admitted with diagnoses including unspecified dementia, epilepsy, and bipolar disorder, was transferred to a mental facility for stabilization due to increased behavioral agitation. Despite plans to return the resident to the facility, the Admissions Coordinator refused to accept the resident back, citing a lack of notification and updated information from the hospital. Interviews with hospital staff and medical transport personnel revealed that the facility was informed of the resident's return, but the Admissions Coordinator claimed not to have received proper notification or an updated report. The transport crew, upon delivering the resident to the facility, was told by the Admissions Coordinator that the resident could not stay and was supposed to go to another hospital. Consequently, the resident was returned to the hospital, and no discharge notice was provided to the resident. The facility's Administrator confirmed that the resident was not denied re-admission but emphasized the need for an update before accepting the resident back. The facility billed Medicaid for bed-hold days until the resident was discharged, yet no discharge notice was issued. The Administrator also acknowledged the absence of an admission/re-admission policy, contributing to the mishandling of the resident's return.
Failure to Implement Pressure Redistribution Device for Resident
Penalty
Summary
The facility failed to implement a pressure redistribution device or cushion in a resident's chair as outlined in the care plan to treat existing pressure ulcers. The resident, who has severe cognitive impairment and multiple health conditions including peripheral vascular disease and diabetes, was at risk for developing pressure injuries. The care plan, updated on 03/12/25, included interventions such as an air mattress and a pressure redistribution device for the resident's chair. However, during an observation on 03/19/25, it was noted that the resident returned from dialysis in a chair without the required pressure redistribution cushion. Interviews with staff members, including a Registered Nurse, two Certified Nursing Assistants, and a Licensed Practical Nurse, revealed a lack of awareness and implementation of the care plan intervention. The RN confirmed the absence of the cushion in the dialysis chair and questioned its use, while the CNAs confirmed that the resident never had a cushion available. The LPN admitted to not knowing whether the resident was supposed to have a cushion. This deficiency was identified during a complaint investigation and affected one resident out of three reviewed for wound care in a facility with a census of 134.
Failure to Implement Water Management Policy for Legionella
Penalty
Summary
The facility failed to implement its water management policy and respond to the local health department's recommendations to remediate their water system to reduce the presence of microorganisms, including Legionella. This deficiency was identified during a review of records, hospital documentation, staff interviews, and local health department communications. The issue affected one resident who tested positive for Legionnaire's disease and had the potential to affect all 128 residents residing in the facility. The medical record review for the affected resident revealed a history of acute kidney failure, gastrointestinal hemorrhage, hypovolemic shock, Legionnaire's disease, and other conditions. The resident was cognitively intact and required extensive assistance for activities of daily living. The resident was admitted to a hospital for acute gastrointestinal bleeding and other complications, where a positive test for Legionella was reported. Despite being notified of the presumptive case of Legionella, the facility did not conduct appropriate water testing or follow their policy for suspected Legionella cases. Interviews with facility staff, including the Administrator, Director of Nursing, and Maintenance Director, revealed a lack of communication and action in response to the local health department's inquiries and recommendations. The facility did not test the water for Legionella after being made aware of the suspected case and failed to install filters on water outlets. The local health department had sent multiple communications requesting information and outlining necessary steps, but the facility did not comply promptly. The facility's policy required immediate procedures to eliminate the presence of Legionella bacteria and prevent further outbreaks, which were not followed.
Medication Reconciliation Failure Leads to Resident Harm
Penalty
Summary
The facility failed to appropriately reconcile medications following a hospital re-admission, resulting in a significant medication error for a resident diagnosed with metabolic encephalopathy, epilepsy without status epilepticus, transient ischemic attack, and cerebral infarction. Upon re-admission from the hospital, the resident's anticonvulsant medication, Keppra, was abruptly stopped without proper consultation or clarification of the transfer orders. This oversight led to the resident experiencing seizure activity and subsequent re-hospitalization. The medical record review revealed that the hospital admission orders included a prescription for Keppra to be administered twice daily for 30 days. However, the facility did not print the necessary hospitalist progress note at the time of re-admission, which included the continuation plan for Keppra. The Medication Administration Record showed that the last dose of Keppra was given on a specific date, and there was no indication that the physician was contacted to clarify the stop date for the medication. Interviews with facility staff, including the NP and DON, indicated a lack of awareness regarding the resident's epilepsy diagnosis and the 30-day order for Keppra. The DON confirmed that the medication was stopped without consulting neurology, and the staff did not have access to the hospital records until requested by the surveyor. The physician involved stated that he was unaware of the 30-day stop order and had not been notified of any seizure activity, which would have influenced the continuation of the medication. The neurologist consulted during the hospital stay expected the Keppra to be continued until a follow-up appointment, highlighting a miscommunication in the nursing home regarding the medication's continuation.
Facility Fails to Maintain Safe and Clean Resident Rooms
Penalty
Summary
The facility failed to maintain a clean and safe environment in several resident rooms, affecting four out of seven rooms reviewed. In one instance, a resident's room contained an adhesive fly paper strip with dead insects, which had been present since the resident moved in. The Maintenance Director was unaware of the fly strip's presence and confirmed that such items should not be in resident rooms. Additionally, another resident's room had a broken heater with a pillow lying on it, and the vent cover was in disrepair. The Maintenance Director verified the heater was functional but unsafe due to the broken vent cover. Further observations revealed structural issues in two other resident rooms. One room had a hole under the air conditioner, allowing bugs to enter, and a significant gap between the air conditioner and the seal. Another room had missing drywall and a gap on the side of the air conditioning and heating unit, exposing insulation and leading outside. The Maintenance Director confirmed these issues had not been reported and noted that the facility was undergoing updates, though the timeline for addressing these specific issues was uncertain.
Privacy Violation During Toileting Due to Broken Facilities
Penalty
Summary
The facility failed to ensure privacy for Resident #54 during toileting, as observed on December 9, 2024. The resident, who has a history of cerebral infarction, hemiplegia, hemiparesis, and chronic obstructive pulmonary disease, was cognitively intact and required substantial assistance for personal hygiene. Due to a broken toilet in the resident's room, which had been non-functional for months, the resident was using the shower room for toileting. However, the shower room door did not shut properly, compromising the resident's privacy. Interviews with staff, including a CNA and an LPN/Unit Manager, confirmed the ongoing issue with the broken toilet and the use of the shower room for toileting. The LPN/Unit Manager acknowledged that the shower room door was difficult to close but could be shut with force. The facility's policy on dignity emphasizes that residents should be treated with respect and their well-being should be promoted, which was not upheld in this situation due to the lack of privacy provided to the resident.
Inaccurate MDS Coding for Oxygen Use and Pressure Devices
Penalty
Summary
The facility failed to ensure the Minimum Data Set (MDS) assessments were accurately coded for three residents, leading to discrepancies in their medical records. Resident #289, who was admitted with chronic obstructive pulmonary disease and chronic respiratory failure with hypoxia, was observed using an auto-adjusting positive airway pressure (APAP) device delivering oxygen. However, the admission MDS assessment inaccurately indicated that the resident did not use oxygen. This was confirmed by the Unit Manager during an interview. Resident #67, admitted with acute pulmonary edema and chronic respiratory failure with hypoxia, was also inaccurately coded in the quarterly MDS assessment as not receiving oxygen therapy, despite having a physician's order for oxygen and documentation in the Treatment Administration Record (TAR) showing daily oxygen therapy. The LPN/MDS Coordinator confirmed the oversight. Additionally, Resident #125, who had multiple pressure ulcers, was inaccurately coded in the quarterly MDS assessment as not having a pressure reduction device in her chair, despite observations of a Roho style cushion in her wheelchair. This was also confirmed by the LPN/MDS Coordinator.
Care Plan Deficiencies for Bathing Assistance and Pressure Ulcer Prevention
Penalty
Summary
The facility failed to ensure that the care plan for Resident #16 was revised to accurately reflect the assistance needed with bathing. Resident #16, who has quadriplegia and requires substantial assistance with various activities of daily living, was observed taking showers without adequate supervision, despite being a fall risk. The care plan did not document the assistance needed during bathing, and interviews with staff confirmed that the resident was not care planned for bathing assistance. Observations showed that the resident took extended showers with repetitive washing, and the CNA did not remain with the resident throughout the shower, which was contrary to the resident's needs. For Resident #125, the facility failed to include the intervention of a pressure-reducing cushion in the care plan, despite a recommendation from the Wound Nurse Practitioner. The resident, who was at risk for pressure ulcers and had multiple stage 2 pressure ulcers, was observed with a Roho style cushion in the wheelchair, but this intervention was not documented in the care plan. Interviews confirmed that the care plan should have included the pressure-reducing cushion as an intervention, as per the facility's wound care policy.
Failure to Assist Residents with ADLs
Penalty
Summary
The facility failed to provide necessary assistance with activities of daily living (ADL) for two residents, leading to deficiencies in care. Resident #16, diagnosed with quadriplegia and other conditions, required substantial assistance with various ADLs, including bathing. Despite this, the care plan did not document the assistance needed for bathing. Observations revealed that Resident #16 was left alone in the shower room for extended periods, despite being a fall risk and unable to transfer or stand without assistance. Interviews with staff confirmed that the resident was not adequately supervised during showers, which contradicted the expectations set by the unit manager. Resident #31, with diagnoses including respiratory failure and Down syndrome, also required significant assistance with ADLs. The care plan indicated a need for two-person assistance with toileting and transfers. However, observations showed that Resident #31 was left alone in the shower room, attempting to exit without assistance. This was confirmed by a CNA, who acknowledged that the resident should not have been left alone due to her need for assistance with toileting. The unit manager confirmed that the resident should not have been using the shower room for toileting without assistance. Both cases highlight a failure in the facility's adherence to care plans and supervision requirements, resulting in residents being left in potentially unsafe situations. The lack of proper documentation and adherence to care plans for bathing and toileting assistance contributed to these deficiencies, as confirmed by staff interviews and observations.
Incomplete Pressure Ulcer Treatment
Penalty
Summary
The facility failed to ensure that pressure ulcer treatments were completed as ordered for a resident, affecting their care. The resident, who was cognitively intact, had multiple diagnoses including post laminectomy syndrome and stage 2 pressure ulcers on the sacral region and buttocks. The resident required various levels of assistance with daily activities and was at risk for pressure ulcers. Despite having a pressure-reducing device for the bed, there was no such device for the resident's chair. On specific dates in October 2024, the Treatment Administration Record (TAR) indicated that prescribed wound care treatments for the resident's coccyx and right buttock were not completed as ordered. Interviews with the LPNs responsible for the resident's care confirmed that the treatments were not completed on the specified dates. One LPN admitted that she did not complete all treatments due to time constraints, despite signing off on them. The facility's Wound Care policy, dated September 2021, was intended to ensure care was provided to promote healing, but the failure to adhere to the treatment orders resulted in a deficiency in the care provided to the resident.
Failure to Implement Fall Prevention Interventions
Penalty
Summary
The facility failed to ensure that interventions were in place for a resident at risk for falls, specifically affecting a resident diagnosed with dementia, low back pain, major depression disorder, hypertension, and Alzheimer's disease. The resident was identified as being at risk for falls due to peripheral vascular disease, dementia with impaired cognition, and decreased mobility. The care plan for the resident included interventions such as keeping the bed in the lowest position and using a low bed, but these were not properly implemented. On a specific date, the resident fell from the bed, prompting hospice to add fall mats as an intervention. During an observation, it was noted that the resident's bed was not in the lowest position, and a fall mat was not placed on the floor as required. Instead, the fall mat was found folded at the end of the bed. An LPN confirmed these observations and had to adjust the bed and place the fall mat correctly. The Director of Nursing also confirmed that the bed should have been in the lowest position and acknowledged that the facility did not have low beds. The facility's policy on falls emphasized the need for staff to identify and implement interventions based on evaluations and current data to prevent falls and minimize complications, which was not adhered to in this case.
Deficiencies in Indwelling Catheter Care and Documentation
Penalty
Summary
The facility failed to provide appropriate indwelling catheter care for two residents, leading to deficiencies in accordance with physician orders and care plans. For one resident, there was a lack of adequate indication for the use of an indwelling urinary catheter. The resident was admitted with a Foley catheter, and the Licensed Practical Nurse (LPN) noted urinary retention with neurogenic bladder as the reason for the catheter. However, the Nurse Practitioner (NP) could not find documentation to support this diagnosis, and the diagnosis of neuromuscular dysfunction of the bladder was only added a month after admission. The Director of Nursing confirmed the absence of a facility policy on reasons to maintain a Foley catheter. For another resident, the facility failed to document the output from the Foley catheter as required by the care plan and physician's orders. The treatment records showed missing documentation of catheter output for specific shifts over several days. The Administrator verified the absence of documentation for these dates and times. The facility's policy on urinary catheter care required maintaining a record of the resident's daily output, which was not adhered to in this case.
Lack of Physician Orders for Respiratory Care
Penalty
Summary
The facility failed to ensure that physician orders were in place for the use of a respiratory device and the administration of oxygen for a resident. The medical record review for a resident with chronic obstructive pulmonary disease and chronic respiratory failure with hypoxia showed no physician order for the use of an Automatically Adjusting Positive Airway (APAP) device. An order was present for oxygen administration at five liters per minute via nasal cannula, but observation revealed the resident using an APAP device delivering oxygen via a nose piece. The resident confirmed the constant use of the APAP device as advised by his doctors due to his need for a lung transplant. An interview with the Unit Manager verified the absence of orders for the APAP device and the incorrect route of oxygen administration. The facility's policy on oxygen administration requires documented hypoxia or a physician's order to determine the initial need, which was not adhered to in this case.
Medication Administration Errors in LTC Facility
Penalty
Summary
The facility failed to ensure medications were administered as ordered, resulting in a 10% medication error rate. This deficiency affected two residents out of three reviewed for medication administration. Resident #105, who has severe cognitive impairment and requires assistance with personal care, was administered Calcium 600 mg/Vitamin D 10 mcg instead of the ordered Calcium 600 mg/Vitamin D 25 mcg. Resident #125, who is cognitively intact and requires supervision with personal care, was administered incorrect dosages of Ferrous Gluconate and Magnesium Glycinate, and did not receive the ordered Calcium 1000 + D due to the facility being out of stock. Observations and interviews with LPN #442 confirmed the medication errors. The LPN administered Iron 27 mg instead of the ordered Ferrous Gluconate 324 mg, and Magnesium Glycinate 400 mg instead of the ordered 100 mg. Additionally, the Calcium 1000/20 mg + D was not available for Resident #125, and the LPN signed the Medication Administration Record as awaiting a provider's order for an alternative. The facility's policy on administering medications, which requires medications to be administered safely and timely, was not adhered to in these instances.
Failure to Assess Cognitive Ability Before Signing Arbitration Agreement
Penalty
Summary
The facility failed to ensure that staff were aware of a resident's cognitive status and ability to understand before having the resident sign an arbitration agreement. This deficiency affected one resident, who had a history of severe cognitive impairment, as indicated by a BIMS score of four out of 15 and a diagnosis of vascular dementia. The resident was admitted with multiple diagnoses, including type two diabetes mellitus, hypertensive heart disease, muscle weakness, prostate cancer, and vascular dementia. Despite these conditions, the resident was asked to sign an arbitration agreement without the presence of a family member or legal representative. Interviews with the Director of Business Development and the Coordinator of Admissions revealed that arbitration agreements are signed during the admission process, and signatures are collected on an iPad, which populates all areas of the resident agreement, including the arbitration agreement. The staff did not check the BIMS scores before obtaining signatures, relying instead on verbal confirmation of understanding from the resident. The resident's family was not present during the signing, and the resident was unable to demonstrate an understanding of the agreement, as evidenced by his inability to state his location, the current year, or month during an interview.
Infection Control Breach in Urinary Catheter Care
Penalty
Summary
The facility failed to maintain infection control protocols for an indwelling urinary catheter bag and tubing for Resident #234. The resident, who was admitted with diagnoses including urinary tract infection, neuromuscular dysfunction of the bladder, retention of urine, and dementia, had a physician's order for Foley catheter care every shift. The care plan specified that the drainage bag should be maintained below the bladder level. However, during an observation, the resident was found in bed with the indwelling urinary catheter bag and tubing lying on the floor under the bed rail. This was confirmed by an LPN, who acknowledged that the catheter bag and tubing should not be on the floor due to infection control concerns. The facility's policy on urinary catheter care also stated that the catheter tubing and drainage bag should be kept off the floor.
Medication Storage Deficiency
Penalty
Summary
The facility failed to ensure medications were stored safely, as observed during a survey. Two medications, a Flomax 0.4 mg capsule and a gemfibrozil 600 mg tablet, were found in a small plastic medication cup on the overbed table of Resident #137. The resident's roommate was present in the room but was not independently mobile, and no other residents were nearby. An LPN confirmed the observation and removed the pills, discarding them. The medical record for Resident #137 showed a diagnosis of hyperlipidemia and benign prostatic hyperplasia without lower urinary tract symptoms, with physician orders for Flomax to be administered at bedtime and gemfibrozil twice daily. The medication administration record indicated these medications were signed off as administered the previous evening. The facility's undated policy on medication storage requires all drugs to be stored safely, securely, and orderly, which was not adhered to in this instance.
Deficiency in Room Cleanliness and Sanitation
Penalty
Summary
The facility failed to maintain resident rooms in a clean and sanitary manner, affecting two residents out of 138 observed. In one instance, an oxygen concentrator beside a resident's bed was found with a large amount of dried white substance on its top and front, which was verified by a registered nurse. In another instance, a resident's room contained a large amount of debris on the floor, including sunflower seeds, an empty water bottle, an empty can of chewing tobacco, a plastic grocery bag with various items, a grabber tool, and various food particles, including French fries under the window. This condition was confirmed by a housekeeping aide. The facility's policy requires that each area be maintained in a safe, clean, and comfortable manner, which was not adhered to in these cases.
Latest citations in Ohio
A resident with intact cognition receiving Medicare Part A skilled services for metabolic encephalopathy had services discontinued while benefit days remained, but the facility did not issue the required Skilled Nursing Facility Advance Beneficiary Notice (SNF ABN). The Social Services Director later confirmed that no SNF ABN was provided and reported she believed only a Notice of Medicare Non-Coverage (NOMNC) was needed when all skilled services were stopped. This practice conflicted with the facility’s written policy, which required SNF ABNs to be issued when extended care items or services were initiated, reduced, or terminated due to expected non-coverage by Medicare.
Surveyors identified that the facility exceeded the acceptable medication error rate when two residents with type 2 DM received insulin doses that were not administered according to orders or manufacturer instructions. In two separate observations, an LPN administered Novolog and another LPN administered insulin glargine and insulin lispro without priming the insulin pens, and the insulin lispro and Novolog were given after the residents had already consumed a significant portion of their breakfast meals, despite orders for administration before meals. Manufacturer information for both insulin products required priming before each injection to ensure accurate dosing, and facility policy required medications, including insulin, to be administered safely, timely, and in accordance with prescriber orders and specified time frames.
Surveyors found that the facility failed to document tray line food temperatures for multiple meals served from two dining room kitchenettes, despite having a “Trayline Taste & Temperature Log” and a policy requiring food to be stored, prepared, distributed, and served according to professional food safety standards. Review of logs showed repeated missing entries for breakfast, lunch, and dinner services in both the Harrison and McClellan dining areas, and the Senior Director of Culinary Services confirmed that temperatures had not been recorded for those meals, potentially affecting all residents receiving meals from those kitchenettes.
The facility failed to conduct and document required periodic care conferences for two residents, despite multiple comprehensive, quarterly, and significant change MDS assessments and a policy requiring periodic care conferences with resident and/or family participation. One resident with Parkinson’s disease, post-stroke hemiplegia, TIA, DMII, and depression had only two documented care conferences over a year, while another resident with aphasia, cerebrovascular disease, DMII, gait difficulty, coagulation defect, depression, and muscle weakness had no documented care conferences in the past year, aside from a declined invitation to the representative. The UCC confirmed that care conferences were expected to occur quarterly and that no additional documentation existed for either resident.
A resident with Alzheimer's disease and type II DM, who required extensive assistance with ADLs and was receiving scheduled Lantus and sliding-scale Humalog, experienced a severely elevated blood glucose level. The on-call provider was notified and ordered an additional dose of lispro insulin with a directive to recheck the blood glucose after administration. Nursing staff administered the extra insulin but did not document any follow-up blood glucose check, and the DON confirmed that this reevaluation was required by the facility's abnormal blood glucose policy and was not completed or documented.
A resident with Parkinson’s disease, dementia, and hypothyroidism was prescribed levothyroxine once daily along with other medications. A consultant pharmacist’s monthly drug regimen review recommended that levothyroxine be given in the morning on an empty stomach, 30–60 minutes before food, per manufacturer instructions. The medical record contained no documented physician response to this recommendation, and the MAR showed the drug scheduled for morning administration while the resident was observed eating breakfast and receiving the medication at the same time. An LPN confirmed administering levothyroxine during the meal, and the DON verified there was no documentation explaining whether or why the pharmacist’s recommendation was or was not followed, resulting in a failure to act on and document the identified irregularity.
A resident with severe cognitive impairment, multiple comorbidities, documented gait and balance abnormalities, and a high fall risk was care planned and assessed by therapy to require contact guard assistance and use of a gait belt for transfers and ambulation. While being assisted by a CNA from a recliner to the bathroom with a walker, the CNA did not apply a gait belt, even though the resident had a known tendency to lean backward when standing. As the CNA reached to open the bathroom door, the resident lost balance and fell backward, striking the back of the head, and was later found by an LPN without a gait belt in place, contrary to the facility’s gait belt policy and the resident’s assessed needs.
A resident with CKD stage five requiring peritoneal dialysis (PD) was admitted with pre-admission physician orders for three daily PD exchanges and monitoring for peritonitis (fever, abdominal pain, cloudy effluent), but these monitoring orders were not entered into the facility’s physician orders. The care plan referenced PD and general monitoring but did not specifically address peritonitis monitoring. Paper PD flowsheets showed incomplete and inconsistent documentation of exchanges and resident condition, including missing condition/comments for individual treatments and no record of one ordered PD exchange. The PD cycler flowsheet lacked effluent descriptions on multiple days. The PD nurse reported facility staff were expected to monitor effluent and symptoms, and the DON confirmed the absence of specific peritonitis monitoring orders, lack of an order for the PD cycler, and documentation gaps, despite a facility policy requiring ongoing assessment and monitoring for complications before, during, and after dialysis treatments.
A nurse was observed preparing multiple oral medications for a resident with depression, traumatic brain injury, anxiety, and impaired cognition by pushing tablets and capsules from unit-dose cards directly into her ungloved hand and then using her fingers to place them into a medication cup. In a follow-up interview, the RN confirmed this practice and acknowledged that the correct procedure is to dispense medications directly from the card into the cup, contrary to the facility’s medication administration policy requiring adherence to good nursing principles and practices.
A resident with Alzheimer’s disease, diabetes, anxiety, significant ADL dependence, and behavioral symptoms was observed seated in a chair positioned against the nursing station with a locked wheelchair placed directly in front, also against the nursing station, effectively restricting movement. An LPN confirmed both wheelchair wheels were locked and that it should not have been placed there, while a CNA stated she had positioned the wheelchair to prepare for lunch, was unable to complete the transfer, and left it in place, acknowledging this was wrong. This arrangement conflicted with the facility’s restraint policy, which prohibits physical restraints except when alternatives are ineffective for treating a medical symptom and defines restraints as devices adjacent to the body that cannot be easily removed and that restrict freedom of movement or access to the body.
Failure to Issue Required SNF ABN When Discontinuing Medicare Part A Services
Penalty
Summary
The deficiency involves the facility’s failure to issue a Skilled Nursing Facility Advance Beneficiary Notice (SNF ABN) when Medicare Part A services were discontinued for a resident who still had available benefit days. The resident was admitted with a diagnosis of metabolic encephalopathy and had intact cognition per the Minimum Data Set assessment. The facility’s own SNF Beneficiary Notification Review documented that Medicare Part A skilled services began on 02/11/26 and the last covered day was 03/11/26, and that the facility initiated discharge from Medicare Part A services before the resident’s benefit days were exhausted. Despite this, no SNF ABN was provided to the resident or the resident’s representative. During interviews, the Social Services Director stated that the SNF ABN was issued hours prior to the last covered day but, upon reviewing her files, confirmed that no SNF ABN had actually been issued for this resident. She further explained that she believed an SNF ABN was only required if one skilled service remained and that if all skilled services were being discontinued, only the Notice of Medicare Non-Coverage (NOMNC) needed to be issued. The Administrator, however, stated that a resident should always receive both a SNF ABN and a NOMNC when Medicare Part A services are discontinued and benefit days remain. Review of the facility’s written policy dated 03/28/23 showed that the facility was required to issue SNF ABNs for initiation, reduction, or termination of extended care items or services when Medicare payment was not expected, which did not occur in this case.
Plan Of Correction
This Plan of Correction is submitted as required under State and Federal law. This Plan of Correction does not constitute an admission on the part of the Facility that the findings cited are accurate, that the findings constitute a deficiency or that the scope and severity regarding the deficiency cited are correctly applied. Any changes to the Facility's policies and procedures should be inadmissible in any proceeding on that basis. Without admitting or denying the validity or the existence of the alleged noncompliance, the Facility submits this Plan of Correction with the intention that it be inadmissible by any third party in any civil or other action against the facility or any employee, agent, officer, director or shareholder of the Facility. The Facility is utilizing this Plan of Correction as its allegation of substantial compliance as of 05/29/2026 F-0582 Corrective action for resident/s: On 5/14/26 Resident #34 was informed of rights and responsibilities related to Advanced Beneficiary Notice and voiced understanding of information for future reference by administrator. Identification of other residents who may be affected: Any resident receiving skilled services from nursing or therapy services. The Administrator audited all residents who were discharged from skilled services in the past 30 days to ensure they were issued a Notice of Non-Coverage and Advanced Beneficiary Notice on 5/29/26. No non-compliance was noted. Measures for systemic change: On 5/14/2026 Business Office Manager, Director of Rehab, Minimum Data Set nurse, Director of Nursing and Social Services Director were educated on proper procedure of issuing of Notice Of Medicare Non Coverage and Advanced Beneficiary Notice by administrator. All upcoming discharges from skilled services will be reviewed weekly at Utilization Review meeting to ensure notices will be delivered timely. How Corrective Action will be monitored: Administrator or designee to complete audits of all residents being discharged from skilled services to ensure they were issued a Notice of Non-Coverage and Advanced Beneficiary. This audit will be completed weekly x 4 weeks, then monthly x 2 months. Corrective action will be initiated for any noted non-compliance. Audit findings will be reviewed as part of the monthly quality assurance process to determine the need for further monitoring. Date of Compliance 5/29/26
Insulin Administration Errors and Failure to Prime Insulin Pens
Penalty
Summary
The deficiency involves the facility’s failure to maintain a medication error rate below 5%, with surveyors identifying 3 errors out of 28 medication administration opportunities, resulting in a 10.71% error rate. For one resident with type 2 diabetes mellitus and moderate cognitive impairment, the physician’s order directed Novolog insulin 10 units via subcutaneous pen-injector to be given before meals. During an observed medication pass, the LPN administered 10 units of Novolog insulin without priming the pen and did so after the resident had already consumed approximately 50% of the breakfast meal. The LPN later confirmed she did not prime the pen and acknowledged that the insulin was ordered to be administered prior to meals. Manufacturer instructions for the Novolog FlexPen specified that an air shot (priming) must be performed before each injection to ensure proper dosing. Another resident, also diagnosed with type 2 diabetes mellitus and with intact cognition, had orders for insulin glargine 35 units subcutaneously twice daily and insulin lispro 20 units subcutaneously before meals, plus 12 units subcutaneously if blood glucose was between 251 mg/dL and 300 mg/dL. During an observed medication administration, an LPN administered 35 units of insulin glargine and 32 units of insulin lispro without priming the insulin pens and after the resident had consumed approximately 90% of the breakfast meal, despite orders for insulin lispro to be given before meals. The LPN later stated she could not remember if she had primed the pen and acknowledged that the insulin was ordered to be administered prior to meals. Manufacturer information for insulin lispro stated that the pen must be primed before each injection to confirm insulin delivery and remove air, and that failure to prime could result in too much or too little insulin. The DON confirmed the expectation that insulin be administered as ordered, including priming each pen with two units before dialing the prescribed dose, and facility policy required medications, including insulin, to be administered safely, timely, and in accordance with prescriber orders and required time frames.
Plan Of Correction
This Plan of Correction is submitted as required under State and Federal law. This Plan of Correction does not constitute an admission on the part of the Facility that the findings cited are accurate, that the findings constitute a deficiency or that the scope and severity regarding the deficiency cited are correctly applied. Any changes to the Facility's policies and procedures should be inadmissible in any proceeding on that basis. Without admitting or denying the validity or the existence of the alleged noncompliance, the Facility submits this Plan of Correction with the intention that it be inadmissible by any third party in any civil or other action against the facility or any employee, agent, officer, director or shareholder of the Facility. The Facility is utilizing this Plan of Correction as an allegation of substantial compliance as of 5/29/2026. F-0759 Corrective action for resident/s: Residents #21 and #22 were assessed and evaluated by nurse and Director of Nursing 5/14/26. Resident #21 and #22 both denied any adverse effects and none were noted upon assessment by the Director of Nursing on 5/14/2026. Notification made to physician on 5/14/2026. LPN # 2 competency Eval on insulin administration with the Director of Nursing completed 5/14/2026. Identification of other residents who may be affected: Diabetic residents on assignment of LPN #2/station 2 have the potential to be affected and were assessed by the DON/Designee on 5/14/26 and found to be within normal limits. Measures for systemic change: All Nurses were educated by the Director of Nursing on the steps for Insulin administration per competency, diabetes clinical protocol policy, Medication and treatment orders policy, administering medications policy, and Obtaining fingerstick Glucose Level policy On 5/14/2026. How Corrective Action will be monitored: Director of Nursing and Assistant Director of Nursing will complete insulin administration audits on 5 nurses. This audit will be completed weekly x 4 weeks, then monthly x 2 months. Corrective action will be initiated for any noted non-compliance. Audit findings will be reviewed as part of the monthly quality assurance process to determine the need for further monitoring. Date of Compliance: 5/29/2026
Failure to Document Tray Line Food Temperatures in Dining Room Kitchenettes
Penalty
Summary
The deficiency involves the facility’s failure to document tray line food temperatures for meals served from the Harrison and McClellan Dining Room kitchenettes, as required by professional standards for food service safety and the facility’s own policy. Review of the “Trayline Taste & Temperature Log” (revised September 2018) showed missing temperature documentation for multiple meals from the Harrison Dining Room kitchenette, including dinner on 03/30/26 and 03/31/26, lunch and dinner on 04/01/26 and 04/02/26, dinner on 04/07/26, and lunch and dinner on 04/08/26 and 04/10/26. The Senior Director of Culinary Services confirmed during interview that tray line food temperatures were not documented on the log for these meals. Similarly, review of the same log for the McClellan Dining Room kitchenette revealed that tray line food temperatures were not documented for dinner on 04/01/26, breakfast and lunch on 04/02/26, and lunch and dinner on 04/07/26. The Senior Director of Culinary Services also verified these omissions during interview. The facility census at the time was 27 residents, and the governing “Food and Nutrition” policy, approved on 09/07/21, stated that the facility must store, prepare, distribute, and serve food in accordance with professional standards for food service safety.
Plan Of Correction
F812 The facility will continue to ensure food temperatures are completed before meals are served for all residents. To ensure compliance with this standard the following measures have been taken: 1. Immediately 4/15/26 culinary supervisor #224 was re-educated by Dietary Manager to this standard and policy "Food and Nutrition" which includes documentation of food temperatures. 2. All dietary staff have been re-educated to the standard and policy "Food and Nutrition" during the month of April 2026. 3. Audits of food temperature documentation to be completed by Dietary Manager 4 x per week for 4 weeks then weekly for 4 weeks. 4. Administrator to validate audits/compliance and provide additional training as needed. Administrator will present to QAPI committee for ongoing monitoring and further direction.
Failure to Conduct and Document Required Care Conferences
Penalty
Summary
The deficiency involves the facility’s failure to complete and document comprehensive care conferences at required intervals in accordance with care plan regulations and facility policy. For one resident with Parkinson’s disease with dyskinesia, cognitive communication deficit, hemiplegia and hemiparesis following cerebral infarction, transient cerebral ischemic attack, type II diabetes mellitus, and major depressive disorder, the record showed multiple MDS assessments over a one-year period, including annual, quarterly, and significant change assessments. However, only two care conferences were documented during the last 12 months, despite the expectation that care conferences be conducted quarterly with the resident and family when possible. The Unit Care Coordinator confirmed that no additional care conference documentation existed for this resident beyond the notes dated 04/21/25 and 01/02/26. A second resident, with diagnoses including aphasia following cerebrovascular disease, cerebral infarction, type II diabetes mellitus, unsteadiness on feet, difficulty in walking, coagulation defect, depression, and muscle weakness, also had multiple MDS assessments completed over the review period, including quarterly and annual assessments. The record contained a note that a care conference was offered to the resident’s representative, who declined to attend, but there was no documentation of any care conferences for the most recent 12 months. The Unit Care Coordinator confirmed that no other care conference documentation was available for this resident. Facility policy stated that periodic care conferences involving the resident, family, and the interdisciplinary team are part of the care planning process, but the required periodic care conferences and corresponding documentation were not completed for these two residents.
Plan Of Correction
THIS PLAN OF CORRECTION SERVES AS BERKELEY SQUARE'S CREDIBLE ALLEGATION OF SUBSTANTIAL COMPLIANCE AS OF June 1, 2026. Without admitting or denying the validity or existence of the alleged deficiencies, Berkeley Square provides the following Plan of Correction: F657 The facility will continue to document completion of care conferences at the required intervals for all residents, including residents #04 & #15. To ensure compliance with this standard the following measures have be taken: 1. The social service designee and the inter- disciplinary team were re-educated by the administrator to the facility policy "Care Conference" on 4/29/26 and verbalized understanding. 2. Care conferences for resident #04 and resident #15 were conducted on or before 4/29/2026 by the interdisciplinary team. 3. Review of all other residents was conducted by the social service designee to validate and ensure that care conference schedule is up to date with timely care conferences scheduled for them on 4/15/2026. Audits of care conferences to be completed weekly for four weeks and then monthly after that by the social service designee. Documentation of the care conference including any identified concerns in the medical record. Administrator to validate audits/compliance and provide additional training as needed. Administrator will present results of these audits to QAPI committee for ongoing monitoring and further direction.
Failure to Reevaluate Blood Glucose After Treatment for Hyperglycemia
Penalty
Summary
The facility failed to ensure that a resident with diabetes received treatment in accordance with professional standards of practice when nursing staff did not reevaluate the resident's blood glucose after treatment for severe hyperglycemia. The resident, admitted with diagnoses including Alzheimer's disease, type II diabetes mellitus, and depression, had physician orders for Humalog insulin on a sliding scale before meals, Lantus insulin 25 units daily, and lisinopril 5 mg daily. The resident required extensive assistance with activities of daily living, including transfers, toileting hygiene, eating, and bathing. On the evening in question, the resident's blood glucose was documented as 532 mg/dL, and the on-call provider was notified. The provider gave a new order to administer an additional 8 units of lispro (Humalog) and to recheck the blood glucose in 30 minutes. The electronic medication administration record showed that the blood glucose of 532 mg/dL was obtained at 9:00 p.m. and that the additional 8 units of lispro were administered at 9:21 p.m. However, there was no documentation in the resident's chart that the blood glucose was rechecked after the additional insulin was given. In an interview, the DON confirmed there was no evidence of reevaluation and verified that, according to the facility's "Abnormal Blood Glucose Procedure" policy, the resident should have been reevaluated and that the evaluation step should have been included in the progress note documentation.
Plan Of Correction
F684 The facility will continue to ensure all residents, including #03, receive treatment in accordance with professional standards of practice and reevaluated for hyperglycemia. To ensure compliance with this standard the following measures have been taken: 1. The director of nursing assessed resident #03, reviewed documentation and orders and found no ill effects immediately 4/16/26. 2. All licensed nurses were re-educated to facility policy "Blood Glucose Monitoring" by the Director of Nursing/designee in April 2026. 3. Audits of like-residents that require blood sugar checks to be completed by the director of nursing/designee two times a week for 4 weeks and then monthly after that to validate correct follow through when there is abnormally high blood glucose result. The Administrator will bring results of these audits to the QAPI committee for ongoing monitoring and further direction.
Failure to Act on Pharmacist Drug Regimen Recommendation for Thyroid Medication
Penalty
Summary
The deficiency involves the facility’s failure to ensure that pharmacy recommendations from the monthly drug regimen review were acted upon and documented for a resident. The resident was admitted with diagnoses including Parkinson’s disease, dementia, and hypothyroidism, and had current physician orders for levothyroxine 150 mcg once daily, buspirone 50 mg twice daily, and losartan 100 mg once daily. A medication regimen review dated 11/25/2025 included a consultant pharmacist recommendation that levothyroxine be administered consistently in the morning on an empty stomach, at least 30–60 minutes before food, per manufacturer instructions. There was no specific physician response in the medical record to this recommendation, and the facility’s policy stated that consulting pharmacist reviews are sent to nursing and addressed with the primary care provider or consulting specialist for review and follow-up. Review of the resident’s medication administration record for April 2026 showed levothyroxine scheduled for 9:00 a.m. On observation, the resident was seen eating breakfast in the dining area at 8:03 a.m., and an LPN reported administering the levothyroxine 150 mcg to the resident while the resident was in the dining area eating breakfast. The DON confirmed there was no evidence in the resident’s medical record explaining why the consultant pharmacist’s recommendation from 11/25/2025 was or was not acted upon. This lack of documented physician review and action on the pharmacist’s identified irregularity constituted noncompliance with the drug regimen review requirements.
Plan Of Correction
F756 The facility will continue to ensure the pharmacy recommendations from the monthly drug regimen review by a licensed pharmacist are acted upon for all residents, including #08. To ensure compliance with this standard the following measures have been taken: 1. Resident #08 was assessed by the registered nurse and med review completed by 4/28/26. After review of resident's drug regime's, it was discovered that resident #8 had 2 separate medication recommendations on the same form, to be reviewed by two separate practitioners, pharmacy has been instructed and agreed to separate meds on individual forms. 2. Licensed nurses re-educated to facility policy "Drug Regimen Review" by Director of nursing/designee in April 2026 and no later than 5/8/26. Licensed nurses are responsible for ensuring the reviews and recommendations are given to the physician for timely review. 3. Review of all other current residents Drug Regimen orders completed by Director of nursing/designee on 4/16/26 to ensure recommendations were followed up on/reviewed by the physician and address concerns if needed. 4. Audit of drug regime recommendations, pharmacy recommendations, and physician follow up to be completed weekly for four weeks by the Director of nursing/designee. Administrator will present results of these audits to the QAPI committee for ongoing monitoring and further direction.
Failure to Use Required Gait Belt During Ambulation Resulting in Resident Fall
Penalty
Summary
The deficiency involves the facility’s failure to ensure that a required gait belt was used while assisting a high fall‑risk resident with ambulation, resulting in a fall with head injury. The resident had multiple diagnoses including metabolic encephalopathy, hypertension, osteoarthritis, muscle weakness, gait and mobility abnormalities, major depressive disorder, anxiety, and visual hallucinations. Admission and subsequent MDS and fall risk assessments documented that the resident was severely cognitively impaired, required moderate to maximal assistance with transfers and ambulation, could not independently come to a standing position, exhibited loss of balance while standing, used an assistive device, and had decreased muscle coordination. The resident had a history of falls prior to admission and was assessed as being at high, later moderate, risk for falls. The resident’s fall care plan identified her as at risk for falls and included interventions such as providing maximum to moderate assistance with transfers and walking short distances, use of a walker and wheelchair, and following the facility’s fall protocol. Therapy notes and care conference documentation indicated that the resident leaned backwards when standing, required contact guard to minimal assistance for bed mobility and transfers, and needed constant verbal cueing for safe sequencing during toilet transfers. The physical therapist confirmed that the resident was to use a gait belt with staff when ambulating, and the DON verified that therapy had assessed the resident as requiring contact guard assistance and a gait belt for ambulation and transfers. On the day of the incident, a CNA was assisting the resident from her recliner to the bathroom using a walker. The CNA walked beside the resident, providing guidance and support, and reported having a hand on the resident while assisting her. As they approached the bathroom door, the CNA reached for the doorknob to open it, and at that moment the resident began to lose her balance and fell backwards to the floor, striking the back of her head. The nurse who responded found the resident on her back at the foot of the bed with her feet near the bathroom, noted a red raised area on the back of the head, and documented that the resident was not wearing a gait belt and that the gait belt was on the dresser. In the facility’s investigative summary and in interviews, the CNA acknowledged that she did not have a gait belt on the resident while ambulating her, despite the resident’s assessed need for hands‑on assistance and gait belt use per facility policy and the resident’s care and therapy plans.
Failure to Implement PD Orders and Monitor Resident Receiving Peritoneal Dialysis
Penalty
Summary
The deficiency involves the facility’s failure to implement pre-admission physician orders for peritoneal dialysis (PD) and to provide ongoing monitoring for a resident with chronic kidney disease (CKD) stage five who required PD. Pre-admission orders dated 11/14/25 specified three daily PD exchanges at 6:00 A.M., 2:00 P.M., and 10:00 P.M., and directed staff to monitor for signs and symptoms of peritonitis, including fever, abdominal pain, and cloudy effluent. These monitoring orders were not entered into the facility’s physician orders. The resident’s care plan noted the need for PD and included general monitoring interventions (labs, signs of bleeding, bacteremia, septic shock, and significant vital sign changes), but did not specifically address the ordered monitoring for peritonitis. Review of PD documentation showed incomplete and inconsistent charting of treatments and resident condition. The paper peritoneal flowsheet had columns for time of PD and condition/comments, including instructions to call the nurse immediately for cloudy fluid, abdominal pain, or fever. However, the first entry on 11/15/26 at 2:00 P.M. only noted that the PD nurse completed the exchange, and the 10:00 P.M. entry that day had no condition/comment documentation. Subsequent days (11/16/25, 11/17/25, and 11/18/25) contained only one condition/comment entry per day rather than for each exchange, and there was no documentation that the 6:00 A.M. PD on 11/18/25 was completed. The PD cycler flowsheet starting 11/19/25 lacked any description of the effluent on multiple days. The PD nurse from the dialysis company stated facility staff were expected to monitor effluent for cloudiness and assess for abdominal pain and fever, and the DON confirmed there was no electronic physician order for peritonitis monitoring or for use of the PD cycler, that the paper charting did not allow for effluent description or symptom documentation for each treatment, and that PD was not documented at one ordered time. The facility’s dialysis policy required ongoing assessment and monitoring for complications before, during, and after treatments, which was not reflected in the documentation for this resident.
Improper Infection Control During Medication Administration
Penalty
Summary
Surveyors identified a deficiency in infection prevention and control related to medication administration for Resident #29. The resident was admitted on 02/28/14 with diagnoses including depression, traumatic brain injury, and anxiety, and had impaired cognition per a quarterly MDS assessment. During an observation on 03/25/26 at 6:58 A.M., RN #281 prepared the resident’s medications by removing an Amoxicillin-Pot Clavulanate tablet from the medication card and pushing it directly into her ungloved hand, then using her fingers to place the pill into a medication cup. The same process was observed for multiple other medications, including Escitalopram Oxalate, Furosemide, Sennosides, Lyrica, and Vitamin D, each being pushed from the card into the RN’s ungloved hand and then transferred by her fingers into the medication cup before administration to Resident #29. In a subsequent interview at 7:27 A.M. the same day, RN #281 confirmed she had placed each medication into her ungloved hands prior to administration and acknowledged that the proper procedure was to push the pills directly from the card into the medication cup. Review of the facility’s “Medication Administration – General guidelines” policy, revised 10/08/25, stated that medications are to be administered in accordance with good nursing principles and practices. This practice failure was cited as a deficiency under Complaint Number 2681777.
Improper Use of Wheelchair as a Physical Restraint
Penalty
Summary
Surveyors identified a deficiency related to the facility’s failure to ensure a resident was free from physical restraints. Resident #7, admitted with diagnoses including Alzheimer’s disease, diabetes mellitus, and anxiety disorder, was documented on a recent MDS as rarely understood and dependent for ADLs except eating. The resident ambulated independently on the unit without an assistive device and had documented verbal and other behaviors occurring one to three days during the look-back period. The care plan noted the resident had potential to be physically aggressive, chase staff, throw objects, and be combative with care, with interventions such as offering choices, administering medications as ordered, and intervening early when agitation occurred. During an observation and interview, Resident #7 was found sitting in a chair with the right arm of the chair positioned against the nursing station and a wheelchair placed directly in front of him. The left arm of the wheelchair was also against the nursing station, and both wheelchair wheels were locked, creating a barrier that appeared to restrain the resident, who was sleeping with his knees touching the locked wheelchair. An LPN confirmed both wheelchair wheels were locked and that the wheelchair should not have been placed in front of the resident. A CNA reported she had placed the wheelchair there in preparation to get the resident up for lunch, was unable to transfer him, and left the wheelchair in that position, acknowledging it was wrong to keep it there. The facility’s physical restraint policy stated that physical restraints are not used except when alternatives are not appropriate or effective for treating a medical symptom and defined physical restraints as any device attached or adjacent to the body that the individual cannot easily remove and that restricts freedom of movement or access to the body.
Trusted data from CMS and state health departments
Every citation, penalty and Plan of Correction is sourced from public CMS records (latest release May 27, 2026) and official state health department websites — never guesswork.
Trusted by long-term care providers and associations.
