Twinsburg Post Acute
Inspection history, citations, penalties and survey trends for this long-term care facility in Twinsburg, Ohio.
- Location
- 8551 Darrow Road, Twinsburg, Ohio 44087
- CMS Provider Number
- 366419
- Inspections on file
- 35
- Latest survey
- February 10, 2026
- Citations (last 12 mo.)
- 21
Citation history
Health deficiencies cited at Twinsburg Post Acute during CMS and state inspections, most recent first.
Surveyors found that the facility failed to implement and maintain individualized, effective fall-prevention measures for several high-risk residents. One resident with moderate cognitive impairment, impaired mobility, and a history of multiple falls experienced repeated unwitnessed falls, including a fall causing an orbital fracture, while staff relied on generic interventions such as a “call before you fall” sign and resident education that were not appropriate to the resident’s condition. The same resident showed lethargy and acute confusion, had a delayed urine collection, and later a positive UA and culture for E. coli that were not promptly communicated to a provider, during a period of ongoing falls. Other residents with severe cognitive impairment, traumatic brain injury, cervical spine fracture, dementia, and high fall risk had care plans requiring low bed positions, floor mats, positioning pillows, and accessible call lights, but surveyors observed raised beds, missing or misplaced mats, absent pillows, and call lights out of reach, with staff confirming these did not match the care plans, contrary to the facility’s own falls policy.
A resident with chronic kidney disease, ESRD, and moderate cognitive impairment developed acute lethargy and altered mental status, prompting a CNP to order a UA C&S to evaluate for a possible UTI and request provider notification when results were available. Over the next several weeks, nursing documentation showed repeated failures to obtain an adequate urine specimen due to issues such as incontinence, resident refusal of straight cath by a male, and lab pickup delays, with no documented notification to the provider about these problems. The urine was finally collected weeks later, and the UA C&S returned positive for nitrites and >100,000 E. coli, but the CNP was not notified of these results for several days until the resident’s daughter requested the lab report. The DON and an LPN acknowledged that lab results were sent to multiple fax machines, were often missed, there were intermittent fax/printer issues, nurses did not consistently monitor for pending labs, and there was no facility lab policy.
Surveyors identified that the facility exceeded the acceptable medication error rate when two residents did not receive medications in accordance with professional standards. One resident with constipation did not receive a prescribed daily dose of MiraLAX because it was not available at the time of the medication pass. Another resident with type II DM received insulin lispro via a pen that an LPN failed to prime before administration, contrary to the manufacturer’s instructions requiring a safety test (priming) before each injection. These observations resulted in a calculated medication error rate above 5%.
A resident with type II DM and severe cognitive impairment had an order for 6 units of insulin lispro SQ before meals. During a medication pass, an LPN checked the resident’s blood sugar, prepared the insulin pen by attaching a needle, and dialed 6 units without first priming the pen, then administered the injection. In interview, the LPN confirmed she does not prime insulin pens, contrary to the manufacturer’s instructions, which require a 2‑unit safety test (priming) before each injection to ensure proper function and correct dosing. Facility policy required medications to be administered safely and as prescribed, and this failure was cited as a significant medication error affecting one resident and potentially affecting other residents receiving insulin pen injections.
A resident with chronic kidney disease, reduced mobility, and constipation risk had an order for daily MiraLAX. The resident’s daughter reported that medications were being left in the room without staff ensuring they were taken, while the MAR was signed as if administered. During a medication pass, an LPN confirmed the MiraLAX was not available yet signed the MAR indicating it was given, and no note was entered to explain the missed dose. Record review showed no documentation clarifying the discrepancy, contrary to the facility’s policy requiring objective, complete, and accurate medication documentation.
Two residents at high risk for pressure ulcers did not receive comprehensive, coordinated prevention and treatment. One resident with hemiplegia, incontinence, and existing pressure ulcers developed a new gluteal wound that was initially treated by a nurse without a provider order, was not promptly assessed as a pressure injury, and was not reported to the wound CNP for several days, during which it deteriorated to an unstageable ulcer with slough, odor, tunneling, and infection requiring antibiotics. Staff interviews showed inconsistent turning and repositioning practices and conflicting statements about the resident’s positioning abilities, despite a policy requiring at least q2h repositioning. A second resident with multiple sclerosis, paraplegia, severe leg contractures, and existing pressure ulcers was observed with contracted legs pressed together without pillows or PRAFO boots as care-planned, and an open wound on the inner knee was found under a foam dressing and calcium alginate that had been applied and treated with zinc by hospice staff without any assessment, documentation, or physician orders in the facility record.
A cognitively impaired resident with multiple serious diagnoses was documented in the facility record and care plan as full code, with an advance directive for CPR, even after admission to hospice. Hospice staff obtained and documented a DNR-CC advance directive signed by the resident’s spouse and reported that such documents are typically faxed to the facility, but no updated DNR orders appeared in the facility chart. On the day of death, hospice staff recognized the resident was actively dying, made him comfortable, and did not initiate CPR; facility staff also did not call a code, despite the MAR still listing full code status and an RN questioning this discrepancy and being told by a unit manager not to worry about it. The Administrator and DON acknowledged that the facility’s documentation did not match the hospice DNR-CC directive, contrary to facility policy requiring current advance directives to be maintained and communicated in the medical record.
Two residents who were cognitively impaired, fully dependent for toileting, and always incontinent did not receive timely incontinence care as required by their care plans and facility policy. One resident was placed in a chair after morning care and remained there for several hours without being checked or changed, later found with a saturated brief and deep red tissue in the buttocks and sacral area. Another resident with hemiplegia, contractures, and a sacral pressure ulcer was observed during wound care with a wet brief and soiled linens; staff refastened the same saturated brief after treatment and left without changing it or alerting others. CNAs reported they had not checked these residents for incontinence since the start of their shift and cited lack of clear direction and staffing support, while nursing leadership stated residents were expected to be checked and changed every two hours or as needed under a check-and-change strategy.
A post-surgical resident with a recent C3–C9 cervical laminectomy and fusion, mobility limitations, and a care plan requiring assisted mobility and pain monitoring attempted to use the bathroom without help, fell, and hit her head. Staff found her on the floor with dizziness, nausea, and repeated vomiting, and an NP chose to treat her in-house with neuro checks, IV fluids, and Zofran rather than send her to the ER, despite nursing staff concerns and surgeon office guidance to send her out if new changes occurred. Required 72-hour neuro checks were not completed at the ordered frequencies, documentation of changes in condition was limited mainly to vomiting, and there was no evidence of pain assessments every shift or non-pharmacologic pain interventions as outlined in the care plan, even though staff observed new positional neck pain after the fall. Days later, after the resident’s daughter requested hospital transfer due to ongoing dizziness and neck pain, a CT scan revealed concerning cervical findings including a possible facet fracture and hardware issues, demonstrating that the resident’s change in condition after the fall had not been timely and thoroughly monitored or addressed.
Staff failed to follow enhanced barrier precautions and hand hygiene requirements during high-contact care for three residents with significant wounds, indwelling devices, incontinence, and total dependence for ADLs. In separate observations, CNAs provided incontinence care without gowns despite posted EBP signage and care plans requiring gown and glove use, allowing their clothing to contact the resident and linens. Hospice staff performed wound care on a resident with multiple pressure ulcers, a feeding tube, and an ostomy without wearing gowns, even though they also cared for several other residents. An LPN repositioned a bedbound resident with multiple pressure ulcers and osteomyelitis without donning a gown and did not wash hands before or after care, despite an EBP sign and facility policies mandating hand hygiene and PPE use for high-contact resident care activities.
A resident did not receive treatment and care in accordance with physician orders and their own preferences and goals, resulting in a deficiency related to the facility's failure to follow the established care plan.
Surveyors found that appropriate care was not consistently provided to residents who were continent or incontinent of bowel and bladder, including improper catheter care and insufficient measures to prevent UTIs.
The facility did not ensure that an area was free from accident hazards and failed to provide adequate supervision to prevent accidents. Surveyors observed environmental hazards and insufficient staff monitoring, resulting in a deficiency related to accident prevention.
A resident experienced a significant medication error due to a failure in the medication administration process. The report does not provide further details about the circumstances or the resident's condition.
Staff did not promptly inform a resident, their physician, and a family member about important events such as injury, decline, or room changes, resulting in a breakdown of required communication.
A resident with severe cognitive impairment and multiple medical conditions did not receive wound care as ordered by the physician, resulting in a dressing remaining unchanged for two days. The dressing was found to be heavily soiled and malodorous, and staff records confirmed that required daily dressing changes were missed, contrary to facility policy.
A resident with a UTI did not receive the prescribed Cipro antibiotic as ordered due to the facility's failure to respond to a pharmacy alert about a drug interaction with tizanidine. The pharmacy withheld the medication pending clarification, but the facility did not act on the notification, resulting in the resident missing several scheduled doses. Documentation showed only partial administration, and the issue was not communicated to the nurse practitioner until days later.
A resident with a history of UTI and urinary retention did not have a urinalysis completed as ordered by a CNP. Although urine was collected, it was not sent to the lab, and the CNP was not notified of the missed test. The DON confirmed the lapse, and no urinalysis results were available in the medical record.
Staff did not wear required PPE, specifically isolation gowns, while performing straight catheterization and peri care for a resident on Enhanced Barrier Precautions. Despite facility policy and CDC guidance mandating gown and glove use for high-contact care involving indwelling devices, staff routinely omitted gowns, and leadership confirmed this was not in line with protocol.
A resident with multiple complex diagnoses and severely impaired cognition experienced a change in condition, prompting her family to repeatedly request contact with the NP or physician. Despite these requests and the family's concerns about possible sepsis, the agency nurse did not promptly notify a provider or facilitate communication, and documentation of provider contact was lacking. The resident was only sent to the hospital after the ADON intervened and obtained an order from the NP.
A resident with moderate cognitive impairment and psychiatric diagnoses left the facility property unsupervised, despite having physician orders for a Wanderguard and supervised LOA. The resident was last seen outside by staff, later found by police walking in the street, and became combative, requiring ER transport. Staff interviews confirmed the resident was not supervised as required.
A long-term care facility failed to administer insulin according to physician's orders for three residents, leading to improper timing and lack of documentation. One resident did not receive insulin as prescribed, with the RN failing to prime the insulin needle. Another resident's insulin was administered hours late, and a third resident also received insulin at incorrect times. The DON confirmed that insulin should be administered as ordered, and facility policy required medications to be given within one hour of their prescribed time.
During an EMR transition, a facility failed to maintain complete and accurate medical records for several residents, including missing documentation of significant incidents, meal intakes, and incontinence care. The DON created binders for documentation, but these were not provided to surveyors promptly, resulting in incomplete records. This deficiency was identified during a complaint investigation.
A facility failed to notify a resident's representative of a medication change and a fall. The resident, with multiple health issues including diabetes, had an insulin dosage increase and experienced an unwitnessed fall. The Director of Nursing confirmed the lack of documentation for notifying the responsible party, violating the facility's policy for prompt notification of changes in a resident's condition.
The facility failed to implement baseline care plans within 48 hours for three residents, as required by policy. A resident with multiple diagnoses, including a fracture and diabetes, had an incomplete care plan lacking goals and interventions. Two other residents, one with chronic heart failure and another with dementia, also lacked baseline care plans. Reviews and interviews confirmed the absence of these plans, despite the facility's policy.
A facility failed to create a comprehensive care plan for a resident with multiple medical conditions, focusing only on nutritional needs despite the resident's history of falls and other health issues. The DON confirmed the care plan's inadequacy, which was identified during a complaint investigation.
A resident with a history of falls and multiple medical conditions experienced a fall that was not thoroughly investigated by the facility. Despite being identified as a fall risk, the resident's care plans lacked specific fall prevention interventions. The incident was not logged during a period of EMR downtime, and no interdisciplinary team meeting was held to address the fall or implement new interventions, contrary to the facility's policy.
The facility failed to maintain a medication error rate below five percent, affecting three residents. A resident with diabetes did not receive Omeprazole on time, and insulin was not primed correctly. Another resident with impaired vision received eye drops late due to positioning issues. A third resident with dementia had delayed insulin administration despite high blood sugar levels. These incidents reflect non-compliance with medication administration policies.
A facility failed to disinfect a blood glucose monitor (BGM) between uses, as observed during a complaint investigation. An RN used the same BGM for two residents without cleaning it, despite knowing the protocol. This affected one resident directly and potentially impacted three others. The facility's policy and CDC guidelines require BGMs to be cleaned and disinfected after each use to prevent infection spread.
A resident with severe cognitive impairment was treated without respect and dignity by an STNA, who ignored the resident's refusal to get out of bed, failed to provide necessary peri care, and did not communicate during care. The facility's policy on resident rights was not followed, as confirmed by staff interviews.
A resident, severely cognitively impaired and dependent on staff for mobility, was improperly transferred by a single STNA, contrary to the care plan requiring two staff members or a mechanical lift. The resident was lowered to the floor, and no assessment or documentation of the fall was made. Staff interviews revealed a lack of written transfer instructions, leading to confusion.
A facility failed to document blood pressure readings before administering hydralazine to a resident with hypertension, as required by physician orders. Despite the care plan's directive to monitor blood pressure, records for August and September 2024 showed no documentation of readings prior to medication administration. Interviews confirmed the oversight, which violated the facility's medication administration policy.
A resident with paraplegia and neuromuscular dysfunction of the bladder did not receive timely incontinence care, as confirmed by observations and staff interviews. The resident's care plan required regular checks and assistance, but staff delayed care, resulting in the resident being left in a soaked incontinence brief and draw sheet. This was contrary to the facility's policy aimed at preventing skin irritation and infection.
A resident with dementia and chronic conditions was sent to the hospital after an unwitnessed fall without prior notification to her POA or hospice. The LPN on duty, unfamiliar with the resident, made the decision despite stable vitals and normal neurological checks. The facility failed to inform the POA about a prior X-ray order and results, violating their policy on notifying changes in a resident's condition.
A facility failed to administer a resident's prescribed pain medication, Tramadol, as ordered, resulting in missed doses on several occasions. The resident, with conditions such as COPD and osteoarthritis, was supposed to receive the medication three times daily. However, discrepancies were found between the narcotic count sheet and the Medication Administration Record, indicating incorrect documentation by nursing staff. The Director of Nursing confirmed the medication was not administered as scheduled.
The facility failed to document medication and treatment administration accurately for two residents. One resident did not receive all prescribed doses of Tramadol, and treatments for their toe, heel, and buttocks were inconsistently documented. Another resident's oxygen saturation assessments and other treatments were not documented on several night shifts. The DON confirmed these discrepancies.
A resident with heart failure and lymphedema was not administered the prescribed diuretic medication, Torsemide, during their stay at the facility. This oversight led to significant shortness of breath and hospitalization. Staff interviews revealed the medication was ordered but not available, resulting in actual harm to the resident.
The facility failed to ensure medications were administered without error, affecting two residents and resulting in a medication administration error rate of 24.13%. Errors included incorrect dosing and failure to administer prescribed medications, as well as improper documentation.
The facility failed to ensure accurate documentation of a resident's shower/bath schedule, affecting one resident with severe cognitive impairment and multiple medical conditions. The review revealed inconsistencies and missing documentation, with illegible nurse signatures and incomplete STNA signatures. Interviews confirmed that the documentation was incomplete and possibly falsified.
The facility failed to ensure proper hand hygiene and use of PPE during medication administration for two residents. An LPN did not wash or sanitize her hands before and after dispensing medications, and an RN did not follow infection control standards, including contaminating eye drop containers and not wearing gloves.
Failure to Implement Effective, Individualized Fall Prevention for High-Risk Residents
Penalty
Summary
The deficiency involves the facility’s failure to develop and implement a comprehensive, individualized, and effective fall management program and to ensure fall-prevention interventions were in place for multiple residents at risk for falls. One resident with moderate cognitive impairment, a history of repeated falls, impaired mobility, and multiple comorbidities experienced at least seven falls over several months, culminating in an unwitnessed fall with an orbital fracture. Despite documented fall risk assessments identifying at least moderate and later high fall risk, the facility repeatedly relied on generic interventions such as a “call before you fall” sign and resident education, without evidence these were appropriate or effective given the resident’s cognitive status and functional limitations. Post-fall assessments and IDT notes did not reflect meaningful root cause analysis or individualized modifications to the care plan, and fall investigations were not provided for review. For this same resident, the facility did not timely identify and act on a suspected urinary tract infection that was associated with lethargy, altered mental status, and increased confusion. A CNP ordered a urinalysis and culture to evaluate for a possible infectious cause of acute delirium, but the urine specimen was not collected until weeks later, and the abnormal results showing nitrite-positive urine and a culture with greater than 100,000 E. coli were not communicated to a provider as required. During this period, the resident continued to have falls, including a fall with major injury. The resident’s daughter reported noticing increased confusion and unusual behaviors and stated she had requested a UA earlier; she later discovered the positive results herself and reported that treatment was only initiated after she confronted staff. Medical literature cited in the report recognizes UTIs as a contributor to increased fall risk in elderly residents, and the facility’s own policy identifies infection as a condition that may contribute to fall risk. Additional deficiencies were identified for three other residents with documented fall risks and care-planned interventions that were not implemented as written. One resident with severe cognitive impairment, traumatic brain injury, and multiple fractures had a care plan requiring the bed to be kept in low position, a pillow for positioning, and floor mats on both sides of the bed; surveyors observed the bed raised, only one mat in place, the second mat leaning against the wall, and no positioning pillow in use. Another resident with severe cognitive impairment, high fall risk, and a history of a cervical spine fracture with a c-collar had care-planned interventions including a low bed, a fall mat on a specified side, and a call light within reach; surveyors found the bed raised, the mat on the wrong side, and the call light on the floor behind the head of the bed, out of reach. A fourth resident with severe cognitive impairment, high fall risk, dementia with behavioral disturbance, and psychosis had a care plan calling for bed pillows for positioning and a call light within reach, but surveyors observed no positioning pillows and the call light stored in a closed nightstand drawer. In each case, staff confirmed that the observed conditions did not match the residents’ fall-prevention care plan interventions, contrary to the facility’s falls policy requiring staff to implement interventions based on identified risks and causes. The facility’s undated Falls and Fall Risk, Managing policy stated that, based on evaluations and current data, staff would identify interventions related to each resident’s specific risks and causes to try to prevent falls and minimize complications, and that fall risk factors include incorrect bed height or width and conditions such as infection. However, surveyors found repeated instances where beds were not in low position, mats were missing or improperly placed, call lights were not accessible, and individualized interventions were either not implemented or not adjusted after repeated falls. The quarterly MDS assessments for at least two residents were also inaccurate, failing to capture documented falls, including one fall that resulted in a six-day hospitalization and another that caused a cervical spine fracture. These inaccuracies further reflected the facility’s failure to maintain accurate assessment data related to falls and fall risk, contributing to the overall deficiency in accident prevention and supervision.
Delayed UA Collection and Provider Notification for Suspected UTI
Penalty
Summary
The deficiency involves the facility’s failure to timely obtain and process a physician-ordered urinalysis with culture and sensitivity (UA C&S) and to promptly notify the provider of positive results for a resident with chronic kidney disease, end stage renal disease, and moderate cognitive impairment. The resident was admitted with occasional bladder incontinence and was noted by a CNP on 12/23/25 to have acute lethargy, altered mental status, and delayed responses, representing a significant change from baseline. In response, the CNP ordered a UA C&S to evaluate for a urinary source of acute delirium/encephalopathy and directed staff to notify the provider when results were available. Despite this order, the urine specimen was not obtained for 22 days. Multiple Medication Administration Notes documented unsuccessful or incomplete attempts to obtain the urine, including that no urine was obtained and the resident was hydrating, the resident’s refusal to be straight cathed by a male, the resident’s incontinence, and that the lab would not pick up until Monday. There was also documentation that urine was collected into a brief and that the UA was “completed,” as well as later notes stating “unable to collect.” Throughout these entries, there was no documented evidence that the physician or CNP was notified of the ongoing inability to obtain the ordered specimen or of the delays. A subsequent order was written to obtain urine via straight catheter, and the UA C&S specimen was finally collected on 01/14/26. Laboratory results showed abnormal UA findings, including positive nitrites, and the urine culture grew greater than 100,000 E. coli with sensitivities reported. The lab reported these results to the facility on 01/23/26, but there was no documented notification to the CNP until 01/28/26, after the resident’s daughter requested a copy of the UA results due to her mother’s increased confusion. Interviews with an LPN and the DON revealed that lab results were sent to three different fax machines, that results were often missed if nurses were not aware a resident was awaiting labs, that there were intermittent issues with fax/printer service, and that there was no facility policy regarding labs. The DON confirmed the 22‑day delay in obtaining the UA, the five‑day delay in notifying the CNP of the positive UA C&S, and that nurses did not follow through with monitoring for and acting on the ordered lab and its results.
Medication Administration Errors Resulting in Exceeded Medication Error Rate
Penalty
Summary
The deficiency involves the facility’s failure to ensure medications were administered in accordance with professional standards of practice, resulting in a medication error rate of 5.12%, which exceeded the required rate of less than 5%. During a medication pass observation, there were two errors out of 39 opportunities. For one resident with chronic kidney disease, reduced mobility, and lumbar intervertebral disc displacement, the care plan identified risk for gastrointestinal complications due to constipation with an intervention to administer medications as ordered. The physician had ordered MiraLAX 17 g by mouth once daily for constipation, but during observation the assigned LPN reported that the MiraLAX was not available and stated the resident would receive it the following day, indicating the ordered medication was not administered as prescribed. Another resident, admitted with type II diabetes mellitus and care planned for diabetes management with an intervention to administer medications as ordered, had a physician’s order for insulin lispro 6 units SQ before meals, to be held if blood sugar was less than 150. The resident had severe cognitive impairment but did not reject care and was largely independent with several ADLs. During observed medication administration, an LPN checked the resident’s blood sugar, found it to be 238, attached a needle to the insulin lispro pen, dialed the pen to 6 units, and administered the insulin SQ without priming the pen. In a subsequent interview, the LPN confirmed she did not prime the pen and stated that pens are never primed. Review of the insulin pen manufacturer’s instructions showed that a safety test (priming) of 2 units must be performed before each injection to ensure the pen and needle are working properly and to ensure the correct dose, demonstrating that the insulin was not administered in accordance with professional standards and manufacturer guidance.
Failure to Properly Prime Insulin Pen Resulting in Medication Error
Penalty
Summary
The deficiency involves the facility’s failure to ensure a resident was free from a significant medication error when insulin was administered incorrectly. Resident #7, admitted with type II diabetes mellitus and care planned for diabetes management with medications to be administered as ordered, had a physician’s order for insulin lispro 100 units/ml, six units SQ before meals, to be held if blood sugar was less than 150. A quarterly MDS showed the resident had severe cognitive impairment with a BIMS score of 2/15, did not reject care, and was independent with eating, transfers, and oral hygiene, requiring supervision for toileting hygiene and showers. During observation of a medication pass, LPN #207 checked Resident #7’s blood sugar, which was 238, then prepared an insulin lispro pen by attaching a needle and dialing the pen to six units without priming the pen before administration. The LPN then administered the insulin SQ. In a subsequent interview, LPN #207 confirmed she did not prime the insulin pen and stated that she believed pens should never be primed to avoid air. Review of the insulin pen instruction manual showed that a safety test (priming) of two units must be performed before each injection to ensure the pen and needle are working properly and to ensure the correct dose is delivered. Facility policy on administering medications required medications to be administered in a safe manner and as prescribed. The failure to prime the insulin pen before dialing and administering the ordered dose constituted the medication error identified during the complaint investigation.
Inaccurate MAR Documentation for Laxative Medication
Penalty
Summary
The deficiency involves the facility’s failure to ensure accurate documentation of medication administration in accordance with professional standards for one resident. The resident had an admission date of 09/09/25 and diagnoses including chronic kidney disease, reduced mobility, and lumbar intervertebral disc displacement. A care plan initiated on 09/10/25 identified the resident as being at risk for gastrointestinal complications due to constipation, with interventions including administering medications as ordered. A quarterly MDS assessment documented moderate cognitive impairment, a need for partial to moderate assistance with bed mobility and transfers, occasional bladder incontinence, and consistent bowel continence. Physician orders included MiraLAX oral powder 17 gm by mouth once daily for constipation, dated 01/30/26. The resident’s daughter reported that the resident was not receiving medications as prescribed, stating that staff left medications in the room without ensuring they were taken, and then signed the MAR as if they had been administered. During a medication pass observation on 02/09/26 at 11:23 A.M., an LPN was administering morning medications for the resident and confirmed that the ordered MiraLAX was not available, stating the resident would have it by the next day. Despite the medication not being available or given, the LPN signed the MAR indicating that the MiraLAX dose for 02/09/26 had been administered. Subsequent record review on 02/10/26 showed the MiraLAX scheduled for 9:00 A.M. on 02/09/26 was documented as given, with no progress notes or MAR notes explaining the discrepancy or addressing the missed dose. In an interview on 02/10/26, the LPN confirmed that the MiraLAX was not available, that the resident did not receive the medication on 02/09/26, and that the MAR had been signed as if it had been administered, without any corrective note entered in the medical record. This conduct was inconsistent with the facility’s charting and documentation policy, which requires that all services provided be documented in an objective, complete, and accurate manner and that medication administration be accurately recorded in the medical record.
Failure to Provide Comprehensive Pressure Ulcer Prevention and Treatment for Two High-Risk Residents
Penalty
Summary
The deficiency involves the facility’s failure to implement comprehensive, resident-centered pressure ulcer prevention and treatment for two residents with significant risk factors and existing wounds. One resident was admitted with hemiplegia, contractures, diabetes, bed confinement, incontinence, and a Stage III sacral pressure ulcer, and was assessed as dependent for all ADLs and at risk for pressure ulcers. The care plan identified risk for skin breakdown and included general interventions such as administering medications and treatments as ordered and keeping skin clean and dry, but there was no documentation of specific turning or repositioning restrictions or a detailed repositioning program. Staff interviews revealed inconsistent understanding of the resident’s ability to be turned to the left or right side, and CNAs and an LPN reported that residents were not consistently checked, changed, turned, and repositioned in a timely manner, despite a facility policy requiring at least every-two-hour repositioning for residents in bed. On one date, an RN documented discovery of a new open area on the resident’s left upper thigh/gluteal region during wound rounds, describing it as a bruise and skin tear, cleansing it with normal saline, and applying a foam dressing. However, no physician order was obtained for this new wound, and no comprehensive wound assessment or further treatment was documented until three days later. When the wound care LPN assessed the area, it was identified as an in-house acquired unstageable pressure ulcer with slough and excoriated surrounding tissue, and the wound care CNP later confirmed she was not notified of the wound until that date, despite expecting notification when new wounds occur. Subsequent documentation showed that this gluteal wound deteriorated, with increased size, 100% slough, heavy exudate, odor, dark reddish-brown surrounding tissue, and heavy dressing saturation, and the resident required oral antibiotics for a wound infection. Observation of wound care later revealed a strong foul odor, drainage on the dressing, a wound bed that was 100% dark gray with sloughing, and tunneling, with the resident moaning and yelling intermittently during care. The same resident developed multiple additional in-house acquired unstageable pressure ulcers after admission, including to the left elbow, both heels, and right plantar foot, while staff reported that he was a “heavy wetter,” stayed in bed to help heal his wounds, and did not refuse wound care. The wound care nurse attributed the gluteal wound to the resident not getting out of bed often and being wet, and confirmed that the date recorded as the wound’s discovery on the skin issue form was incorrect, as the wound was actually found three days earlier. Observations also showed the resident lying on his backside without an indwelling catheter in place at the time, despite later orders for catheter placement, and the facility’s repositioning policy emphasized avoiding positioning on existing ulcers and maintaining a documented, monitored, and evaluated turning/repositioning program, which was not consistently implemented or documented for this resident. For the second resident, who had multiple sclerosis, paraplegia, severe lower extremity contractures, and existing pressure ulcers, the care plan identified increased risk for skin breakdown due to impaired mobility and called for offloading heels, positioning pillows to lower extremities, and use of PRAFO boots to keep heels elevated. The MDS documented existing Stage II and Stage III pressure ulcers and use of a pressure-reducing device for the bed. During observation with a hospice RN, the resident’s severely contracted lower legs were found pressed tightly together with no device or padding to separate bone-on-bone contact. A foam dressing dated four days earlier was discovered on the left inner knee, covering a piece of calcium alginate over an open wound that measured 3 cm by 2 cm by 0.1 cm with serosanguinous drainage and red surrounding tissue. The hospice RN stated that the area had been red the prior week and that zinc had been applied, and that the wound care nurse had been told about the area, but she acknowledged that no physician order had been obtained for zinc or for treatment of the wound. Review of the medical record with an LPN and the wound care nurse confirmed there was no assessment, documentation, or physician order for care or treatment of the left inner knee wound, including no order for zinc. The wound care nurse stated that she did not monitor wounds for residents on hospice and believed hospice was responsible, and also acknowledged that wounds were sometimes found being treated without documentation or notification. A later observation showed the resident’s contracted lower legs still lying directly one on top of the other without pillows or PRAFO boots in place, despite the care plan interventions and the facility’s repositioning policy requiring a documented, consistent repositioning program and avoidance of positioning on existing ulcers.
Failure to Maintain Current Hospice DNR in Medical Record and Code Status Discrepancy at Time of Death
Penalty
Summary
The deficiency involves the facility’s failure to maintain the most current and accurate advance directive in a resident’s medical record and to ensure that the documented code status matched the resident’s actual wishes as established through hospice. The resident had multiple diagnoses including muscle wasting and atrophy, depression, dementia with behavioral disturbance, dysphagia, hypertension, and diffuse large B-cell lymphoma, and was cognitively impaired per the admission MDS. The physician’s orders and care plan in the facility record documented the resident as "full code" with an advance directive for CPR, and the plan of care specified that the advance directive and code status would be honored and kept in the medical record at all times. No updated advance directive orders were found in the facility record after the resident’s admission to hospice. Hospice documentation showed that upon hospice admission, hospice staff discussed advance directives with the resident’s wife, who stated they did not want CPR or other life-sustaining measures if the resident’s heart or lungs stopped, and a DNR order (DNR-CC) was completed and signed by the wife. Hospice staff reported that these documents are typically faxed to the facility, and hospice records reviewed by the hospice RN showed a DNR-CC advance directive in place. However, the facility’s medical record continued to list the resident as full code, and the CNP confirmed that only full code status was evident in the facility’s documentation. The Administrator and DON were informed of the discrepancy between the facility’s documentation and the hospice DNR-CC documents and did not dispute the findings. On the day of the resident’s death, multiple staff interactions occurred while the facility record still reflected full code status. Hospice staff reported the resident was actively dying, transferred him from his wheelchair to bed, and made him comfortable. A CNA later found the resident unresponsive and reported this to a nurse; no code was called. An agency RN, who administered Morphine per hospice direction, noticed the full code status on the MAR and reported it to the unit manager/LPN, who told her not to worry about the code status and that it would be taken care of. Hospice staff documented that the resident expired and that CPR was not initiated, consistent with the hospice DNR-CC directive, but this directive was not present or reflected in the facility’s medical record as required by the facility’s advance directive policy, which calls for obtaining, filing, and communicating current advance directives and updating physician orders and the care plan accordingly.
Failure to Provide Timely Incontinence Care for Dependent Residents
Penalty
Summary
The deficiency involves the facility’s failure to provide timely incontinence care to dependent residents, contrary to its policy and stated expectations for two-hourly checks and changes. One resident with dementia, severe cognitive impairment, total dependence for transfers, toileting, and hygiene, and a care plan calling for toileting rounds and incontinence care as needed, was placed in a Geri chair after a hospice aide provided a morning shower and incontinence care around 9:00 A.M. The resident remained in essentially the same position across from the nurses’ station for several hours without being checked or changed. By approximately 2:00 P.M., when incontinence care was finally provided, the resident’s brief was found to be saturated, and staff identified a dressing on the buttocks with surrounding deep red tissue in the buttocks and coccyx/sacral area. The primary CNA stated no one had told her how often to check and change residents and that she typically relied on hospice to provide morning care and then tried to change residents after lunch and dinner. A second resident, with hemiplegia, multiple contractures, a sacral pressure ulcer, total dependence for toileting hygiene and transfers, and a care plan directing staff to check continence, assist with toileting, and provide incontinence care when wet or soiled, was observed during wound care with a brief that was wet with urine. The bed sheets under this resident were peppered with crumbs and flaking skin cells, which were verified by nursing staff. During the wound care procedure, the resident was turned, the soiled brief was opened to access the sacral wound, and the wound was measured and treated. After treatment, the same saturated brief was refastened, and the involved nursing staff left the room without changing the brief or notifying other staff that the resident was wet. Later that morning, when CNAs provided incontinence care to the second resident, the brief was again confirmed to be saturated with urine, and the bed sheets remained covered with crumbs and dried skin cells. The primary CNA for this resident reported that her shift began at 7:00 A.M., that this was the first time she had checked and changed the resident that shift, and that the resident required two staff for turning, which she stated was difficult due to lack of available help. Another LPN acknowledged that residents were not being changed timely and that there were many heavy-care residents. The MDS RN, DON, and Administrator all indicated that residents were expected to be checked, changed, and repositioned every two hours or as needed, and the facility’s urinary continence and incontinence policy described a “check and change” strategy at regular intervals to maintain dignity, comfort, and skin protection. Despite these expectations and policies, the observed care for both residents did not meet the stated standards for timely incontinence care.
Failure to Monitor and Treat Change in Condition After Post-Surgical Fall With Head Impact
Penalty
Summary
The deficiency involves the facility’s failure to timely monitor and treat a resident’s change in condition following a fall with head impact. The resident had been admitted after cervical spine surgery (C3–C9 laminectomy and fusion) with diagnoses including cervical spinal stenosis, fusion of the cervical spine, fibromyalgia, muscle weakness, need for assistance with personal care, and lack of coordination. The care plan identified a decline in functional abilities and mobility related to recent surgery and specified that nursing should provide skilled services per physician orders, assist with mobility, and monitor for changes in condition or declines in ability, strength, or cognition, with physician notification if such changes occurred. The resident also had a care plan for pain that required pain assessment every shift, assessment for non-verbal indicators of pain, use of non-pharmacological interventions, and positioning for comfort. On the day of the fall, the resident attempted to use the bathroom without assistance and was found on the bathroom floor lying on her back with her walker in front of her. She reported that she had tried to use the bathroom without help and had hit her head on the wall before falling. Nursing staff assessed her and noted no visible injury but documented that she complained of dizziness, nausea, and vomited twice. The NP evaluated the resident, initiated neuro checks, ordered IV normal saline and Zofran, and decided to treat the resident in-house rather than send her to the ER, despite the primary nurse’s initial desire to send her out. The surgeon’s office, when contacted after the fall, stated that if there were any new changes after the fall, the resident should be sent to the ER, but left the determination to the facility. Staff interviews confirmed that after the fall the resident repeatedly complained of dizziness and vomited multiple times, and that when attempts were made to sit her up from the floor she would vomit and had to be laid back down. The facility’s monitoring and documentation after the fall did not follow ordered protocols or the resident’s care plan. The 72-hour neuro assessment flow sheet ordered after the fall required neuro checks at frequent intervals (every 15 minutes, then every 30 minutes, then hourly, then every 4 hours), but the DON confirmed that neuro assessments were not completed at the required times; there was a gap between a 3:00 p.m. assessment and the next at 7:00 p.m., and then not again until 2:00 a.m. The DON also confirmed there was no documentation of changes in condition after the fall other than vomiting, despite staff reports of dizziness and positional neck pain. The medical record, including the MAR and TAR, contained no evidence that the resident was monitored for pain every shift as required by the care plan, and there was no documentation of non-pharmacological pain interventions post-fall. Staff, including the RN and CNA who cared for the resident, reported that after the fall the resident had a new pattern of neck pain that occurred when sitting up and resolved when lying down, which they had not observed before the fall. Several days later, the resident was transported to the ER, where a CT scan of the cervical spine showed findings concerning for a fracture adjacent to the C3 screw and possible backing out of hardware at C3, with surgical evaluation suggested. Interviews with the resident’s daughter revealed that the resident had been admitted with a neck brace after surgery, which the surgeon later allowed to be removed, and that after the fall the daughter was told there had been debate among staff about sending the resident to the hospital. The daughter stated that when she visited days later, the resident complained of dizziness and neck pain, and the daughter then insisted on hospital transfer, after which multiple neck fractures were identified. The NP confirmed she was aware of the resident’s vomiting and dizziness after the fall, performed a neuro exam she considered normal, ordered neuro checks and Zofran, and recommended the resident stay in the facility, stating she left the decision to the resident, who reportedly declined hospital transfer. The NP acknowledged she did not speak with the daughter after the fall and stated that staff did not report further changes in condition to her. The facility’s own policy on change in condition required prompt notification of the resident, attending physician, and resident representative of changes in medical or mental condition or status, but the record and interviews showed gaps in monitoring, documentation, and communication following the resident’s fall and subsequent change in condition.
Failure to Follow Enhanced Barrier Precautions and Hand Hygiene During High-Contact Care
Penalty
Summary
The deficiency involves the facility’s failure to implement its infection prevention and control program, specifically enhanced barrier precautions (EBP) and hand hygiene, during high-contact resident care activities. For one resident with hemiplegia, multiple contractures, sacral pressure ulcer, total dependence for toileting, and continuous incontinence, the care plan required EBP due to open wounds. During observed incontinence care, two CNAs did not wear isolation gowns despite an EBP sign on the door instructing staff to wear gowns and gloves for activities such as changing linens, providing hygiene, and changing briefs. Their shirts came into direct contact with the resident and linens, and both CNAs confirmed they did not don gowns while providing incontinence care or changing soiled linens. Another resident with multiple sclerosis, paraplegia, pressure ulcers including stage 2 and stage 3 wounds, an indwelling medical device, feeding tube, ostomy, and open wounds had a care plan requiring EBP. The plan specified use of gown and gloves during high-contact care such as dressing, bathing, transferring, hygiene, linen and brief changes, toileting, device care, and wound care. During an observed wound care procedure to this resident’s left knee, a hospice RN and hospice aide provided care without wearing isolation gowns, and an LPN was present in the room. Both hospice staff confirmed they did not wear gowns during the wound care and also confirmed they provided care to multiple other residents in the facility that day. The DON later confirmed hospice staff were expected to follow the facility’s infection control practices, including proper PPE use. A third resident with hemiplegia, contractures, protein-calorie malnutrition, multiple pressure ulcers (including stage 3 and unstageable ulcers), bed confinement, an indwelling catheter, total incontinence, and total dependence for ADLs had a care plan requiring EBP during high-contact care due to open wounds and osteomyelitis. Interventions included use of PPE (gown and gloves, face shield as indicated) for activities such as dressing, bathing, transferring, hygiene, linen and brief changes, toileting assistance, device care, and wound care. During an observation of turning and repositioning in bed, an LPN adjusted the resident’s pillows, linens, and blankets without donning an isolation gown, and the resident and linens frequently contacted the LPN’s shirt. The LPN did not perform hand hygiene before providing care or after completing care and before leaving the room, despite an EBP sign on the door instructing everyone to clean their hands before entering and when leaving, and to wear gloves and a gown when transferring. Review of facility policies confirmed that hand hygiene is required immediately before and after touching a resident or the resident’s environment, and that EBP requires gown and gloves for specified high-contact care activities for residents with wounds or indwelling devices.
Failure to Provide Care According to Orders and Resident Preferences
Penalty
Summary
The deficiency involves a failure to provide appropriate treatment and care according to physician orders, as well as the resident’s preferences and goals. The report indicates that care was not delivered in alignment with the established plan or the expressed wishes and objectives of the resident, as required.
Deficient Continence and Catheter Care Leading to UTI Risk
Penalty
Summary
The report identifies a deficiency related to the provision of care for residents who are continent or incontinent of bowel and bladder, as well as the management of catheter care and the prevention of urinary tract infections (UTIs). Surveyors found that appropriate care was not consistently provided to residents in these areas. Specific failures included inadequate attention to the needs of residents with continence or incontinence issues, improper catheter care, and insufficient measures to prevent UTIs. These findings indicate that the facility did not meet the required standards for ensuring proper continence management, catheter maintenance, and infection prevention for its residents.
Failure to Maintain Safe Environment and Supervision
Penalty
Summary
The facility failed to ensure that an area was free from accident hazards and did not provide adequate supervision to prevent accidents. Surveyors observed that the environment contained hazards that could lead to resident accidents, and staff did not implement sufficient measures to monitor or protect residents from these risks. This deficiency was identified based on direct observations and findings during the survey, which indicated lapses in maintaining a safe environment and in providing necessary supervision to prevent accidents.
Significant Medication Error Occurred
Penalty
Summary
Residents were not ensured to be free from significant medication errors. The report identifies that there was at least one instance where a resident experienced a significant medication error, indicating a failure in the medication administration process. Specific details regarding the actions or inactions that led to the error, as well as information about the resident's medical history or condition at the time, are not provided in the report.
Failure to Notify Resident, Physician, and Family of Significant Events
Penalty
Summary
Facility staff failed to immediately notify the resident, the resident's physician, and a family member about situations that affected the resident, such as injury, decline, or changes in room assignment. This lack of timely communication was observed and documented by surveyors as a deficiency in the facility's process for keeping relevant parties informed about significant events impacting the resident's care or condition.
Failure to Provide Wound Care as Ordered
Penalty
Summary
A deficiency occurred when wound care for a resident with multiple complex medical conditions, including paraplegia, stage IV pressure ulcer, and severe cognitive impairment, was not completed as ordered by the physician. The resident was dependent on staff for all activities of daily living and had orders for daily dressing changes to a right foot wound. Observation revealed that the dressing on the resident's right foot had not been changed for two days, despite physician orders specifying daily changes. The dressing was found to be heavily soiled with drainage and had a foul odor, and the tissue around the wound was white and emaciated. Review of staff assignment sheets and timecards confirmed that the dressing change was last completed by an LPN on one day, and then not again until two days later, missing at least one required dressing change. The facility's wound care policy required dressings to be changed and marked with the date, time, and staff initials. The failure to follow physician orders and facility policy for wound care led to the deficiency cited in the report.
Failure to Respond to Pharmacy Drug Interaction Alert Resulting in Missed Antibiotic Doses
Penalty
Summary
The facility failed to respond in a timely manner to a pharmacy notification regarding a drug interaction for a resident who was prescribed Cipro for a urinary tract infection (UTI). The resident, who was cognitively intact and admitted with diagnoses including UTI and urinary retention, had a new order for Cipro. The pharmacy identified a potential drug interaction between Cipro and tizanidine and notified the facility, requesting clarification or a change in medication. Despite this notification, the pharmacy did not receive a response from the facility, and as a result, did not send the Cipro to the facility. During this period, documentation showed that the resident received only three out of ten scheduled doses of Cipro, with some doses being documented as administered from prepackaged medications. The Certified Pharmacy Technician confirmed that the medication was withheld pending clarification, and the DON acknowledged that the pharmacy's recommendation was not completed. The nurse practitioner was not made aware of the missed doses until several days later. The breakdown in communication and failure to act on the pharmacy's alert led to the resident not receiving the prescribed antibiotic as ordered.
Failure to Timely Obtain and Process Ordered Urinalysis
Penalty
Summary
The facility failed to timely obtain and process a urinalysis as ordered by a certified nurse practitioner (CNP) for a resident with a history of urinary tract infection (UTI) and urinary retention. The resident, who was cognitively intact and required assistance with toileting, had an order to remove an indwelling catheter and perform straight catheterization every four to six hours. On a subsequent date, the CNP ordered to hold Cipro, start intravenous Ceftriaxone, and obtain a urinalysis due to ongoing infection concerns. However, the CNP was not informed that the resident was not receiving Cipro as ordered, nor that straight catheterization was not being performed as prescribed, despite evidence of significant urine retention. Interviews and record reviews confirmed that although urine was collected for the urinalysis, it was never sent to the laboratory, and no results were available in the medical record. The DON confirmed the urine sample was not processed and could not provide a reason for this failure. The CNP was not notified that the urinalysis was not completed, and only became aware of the issue during the investigation. This deficiency was identified during the course of a complaint investigation.
Failure to Use Required PPE During Enhanced Barrier Precautions
Penalty
Summary
Staff failed to follow infection prevention and control protocols by not wearing required personal protective equipment (PPE) during high-contact care for a resident on Enhanced Barrier Precautions (EBP). Specifically, during an observed straight catheterization procedure, neither the LPN nor the Unit Manager donned an isolation gown, despite facility policy and CDC guidance requiring gown and glove use for such activities. The resident, who was cognitively intact and had diagnoses including Parkinson's disease and urinary retention, had physician orders for straight catheterization and EBP, which specified gown and glove use for high-contact care. Interviews revealed that staff routinely did not wear isolation gowns during straight catheterization, with the Unit Manager stating that gowns were only used if the resident had an infection. The Director of Nursing confirmed that staff should have worn an isolation gown for hands-on care in this situation. Review of facility policy and CDC guidance further supported the requirement for targeted gown and glove use during high-contact care for residents with indwelling devices or wounds, regardless of infection status.
Failure to Notify Provider and Respond to Family Requests Regarding Change in Condition
Penalty
Summary
The facility failed to ensure that a Nurse Practitioner (NP) or physician was contacted when the family of a resident with multiple complex medical conditions, including sepsis, acute respiratory failure, diabetes, dementia, and recent hospitalizations, repeatedly requested to speak with one of them. The resident, who had severely impaired cognition, was reported by her daughter to be crying, miserable, and not acting like herself. Despite the family's multiple requests throughout the day for NP or physician contact due to concerns about the resident's change in condition and history of sepsis, there was no documented evidence that the NP or physician was contacted in a timely manner. The agency nurse responded dismissively to the family's requests and attempted to deter them from seeking hospital evaluation, even as the family expressed fear of a recurring infection. It was only after the Assistant Director of Nursing (ADON) became involved later in the evening that the NP on call was contacted and an order was obtained to send the resident to the emergency room. Documentation and interviews confirmed that the family had made several requests to speak with a provider and to have the resident evaluated, but these requests were not acted upon promptly. The deficiency was identified through record review and interviews, which revealed a lack of appropriate response to the family's concerns and failure to follow through with provider notification as required.
Resident Left Facility Property Unsupervised Despite Supervision Orders
Penalty
Summary
A deficiency occurred when a resident with diagnoses of paranoid personality disorder, bipolar disorder, and schizophrenia, and with moderately impaired cognition, was not provided adequate supervision to prevent leaving the facility property unsupervised. The resident had a history of confusion and exit-seeking behavior, which was documented in nurse's notes. Physician orders were in place for a Wanderguard device and for the resident to have supervised leave of absence (LOA), including for smoking. Despite these orders, the resident was allowed to go outside to smoke and was last seen by staff in the back parking lot area. Staff later realized the resident had not returned, prompting a search of the facility and surrounding area. The resident was subsequently found by local police walking in the street and became combative when approached, resulting in transport to the emergency room. Interviews with staff confirmed that the resident had an order for supervised LOA but left the property unsupervised. The facility census at the time was 70, and this incident affected one of four residents reviewed for LOA. The deficiency was substantiated through record review and staff interviews, confirming that the required supervision was not provided as ordered.
Improper Insulin Administration in LTC Facility
Penalty
Summary
The facility failed to ensure that medications were administered according to physician's orders for three residents, which included improper administration of insulin. Resident #38, who had multiple health conditions including type two diabetes mellitus and chronic kidney disease, did not receive insulin as prescribed. The Registered Nurse (RN) failed to prime the insulin needle before administering the dose, and there were multiple instances of insulin being administered at incorrect times, with no documentation of blood sugar results or insulin administration on certain dates. The Director of Nursing (DON) confirmed that insulin should be administered as ordered, and the facility policy required medications to be administered within one hour of their prescribed time. Resident #54, who had severe dementia and other health issues, also experienced improper insulin administration. The RN did not administer the scheduled insulin at the correct time and failed to notify the surveyor when the insulin was being prepared. The Medication Administration Audit Report (MAAR) revealed that insulin was frequently administered hours after the scheduled time, and the DON confirmed that insulin should be given as ordered. The manufacturer's instructions for insulin glargine emphasized the importance of administering the medication at the same time each day. Resident #22, with a history of diabetes and other medical conditions, also received insulin at incorrect times. The MAAR showed that insulin doses were often given several hours after the scheduled time, and the facility policy required medications to be administered according to prescriber orders. The DON confirmed that insulin should be administered as ordered, and the manufacturer's instructions highlighted the need for consistent timing in insulin administration. This deficiency was investigated under a specific complaint number, indicating non-compliance with medication administration protocols.
Incomplete and Inaccurate Medical Records During EMR Transition
Penalty
Summary
The facility failed to maintain complete, accurate, and readily accessible medical records for several residents during a transition to an electronic medical records (EMR) system. This deficiency was identified through a review of electronic and hard copy records, as well as staff interviews. For Resident #6, the records were incomplete and did not document a significant behavioral incident where the resident choked a CNA during a transfer. Additionally, the fall risk assessment for this resident was missing critical information, and there was no behavior tracking documented in the Treatment Administration Record (TAR) for the incident. Furthermore, there was a lack of documentation regarding meal intake and incontinence care for this resident. Resident #17's records also lacked documentation, specifically missing bowel movement (BM) records and incontinence care documentation. Similarly, Resident #22's records were incomplete, with only two entries for meal intakes and no BM records. An incident where Resident #22 fell and sustained a facial laceration was not logged in the facility's incident/accident log, and there was no follow-up investigation or review of fall interventions documented. Resident #51's records showed only two entries for meal intake and no BM records for several days. Resident #53's records had only one entry for bladder continence tasks over a 30-day period, and there was no documentation of incontinence care. The Director of Nursing (DON) created binders for each unit to use during the EMR transition, but these were not provided to surveyors in a timely manner. The DON admitted to simplifying the documentation process for nursing staff during the transition, opting for written documentation in binders rather than in residents' hard charts. This approach resulted in little to no documentation for the affected residents. The facility's policy on documentation and communication was not adhered to, as the records did not include all necessary assessment data and interventions. This deficiency was identified during a complaint investigation.
Failure to Notify Resident Representative of Medication Change and Fall
Penalty
Summary
The facility failed to ensure that the resident representative of Resident #22 was informed of significant changes in the resident's condition, specifically a medication change and a fall. Resident #22, who was admitted with multiple diagnoses including fractures, emphysema, and diabetes, had an order to increase his insulin dosage. However, there was no documented evidence that his responsible party was notified of this change. Additionally, Resident #22 experienced an unwitnessed fall, yet again, there was no documentation indicating that his responsible party was informed of this incident. The Director of Nursing confirmed the absence of documentation regarding the notification of the resident's representative about the insulin dosage change and the fall. The facility's policy mandates prompt notification of the resident's representative for any changes in the resident's medical or mental condition, including incidents or injuries. This deficiency was identified during an investigation under Complaint Number OH00161190, affecting one of the three residents reviewed for changes in condition.
Failure to Implement Baseline Care Plans Within 48 Hours
Penalty
Summary
The facility failed to implement baseline care plans within 48 hours of admission for three residents, as required by their policy. Resident #22 was admitted with multiple diagnoses, including a fracture of nasal bones and diabetes, but did not have a baseline care plan in place upon initial review of both the electronic medical record (EMR) and hard chart. A baseline care plan was later uploaded into the EMR, but it was incomplete, lacking goals and care plan interventions. The Director of Nursing (DON) confirmed the absence of interventions or goals for Resident #22. Similarly, Resident #38, who was admitted and readmitted with conditions such as diabetes and chronic heart failure, and Resident #62, admitted with congestive heart failure and dementia, also lacked baseline care plans. Reviews of their EMRs, hard charts, and documentation binders confirmed the absence of these plans. Interviews with the DON, Administrator, and Social Service Designee verified that no baseline care plans were in place for these residents, despite the facility's policy requiring such plans to be developed within 48 hours of admission.
Incomplete Care Plan for Resident with Complex Needs
Penalty
Summary
The facility failed to develop and implement a comprehensive care plan for a resident, identified as Resident #22, who was admitted with multiple medical conditions including fractures, emphysema, repeated falls, severe protein-calorie malnutrition, muscle weakness, ischemic cardiomyopathy, and type two diabetes mellitus. The resident's admission Minimum Data Set (MDS) assessment indicated intact cognition and a history of falls both prior to and after admission. Despite these complex medical needs, the care plan for Resident #22, dated 12/23/24, focused solely on nutritional aspects and did not address other critical areas of care. An interview with the Director of Nursing (DON) confirmed that the care plan was incomplete and did not accurately reflect the resident's comprehensive care needs. The facility's policy on comprehensive person-centered care plans requires that such plans be developed within seven days of completing the MDS, including all necessary services, goals, and objectives to maintain the resident's well-being. This deficiency was identified during a complaint investigation, highlighting a lapse in the facility's adherence to its care planning policy.
Failure to Investigate and Prevent Falls
Penalty
Summary
The facility failed to thoroughly investigate a fall incident involving Resident #22 and did not implement necessary fall prevention interventions. Resident #22, who was admitted with a history of falls and multiple medical conditions including fractures, emphysema, and diabetes, experienced a fall on 12/22/24. Despite being identified as a fall risk upon admission, the baseline care plan lacked specific goals or interventions for fall prevention. The comprehensive care plan also did not address fall prevention, and the incident was not logged in the facility's records during a period of electronic medical record downtime. The Director of Nursing confirmed that no interdisciplinary team meeting was held to review the fall or to develop new interventions. The facility's policy required an interdisciplinary care team to assess fall risks and create a prevention plan, but this was not followed. The lack of a thorough investigation and the absence of a fall prevention plan for Resident #22 represent a deficiency in the facility's compliance with its own policies and procedures.
Medication Administration Errors and Delays
Penalty
Summary
The facility failed to maintain a medication error rate of less than five percent, resulting in a 13.79 percent error rate. This deficiency affected three residents during medication administration. Resident #38, who has multiple chronic conditions including type two diabetes mellitus and chronic kidney disease, did not receive her Omeprazole at the scheduled time due to it not being in stock initially. The medication was administered later in the afternoon, well past the prescribed time. Additionally, the insulin pen used for Resident #38 was not primed according to the manufacturer's instructions, which could have affected the insulin dosage administered. Resident #4, who has impaired vision and requires assistance with personal care, did not receive his brimonidine tartrate ophthalmic solution at the scheduled time. The medication was supposed to be administered at 9:00 A.M., but due to difficulties in positioning the resident, it was not given until the afternoon. This delay was not documented in the medication administration record until later in the day, indicating a lapse in timely medication administration and documentation. Resident #54, who has severe dementia and diabetes, did not receive his scheduled insulin at the prescribed time. The insulin was supposed to be administered at 7:00 A.M., but was delayed until 11:00 A.M. This delay occurred despite the resident's elevated blood sugar levels, which were noted during a fingerstick blood sugar test. The facility's policy requires medications to be administered within one hour of their prescribed time, which was not adhered to in these cases.
Failure to Disinfect Blood Glucose Monitor Between Uses
Penalty
Summary
The facility failed to properly clean and disinfect a blood glucose monitor (BGM) between resident uses, as observed during a complaint investigation. A registered nurse (RN) used the same BGM for two residents without cleaning it in between uses. The RN admitted to knowing the protocol for cleaning and disinfecting the BGM but failed to do so due to being rushed. This oversight was confirmed during an interview with the RN, who acknowledged the lapse in following the proper procedure. The deficiency was identified during the observation of medication administration, affecting one resident directly and having the potential to affect three additional residents who receive blood sugar monitoring. The facility's policy and CDC guidelines require BGMs to be cleaned and disinfected after each use to prevent the spread of infectious agents. The facility's policy specifically mandates the use of EPA-registered disinfectant wipes effective against certain viruses. This incident was an incidental finding during the complaint investigation.
Failure to Respect Resident's Rights and Dignity
Penalty
Summary
The facility failed to treat a resident with respect and dignity, as evidenced by a video recording and staff interviews. A resident, who was severely cognitively impaired and dependent on staff for various activities, was subjected to disrespectful treatment by a State Tested Nursing Assistant (STNA). The STNA entered the resident's room without greeting or communicating with the resident, proceeded to remove the resident's blanket and gown without consent, and ignored the resident's verbal refusal to get out of bed. The STNA also failed to provide necessary peri care after changing the resident's brief and dressed the resident without explaining the care being provided. The STNA attempted to transfer the resident to a chair despite the resident's resistance and refusal, resulting in the resident being lowered to the floor. Interviews with the Unit Manager and the Administrator confirmed that the resident had the right to refuse to get out of bed and that staff were expected to honor residents' rights. The facility's policy on resident rights emphasizes the importance of treating residents with dignity and respecting their right to refuse treatment, which was not adhered to in this case.
Failure to Safely Transfer Resident and Document Fall
Penalty
Summary
The facility failed to safely transfer a resident according to the care plan, assess the resident's status after a fall, and document the incident in the medical record. The resident, who was severely cognitively impaired and dependent on staff for mobility, was identified as a fall risk. The care plan specified that the resident should be transferred with two staff members if weight-bearing, or with a mechanical lift if not. However, a video recording showed a single State Tested Nursing Assistant (STNA) attempting to transfer the resident alone, resulting in the resident being lowered to the floor. The resident's feet slid forward and became entangled with a bedside table during the transfer attempt. After the resident was lowered to the floor, two additional staff members entered the room and assisted in lifting the resident into a chair without conducting an assessment for potential injuries. The medical record lacked documentation of the fall or any subsequent assessment. Interviews with staff revealed a lack of written instructions on how to transfer residents, leading to confusion. The facility's policy required that any fall be assessed and documented, which was not followed in this case.
Failure to Document Blood Pressure Before Medication Administration
Penalty
Summary
The facility failed to follow physician orders for a resident with multiple medical diagnoses, including hypertension, by not obtaining and documenting blood pressure readings prior to administering hydralazine, an anti-hypertensive medication. The resident's care plan included monitoring for signs and symptoms of elevated blood pressure and administering medications per physician orders. However, the medication administration record for August and September 2024 showed that hydralazine was given without documenting the required blood pressure readings. Interviews with the Nurse Practitioner and the Director of Nursing confirmed the lack of documentation of blood pressure readings before administering the medication, which was necessary to ensure the resident's blood pressure was above the specified parameter. The facility's policy on medication administration required medications to be administered according to the prescriber's written orders, which was not adhered to in this case. This deficiency was identified during an investigation under specific complaint numbers.
Failure to Provide Timely Incontinence Care
Penalty
Summary
The facility failed to provide timely incontinence care for a resident, identified as Resident #70, who was frequently incontinent of bladder and always incontinent of bowel. The resident, who was cognitively intact, had medical diagnoses including chronic obstructive pulmonary disease, paraplegia, and neuromuscular dysfunction of the bladder. The care plan for the resident included interventions to check for continence, offer toileting assistance, and provide incontinence care after each episode. However, during an interview, the resident expressed uncertainty about when they were last changed and mentioned having requested assistance earlier, which was delayed by the staff. An observation revealed that the resident's incontinence brief and draw sheet were soaked with urine and had a large dried brown ring, indicating a lack of timely care. Interviews with the state tested nurse aides (STNAs) confirmed that the resident had not received timely incontinence care. One STNA admitted that they had not checked the resident since the start of their shift, which began at 7:00 A.M., and by 10:10 A.M., the resident had not been changed. The facility's policy on incontinence care emphasized keeping residents' skin clean and dry to prevent irritation, skin breakdown, and infection, which was not adhered to in this instance.
Failure to Notify POA and Hospice of Resident's Condition Change
Penalty
Summary
The facility failed to notify Resident #28's physician, power-of-attorney (POA), and hospice service in a timely manner following a change in the resident's condition. Resident #28, who had chronic obstructive pulmonary disease, chronic respiratory failure, and dementia, was admitted to hospice care. On 06/18/24, a new order for an X-ray of her right hip was issued, but there was no documentation indicating that her POA was informed of this order or the results. On 06/22/24, Resident #28 experienced an unwitnessed fall, and although she was responsive and her vital signs were stable, she was sent to the emergency room without prior notification to her POA or the on-call nurse practitioner. The nurse on duty, LPN #207, who was an agency nurse working her first and last day at the facility, decided to send Resident #28 to the hospital due to uncertainty about whether the resident had hit her head. This decision was made despite the resident's stable condition and without consulting the nurse practitioner or hospice service. The nurse practitioner and the resident's son were only informed after the resident had been sent to the hospital. The Director of Nursing confirmed that the resident's vital signs were stable and that there was no documentation of the POA being notified about the X-ray order or results. The facility's policy required notifying the resident's physician and family or representative of any changes in the resident's condition, which was not adhered to in this case.
Failure to Administer Pain Medication as Ordered
Penalty
Summary
The facility failed to ensure that a resident's pain medications were administered as ordered, affecting one of five residents reviewed for medication administration. The resident, who had diagnoses including chronic obstructive pulmonary disease, chronic respiratory failure, dementia, and osteoarthritis, was prescribed Tramadol 50 mg three times a day for pain management. However, a review of the narcotic count sheet revealed discrepancies in the administration of the medication, with the resident receiving fewer doses than prescribed on specific dates. The Director of Nursing confirmed that the resident's pain medication was not given as scheduled and that the nursing staff had incorrectly documented the administration on the Medication Administration Record. This deficiency was investigated under two complaint numbers.
Incomplete Documentation of Medication and Treatment Administration
Penalty
Summary
The facility failed to ensure complete and accurate documentation in the medical records for two residents, affecting the administration of medications and treatments. For one resident, there were discrepancies in the documentation of Tramadol administration, with the resident receiving fewer doses than prescribed on specific dates, despite the MAR indicating otherwise. Additionally, treatments for the resident's toe, heel, buttocks, and wheelchair safety measures were not consistently documented as completed. The Director of Nursing confirmed these discrepancies during an interview. For another resident, the facility staff did not document the completion of oxygen saturation assessments, heel offloading, mattress placement, moisture barrier application, and repositioning on several night shifts. The Director of Nursing verified the lack of documentation for these treatments. The facility's policy requires that medications and treatments be documented immediately after administration, which was not adhered to in these cases.
Failure to Administer Prescribed Medication Leads to Hospitalization
Penalty
Summary
The facility failed to prevent a significant medication error for a resident, resulting in an acute change in condition that required hospitalization. The resident, who had a history of heart failure, chronic bilateral lower extremity lymphedema, and sarcoidosis, was admitted to the facility with a physician's order for Torsemide, a diuretic medication, to be administered twice daily. However, the medication was not administered during the resident's stay, as confirmed by a review of the medication administration records and pharmacy packing slip. The resident experienced significant shortness of breath and was transferred to the hospital, where it was noted that aggressive diuresis was performed. Interviews with facility staff revealed that the medication was ordered from the pharmacy but was not available for administration. The resident's condition deteriorated, leading to a call to emergency medical services, who found the resident in distress and transported him to the hospital. The facility's failure to administer the prescribed medication as per the physician's orders resulted in actual harm to the resident, who required hospitalization for treatment of fluid on the lungs. The deficiency was investigated under specific complaint numbers, and the facility's medication administration policy was reviewed, highlighting the requirement for medications to be administered as prescribed.
Medication Administration Errors
Penalty
Summary
The facility failed to ensure medications were administered without error, affecting two residents during 29 medication opportunities, resulting in a medication administration error rate of 24.13%. Resident #32, diagnosed with Alzheimer's disease, dementia, anxiety, high blood pressure, pulmonary embolism, constipation, and hyperlipidemia, received an inaccurate dose of ethylene glycol. The LPN measured 17 milliliters of ethylene glycol powder instead of using the provided cap to measure 17 grams and did not observe the resident to ensure the full mixture was consumed. This error was verified through an interview with the LPN involved. Resident #79, with diagnoses including diabetes mellitus, multiple sclerosis, heart failure, glaucoma, paranoid personality disorder, psychosis, and cerebral vascular disease, experienced multiple medication administration errors. The RN administered six units of Humalog insulin instead of the prescribed three units of Humalog and two units of Novolog based on the sliding scale for a blood sugar level of 191 mg/dL. Additionally, the RN failed to administer five oral medications (carvedilol, colace, potassium, senna, and vitamin B12) and discarded the carvedilol tablet. The RN documented that all medications were administered, which was later found to be inaccurate. The facility's policy on medication administration, which includes the Five Rights (right resident, right drug, right dose, right route, right time) and a triple-check process, was not followed. This deficiency was identified during an investigation under Complaint Numbers OH00153682 and OH00153544.
Inaccurate Documentation of Resident's Shower/Bath Schedule
Penalty
Summary
The facility failed to ensure accurate documentation of a resident's shower/bath schedule, affecting one out of three residents reviewed for activities of daily living needs. Resident #32, who has severe cognitive impairment and multiple medical conditions including Alzheimer's disease, dementia, and anxiety, was supposed to receive showers on Tuesdays and Saturdays during the night shift. However, a review of the facility's records revealed inconsistencies and missing documentation for Resident #32's showers in May 2024. The Minimum Data Set (MDS) assessment indicated that showers were not attempted due to medical or safety concerns, and the resident required substantial assistance with personal hygiene and other activities of daily living. During an observation and interview, the Director of Nursing (DON) and Registered Nurse Unit Manager (RNUM) were unable to locate the shower sheet documentation for Resident #32 initially. Later, five shower sheets were found, but they contained illegible nurse signatures and incomplete state-tested nursing assistant (STNA) signatures. Further interviews revealed that STNA #85 did not complete the shower sheet on one of the dates and was unaware of the requirement to document showers/bed baths. The DON confirmed the findings, verifying that the documentation was incomplete and inaccurate, and that the shower sheets were possibly falsified.
Failure to Follow Hand Hygiene and PPE Protocols During Medication Administration
Penalty
Summary
The facility failed to ensure proper hand hygiene and use of personal protective equipment (PPE) during medication administration for two residents. An LPN did not wash or sanitize her hands before and after dispensing medications for a resident, even after traveling to a different floor to obtain a medication. This failure was confirmed during an interview with the LPN, who acknowledged not following proper hand hygiene protocols to prevent cross-contamination of germs. Additionally, an RN did not wash or sanitize her hands or wear appropriate PPE before administering insulin and eye drops to another resident. The RN also contaminated the tips of the eye drop containers by touching them with her bare arm. This was observed during the medication administration process and confirmed in an interview with the RN, who admitted to not following infection control standards. The facility's policies on hand hygiene and medication administration clearly state the need for thorough hand washing before and after handling medications and direct resident contact. However, these protocols were not adhered to, leading to potential cross-contamination and infection risks for the residents involved.
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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.
Trusted data from CMS and state health departments
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