University Manor Health & Reha
Inspection history, citations, penalties and survey trends for this long-term care facility in Cleveland, Ohio.
- Location
- 2186 Ambleside Rd, Cleveland, Ohio 44106
- CMS Provider Number
- 365832
- Inspections on file
- 38
- Latest survey
- February 3, 2025
- Citations (last 12 mo.)
- 0
Citation history
Health deficiencies cited at University Manor Health & Reha during CMS and state inspections, most recent first.
The facility failed to maintain required ambient temperatures in resident rooms and common areas, affecting residents on the second and third floors. Staff and residents reported cold conditions, with temperatures recorded below the required range due to boiler system issues. Observations showed residents wearing coats indoors, and mobile heaters were used to address the cold.
A resident with a history of psychiatric issues and another resident entered a third resident's room, accusing him of theft, which led to a physical altercation. The accused resident sustained multiple injuries, including scratches and a bloody mouth. The facility's staff intervened, but inconsistencies in reporting and monitoring contributed to the deficiency.
An LPN on the fifth floor of an LTC facility prepared medications for multiple residents at once, contrary to the facility's policy of preparing medications for one resident at a time. This practice was observed as the LPN assembled 13 medication cups labeled with resident names, potentially affecting 35 residents. The LPN cited the busier day shift as the reason for this practice.
The facility failed to provide scheduled activities for residents on the fifth floor, affecting 34 residents. The Activity Director was observed counting money instead of conducting activities, leaving residents with only a television and music for entertainment. The AD was the only staff member working that day, and scheduled activities were not completed due to understaffing following a recent termination.
The facility failed to address pharmacy recommendations timely for four residents, including medication adjustments and monitoring. A resident's antipsychotic GDR and Metformin dosage increase were not acted upon, and another resident's anticoagulant diagnosis was incorrect. A third resident's Seroquel GDR was declined without rationale, and a fourth resident's Meloxicam discontinuation was delayed.
The facility's fourth floor was found to be in disrepair, affecting 42 residents. Observations revealed a caved-in wall in a resident's room, a sink not affixed to the wall in the shower room, and a bathroom with missing tiles. CNAs confirmed these issues, noting some had persisted for months. The DOM was aware of some problems but not others, indicating a lack of consistent maintenance.
A facility failed to timely disburse a deceased resident's funds from the authorized resident fund account (RFA). The resident, diagnosed with schizophrenia and pulmonary heart disease, passed away in the facility. Despite policy requirements for refunding personal funds within 30 days, the RFA dispersal check was delayed. This was confirmed by the Business Office Manager, acknowledging the delay in compliance with the facility's policy and state regulations.
The facility failed to ensure accurate and readily available advanced directives for three residents. One resident lacked a completed DNR form despite having a DNRCC-A order. Another resident's signed DNR paperwork conflicted with electronic records. A third resident's code status was missing from the electronic medical record's main screen. Staff interviews confirmed these discrepancies, which violated the facility's policy requiring coordination to obtain and document legal directives.
The facility failed to provide written bed-hold notices to three residents or their representatives upon hospital transfer, as required by policy. A resident with schizophrenia was transferred due to breathing difficulties, another with bipolar disorder was transferred after a fall, and a third with multiple sclerosis was transferred following an altercation. None received the necessary bed-hold notices, confirmed by a Regional RN.
A facility failed to notify the Ohio Department of Mental Health of a significant change in a resident's mental health condition. The resident, initially diagnosed with dementia, later developed bipolar disorder, schizoaffective disorder, and paranoid schizophrenia. Despite these changes, no new PASARR was conducted after the initial review in 2022, until the day of the survey.
The facility failed to develop individualized care plans for three residents, leading to deficiencies in addressing their medical and psychosocial needs. A resident with PTSD did not have a care plan until it was created with errors, while another resident receiving psychotropic and anticoagulant medications lacked corresponding care plans. Additionally, a resident with a PTSD diagnosis since June did not have a care plan addressing this condition, contrary to the facility's policy.
The facility failed to update a resident's care plans to reflect necessary interventions for behaviors, including sleeping on a yoga mat and removing furniture. Additionally, two residents did not have quarterly care conferences as required, despite severe cognitive impairments and legal guardianship. The facility's policy mandates weekly scheduling of care conferences for certain conditions, which was not followed.
A resident requiring total assistance with ADLs, including bathing, did not receive scheduled showers or consistent bed baths over a 90-day period. Despite being scheduled for twice-weekly bathing, documentation showed only four instances of bathing. The DON confirmed the resident should have been bathed twice weekly according to facility policy.
A facility failed to monitor and assess a resident's wound on the left great toe, despite a physician's order for daily care. The resident, with severe cognitive impairment and multiple diagnoses, had no documented wound assessments. An observation revealed no dressing on the wound, and interviews confirmed the lack of monitoring. The wound was first evaluated by a nurse practitioner days after the order was issued, contrary to the facility's wound care policy.
The facility failed to ensure proper dialysis communication for two residents requiring dialysis services. One resident's communication forms were not consistently completed, while another resident's forms were either incomplete or not sent. The facility's policy required pre-assessment documentation to be sent with residents, but this was not adhered to, and there was a lack of communication from the dialysis center.
A facility failed to limit a resident's PRN antipsychotic medication to 14 days and did not attempt non-pharmacological interventions before administration. The resident, with schizoaffective and bipolar disorders, had olanzapine ordered without a stop date, and it was administered without prior non-pharmacological attempts. The facility's policy requires monitoring and documentation of interventions, which was not followed.
The facility failed to provide the correct diets to two residents, as observed during lunch. One resident did not receive the prescribed double protein diet, and another received a meal inconsistent with their dietary needs, including items not ordered. Medical records confirmed these discrepancies, and CNAs verified the observations.
A facility failed to offer and educate a resident with intact cognition on influenza and pneumococcal vaccines, as required by their policies. Despite the resident's medical record showing no evidence of being offered or educated on these vaccines, this was confirmed by interviews with nursing staff. The facility's policies mandated offering vaccines and providing educational information, which was not followed in this instance.
A facility failed to prevent emotional abuse when an STNA posted a video on social media showing a resident with their brief around their ankles without consent. The resident, with severe cognitive impairments, was unaware of the incident. The STNA admitted to posting the video on TikTok, which was deleted after discovery. The facility's policies were reviewed, and the STNA was terminated. No additional violations were found during staff and resident interviews.
The facility did not properly dispose of garbage, as observed with uncovered dumpsters emitting a sour smell and surrounded by debris. The Maintenance Director acknowledged the issue, citing difficulty in cleaning and lack of lids. An exterminator highlighted the importance of sanitation to prevent pests. The facility's policy required secure dumpster lids and routine pest control.
A facility failed to notify a physician or NP of abnormal lab results for a resident with chronic kidney disease, leading to a deficiency. Despite elevated BUN and creatinine levels, there was no documentation of communication with the healthcare provider. An LPN attempted to fax the results, but they were not received, and the NP was unaware of the labs during a follow-up assessment. The DON confirmed it was the nurse supervisor's responsibility to ensure notification, which was not done.
An incident of physical abuse occurred involving two residents, resulting in serious injuries to one resident, including abrasions, swelling, brain bleeding, and a fractured sacrum. The aggressor had a history of paranoid schizophrenia, paranoid personality disorder, anxiety disorder, and violent behavior, with documented aggressive incidents in multiple facilities. The care plan for the aggressor focused on mood management but lacked specific interventions for violent behavior. The facility's psychiatrist noted challenges in reducing psychiatric medications due to relapse risks. The deficiency was linked to the absence of individualized interventions to prevent resident-to-resident abuse.
The facility failed to ensure adequate behavioral health services and person-centered care planning for a resident with a history of mental disorders and violent behaviors. Despite multiple incidents of aggression and a history of violent behavior, the care plan lacked specific interventions to manage the resident's tendencies, leading to repeated incidents of harm to other residents.
The facility failed to ensure that STNAs were given yearly performance evaluations as required. Two STNAs, employed for more than one year, did not have documented yearly performance evaluations. The HR Director confirmed the absence of these evaluations, potentially affecting all 143 residents.
Facility Fails to Maintain Required Ambient Temperatures
Penalty
Summary
The facility failed to maintain an appropriate ambient temperature in resident rooms and common areas, affecting residents on the second and third floors. Interviews with staff and residents confirmed that the facility had been cold for several days, with temperatures recorded below the required range of 71 to 81 degrees Fahrenheit. The issue was linked to problems with the boiler system in the basement, which had been previously serviced due to a sewage flood. Observations and temperature readings taken by the Mobile Administrator and recorded on the Floor Plan Master Audit Sheet revealed that temperatures in various resident rooms ranged from 60 to 69 degrees Fahrenheit, consistently below the required minimum. Residents were observed wearing coats and hats indoors, and mobile air and power rental units were deployed in an attempt to mitigate the cold temperatures. The facility's Extreme Weather Heat or Cold policy was reviewed, which outlined procedures for monitoring weather conditions, contacting utility companies, and ensuring resident care during extreme temperatures. However, the policy's implementation appeared inadequate, as the facility did not maintain the required ambient temperatures, potentially affecting the health and comfort of the residents.
Resident-to-Resident Abuse Incident
Penalty
Summary
The facility failed to protect a resident, identified as Resident #74, from physical abuse by other residents. The incident involved Resident #701 and Resident #141, who entered Resident #74's room and accused him of theft, leading to a physical altercation. Resident #701 and Resident #141 struck Resident #74, resulting in multiple scratches, red eyes, and a bloody mouth. The facility's staff intervened and separated the residents, but the incident highlighted a lapse in monitoring and preventing resident-to-resident abuse. Resident #701 had a history of psychiatric issues, including delusions and paranoia, which contributed to the altercation. Despite being monitored closely by staff, Resident #701 accused Resident #74 of stealing her belongings and, along with Resident #141, confronted him in his room. This confrontation escalated into physical violence, with Resident #701 later stabbing Resident #74 with a pen, causing injuries that required medical attention. The facility's records indicate that Resident #701 had a pattern of making false allegations and targeting male residents, which was not adequately addressed to prevent the incident. The facility's documentation and interviews with staff revealed inconsistencies in the reporting of the events, with some staff members providing conflicting accounts of the altercation. The facility's investigation into the incident initially deemed the allegations unsubstantiated, but subsequent events confirmed the abuse. The failure to prevent the altercation and the inadequate response to Resident #701's behavioral issues contributed to the deficiency, as the facility did not ensure a safe environment free from abuse for Resident #74.
Medication Preparation Deficiency
Penalty
Summary
The facility failed to ensure that medications were prepared and administered for one resident at a time, as observed on the fifth floor. An LPN was found to have assembled 13 medication cups, each labeled with a resident's name, containing varying amounts of pills. These cups were placed on the medication carts for later administration. The LPN confirmed that this practice was done to manage the workload after switching to a busier day shift. This practice was contrary to the facility's medication administration policy, which mandates that medications be prepared for one resident at a time. This deficiency had the potential to affect 35 residents on the fifth floor, with a total facility census of 144.
Failure to Provide Scheduled Activities for Residents
Penalty
Summary
The facility failed to provide scheduled activities for residents on the fifth floor, affecting 34 residents. On the observed date, the Activity Director (AD) was seen counting money for residents instead of conducting scheduled activities. The residents were left in their rooms or in the common area with only a television and music for entertainment, and no formal activities were conducted in the afternoon. The AD revealed that she was the only activity staff member working that day, and the scheduled activities, including Hydration Hour, Griddle Goodies, and Table Games, were not completed. The facility's activity staff was understaffed due to a recent termination, leaving only the AD and two other staff members to cover activities during the week and weekends. The facility's Life Enrichment Programming Policy requires a resident-centered program based on comprehensive assessments and care plans, which was not adhered to in this instance.
Failure to Address Pharmacy Recommendations Timely
Penalty
Summary
The facility failed to ensure that pharmacy recommendations were addressed by the physician in a timely manner, affecting four residents. For Resident #10, multiple pharmacy consultation reports indicated recommendations for medication adjustments and monitoring, such as a gradual dose reduction (GDR) for antipsychotics, increasing Metformin dosage, and monitoring valproic acid trough concentrations. However, there was no evidence of physician responses or actions taken on these recommendations within the required 30-day period. Additionally, there were no documented diagnoses for several medications prescribed to Resident #10. Resident #75's records showed that the pharmacy had repeatedly recommended correcting the diagnosis associated with the anticoagulant Eliquis, which was incorrectly listed for hypertension. Despite multiple recommendations, there was no physician response or correction made. Similarly, for Resident #92, a recommendation for a GDR of Seroquel was declined by the physician without providing a rationale, and there was no documentation in the medical record to support the decision. Resident #19's records revealed that pharmacy recommendations to discontinue Meloxicam and consider an alternative analgesic were not acted upon in a timely manner. The recommendations were made multiple times, yet the physician's response was delayed, and the medication was not discontinued until several months later. The facility's Medication Regimen Review policy requires that the consultant pharmacist's recommendations be documented and addressed, but this was not adhered to in these cases.
Environmental Disrepair on Fourth Floor
Penalty
Summary
The facility failed to maintain the resident environment on the fourth floor in good repair, affecting all 42 residents residing there. Observations revealed several areas of disrepair, including a caved-in wall in a resident's room, a sink in the shower room that was not affixed to the wall, and a bathroom with missing ceiling and floor tiles. Interviews with Certified Nurse Aides (CNAs) confirmed these observations, with one resident stating that the wall damage had been present since they moved into the room four months prior. The CNAs also noted that the bathroom had been in disrepair for over five months. During a follow-up observation with the Director of Maintenance (DOM), it was confirmed that the sink in the shower room was not properly affixed, and the DOM was unaware of the missing tiles in the bathroom. The DOM acknowledged awareness of the patched wall but was uncertain about the timeline of the repairs due to the frequency of such issues. Additionally, a baseball-sized hole was discovered in another wall, which the DOM was not previously aware of. The facility census report confirmed that 42 residents were affected by these environmental deficiencies.
Delayed Disbursement of Deceased Resident's Funds
Penalty
Summary
The facility failed to ensure the timely disbursement of a deceased resident's funds from the authorized resident fund account (RFA). The deficiency was identified during a review of the medical records and an interview with the Business Office Manager (BOM). The resident, who had been diagnosed with other specified schizophrenia and pulmonary heart disease, passed away in the facility. Despite the policy requiring that personal funds be refunded within 30 days of a resident's death, the RFA dispersal check was not issued in a timely manner. This was confirmed by the BOM, who acknowledged the delay in disbursing the funds as required by the facility's policy and state regulations.
Failure to Ensure Accurate and Available Advanced Directives
Penalty
Summary
The facility failed to ensure that advanced directives were accurate and readily available for three residents. Resident #87 had an active physician order for a Do Not Resuscitate Comfort Care Arrest (DNRCC-A) status, but there was no completed and signed DNR form in the medical record. Interviews with an LPN confirmed the absence of the DNR form, despite the resident's confirmation of their advance directive preferences. The facility's policy required coordination among the patient, family, and staff to obtain and place legal documents in the clinical record, which was not adhered to in this case. Resident #99's records showed a discrepancy between the signed DNR paperwork and the electronic medical records. The signed paperwork indicated a DNR-CC (comfort care only) status, while the electronic records showed a DNR-CCA status. An LPN confirmed this inconsistency. For Resident #143, there was a lack of documentation of the code status on the main screen of the electronic medical record, despite a full code status being indicated in the care plan and physician orders. Interviews with staff confirmed that the code status should be displayed on the main screen, but it was missing. The facility's policy required coordination to ensure legal documents were obtained and placed in the clinical record, which was not followed in these instances.
Failure to Provide Bed-Hold Notices to Residents
Penalty
Summary
The facility failed to provide written bed-hold notices to three residents or their representatives upon transfer to a hospital, as required by their policy. Resident #29, who was admitted with schizophrenia, anxiety disorder, and violent behavior, was transferred to the hospital due to difficulty breathing. Despite having intact cognition, there was no evidence that Resident #29 or their representative received a bed-hold notice upon transfer. Similarly, Resident #43, with diagnoses including bipolar disorder and epilepsy, was transferred to the hospital after reporting hand pain and was later diagnosed with fractures. The medical record did not show that Resident #43 or their representative received a bed-hold notice. Resident #47, diagnosed with multiple sclerosis and vascular dementia, was transferred to the emergency room following a fall during an altercation with another resident. The medical record did not indicate that Resident #47 or their representative received a bed-hold notice upon transfer. Interviews with the Regional Registered Nurse confirmed that none of the residents were provided with the necessary bed-hold notices, which should have included information on bed-hold days and the policy for returning to the facility. The facility's policy, revised in 2020, mandates tracking Medicaid bed hold days and notifying the appropriate parties via a Medicaid Bed Hold Letter.
Failure to Notify State Agency of Resident's Mental Health Changes
Penalty
Summary
The facility failed to notify the Ohio Department of Mental Health of a significant change in a resident's mental health condition as required by regulations. This deficiency affected a resident who was admitted with a diagnosis of dementia and later developed additional mental health diagnoses, including bipolar disorder, schizoaffective disorder, and paranoid schizophrenia. Despite these changes, the facility did not conduct a new Preadmission Screening and Resident Review (PASARR) after the initial review in 2022, which had ruled out further PASARR related to dementia or other neurocognitive disorders. Interviews with the Administrator confirmed that no additional PASARRs were conducted until the day of the survey, despite the resident's evolving mental health conditions.
Failure to Develop Individualized Care Plans for Residents
Penalty
Summary
The facility failed to ensure individualized care plans were developed and accurate for three residents. Resident #133, who was admitted with diagnoses including PTSD, end-stage renal disease, and schizophrenia, did not have a care plan addressing PTSD until it was created on 12/04/24. The care plan was erroneously copied from another resident's plan, leading to incorrect information being included. MDSRN #356 acknowledged the error, stating that she had created a template from another resident's care plan and copied it to Resident #133's care plan. Resident #92, admitted with diagnoses such as schizoaffective disorder and bipolar disorder, was receiving psychotropic and anticoagulant medications without corresponding care plans. Regional Nurse #467 confirmed the absence of care plans for these medications. Additionally, Resident #40, with a diagnosis of PTSD since 06/29/23, did not have a care plan addressing PTSD. Social Services #317 and Regional Nurse #467 confirmed the lack of a PTSD care plan for Resident #40. The facility's Comprehensive Care Planning Policy requires a comprehensive Person-Centered Care Plan for each resident, which was not adhered to in these cases.
Failure to Update Care Plans and Conduct Quarterly Care Conferences
Penalty
Summary
The facility failed to update Resident #44's care plans to reflect the resident's behaviors and necessary interventions. Despite the resident's preference to sleep on a yoga mat on the floor and the removal of furniture to prevent it from being thrown out of windows, these interventions were not documented in the care plans. The resident was admitted with diagnoses including schizoaffective disorder, bipolar disorder, antisocial disorder, and generalized anxiety, and exhibited moderate cognitive impairment. The care plans included interventions for violent behavior and other behaviors such as pacing and hallucinations, but did not include the specific interventions related to the resident's sleeping arrangements and room setup. Additionally, the facility did not conduct care conferences quarterly for Residents #13 and #29. Resident #29, who has severe cognitive impairment and a legal guardian, had not had a care conference in over three months, despite the guardian not being present after three notifications. Resident #13, with diagnoses including epileptic seizures and dementia, had no documentation of a care conference in the past twelve months. The facility's policy required care conferences to be scheduled at least weekly for various resident conditions, but this was not adhered to, as confirmed by interviews with facility staff.
Failure to Provide Scheduled Bathing for a Dependent Resident
Penalty
Summary
The facility failed to ensure that a resident who required total assistance with activities of daily living, including bathing, received the necessary care. The resident, who had intact cognition and was dependent on staff for all ADLs, reported not being offered a shower in two months and only sometimes receiving a bed bath. The resident's care plan, last reviewed on 11/18/24, indicated a self-care deficit but did not specify bathing preferences or frequency. The facility's shower rotation sheet indicated that the resident was scheduled for bathing twice weekly, on Wednesdays and Saturdays. However, a review of the resident's shower sheets for the past 90 days showed only four documented instances of bathing, with one sheet undated. The Director of Nursing confirmed the lack of documentation for the required bathing schedule and acknowledged that the resident should have been bathed twice weekly, as per the facility's policy revised on 09/09/22.
Failure to Monitor and Assess Resident's Wound
Penalty
Summary
The facility failed to ensure proper assessment and monitoring of a wound on a resident's left great toe. The resident, who was admitted with diagnoses including Huntington's disease, acute respiratory failure with hypoxia, and muscle weakness, exhibited severe cognitive impairment according to their annual MDS assessment. A physician's order dated 10/22/24 required daily cleansing and dressing of the wound on the night shift. However, there was no evidence in the medical record of any monitoring or assessment of the wound. An observation on 12/02/24 revealed the absence of a dressing on the resident's toe. Interviews with the interim LPN wound nurse and the wound nurse practitioner confirmed that the wound was not assessed or monitored, and the wound nurse practitioner only evaluated the wound for the first time on 12/04/24. The facility's Skin and Wound Care Best Practices policy, revised on 11/05/24, stated that evidence-based preventative skin care and wound treatment should be provided to prevent unavoidable skin complications.
Failure in Dialysis Communication for Two Residents
Penalty
Summary
The facility failed to ensure proper pre and post dialysis communication for two residents requiring dialysis services. Resident #100, diagnosed with end-stage renal disease and acute kidney failure, had an order for dialysis observation tools to be completed and sent with the resident to dialysis. However, interviews and record reviews revealed that these communication forms were not consistently completed as required. The facility's policy mandated documentation of pre-assessments, including vital signs and pre-treatment weight, to be sent with the resident, but this was not adhered to. Similarly, Resident #133, who had diagnoses including end-stage renal disease and schizophrenia, also experienced lapses in dialysis communication. The resident's records showed that communication tools were either incomplete or not sent on several occasions, and there was no documentation from the dialysis center on the forms that were sent. Additionally, there were days when the resident refused dialysis, but on other days, the communication tools were not utilized as per the facility's policy. Interviews confirmed the lack of communication from the dialysis center and the failure to send the necessary documentation.
Failure to Limit PRN Antipsychotic Use and Implement Non-Pharmacological Interventions
Penalty
Summary
The facility failed to ensure that a resident's as-needed antipsychotic medications were limited to fourteen days until the physician evaluated the resident, and non-pharmacological interventions were attempted prior to administering as-needed antipsychotic medications. The resident, who was admitted with diagnoses including schizoaffective disorder, bipolar disorder, and generalized anxiety, had a physician order for olanzapine without a stop date. The pharmacy consultation report later indicated a stop date, but the medication administration records showed no evidence of the medication being administered during that time frame. A regional RN confirmed the lack of an appropriate stop date. Additionally, the resident's medical record showed that olanzapine was administered on three occasions without evidence of non-pharmacological interventions being attempted first. The facility's psychoactive medication policy requires that all residents receiving such medications have their behaviors and the effectiveness of interventions monitored and documented, but this was not done in this case. The regional RN confirmed the absence of documentation for non-pharmacological interventions prior to administering the medication.
Failure to Provide Correct Diets to Residents
Penalty
Summary
The facility failed to ensure the coordination of dietary services, resulting in two residents not receiving the correct diets as prescribed. During an observation of lunch, it was noted that one resident's meal ticket indicated a regular double protein diet, but the meal provided did not include the double protein. A review of the medical record confirmed that this resident was supposed to receive double protein with meals, and a CNA verified the absence of double protein in the meal. Another resident's meal ticket indicated a regular, renal diet, but the meal served included items not consistent with the prescribed diet, such as noodles and a plain hamburger instead of fortified potatoes. The medical record review revealed that this resident was not ordered a renal diet, and a CNA confirmed the discrepancy in the meal provided.
Failure to Offer and Educate on Vaccines
Penalty
Summary
The facility failed to ensure that a resident was provided education and offered the influenza and pneumococcal vaccines. The resident, who was admitted with diagnoses including essential hypertension, other chronic pain, and a history of falling, exhibited intact cognition according to their Minimum Data Set (MDS) 3.0 assessment. However, a review of the resident's medical record did not reveal any evidence that the resident was offered or educated on the influenza and pneumococcal vaccines. This was confirmed during an interview with the Registered Nurse Infection Preventionist and a Regional Registered Nurse. The facility's policies, revised in August 2020, stated that all residents should be offered these vaccines and provided with educational information, but this was not adhered to in the case of this resident.
Emotional Abuse Incident Due to Social Media Post
Penalty
Summary
The facility failed to prevent an incident of staff-to-resident emotional abuse when a State Tested Nurse Aide (STNA) posted a video on social media showing a resident with their brief around their ankles. The video, which was captioned inappropriately, was posted without the resident's consent. The resident involved had severe intellectual disabilities, seizures, schizophrenia, and dementia, and was noted to have severely impaired cognition with various behavioral symptoms. The incident was discovered when the Director of Nursing (DON) was notified of the video, which had been posted a few days prior. The STNA involved admitted to posting the video on TikTok, claiming it was meant to showcase her work life and not to cause harm. The video was deleted after the facility became aware of it, and the STNA was suspended pending investigation. The facility's investigation revealed that the resident had no awareness of the incident due to their cognitive condition and showed no signs of distress or harm. The facility's policies on abuse and social media were reviewed, and it was found that the STNA did not adhere to these policies. The facility's personnel records indicated that the STNA was terminated following the incident. Interviews with staff and residents revealed no additional violations of the social media policy. The facility's abuse policy was found to be adequate, and the incident was reported to the state agency as required. The facility took immediate steps to address the situation, including notifying the resident's legal guardian and conducting staff education on relevant policies.
Improper Garbage Disposal and Pest Control
Penalty
Summary
The facility failed to ensure proper disposal of garbage and refuse, which could potentially affect all 144 residents. During an observation, it was noted that three outside dumpsters near the kitchen doors were not covered with lids, and a sour smell was present. Additionally, wet boxes and debris were piled around the dumpsters. The Maintenance Director confirmed these findings and mentioned the difficulty in cleaning the area behind the dumpsters and the absence of lids to cover the trash. An exterminator emphasized the importance of garbage containment and sanitation to prevent and control pests. The facility's pest control policy required routine pest control measures and maintenance of the garbage storage area to prevent pest harborage, including keeping dumpster lids shut and secure.
Failure to Notify Practitioner of Abnormal Lab Results
Penalty
Summary
The facility failed to notify the physician or nurse practitioner of abnormal laboratory results for a resident, which was identified as a deficiency. The resident, who had a history of intracranial hemorrhage, hyperparathyroidism, cocaine abuse, hypertension, chronic kidney disease stage four, and hemiplegia, was admitted to the facility. A physician ordered a complete blood count with differential, a comprehensive metabolic panel, and magnesium to be drawn, with specific instructions to monitor for chronic kidney disease. The lab results showed elevated levels of blood urea nitrogen and creatinine, indicating a potential change in the resident's condition. Despite the abnormal lab results, there was no documentation that the ordering physician or nurse practitioner was notified. A progress note indicated that the resident's family was informed about the lab results, but it did not mention any communication with the healthcare provider. The nurse practitioner, during a follow-up assessment, noted the absence of recent labs to review, which suggests a lack of communication regarding the abnormal findings. An interview with the LPN revealed that the labs were faxed to the nurse practitioner, but the fax did not reach the intended recipient, and there was no documentation to confirm that the nurse practitioner received or reviewed the labs. The Director of Nursing confirmed that it was the responsibility of the nurse supervisor to ensure the practitioner was notified of lab results at the end of each shift. An audit revealed that the nurse supervisor failed to notify the nurse practitioner about the high blood urea nitrogen level from the lab draw, which was a significant oversight in the resident's care management.
Removal Plan
- The facility identified that the lab work completed for Resident #113 was not reported to the Nurse Practitioner.
- The NP evaluated Resident #113 and ordered a STAT lab to be obtained and a STAT dose of Lokelma was administered and IV fluid was ordered after review of STAT labs.
- The Director of Nursing completed audits of all current resident's medical records for validation of laboratory testing and results reported to the practitioner from the past thirty days. All labs were found to have been reported to the practitioner.
- The DON educated all nursing staff in person or by phone related to immediate reporting of resident change in condition pertaining to laboratory results and timely follow up for physician orders. All education was completed.
- The specified nurse was placed on a Performance Improvement Plan regarding follow through with reporting of labs.
- The facility conducted an Ad-Hoc Quality Assurance and Performance Improvement Action Plan to review during the meeting. The Medical Director was in attendance by phone.
- The facility implemented a plan for twice a week audits of laboratory testing documentation and reporting results to the physician. The audits will continue for four weeks then monthly times two months. Results of the audits would be submitted to the QAPI Committee for further review and recommendation.
Incident of Resident-to-Resident Physical Abuse Due to Inadequate Behavioral Interventions
Penalty
Summary
The deficiency reported in the survey pertains to an incident of physical abuse involving Resident #1 and Resident #2 at the facility. Resident #1 was found on the floor with injuries including abrasions, swelling, bleeding on the brain, and a fractured sacrum, following an assault by Resident #2. Resident #1 had a history of seizures, depression, and post-traumatic stress disorder, while Resident #2 had diagnoses of paranoid schizophrenia, paranoid personality disorder, anxiety disorder, and violent behavior. Resident #2 had a documented history of aggressive behaviors, including incidents of physical altercations with other residents in the facility. The report highlighted that Resident #2's care plan focused on managing mood problems related to paranoid schizophrenia but lacked specific interventions to address his violent and aggressive behaviors. Resident #2 had been involved in multiple incidents of physical altercations with other residents in various nursing facilities, indicating a pattern of behavior. The facility's psychiatrist noted Resident #2's ongoing behaviors and the challenges in reducing his psychiatric medications due to the risk of relapse if lowered. The deficiency was exacerbated by the lack of individualized interventions to prevent Resident #2 from physically abusing other residents, including Resident #1. The investigation revealed that Resident #1 reported being assaulted by Resident #2, leading to serious injuries requiring hospitalization. Law enforcement confirmed the incident as a case of felonious assault, with charges being pursued against Resident #2. The facility's failure to develop specific interventions to address Resident #2's violent tendencies and protect other residents, such as Resident #1, contributed to the deficiency. The lack of tailored interventions and oversight to prevent resident-to-resident abuse, particularly in cases involving residents with a history of violent behaviors, underscored the critical need for enhanced monitoring and individualized care planning to ensure resident safety and well-being.
Failure to Provide Adequate Behavioral Health Services
Penalty
Summary
The facility failed to ensure adequate behavioral health services and person-centered care planning for a resident with a history of mental disorders and violent behaviors. Resident #2, who was admitted with diagnoses including paranoid schizophrenia, paranoid personality disorder, anxiety disorder, and violent behavior, had a history of physically assaulting other residents and staff. Despite this history, the facility did not have specific care plan interventions to address Resident #2's violent behaviors, which resulted in multiple incidents of aggression towards other residents, including physical altercations and assaults causing injuries. The medical record review revealed that Resident #2 had been involved in 16 separate incidents resulting in facility self-reported incidents (SRIs) across four different nursing facilities since 2014. Notable incidents in the current facility included Resident #2 placing another resident in a chokehold and punching a roommate for no reason. Despite these behaviors, the care plan for Resident #2 lacked specific interventions to manage his violent tendencies, focusing instead on general mood management and medication administration. Interviews with the facility's Administrator, Director of Nursing (DON), and various staff members confirmed that there were no specific behavioral health interventions in place for Resident #2. The facility's assessment and policy on behavior management did not adequately address the individualized needs of residents with violent behaviors, leading to repeated incidents of aggression and harm to other residents. This deficiency represents non-compliance with the requirement to provide necessary behavioral health care and services to residents.
Failure to Conduct Yearly Performance Evaluations for STNAs
Penalty
Summary
The facility failed to ensure that state tested nurse aides (STNAs) were given yearly performance evaluations as required. This deficiency was identified during a review of personnel files and staff interviews. Specifically, two STNAs, who had been employed for more than one year, did not have documented yearly performance evaluations in their personnel records. The Human Resources Director confirmed that no yearly performance reviews were completed for these STNAs. This deficiency had the potential to affect all 143 residents residing in the facility.
Latest citations in Ohio
A resident with intact cognition receiving Medicare Part A skilled services for metabolic encephalopathy had services discontinued while benefit days remained, but the facility did not issue the required Skilled Nursing Facility Advance Beneficiary Notice (SNF ABN). The Social Services Director later confirmed that no SNF ABN was provided and reported she believed only a Notice of Medicare Non-Coverage (NOMNC) was needed when all skilled services were stopped. This practice conflicted with the facility’s written policy, which required SNF ABNs to be issued when extended care items or services were initiated, reduced, or terminated due to expected non-coverage by Medicare.
Surveyors identified that the facility exceeded the acceptable medication error rate when two residents with type 2 DM received insulin doses that were not administered according to orders or manufacturer instructions. In two separate observations, an LPN administered Novolog and another LPN administered insulin glargine and insulin lispro without priming the insulin pens, and the insulin lispro and Novolog were given after the residents had already consumed a significant portion of their breakfast meals, despite orders for administration before meals. Manufacturer information for both insulin products required priming before each injection to ensure accurate dosing, and facility policy required medications, including insulin, to be administered safely, timely, and in accordance with prescriber orders and specified time frames.
Surveyors found that the facility failed to document tray line food temperatures for multiple meals served from two dining room kitchenettes, despite having a “Trayline Taste & Temperature Log” and a policy requiring food to be stored, prepared, distributed, and served according to professional food safety standards. Review of logs showed repeated missing entries for breakfast, lunch, and dinner services in both the Harrison and McClellan dining areas, and the Senior Director of Culinary Services confirmed that temperatures had not been recorded for those meals, potentially affecting all residents receiving meals from those kitchenettes.
The facility failed to conduct and document required periodic care conferences for two residents, despite multiple comprehensive, quarterly, and significant change MDS assessments and a policy requiring periodic care conferences with resident and/or family participation. One resident with Parkinson’s disease, post-stroke hemiplegia, TIA, DMII, and depression had only two documented care conferences over a year, while another resident with aphasia, cerebrovascular disease, DMII, gait difficulty, coagulation defect, depression, and muscle weakness had no documented care conferences in the past year, aside from a declined invitation to the representative. The UCC confirmed that care conferences were expected to occur quarterly and that no additional documentation existed for either resident.
A resident with Alzheimer's disease and type II DM, who required extensive assistance with ADLs and was receiving scheduled Lantus and sliding-scale Humalog, experienced a severely elevated blood glucose level. The on-call provider was notified and ordered an additional dose of lispro insulin with a directive to recheck the blood glucose after administration. Nursing staff administered the extra insulin but did not document any follow-up blood glucose check, and the DON confirmed that this reevaluation was required by the facility's abnormal blood glucose policy and was not completed or documented.
A resident with Parkinson’s disease, dementia, and hypothyroidism was prescribed levothyroxine once daily along with other medications. A consultant pharmacist’s monthly drug regimen review recommended that levothyroxine be given in the morning on an empty stomach, 30–60 minutes before food, per manufacturer instructions. The medical record contained no documented physician response to this recommendation, and the MAR showed the drug scheduled for morning administration while the resident was observed eating breakfast and receiving the medication at the same time. An LPN confirmed administering levothyroxine during the meal, and the DON verified there was no documentation explaining whether or why the pharmacist’s recommendation was or was not followed, resulting in a failure to act on and document the identified irregularity.
A resident with severe cognitive impairment, multiple comorbidities, documented gait and balance abnormalities, and a high fall risk was care planned and assessed by therapy to require contact guard assistance and use of a gait belt for transfers and ambulation. While being assisted by a CNA from a recliner to the bathroom with a walker, the CNA did not apply a gait belt, even though the resident had a known tendency to lean backward when standing. As the CNA reached to open the bathroom door, the resident lost balance and fell backward, striking the back of the head, and was later found by an LPN without a gait belt in place, contrary to the facility’s gait belt policy and the resident’s assessed needs.
A resident with CKD stage five requiring peritoneal dialysis (PD) was admitted with pre-admission physician orders for three daily PD exchanges and monitoring for peritonitis (fever, abdominal pain, cloudy effluent), but these monitoring orders were not entered into the facility’s physician orders. The care plan referenced PD and general monitoring but did not specifically address peritonitis monitoring. Paper PD flowsheets showed incomplete and inconsistent documentation of exchanges and resident condition, including missing condition/comments for individual treatments and no record of one ordered PD exchange. The PD cycler flowsheet lacked effluent descriptions on multiple days. The PD nurse reported facility staff were expected to monitor effluent and symptoms, and the DON confirmed the absence of specific peritonitis monitoring orders, lack of an order for the PD cycler, and documentation gaps, despite a facility policy requiring ongoing assessment and monitoring for complications before, during, and after dialysis treatments.
A nurse was observed preparing multiple oral medications for a resident with depression, traumatic brain injury, anxiety, and impaired cognition by pushing tablets and capsules from unit-dose cards directly into her ungloved hand and then using her fingers to place them into a medication cup. In a follow-up interview, the RN confirmed this practice and acknowledged that the correct procedure is to dispense medications directly from the card into the cup, contrary to the facility’s medication administration policy requiring adherence to good nursing principles and practices.
A resident with Alzheimer’s disease, diabetes, anxiety, significant ADL dependence, and behavioral symptoms was observed seated in a chair positioned against the nursing station with a locked wheelchair placed directly in front, also against the nursing station, effectively restricting movement. An LPN confirmed both wheelchair wheels were locked and that it should not have been placed there, while a CNA stated she had positioned the wheelchair to prepare for lunch, was unable to complete the transfer, and left it in place, acknowledging this was wrong. This arrangement conflicted with the facility’s restraint policy, which prohibits physical restraints except when alternatives are ineffective for treating a medical symptom and defines restraints as devices adjacent to the body that cannot be easily removed and that restrict freedom of movement or access to the body.
Failure to Issue Required SNF ABN When Discontinuing Medicare Part A Services
Penalty
Summary
The deficiency involves the facility’s failure to issue a Skilled Nursing Facility Advance Beneficiary Notice (SNF ABN) when Medicare Part A services were discontinued for a resident who still had available benefit days. The resident was admitted with a diagnosis of metabolic encephalopathy and had intact cognition per the Minimum Data Set assessment. The facility’s own SNF Beneficiary Notification Review documented that Medicare Part A skilled services began on 02/11/26 and the last covered day was 03/11/26, and that the facility initiated discharge from Medicare Part A services before the resident’s benefit days were exhausted. Despite this, no SNF ABN was provided to the resident or the resident’s representative. During interviews, the Social Services Director stated that the SNF ABN was issued hours prior to the last covered day but, upon reviewing her files, confirmed that no SNF ABN had actually been issued for this resident. She further explained that she believed an SNF ABN was only required if one skilled service remained and that if all skilled services were being discontinued, only the Notice of Medicare Non-Coverage (NOMNC) needed to be issued. The Administrator, however, stated that a resident should always receive both a SNF ABN and a NOMNC when Medicare Part A services are discontinued and benefit days remain. Review of the facility’s written policy dated 03/28/23 showed that the facility was required to issue SNF ABNs for initiation, reduction, or termination of extended care items or services when Medicare payment was not expected, which did not occur in this case.
Plan Of Correction
This Plan of Correction is submitted as required under State and Federal law. This Plan of Correction does not constitute an admission on the part of the Facility that the findings cited are accurate, that the findings constitute a deficiency or that the scope and severity regarding the deficiency cited are correctly applied. Any changes to the Facility's policies and procedures should be inadmissible in any proceeding on that basis. Without admitting or denying the validity or the existence of the alleged noncompliance, the Facility submits this Plan of Correction with the intention that it be inadmissible by any third party in any civil or other action against the facility or any employee, agent, officer, director or shareholder of the Facility. The Facility is utilizing this Plan of Correction as its allegation of substantial compliance as of 05/29/2026 F-0582 Corrective action for resident/s: On 5/14/26 Resident #34 was informed of rights and responsibilities related to Advanced Beneficiary Notice and voiced understanding of information for future reference by administrator. Identification of other residents who may be affected: Any resident receiving skilled services from nursing or therapy services. The Administrator audited all residents who were discharged from skilled services in the past 30 days to ensure they were issued a Notice of Non-Coverage and Advanced Beneficiary Notice on 5/29/26. No non-compliance was noted. Measures for systemic change: On 5/14/2026 Business Office Manager, Director of Rehab, Minimum Data Set nurse, Director of Nursing and Social Services Director were educated on proper procedure of issuing of Notice Of Medicare Non Coverage and Advanced Beneficiary Notice by administrator. All upcoming discharges from skilled services will be reviewed weekly at Utilization Review meeting to ensure notices will be delivered timely. How Corrective Action will be monitored: Administrator or designee to complete audits of all residents being discharged from skilled services to ensure they were issued a Notice of Non-Coverage and Advanced Beneficiary. This audit will be completed weekly x 4 weeks, then monthly x 2 months. Corrective action will be initiated for any noted non-compliance. Audit findings will be reviewed as part of the monthly quality assurance process to determine the need for further monitoring. Date of Compliance 5/29/26
Insulin Administration Errors and Failure to Prime Insulin Pens
Penalty
Summary
The deficiency involves the facility’s failure to maintain a medication error rate below 5%, with surveyors identifying 3 errors out of 28 medication administration opportunities, resulting in a 10.71% error rate. For one resident with type 2 diabetes mellitus and moderate cognitive impairment, the physician’s order directed Novolog insulin 10 units via subcutaneous pen-injector to be given before meals. During an observed medication pass, the LPN administered 10 units of Novolog insulin without priming the pen and did so after the resident had already consumed approximately 50% of the breakfast meal. The LPN later confirmed she did not prime the pen and acknowledged that the insulin was ordered to be administered prior to meals. Manufacturer instructions for the Novolog FlexPen specified that an air shot (priming) must be performed before each injection to ensure proper dosing. Another resident, also diagnosed with type 2 diabetes mellitus and with intact cognition, had orders for insulin glargine 35 units subcutaneously twice daily and insulin lispro 20 units subcutaneously before meals, plus 12 units subcutaneously if blood glucose was between 251 mg/dL and 300 mg/dL. During an observed medication administration, an LPN administered 35 units of insulin glargine and 32 units of insulin lispro without priming the insulin pens and after the resident had consumed approximately 90% of the breakfast meal, despite orders for insulin lispro to be given before meals. The LPN later stated she could not remember if she had primed the pen and acknowledged that the insulin was ordered to be administered prior to meals. Manufacturer information for insulin lispro stated that the pen must be primed before each injection to confirm insulin delivery and remove air, and that failure to prime could result in too much or too little insulin. The DON confirmed the expectation that insulin be administered as ordered, including priming each pen with two units before dialing the prescribed dose, and facility policy required medications, including insulin, to be administered safely, timely, and in accordance with prescriber orders and required time frames.
Plan Of Correction
This Plan of Correction is submitted as required under State and Federal law. This Plan of Correction does not constitute an admission on the part of the Facility that the findings cited are accurate, that the findings constitute a deficiency or that the scope and severity regarding the deficiency cited are correctly applied. Any changes to the Facility's policies and procedures should be inadmissible in any proceeding on that basis. Without admitting or denying the validity or the existence of the alleged noncompliance, the Facility submits this Plan of Correction with the intention that it be inadmissible by any third party in any civil or other action against the facility or any employee, agent, officer, director or shareholder of the Facility. The Facility is utilizing this Plan of Correction as an allegation of substantial compliance as of 5/29/2026. F-0759 Corrective action for resident/s: Residents #21 and #22 were assessed and evaluated by nurse and Director of Nursing 5/14/26. Resident #21 and #22 both denied any adverse effects and none were noted upon assessment by the Director of Nursing on 5/14/2026. Notification made to physician on 5/14/2026. LPN # 2 competency Eval on insulin administration with the Director of Nursing completed 5/14/2026. Identification of other residents who may be affected: Diabetic residents on assignment of LPN #2/station 2 have the potential to be affected and were assessed by the DON/Designee on 5/14/26 and found to be within normal limits. Measures for systemic change: All Nurses were educated by the Director of Nursing on the steps for Insulin administration per competency, diabetes clinical protocol policy, Medication and treatment orders policy, administering medications policy, and Obtaining fingerstick Glucose Level policy On 5/14/2026. How Corrective Action will be monitored: Director of Nursing and Assistant Director of Nursing will complete insulin administration audits on 5 nurses. This audit will be completed weekly x 4 weeks, then monthly x 2 months. Corrective action will be initiated for any noted non-compliance. Audit findings will be reviewed as part of the monthly quality assurance process to determine the need for further monitoring. Date of Compliance: 5/29/2026
Failure to Document Tray Line Food Temperatures in Dining Room Kitchenettes
Penalty
Summary
The deficiency involves the facility’s failure to document tray line food temperatures for meals served from the Harrison and McClellan Dining Room kitchenettes, as required by professional standards for food service safety and the facility’s own policy. Review of the “Trayline Taste & Temperature Log” (revised September 2018) showed missing temperature documentation for multiple meals from the Harrison Dining Room kitchenette, including dinner on 03/30/26 and 03/31/26, lunch and dinner on 04/01/26 and 04/02/26, dinner on 04/07/26, and lunch and dinner on 04/08/26 and 04/10/26. The Senior Director of Culinary Services confirmed during interview that tray line food temperatures were not documented on the log for these meals. Similarly, review of the same log for the McClellan Dining Room kitchenette revealed that tray line food temperatures were not documented for dinner on 04/01/26, breakfast and lunch on 04/02/26, and lunch and dinner on 04/07/26. The Senior Director of Culinary Services also verified these omissions during interview. The facility census at the time was 27 residents, and the governing “Food and Nutrition” policy, approved on 09/07/21, stated that the facility must store, prepare, distribute, and serve food in accordance with professional standards for food service safety.
Plan Of Correction
F812 The facility will continue to ensure food temperatures are completed before meals are served for all residents. To ensure compliance with this standard the following measures have been taken: 1. Immediately 4/15/26 culinary supervisor #224 was re-educated by Dietary Manager to this standard and policy "Food and Nutrition" which includes documentation of food temperatures. 2. All dietary staff have been re-educated to the standard and policy "Food and Nutrition" during the month of April 2026. 3. Audits of food temperature documentation to be completed by Dietary Manager 4 x per week for 4 weeks then weekly for 4 weeks. 4. Administrator to validate audits/compliance and provide additional training as needed. Administrator will present to QAPI committee for ongoing monitoring and further direction.
Failure to Conduct and Document Required Care Conferences
Penalty
Summary
The deficiency involves the facility’s failure to complete and document comprehensive care conferences at required intervals in accordance with care plan regulations and facility policy. For one resident with Parkinson’s disease with dyskinesia, cognitive communication deficit, hemiplegia and hemiparesis following cerebral infarction, transient cerebral ischemic attack, type II diabetes mellitus, and major depressive disorder, the record showed multiple MDS assessments over a one-year period, including annual, quarterly, and significant change assessments. However, only two care conferences were documented during the last 12 months, despite the expectation that care conferences be conducted quarterly with the resident and family when possible. The Unit Care Coordinator confirmed that no additional care conference documentation existed for this resident beyond the notes dated 04/21/25 and 01/02/26. A second resident, with diagnoses including aphasia following cerebrovascular disease, cerebral infarction, type II diabetes mellitus, unsteadiness on feet, difficulty in walking, coagulation defect, depression, and muscle weakness, also had multiple MDS assessments completed over the review period, including quarterly and annual assessments. The record contained a note that a care conference was offered to the resident’s representative, who declined to attend, but there was no documentation of any care conferences for the most recent 12 months. The Unit Care Coordinator confirmed that no other care conference documentation was available for this resident. Facility policy stated that periodic care conferences involving the resident, family, and the interdisciplinary team are part of the care planning process, but the required periodic care conferences and corresponding documentation were not completed for these two residents.
Plan Of Correction
THIS PLAN OF CORRECTION SERVES AS BERKELEY SQUARE'S CREDIBLE ALLEGATION OF SUBSTANTIAL COMPLIANCE AS OF June 1, 2026. Without admitting or denying the validity or existence of the alleged deficiencies, Berkeley Square provides the following Plan of Correction: F657 The facility will continue to document completion of care conferences at the required intervals for all residents, including residents #04 & #15. To ensure compliance with this standard the following measures have be taken: 1. The social service designee and the inter- disciplinary team were re-educated by the administrator to the facility policy "Care Conference" on 4/29/26 and verbalized understanding. 2. Care conferences for resident #04 and resident #15 were conducted on or before 4/29/2026 by the interdisciplinary team. 3. Review of all other residents was conducted by the social service designee to validate and ensure that care conference schedule is up to date with timely care conferences scheduled for them on 4/15/2026. Audits of care conferences to be completed weekly for four weeks and then monthly after that by the social service designee. Documentation of the care conference including any identified concerns in the medical record. Administrator to validate audits/compliance and provide additional training as needed. Administrator will present results of these audits to QAPI committee for ongoing monitoring and further direction.
Failure to Reevaluate Blood Glucose After Treatment for Hyperglycemia
Penalty
Summary
The facility failed to ensure that a resident with diabetes received treatment in accordance with professional standards of practice when nursing staff did not reevaluate the resident's blood glucose after treatment for severe hyperglycemia. The resident, admitted with diagnoses including Alzheimer's disease, type II diabetes mellitus, and depression, had physician orders for Humalog insulin on a sliding scale before meals, Lantus insulin 25 units daily, and lisinopril 5 mg daily. The resident required extensive assistance with activities of daily living, including transfers, toileting hygiene, eating, and bathing. On the evening in question, the resident's blood glucose was documented as 532 mg/dL, and the on-call provider was notified. The provider gave a new order to administer an additional 8 units of lispro (Humalog) and to recheck the blood glucose in 30 minutes. The electronic medication administration record showed that the blood glucose of 532 mg/dL was obtained at 9:00 p.m. and that the additional 8 units of lispro were administered at 9:21 p.m. However, there was no documentation in the resident's chart that the blood glucose was rechecked after the additional insulin was given. In an interview, the DON confirmed there was no evidence of reevaluation and verified that, according to the facility's "Abnormal Blood Glucose Procedure" policy, the resident should have been reevaluated and that the evaluation step should have been included in the progress note documentation.
Plan Of Correction
F684 The facility will continue to ensure all residents, including #03, receive treatment in accordance with professional standards of practice and reevaluated for hyperglycemia. To ensure compliance with this standard the following measures have been taken: 1. The director of nursing assessed resident #03, reviewed documentation and orders and found no ill effects immediately 4/16/26. 2. All licensed nurses were re-educated to facility policy "Blood Glucose Monitoring" by the Director of Nursing/designee in April 2026. 3. Audits of like-residents that require blood sugar checks to be completed by the director of nursing/designee two times a week for 4 weeks and then monthly after that to validate correct follow through when there is abnormally high blood glucose result. The Administrator will bring results of these audits to the QAPI committee for ongoing monitoring and further direction.
Failure to Act on Pharmacist Drug Regimen Recommendation for Thyroid Medication
Penalty
Summary
The deficiency involves the facility’s failure to ensure that pharmacy recommendations from the monthly drug regimen review were acted upon and documented for a resident. The resident was admitted with diagnoses including Parkinson’s disease, dementia, and hypothyroidism, and had current physician orders for levothyroxine 150 mcg once daily, buspirone 50 mg twice daily, and losartan 100 mg once daily. A medication regimen review dated 11/25/2025 included a consultant pharmacist recommendation that levothyroxine be administered consistently in the morning on an empty stomach, at least 30–60 minutes before food, per manufacturer instructions. There was no specific physician response in the medical record to this recommendation, and the facility’s policy stated that consulting pharmacist reviews are sent to nursing and addressed with the primary care provider or consulting specialist for review and follow-up. Review of the resident’s medication administration record for April 2026 showed levothyroxine scheduled for 9:00 a.m. On observation, the resident was seen eating breakfast in the dining area at 8:03 a.m., and an LPN reported administering the levothyroxine 150 mcg to the resident while the resident was in the dining area eating breakfast. The DON confirmed there was no evidence in the resident’s medical record explaining why the consultant pharmacist’s recommendation from 11/25/2025 was or was not acted upon. This lack of documented physician review and action on the pharmacist’s identified irregularity constituted noncompliance with the drug regimen review requirements.
Plan Of Correction
F756 The facility will continue to ensure the pharmacy recommendations from the monthly drug regimen review by a licensed pharmacist are acted upon for all residents, including #08. To ensure compliance with this standard the following measures have been taken: 1. Resident #08 was assessed by the registered nurse and med review completed by 4/28/26. After review of resident's drug regime's, it was discovered that resident #8 had 2 separate medication recommendations on the same form, to be reviewed by two separate practitioners, pharmacy has been instructed and agreed to separate meds on individual forms. 2. Licensed nurses re-educated to facility policy "Drug Regimen Review" by Director of nursing/designee in April 2026 and no later than 5/8/26. Licensed nurses are responsible for ensuring the reviews and recommendations are given to the physician for timely review. 3. Review of all other current residents Drug Regimen orders completed by Director of nursing/designee on 4/16/26 to ensure recommendations were followed up on/reviewed by the physician and address concerns if needed. 4. Audit of drug regime recommendations, pharmacy recommendations, and physician follow up to be completed weekly for four weeks by the Director of nursing/designee. Administrator will present results of these audits to the QAPI committee for ongoing monitoring and further direction.
Failure to Use Required Gait Belt During Ambulation Resulting in Resident Fall
Penalty
Summary
The deficiency involves the facility’s failure to ensure that a required gait belt was used while assisting a high fall‑risk resident with ambulation, resulting in a fall with head injury. The resident had multiple diagnoses including metabolic encephalopathy, hypertension, osteoarthritis, muscle weakness, gait and mobility abnormalities, major depressive disorder, anxiety, and visual hallucinations. Admission and subsequent MDS and fall risk assessments documented that the resident was severely cognitively impaired, required moderate to maximal assistance with transfers and ambulation, could not independently come to a standing position, exhibited loss of balance while standing, used an assistive device, and had decreased muscle coordination. The resident had a history of falls prior to admission and was assessed as being at high, later moderate, risk for falls. The resident’s fall care plan identified her as at risk for falls and included interventions such as providing maximum to moderate assistance with transfers and walking short distances, use of a walker and wheelchair, and following the facility’s fall protocol. Therapy notes and care conference documentation indicated that the resident leaned backwards when standing, required contact guard to minimal assistance for bed mobility and transfers, and needed constant verbal cueing for safe sequencing during toilet transfers. The physical therapist confirmed that the resident was to use a gait belt with staff when ambulating, and the DON verified that therapy had assessed the resident as requiring contact guard assistance and a gait belt for ambulation and transfers. On the day of the incident, a CNA was assisting the resident from her recliner to the bathroom using a walker. The CNA walked beside the resident, providing guidance and support, and reported having a hand on the resident while assisting her. As they approached the bathroom door, the CNA reached for the doorknob to open it, and at that moment the resident began to lose her balance and fell backwards to the floor, striking the back of her head. The nurse who responded found the resident on her back at the foot of the bed with her feet near the bathroom, noted a red raised area on the back of the head, and documented that the resident was not wearing a gait belt and that the gait belt was on the dresser. In the facility’s investigative summary and in interviews, the CNA acknowledged that she did not have a gait belt on the resident while ambulating her, despite the resident’s assessed need for hands‑on assistance and gait belt use per facility policy and the resident’s care and therapy plans.
Failure to Implement PD Orders and Monitor Resident Receiving Peritoneal Dialysis
Penalty
Summary
The deficiency involves the facility’s failure to implement pre-admission physician orders for peritoneal dialysis (PD) and to provide ongoing monitoring for a resident with chronic kidney disease (CKD) stage five who required PD. Pre-admission orders dated 11/14/25 specified three daily PD exchanges at 6:00 A.M., 2:00 P.M., and 10:00 P.M., and directed staff to monitor for signs and symptoms of peritonitis, including fever, abdominal pain, and cloudy effluent. These monitoring orders were not entered into the facility’s physician orders. The resident’s care plan noted the need for PD and included general monitoring interventions (labs, signs of bleeding, bacteremia, septic shock, and significant vital sign changes), but did not specifically address the ordered monitoring for peritonitis. Review of PD documentation showed incomplete and inconsistent charting of treatments and resident condition. The paper peritoneal flowsheet had columns for time of PD and condition/comments, including instructions to call the nurse immediately for cloudy fluid, abdominal pain, or fever. However, the first entry on 11/15/26 at 2:00 P.M. only noted that the PD nurse completed the exchange, and the 10:00 P.M. entry that day had no condition/comment documentation. Subsequent days (11/16/25, 11/17/25, and 11/18/25) contained only one condition/comment entry per day rather than for each exchange, and there was no documentation that the 6:00 A.M. PD on 11/18/25 was completed. The PD cycler flowsheet starting 11/19/25 lacked any description of the effluent on multiple days. The PD nurse from the dialysis company stated facility staff were expected to monitor effluent for cloudiness and assess for abdominal pain and fever, and the DON confirmed there was no electronic physician order for peritonitis monitoring or for use of the PD cycler, that the paper charting did not allow for effluent description or symptom documentation for each treatment, and that PD was not documented at one ordered time. The facility’s dialysis policy required ongoing assessment and monitoring for complications before, during, and after treatments, which was not reflected in the documentation for this resident.
Improper Infection Control During Medication Administration
Penalty
Summary
Surveyors identified a deficiency in infection prevention and control related to medication administration for Resident #29. The resident was admitted on 02/28/14 with diagnoses including depression, traumatic brain injury, and anxiety, and had impaired cognition per a quarterly MDS assessment. During an observation on 03/25/26 at 6:58 A.M., RN #281 prepared the resident’s medications by removing an Amoxicillin-Pot Clavulanate tablet from the medication card and pushing it directly into her ungloved hand, then using her fingers to place the pill into a medication cup. The same process was observed for multiple other medications, including Escitalopram Oxalate, Furosemide, Sennosides, Lyrica, and Vitamin D, each being pushed from the card into the RN’s ungloved hand and then transferred by her fingers into the medication cup before administration to Resident #29. In a subsequent interview at 7:27 A.M. the same day, RN #281 confirmed she had placed each medication into her ungloved hands prior to administration and acknowledged that the proper procedure was to push the pills directly from the card into the medication cup. Review of the facility’s “Medication Administration – General guidelines” policy, revised 10/08/25, stated that medications are to be administered in accordance with good nursing principles and practices. This practice failure was cited as a deficiency under Complaint Number 2681777.
Improper Use of Wheelchair as a Physical Restraint
Penalty
Summary
Surveyors identified a deficiency related to the facility’s failure to ensure a resident was free from physical restraints. Resident #7, admitted with diagnoses including Alzheimer’s disease, diabetes mellitus, and anxiety disorder, was documented on a recent MDS as rarely understood and dependent for ADLs except eating. The resident ambulated independently on the unit without an assistive device and had documented verbal and other behaviors occurring one to three days during the look-back period. The care plan noted the resident had potential to be physically aggressive, chase staff, throw objects, and be combative with care, with interventions such as offering choices, administering medications as ordered, and intervening early when agitation occurred. During an observation and interview, Resident #7 was found sitting in a chair with the right arm of the chair positioned against the nursing station and a wheelchair placed directly in front of him. The left arm of the wheelchair was also against the nursing station, and both wheelchair wheels were locked, creating a barrier that appeared to restrain the resident, who was sleeping with his knees touching the locked wheelchair. An LPN confirmed both wheelchair wheels were locked and that the wheelchair should not have been placed in front of the resident. A CNA reported she had placed the wheelchair there in preparation to get the resident up for lunch, was unable to transfer him, and left the wheelchair in that position, acknowledging it was wrong to keep it there. The facility’s physical restraint policy stated that physical restraints are not used except when alternatives are not appropriate or effective for treating a medical symptom and defined physical restraints as any device attached or adjacent to the body that the individual cannot easily remove and that restricts freedom of movement or access to the body.
Trusted data from CMS and state health departments
Every citation, penalty and Plan of Correction is sourced from public CMS records (latest release May 27, 2026) and official state health department websites — never guesswork.
Trusted by long-term care providers and associations.
