Vista Care Center Of Milan
Inspection history, citations, penalties and survey trends for this long-term care facility in Milan, Ohio.
- Location
- 185 S Main St, Milan, Ohio 44846
- CMS Provider Number
- 366067
- Inspections on file
- 25
- Latest survey
- September 9, 2025
- Citations (last 12 mo.)
- 4
Citation history
Health deficiencies cited at Vista Care Center Of Milan during CMS and state inspections, most recent first.
Staff observed an LPN pre-pouring Tylenol PM and melatonin for multiple residents without physician orders, and concerns were reported to nursing leadership. Despite these reports, the incidents were not investigated or reported to the state agency as required, and there was no documentation of resident or staff interviews or assessments. This failure to follow reporting and investigation protocols had the potential to affect dozens of residents on one unit.
The facility did not investigate reports that an LPN was pre-pouring and potentially administering Tylenol PM to multiple residents without physician orders. Despite staff observations and reports to nursing leadership, no thorough investigation, resident monitoring, or required notifications were completed, affecting numerous residents with complex medical and psychiatric conditions.
A resident with impaired mobility and a recent inability to use a prosthetic leg was not properly reassessed for transfer assistance, resulting in staff attempting a manual transfer without a gait belt or mechanical lift, contrary to orders. The resident fell during the transfer, and the incident was not immediately reported or investigated as required by facility policy. Staff involved attempted to conceal the fall, and there was no immediate post-fall assessment or timely update to the care plan.
Two residents with multiple diagnoses received Tylenol PM without a physician order after an LPN was observed pre-pouring and distributing the medication to multiple residents. Staff and resident interviews confirmed the administration of unprescribed medications, and the facility failed to assess, monitor, or document potential adverse effects or notify the pharmacy. The investigation was incomplete, and required procedures for medication administration and monitoring were not followed.
A facility failed to timely report a potential abuse incident involving a cognitively impaired resident. The resident was taken outside for re-direction during a New Year's event, which a CNA later reported as inappropriate. The incident was investigated and deemed unsubstantiated, but the facility did not report it to authorities, citing adherence to the care plan. The facility's policy requires immediate reporting of such allegations.
Two residents experienced medication errors due to transcription mistakes by an LPN. One resident with severe cognitive impairment did not receive prescribed Austedo for Huntington's disease, while another resident received Austedo in error despite not having Huntington's disease. The errors were confirmed by the DON, highlighting a failure to adhere to the facility's medication administration policy.
A resident with a history of paranoid schizophrenia and moderate elopement risk eloped from a secured unit due to inadequate supervision during a smoke break. The resident was not accounted for upon returning inside, and staff failed to conduct required hourly rounds. The resident was found 20 miles away after being transported by a police officer earlier in the day.
A resident with chronic pain did not receive timely pain medication due to the facility's failure to obtain a new prescription for Oxycodone, resulting in severe pain and an emergency room visit. Despite attempts to contact the resident's provider, the facility did not document further efforts until after the medication was exhausted. The deficiency was investigated under a complaint, revealing non-compliance with pain management policies.
The facility did not serve meals according to the menu, affecting all 86 residents. A resident reported small portion sizes, and it was observed that only one slice of toast was served instead of the two slices listed on the menu. The dietary staff confirmed this error.
The facility failed to maintain safe and sanitary food storage, affecting all 86 residents. Observations revealed undated and unlabeled food items, as well as expired products in the refrigerator and walk-in cooler. These issues were confirmed by a dietary staff member.
The facility failed to isolate residents with Covid-19, improperly disinfected shared glucometers, and did not follow enhanced-barrier precautions during wound care. Two residents with Covid-19 were not isolated from their negative roommates, and one participated in communal activities without a mask. An LPN used alcohol swabs instead of bleach wipes to clean glucometers, and staff did not wear gowns or change gloves during wound care.
The facility failed to maintain a clean and safe environment for residents on a secured unit, with multiple holes in the drywall, missing tiles, and unsanitary bathroom conditions. Residents and staff confirmed these issues had persisted, and the administrator acknowledged the lack of repair documentation and deep cleaning schedules.
The facility failed to treat residents with respect and dignity, as a CNA was observed yelling during a smoke break, making residents uncomfortable. Additionally, the facility did not cover urinary drainage bags for two residents, despite policies requiring coverage for privacy. These deficiencies were confirmed through observations and interviews with staff and residents.
The facility failed to notify the guardians and physicians of three residents who tested positive for COVID-19. Despite testing positive, the results were not documented in the medical records, and no notifications were made. This oversight was confirmed by the ADON and Infection Preventionist, highlighting a breach in the facility's policy requiring prompt notification of changes in resident condition.
A resident was placed on a secure unit due to bed availability, despite being a low elopement risk and having intact cognition. The resident was not informed of her ability to leave the unit or given the access code, leading to feelings of confinement. The DON confirmed the placement was due to bed availability and acknowledged the oversight in not providing the resident with the door code or informing her of her right to leave.
The facility failed to develop and implement comprehensive care plans for two residents, leading to deficiencies in addressing their needs. One resident had an incomplete care plan lacking interventions for smoking, ADLs, and behaviors, while another resident, identified as a fall risk, experienced multiple falls due to the absence of non-skid strips. The facility's policies on fall management and care planning were not followed.
The facility failed to accommodate the food preferences of three residents. Two residents did not receive ice cream as per their meal tickets due to a lack of stock, and another resident was served rice despite a documented dislike. Additionally, no breakfast alternatives were offered to a resident who disliked the main option.
A resident with a history of paranoid schizophrenia and schizoaffective disorder eloped from a secured unit and was later found with an abrasion. The facility failed to report the incident to the state agency, as required by their policy. The Administrator did not believe the incident met the criteria for reporting, despite the policy's clear guidelines.
A resident with major depression and other conditions did not receive the correct dosage of Prozac for six days due to a delay in processing a physician's order. The order for an increased dosage was misplaced and not entered into the system promptly, despite the resident's inquiries. Interviews confirmed the oversight, which violated the facility's medication administration policy.
A facility failed to ensure timely lab testing for a resident on psychotropic medications, resulting in missed monitoring of therapeutic drug levels. Despite orders for regular lithium and valproic acid level checks, low lithium levels were not reported to the psychiatric provider. Staff interviews revealed confusion about lab testing procedures, contributing to the deficiency.
A facility failed to provide a resident with a physician-ordered handled cup for meals, despite the resident's difficulty in grasping regular cups due to medical conditions. Observations showed the resident was not given the handled cup during meals, and interviews confirmed the absence of the adaptive equipment, impacting the resident's ability to drink independently.
The facility failed to document COVID-19 positive test results and notify guardians for three residents, including one with paranoid schizophrenia and another with traumatic brain injury. The Assistant Director of Nursing confirmed the lack of documentation and notification, contrary to facility policy.
Failure to Report and Investigate Alleged Medication Misadministration and Neglect
Penalty
Summary
The facility failed to report allegations of abuse and neglect related to the suspected administration of medications without physician orders. Multiple staff members observed an LPN pre-pouring Tylenol PM and melatonin into medication cups for residents, despite no residents having orders for these medications. Staff statements indicated that the LPN routinely prepared these medications in advance and that concerns were reported to the Assistant Director of Nursing (ADON) and the Director of Nursing (DON). However, there was no documentation that these allegations were investigated at the time they were reported. Further review revealed that the incidents were not reported to the state agency as required by facility policy and federal regulations. The ADON and DON were both made aware of the allegations, but failed to initiate a thorough investigation or notify the Administrator in a timely manner. There was no evidence of resident or staff interviews, resident assessments, or monitoring for potential adverse medication reactions related to the alleged incidents. The facility's own policies required immediate reporting and investigation of such allegations, but these procedures were not followed. The failure to report and investigate these allegations had the potential to affect 38 residents residing on one unit. The facility census at the time was 87. The Administrator confirmed that the incidents were not reported to the state agency and that there was no documentation of a completed investigation, including interviews or assessments of potentially affected residents.
Failure to Investigate Alleged Unauthorized Medication Administration
Penalty
Summary
The facility failed to investigate allegations of abuse and neglect related to the administration of Tylenol PM without physician orders on two separate occasions. On the first occasion, a nurse was observed pre-pouring Tylenol PM and melatonin into medication cups for multiple residents, despite no physician orders for these medications. This incident was reported to the Assistant Director of Nursing (ADON), who in turn notified the Director of Nursing (DON), but no investigation was documented, and the allegations were not reported to the state agency as required by facility policy. The nurse in question continued to work on the unit for several days following the initial report. A second incident involved another nurse observing the same LPN preparing and placing Tylenol PM in medication cups for several residents. The nurse took photographs and reported the incident to the ADON, who removed the medication from the cart but did not ensure a thorough investigation or resident monitoring. Interviews with staff and residents revealed that some residents recalled receiving Tylenol PM without an order, while others were unaware. There was no documentation of resident assessments, monitoring for adverse reactions, or pharmacy notification. The facility's own policies required immediate reporting, thorough investigation, and resident assessment, none of which were completed. The deficiency affected up to 38 residents on one unit, many of whom had complex medical and psychiatric diagnoses, including diabetes, bipolar disorder, schizophrenia, and anxiety. Despite multiple staff members reporting concerns about the LPN's medication practices, facility leadership failed to conduct a comprehensive investigation, interview all potentially affected residents and staff, or document any monitoring or assessment for possible adverse effects. The lack of action and documentation directly violated the facility's abuse prohibition and medication administration policies.
Failure to Reevaluate Transfer Needs and Report Fall Incident
Penalty
Summary
A deficiency occurred when a resident with a history of hemiplegia, hemiparesis, diabetes, and a right leg amputation was not properly reevaluated for transfer assistance after being unable to use a prosthetic leg due to a blister and improper fit. Despite a physician order discontinuing the use of the prosthesis and a subsequent order for mechanical lift transfers, there was no documentation that the resident’s transfer status was reassessed when the prosthesis was removed. Staff continued to use manual transfer methods without a gait belt or walker, contrary to the care plan and physician orders, and did not consult therapy for updated transfer recommendations. The resident experienced a fall during a transfer attempt by two CNAs who did not use a mechanical lift or gait belt, and involved the resident’s roommate in the process. The fall was not immediately reported to nursing staff as required. Instead, the CNAs attempted to conceal the incident, instructing each other and the resident not to report it. The fall only came to light two days later when another CNA reported it to a nurse, prompting a delayed assessment and notification of the nurse practitioner. There was no immediate post-fall assessment or thorough investigation at the time of the incident. Interviews and record reviews revealed that staff were unclear about the resident’s current transfer needs and failed to follow established protocols for safe transfers and fall reporting. The facility’s policies required prompt reassessment after a change in condition, use of appropriate transfer equipment, and immediate reporting and investigation of falls. These procedures were not followed, affecting the resident involved and potentially impacting other residents on the same units.
Failure to Administer Medications per Physician Orders and Inadequate Monitoring
Penalty
Summary
The facility failed to ensure that medications were administered per physician orders and did not assess or monitor for potential medication interactions and adverse effects. Two residents with intact cognition and multiple diagnoses, including diabetes, bipolar disorder, schizophrenia, and hypertension, were found to have received or potentially received Tylenol PM without a physician order. Review of medical records showed that neither resident had an order for Tylenol PM during the period in question, yet staff statements and interviews indicated that an LPN was observed pre-pouring Tylenol PM and Melatonin into medication cups for multiple residents, regardless of whether there was a physician order. Multiple staff members reported witnessing the LPN preparing and distributing Tylenol PM to residents without verifying current orders. Statements revealed that the LPN routinely pre-poured medications, including Tylenol PM, and placed them in medication cups before checking for new orders. The LPN admitted to preparing the medications in advance for convenience and stated that any unused Tylenol PM was returned to the bottle at the end of the medication pass. However, other staff and resident interviews indicated that some residents did receive Tylenol PM, with at least two residents recalling being given two Tylenol PM tablets, which was not in accordance with any physician order at the time. The facility's investigation into the incident was incomplete. There was no documentation of pharmacy notification, resident assessments, or monitoring for adverse reactions. Not all potentially affected residents or staff were interviewed, and there was no evidence of systematic monitoring or assessment following the allegations. The facility's own policy required medications to be administered only after confirming orders and to observe and document resident reactions, but these procedures were not followed. The incident was not reported to the state agency as required, and the lack of thorough investigation and documentation was confirmed by the current DON and Administrator.
Failure to Timely Report Potential Abuse Incident
Penalty
Summary
The facility failed to ensure timely reporting of a potential incident of physical abuse involving a resident with severe cognitive impairment and multiple diagnoses, including COPD, type II diabetes, and schizoaffective disorder. The incident occurred when a CNA, following instructions from an LPN, took the resident outside for re-direction due to disruptive behavior during a New Year's celebration. The resident was dressed appropriately for the weather, and the re-direction was brief, lasting two to three minutes. However, another CNA, who witnessed the incident, believed the action was inappropriate and potentially abusive but delayed reporting it due to fear of retaliation. The CNA eventually reported the incident to another nurse on January 17, who then informed the Social Service Director. An investigation was launched and concluded on February 14, finding the abuse allegations unsubstantiated. Despite this, the facility did not report the incident to the state agency or law enforcement, as they deemed it unsubstantiated and in line with the resident's care plan, which included going outside as a form of re-direction. The facility's policy on abuse, neglect, and exploitation requires immediate reporting of allegations to the Administrator or designee, with an investigation to follow. The policy also emphasizes training staff on appropriate interventions and reporting procedures without fear of reprisal. The deficiency was identified as non-compliance under a specific complaint number, highlighting the failure to adhere to the facility's abuse policy and timely reporting requirements.
Medication Transcription and Administration Errors
Penalty
Summary
The facility failed to ensure accurate transcription of physician orders and proper medication administration for two residents. Resident #61, who has severe cognitive impairment and multiple psychiatric diagnoses, did not receive the prescribed medication Austedo for Huntington's disease due to a transcription error by an LPN. The LPN mistakenly entered the order into another resident's medical record, resulting in Resident #61 not receiving any doses of Austedo in December 2024. This error was confirmed by the Director of Nursing during a quality assurance meeting. Resident #29, diagnosed with schizoaffective disorder and other medical conditions, was incorrectly administered Austedo due to a transcription error. The resident, who is cognitively intact and on hospice care, received four doses of Austedo despite not having Huntington's disease. The resident frequently refused medications, and the error was confirmed by the Director of Nursing. The facility's Medication Administration Policy and Procedures require medications to be administered according to valid physician orders, which was not adhered to in these cases.
Resident Elopement Due to Inadequate Supervision
Penalty
Summary
The facility failed to provide adequate supervision to prevent the elopement of a resident at risk for elopement, residing on a secured unit. The incident involved a resident with diagnoses including paranoid schizophrenia, schizoaffective disorder, and chronic obstructive pulmonary disease, who was identified as having intact cognition and a moderate risk for elopement. The resident left the facility without staff knowledge and was missing for over five hours before being identified as missing by the staff. The deficiency occurred when the resident was taken outside for a smoke break by a State Tested Nurse Aide (STNA) and was not accounted for upon returning inside. The staff did not realize the resident was missing until a Registered Nurse (RN) attempted to administer medication and could not locate the resident. It was later discovered that the resident had left through an unlocked gate in the courtyard, which was found open by staff during their search. Interviews with staff and residents revealed that the resident had been seen hopping the fence and that the gate had been left open. The facility's policy required hourly rounds to visually observe residents, which were not conducted, contributing to the resident's ability to elope unnoticed. The resident was eventually found 20 miles away, sitting in a lawn chair at a previous residence, after being transported by a police officer who had encountered him earlier in the day.
Removal Plan
- The DON notified the local police department Resident #69 was missing. A search was initiated with staff in vehicles and on foot searching surrounding areas.
- A Root Cause Analysis was completed by the Administrator, DON, Regional Director of Operation (RDO) #500 and Regional Quality Assurance Nurse (RQAN) #410. A plan of correction was started for the failure of direct care staff on the behavior unit to follow policy and procedure for supervision with outside time.
- The DON initiated a Count In/Count Out form for all residents exiting to the courtyard for supervised smoke breaks. The DON notified the physician, guardian, and residents' sister with guardian approval, Resident #69 was missing.
- The DON/designee began audits for the completion of the Count In/Count Out form for resident smoke breaks. These audits will be completed four times a week, times four weeks.
- The DON began education to all staff regarding elopement, notification, resident supervision during outside times, and the abuse policy. The education was completed.
- Resident #69 arrived back to the facility, returned to the secured unit, and was placed on one-on-one supervision. Licensed Practical Nurse (LPN) #294 completed a head-to-toe assessment of the resident with no major injuries found. Resident #69 was sent to the emergency room (ER) for evaluation and treatment related to the elopement.
- LPN #301 and LPN #351 began to assess all residents for elopement risk with care plans updated. All assessments were completed.
- The Quality Assurance Performance Improvement (QAPI) committee met to review the elopement and develop a plan.
- The DON updated the Elopement book.
- Maintenance Director #299 completed an elopement drill.
- Daily audits were completed by Maintenance Director #299 and/or the 300 Unit nurse of the south and north gates in the courtyard to ensure they were locked. These audits continued.
- Resident #69 was discharged to a sister facility with increased supervision levels.
- Maintenance Director #299 installed sensory alarms on the south and north gates in the courtyard. A motion detector was placed outside of the north gate.
- Maintenance Director #299/designee began audits three times a day until further notice to ensure the south and north gates are latched with alarms and motion detector in working order.
- Maintenance Director #299 educated all staff on checking the gates to ensure they were latched with alarms and motion detector in working order at every smoke break and documenting the check.
Failure to Provide Timely Pain Management
Penalty
Summary
The facility failed to ensure timely procurement and administration of pain medication for a resident, resulting in actual harm. Resident #05, who was admitted with chronic pain and other related diagnoses, had a physician's order for Oxycodone, a narcotic analgesic, which was exhausted on 09/14/24 at 4:00 A.M. The facility did not obtain a new written prescription in a timely manner, leading to the resident not receiving the medication for 91 hours. This delay caused the resident to experience severe pain, rated at 10/10, and necessitated an emergency department visit to obtain a dose of Oxycodone and a short-term prescription. The resident's medical records indicated a history of chronic pain, neuropathy, and other conditions requiring pain management. Despite having a care plan that included administering medications as ordered, the facility did not document any non-pharmacological interventions for pain management. Attempts to contact the resident's outside provider for a new prescription were noted but were unsuccessful, and there were no further attempts documented until after the resident's medication had run out. The facility's Director of Nursing confirmed the delay in obtaining the prescription and acknowledged that the resident went without Oxycodone from 09/14/24 to 09/17/24. Interviews with the resident and staff revealed that the resident had requested to go to the emergency room multiple times due to severe pain. The facility's policy on pain management emphasized the importance of timely communication and documentation between the prescriber and staff, which was not adhered to in this case. The deficiency was investigated under Complaint Number OH00158190, highlighting the facility's non-compliance in managing the resident's pain effectively.
Deficiency in Meal Portion Sizes
Penalty
Summary
The facility failed to ensure that food was served according to the facility menu and dietary spreadsheet, which had the potential to affect all 86 residents receiving meals. During an interview, a resident expressed concerns about meal portion sizes being too small. A review of the weekly menu indicated that the regular breakfast meal included two slices of toast. However, during meal service, it was observed that the dietary staff member served only one slice of toast per resident. The dietary staff member confirmed this discrepancy, acknowledging that residents were supposed to receive two slices of toast with their breakfast meal.
Deficiency in Food Storage and Labeling
Penalty
Summary
The facility failed to ensure the safe and sanitary storage of food items in the kitchen, affecting all 86 residents residing in the facility. During an observation of the facility's refrigerator and walk-in cooler, several issues were identified. These included a container of undated and unlabeled sliced cheese, a container of undated and unlabeled baked beans, and two undated and unlabeled cups containing a brown substance. Additionally, there were expired items such as a box of tortilla shells, a box of puff pastry sheets, and a box of burritos delivered in a previous month. A box of tuna was also found with an expiration date that had passed. These findings were confirmed during a concurrent interview with a dietary staff member.
Infection Control Deficiencies in Isolation, Glucometer Disinfection, and Wound Care
Penalty
Summary
The facility failed to appropriately isolate residents with communicable diseases and ensure proper use of personal protective equipment (PPE) for residents under transmission-based precautions (TBP). This deficiency was observed in two residents who tested positive for Covid-19 but were not isolated from their Covid-19 negative roommates. Additionally, one of these residents was seen participating in communal activities without wearing a mask, increasing the risk of spreading the infection. The Assistant Director of Nursing (ADON) Infection Preventionist (IP) confirmed that the facility was not following proper cohorting practices and did not provide adequate PPE or isolation instructions to residents who refused to move rooms. The facility also failed to properly disinfect shared glucometers, affecting one resident reviewed for glucometer use. A Licensed Practical Nurse (LPN) was observed cleaning a glucometer with an alcohol swab instead of the required healthcare-grade bleach wipes. The LPN admitted to using alcohol swabs as her usual practice, unaware that it was incorrect. The ADON IP confirmed that glucometers should be disinfected with hospital-grade wipes to prevent the transmission of blood-borne pathogens. Furthermore, the facility did not adhere to enhanced-barrier precautions (EBP) during wound care activities. During a wound assessment, the ADON IP and a Wound Nurse Practitioner (NP) did not wear gowns and failed to change gloves after removing a soiled dressing. The ADON IP acknowledged confusion about EBP requirements and admitted to not following proper infection control techniques. The facility's policy required the use of gowns and gloves for high-contact activities, such as wound care, to prevent infection spread.
Facility Fails to Maintain Clean and Safe Environment
Penalty
Summary
The facility failed to maintain a clean and well-repaired environment for residents on the secured unit, affecting all 32 residents residing there. Observations revealed multiple holes in the drywall throughout the hallways and rooms, with sizes ranging from small fist-sized holes to a large 84-inch by 2-foot hole with exposed insulation. Additionally, the flooring in some rooms was in poor condition, with missing tiles and a persistent urine odor. Interviews with residents and staff confirmed that these issues had been present for some time, with one resident expressing dissatisfaction with the condition of their room and another resident having been moved due to the large hole in the wall. Further observations highlighted unsanitary conditions in shared bathrooms, with missing tiles, dirt buildup, and possible black mold. Housekeeping staff reported difficulties in maintaining cleanliness due to the long-standing disrepair of the facilities. The facility administrator acknowledged the environmental concerns and the lack of documentation for repairs or deep cleaning schedules. The administrator also noted that a resident who had been discharged was responsible for some of the damage, but maintenance was unable to keep up with the repairs. The administrator confirmed that a resident should not have been placed in a room requiring repairs.
Failure to Maintain Resident Dignity and Privacy
Penalty
Summary
The facility failed to ensure residents were treated with respect and dignity, as evidenced by an incident involving a Certified Nursing Assistant (CNA) who was observed yelling loudly in the presence of residents during a smoke break. The CNA, who had worked 78 hours in the past week, was venting her frustrations to the residents, which made them uncomfortable. This behavior was confirmed by interviews with the CNA and two residents who witnessed the outburst. The Director of Nursing (DON) and the Administrator acknowledged that such interactions were not appropriate or respectful. Additionally, the facility did not maintain the dignity of residents with indwelling urinary catheters by failing to cover the drainage bags. Resident #68, who had a suprapubic catheter, was observed multiple times with an uncovered urinary drainage bag, visible from the doorway. This was confirmed by a CNA who was unsure why the bag was not covered, despite the facility's policy requiring it to be covered for privacy. Resident #68 later confirmed that a staff member eventually provided a cover for the bag, which he appreciated. Similarly, Resident #41, who also had an indwelling urinary catheter, was observed with an uncovered drainage bag on several occasions. The resident expressed a preference for the bag to be covered, especially when in public areas, to prevent it from getting caught in the wheelchair wheels. The facility's policy mandates that urinary drainage bags be covered to maintain residents' dignity, but this was not consistently followed, as confirmed by interviews with nursing staff and the DON.
Failure to Notify of Positive COVID-19 Results
Penalty
Summary
The facility failed to notify the residents' representatives and physicians of positive COVID-19 test results for three residents, which was identified during a review of infection control practices. Resident #23, who had paranoid schizophrenia, depression, and asthma, tested positive for COVID-19 during routine weekly testing. Despite this, there was no documentation in the medical record of the positive test result, nor was there any notification to the resident's guardian or physician. Similarly, Resident #76, with diagnoses including traumatic brain injury and schizophrenia, also tested positive for COVID-19, but the facility did not document the result in the medical record or notify the guardian or physician. Additionally, Resident #53, who had dementia and chronic atrial fibrillation and was under hospice care, tested positive for COVID-19. The facility again failed to document the positive test result in the medical record and did not notify the resident's guardian or physician. An interview with the Assistant Director of Nursing and Infection Preventionist confirmed the lack of documentation and notification for all three residents. The facility's policy on status change in resident condition requires prompt notification of the resident, attending physician, and responsible party, which was not adhered to in these cases.
Failure to Ensure Proper Placement on Secure Unit
Penalty
Summary
The facility failed to ensure that residents met the criteria to be admitted to and reside on the secure unit, affecting one resident who was reviewed for involuntary seclusion. The resident, who had diagnoses including neuropathy, muscle weakness, lack of coordination, and anxiety, was admitted to the secure unit due to a lack of available beds elsewhere, despite having intact cognition and being assessed as a low elopement risk. The resident's care plan did not include any information related to the secure unit, and there were no physician orders or documentation justifying the placement on the secure unit. The resident was not informed of her ability to leave the secure unit or given the access code to do so, which was confirmed by both the resident and the Director of Nursing (DON). The DON acknowledged that the resident was placed on the secure unit due to bed availability and was not provided with the door code or informed of her right to leave the unit. This oversight resulted in the resident feeling as though the secure unit was akin to a prison, as she was not made aware of her autonomy to leave the unit at will.
Failure to Develop and Implement Comprehensive Care Plans
Penalty
Summary
The facility failed to develop and implement comprehensive care plans for two residents, leading to deficiencies in addressing their needs. Resident #72, who was admitted with conditions including a left femur fracture, COPD, muscle weakness, and pneumonia, had an incomplete care plan. The care plan lacked interventions for smoking, activities of daily living, medication or diagnosis-specific monitoring, discharge planning, and code status. Additionally, the resident exhibited behaviors such as following a female resident and making inappropriate comments, which were not addressed in the care plan. The MDS Coordinator acknowledged the oversight, attributing it to a high volume of admissions at the time. Resident #49, admitted with multiple diagnoses including hypertension, dementia, and bipolar disorder, was identified as a fall risk. Despite this, the care plan did not effectively implement interventions to prevent falls. The resident experienced multiple falls, and observations revealed the absence of non-skid strips, which were ordered by a physician to prevent sliding. The facility's policies on fall management and care planning were not adhered to, as evidenced by the lack of necessary interventions and incomplete care plans.
Failure to Accommodate Resident Food Preferences
Penalty
Summary
The facility failed to adhere to the food preferences of three residents, as observed during meal services. Resident #29 and Resident #62 were both supposed to receive ice cream with their lunch meal on 09/30/24, as indicated on their meal tickets. However, neither resident received ice cream because the facility was out of stock. This was confirmed by Dietary Aide #348 during an interview, who acknowledged the absence of ice cream and the failure to provide it to the residents as per their preferences. Additionally, Resident #80's meal ticket indicated a dislike for rice, yet rice was served to them during the lunch meal on 09/30/24. This was verified by both DA #348 and Dietary [NAME] #343. Furthermore, on 10/07/24, it was observed that Resident #80 did not like omelets and was not offered an alternative for breakfast, as the facility only provided alternatives for lunch and dinner. This lack of accommodation for Resident #80's preferences was confirmed by DC #344, who stated that the breakfast menu was set without alternatives.
Failure to Report Resident Elopement
Penalty
Summary
The facility failed to report a resident elopement to the state agency, which was a deficiency identified during the survey. Resident #69, who had diagnoses including paranoid schizophrenia, schizoaffective disorder, and chronic obstructive pulmonary disease, was residing in a secured unit due to his conditions, which included agitation and exit-seeking behaviors. Despite being at moderate to high risk for elopement, the resident managed to leave the facility on 09/15/24. The resident was later found and returned to the facility, showing no signs of distress but with an abrasion on the right forearm. He was placed under one-on-one supervision and sent to the hospital for evaluation. The incident was not reported to the state agency as required by the facility's policy. The LPN on duty realized the resident was missing when he did not show up for medication and notified the DON. However, the Administrator did not report the elopement to the state agency, believing it did not meet the criteria for reporting. The facility's policy mandates that all alleged violations, including elopements, be reported to the state agency within specified timeframes, which was not adhered to in this case.
Medication Administration Deficiency
Penalty
Summary
The facility failed to ensure medications were administered as ordered for Resident #291, who was admitted with diagnoses including alcoholic cirrhosis of the liver, suicidal ideations, and major depression. A telephone order from a nurse practitioner on 09/24/24 prescribed Prozac 10 mg daily for anxiety and depression, with a follow-up with psychiatric services. Later that day, a physician increased the Prozac dosage to 40 mg, but the order was not implemented until 09/30/24. The resident did not receive the increased dosage for six days, despite questioning the nursing staff about the delay. Interviews with the resident, the Director of Nursing, and LPN #327 confirmed the delay in administering the correct dosage of Prozac. The LPN acknowledged that the order for the increased dosage was misplaced on a clipboard and not entered into the system until 09/30/24. The facility's policy on medication administration, which mandates that medications be administered as prescribed, was not followed in this instance, leading to a lapse in the resident's treatment plan.
Failure to Monitor Therapeutic Drug Levels
Penalty
Summary
The facility failed to ensure timely laboratory testing to monitor therapeutic drug levels for psychotropic medications was completed as ordered for a resident with schizophrenia, drug-induced parkinsonism, and lack of coordination. The resident had orders for Lithium Carbonate and Divalproex Sodium, with specific instructions for regular monitoring of lithium and valproic acid levels. However, laboratory results from March and September indicated low lithium levels, and there was no evidence that these results were reported to the psychiatric provider. Additionally, the psychiatric progress notes did not reflect recent laboratory results, indicating a lapse in communication and monitoring. Interviews with facility staff revealed a lack of clarity and consistency in the process for ordering and communicating laboratory tests. An LPN was unsure of the procedure for lab testing, while the ADON confirmed that multiple laboratory tests for the resident's therapeutic drug level monitoring had been missed. The facility's policy required nurses to enter lab orders into the lab computer and report results to the physician or nurse practitioner, but this process was not followed, leading to the deficiency.
Failure to Provide Physician-Ordered Adaptive Equipment
Penalty
Summary
The facility failed to provide a resident with physician-ordered adaptive equipment for meals, specifically a handled cup for liquids. This deficiency affected a resident who had medical diagnoses including muscle weakness, lack of coordination, and neuropathy, which made it difficult for her to grasp cups and glasses. Despite a physician's order for a handled cup dated 07/22/24, observations on multiple occasions revealed that the resident did not have access to the handled cup during meals. Instead, she was provided with a styrofoam cup without a lid, which she found difficult to use due to her hand limitations. Interviews with the resident and staff confirmed the absence of the handled cup, and the resident expressed difficulty in drinking from the provided cups, sometimes resulting in spills. A CNA mentioned that the handled cup was supposed to come from the kitchen on meal trays, but it was not typically kept in the resident's room for use between meals. The Director of Nursing acknowledged that the facility did not have an order for providing adaptive equipment but stated that they would follow written physician's orders.
Failure to Document COVID-19 Positive Results and Notify Guardians
Penalty
Summary
The facility failed to ensure complete and accurate medical records for three residents who tested positive for COVID-19. Resident #23, diagnosed with paranoid schizophrenia, depression, and asthma, tested positive for COVID-19 during routine weekly testing. However, there was no documentation of this positive test result in the resident's medical record, nor was there any evidence that the resident's guardian or provider had been notified. Similarly, Resident #76, with diagnoses including traumatic brain injury, schizophrenia, and delusional disorder, also tested positive for COVID-19, but this was not documented in their medical record, and no notification was made to the guardian or provider. Additionally, Resident #53, who had dementia, chronic atrial fibrillation, and muscle weakness, and was under hospice care, tested positive for COVID-19. Like the other two residents, there was no documentation of the positive test result in the medical record, and no notification was made to the guardian or provider. The Assistant Director of Nursing and Infection Preventionist confirmed the lack of documentation and notification for all three residents. The facility's policy required licensed nurses to record any changes in a resident's medical condition or status, which was not adhered to in these cases.
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Surveyors found that multiple hazardous storage areas, including a closet near medical records, a beauty salon used to store chemical cases, a supply room in one nursing station, a room leading to a smoking area, a housekeeping room near therapy, and a lobby storage room, lacked required self-closing or automatic-closing doors. These conditions did not comply with NFPA 101 requirements for hazardous area enclosure and had the potential to affect all residents and staff in an emergency.
Surveyors found that the facility did not conduct fire drills on every shift each quarter and did not vary drill conditions as required by NFPA 101. Record review showed that one shift lacked a documented drill for an entire quarter, and the pattern of drill times and dates did not demonstrate varied conditions. The Maintenance Director confirmed the incomplete and noncompliant fire drill schedule, which affected all residents and staff emergency preparedness.
Surveyors found that the facility did not maintain clear egress corridors as required by NFPA 101, with a TV/video cart plugged into a corridor outlet and multiple unsecured chairs placed in the hallway near resident rooms and the secured unit dining room, including directly in front of a fire extinguisher. These items projected about 29 inches into an approximately eight-foot-wide corridor and were located in front of the handrail, potentially affecting 28 residents and staff’s ability to assist in an emergency. The Maintenance Director confirmed these corridor obstructions during the survey.
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.
The facility failed to maintain accurate and complete crash cart audits for multiple full-code residents. Surveyors, accompanied by the DON, found that daily crash cart checks did not include verification of supply expiration dates, and that an extension cord documented as present on several audit dates was not actually in the cart. Audit logs also conflicted with the cart’s contents by indicating that required items such as eye protection, saline, and clear plastic were present when they were not. These findings were inconsistent with the facility’s policy requiring the crash cart to be checked every 24 hours and after each use, with prompt replacement of equipment and supplies.
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.
Failure to Maintain Self-Closing Doors for Multiple Hazardous Storage Areas
Penalty
Summary
Surveyors identified a deficiency related to hazardous area protection and door requirements under NFPA 101, 2012 Edition. During facility tours, they observed that multiple hazardous storage areas did not have self-closing or automatic-closing doors as required for hazardous areas such as combustible storage and chemical storage. These areas included a closet next to medical records, a beauty salon being used to store cases of chemicals, a supply room in Station #2, and the room leading to the smoking area in Station #3. On a subsequent tour, surveyors observed additional hazardous areas without self-closing doors. The housekeeping room across from therapy and the lobby storage room were both noted to lack self-closing door mechanisms. The facility census at the time was 59 residents, and the surveyors stated that this deficient practice had the potential to affect all residents and staff's ability to assist in an emergency. The Maintenance Director verified these findings at the time they were observed.
Plan Of Correction
K 0321 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 admissible 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 06/12/2026 K-0321 Doors with Self-Closing Devices Corrective action for resident/s: 1. The closet door next to medical records was lacking a self-closing door on 5/19/2026. Maintenance director to add self-closing device to closet door next to medical records on or before 06/12/2026 in accordance with applicable code. 2. The beauty salon had chemicals stored in it on 5/19/2026. Maintenance director moved chemicals from beauty salon on 05/20/2026 in accordance with applicable code. 3. The supply room on station 2 was lacking a self-closing door on 5/19/2026. Maintenance director to add self-closing door to supply room on station 2 on or before 06/12/2026 in accordance with applicable code. 4. The room to the smoking area on station 3 was lacking a self-closing door on 5/19/2026. Maintenance director to add a self-closing door to the smoking are on station 3 on or before 06/12/2026 in accordance with applicable code. 4. The housekeeping room across from therapy was lacking a self-closing door on 5/19/2026. Maintenance director to add a self-closing door to the housekeeping room across from therapy gym on or before 06/12/2026 in accordance with applicable code. 5. The lobby storage room was lacking a self-closing door on 5/19/2026. Maintenance director to add a self-closing door to the lobby storage room on or before 06/12/2026 in accordance with applicable code. Identification of other residents who may be affected: LNHA and Maintenance director/designee completed a full facility audit for doors with self-closing devices on 05/26/2026. Any corrective action, including, doors identified as needing self-closures will be added on or before 06/09/2026 in accordance with applicable code. Measures for systemic change: LNHA educated Maintenance Director on 05/26/2026 regarding NFPA 101-2012 sections 19.3.2.1 and 19.3.5.9 specifically regarding doors with self-closing devices. How Corrective Action will be monitored Ongoing "Doors with Self-Closing device audit" to be completed weekly x 2 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 06/12/2026
Failure to Conduct Required Quarterly Fire Drills on All Shifts
Penalty
Summary
The facility failed to conduct fire drills in accordance with NFPA 101, 2012 Edition, sections 19.7.1 through 19.7.1.8, specifically by not holding drills every shift each quarter and not varying drill conditions as required. Record review on 06/09/25 at approximately 10:32 A.M. showed there was no fire drill conducted for the first shift during the third quarter. The documented first-shift fire drills occurred on 01/30/26 at 2:42 P.M., 04/30/26 at 1:51 P.M., and 10/31/25 at 10:58 A.M., indicating a missed quarter. Second-shift fire drills were recorded on 02/26/26 at 5:20 P.M., 06/03/25 at 4:35 P.M., 08/29/25 at 3:46 P.M., and 11/25/25 at 5:09 P.M., and third-shift drills on 02/28/26 at 11:47 P.M., 05/30/25 at 12:18 A.M., 07/22/25 at 11:34 P.M., 09/26/25 at 11:40 P.M., and 12/15/25 at 5:17 A.M. The surveyor determined that drills were not conducted under varied conditions and that the required quarterly drill on each shift was not consistently performed. The Maintenance Director confirmed these findings at the time they were identified, and the deficiency had the potential to affect all 59 residents and staff response in an emergency. No specific residents, medical histories, or clinical conditions were described in the report; the deficiency related to facility-wide emergency preparedness practices and documentation of fire drills.
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 05/29/2026 K-0712 Fire Drills Corrective action for resident/s: There were no records of a fire drill for the first shift of the third quarter of 2025. First shift fire drill completed on 5/24/2026 by maintenance director/designee with no findings or corrective action necessary. Identification of other residents who may be affected: On 5/26/2026 Maintenance director/designee completed 100% audit of the scheduled fire drills to ensure a drill is scheduled quarterly each shift with no findings or corrective action necessary. Measures for systemic change: LNHA educated Maintenance Director on 05/26/2026 regarding NFPA 101-2012 section 19.7.1.4 through 19.7.1.7. specifically including fire drill frequency requirements. How Corrective Action will be monitored Ongoing "Fire Drill Audit" to be completed weekly x 2 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 05/29/2026
Obstructed Egress Corridors Due to Equipment and Chairs
Penalty
Summary
The facility failed to maintain required clear egress widths in corridors in accordance with NFPA 101, 2012 Edition, sections 19.2.3.4 through 19.2.3.5 and 7.3.2 through 7.3.2.3, creating projections into the egress corridor that exceeded allowable limits. Surveyors observed that on one day in Station #3, a cart with a television and video equipment was plugged into an outlet in the corridor by room 38, and five activity room chairs were placed in the corridor near the secured unit dining room directly in front of a fire extinguisher. On the following day, surveyors again observed chairs in the Station #3 corridor, with four by room 35 and four by the activities room, and the same television cart still in the corridor; the chairs were not secured. The corridor was approximately eight feet wide, and the projections extended approximately 29 inches into the corridor in front of the handrail. These conditions had the potential to affect 28 residents in the facility and the staff’s ability to assist in an emergency, and the Maintenance Director confirmed the observations at the time of discovery. No specific resident medical histories or conditions were described in the report, only that 28 residents were potentially affected and the facility census was 59.
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 subsequent remedial measures and 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 05/29/2026 K-0232 Clear path of egress Corrective action for resident/s: 1. On 05/18/2026 station 3 had a cart with a television parked in the corridor by room 38 that exceeded allowable limits. Maintenance director/designee moved the TV cart into the activity room, out to the corridor on 05/18/2026 in accordance with applicable code. 2. On 5/18/2026 station 3 had 5 chairs in the corridor near the dining room directly in front of the fire extinguisher. Maintenance director/designee moved the chairs into the dining room, out of the corridor on 5/18/2026 in accordance with applicable code. 3. On 5/19/2026 station 3 had 4 chairs by the activity room and 4 by room 35. In addition, the TV cart was in the corridor. The maintenance director/designee moved the chairs and TV cart into the dining room, out of the corridor on 5/19/2026 in accordance with applicable code. Identification of other residents who may be affected: Maintenance director/designee completed a 100% facility audit for clear paths of egress on 5/26/26 with no findings or corrective action necessary. Measures for systemic change: Maintenance Director/designee educated staff on 5/26/2026 regarding NFPA 101-2012 section 19.2.3.4 and 19.2.3.5 specifically including maintaining a clear path of egress. How Corrective Action will be monitored Ongoing "Path of Egress Audit" to be completed weekly x 2 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 05/29/2026
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
Inaccurate Crash Cart Audits and Missing Emergency Equipment
Penalty
Summary
The facility failed to ensure accurate and complete crash cart audits for residents requiring basic life support, affecting eighteen of thirty-five residents who were designated as full code. During an observation of the crash cart with the DON, surveyors found that the daily audit documentation for the month did not include verification of expiration dates for crash cart supplies. Review of the crash cart audit logs showed that an extension cord was documented as being in the cart on multiple dates, but the extension cord was not present in the cart at the time of inspection. Additionally, the audit documentation indicated that required items, including eye protection, saline, and clear plastic, were not present in the crash cart, yet they were documented as being in the cart. The facility’s undated “Emergency Crash Cart” policy stated that the crash cart is to be checked every 24 hours and after every use, and that equipment and supplies are to be noted and replaced promptly, but the observed documentation and contents of the cart did not match these requirements. This deficiency was verified with the DON at the time of the survey and was cited under the requirement that personnel provide basic life support, including CPR, to residents requiring emergency care, subject to physician orders and advance directives, and was investigated under Complaint Number 2687380.
Plan Of Correction
Cridersville Care Center Provider Number:366171 Survey Type: Complaint Survey Survey Date: 04/29/26 This Plan of Correction (PoC) outlines the actions completed by the facility with regards to the deficiency citation. This Plan of correction does not constitute any admission of guilt or liability by the facility and is submitted only in response to the regulatory requirements. Please accept the following as the facility's credible allegation of compliance as of 4/30/26. F678 CPR All Full Code residents #18 have the potential to be affected by the alleged deficiency. On 4/27/26 the DON/ADON re-stocked the crash cart per the inventory sheet for all missing items. Crash cart inventory sheet updated and new one will go into effect on 5/1/26. All licensed nursing staff provided with training related to crash cart inventory being a daily audit review using inventory sheet on 4/27/26 per DON/designee. The DON/designee will conduct clinical rounds and conduct a random audit of crash cart three times per week for 4 (four) weeks to ensure compliance. The results of the audit will be documented. The facility conducted an Ad-Hoc QAPI meeting on 4/27/26 and discussed the alleged deficiency and corrective actions. Date when corrective action will be completed: 4/30/26
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.
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