Vista Center, The
Inspection history, citations, penalties and survey trends for this long-term care facility in Lisbon, Ohio.
- Location
- 100 Vista Drive, Lisbon, Ohio 44432
- CMS Provider Number
- 366087
- Inspections on file
- 21
- Latest survey
- February 19, 2026
- Citations (last 12 mo.)
- 4
Citation history
Health deficiencies cited at Vista Center, The during CMS and state inspections, most recent first.
The facility failed to provide consistently palatable meals at appropriate temperatures for all residents receiving meals from the kitchen. Several residents reported that their food was sometimes cold, often only warm instead of hot, and in some cases overcooked and difficult to eat. Observations showed a delay between tray plating and delivery on one wing, with CNAs starting room tray service shortly after plating but the last tray not being served until more than 20 minutes later. A test tray followed to the wing and sampled after service revealed green beans that were not warm, with the Dietary Manager confirming a temperature of 120°F, which was not appropriate for palatable consumption.
Surveyors found hallways and an emergency exit obstructed by carts, wheelchairs, furniture, and equipment, blocking handrails and making passage difficult or impossible for a resident using a wheelchair or a walker. An emergency exit in one hall was blocked by wheelchairs, a bucket of bird food, and a vital sign machine, contrary to the facility’s egress policy. In addition, the main, east, and west hallways had missing plaster, dirty floors and baseboards, stained and broken ceiling tiles (including one with a black, mold-like appearance), water-stained ceiling areas around a light, dirty and rusty ceiling vents, and lint and debris hanging between ceiling tiles, all confirmed by facility leadership and staff.
A pervasive sewage odor in the shower room and nearby hallway, used by multiple residents, was observed to be strong enough to cause eye irritation, with staff and a resident reporting that the smell had been present for years and sometimes spread into the hallway despite the door being closed. The Maintenance Director acknowledged the odor as a longstanding issue and, despite plumbing evaluations, did not complete recommended repairs to a leaking toilet that a plumber had identified as allowing sewage odor to escape when toilets were flushed. A family member reported the shower room was consistently dirty, smelling of sewage with visible hair and debris in the drains, indicating residents were routinely exposed to an unclean, uncomfortable environment during bathing.
Surveyors found that during a PEG tube dressing change for a resident with ALS, severe cognitive impairment, and multiple care needs, an RN removed a soiled dressing and then cleansed the PEG site while still wearing the soiled gloves, only later removing them to reveal a second glove layer, contrary to facility policies requiring glove removal and hand hygiene after handling soiled dressings. In addition, review of infection surveillance logs showed a marked increase in UTIs on one hall, with several cases lacking identified organisms and multiple affected residents in close proximity, while the new IP and a new RN had not yet analyzed January and February infection trends, and prior QAPI minutes documented multiple nosocomial infections without identifying problems or action plans.
Facility staff did not consistently answer telephones, preventing residents and family members from contacting the facility. Multiple calls from the state agency, family members, and outside physicians went unanswered, with no option to leave a message. A resident and a family member both reported having to contact police due to lack of response from staff. Staff and the Ombudsman confirmed ongoing issues with phone access, and the administrator was unaware of recent problems.
Surveyors found that two residents did not receive proper respiratory care: one was given oxygen at a higher flow rate than ordered, and another had nebulizer equipment stored unsafely on the floor with visible contamination. These deficiencies were confirmed through observation and staff interviews.
The facility did not complete required performance evaluations for four CNAs, as mandated by their policy. Two CNAs lacked annual evaluations for 2024, while two others did not receive their 90-day evaluations. This was confirmed through personnel file reviews and an HR interview.
The facility did not adhere to menu and portion control guidelines, leading to incorrect serving sizes and missing food items for residents. Observations showed that dietary staff used inappropriate serving utensils, resulting in discrepancies in portion sizes. The dietary manager confirmed that the menu diet spreadsheet and packaging labels were not followed, affecting all residents.
The facility failed to provide bedtime snacks to residents, with several reporting that snacks were not offered and staff claiming none were available. The Dietary Manager noted that residents were interviewed about snack preferences, but it was their responsibility to inform the department of changes. Observations showed unopened snacks with no refusal documentation, and staff were unaware of snack intake recording. The Activity Director confirmed no documentation of snack offerings or refusals.
The facility failed to maintain the ice machine in a clean and sanitary manner, potentially affecting all residents except one with a no fluids order. A white substance was observed on the ice machine, and the Dietary Manager confirmed its presence, suggesting a water softener might help. The ice machine was believed to be cleaned monthly, contrary to the facility's policy requiring regular cleaning and sanitization.
The facility failed to submit accurate staffing data to CMS from July to September 2024. Review of schedules and interviews revealed that the RCF hall had no separate staff from 11:00 P.M. to 7:00 A.M., with nursing facility staff covering these hours. Payroll records used for CMS submissions did not subtract hours worked in the RCF, resulting in inaccurate data.
The facility failed to implement proper isolation protocols for a resident with C. diff, as staff entered the room without PPE and did not follow hand hygiene protocols. Additionally, catheter care deficiencies were observed for two residents, with catheter tubing found on the floor, contrary to facility policy. These lapses in infection control and catheter management could affect all 48 residents.
The facility failed to maintain adequate staffing levels, resulting in delayed responses to resident needs, including toileting and medication administration. Residents and staff reported long wait times for assistance, with some residents experiencing incontinence due to delays. Observations confirmed that call lights were often ignored or turned off without providing help, highlighting significant staffing issues.
The facility failed to maintain complete and accurate medical records, affecting several residents. Issues included missing documentation for medication administration, catheter care, falls, dietary upgrades, ADLs, restorative care, and refusal of dental procedures. For instance, a resident's antipsychotic medication was not documented for three months, and another resident's migraine medication availability was mishandled. Additionally, falls and catheter care were inadequately documented, and there was a lack of records for ADL assistance and dietary trials. A resident's refusal of dental extraction was also not documented.
The facility failed to maintain a clean and functional environment, affecting 14 residents. Observations revealed dirty floors, stained bathrooms, and a malfunctioning bed rail. Residents reported that floors had not been mopped for weeks. The Director of Maintenance acknowledged staffing issues in housekeeping, and the facility's policy requiring daily cleaning was not followed.
A resident with multiple health conditions was denied timely access to his medical records despite requesting to view x-ray results and wound assessments. The facility's Administrator was initially unaware of the request, and even after being informed, the resident was not granted access as per the facility's policy. The lack of communication and action within the facility led to this deficiency.
A facility failed to ensure accurate documentation of a resident's advance directive, resulting in a discrepancy between the electronic and paper medical records and the signed advance directive form. The resident's records indicated a DNRCC-A status, while the signed form specified a DNRCC status. This inconsistency was confirmed by the DON.
A resident with Alzheimer's and dementia was left in a chair overnight without incontinence care, and the incident was not reported to the state survey agency. Surveillance footage confirmed the lack of care, and the facility's policy on neglect was not followed.
A resident with Alzheimer's and dementia was reportedly left in a chair overnight without incontinence care, contrary to their care plan. Surveillance footage confirmed the resident remained in a common area from afternoon until morning without care. The facility's investigation was incomplete, lacking interviews with other staff present during the incident, despite policy requirements for thorough investigation of neglect allegations.
A facility failed to ensure a resident's PASRR document accurately reflected all diagnoses. The resident was admitted with multiple conditions, including bipolar disorder and alcohol abuse, but the PASRR only listed some of these diagnoses. This discrepancy was confirmed by the Social Services Designee.
The facility failed to provide baseline care plan summaries to three residents upon admission. A resident with Alzheimer's and another with spinal stenosis did not receive the necessary documentation, as confirmed by the DON. A third resident with osteomyelitis also lacked a care plan summary.
The facility failed to properly transcribe and administer a laxative order for a resident with constipation, and did not obtain vital signs as ordered for another resident with multiple diagnoses. The laxative was not adjusted after a bowel movement, and vital signs were not documented on several occasions, as confirmed by the DON.
A resident with a history of falls and severe cognitive impairment was found on the floor. Two CNAs moved the resident to a wheelchair without notifying a nurse for assessment, contrary to the facility's policy. The DON confirmed that a nurse should have been notified and assessed the resident before moving. The facility's Falls Program policy required immediate notification of the falls committee to investigate the fall's root cause.
A facility failed to ensure consistent communication with a dialysis center and proper medication administration for a resident requiring dialysis. The resident missed several doses of prescribed medications on dialysis days due to leaving before the morning medication administration time. Facility staff acknowledged the issue, and communication with the dialysis center was inconsistent, with paperwork not always returned completed.
The facility failed to ensure physician response to pharmacy recommendations for two residents. One resident, with multiple diagnoses, had unaddressed recommendations regarding corticosteroid inhaler use and Meloxicam dosage. Another resident, with chronic osteomyelitis and paraplegia, had unaddressed recommendations about Percocet use for minor pain. The facility policy mandates timely communication and response to pharmacy recommendations, which was not followed.
The facility failed to obtain timely lab samples for two residents. One resident with clostridium difficile had a delayed diagnosis due to an incorrect specimen container, while another resident's lab tests were not documented or rescheduled properly after refusal. These actions did not adhere to the facility's lab order policy.
The facility failed to ensure appropriate antibiotic use for two residents, leading to deficiencies in antibiotic stewardship. A resident was started on Cefdinir for a UTI without urinalysis culture and sensitivity results, and another was prescribed ciprofloxacin for a wound infection without documented assessment. The facility's antibiotic stewardship policy was not followed, indicating a systemic issue in infection control practices.
The facility failed to document refusals for pneumococcal and influenza immunizations for two residents. One resident with multiple diagnoses, including ALS and schizophrenia, and another with conditions like cerebral ischemia and diabetes, both refused immunizations without signed declination forms. The ADON confirmed the absence of these forms, contrary to facility policy requiring completion upon admission.
The facility failed to treat residents with dignity in two incidents. A resident's room was searched without his knowledge, violating the facility's policy requiring resident notification and presence during searches. Another resident received incontinence care in a common area, compromising her privacy. These actions breached the residents' rights to dignity and respect.
A facility failed to notify a resident's family when the resident, who had intact cognition and multiple health issues, was transferred to the hospital for emergency surgery. The resident's son was listed as the emergency contact and power of attorney, but the facility's practice was not to inform emergency contacts if the resident was their own responsible party, contrary to their policy.
A resident with Alzheimer's and dementia was left in a common area overnight without receiving incontinence care, contrary to the facility's policy requiring care every two hours. Surveillance footage confirmed the resident's prolonged stay without staff interaction, and discrepancies were found in staff accounts regarding the incident.
The facility did not post the required daily nurse staffing information, affecting all 48 residents. On a specific day, the posted information was outdated, and the responsible nurse was unaware of the correct posting location. The Activity Director confirmed the issue, noting that residents and visitors could not access the information in the staff break room.
A resident with multiple health conditions left the facility AMA after not receiving scheduled doses of buspirone. The resident expressed breathing difficulties and anxiety, but the LPN did not notify the physician of the missed doses or symptoms. The resident left, citing previous heart attack concerns and lack of medication.
Failure to Provide Palatable Meals at Appropriate Temperatures
Penalty
Summary
The facility failed to ensure food and drink were palatable, attractive, and served at safe and appetizing temperatures for residents receiving meals from the kitchen. One resident reported that food was sometimes cold and attributed this to living at the end of a hall and being served last, another resident stated that food was often cold or only warm but not hot, and a third resident described some food as lousy, specifically noting a hamburger that was very overcooked and tough to bite and eat. Observation showed that the last tray for a room on the east wing was plated and placed on the cart at 12:20 P.M., and a test tray with pizza casserole, green beans, and pumpkin mousse was prepared and followed to the east wing. CNAs began passing trays and drinks to residents in their rooms at 12:23 P.M., and the last tray for the identified room was not served until 12:46 P.M., at which time the test tray was sampled for taste, texture, and temperature. The green beans on the test tray were found not to be warm, and the Dietary Manager measured their temperature at 120 degrees Fahrenheit, confirming they were not at an appropriate temperature for palatability as intended. This deficiency was investigated under Master Complaint Number 2733050.
Obstructed Egress and Unsanitary Hallways
Penalty
Summary
Surveyors identified that the facility failed to maintain safe, unobstructed, and sanitary corridors and exits, affecting the environment for residents, staff, and the public. In the west hallway between specified rooms, surveyors observed multiple pieces of equipment on both sides of the corridor, including a large covered laundry cart, a blue straight-back chair, a dirty linen cart, a housekeeping cart, and a medication cart where a nurse was preparing medications. These items blocked the handrails on both sides and made the hallway impassable for a wheelchair user or a person using a walker, despite this being the hallway leading to the main dining room. In a separate area, an emergency exit in the east hall (Mary's Place) was blocked by two large wheelchairs, a bucket of bird food, and a vital sign machine, obstructing the path of egress. The Administrator and an RN confirmed these observations, and review of the facility’s “Means of Egress” policy showed that it required all emergency egress paths and exits to be clear, unobstructed, and free of furniture or other objects. Additional environmental deficiencies were observed in the main, east, and west hallways. Surveyors noted missing plaster from wall corners, a buildup of dirt along the floors and baseboards, large brown stains on multiple ceiling tiles, broken ceiling tiles in all three hallways, and one ceiling tile with a large brown stain and a black, mold-like appearance in the center. A portion of the ceiling containing a large light had a water stain extending from around the light across the ceiling. Three ceiling vents were coated with dirt and debris, with two appearing rusty, and balls of lint, dirt, and debris were hanging between several ceiling tiles. The Maintenance Director confirmed the dirty floors, broken and soiled ceiling tiles, and dirty vents, and reported that the stained tile with the mold-like appearance had been replaced several times but the stain kept returning. An anonymous source also reported that a resident using a wheelchair had difficulty getting through the hallways due to carts of towels, beds, and other items blocking the way.
Persistent Sewage Odor and Poor Sanitation in Shower Room
Penalty
Summary
The facility failed to provide a safe, clean, and comfortable environment when a pervasive sewage odor was present in the shower room and adjacent hallway used by multiple residents. On observation, the shower room had an overwhelming sewage smell strong enough to cause the surveyor’s eyes to water, and the nearby hallway also smelled of sewage. A CNA reported that at least three residents used this shower and that, even with the door closed, a sulfur-like odor would spread into the hallway; she stated she did not think anyone knew what was wrong. One resident, who had lived in the facility for three years, stated the smell had been present since his admission, that bleach had once been poured into the drain with only temporary improvement, and that the odor had recently worsened, making him hate using the shower but feeling he had no other option. The Maintenance Director acknowledged that the smell in the shower room was “about normal” and had always been present, and stated that plumbers had evaluated the issue and told him there was nothing wrong, while also noting that residents did not use the shower during the day so housekeeping could clean it then. However, a contracted plumber reported that on a prior visit his company had identified a leaking toilet in the shower room and advised the Maintenance Director that the toilet needed to be pulled and resealed with new bolts, warning that failure to do so would allow sewage odor to escape whenever toilets in the facility were flushed. On a subsequent visit, the plumbers found the issue had not been corrected, and the technician reported the Maintenance Director acknowledged he should have completed the recommended work. An anonymous family member stated that whenever their relative used the shower room it was dirty, smelled like sewage, and appeared as if it was never cleaned, with hair and debris consistently present in the drains. Invoices from the plumbing service documented visits for checking the smell in the drain and work related to the floor drain and main line in the tub room.
Failure to Follow Hand Hygiene During PEG Dressing Change and Inadequate UTI Surveillance
Penalty
Summary
The deficiency involves failure to follow infection prevention and control practices during a dressing change and inadequate infection surveillance for UTIs. During observation of wound care for Resident #20, who had multiple diagnoses including ALS, severe cognitive impairment (BIMS score 0), dependence for nearly all ADLs, and a stage 4 sacral pressure ulcer, an RN performed a PEG tube dressing change without proper hand hygiene. After removing the soiled dressing with gloved hands, the RN did not remove the soiled gloves, perform hand hygiene, and don clean gloves before cleansing the PEG stoma. Instead, the RN cleansed the site while still wearing the soiled outer gloves, then removed them to reveal a second pair of gloves underneath, and proceeded to apply a clean dressing. The RN confirmed this sequence of actions after the procedure. Facility policies titled "Dressing Change-Clean" and "Handwashing" required staff to remove and dispose of gloves and wash hands thoroughly after removing a soiled dressing, and to wash hands before and after contact with resident bodily fluids, indwelling lines, resident equipment, soiled linen, specimen collection, or general cleaning. These policies were confirmed by an LPN during interview. The observed practice during the PEG tube dressing change did not follow these written policies, as the nurse did not remove the soiled gloves and perform hand hygiene before cleansing the site and applying a new dressing. The facility also failed to conduct effective infection surveillance for UTIs. Review of infection control surveillance logs showed that in January 2026 the west wing had seven UTIs and the east wing had two, compared to three total UTIs in December 2025, all on the west wing. Three of the seven January west wing UTI cases lacked an identified organism on the surveillance log and were entered as "unknown" based on ER diagnoses and antibiotic orders. Room mapping for January showed multiple residents with UTIs in close proximity, including multiple residents in the same rooms and nearby rooms. The newly appointed infection preventionist reported she had been in the role for four weeks, had not yet investigated or monitored infection trends for January or February, and was still learning the program. A regional nurse and a newly hired RN were only beginning to review the logs for trends, and QAPI meeting minutes from the prior quarter documented multiple nosocomial infections without identifying problems, trends, or action plans related to those infections.
Failure to Ensure Telephone Access for Residents and Families
Penalty
Summary
Facility staff failed to ensure that residents and family members could reliably contact the facility via telephone. Multiple attempts by the state agency to reach the facility by phone on several occasions went unanswered, and there was no option to leave a message. Interviews with staff, the Ombudsman, family members, and residents confirmed ongoing issues with unanswered calls. A registered nurse acknowledged that phones sometimes went unanswered, especially during periods of short staffing, and the Ombudsman reported receiving complaints from families about this issue. Family members described repeated unsuccessful attempts to contact the facility, including one instance where a family member had to involve the police for a wellness check due to lack of response. Outside physicians also reported being unable to reach facility staff. A resident reported that after waiting 90 minutes for a response to his call light, he attempted to call the facility for assistance but received no answer, ultimately contacting the police for help. The administrator was aware of previous concerns but was not aware of the specific phone system issues on the dates in question. These findings indicate that the facility did not provide immediate access to residents as required, affecting the ability of residents and their families to communicate with staff and receive timely assistance.
Failure to Provide Safe and Appropriate Respiratory Care
Penalty
Summary
The facility failed to provide safe and appropriate respiratory care for two residents. For one resident with metabolic encephalopathy, dementia, dysphagia, and diabetes mellitus type two, physician orders specified continuous oxygen at two liters per minute via nasal cannula. However, during multiple observations, the resident's oxygen was set at 3.5 liters per minute, exceeding the prescribed dose. Nursing staff had documented that the oxygen was set correctly, but direct observation contradicted these records. For another resident with COPD, dysphagia, and dependence on supplemental oxygen, the nebulizer machine was found stored directly on the floor, with the mouthpiece in contact with both the machine and the wall, and the top of the machine covered in an unknown dried substance. The resident reported that nurses stored the nebulizer on the floor due to lack of table space and expressed a preference for it not to be stored there. These findings were confirmed by an LPN during the survey.
Failure to Complete Required Performance Evaluations for CNAs
Penalty
Summary
The facility failed to ensure that performance evaluations were completed for its certified nursing assistants (CNAs) as required by their policy. Specifically, four CNAs did not receive the necessary evaluations: CNA #807, hired in 2000, and CNA #816, hired in 2018, both lacked annual evaluations for 2024. Additionally, CNA #850 and CNA #873, both hired in 2024, did not have their 90-day evaluations completed. This deficiency was confirmed during a review of personnel files with Human Resources and through an interview with HR staff. The facility's policy mandates a 90-day evaluation and an annual evaluation on or before the employee's anniversary date, which was not adhered to in these cases.
Failure to Follow Menu and Portion Control Guidelines
Penalty
Summary
The facility failed to ensure that the menu and menu spreadsheet were followed, resulting in inaccurate portions and food items being served to residents. Observations revealed that the dietary staff used incorrect serving utensils, leading to discrepancies in portion sizes. For instance, a black slotted spoon was used to serve meatballs for both regular and mechanical soft diets, without knowledge of the serving size it provided. Additionally, the test tray for the regular diet contained only two meatballs instead of the three specified in the menu diet spreadsheet. The dietary manager confirmed that the recipe called for two meatballs, but the packaging label for the frozen meatballs and the menu diet spreadsheet indicated a serving size of three meatballs. Further observations showed that the facility did not prepare or serve carrots for the mechanical soft diet, despite having them available. The portion control chart and facility policies were not adhered to, as evidenced by the use of incorrect scoops for serving pureed pasta and meatballs. The dietary manager and staff acknowledged these discrepancies and verified that the serving utensils used did not match the required portion sizes outlined in the facility's policies. This failure to follow the menu and portion control guidelines had the potential to affect all residents in the facility.
Failure to Provide Bedtime Snacks
Penalty
Summary
The facility failed to ensure that snacks were provided at bedtime, affecting several residents and potentially impacting all 48 residents in the facility. During a resident council meeting, multiple residents reported that bedtime snacks were not offered, and when requested, staff claimed none were available. The Dietary Manager stated that upon admission, residents were interviewed about their snack preferences, and labels were made accordingly. However, it was the responsibility of the residents or nursing staff to inform the dietary department of any changes in snack preferences. A review of snack labels showed discrepancies, with some residents not having labels for snacks and others having specific snacks assigned. Observations revealed unopened snacks with labels from the previous night, with no documentation of refusal. A Dietary Aide mentioned that extra snacks were sent to each unit, assuming aides would distribute them, but sometimes snacks were returned to the kitchen uneaten. An LPN was unaware of where snack intake was recorded, and the Activity Director, who had been covering as a dietary manager, confirmed there was no documentation of snack offerings or refusals. The staff present during the interview could not provide an explanation for the discrepancies between resident reports and staff information.
Ice Machine Sanitation Deficiency
Penalty
Summary
The facility failed to maintain the ice machine in a clean and sanitary manner, which had the potential to affect all residents except one who had a physician order for no fluids. During a kitchen tour, a moderate amount of a white substance was observed running down each side of the ice machine located outside the kitchen. The Dietary Manager confirmed the presence of the white substance and mentioned that the installation of a water softener might help eliminate it. The Dietary Manager also stated that the ice machine was believed to be cleaned monthly. The facility's policy on food safety for ice, which was undated, indicated that ice machines and containers should be cleaned and sanitized regularly.
Inaccurate Staffing Data Submission to CMS
Penalty
Summary
The facility failed to submit accurate direct care staffing data to the Centers for Medicare and Medicaid Services (CMS) from July 2024 through September 2024. This deficiency was identified through a review of staffing schedules, time sheets, and interviews with staff. It was found that the Residential Care Facility (RCF) hall had no separate staff assigned between 11:00 P.M. and 7:00 A.M., with nursing facility staff covering these hours instead. Specifically, two nurses were splitting the hall, and nursing assistants attended to the personal needs of the RCF residents. The schedules reviewed showed no RCF staff scheduled during these hours, and there were 34 other shifts where the RCF schedule did not reflect separate staff. The Human Resources manager and the Administrator confirmed that nurses from the nursing facility were also assigned to half of the RCF residents throughout the day. Payroll records were used to submit staffing information to CMS, but there was no subtraction of hours worked in the RCF, leading to inaccurate data submission.
Infection Control and Catheter Care Deficiencies
Penalty
Summary
The facility failed to implement proper isolation protocols for a resident diagnosed with Clostridium difficile (C. diff). Despite the resident testing positive for C. diff, there were no isolation signs posted initially, and staff members, including an Activity Assistant and a Certified Nursing Assistant (CNA), entered the resident's room without donning personal protective equipment (PPE). The CNA also failed to perform appropriate hand hygiene after handling the resident's meal tray. The facility's policy required isolation precautions and specific handwashing protocols, which were not followed. Additionally, there was confusion regarding the appropriate disinfectant for shared equipment, as bleach wipes effective against C. diff were not readily available. The facility also failed to maintain proper catheter care for two residents, increasing the risk of urinary tract infections. One resident was observed with catheter tubing on the floor while sitting in a common area, and staff did not address the issue promptly. Another resident was found with a urinary catheter drainage bag and tubing lying on the floor next to their bed. The facility's policy clearly instructed staff to keep catheter bags and tubing off the floor, but this was not adhered to in both cases. These deficiencies highlight lapses in infection control and catheter care protocols, which could potentially affect all 48 residents in the facility. The lack of adherence to established policies and procedures for infection prevention and control, as well as catheter management, indicates a need for improved staff training and oversight to ensure resident safety and compliance with health regulations.
Inadequate Staffing Leads to Delayed Resident Care
Penalty
Summary
The facility failed to ensure sufficient staffing levels to meet the needs of all 48 residents, as evidenced by multiple observations and interviews. Residents and family members expressed concerns about long wait times for call light responses, sometimes extending to an hour or more, which affected toileting, transfers, medication administration, and led to incontinence. Certified Nursing Assistants (CNAs) and Licensed Practical Nurses (LPNs) reported working with inadequate staff, which hindered their ability to provide timely care, including assistance with mechanical lifts and showers. During a resident council meeting, additional residents reported insufficient staff to provide necessary care without long waits. An anonymous CNA revealed that even when a light-duty aide was present, the lone full-duty nursing assistant was expected to cover both the nursing facility and the attached residential care facility, which was challenging given the number of residents requiring two-person assistance. The facility's staffing issues were further highlighted by observations of call lights being ignored or turned off without providing assistance, leading to prolonged wait times for residents needing help with toileting and other care needs. The facility's assessment indicated that staffing was based on resident population and acuity, but the observed staffing levels were inadequate to meet these needs. The Regional Director of Operations acknowledged that toileting should occur within 20 minutes of a request, but observations showed that residents, such as Resident #2, waited significantly longer. The Ombudsman also reported previous observations of call lights taking over an hour for response, particularly on the 100 hall, where many residents required two-person assistance. This deficiency was investigated under specific complaint numbers, indicating ongoing concerns about staffing levels and their impact on resident care.
Deficiencies in Medical Record Documentation
Penalty
Summary
The facility failed to maintain complete and accurate medical records for several residents, leading to deficiencies in documentation regarding medication administration, catheter care, falls, dietary upgrades, activities of daily living, restorative care, and refusal of dental procedures. For Resident #9, there was no documentation of the administration of Aristada, an antipsychotic medication, for three consecutive months, which was confirmed by the Director of Nursing. Resident #13 experienced issues with migraine medication availability, with discrepancies between the number of doses delivered and administered, and a failure to document one administration. Resident #26's medical record lacked documentation for two falls, which were later found under a different section of the electronic health record, not part of the official medical record. Resident #97's catheter care was inadequately documented, with discrepancies in catheter size and type not clarified until after a urology consult. Resident #1's medical record showed a lack of documentation for assistance with activities of daily living, a dietary upgrade trial, and the use or refusal of splints for contractures, despite being dependent on staff for these needs. Resident #10's medical record did not document the refusal of a dental extraction recommended by the facility's dental provider. The Social Services Designee confirmed the resident's refusal but acknowledged the absence of documentation in the medical record. These deficiencies highlight significant lapses in maintaining accurate and complete medical records, impacting the quality of care provided to the residents.
Facility Fails to Maintain Clean and Functional Environment
Penalty
Summary
The facility failed to maintain a clean, sanitary, and functional environment, affecting 14 out of 49 residents. Observations revealed multiple issues, including a yellow/brown ring around the commode in one bathroom, gouged areas in bathroom walls, and trash on the floor in another room. Several rooms had dirty floors with dirt stains, and one room had a large dried dirt stain on the shower floor. Interviews with residents confirmed that the floors had not been mopped for weeks, and one resident reported a malfunctioning bed rail that had not been addressed since their arrival at the facility. The Director of Maintenance acknowledged staffing issues in housekeeping and verified the findings during a tour. The facility's housekeeping policy requires daily cleaning of surfaces, but this was not adhered to, as evidenced by the persistent dirt and stains in multiple rooms. The Director of Maintenance also noted that the painter had been let go, and priorities had to be adjusted due to staffing constraints. Despite recent floor maintenance, the yellowing/brown stain around one toilet remained, indicating a failure to maintain a homelike environment as per the facility's policy.
Failure to Provide Timely Access to Medical Records
Penalty
Summary
The facility failed to provide timely access to medical records for a resident, identified as Resident #10, who was cognitively intact and had multiple diagnoses including chronic osteomyelitis, metabolic encephalopathy, paraplegia, a pressure ulcer, depression, and diabetes mellitus type II. Resident #10 reported during a resident council meeting that he had requested to see his medical record concerning x-ray results and wound assessments but was denied access. Despite the resident's report, the facility's Administrator was initially unaware of any such request. The resident could not recall who he had spoken to about the request, but he permitted his name to be shared with the Administrator. Following the initial report on 01/09/25, Resident #10 stated on 01/13/25 that he still had not been granted access to his medical record. The facility's policy, last updated in May 2023, stipulates that a resident's record should be accessible within 24 hours of a request, excluding weekends and holidays. However, the Administrator admitted to not knowing if anyone had provided the requested access and was unable to identify who was responsible for ensuring compliance with the request. This lack of action and communication within the facility led to the deficiency in providing the resident with timely access to his medical records.
Inaccurate Advance Directive Documentation
Penalty
Summary
The facility failed to ensure the accuracy of advance directives for a resident, leading to a discrepancy between the documented wishes and the actual advance directive form. The medical record for a resident, who was admitted with diagnoses including intentional self-harm by firearm discharge, traumatic brain injury, and vascular dementia, indicated a DNRCC-A status in both the electronic and paper records. However, the advance directive form, signed by the resident's guardian and physician, specified a DNRCC status. This inconsistency was confirmed during an interview with the Director of Nursing, highlighting a failure to align the resident's documented wishes with the signed advance directive form.
Failure to Report Neglect of Resident's Physical Needs
Penalty
Summary
The facility failed to timely report allegations of possible neglect of a resident's physical needs and did not report these allegations to the state survey agency. The incident involved a resident with Alzheimer's disease, dementia, and other cognitive impairments, who was left in a chair overnight without receiving incontinence care. The resident was placed in a common area at approximately 2:43 P.M. and was not attended to until 6:02 A.M. the following morning, when a CNA provided incontinence care in the common area. Surveillance footage confirmed the lack of care during this period. The facility's policy on abuse, neglect, and exploitation required immediate reporting of such incidents, but the incident was not reported until two weeks later. The Administrator did not consider the lack of care as neglect, which led to the failure to report the incident to the state survey agency. The facility's policy defined neglect as failing to provide necessary care or services to avoid physical harm or mental anguish, which was not adhered to in this case.
Failure to Investigate Alleged Neglect of Resident
Penalty
Summary
The facility failed to conduct a thorough investigation of an allegation of possible neglect involving a resident diagnosed with Alzheimer's disease, dementia, generalized anxiety disorder, restlessness, and agitation. The resident, who had short and long-term memory loss and moderately impaired cognitive skills, was reportedly left in a chair overnight without receiving incontinence care. The care plan for the resident included goals to ensure the resident's needs were consistently met, including being clean, dry, and odor-free, and receiving assistance with toileting and incontinence care as needed. The incident was reported by a CNA who stated that another CNA had left the resident in a chair all night and only changed her before the day shift arrived. Surveillance footage reviewed by the Administrator and Activity Director confirmed that the resident was placed in a common area at 2:43 PM and remained there until 6:02 AM the following day, when she was changed in the common area. The CNA involved claimed not to have provided care to the resident since a previous date and denied seeing the resident in the chair overnight. However, the footage showed the CNA entering the area multiple times during the shift. The investigation was incomplete as there was no evidence of interviews with other staff who were present or aware of the situation. The facility's policy on abuse, neglect, and exploitation required immediate reporting and a thorough investigation of all allegations, but the investigation lacked documentation of interviews with other aides or an explanation for the lack of action or education with other staff. The Administrator acknowledged the failure to locate evidence of other staff involvement or interviews as part of the investigation.
Inaccurate PASRR Documentation for Resident
Penalty
Summary
The facility failed to ensure that a resident's Pre-Admission Screening and Resident Review (PASRR) document accurately reflected all of the resident's diagnoses. This deficiency was identified during a review of medical records and staff interviews. The resident in question was admitted with multiple diagnoses, including bipolar disorder, quadriplegia, depressive disorder, obsessive-compulsive disorder, and alcohol abuse. However, the PASRR document only listed bipolar disorder and major depression, omitting the diagnoses of obsessive-compulsive disorder and alcohol abuse. This discrepancy was confirmed during an interview with the Social Services Designee, who acknowledged the omissions in the PASRR document.
Failure to Provide Baseline Care Plan Summaries
Penalty
Summary
The facility failed to provide residents and/or their representatives with a written summary of the baseline care plan upon admission, affecting three residents. Resident #28, diagnosed with Alzheimer's disease, dementia, and other conditions, was admitted without evidence of receiving a baseline care plan summary. The Director of Nursing (DON) confirmed that no documentation was available to show that Resident #28 or their representative received this information. Similarly, Resident #29, who has multiple diagnoses including spinal stenosis, muscle wasting, and chronic pain, was admitted without receiving a baseline care plan summary. The resident, who is cognitively intact, reported not being offered meetings with the interdisciplinary team to discuss care and felt that their input was not considered. The DON verified the absence of a baseline care plan summary for Resident #29. Additionally, Resident #97, with conditions such as osteomyelitis and diabetes, also did not receive a baseline care plan summary, as confirmed by the DON.
Medication and Vital Sign Monitoring Deficiencies
Penalty
Summary
The facility failed to ensure proper transcription and administration of medication orders for a resident with constipation. The resident, who had diagnoses including spinal stenosis and chronic pulmonary edema, was prescribed Milk of Magnesia to be taken daily until a bowel movement, then as needed. However, the medication was incorrectly transcribed as 'daily as needed' and not administered as ordered. Even after a bowel movement was recorded, the medication was not adjusted to 'as needed' as per the physician's instructions. This transcription error was discovered by the Director of Nursing, but the order was still not corrected appropriately. Additionally, the facility did not obtain and document vital signs for another resident as ordered by the physician. This resident, with conditions such as amyotrophic lateral sclerosis and cerebral palsy, had a care plan that included monitoring vital signs. Despite orders to obtain vital signs every day shift and later every Thursday, there was no evidence of vital signs being recorded on several specified dates. The Director of Nursing confirmed the lack of documentation in the electronic medical record, indicating a failure to follow physician orders for vital sign monitoring.
Failure to Follow Fall Assessment Protocol
Penalty
Summary
The facility failed to provide appropriate services after a resident was observed on the floor. The resident, identified as Resident #26, had a medical history that included schizophrenia, muscle wasting and atrophy, parkinsonism, generalized muscle weakness, difficulty walking, need for assistance with personal care, blindness in one eye, and seizures. The resident was severely cognitively impaired and had experienced two or more falls since the prior assessment. On the day of the incident, the resident was found sitting on the floor by her bed. Two CNAs were notified and proceeded to move the resident into her wheelchair before informing the nurse, contrary to the facility's policy. The facility's policy required that a nurse be notified and assess the resident before moving them if they were found on the floor or if a fall was witnessed. However, the CNAs moved the resident without a nurse's assessment because the resident had previously stated she sometimes sat herself on the floor. The Director of Nursing confirmed that the correct procedure was not followed, as the nurse should have been notified and assessed the resident before any movement. The facility's Falls Program policy also required immediate notification of the falls committee to determine the resident's condition and investigate the potential root cause of the fall.
Inconsistent Dialysis Communication and Medication Administration
Penalty
Summary
The facility failed to ensure consistent communication with the dialysis center and proper administration of medications for a resident requiring dialysis. The resident, who has a history of end-stage renal disease and other medical conditions, was scheduled for dialysis on Mondays, Wednesdays, and Fridays. However, the facility did not administer the resident's morning medications on dialysis days, as the resident left for dialysis before the morning medication administration time. This resulted in the resident missing several doses of prescribed medications, including Calcium Acetate, Eliquis, and Trulicity, on multiple occasions. Interviews with facility staff revealed that the resident's morning medications were not given before dialysis, and there was no order to hold or administer them early. The Registered Nurse (RN) stated that the resident left for dialysis during the night shift, and the medications were not administered upon the resident's return. Additionally, the facility's communication with the dialysis center was inconsistent, as paperwork sent with the resident was not always returned completed, and the facility dietitian's communication with the dialysis center was not documented. The facility's policy on dialysis care was reviewed, indicating that residents receiving dialysis should be monitored for nutritional and fluid needs, with intake and output recorded per physician's orders. However, the facility did not adhere to this policy, as evidenced by the lack of consistent communication with the dialysis center and failure to administer medications as prescribed. The Director of Nursing (DON) acknowledged the issue and stated that there was no order to adjust the medication schedule for dialysis days.
Failure to Address Pharmacy Recommendations for Residents
Penalty
Summary
The facility failed to ensure that pharmacy recommendations were addressed by the physician for two residents, leading to deficiencies in medication management. Resident #38, who was admitted with multiple diagnoses including cerebral ischemia and diabetes mellitus, had pharmacy recommendations that were not addressed by the physician. The pharmacist recommended rinsing the resident's mouth after using a corticosteroid inhaler to prevent thrush and suggested using the lowest effective dose of Meloxicam. However, these recommendations were neither addressed nor signed by the physician, as confirmed by the Director of Nursing. Similarly, Resident #10, who had diagnoses including chronic osteomyelitis and paraplegia, also experienced a lack of physician response to pharmacy recommendations. The pharmacist requested clarification on the use of Percocet for minor pain on multiple occasions, but there was no evidence that the physician addressed these recommendations. The facility's policy requires that pharmacy findings and recommendations be communicated and responded to in a timely manner, which was not adhered to in these cases.
Failure to Timely Obtain Laboratory Samples
Penalty
Summary
The facility failed to obtain a laboratory sample in a timely manner for Resident #37, who had a diagnosis of enterocolitis due to clostridium difficile, among other conditions. On 12/19/24, a physician ordered a stool specimen to rule out clostridium difficile after the resident complained of severe diarrhea. Although a sample was collected the same day, it was not in the correct container, and the error was not rectified until 12/27/24, despite the resident having multiple bowel movements in the interim. The delay in obtaining the correct sample led to a late diagnosis and treatment initiation for the infection. For Resident #9, who had multiple diagnoses including amyotrophic lateral sclerosis and schizophrenia, a comprehensive metabolic panel was ordered but could not be obtained on 10/14/24 due to the resident's combative behavior. The physician was notified, and the labs were rescheduled for 10/16/24. However, there was no documented evidence of a laboratory order for the rescheduled date or of the resident's refusal. The facility's policy requires lab orders to be implemented as written, but this was not adhered to in this case.
Failure in Antibiotic Stewardship for Two Residents
Penalty
Summary
The facility failed to ensure the appropriate use of antibiotics for two residents, leading to deficiencies in antibiotic stewardship. Resident #9, diagnosed with conditions including amyotrophic lateral sclerosis and schizophrenia, was started on Cefdinir for a urinary tract infection (UTI) without the urinalysis culture and sensitivity (C&S) results. The urinalysis showed significant leukocytes and bacteria, prompting the physician to initiate antibiotic treatment before receiving the C&S report. The Infection Preventionist and Director of Nursing confirmed that the McGeer Criteria was not applied, and the C&S report was not available in the resident's medical record, indicating a lack of appropriate follow-up and adherence to antibiotic stewardship protocols. Resident #10, with diagnoses including chronic osteomyelitis and paraplegia, was prescribed ciprofloxacin for a wound infection without any documented assessment to justify the antibiotic's use. The facility's policy on antibiotic stewardship, which mandates the use of antibiotics only when necessary and with the correct indication, was not followed. Interviews with staff confirmed the absence of assessments for the appropriate use of antibiotics, highlighting a systemic issue in the facility's infection control practices.
Failure to Document Immunization Refusals
Penalty
Summary
The facility failed to provide documented evidence of refusals for pneumococcal and influenza immunizations for two residents. Resident #9, who was admitted with diagnoses including amyotrophic lateral sclerosis, cerebral palsy, muscle weakness, dysphagia, pressure ulcer of the sacrum, and schizophrenia, refused a Pneumovax immunization. However, there was no signed refusal or declination form by the resident or responsible party in the medical record. Similarly, Resident #38, admitted with diagnoses such as cerebral ischemia, muscle weakness, diabetes mellitus, chronic obstructive pulmonary disease, and peripheral vascular disease, also refused a pneumococcal immunization without a signed declination form. The Assistant Director of Nursing/Infection Preventionist confirmed the absence of completed and signed declination forms for both residents. The facility's policy stated that consent or declination forms should be completed upon admission, but this was not adhered to in these cases.
Failure to Uphold Resident Dignity and Privacy
Penalty
Summary
The facility failed to treat residents with dignity, as evidenced by two separate incidents involving Residents #13 and #28. In the first incident, Resident #13 reported that staff entered his room without his knowledge or permission and searched his belongings. This was confirmed by staff interviews, which revealed that the Activity Assistant entered Resident #13's room and removed beer without informing him or allowing him to be present. The facility's policy on room searches requires that residents be informed and allowed to be present during searches, which was not adhered to in this case. In the second incident, Resident #28, who has Alzheimer's disease and dementia, was provided incontinence care in a common area, which was captured on video. The video showed a CNA changing Resident #28's brief and clothing in the common area before moving her. The Administrator confirmed the accuracy of the investigation report, which documented the incident. This action violated the resident's right to dignity and privacy, as care was provided in a public space. Both incidents highlight a failure to uphold residents' rights to dignity and respect, as outlined in the facility's policies. The facility's Alcohol and Illegal Substance Use/Abuse policy and Room/Personal Space Search policy were not followed, leading to these deficiencies. The report indicates non-compliance with dignity standards, as investigated under Complaint Number OH00159892.
Failure to Notify Family of Resident's Hospital Transfer
Penalty
Summary
The facility failed to notify the resident's representative of a change in health status, affecting one resident. The resident, who had intact cognition, was admitted with multiple diagnoses including muscle weakness and cognitive communication deficit. The resident's son was listed as the emergency contact and power of attorney. Despite this, the facility did not inform the family when the resident was transferred to the hospital for emergency surgery after experiencing severe abdominal pain. The Director of Nursing confirmed that the facility's practice was not to notify emergency contacts if the resident was their own responsible party. This was despite the facility's policy stating that changes in a resident's condition should be promptly communicated to the resident, their physician, and the responsible party. The omission was highlighted by an Ombudsman who had an open case regarding the resident's concern about the lack of family notification during the hospital transfer.
Neglect of Resident's Incontinence Care
Penalty
Summary
The facility failed to prevent neglect of a resident's physical needs, specifically incontinence care, for Resident #28, who was diagnosed with Alzheimer's disease, dementia, generalized anxiety disorder, restlessness, and agitation. The resident had short and long-term memory loss and was always incontinent of bowel and bladder. The care plan for Resident #28 included goals to keep the resident clean, dry, and odor-free, with interventions for assisting with toileting and incontinence care as needed. On the night of the incident, Resident #28 was left in a chair in the common area from approximately 2:43 P.M. until 6:02 A.M. the following morning without receiving incontinence care. Surveillance footage confirmed that the resident was placed in the television room by a visitor and remained there throughout the night, receiving no staff interaction or hands-on care until the morning. CNA #873 was observed changing the resident in the common area before moving her, despite the facility's policy requiring incontinence care every two hours. The facility's investigation revealed discrepancies in staff accounts, with CNA #873 denying knowledge of the resident's prolonged stay in the common area and claiming to have never provided incontinence care in such settings. However, other staff members reported that it was not unusual for CNA #873 to delay incontinence care until the end of the shift. The facility's policy on neglect defines it as failing to provide necessary care, which in this case, resulted in the resident not receiving timely incontinence care, leading to the deficiency finding.
Failure to Post Daily Nurse Staffing Information
Penalty
Summary
The facility failed to post the required daily nursing staffing information, which had the potential to affect all 48 residents. On December 30, 2024, at 6:35 A.M., it was observed that the staffing information posted near the kitchen was dated December 25, 2024, with no additional forms available. This was confirmed by the Activity Director, who verified the outdated posting and acknowledged the absence of updated information. Later, the Activity Director provided a notebook found in the staff break room, explaining that the nurse responsible for posting the forms was unaware of the correct posting location as she was covering for another staff member. It was noted that residents and visitors did not have access to the break room to view the staffing information.
Failure to Administer Medication Leads to Resident Leaving AMA
Penalty
Summary
The facility failed to timely address the health concerns of a resident, resulting in the resident leaving the facility against medical advice (AMA). The resident, who was cognitively intact, had been admitted with multiple diagnoses including acute and chronic respiratory failure, chronic congestive heart failure, and major depressive disorder. A physician's order was in place for the resident to receive buspirone, an anti-anxiety medication, four times per day. However, the resident did not receive the scheduled doses of this medication at 5:00 P.M. or 9:00 P.M. on the day of the incident. The resident expressed difficulty breathing and anxiety, but was informed by the LPN that her vital signs were normal and that she had received medications from the emergency kit. Despite this, the resident decided to leave the facility, citing her previous heart attack and the lack of medication as reasons. The LPN failed to notify the physician of the missed doses or the resident's symptoms, as required by facility policy. The Director of Nursing confirmed that the medication was not administered as ordered, and the Administrator noted that the LPN should have informed a manager when the resident expressed the desire to leave AMA.
Latest citations in Ohio
A resident with intact cognition receiving Medicare Part A skilled services for metabolic encephalopathy had services discontinued while benefit days remained, but the facility did not issue the required Skilled Nursing Facility Advance Beneficiary Notice (SNF ABN). The Social Services Director later confirmed that no SNF ABN was provided and reported she believed only a Notice of Medicare Non-Coverage (NOMNC) was needed when all skilled services were stopped. This practice conflicted with the facility’s written policy, which required SNF ABNs to be issued when extended care items or services were initiated, reduced, or terminated due to expected non-coverage by Medicare.
Surveyors identified that the facility exceeded the acceptable medication error rate when two residents with type 2 DM received insulin doses that were not administered according to orders or manufacturer instructions. In two separate observations, an LPN administered Novolog and another LPN administered insulin glargine and insulin lispro without priming the insulin pens, and the insulin lispro and Novolog were given after the residents had already consumed a significant portion of their breakfast meals, despite orders for administration before meals. Manufacturer information for both insulin products required priming before each injection to ensure accurate dosing, and facility policy required medications, including insulin, to be administered safely, timely, and in accordance with prescriber orders and specified time frames.
Surveyors found that the facility failed to document tray line food temperatures for multiple meals served from two dining room kitchenettes, despite having a “Trayline Taste & Temperature Log” and a policy requiring food to be stored, prepared, distributed, and served according to professional food safety standards. Review of logs showed repeated missing entries for breakfast, lunch, and dinner services in both the Harrison and McClellan dining areas, and the Senior Director of Culinary Services confirmed that temperatures had not been recorded for those meals, potentially affecting all residents receiving meals from those kitchenettes.
The facility failed to conduct and document required periodic care conferences for two residents, despite multiple comprehensive, quarterly, and significant change MDS assessments and a policy requiring periodic care conferences with resident and/or family participation. One resident with Parkinson’s disease, post-stroke hemiplegia, TIA, DMII, and depression had only two documented care conferences over a year, while another resident with aphasia, cerebrovascular disease, DMII, gait difficulty, coagulation defect, depression, and muscle weakness had no documented care conferences in the past year, aside from a declined invitation to the representative. The UCC confirmed that care conferences were expected to occur quarterly and that no additional documentation existed for either resident.
A resident with Alzheimer's disease and type II DM, who required extensive assistance with ADLs and was receiving scheduled Lantus and sliding-scale Humalog, experienced a severely elevated blood glucose level. The on-call provider was notified and ordered an additional dose of lispro insulin with a directive to recheck the blood glucose after administration. Nursing staff administered the extra insulin but did not document any follow-up blood glucose check, and the DON confirmed that this reevaluation was required by the facility's abnormal blood glucose policy and was not completed or documented.
A resident with Parkinson’s disease, dementia, and hypothyroidism was prescribed levothyroxine once daily along with other medications. A consultant pharmacist’s monthly drug regimen review recommended that levothyroxine be given in the morning on an empty stomach, 30–60 minutes before food, per manufacturer instructions. The medical record contained no documented physician response to this recommendation, and the MAR showed the drug scheduled for morning administration while the resident was observed eating breakfast and receiving the medication at the same time. An LPN confirmed administering levothyroxine during the meal, and the DON verified there was no documentation explaining whether or why the pharmacist’s recommendation was or was not followed, resulting in a failure to act on and document the identified irregularity.
A resident with severe cognitive impairment, multiple comorbidities, documented gait and balance abnormalities, and a high fall risk was care planned and assessed by therapy to require contact guard assistance and use of a gait belt for transfers and ambulation. While being assisted by a CNA from a recliner to the bathroom with a walker, the CNA did not apply a gait belt, even though the resident had a known tendency to lean backward when standing. As the CNA reached to open the bathroom door, the resident lost balance and fell backward, striking the back of the head, and was later found by an LPN without a gait belt in place, contrary to the facility’s gait belt policy and the resident’s assessed needs.
A resident with CKD stage five requiring peritoneal dialysis (PD) was admitted with pre-admission physician orders for three daily PD exchanges and monitoring for peritonitis (fever, abdominal pain, cloudy effluent), but these monitoring orders were not entered into the facility’s physician orders. The care plan referenced PD and general monitoring but did not specifically address peritonitis monitoring. Paper PD flowsheets showed incomplete and inconsistent documentation of exchanges and resident condition, including missing condition/comments for individual treatments and no record of one ordered PD exchange. The PD cycler flowsheet lacked effluent descriptions on multiple days. The PD nurse reported facility staff were expected to monitor effluent and symptoms, and the DON confirmed the absence of specific peritonitis monitoring orders, lack of an order for the PD cycler, and documentation gaps, despite a facility policy requiring ongoing assessment and monitoring for complications before, during, and after dialysis treatments.
A nurse was observed preparing multiple oral medications for a resident with depression, traumatic brain injury, anxiety, and impaired cognition by pushing tablets and capsules from unit-dose cards directly into her ungloved hand and then using her fingers to place them into a medication cup. In a follow-up interview, the RN confirmed this practice and acknowledged that the correct procedure is to dispense medications directly from the card into the cup, contrary to the facility’s medication administration policy requiring adherence to good nursing principles and practices.
A resident with Alzheimer’s disease, diabetes, anxiety, significant ADL dependence, and behavioral symptoms was observed seated in a chair positioned against the nursing station with a locked wheelchair placed directly in front, also against the nursing station, effectively restricting movement. An LPN confirmed both wheelchair wheels were locked and that it should not have been placed there, while a CNA stated she had positioned the wheelchair to prepare for lunch, was unable to complete the transfer, and left it in place, acknowledging this was wrong. This arrangement conflicted with the facility’s restraint policy, which prohibits physical restraints except when alternatives are ineffective for treating a medical symptom and defines restraints as devices adjacent to the body that cannot be easily removed and that restrict freedom of movement or access to the body.
Failure to Issue Required SNF ABN When Discontinuing Medicare Part A Services
Penalty
Summary
The deficiency involves the facility’s failure to issue a Skilled Nursing Facility Advance Beneficiary Notice (SNF ABN) when Medicare Part A services were discontinued for a resident who still had available benefit days. The resident was admitted with a diagnosis of metabolic encephalopathy and had intact cognition per the Minimum Data Set assessment. The facility’s own SNF Beneficiary Notification Review documented that Medicare Part A skilled services began on 02/11/26 and the last covered day was 03/11/26, and that the facility initiated discharge from Medicare Part A services before the resident’s benefit days were exhausted. Despite this, no SNF ABN was provided to the resident or the resident’s representative. During interviews, the Social Services Director stated that the SNF ABN was issued hours prior to the last covered day but, upon reviewing her files, confirmed that no SNF ABN had actually been issued for this resident. She further explained that she believed an SNF ABN was only required if one skilled service remained and that if all skilled services were being discontinued, only the Notice of Medicare Non-Coverage (NOMNC) needed to be issued. The Administrator, however, stated that a resident should always receive both a SNF ABN and a NOMNC when Medicare Part A services are discontinued and benefit days remain. Review of the facility’s written policy dated 03/28/23 showed that the facility was required to issue SNF ABNs for initiation, reduction, or termination of extended care items or services when Medicare payment was not expected, which did not occur in this case.
Plan Of Correction
This Plan of Correction is submitted as required under State and Federal law. This Plan of Correction does not constitute an admission on the part of the Facility that the findings cited are accurate, that the findings constitute a deficiency or that the scope and severity regarding the deficiency cited are correctly applied. Any changes to the Facility's policies and procedures should be inadmissible in any proceeding on that basis. Without admitting or denying the validity or the existence of the alleged noncompliance, the Facility submits this Plan of Correction with the intention that it be inadmissible by any third party in any civil or other action against the facility or any employee, agent, officer, director or shareholder of the Facility. The Facility is utilizing this Plan of Correction as its allegation of substantial compliance as of 05/29/2026 F-0582 Corrective action for resident/s: On 5/14/26 Resident #34 was informed of rights and responsibilities related to Advanced Beneficiary Notice and voiced understanding of information for future reference by administrator. Identification of other residents who may be affected: Any resident receiving skilled services from nursing or therapy services. The Administrator audited all residents who were discharged from skilled services in the past 30 days to ensure they were issued a Notice of Non-Coverage and Advanced Beneficiary Notice on 5/29/26. No non-compliance was noted. Measures for systemic change: On 5/14/2026 Business Office Manager, Director of Rehab, Minimum Data Set nurse, Director of Nursing and Social Services Director were educated on proper procedure of issuing of Notice Of Medicare Non Coverage and Advanced Beneficiary Notice by administrator. All upcoming discharges from skilled services will be reviewed weekly at Utilization Review meeting to ensure notices will be delivered timely. How Corrective Action will be monitored: Administrator or designee to complete audits of all residents being discharged from skilled services to ensure they were issued a Notice of Non-Coverage and Advanced Beneficiary. This audit will be completed weekly x 4 weeks, then monthly x 2 months. Corrective action will be initiated for any noted non-compliance. Audit findings will be reviewed as part of the monthly quality assurance process to determine the need for further monitoring. Date of Compliance 5/29/26
Insulin Administration Errors and Failure to Prime Insulin Pens
Penalty
Summary
The deficiency involves the facility’s failure to maintain a medication error rate below 5%, with surveyors identifying 3 errors out of 28 medication administration opportunities, resulting in a 10.71% error rate. For one resident with type 2 diabetes mellitus and moderate cognitive impairment, the physician’s order directed Novolog insulin 10 units via subcutaneous pen-injector to be given before meals. During an observed medication pass, the LPN administered 10 units of Novolog insulin without priming the pen and did so after the resident had already consumed approximately 50% of the breakfast meal. The LPN later confirmed she did not prime the pen and acknowledged that the insulin was ordered to be administered prior to meals. Manufacturer instructions for the Novolog FlexPen specified that an air shot (priming) must be performed before each injection to ensure proper dosing. Another resident, also diagnosed with type 2 diabetes mellitus and with intact cognition, had orders for insulin glargine 35 units subcutaneously twice daily and insulin lispro 20 units subcutaneously before meals, plus 12 units subcutaneously if blood glucose was between 251 mg/dL and 300 mg/dL. During an observed medication administration, an LPN administered 35 units of insulin glargine and 32 units of insulin lispro without priming the insulin pens and after the resident had consumed approximately 90% of the breakfast meal, despite orders for insulin lispro to be given before meals. The LPN later stated she could not remember if she had primed the pen and acknowledged that the insulin was ordered to be administered prior to meals. Manufacturer information for insulin lispro stated that the pen must be primed before each injection to confirm insulin delivery and remove air, and that failure to prime could result in too much or too little insulin. The DON confirmed the expectation that insulin be administered as ordered, including priming each pen with two units before dialing the prescribed dose, and facility policy required medications, including insulin, to be administered safely, timely, and in accordance with prescriber orders and required time frames.
Plan Of Correction
This Plan of Correction is submitted as required under State and Federal law. This Plan of Correction does not constitute an admission on the part of the Facility that the findings cited are accurate, that the findings constitute a deficiency or that the scope and severity regarding the deficiency cited are correctly applied. Any changes to the Facility's policies and procedures should be inadmissible in any proceeding on that basis. Without admitting or denying the validity or the existence of the alleged noncompliance, the Facility submits this Plan of Correction with the intention that it be inadmissible by any third party in any civil or other action against the facility or any employee, agent, officer, director or shareholder of the Facility. The Facility is utilizing this Plan of Correction as an allegation of substantial compliance as of 5/29/2026. F-0759 Corrective action for resident/s: Residents #21 and #22 were assessed and evaluated by nurse and Director of Nursing 5/14/26. Resident #21 and #22 both denied any adverse effects and none were noted upon assessment by the Director of Nursing on 5/14/2026. Notification made to physician on 5/14/2026. LPN # 2 competency Eval on insulin administration with the Director of Nursing completed 5/14/2026. Identification of other residents who may be affected: Diabetic residents on assignment of LPN #2/station 2 have the potential to be affected and were assessed by the DON/Designee on 5/14/26 and found to be within normal limits. Measures for systemic change: All Nurses were educated by the Director of Nursing on the steps for Insulin administration per competency, diabetes clinical protocol policy, Medication and treatment orders policy, administering medications policy, and Obtaining fingerstick Glucose Level policy On 5/14/2026. How Corrective Action will be monitored: Director of Nursing and Assistant Director of Nursing will complete insulin administration audits on 5 nurses. This audit will be completed weekly x 4 weeks, then monthly x 2 months. Corrective action will be initiated for any noted non-compliance. Audit findings will be reviewed as part of the monthly quality assurance process to determine the need for further monitoring. Date of Compliance: 5/29/2026
Failure to Document Tray Line Food Temperatures in Dining Room Kitchenettes
Penalty
Summary
The deficiency involves the facility’s failure to document tray line food temperatures for meals served from the Harrison and McClellan Dining Room kitchenettes, as required by professional standards for food service safety and the facility’s own policy. Review of the “Trayline Taste & Temperature Log” (revised September 2018) showed missing temperature documentation for multiple meals from the Harrison Dining Room kitchenette, including dinner on 03/30/26 and 03/31/26, lunch and dinner on 04/01/26 and 04/02/26, dinner on 04/07/26, and lunch and dinner on 04/08/26 and 04/10/26. The Senior Director of Culinary Services confirmed during interview that tray line food temperatures were not documented on the log for these meals. Similarly, review of the same log for the McClellan Dining Room kitchenette revealed that tray line food temperatures were not documented for dinner on 04/01/26, breakfast and lunch on 04/02/26, and lunch and dinner on 04/07/26. The Senior Director of Culinary Services also verified these omissions during interview. The facility census at the time was 27 residents, and the governing “Food and Nutrition” policy, approved on 09/07/21, stated that the facility must store, prepare, distribute, and serve food in accordance with professional standards for food service safety.
Plan Of Correction
F812 The facility will continue to ensure food temperatures are completed before meals are served for all residents. To ensure compliance with this standard the following measures have been taken: 1. Immediately 4/15/26 culinary supervisor #224 was re-educated by Dietary Manager to this standard and policy "Food and Nutrition" which includes documentation of food temperatures. 2. All dietary staff have been re-educated to the standard and policy "Food and Nutrition" during the month of April 2026. 3. Audits of food temperature documentation to be completed by Dietary Manager 4 x per week for 4 weeks then weekly for 4 weeks. 4. Administrator to validate audits/compliance and provide additional training as needed. Administrator will present to QAPI committee for ongoing monitoring and further direction.
Failure to Conduct and Document Required Care Conferences
Penalty
Summary
The deficiency involves the facility’s failure to complete and document comprehensive care conferences at required intervals in accordance with care plan regulations and facility policy. For one resident with Parkinson’s disease with dyskinesia, cognitive communication deficit, hemiplegia and hemiparesis following cerebral infarction, transient cerebral ischemic attack, type II diabetes mellitus, and major depressive disorder, the record showed multiple MDS assessments over a one-year period, including annual, quarterly, and significant change assessments. However, only two care conferences were documented during the last 12 months, despite the expectation that care conferences be conducted quarterly with the resident and family when possible. The Unit Care Coordinator confirmed that no additional care conference documentation existed for this resident beyond the notes dated 04/21/25 and 01/02/26. A second resident, with diagnoses including aphasia following cerebrovascular disease, cerebral infarction, type II diabetes mellitus, unsteadiness on feet, difficulty in walking, coagulation defect, depression, and muscle weakness, also had multiple MDS assessments completed over the review period, including quarterly and annual assessments. The record contained a note that a care conference was offered to the resident’s representative, who declined to attend, but there was no documentation of any care conferences for the most recent 12 months. The Unit Care Coordinator confirmed that no other care conference documentation was available for this resident. Facility policy stated that periodic care conferences involving the resident, family, and the interdisciplinary team are part of the care planning process, but the required periodic care conferences and corresponding documentation were not completed for these two residents.
Plan Of Correction
THIS PLAN OF CORRECTION SERVES AS BERKELEY SQUARE'S CREDIBLE ALLEGATION OF SUBSTANTIAL COMPLIANCE AS OF June 1, 2026. Without admitting or denying the validity or existence of the alleged deficiencies, Berkeley Square provides the following Plan of Correction: F657 The facility will continue to document completion of care conferences at the required intervals for all residents, including residents #04 & #15. To ensure compliance with this standard the following measures have be taken: 1. The social service designee and the inter- disciplinary team were re-educated by the administrator to the facility policy "Care Conference" on 4/29/26 and verbalized understanding. 2. Care conferences for resident #04 and resident #15 were conducted on or before 4/29/2026 by the interdisciplinary team. 3. Review of all other residents was conducted by the social service designee to validate and ensure that care conference schedule is up to date with timely care conferences scheduled for them on 4/15/2026. Audits of care conferences to be completed weekly for four weeks and then monthly after that by the social service designee. Documentation of the care conference including any identified concerns in the medical record. Administrator to validate audits/compliance and provide additional training as needed. Administrator will present results of these audits to QAPI committee for ongoing monitoring and further direction.
Failure to Reevaluate Blood Glucose After Treatment for Hyperglycemia
Penalty
Summary
The facility failed to ensure that a resident with diabetes received treatment in accordance with professional standards of practice when nursing staff did not reevaluate the resident's blood glucose after treatment for severe hyperglycemia. The resident, admitted with diagnoses including Alzheimer's disease, type II diabetes mellitus, and depression, had physician orders for Humalog insulin on a sliding scale before meals, Lantus insulin 25 units daily, and lisinopril 5 mg daily. The resident required extensive assistance with activities of daily living, including transfers, toileting hygiene, eating, and bathing. On the evening in question, the resident's blood glucose was documented as 532 mg/dL, and the on-call provider was notified. The provider gave a new order to administer an additional 8 units of lispro (Humalog) and to recheck the blood glucose in 30 minutes. The electronic medication administration record showed that the blood glucose of 532 mg/dL was obtained at 9:00 p.m. and that the additional 8 units of lispro were administered at 9:21 p.m. However, there was no documentation in the resident's chart that the blood glucose was rechecked after the additional insulin was given. In an interview, the DON confirmed there was no evidence of reevaluation and verified that, according to the facility's "Abnormal Blood Glucose Procedure" policy, the resident should have been reevaluated and that the evaluation step should have been included in the progress note documentation.
Plan Of Correction
F684 The facility will continue to ensure all residents, including #03, receive treatment in accordance with professional standards of practice and reevaluated for hyperglycemia. To ensure compliance with this standard the following measures have been taken: 1. The director of nursing assessed resident #03, reviewed documentation and orders and found no ill effects immediately 4/16/26. 2. All licensed nurses were re-educated to facility policy "Blood Glucose Monitoring" by the Director of Nursing/designee in April 2026. 3. Audits of like-residents that require blood sugar checks to be completed by the director of nursing/designee two times a week for 4 weeks and then monthly after that to validate correct follow through when there is abnormally high blood glucose result. The Administrator will bring results of these audits to the QAPI committee for ongoing monitoring and further direction.
Failure to Act on Pharmacist Drug Regimen Recommendation for Thyroid Medication
Penalty
Summary
The deficiency involves the facility’s failure to ensure that pharmacy recommendations from the monthly drug regimen review were acted upon and documented for a resident. The resident was admitted with diagnoses including Parkinson’s disease, dementia, and hypothyroidism, and had current physician orders for levothyroxine 150 mcg once daily, buspirone 50 mg twice daily, and losartan 100 mg once daily. A medication regimen review dated 11/25/2025 included a consultant pharmacist recommendation that levothyroxine be administered consistently in the morning on an empty stomach, at least 30–60 minutes before food, per manufacturer instructions. There was no specific physician response in the medical record to this recommendation, and the facility’s policy stated that consulting pharmacist reviews are sent to nursing and addressed with the primary care provider or consulting specialist for review and follow-up. Review of the resident’s medication administration record for April 2026 showed levothyroxine scheduled for 9:00 a.m. On observation, the resident was seen eating breakfast in the dining area at 8:03 a.m., and an LPN reported administering the levothyroxine 150 mcg to the resident while the resident was in the dining area eating breakfast. The DON confirmed there was no evidence in the resident’s medical record explaining why the consultant pharmacist’s recommendation from 11/25/2025 was or was not acted upon. This lack of documented physician review and action on the pharmacist’s identified irregularity constituted noncompliance with the drug regimen review requirements.
Plan Of Correction
F756 The facility will continue to ensure the pharmacy recommendations from the monthly drug regimen review by a licensed pharmacist are acted upon for all residents, including #08. To ensure compliance with this standard the following measures have been taken: 1. Resident #08 was assessed by the registered nurse and med review completed by 4/28/26. After review of resident's drug regime's, it was discovered that resident #8 had 2 separate medication recommendations on the same form, to be reviewed by two separate practitioners, pharmacy has been instructed and agreed to separate meds on individual forms. 2. Licensed nurses re-educated to facility policy "Drug Regimen Review" by Director of nursing/designee in April 2026 and no later than 5/8/26. Licensed nurses are responsible for ensuring the reviews and recommendations are given to the physician for timely review. 3. Review of all other current residents Drug Regimen orders completed by Director of nursing/designee on 4/16/26 to ensure recommendations were followed up on/reviewed by the physician and address concerns if needed. 4. Audit of drug regime recommendations, pharmacy recommendations, and physician follow up to be completed weekly for four weeks by the Director of nursing/designee. Administrator will present results of these audits to the QAPI committee for ongoing monitoring and further direction.
Failure to Use Required Gait Belt During Ambulation Resulting in Resident Fall
Penalty
Summary
The deficiency involves the facility’s failure to ensure that a required gait belt was used while assisting a high fall‑risk resident with ambulation, resulting in a fall with head injury. The resident had multiple diagnoses including metabolic encephalopathy, hypertension, osteoarthritis, muscle weakness, gait and mobility abnormalities, major depressive disorder, anxiety, and visual hallucinations. Admission and subsequent MDS and fall risk assessments documented that the resident was severely cognitively impaired, required moderate to maximal assistance with transfers and ambulation, could not independently come to a standing position, exhibited loss of balance while standing, used an assistive device, and had decreased muscle coordination. The resident had a history of falls prior to admission and was assessed as being at high, later moderate, risk for falls. The resident’s fall care plan identified her as at risk for falls and included interventions such as providing maximum to moderate assistance with transfers and walking short distances, use of a walker and wheelchair, and following the facility’s fall protocol. Therapy notes and care conference documentation indicated that the resident leaned backwards when standing, required contact guard to minimal assistance for bed mobility and transfers, and needed constant verbal cueing for safe sequencing during toilet transfers. The physical therapist confirmed that the resident was to use a gait belt with staff when ambulating, and the DON verified that therapy had assessed the resident as requiring contact guard assistance and a gait belt for ambulation and transfers. On the day of the incident, a CNA was assisting the resident from her recliner to the bathroom using a walker. The CNA walked beside the resident, providing guidance and support, and reported having a hand on the resident while assisting her. As they approached the bathroom door, the CNA reached for the doorknob to open it, and at that moment the resident began to lose her balance and fell backwards to the floor, striking the back of her head. The nurse who responded found the resident on her back at the foot of the bed with her feet near the bathroom, noted a red raised area on the back of the head, and documented that the resident was not wearing a gait belt and that the gait belt was on the dresser. In the facility’s investigative summary and in interviews, the CNA acknowledged that she did not have a gait belt on the resident while ambulating her, despite the resident’s assessed need for hands‑on assistance and gait belt use per facility policy and the resident’s care and therapy plans.
Failure to Implement PD Orders and Monitor Resident Receiving Peritoneal Dialysis
Penalty
Summary
The deficiency involves the facility’s failure to implement pre-admission physician orders for peritoneal dialysis (PD) and to provide ongoing monitoring for a resident with chronic kidney disease (CKD) stage five who required PD. Pre-admission orders dated 11/14/25 specified three daily PD exchanges at 6:00 A.M., 2:00 P.M., and 10:00 P.M., and directed staff to monitor for signs and symptoms of peritonitis, including fever, abdominal pain, and cloudy effluent. These monitoring orders were not entered into the facility’s physician orders. The resident’s care plan noted the need for PD and included general monitoring interventions (labs, signs of bleeding, bacteremia, septic shock, and significant vital sign changes), but did not specifically address the ordered monitoring for peritonitis. Review of PD documentation showed incomplete and inconsistent charting of treatments and resident condition. The paper peritoneal flowsheet had columns for time of PD and condition/comments, including instructions to call the nurse immediately for cloudy fluid, abdominal pain, or fever. However, the first entry on 11/15/26 at 2:00 P.M. only noted that the PD nurse completed the exchange, and the 10:00 P.M. entry that day had no condition/comment documentation. Subsequent days (11/16/25, 11/17/25, and 11/18/25) contained only one condition/comment entry per day rather than for each exchange, and there was no documentation that the 6:00 A.M. PD on 11/18/25 was completed. The PD cycler flowsheet starting 11/19/25 lacked any description of the effluent on multiple days. The PD nurse from the dialysis company stated facility staff were expected to monitor effluent for cloudiness and assess for abdominal pain and fever, and the DON confirmed there was no electronic physician order for peritonitis monitoring or for use of the PD cycler, that the paper charting did not allow for effluent description or symptom documentation for each treatment, and that PD was not documented at one ordered time. The facility’s dialysis policy required ongoing assessment and monitoring for complications before, during, and after treatments, which was not reflected in the documentation for this resident.
Improper Infection Control During Medication Administration
Penalty
Summary
Surveyors identified a deficiency in infection prevention and control related to medication administration for Resident #29. The resident was admitted on 02/28/14 with diagnoses including depression, traumatic brain injury, and anxiety, and had impaired cognition per a quarterly MDS assessment. During an observation on 03/25/26 at 6:58 A.M., RN #281 prepared the resident’s medications by removing an Amoxicillin-Pot Clavulanate tablet from the medication card and pushing it directly into her ungloved hand, then using her fingers to place the pill into a medication cup. The same process was observed for multiple other medications, including Escitalopram Oxalate, Furosemide, Sennosides, Lyrica, and Vitamin D, each being pushed from the card into the RN’s ungloved hand and then transferred by her fingers into the medication cup before administration to Resident #29. In a subsequent interview at 7:27 A.M. the same day, RN #281 confirmed she had placed each medication into her ungloved hands prior to administration and acknowledged that the proper procedure was to push the pills directly from the card into the medication cup. Review of the facility’s “Medication Administration – General guidelines” policy, revised 10/08/25, stated that medications are to be administered in accordance with good nursing principles and practices. This practice failure was cited as a deficiency under Complaint Number 2681777.
Improper Use of Wheelchair as a Physical Restraint
Penalty
Summary
Surveyors identified a deficiency related to the facility’s failure to ensure a resident was free from physical restraints. Resident #7, admitted with diagnoses including Alzheimer’s disease, diabetes mellitus, and anxiety disorder, was documented on a recent MDS as rarely understood and dependent for ADLs except eating. The resident ambulated independently on the unit without an assistive device and had documented verbal and other behaviors occurring one to three days during the look-back period. The care plan noted the resident had potential to be physically aggressive, chase staff, throw objects, and be combative with care, with interventions such as offering choices, administering medications as ordered, and intervening early when agitation occurred. During an observation and interview, Resident #7 was found sitting in a chair with the right arm of the chair positioned against the nursing station and a wheelchair placed directly in front of him. The left arm of the wheelchair was also against the nursing station, and both wheelchair wheels were locked, creating a barrier that appeared to restrain the resident, who was sleeping with his knees touching the locked wheelchair. An LPN confirmed both wheelchair wheels were locked and that the wheelchair should not have been placed in front of the resident. A CNA reported she had placed the wheelchair there in preparation to get the resident up for lunch, was unable to transfer him, and left the wheelchair in that position, acknowledging it was wrong to keep it there. The facility’s physical restraint policy stated that physical restraints are not used except when alternatives are not appropriate or effective for treating a medical symptom and defined physical restraints as any device attached or adjacent to the body that the individual cannot easily remove and that restricts freedom of movement or access to the body.
Trusted data from CMS and state health departments
Every citation, penalty and Plan of Correction is sourced from public CMS records (latest release May 27, 2026) and official state health department websites — never guesswork.
Trusted by long-term care providers and associations.
