Vista Center Of Boardman
Inspection history, citations, penalties and survey trends for this long-term care facility in Boardman, Ohio.
- Location
- 830 Boardman Canfield Rd, Boardman, Ohio 44512
- CMS Provider Number
- 365760
- Inspections on file
- 23
- Latest survey
- February 19, 2026
- Citations (last 12 mo.)
- 18
Citation history
Health deficiencies cited at Vista Center Of Boardman during CMS and state inspections, most recent first.
The facility did not establish or maintain an infection prevention and control program as required, resulting in a deficiency identified by surveyors.
The facility did not have an RN present for eight consecutive hours on one day, despite meeting overall direct care staffing requirements. This lapse in RN coverage was confirmed by the Human Resources Manager and had the potential to affect all residents.
The facility did not report or thoroughly investigate multiple allegations of resident-to-resident abuse, including an incident where a resident with cognitive impairment sustained facial burns from hot coffee thrown by another resident, and another case involving verbal and alleged physical abuse between roommates. Staff and administration confirmed these incidents were not reported to the state agency, and responsible parties were not notified, contrary to facility policy.
The facility did not thoroughly investigate or report multiple allegations of resident-to-resident abuse, including an incident where a resident sustained facial burns from hot coffee thrown by another resident and another case involving verbal and alleged physical abuse between roommates. Staff failed to notify responsible parties and relied solely on resident statements, even when cognitive impairment was present, contrary to facility policy requiring thorough investigation and reporting.
A pest control deficiency was identified when bed bugs were found in several resident rooms and common areas on a secured unit. Staff and an LPN reported discovering bed bugs about a week before treatment was initiated, and pest control services confirmed only chemical treatment had been performed, with no heat treatment completed. The infestation affected multiple residents and required disposal of infested furniture.
Multiple residents who were dependent on staff for ADLs did not receive timely incontinence care or scheduled showers as required by their care plans and facility policy. Staff failed to provide incontinence care every two hours for a resident with severe cognitive impairment, did not use proper PPE, and did not maintain proper hygiene during care. Several residents missed numerous scheduled showers, with staff and residents confirming that showers were often skipped due to time constraints, and complaints were received from residents and families.
Two CNAs provided incontinence care to a resident on Enhanced Barrier Precautions without wearing the required gown and gloves, despite clear signage and available PPE, in violation of facility policy for infection control.
The facility failed to provide scheduled therapeutic activities, particularly during weekends and evenings, affecting all residents. Observations and interviews revealed a lack of activities after 3:00 P.M. for Secure Unit A and after 4:00 P.M. for Unit B/C, with understaffing and reliance on a counseling service not responsible for activities. Residents expressed boredom, and scheduled activities were not conducted due to staff shortages and lack of materials.
The facility did not have a qualified Activity Director overseeing the activity department, affecting all 50 residents. The former Activity Director's file lacked necessary certification, and the facility relied on [NAME] Counseling staff, who were not certified in activities, to provide activities. The facility's policy required an Activities Director to plan and organize activities, but this was not being met.
The facility did not ensure that each STNA received the required twelve hours of annual in-service education, affecting all residents. A review of a personnel file revealed that an STNA hired in 2022 had completed only one training session on corporate compliance, with zero hours of training out of 20.83 assigned. Various trainings were assigned but not attempted. The HR Manager confirmed the lack of completed training and did not have a policy for in-service training.
The facility did not ensure the dietary manager was qualified, affecting meal services for 50 residents. The manager, promoted from a cook position, lacked formal training and certification. A dietitian was only present part-time, focusing on clinical work rather than kitchen oversight. The administrator confirmed the manager's lack of qualifications.
The facility failed to serve food at a palatable and safe temperature, affecting residents' meal satisfaction. Observations and interviews revealed that food temperatures dropped significantly by the time meals were served, leading to complaints about cold and unappetizing food. The facility lacked a policy on food palatability, and the issue had the potential to affect all residents receiving meals.
The facility failed to maintain proper food storage and sanitation standards, as observed during a kitchen inspection. Issues included improperly stored and labeled food items, dirty utensils, and unsanitary conditions in the kitchen and storage areas. These deficiencies were verified by the dietary manager, indicating non-compliance with food safety policies.
The facility failed to manage resources effectively, impacting resident care. QAPI meetings lacked required medical director attendance, and no evidence of meetings existed before April 2024. The facility lacked a certified Activities Director, relying on uncertified external counselors for activities, leading to insufficient resident engagement, especially on weekends and after 3:00 P.M.
The facility did not conduct quarterly QAPI meetings and failed to ensure the medical director's participation. Attendance records showed the medical director was absent from meetings held from April to September 2024, and there was no evidence of meetings before April 2024. The Administrator confirmed these deficiencies, potentially affecting all 50 residents.
The facility failed to follow Enhanced Barrier Precautions for a resident with a gastric tube, as a CNA did not wear a gown during incontinence care. Additionally, the facility did not complete annual TB screenings for several employees, as required by their policy. These deficiencies had the potential to affect all 50 residents.
The facility did not maintain a safe and comfortable environment, as evidenced by a resident's bed with a broken side rail, an open corroded hole in the ceiling, sharp edges in the 100 hall, exposed sharp wall pieces, and an unsecured floor strip creating a tripping hazard. These issues were confirmed by the Maintenance Director.
The facility failed to maintain a surety bond sufficient to cover all resident personal funds, affecting 20 residents. The total amount in resident fund accounts exceeded the bond amount, which was initially set at $20,000 and later adjusted to $120,000. Facility policy required the bond to match the total resident funds.
A facility failed to ensure consistent documentation of a resident's advance directives, leading to a discrepancy between the resident's DNR Comfort Care status and their expressed wish to be Full Code. Despite the resident's clear communication and updated physician orders, the outdated DNR form remained in the electronic record, causing confusion among staff about which code status to follow. Interviews revealed a lack of clear policy and training on verifying code status, potentially affecting all residents.
A resident with a history of aggression threw hot coffee on his roommate, who was unable to move independently, causing the roommate to feel scared and perceive the incident as abusive. The facility failed to report this resident-to-resident abuse to the state agency within the required 24-hour timeframe, as the Administrator did not initially view the incident as abuse.
The facility failed to ensure accurate care plans for two residents, affecting potential care for all 50 residents. One resident's care plan omitted Depakote medication and inaccurately listed their code status. Another resident lacked a care plan for anti-coagulant therapy despite being on such medication and refusing lab work. These deficiencies were confirmed by facility staff and violated the facility's care planning policy.
The facility failed to ensure timely and accurate care plans for two residents, affecting their discharge plans and care status. One resident's care plan was not updated to reflect a change from short-term to LTC, and another's care plan inaccurately indicated a discharge home despite being LTC. Staffing changes and lack of adherence to facility policy contributed to these deficiencies.
A resident with hemiplegia and hemiparesis, requiring assistance for oral hygiene, did not receive oral care since admission, as confirmed by observations and interviews. Despite a physician's order for oral care every shift, the resident's teeth showed food and plaque buildup, and no oral care supplies were found in the room. The DON was informed of the deficiency, which contradicted the facility's policy to provide personal care according to the resident's plan.
The facility failed to ensure timely and accurate weight monitoring for residents, leading to deficiencies in nutritional health management. A resident with PTSD and bipolar disorder had inconsistent weight records, with no weight recorded for a month and an inaccurate weight noted later. Another resident with pulmonary disease experienced significant weight loss without proper reweighing, and a third resident with chronic bronchitis had fluctuating weights due to edema, with no reweighs conducted. The facility did not adhere to its policy requiring monthly weights and reweighs for significant variances.
A facility failed to provide trauma-informed care for a resident with PTSD, bipolar disorder, and major depression. Despite the resident's identified trauma triggers, there was no care plan or staff training to manage these issues. Interviews revealed staff were unaware of the resident's PTSD and potential triggers, and observations showed the resident exhibited behaviors like pacing and verbal aggression. The facility's policy required care planning and staff education, which were not implemented.
The facility failed to conduct an AIMS test for a resident on Olanzapine and did not monitor Depakote levels for another resident. Despite policy requirements, the AIMS test was not performed for a resident with severe psychotic symptoms, and no lab orders were in place for monitoring Depakote levels in a resident with dementia. The DON confirmed these oversights, indicating a lack of adherence to monitoring protocols.
Failure to Implement Infection Prevention and Control Program
Penalty
Summary
The facility failed to provide and implement an infection prevention and control program. This deficiency was identified during the survey process, indicating that the required measures to prevent and control infections were not established or maintained as per regulatory standards. The report notes the absence of a comprehensive infection prevention and control program but does not provide further details regarding specific actions, inactions, or events, nor does it mention any particular residents or staff involved.
Failure to Provide Required RN Coverage
Penalty
Summary
The facility failed to ensure that a Registered Nurse (RN) was present in the facility for eight consecutive hours on a specific day, as required by regulations. Record review of the nursing services staffing schedule and staffing tool for the period of 06/22/25 to 06/27/25 showed that, although the facility met or exceeded the minimum staffing requirement of 2.5 hours of direct care per resident per day, there was no RN on staff for eight consecutive hours on 06/25/25. During an interview, the Human Resources Manager confirmed that the facility was staffed based on acuity and census numbers, with one nurse and one aide per unit, and acknowledged that the required RN coverage was not met on the identified day. The Director of Nursing (DON) was full-time, but the facility did not have an RN present for the required duration on that day. This deficiency was identified during the investigation of a specific complaint and had the potential to affect all residents in the facility.
Failure to Report and Investigate Allegations of Abuse
Penalty
Summary
The facility failed to ensure that all allegations of abuse were reported to the state agency as required, affecting four residents out of five reviewed for abuse. In one incident, a resident with impaired cognition sustained facial burns after another resident threw coffee at him. The incident was documented in the medical record, and the resident was treated with Silvadene cream, but there was no documentation regarding how the burns occurred, and the event was not reported to the state agency. Interviews with staff and administration confirmed that the incident was not reported, and the responsible parties for the injured resident were not notified. Another incident involved a resident being verbally abused and allegedly hit by his roommate. Staff observed verbal abuse and were informed by a visitor about physical abuse. The staff assessed the resident and questioned both parties, but when both denied the incident, no further investigation was conducted, and the event was not reported to the state agency. The administration acknowledged that the resident who was allegedly abused had cognitive impairment and that further investigation and reporting should have occurred. Review of facility policy indicated that all allegations of abuse, neglect, or misappropriation should be reported to the state agency and thoroughly investigated. However, the facility did not submit self-reported incidents for these events and did not conduct thorough investigations as required by policy. This deficiency was identified during the investigation of a specific complaint.
Failure to Investigate and Report Allegations of Abuse
Penalty
Summary
The facility failed to ensure that all allegations of abuse were thoroughly investigated and reported as required. In one incident, a resident with impaired cognition sustained facial burns after another resident threw coffee at him. The incident was documented in the medical record, and the resident was treated with Silvadene cream, but there was no documentation regarding how the burns occurred. The event was not reported to the state agency, and the responsible parties were not notified. Interviews with staff confirmed that the incident was not thoroughly investigated or reported as required by facility policy. Another incident involved a resident being verbally abused and allegedly hit by his roommate. Staff observed verbal abuse and were later informed by a visitor that physical abuse may have occurred. The staff assessed the resident and questioned both parties, but when both denied the incident, no further investigation was conducted, and the event was not reported to the state agency. The resident who was allegedly abused had severely impaired cognition, which was not taken into account during the investigation. Review of facility policy indicated that all allegations of abuse should be reported and thoroughly investigated. However, in these cases, the facility did not follow its own policy, as multiple incidents involving resident-to-resident abuse were neither reported to the state agency nor thoroughly investigated. This deficiency affected four residents out of five reviewed for abuse, as documented in the survey findings.
Failure to Maintain Effective Pest Control Program Resulting in Bed Bug Infestation
Penalty
Summary
The facility failed to maintain an effective pest control program, resulting in the presence of bed bugs in multiple resident rooms and common areas on the secured A unit. Observations confirmed bed bugs in the rooms of several residents, and interviews with staff revealed that bed bugs had been found approximately one week prior to treatment. Staff reported capturing bed bugs, notifying maintenance and the DON, and following internal procedures such as bagging resident clothing and cleaning affected areas. However, treatment for the infestation was not initiated until the day of the survey, despite earlier detection. Further interviews indicated that bed bugs were also found on a staff member and in the dining/lounge area, leading to the disposal of infested furniture. The pest control contractor confirmed that only a chemical treatment was performed, and no heat treatment, which was identified as necessary to stop the infestation, had been completed at the time of the survey. The deficiency affected 19 residents on the secured unit and was identified during the investigation of specific complaint numbers.
Failure to Provide Timely Incontinence Care and Scheduled Showers
Penalty
Summary
The facility failed to provide timely incontinence care and scheduled showers for multiple residents who were dependent on staff for activities of daily living (ADLs). One resident with severe cognitive impairment and total dependence for ADLs was found to have not received incontinence care for three and a half hours, despite care plans requiring assistance every two hours and as needed. During observation, staff did not use required personal protective equipment (PPE) while providing care, and soiled wipes were placed on the resident's bed instead of being disposed of properly. The resident was found to be soaked through their brief and incontinence pad, with a strong odor of urine present, and the fitted sheet was not changed after contamination. Several residents did not receive showers according to their scheduled frequency. One resident, dependent on staff for showers and other ADLs, received only six out of thirty scheduled showers. Another resident, also dependent on staff for personal care and showers, received only one shower in February, eight in March, and seven in April, despite being scheduled for three showers per week. Two additional residents received only two and four showers, respectively, out of seventeen scheduled sessions. Documentation confirmed these missed showers, and interviews with staff and residents corroborated that showers were often not completed as scheduled, with some residents and families voicing complaints. Facility policy required that residents be interviewed about their bathing preferences upon admission and that these preferences be reviewed quarterly. Staff were expected to assist with daily hygiene and showers per policy. However, interviews with CNAs, LPNs, and RNs revealed that showers were frequently missed due to time constraints, and staff only completed assigned showers if time allowed. The facility's leadership confirmed the discrepancies in shower provision and acknowledged the lack of documentation for missed showers.
Failure to Follow Enhanced Barrier Precautions During Incontinence Care
Penalty
Summary
The facility failed to ensure effective infection control techniques were practiced during incontinence care for a resident who was under Enhanced Barrier Precautions (EBP). The resident, who had multiple diagnoses including epilepsy, muscle weakness, hemiplegia, aphasia, and was dependent on staff for all activities of daily living, was ordered to be on EBP due to wounds and the presence of a PEG tube. Facility policy required staff to wear gowns and gloves during high-contact care activities for residents on EBP, with proper signage and PPE available in the resident's room. During an observation, two CNAs provided incontinence care to the resident without donning the required gown and gloves, despite being aware of the EBP status, signage, and availability of PPE. Both CNAs confirmed in interviews that they should have worn the appropriate PPE but did not do so. Review of facility policy confirmed the requirement for gown and glove use during such care activities for residents on EBP.
Failure to Provide Scheduled Therapeutic Activities
Penalty
Summary
The facility failed to provide therapeutic activities as scheduled, particularly during weekends and evenings, affecting all 50 residents. Observations and interviews revealed that no activities were scheduled after 3:00 P.M. for Secure Unit A in October and after 4:00 P.M. in September. Unit B/C had no activities scheduled after 3:00 P.M., except on Wednesdays. The activity department was understaffed, with no activity aid scheduled on several days in September and October. The former Activities Director and an Activities Aid had left, and the facility was relying on a counseling service that was not responsible for activities. Interviews with residents and staff highlighted the lack of activities, with residents expressing boredom and a lack of engagement. The Director of Nursing confirmed the absence of an Activity Director and the reliance on a counseling service for activities. Observations showed that scheduled activities were not conducted, with residents left unattended or watching television without engagement. Staff shortages further hindered the ability to provide planned activities, and necessary materials for activities were not available. The facility's policy required the Activities Director to plan and organize activities to meet residents' interests and preferences. However, the absence of a qualified Activities Director and insufficient staffing led to a failure in implementing the policy. The facility did not notify residents of changes in the activity schedule or offer alternatives, contributing to the deficiency in meeting residents' needs for therapeutic activities.
Lack of Qualified Activity Director
Penalty
Summary
The facility failed to ensure that a qualified Activity Director was overseeing the activity department, affecting all 50 residents. The job description for the Activity Director required a qualified therapeutic recreation specialist or an activities professional licensed by the state and eligible for certification. However, the personnel file for the former Activity Director, who was hired on 05/16/23 and last worked on 09/16/24, lacked certification from the Activity Directors Network. Interviews revealed that there had been no Activity Director for the past month, and the facility was relying on a social worker and two counselors from [NAME] Counseling to provide activities, despite them not being certified in activities. The Behavioral Health Service Agreement with [NAME] Counseling did not include responsibility for ensuring activities were provided to residents. Interviews with [NAME] Counseling staff confirmed that they were not the activities department and were only providing activities as part of their counseling sessions. The facility had only one activity aid who worked every other weekend, and nursing staff were tasked with providing activities on weekends when the aid was not present. The facility's policy stated that the Activities Director should plan and organize activities to meet residents' interests and preferences, but this was not being fulfilled due to the lack of a qualified director.
Failure to Ensure Required Annual In-Service Education for STNAs
Penalty
Summary
The facility failed to ensure that each state tested nurse aide (STNA) received the required twelve hours of annual in-service education, potentially affecting all residents in the facility with a census of 50. A review of the personnel file for STNA #551, who was hired on 02/02/22, revealed that she had completed only one training session on corporate compliance on 06/04/24. This training did not specify its duration, and the report indicated that STNA #551 had zero hours of training out of the 20.83 hours assigned. The training record showed that she was assigned various trainings, including abuse, dementia care, infection control, fall management, fire safety, resident rights, and elopement prevention, but these were marked as not attempted. An interview with Human Resource Manager #525 confirmed that STNA #551 had not completed the required annual training. The HR Manager acknowledged that she assigns the training but cannot compel the aides to complete it, as evidenced by the report sheet showing uncompleted trainings. Additionally, the HR Manager did not have a policy regarding in-service training for STNAs.
Unqualified Dietary Manager in Facility
Penalty
Summary
The facility failed to ensure that the dietary manager was qualified to oversee dietary service operations, potentially affecting all 50 residents receiving meals from the kitchen. The dietary manager, who was promoted from a cook position in May 2024, lacked formal certified dietary manager training and had not completed the SERV Safe course. Interviews revealed that there was no full-time dietitian on-site, with a dietitian only scheduled to be present one day a week for six hours and two hours remotely, focusing on clinical work rather than kitchen oversight. The facility's administrator confirmed that the dietary manager did not meet the required qualifications for the position and was not certified, although efforts were being made to obtain certification.
Deficiency in Food Temperature and Palatability
Penalty
Summary
The facility failed to ensure that food served to residents was palatable, attractive, and at a safe and appetizing temperature. This deficiency was observed during interviews and a test tray observation. Resident #15 reported that if his tray was served last, the food was often cold, which affected the quality and nourishment of the meals. Resident #196 also expressed dissatisfaction with the taste and temperature of the food, leading his family to bring in outside food. An observation of the lunch tray line revealed that while the starting temperatures of the food were within safe limits, by the time the food was served, the temperatures had dropped significantly, rendering the food lukewarm and unpalatable. The test tray observation conducted with the Dietary Manager showed that the food temperatures had fallen into the danger zone for bacterial growth, as defined by the 2013 Federal Food Code. The facility did not provide a policy related to the palatability of food, and interviews with residents and a registered nurse confirmed that complaints about cold food were common. The facility census was 50, and the deficiency had the potential to affect all residents receiving meals from the facility kitchen.
Food Storage and Sanitation Deficiencies
Penalty
Summary
The facility failed to ensure that food was stored and handled in a manner that prevents contamination and foodborne illness, as observed during a kitchen inspection. During the initial tour, dried noodles and chicken were found in the empty wash bay of a three-bay sink, and noodles and white beans were observed in the dishwasher drain. The dry storage area contained dented cans of food, an opened and undated bag of pancake mix, and a case of bananas placed directly on the floor. Additionally, a plastic drawer under the preparation counter was found to contain dirty utensils, and the walk-in refrigerator had an unwrapped piece of cake. The walk-in freezer had ice buildup on the floor and icicles hanging from the fan. A black substance was noted on a paper towel after wiping the ice distribution area of the ice machine. A follow-up observation revealed further issues, including opened, undated, and unlabeled garlic bread slices and mini meatballs in the freezer, as well as an opened and unlabeled 50-pound bag of rice in the dry storage area. The facility's policies on food storage and safety, which require proper labeling, dating, and storage of food items, were not adhered to. These deficiencies were verified by the dietary manager during the observations, indicating a lack of compliance with established food safety and sanitation standards.
Deficiency in Resource Management and Activity Program
Penalty
Summary
The facility failed to administer its resources effectively and efficiently, impacting the quality of care for its residents. The Quality Assurance Performance Improvement (QAPI) committee meetings were not conducted with the required attendance of the medical director or a designee, and there was no evidence of such meetings prior to April 2024. This lack of oversight and documentation was confirmed by the Administrator, who assumed the position in April 2024. Additionally, the facility did not employ a qualified director of activities, as the former Activities Director was not certified, and there was no Activities Director for the past month. The facility relied on a social worker and counselors from an external counseling service to provide activities, but these individuals were not certified in activities and did not work on weekends or past 4:00 P.M. This resulted in a lack of structured activities for residents, particularly on weekends and after 3:00 P.M. on weekdays. Observations and interviews revealed that scheduled activities were not being conducted as planned. Residents reported a lack of engagement and boredom due to the absence of activities, and staff confirmed that activities were not always provided due to staffing shortages. The activity calendars showed no scheduled activities after certain hours, and observations confirmed that planned activities were not taking place, with residents left unengaged and without the necessary resources to participate in scheduled activities.
Failure to Conduct QAPI Meetings and Ensure Medical Director Participation
Penalty
Summary
The facility failed to conduct quarterly Quality Assurance Performance Improvement (QAPI) meetings and did not ensure the participation of the designated medical director in these meetings. This deficiency was identified through a review of attendance signature sheets, which showed that the medical director was not present at any of the QAPI meetings held on several dates from April to September 2024. Additionally, there was no evidence of any QAPI meetings being conducted prior to April 2024. An interview with the Administrator confirmed the absence of the medical director's attendance and the lack of QAPI meetings before April 2024, when the current Administrator assumed her role. This failure had the potential to affect all residents, with the facility census being 50.
Infection Control and TB Screening Deficiencies
Penalty
Summary
The facility failed to adhere to Enhanced Barrier Precautions (EBP) for a resident identified as being at risk for infection due to the presence of a gastric tube and total parenteral nutrition (TPN). During an observation, a Certified Nurse Assistant (CNA) provided incontinence care to the resident without wearing a gown, despite the facility's policy requiring gown and glove use during high-contact resident care activities. This was confirmed by both the CNA and the infection control nurse, who acknowledged that the resident was on EBP and that a gown should have been worn. Additionally, the facility did not complete annual tuberculosis (TB) signs and symptoms screenings for several employees as required by their TB risk assessment and policy. Personnel files for a State Tested Nursing Assistant (STNA) and a Licensed Practical Nurse (LPN) revealed that annual TB screenings were not conducted within the last year. Interviews with the Human Resource (HR) Manager and the Director of Nursing confirmed the absence of these screenings, despite the facility's policy stating that employees should receive annual TB screenings. The facility's failure to implement these infection prevention and control measures had the potential to affect all 50 residents. The facility's TB risk assessment indicated a low risk for TB, yet it required baseline skin testing and annual symptom screenings for healthcare workers. The HR Manager admitted to not tracking or completing these screenings, and the Director of Nursing assumed HR was responsible for them, indicating a lack of clarity in roles and responsibilities regarding TB screening compliance.
Unsafe and Uncomfortable Environment in Facility
Penalty
Summary
The facility failed to ensure a safe, functional, and comfortable environment for all residents, as observed during a survey. A resident's bed had a side rail that was breaking off and could be pulled away from the bed, posing a safety risk. Additionally, a corroded hole in the ceiling of the 100 hall was left open due to water leakage from the roof, which the Maintenance Director acknowledged but lacked materials to repair. This hole was large enough to allow potential pests to enter resident-occupied areas. Furthermore, the 100 hall had a hole with sharp edges that could cause injury to residents passing by, and a ripped corner molding in the transition from C hall to B hall exposed a sharp piece of the wall. Lastly, a floor strip leading into a resident's room was not secured, creating a tripping hazard. These deficiencies were verified by the Maintenance Director during the observation.
Inadequate Surety Bond for Resident Funds
Penalty
Summary
The facility failed to maintain a surety bond large enough to cover the total amount of money in all resident personal funds accounts, which had the potential to affect 20 residents. A review of the resident fund accounts on a specific date revealed a total amount of $98,931.82, while one resident had deposited $101,801.07 earlier in the year and had $91,442.68 in their account on the same date. An email from the Business Office Manager indicated that the active surety bond did not cover the amount in resident fund accounts. The surety bond, effective from a certain date, was initially for $20,000, but was later changed to $120,000 and backdated. The facility's policy required the bond to be at least equal to the total amount of residents' funds as of the most recent quarter.
Inconsistent Advance Directives and Code Status Documentation
Penalty
Summary
The facility failed to ensure that a resident's advance directives in the medical record and physician orders were consistent, leading to a discrepancy in the resident's code status. The resident, who had intact cognition, initially had a Do Not Resuscitate (DNR) Comfort Care status documented by a nurse practitioner. However, during a quarterly care plan meeting, the resident expressed a desire to change his code status to Full Code, which was documented in the care plan and physician orders. Despite this change, the DNR form remained in the miscellaneous section of the electronic medical record, creating a conflict between the documented code statuses. Interviews with facility staff revealed a lack of clarity and training regarding which code status to follow in the event of an emergency. A Licensed Practical Nurse (LPN) indicated she would rely on the state DNR form found in the miscellaneous section, even if it conflicted with the physician's orders. The Director of Nursing (DON) confirmed the inconsistency between the physician's order and the electronic record and acknowledged the absence of a clear policy or training for staff on how to verify a resident's code status. This deficiency had the potential to affect all residents in the facility.
Failure to Timely Report Resident-to-Resident Abuse
Penalty
Summary
The facility failed to report an allegation of resident-to-resident abuse within 24 hours to the state agency. This incident involved Resident #38, who threw a cup of hot coffee on Resident #144. Resident #38 had a history of behavior problems, including verbal outbursts and physical aggression, and was diagnosed with psychosis, dementia, and malignant neoplasm of the colon. At the time of the incident, Resident #38 approached a nurse and admitted to throwing coffee on his roommate, Resident #144, who was in bed and unable to move independently. Resident #144, diagnosed with schizoaffective disorder, depression, anxiety, and unspecified psychosis, was dependent on staff for transfers and had moderately impaired cognition. After the incident, Resident #144 expressed feeling scared and described the event as abusive, noting that the hot coffee burned when it was thrown on him, although no redness was observed on his skin. Despite Resident #144's perception of the incident as abusive, the facility's Administrator did not initially report the incident as abuse, as she did not view it as such. The Director of Nursing interviewed Resident #38, who mentioned the word 'revenge' but could not explain his actions. The facility increased monitoring of Resident #38 and sent him to a psychiatric hospital for evaluation. However, the facility did not file a self-reported incident (SRI) with the Ohio Department of Health within the required 24-hour timeframe. The report was only filed after surveyor questioning, which highlighted the facility's failure to adhere to its policy on reporting allegations of abuse promptly.
Deficient Care Planning for Residents
Penalty
Summary
The facility failed to ensure accurate care plans were in place for two residents, which had the potential to affect all 50 residents residing in the facility. For Resident #19, the care plan did not include the medication Depakote, which was prescribed for behaviors related to dementia with behavioral disturbances. Additionally, the care plan inaccurately listed the resident as Full Code status instead of Do Not Resuscitate Comfort Care Arrest (DNRCCA) as ordered. The absence of Depakote monitoring in the care plan was confirmed by the Regional MDS Nurse/RN, and the facility's policy on care planning was not adhered to, as it requires the interdisciplinary team to review and update care plans quarterly and annually. For Resident #148, the facility did not have a care plan in place for anti-coagulant therapy, despite the resident being on Coumadin and later switched to Eliquis due to refusal of PT/INR lab work. The resident had diagnoses including hypertension, diabetes, and atrial fibrillation, and was dependent on staff for most activities of daily living. The lack of a care plan for monitoring adverse side effects and medication management was verified by both the Regional MDS Nurse/RN and the Director of Nursing. The facility's policy mandates the creation of a care plan that includes measurable goals and specific interventions, which was not followed in this case.
Failure to Ensure Timely and Accurate Care Plans
Penalty
Summary
The facility failed to ensure timely and accurate care plans for two residents, which had the potential to affect all 50 residents residing in the facility. For Resident #34, the medical record indicated an admission with diagnoses including atrial fibrillation, multiple sclerosis, diabetes mellitus type two, and morbid obesity. Despite a change in discharge plans from short-term to long-term care during a care conference, the care plan dated later still indicated a discharge home. Interviews revealed that the responsibility for long-term care plan meetings was not being fulfilled due to staffing changes, and the Director of Nursing confirmed that a care plan meeting should have occurred in September. Similarly, for Resident #35, the medical record showed an admission with diagnoses including sepsis, absence of the left foot, and diabetes mellitus type two. The care plan dated before a care conference indicated a discharge home, while the conference confirmed a long-term care status. The Regional MDS Nurse verified that only one care plan conference was documented, and the care plan was not updated to reflect the resident's long-term care status. The facility's policy required regular interdisciplinary team meetings to review care plans, which were not adhered to in these cases.
Failure to Provide Oral Care for Resident with Hemiplegia
Penalty
Summary
The facility failed to provide necessary oral care for a resident who had hemiplegia and hemiparesis affecting the right dominant side and required supervision or touching assistance for oral hygiene. The resident, who was cognitively intact, had a physician's order for oral care every shift and was admitted with diagnoses including cerebral infarction and ulcerative colitis. Despite these requirements, observations on multiple occasions revealed a buildup of food and plaque on the resident's teeth, indicating a lack of oral hygiene care since admission. Interviews with the resident and her mother confirmed that no oral care had been provided since the resident's admission, and there were no supplies for oral care in the resident's room. The Director of Nursing was informed of the situation and acknowledged the lack of oral care supplies. The facility's policy stated that residents would receive personal care according to their plan of care, which includes oral care, but this was not adhered to in the case of this resident.
Deficiency in Weight Monitoring and Reweighing Procedures
Penalty
Summary
The facility failed to ensure timely and accurate weight monitoring for residents, which is crucial for maintaining their nutritional health. Resident #15, who was admitted with diagnoses including PTSD, bipolar disorder, and hypertension, had inconsistent weight records. His weight was recorded as 160.2 pounds on admission, 158.2 pounds in August, and an inaccurate 1722.0 pounds in October, with no weight recorded for September. Interviews revealed that the dietician oversight was inconsistent during this period, and the staff failed to reweigh Resident #15 to confirm his actual weight. Resident #31, diagnosed with obstructive pulmonary disease, acute respiratory failure, and other conditions, also experienced issues with weight monitoring. His weight was recorded as 221 pounds on admission, 218 pounds in June, 222 pounds in August, and an inaccurate 146.8 pounds in October, indicating a significant weight loss. However, there were no weights recorded for July and September, and the staff did not reweigh him to verify the October weight. The facility's policy required monthly weights and reweighs for significant variances, which were not followed. Resident #195, with diagnoses including chronic bronchitis and heart failure, had fluctuating weights due to edema. Her weight was recorded as 174.5 pounds on October 2, 201.6 pounds on October 3, and 187.0 pounds on October 8, with no reweighs noted. The facility's policy required weekly weights for new admissions and reweighs for significant variances, which were not adhered to. The lack of accurate weight monitoring and reweighs for these residents indicates a deficiency in the facility's adherence to its weight policy and procedures.
Failure to Provide Trauma-Informed Care for Resident with PTSD
Penalty
Summary
The facility failed to provide culturally competent trauma-informed care for a resident diagnosed with PTSD, bipolar disorder, major depression with severe psychotic symptoms, and hypertension. The resident, a Vietnam War veteran, had identified trauma triggers but did not have a care plan addressing these triggers or interventions to manage them. The resident's medical records and assessments indicated a history of psychiatric hospital stays and behaviors such as verbal outbursts, rejection of care, and wandering, yet no specific care plan was in place to address these issues. Interviews with facility staff, including the Director of Nursing and a State Tested Nursing Assistant, revealed a lack of awareness and training regarding the resident's PTSD and potential triggers. The Director of Nursing confirmed the absence of a care plan for the resident's PTSD and acknowledged that staff had not been educated on managing the resident's condition. The facility's policy on trauma-informed care required staff education and care planning for identified triggers, but this was not implemented for the resident. Observations of the resident's behavior, such as pacing and verbal aggression towards other residents, further highlighted the deficiency in care. The facility's failure to document and educate staff on the resident's PTSD and triggers resulted in inadequate management of the resident's condition, contrary to the facility's policy on trauma-informed care.
Failure to Conduct AIMS Test and Monitor Depakote Levels
Penalty
Summary
The facility failed to ensure that an Abnormal Involuntary Movement Scale (AIMS) test was completed for a resident who was prescribed Olanzapine, an antipsychotic medication. The resident, who had diagnoses including PTSD, bipolar disorder, and major depression with severe psychotic symptoms, was admitted on 07/30/24 and had been receiving Olanzapine since admission. Despite the facility's policy requiring AIMS testing upon initiation of psychotropic medications and at least every six months, no AIMS test was conducted for this resident. The Director of Nursing confirmed the absence of the AIMS test, which is crucial for monitoring potential adverse side effects of the medication. Additionally, the facility did not ensure appropriate diagnosis and lab monitoring for another resident's use of Depakote, a medication prescribed for behavioral issues. This resident, diagnosed with dementia and other cognitive disturbances, had been receiving Depakote without any orders for monitoring Depakote levels through lab tests. The care plan did not include monitoring for Depakote, and the last psychiatric note was dated over a year prior, with no subsequent follow-up. The Director of Nursing confirmed that no Depakote levels had been drawn, indicating a lack of proper monitoring as required by the facility's policy on unnecessary drugs.
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A resident with intact cognition receiving Medicare Part A skilled services for metabolic encephalopathy had services discontinued while benefit days remained, but the facility did not issue the required Skilled Nursing Facility Advance Beneficiary Notice (SNF ABN). The Social Services Director later confirmed that no SNF ABN was provided and reported she believed only a Notice of Medicare Non-Coverage (NOMNC) was needed when all skilled services were stopped. This practice conflicted with the facility’s written policy, which required SNF ABNs to be issued when extended care items or services were initiated, reduced, or terminated due to expected non-coverage by Medicare.
Surveyors identified that the facility exceeded the acceptable medication error rate when two residents with type 2 DM received insulin doses that were not administered according to orders or manufacturer instructions. In two separate observations, an LPN administered Novolog and another LPN administered insulin glargine and insulin lispro without priming the insulin pens, and the insulin lispro and Novolog were given after the residents had already consumed a significant portion of their breakfast meals, despite orders for administration before meals. Manufacturer information for both insulin products required priming before each injection to ensure accurate dosing, and facility policy required medications, including insulin, to be administered safely, timely, and in accordance with prescriber orders and specified time frames.
Surveyors found that the facility failed to document tray line food temperatures for multiple meals served from two dining room kitchenettes, despite having a “Trayline Taste & Temperature Log” and a policy requiring food to be stored, prepared, distributed, and served according to professional food safety standards. Review of logs showed repeated missing entries for breakfast, lunch, and dinner services in both the Harrison and McClellan dining areas, and the Senior Director of Culinary Services confirmed that temperatures had not been recorded for those meals, potentially affecting all residents receiving meals from those kitchenettes.
The facility failed to conduct and document required periodic care conferences for two residents, despite multiple comprehensive, quarterly, and significant change MDS assessments and a policy requiring periodic care conferences with resident and/or family participation. One resident with Parkinson’s disease, post-stroke hemiplegia, TIA, DMII, and depression had only two documented care conferences over a year, while another resident with aphasia, cerebrovascular disease, DMII, gait difficulty, coagulation defect, depression, and muscle weakness had no documented care conferences in the past year, aside from a declined invitation to the representative. The UCC confirmed that care conferences were expected to occur quarterly and that no additional documentation existed for either resident.
A resident with Alzheimer's disease and type II DM, who required extensive assistance with ADLs and was receiving scheduled Lantus and sliding-scale Humalog, experienced a severely elevated blood glucose level. The on-call provider was notified and ordered an additional dose of lispro insulin with a directive to recheck the blood glucose after administration. Nursing staff administered the extra insulin but did not document any follow-up blood glucose check, and the DON confirmed that this reevaluation was required by the facility's abnormal blood glucose policy and was not completed or documented.
A resident with Parkinson’s disease, dementia, and hypothyroidism was prescribed levothyroxine once daily along with other medications. A consultant pharmacist’s monthly drug regimen review recommended that levothyroxine be given in the morning on an empty stomach, 30–60 minutes before food, per manufacturer instructions. The medical record contained no documented physician response to this recommendation, and the MAR showed the drug scheduled for morning administration while the resident was observed eating breakfast and receiving the medication at the same time. An LPN confirmed administering levothyroxine during the meal, and the DON verified there was no documentation explaining whether or why the pharmacist’s recommendation was or was not followed, resulting in a failure to act on and document the identified irregularity.
A resident with severe cognitive impairment, multiple comorbidities, documented gait and balance abnormalities, and a high fall risk was care planned and assessed by therapy to require contact guard assistance and use of a gait belt for transfers and ambulation. While being assisted by a CNA from a recliner to the bathroom with a walker, the CNA did not apply a gait belt, even though the resident had a known tendency to lean backward when standing. As the CNA reached to open the bathroom door, the resident lost balance and fell backward, striking the back of the head, and was later found by an LPN without a gait belt in place, contrary to the facility’s gait belt policy and the resident’s assessed needs.
A resident with CKD stage five requiring peritoneal dialysis (PD) was admitted with pre-admission physician orders for three daily PD exchanges and monitoring for peritonitis (fever, abdominal pain, cloudy effluent), but these monitoring orders were not entered into the facility’s physician orders. The care plan referenced PD and general monitoring but did not specifically address peritonitis monitoring. Paper PD flowsheets showed incomplete and inconsistent documentation of exchanges and resident condition, including missing condition/comments for individual treatments and no record of one ordered PD exchange. The PD cycler flowsheet lacked effluent descriptions on multiple days. The PD nurse reported facility staff were expected to monitor effluent and symptoms, and the DON confirmed the absence of specific peritonitis monitoring orders, lack of an order for the PD cycler, and documentation gaps, despite a facility policy requiring ongoing assessment and monitoring for complications before, during, and after dialysis treatments.
A nurse was observed preparing multiple oral medications for a resident with depression, traumatic brain injury, anxiety, and impaired cognition by pushing tablets and capsules from unit-dose cards directly into her ungloved hand and then using her fingers to place them into a medication cup. In a follow-up interview, the RN confirmed this practice and acknowledged that the correct procedure is to dispense medications directly from the card into the cup, contrary to the facility’s medication administration policy requiring adherence to good nursing principles and practices.
A resident with Alzheimer’s disease, diabetes, anxiety, significant ADL dependence, and behavioral symptoms was observed seated in a chair positioned against the nursing station with a locked wheelchair placed directly in front, also against the nursing station, effectively restricting movement. An LPN confirmed both wheelchair wheels were locked and that it should not have been placed there, while a CNA stated she had positioned the wheelchair to prepare for lunch, was unable to complete the transfer, and left it in place, acknowledging this was wrong. This arrangement conflicted with the facility’s restraint policy, which prohibits physical restraints except when alternatives are ineffective for treating a medical symptom and defines restraints as devices adjacent to the body that cannot be easily removed and that restrict freedom of movement or access to the body.
Failure to Issue Required SNF ABN When Discontinuing Medicare Part A Services
Penalty
Summary
The deficiency involves the facility’s failure to issue a Skilled Nursing Facility Advance Beneficiary Notice (SNF ABN) when Medicare Part A services were discontinued for a resident who still had available benefit days. The resident was admitted with a diagnosis of metabolic encephalopathy and had intact cognition per the Minimum Data Set assessment. The facility’s own SNF Beneficiary Notification Review documented that Medicare Part A skilled services began on 02/11/26 and the last covered day was 03/11/26, and that the facility initiated discharge from Medicare Part A services before the resident’s benefit days were exhausted. Despite this, no SNF ABN was provided to the resident or the resident’s representative. During interviews, the Social Services Director stated that the SNF ABN was issued hours prior to the last covered day but, upon reviewing her files, confirmed that no SNF ABN had actually been issued for this resident. She further explained that she believed an SNF ABN was only required if one skilled service remained and that if all skilled services were being discontinued, only the Notice of Medicare Non-Coverage (NOMNC) needed to be issued. The Administrator, however, stated that a resident should always receive both a SNF ABN and a NOMNC when Medicare Part A services are discontinued and benefit days remain. Review of the facility’s written policy dated 03/28/23 showed that the facility was required to issue SNF ABNs for initiation, reduction, or termination of extended care items or services when Medicare payment was not expected, which did not occur in this case.
Plan Of Correction
This Plan of Correction is submitted as required under State and Federal law. This Plan of Correction does not constitute an admission on the part of the Facility that the findings cited are accurate, that the findings constitute a deficiency or that the scope and severity regarding the deficiency cited are correctly applied. Any changes to the Facility's policies and procedures should be inadmissible in any proceeding on that basis. Without admitting or denying the validity or the existence of the alleged noncompliance, the Facility submits this Plan of Correction with the intention that it be inadmissible by any third party in any civil or other action against the facility or any employee, agent, officer, director or shareholder of the Facility. The Facility is utilizing this Plan of Correction as its allegation of substantial compliance as of 05/29/2026 F-0582 Corrective action for resident/s: On 5/14/26 Resident #34 was informed of rights and responsibilities related to Advanced Beneficiary Notice and voiced understanding of information for future reference by administrator. Identification of other residents who may be affected: Any resident receiving skilled services from nursing or therapy services. The Administrator audited all residents who were discharged from skilled services in the past 30 days to ensure they were issued a Notice of Non-Coverage and Advanced Beneficiary Notice on 5/29/26. No non-compliance was noted. Measures for systemic change: On 5/14/2026 Business Office Manager, Director of Rehab, Minimum Data Set nurse, Director of Nursing and Social Services Director were educated on proper procedure of issuing of Notice Of Medicare Non Coverage and Advanced Beneficiary Notice by administrator. All upcoming discharges from skilled services will be reviewed weekly at Utilization Review meeting to ensure notices will be delivered timely. How Corrective Action will be monitored: Administrator or designee to complete audits of all residents being discharged from skilled services to ensure they were issued a Notice of Non-Coverage and Advanced Beneficiary. This audit will be completed weekly x 4 weeks, then monthly x 2 months. Corrective action will be initiated for any noted non-compliance. Audit findings will be reviewed as part of the monthly quality assurance process to determine the need for further monitoring. Date of Compliance 5/29/26
Insulin Administration Errors and Failure to Prime Insulin Pens
Penalty
Summary
The deficiency involves the facility’s failure to maintain a medication error rate below 5%, with surveyors identifying 3 errors out of 28 medication administration opportunities, resulting in a 10.71% error rate. For one resident with type 2 diabetes mellitus and moderate cognitive impairment, the physician’s order directed Novolog insulin 10 units via subcutaneous pen-injector to be given before meals. During an observed medication pass, the LPN administered 10 units of Novolog insulin without priming the pen and did so after the resident had already consumed approximately 50% of the breakfast meal. The LPN later confirmed she did not prime the pen and acknowledged that the insulin was ordered to be administered prior to meals. Manufacturer instructions for the Novolog FlexPen specified that an air shot (priming) must be performed before each injection to ensure proper dosing. Another resident, also diagnosed with type 2 diabetes mellitus and with intact cognition, had orders for insulin glargine 35 units subcutaneously twice daily and insulin lispro 20 units subcutaneously before meals, plus 12 units subcutaneously if blood glucose was between 251 mg/dL and 300 mg/dL. During an observed medication administration, an LPN administered 35 units of insulin glargine and 32 units of insulin lispro without priming the insulin pens and after the resident had consumed approximately 90% of the breakfast meal, despite orders for insulin lispro to be given before meals. The LPN later stated she could not remember if she had primed the pen and acknowledged that the insulin was ordered to be administered prior to meals. Manufacturer information for insulin lispro stated that the pen must be primed before each injection to confirm insulin delivery and remove air, and that failure to prime could result in too much or too little insulin. The DON confirmed the expectation that insulin be administered as ordered, including priming each pen with two units before dialing the prescribed dose, and facility policy required medications, including insulin, to be administered safely, timely, and in accordance with prescriber orders and required time frames.
Plan Of Correction
This Plan of Correction is submitted as required under State and Federal law. This Plan of Correction does not constitute an admission on the part of the Facility that the findings cited are accurate, that the findings constitute a deficiency or that the scope and severity regarding the deficiency cited are correctly applied. Any changes to the Facility's policies and procedures should be inadmissible in any proceeding on that basis. Without admitting or denying the validity or the existence of the alleged noncompliance, the Facility submits this Plan of Correction with the intention that it be inadmissible by any third party in any civil or other action against the facility or any employee, agent, officer, director or shareholder of the Facility. The Facility is utilizing this Plan of Correction as an allegation of substantial compliance as of 5/29/2026. F-0759 Corrective action for resident/s: Residents #21 and #22 were assessed and evaluated by nurse and Director of Nursing 5/14/26. Resident #21 and #22 both denied any adverse effects and none were noted upon assessment by the Director of Nursing on 5/14/2026. Notification made to physician on 5/14/2026. LPN # 2 competency Eval on insulin administration with the Director of Nursing completed 5/14/2026. Identification of other residents who may be affected: Diabetic residents on assignment of LPN #2/station 2 have the potential to be affected and were assessed by the DON/Designee on 5/14/26 and found to be within normal limits. Measures for systemic change: All Nurses were educated by the Director of Nursing on the steps for Insulin administration per competency, diabetes clinical protocol policy, Medication and treatment orders policy, administering medications policy, and Obtaining fingerstick Glucose Level policy On 5/14/2026. How Corrective Action will be monitored: Director of Nursing and Assistant Director of Nursing will complete insulin administration audits on 5 nurses. This audit will be completed weekly x 4 weeks, then monthly x 2 months. Corrective action will be initiated for any noted non-compliance. Audit findings will be reviewed as part of the monthly quality assurance process to determine the need for further monitoring. Date of Compliance: 5/29/2026
Failure to Document Tray Line Food Temperatures in Dining Room Kitchenettes
Penalty
Summary
The deficiency involves the facility’s failure to document tray line food temperatures for meals served from the Harrison and McClellan Dining Room kitchenettes, as required by professional standards for food service safety and the facility’s own policy. Review of the “Trayline Taste & Temperature Log” (revised September 2018) showed missing temperature documentation for multiple meals from the Harrison Dining Room kitchenette, including dinner on 03/30/26 and 03/31/26, lunch and dinner on 04/01/26 and 04/02/26, dinner on 04/07/26, and lunch and dinner on 04/08/26 and 04/10/26. The Senior Director of Culinary Services confirmed during interview that tray line food temperatures were not documented on the log for these meals. Similarly, review of the same log for the McClellan Dining Room kitchenette revealed that tray line food temperatures were not documented for dinner on 04/01/26, breakfast and lunch on 04/02/26, and lunch and dinner on 04/07/26. The Senior Director of Culinary Services also verified these omissions during interview. The facility census at the time was 27 residents, and the governing “Food and Nutrition” policy, approved on 09/07/21, stated that the facility must store, prepare, distribute, and serve food in accordance with professional standards for food service safety.
Plan Of Correction
F812 The facility will continue to ensure food temperatures are completed before meals are served for all residents. To ensure compliance with this standard the following measures have been taken: 1. Immediately 4/15/26 culinary supervisor #224 was re-educated by Dietary Manager to this standard and policy "Food and Nutrition" which includes documentation of food temperatures. 2. All dietary staff have been re-educated to the standard and policy "Food and Nutrition" during the month of April 2026. 3. Audits of food temperature documentation to be completed by Dietary Manager 4 x per week for 4 weeks then weekly for 4 weeks. 4. Administrator to validate audits/compliance and provide additional training as needed. Administrator will present to QAPI committee for ongoing monitoring and further direction.
Failure to Conduct and Document Required Care Conferences
Penalty
Summary
The deficiency involves the facility’s failure to complete and document comprehensive care conferences at required intervals in accordance with care plan regulations and facility policy. For one resident with Parkinson’s disease with dyskinesia, cognitive communication deficit, hemiplegia and hemiparesis following cerebral infarction, transient cerebral ischemic attack, type II diabetes mellitus, and major depressive disorder, the record showed multiple MDS assessments over a one-year period, including annual, quarterly, and significant change assessments. However, only two care conferences were documented during the last 12 months, despite the expectation that care conferences be conducted quarterly with the resident and family when possible. The Unit Care Coordinator confirmed that no additional care conference documentation existed for this resident beyond the notes dated 04/21/25 and 01/02/26. A second resident, with diagnoses including aphasia following cerebrovascular disease, cerebral infarction, type II diabetes mellitus, unsteadiness on feet, difficulty in walking, coagulation defect, depression, and muscle weakness, also had multiple MDS assessments completed over the review period, including quarterly and annual assessments. The record contained a note that a care conference was offered to the resident’s representative, who declined to attend, but there was no documentation of any care conferences for the most recent 12 months. The Unit Care Coordinator confirmed that no other care conference documentation was available for this resident. Facility policy stated that periodic care conferences involving the resident, family, and the interdisciplinary team are part of the care planning process, but the required periodic care conferences and corresponding documentation were not completed for these two residents.
Plan Of Correction
THIS PLAN OF CORRECTION SERVES AS BERKELEY SQUARE'S CREDIBLE ALLEGATION OF SUBSTANTIAL COMPLIANCE AS OF June 1, 2026. Without admitting or denying the validity or existence of the alleged deficiencies, Berkeley Square provides the following Plan of Correction: F657 The facility will continue to document completion of care conferences at the required intervals for all residents, including residents #04 & #15. To ensure compliance with this standard the following measures have be taken: 1. The social service designee and the inter- disciplinary team were re-educated by the administrator to the facility policy "Care Conference" on 4/29/26 and verbalized understanding. 2. Care conferences for resident #04 and resident #15 were conducted on or before 4/29/2026 by the interdisciplinary team. 3. Review of all other residents was conducted by the social service designee to validate and ensure that care conference schedule is up to date with timely care conferences scheduled for them on 4/15/2026. Audits of care conferences to be completed weekly for four weeks and then monthly after that by the social service designee. Documentation of the care conference including any identified concerns in the medical record. Administrator to validate audits/compliance and provide additional training as needed. Administrator will present results of these audits to QAPI committee for ongoing monitoring and further direction.
Failure to Reevaluate Blood Glucose After Treatment for Hyperglycemia
Penalty
Summary
The facility failed to ensure that a resident with diabetes received treatment in accordance with professional standards of practice when nursing staff did not reevaluate the resident's blood glucose after treatment for severe hyperglycemia. The resident, admitted with diagnoses including Alzheimer's disease, type II diabetes mellitus, and depression, had physician orders for Humalog insulin on a sliding scale before meals, Lantus insulin 25 units daily, and lisinopril 5 mg daily. The resident required extensive assistance with activities of daily living, including transfers, toileting hygiene, eating, and bathing. On the evening in question, the resident's blood glucose was documented as 532 mg/dL, and the on-call provider was notified. The provider gave a new order to administer an additional 8 units of lispro (Humalog) and to recheck the blood glucose in 30 minutes. The electronic medication administration record showed that the blood glucose of 532 mg/dL was obtained at 9:00 p.m. and that the additional 8 units of lispro were administered at 9:21 p.m. However, there was no documentation in the resident's chart that the blood glucose was rechecked after the additional insulin was given. In an interview, the DON confirmed there was no evidence of reevaluation and verified that, according to the facility's "Abnormal Blood Glucose Procedure" policy, the resident should have been reevaluated and that the evaluation step should have been included in the progress note documentation.
Plan Of Correction
F684 The facility will continue to ensure all residents, including #03, receive treatment in accordance with professional standards of practice and reevaluated for hyperglycemia. To ensure compliance with this standard the following measures have been taken: 1. The director of nursing assessed resident #03, reviewed documentation and orders and found no ill effects immediately 4/16/26. 2. All licensed nurses were re-educated to facility policy "Blood Glucose Monitoring" by the Director of Nursing/designee in April 2026. 3. Audits of like-residents that require blood sugar checks to be completed by the director of nursing/designee two times a week for 4 weeks and then monthly after that to validate correct follow through when there is abnormally high blood glucose result. The Administrator will bring results of these audits to the QAPI committee for ongoing monitoring and further direction.
Failure to Act on Pharmacist Drug Regimen Recommendation for Thyroid Medication
Penalty
Summary
The deficiency involves the facility’s failure to ensure that pharmacy recommendations from the monthly drug regimen review were acted upon and documented for a resident. The resident was admitted with diagnoses including Parkinson’s disease, dementia, and hypothyroidism, and had current physician orders for levothyroxine 150 mcg once daily, buspirone 50 mg twice daily, and losartan 100 mg once daily. A medication regimen review dated 11/25/2025 included a consultant pharmacist recommendation that levothyroxine be administered consistently in the morning on an empty stomach, at least 30–60 minutes before food, per manufacturer instructions. There was no specific physician response in the medical record to this recommendation, and the facility’s policy stated that consulting pharmacist reviews are sent to nursing and addressed with the primary care provider or consulting specialist for review and follow-up. Review of the resident’s medication administration record for April 2026 showed levothyroxine scheduled for 9:00 a.m. On observation, the resident was seen eating breakfast in the dining area at 8:03 a.m., and an LPN reported administering the levothyroxine 150 mcg to the resident while the resident was in the dining area eating breakfast. The DON confirmed there was no evidence in the resident’s medical record explaining why the consultant pharmacist’s recommendation from 11/25/2025 was or was not acted upon. This lack of documented physician review and action on the pharmacist’s identified irregularity constituted noncompliance with the drug regimen review requirements.
Plan Of Correction
F756 The facility will continue to ensure the pharmacy recommendations from the monthly drug regimen review by a licensed pharmacist are acted upon for all residents, including #08. To ensure compliance with this standard the following measures have been taken: 1. Resident #08 was assessed by the registered nurse and med review completed by 4/28/26. After review of resident's drug regime's, it was discovered that resident #8 had 2 separate medication recommendations on the same form, to be reviewed by two separate practitioners, pharmacy has been instructed and agreed to separate meds on individual forms. 2. Licensed nurses re-educated to facility policy "Drug Regimen Review" by Director of nursing/designee in April 2026 and no later than 5/8/26. Licensed nurses are responsible for ensuring the reviews and recommendations are given to the physician for timely review. 3. Review of all other current residents Drug Regimen orders completed by Director of nursing/designee on 4/16/26 to ensure recommendations were followed up on/reviewed by the physician and address concerns if needed. 4. Audit of drug regime recommendations, pharmacy recommendations, and physician follow up to be completed weekly for four weeks by the Director of nursing/designee. Administrator will present results of these audits to the QAPI committee for ongoing monitoring and further direction.
Failure to Use Required Gait Belt During Ambulation Resulting in Resident Fall
Penalty
Summary
The deficiency involves the facility’s failure to ensure that a required gait belt was used while assisting a high fall‑risk resident with ambulation, resulting in a fall with head injury. The resident had multiple diagnoses including metabolic encephalopathy, hypertension, osteoarthritis, muscle weakness, gait and mobility abnormalities, major depressive disorder, anxiety, and visual hallucinations. Admission and subsequent MDS and fall risk assessments documented that the resident was severely cognitively impaired, required moderate to maximal assistance with transfers and ambulation, could not independently come to a standing position, exhibited loss of balance while standing, used an assistive device, and had decreased muscle coordination. The resident had a history of falls prior to admission and was assessed as being at high, later moderate, risk for falls. The resident’s fall care plan identified her as at risk for falls and included interventions such as providing maximum to moderate assistance with transfers and walking short distances, use of a walker and wheelchair, and following the facility’s fall protocol. Therapy notes and care conference documentation indicated that the resident leaned backwards when standing, required contact guard to minimal assistance for bed mobility and transfers, and needed constant verbal cueing for safe sequencing during toilet transfers. The physical therapist confirmed that the resident was to use a gait belt with staff when ambulating, and the DON verified that therapy had assessed the resident as requiring contact guard assistance and a gait belt for ambulation and transfers. On the day of the incident, a CNA was assisting the resident from her recliner to the bathroom using a walker. The CNA walked beside the resident, providing guidance and support, and reported having a hand on the resident while assisting her. As they approached the bathroom door, the CNA reached for the doorknob to open it, and at that moment the resident began to lose her balance and fell backwards to the floor, striking the back of her head. The nurse who responded found the resident on her back at the foot of the bed with her feet near the bathroom, noted a red raised area on the back of the head, and documented that the resident was not wearing a gait belt and that the gait belt was on the dresser. In the facility’s investigative summary and in interviews, the CNA acknowledged that she did not have a gait belt on the resident while ambulating her, despite the resident’s assessed need for hands‑on assistance and gait belt use per facility policy and the resident’s care and therapy plans.
Failure to Implement PD Orders and Monitor Resident Receiving Peritoneal Dialysis
Penalty
Summary
The deficiency involves the facility’s failure to implement pre-admission physician orders for peritoneal dialysis (PD) and to provide ongoing monitoring for a resident with chronic kidney disease (CKD) stage five who required PD. Pre-admission orders dated 11/14/25 specified three daily PD exchanges at 6:00 A.M., 2:00 P.M., and 10:00 P.M., and directed staff to monitor for signs and symptoms of peritonitis, including fever, abdominal pain, and cloudy effluent. These monitoring orders were not entered into the facility’s physician orders. The resident’s care plan noted the need for PD and included general monitoring interventions (labs, signs of bleeding, bacteremia, septic shock, and significant vital sign changes), but did not specifically address the ordered monitoring for peritonitis. Review of PD documentation showed incomplete and inconsistent charting of treatments and resident condition. The paper peritoneal flowsheet had columns for time of PD and condition/comments, including instructions to call the nurse immediately for cloudy fluid, abdominal pain, or fever. However, the first entry on 11/15/26 at 2:00 P.M. only noted that the PD nurse completed the exchange, and the 10:00 P.M. entry that day had no condition/comment documentation. Subsequent days (11/16/25, 11/17/25, and 11/18/25) contained only one condition/comment entry per day rather than for each exchange, and there was no documentation that the 6:00 A.M. PD on 11/18/25 was completed. The PD cycler flowsheet starting 11/19/25 lacked any description of the effluent on multiple days. The PD nurse from the dialysis company stated facility staff were expected to monitor effluent for cloudiness and assess for abdominal pain and fever, and the DON confirmed there was no electronic physician order for peritonitis monitoring or for use of the PD cycler, that the paper charting did not allow for effluent description or symptom documentation for each treatment, and that PD was not documented at one ordered time. The facility’s dialysis policy required ongoing assessment and monitoring for complications before, during, and after treatments, which was not reflected in the documentation for this resident.
Improper Infection Control During Medication Administration
Penalty
Summary
Surveyors identified a deficiency in infection prevention and control related to medication administration for Resident #29. The resident was admitted on 02/28/14 with diagnoses including depression, traumatic brain injury, and anxiety, and had impaired cognition per a quarterly MDS assessment. During an observation on 03/25/26 at 6:58 A.M., RN #281 prepared the resident’s medications by removing an Amoxicillin-Pot Clavulanate tablet from the medication card and pushing it directly into her ungloved hand, then using her fingers to place the pill into a medication cup. The same process was observed for multiple other medications, including Escitalopram Oxalate, Furosemide, Sennosides, Lyrica, and Vitamin D, each being pushed from the card into the RN’s ungloved hand and then transferred by her fingers into the medication cup before administration to Resident #29. In a subsequent interview at 7:27 A.M. the same day, RN #281 confirmed she had placed each medication into her ungloved hands prior to administration and acknowledged that the proper procedure was to push the pills directly from the card into the medication cup. Review of the facility’s “Medication Administration – General guidelines” policy, revised 10/08/25, stated that medications are to be administered in accordance with good nursing principles and practices. This practice failure was cited as a deficiency under Complaint Number 2681777.
Improper Use of Wheelchair as a Physical Restraint
Penalty
Summary
Surveyors identified a deficiency related to the facility’s failure to ensure a resident was free from physical restraints. Resident #7, admitted with diagnoses including Alzheimer’s disease, diabetes mellitus, and anxiety disorder, was documented on a recent MDS as rarely understood and dependent for ADLs except eating. The resident ambulated independently on the unit without an assistive device and had documented verbal and other behaviors occurring one to three days during the look-back period. The care plan noted the resident had potential to be physically aggressive, chase staff, throw objects, and be combative with care, with interventions such as offering choices, administering medications as ordered, and intervening early when agitation occurred. During an observation and interview, Resident #7 was found sitting in a chair with the right arm of the chair positioned against the nursing station and a wheelchair placed directly in front of him. The left arm of the wheelchair was also against the nursing station, and both wheelchair wheels were locked, creating a barrier that appeared to restrain the resident, who was sleeping with his knees touching the locked wheelchair. An LPN confirmed both wheelchair wheels were locked and that the wheelchair should not have been placed in front of the resident. A CNA reported she had placed the wheelchair there in preparation to get the resident up for lunch, was unable to transfer him, and left the wheelchair in that position, acknowledging it was wrong to keep it there. The facility’s physical restraint policy stated that physical restraints are not used except when alternatives are not appropriate or effective for treating a medical symptom and defined physical restraints as any device attached or adjacent to the body that the individual cannot easily remove and that restricts freedom of movement or access to the body.
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