Wexner Heritage House
Inspection history, citations, penalties and survey trends for this long-term care facility in Columbus, Ohio.
- Location
- 1151 College Avenue, Columbus, Ohio 43209
- CMS Provider Number
- 365026
- Inspections on file
- 34
- Latest survey
- December 29, 2025
- Citations (last 12 mo.)
- 26
Citation history
Health deficiencies cited at Wexner Heritage House during CMS and state inspections, most recent first.
A resident with severe cognitive impairment and total dependence for care did not receive proper incontinence care from a CNA, who failed to dry the vaginal area and did not cleanse or dry the buttocks, rectal, or coccyx area, contrary to facility policy.
Staff failed to perform hand hygiene during meal tray service, as observed with three residents who required assistance with meal setup and feeding. Despite the availability of hand sanitizer and facility policy requiring hand hygiene, a CNA assisted residents without sanitizing hands before or after contact, potentially affecting all residents on the unit. The residents involved had complex medical conditions, including dementia, diabetes, and chronic kidney disease.
A resident with severe cognitive impairment and multiple health conditions was admitted with a skin alteration that was inconsistently assessed and documented by staff. Despite care plans and physician orders for skin care, there was no evidence of consistent repositioning or timely notification of the wound nurse and wound physician. Incomplete assessments and lack of documentation led to the worsening of the wound, resulting in an unstageable pressure ulcer with necrosis requiring debridement.
A resident with severe cognitive impairment alleged sexual assault by a male staff member. The facility's investigation was incomplete, as only night shift staff were interviewed, key staff statements were delayed, and new bruising was not fully documented or investigated. The facility did not follow its own policy for abuse investigations, resulting in an insufficient response to the allegation.
A resident with multiple complex conditions did not receive physician-ordered wound care on several days, and there was no evidence that critical medications for low potassium were administered as ordered. Nursing staff failed to document or recall the administration of these treatments, and required orders were not entered into the medical record, resulting in non-compliance with facility policy.
A resident with multiple serious health conditions experienced a critically low potassium level, prompting a physician to order immediate potassium administration and additional lab tests. Although the RN relayed the orders to an LPN, only a basic metabolic panel was completed, and the required comprehensive metabolic panel and magnesium tests were not performed. The DON confirmed the orders were not entered into the medical record, and staff interviews revealed a breakdown in communication and follow-through.
Two residents experienced harm due to the facility's failure to promptly assess, monitor, and implement individualized interventions for pressure ulcer prevention and care. One resident developed an unstageable heel ulcer that was not identified or treated in a timely manner, while another was admitted with existing unstageable ulcers that were not comprehensively assessed or treated for two days. The facility did not follow its own wound care policies, resulting in delayed interventions and inadequate documentation.
Two residents with indwelling urinary catheters were observed with their catheter collection bags uncovered and visible to others, despite physician orders requiring privacy covers. LPNs confirmed the lack of privacy bags, resulting in urine being visible from the hallway and during resident mobility, which failed to uphold resident dignity.
A resident with multiple medical conditions developed an unstageable deep tissue injury to the left heel, which was identified by staff and reported to management and the resident's power of attorney, but not to the primary care physician as required by facility policy. Medical records showed no evidence of physician notification or immediate intervention for the wound at the time of discovery, despite the resident being at risk for skin breakdown.
A resident with severe cognitive impairment and multiple medical conditions was transferred to a hospital without proper documentation of the transfer or required information being provided to the receiving provider. The DON confirmed that essential details such as responsible physician, representative information, advance directives, and care instructions were missing from the record, contrary to facility policy.
A resident with a gastrostomy tube and multiple complex medical conditions received incontinence care from CNAs who wore gloves but did not don a gown, as required by the facility's enhanced barrier precautions policy for residents with indwelling medical devices. Both staff confirmed that the required precautions were not followed during the observed care.
The facility failed to conduct accurate and timely weekly skin assessments and treatment orders for two residents, leading to deficiencies in care. One resident had a skin alteration under the right breast with no documented weekly assessments, while another had multiple wounds with delayed treatment orders and insufficient documentation. The facility's policies on wound care were not adhered to, resulting in non-compliance.
A facility failed to report an abuse allegation involving a resident with multiple medical conditions to the State agency within the required two-hour timeframe. The incident was reported to an LPN and then to the DON, who informed the Administrator. However, the Administrator delayed reporting to the State agency until the next day, misunderstanding the policy requirements.
A resident with a DNRCC code status was mistakenly given CPR after experiencing cardiac arrest due to a miscommunication about their code status. The error occurred when an LPN provided the wrong room number to the ADON, leading to the incorrect assumption of a full code status. CPR was administered until emergency services arrived, but the resident did not survive.
A facility failed to obtain a urine sample for a resident with end-stage renal disease and urinary tract infections, despite a verbal order due to cloudy urine. The resident experienced no urine output overnight, and it was discovered that the Foley catheter was incorrectly placed. After reinsertion, 350 ml of urine was returned, but no sample was collected. The resident was later hospitalized with an acute complicated UTI. The DON revealed that the nurse involved could not recall if the physician was updated about the situation.
A facility failed to maintain infection control during catheter care for a resident with end-stage renal disease and urinary tract infections. A CNA used alcohol wipes incorrectly and failed to change gloves after care, as confirmed by the ADON. The facility's hand hygiene policy requires hand hygiene before and after resident care and glove removal.
Inadequate Incontinence Care Provided by CNA
Penalty
Summary
A deficiency was identified when a certified nursing assistant (CNA) failed to provide appropriate incontinence care to a resident who was always incontinent of bowel and bladder. The resident had severe cognitive impairment and required total assistance with activities of daily living, including toileting and personal hygiene. During observed incontinence care, the CNA washed and rinsed the vaginal area and creases, then applied a clean adult brief, but did not dry the vaginal area as required by facility policy. Additionally, the CNA did not cleanse or dry the resident's buttocks, rectal, or coccyx area during the care process. The CNA confirmed in an interview that these steps were omitted. Facility policy specifies that after washing and rinsing, the genital area should be dried, and the rectal area should be washed, rinsed, and dried using a clean area of the washcloth for each stroke. The failure to follow these procedures resulted in non-compliance with the facility's incontinence care policy.
Failure to Perform Hand Hygiene During Meal Tray Service
Penalty
Summary
The facility failed to maintain infection control practices during meal tray service, as observed with three residents. Certified nursing assistant (CNA) #100 was seen assisting residents with meal tray setup and other tasks, such as raising the head of the bed and removing linens, without performing hand hygiene before or after these activities. This occurred despite the presence of hand sanitizer on the meal delivery cart and the facility's policy requiring hand hygiene by all employees. CNA #100 confirmed during interviews that hand hygiene was not performed during the lunch tray pass. The residents involved had significant medical histories, including dementia, diabetes mellitus with chronic kidney disease, Crohn's disease, heart failure, arthritis, peripheral vascular disease, and cognitive impairment. Observations were made both in resident rooms and the dining area, affecting all three residents observed during the meal service. The failure to perform hand hygiene had the potential to impact all thirteen residents on the unit, with a total facility census of seventy-six.
Failure to Implement Comprehensive Pressure Ulcer Prevention and Care
Penalty
Summary
A cognitively impaired resident with multiple comorbidities, including diabetes, peripheral vascular disease, and a recent surgical amputation, was admitted to the facility with a documented skin alteration to the coccyx. Upon admission, there were inconsistencies in the assessment and documentation of the resident's skin condition, with records alternately describing the area as moisture-associated skin damage (MASD), an open area, and an unstageable pressure ulcer. The initial assessments failed to provide a comprehensive description, staging, or measurements of the wound, and there was no clear photographic evidence to support the presence or stage of a pressure ulcer. Despite care plans and physician orders for skin care interventions, such as the application of Triad paste and HydraGuard, there was no documented evidence that staff consistently provided or encouraged turning and repositioning every two hours as required. Additionally, the facility failed to ensure timely notification and involvement of the wound nurse and wound physician when the skin alteration was first identified. The wound physician was not made aware of the resident's condition until several days after admission, and the wound nurse was not notified at all during the initial period. Weekly skin assessments and wound documentation were either incomplete or missing, with staff failing to document wound descriptions, measurements, or photographs as required by facility policy. The lack of comprehensive assessment, documentation, and timely intervention led to the deterioration of the resident's skin condition, resulting in the development of an unstageable pressure ulcer with necrosis that required debridement. The facility's failure to implement a resident-centered plan for the prevention and treatment of pressure ulcers, including appropriate assessment, documentation, and communication among staff and consulting clinicians, directly contributed to actual harm to the resident.
Failure to Conduct Thorough Investigation of Alleged Sexual Assault
Penalty
Summary
The facility failed to conduct a thorough investigation into an alleged sexual assault involving a resident with severely impaired cognitive skills, who was admitted with multiple diagnoses including a urinary tract infection, Parkinson's disease, fibromyalgia, and dystonia. The resident, who was incontinent of bowel and bladder, reported to her daughter that she had been raped by a male staff member. The allegation was reported to the facility, and a self-reported incident was created. The resident described the alleged perpetrator as a short man with short black hair, but the only male CNA on duty did not match this description, and no other males were present according to the staff schedule and employee list. The resident was assessed, and no immediate signs of abuse were found, though a full body assessment later revealed multiple bruises and a hematoma. The facility's investigation was limited in scope. Only staff working the night shift on the date of the alleged incident were interviewed, and staff who provided care during the following day were not questioned about the resident's condition or demeanor. Statements from key staff, including the accused CNA, were not obtained until several days after the incident, and the investigation did not address new findings of bruising to the back of the resident's knees. Documentation of the bruising was incomplete, lacking photographs, measurements, or detailed descriptions. The facility's policy required interviews with all relevant witnesses and thorough documentation, but these steps were not fully followed. The resident was ultimately sent to the hospital for examination, where a rape kit was performed, and a police report was filed by the family. The family also requested additional safety measures for the resident. Despite these actions, the facility's internal investigation did not meet its own policy standards for thoroughness, as it failed to interview all potentially relevant staff, did not fully document physical findings, and delayed obtaining statements from involved personnel. The deficiency centers on the incomplete and insufficient investigation of the abuse allegation.
Failure to Complete Physician-Ordered Treatments, Medications, and Lab Testing
Penalty
Summary
The facility failed to provide treatments, administer medications, and obtain laboratory testing as ordered by the physician for a resident with multiple complex medical conditions, including acute osteomyelitis, sepsis due to MRSA, diabetes, peripheral vascular disease, congestive heart failure, atrial fibrillation, dementia, and an open surgical wound. The resident was at risk for skin breakdown and had a physician order for daily wound care, but the treatment administration record showed no evidence that the wound care was completed on several specified days. The Director of Nursing confirmed there was no documentation of the required treatments on those dates, despite facility policy requiring immediate documentation after treatment. Additionally, the resident experienced critically low potassium levels as revealed by laboratory results. Although the physician provided orders for immediate administration of potassium and anti-nausea medication, there was no evidence in the medical record that these medications were administered or that the orders were entered as required. Interviews with nursing staff confirmed a lack of recall or documentation regarding the administration of these medications, and the DON verified the absence of evidence for the ordered interventions. Facility policy required that verbal orders be transcribed and executed or safely handed off, but this process was not followed in this case.
Failure to Complete Physician-Ordered Laboratory Tests
Penalty
Summary
The facility failed to ensure that laboratory testing was completed as ordered by the physician for a resident with multiple complex medical conditions, including acute osteomyelitis, sepsis due to MRSA, diabetes, and an open wound. The resident had a critically low potassium level identified through laboratory testing, which prompted the physician to order immediate administration of potassium chloride and additional laboratory tests, specifically a comprehensive metabolic panel (CMP) and magnesium level. The orders were communicated by an RN to an LPN, who acknowledged understanding of the instructions. Despite these orders, only a basic metabolic panel (BMP) was completed, and the required CMP and magnesium tests were not performed. The failure was confirmed through closed record review and interviews, with the DON verifying that the orders for the additional blood work were not entered into the medical record. The LPN involved could not recall details about the potassium or the ordered blood work, and the RN confirmed that the orders were relayed but not executed. Facility policies required nurses to transcribe and execute physician orders or ensure a safe hand-off, and to contact laboratory services as needed, but these procedures were not followed in this instance.
Failure to Prevent and Manage Pressure Ulcers
Penalty
Summary
The facility failed to assess, monitor, and implement a comprehensive and individualized pressure ulcer prevention program for two residents, resulting in the development and inadequate management of pressure ulcers. One resident, who was dependent on staff for bed mobility and used a wheelchair, was admitted without skin issues but was identified as at risk for skin breakdown. Despite care plans and physician orders for preventive measures such as floating heels and regular repositioning, the resident developed an unstageable pressure ulcer on the left heel. The ulcer was not discovered until it had progressed significantly, and there was no evidence of timely intervention, assessment, or notification to the physician at the time of discovery. The facility did not implement appropriate offloading interventions or wound care until several days after the ulcer was identified. Another resident was admitted with multiple complex medical conditions, including end-stage renal disease and an unstageable pressure ulcer to the sacrum and right heel, as documented in the hospital discharge summary. However, the facility's admission assessment failed to identify these skin issues, and the resident was not comprehensively assessed for pressure ulcers upon admission. There was a delay of two days before any wound treatment was initiated, and the required comprehensive wound assessment and documentation were not completed as per facility policy. Both cases demonstrate a lack of timely and thorough skin assessments, failure to implement and document individualized interventions, and delays in initiating appropriate wound care. The facility's actions did not align with its own wound care policy, which requires prompt assessment, documentation, and intervention for residents at risk of or presenting with pressure ulcers. These deficiencies resulted in actual harm to at least one resident and affected two out of three residents reviewed for pressure ulcers.
Failure to Ensure Privacy for Residents with Indwelling Catheters
Penalty
Summary
Surveyors identified that two residents were not treated in a dignified manner due to the facility's failure to ensure privacy for residents with indwelling urinary catheters. One resident, admitted with multiple diagnoses including surgical aftercare, chronic kidney disease, and lymphoma, was observed with a visible urinary catheter collection bag containing clear yellow urine that could be seen from the hallway. The resident's medical orders specified that the urinary drainage bag should have a cover over it every shift, but no privacy bag was present in the room at the time of observation. An LPN confirmed that the catheter bag was not contained in a privacy bag and was visible from the hallway. Another resident, with a history of acute transverse myelitis, quadriplegia, and other chronic conditions, was observed mobilizing in a power wheelchair with the indwelling urinary catheter collection bag resting on the footrest, uncovered and visible while moving down the hallway. This resident's physician orders also required a privacy cover for the urinary drainage bag every shift. An LPN verified that the catheter bag was not contained in a privacy bag and urine was visible as the resident moved through the hallway. These observations demonstrated the facility's failure to maintain resident dignity as required by their care plans and physician orders.
Failure to Notify Physician of Unstageable Deep Tissue Injury
Penalty
Summary
The facility failed to notify a resident's primary care physician of an unstageable deep tissue injury (DTI) to the resident's left heel at the time of discovery. The resident, who had multiple diagnoses including COPD, pressure-induced deep tissue damage, and a history of traumatic brain injury, was found by a CNA to have a dark, painful mark on the left heel. The nurse observed an 8.0 cm unstageable pressure area with intact skin and notified management and the resident's power of attorney, but did not notify the physician. The weekly skin and wound evaluation confirmed the presence of an unstageable pressure ulcer with slough and/or eschar, but lacked a detailed wound description. Medical record review showed no evidence of treatment or intervention for the unstageable DTI at the time of discovery, nor documentation that the physician was informed. The resident's quarterly MDS assessment indicated risk for skin breakdown and the presence of an unstageable pressure ulcer not present on admission, with interventions such as pressure-reducing devices and skin care in place. The Director of Nursing later verified that the physician had not been notified when the wound was first identified. Facility policy requires immediate notification of the physician and resident representative in the event of significant changes in a resident's condition, which was not followed in this instance.
Failure to Document and Communicate Required Transfer Information
Penalty
Summary
A deficiency was identified when a resident with multiple complex medical conditions, including dementia with behavioral disturbances, diabetes, hypertension, and a history of repeated falls, was transferred from the facility to an acute care hospital. The resident, who had a severe cognitive deficit, was assessed by a nurse after becoming unresponsive to commands, and the transfer to the emergency room was initiated at the request of the resident's son. However, the medical record review revealed that there was no documentation of the disposition of the resident's transfer or the required information provided to the receiving provider. Specifically, the facility failed to document essential transfer information such as the physician responsible for the resident's care, resident representative information, advance directives, special instructions or precautions for ongoing care, comprehensive care plan goals, and other necessary details to ensure a safe and effective transition. The Director of Nursing confirmed that there was no evidence in the medical record that the receiving facility received the required information, and the transfer itself was not properly documented, which was not in accordance with the facility's own policy.
Failure to Implement Enhanced Barrier Precautions During Incontinence Care
Penalty
Summary
The facility failed to implement enhanced barrier precautions (EBP) as required for a resident with an indwelling medical device. During an observation of incontinence care provided to a resident with multiple diagnoses, including dementia, chronic pulmonary edema, hepatic failure, and a stage IV sacral pressure ulcer, staff were seen performing incontinence care without donning a disposable gown, despite the presence of a gastrostomy tube. The care plan for the resident indicated a high risk for infection due to incontinence and the use of an indwelling device. Certified Nursing Assistants (CNAs) washed their hands and wore gloves but did not use a gown during high-contact care activities, such as changing briefs and cleansing the resident. Both CNAs confirmed in an interview that EBP, specifically the use of a disposable gown, was not maintained during the procedure. Facility policy required the use of gowns and gloves during high-contact care for residents with indwelling medical devices, but this protocol was not followed during the observed care event.
Deficiencies in Skin Assessment and Treatment Orders
Penalty
Summary
The facility failed to ensure accurate and timely weekly skin assessments and treatment orders for two residents, leading to deficiencies in care. Resident #21, who was admitted with conditions including unspecified dementia and a need for assistance with personal care, had a treatment order for a skin alteration under the right breast. However, there were no weekly skin assessments documented to monitor the wound, as confirmed by the Director of Nursing (DON). Resident #41, admitted with conditions such as acute kidney failure and type 2 diabetes, had multiple wounds upon admission, including arterial wounds on the right leg and a surgical wound on the right knee. The plan of care did not include these wounds, and there were no documented skin assessments or treatments for these wounds from admission through mid-November. The DON confirmed that the orders for wound care were placed late, and there was a lack of documentation regarding the wounds' types, locations, and descriptions. The facility's policies required specific documentation and weekly assessments for wounds, which were not followed in these cases. The deficiencies were identified during an investigation under several complaint numbers, highlighting the facility's non-compliance with its wound and skin care program guidelines.
Failure to Timely Report Abuse Allegation
Penalty
Summary
The facility failed to report an allegation of resident abuse to the State agency within the required timeframe. Resident #46, who was cognitively intact and had multiple medical conditions including chronic respiratory failure, cirrhosis, and dementia, was involved in the incident. An allegation of abuse was reported to an LPN on the evening of 12/16/24, who then informed the DON. The DON subsequently notified the Administrator. However, the Administrator did not report the allegation to the State agency until the following day, exceeding the two-hour reporting requirement for abuse allegations. The facility's policy mandates that allegations of abuse or serious bodily injury be reported to the State Department of Health immediately, but no later than two hours after the allegation is made. The Administrator misunderstood the policy, believing he had 24 hours to report the incident due to the absence of significant injury to the resident. This misunderstanding led to the delay in reporting the abuse allegation, resulting in a deficiency finding during the survey related to Complaint Number OH00160901.
Failure to Honor DNRCC Code Status
Penalty
Summary
The facility failed to honor a resident's Do Not Resuscitate Comfort Care (DNRCC) code status, resulting in the administration of life-saving measures and cardiopulmonary resuscitation (CPR) after the resident experienced cardiac arrest. The resident, who had diagnoses including chronic obstructive pulmonary disease, cirrhosis of the liver, and viral hepatitis B, was found by a State tested Nursing Assistant (STNA) to be having difficulty breathing. A Licensed Practical Nurse (LPN) was informed and, upon assessing the situation, called for assistance from the Assistant Director of Nursing (ADON). Despite the resident's DNRCC status, CPR was initiated due to a miscommunication regarding the resident's code status. The incident occurred when the LPN, after being alerted to the resident's distress, mistakenly provided the wrong room number to the ADON, leading to the incorrect assumption that the resident had a full code status. As a result, CPR was administered until emergency medical services arrived. It was only after the resident was transported to the hospital that the error was discovered, revealing that the resident had a DNRCC code status. Unfortunately, the resident did not survive the incident.
Failure to Obtain Urine Sample and Incorrect Catheter Placement
Penalty
Summary
The facility failed to obtain ordered urine samples for testing due to cloudy urine for Resident #196, who was admitted with diagnoses including end-stage renal disease and urinary tract infections. The resident required an indwelling catheter for urine elimination and was dependent on staff for personal care. On a specific date, a nurse received a verbal order to change the Foley catheter and perform a urine dip test due to the cloudy appearance of the urine. However, the urine sample was not obtained, and the order was not documented as completed. Subsequently, the resident experienced no urine output overnight, and it was discovered that the Foley catheter was incorrectly placed in the vagina instead of the bladder. After reinsertion, 350 ml of urine was returned, but there was no documentation indicating that a urine sample was collected. The resident later presented with symptoms of nausea, labored breathing, and confusion, leading to hospitalization where she was diagnosed with an acute complicated urinary tract infection due to the chronic indwelling Foley catheter. The Director of Nursing (DON) revealed that the nurse involved could not recall if the physician was updated about the inability to obtain the urine sample. The facility's policy on catheter care emphasizes meeting the psychosocial, physical, and emotional needs of residents, yet the failure to complete the urine test and the incorrect catheter placement contributed to the resident's hospitalization. This deficiency was investigated under a specific complaint number.
Infection Control Deficiency During Catheter Care
Penalty
Summary
The facility failed to maintain proper infection control measures during catheter care for a resident. The resident, who had end-stage renal disease, urinary tract infections, and required assistance with personal care, was observed to have intact cognition and was dependent on staff for toileting and personal hygiene. During an observation, a CNA was seen wearing a gown and gloves while performing catheter care but used alcohol wipes incorrectly by wiping towards the body instead of away. Additionally, the CNA used the same gloves to adjust the bed and cover the resident after completing the care, which violated infection control protocols. The Assistant Director of Nursing (ADON) was present during the procedure and confirmed that infection control measures were not maintained. The facility's policy on hand hygiene, dated March 31, 2022, requires hand hygiene before and after caring for a resident and after glove removal. This incident was identified during an investigation for a specific complaint, indicating a deficiency in the facility's infection control practices.
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.
