Widows Home Of Dayton
Inspection history, citations, penalties and survey trends for this long-term care facility in Dayton, Ohio.
- Location
- 50 South Findlay Street, Dayton, Ohio 45403
- CMS Provider Number
- 366178
- Inspections on file
- 24
- Latest survey
- February 24, 2026
- Citations (last 12 mo.)
- 4
Citation history
Health deficiencies cited at Widows Home Of Dayton during CMS and state inspections, most recent first.
A resident with significant cardiac history and an ICD repeatedly screamed out and reported being shocked over the course of a day. An LPN assessed the resident, suspected a UTI, unplugged and checked the bed, took vital signs, and wrote a note in a provider binder but did not document in the medical record or notify a physician, and she was unaware the resident had an ICD. Later, an RN received report that the resident had been screaming all day about being shocked, confirmed the presence of a pacemaker/ICD, noted an irregular and elevated heart rhythm, attempted to reach the on-call provider without success, and awaited a return call without sending the resident out before shift change. On the next shift, another LPN responded when the resident again screamed in pain, documented that the resident reported ICD shocks for several hours, obtained low BP and elevated HR, honored the resident’s request to go to the ER, contacted the on-call provider, and called EMS. EMS and hospital records showed the resident had experienced numerous ICD shocks associated with serious arrhythmias and required emergency treatment and ICU admission, while facility policy required vigilant monitoring, timely assessment, documentation, and immediate physician notification for significant changes in condition.
The facility failed to ensure that a CNA providing personal care was properly certified with the State of Ohio. A staff member originally hired as a housekeeper completed an online NATCEP but never took the state certification exam, and there was no CNA license listed for this individual on the Ohio Nurse Aide Registry. Despite this, the staff member worked multiple 12-hour shifts providing direct care. The DON and HR later acknowledged they were unaware the state test had not been completed and that required follow-up on certification status did not occur, affecting all residents in the facility.
A resident with significant cardiac history and an ICD experienced an acute change in condition characterized by screaming, reports that someone or the bed was shocking him, and later clear complaints of repeated ICD shocks over several hours. An LPN assessed the resident, suspected a UTI, unplugged and checked the bed, obtained vital signs but did not document them, did not recognize the presence of an ICD, and did not call the provider, instead only placing a note in a provider binder. Hours later, an RN documented chest "shocking" complaints and attempted to contact the on-call provider without a response, and subsequently another LPN documented ongoing ICD shocks, abnormal vital signs, and the resident’s request to go to the ER, after which the provider agreed to hospital transfer. EMS and hospital records confirmed frequent ICD firings, A-fib with RVR, and the need for cardiology consultation, antiarrhythmic therapy, and ICU admission. The DON confirmed that staff failed to notify the provider and document the acute change in condition as required by the facility’s Change in Condition policy.
A resident with a history of stroke, COPD, severe CAD, prior CABG, and an ICD repeatedly screamed out in pain and reported being shocked throughout a day and evening shift, but an LPN who assessed the resident did not document the complaints, assessment, or vital signs in the medical record or notify a physician, instead only noting the issue in a provider binder. A subsequent RN and then an LPN received report that the resident had been screaming about being shocked, and when the symptoms recurred, the resident was assessed, EMS was called, and he was found to be in A-fib with RVR and transported to the hospital, where he reported repeated ICD firings and required cardiology consultation, amiodarone, and ICU admission. The DON confirmed that facility policy requires documentation of changes in condition and that the resident’s record lacked required entries for the earlier acute change in condition.
A resident admitted without pressure ulcers and assessed as low risk developed an unstageable, facility-acquired pressure ulcer after staff failed to complete required weekly skin assessments and did not identify the wound until it had advanced. Despite a care plan outlining preventive measures, documentation and assessment lapses led to the pressure ulcer's progression before it was properly addressed.
The facility did not ensure an RN was present for at least eight consecutive hours on one day, as confirmed by staffing records and staff interview, despite facility policy requiring daily RN coverage. This affected all residents in the facility.
Surveyors identified multiple failures in food safety and sanitation, including staff not wearing hair nets or gloves while handling food, improper labeling and storage of food items, evidence of pest infestation, and unsanitary kitchen conditions. These deficiencies were confirmed by staff and were not in compliance with facility policies, affecting all residents receiving dietary services.
Surveyors observed that two garbage cans in the kitchen food preparation area were left uncovered on multiple occasions, which was confirmed by a dietary staff member. Facility policy requires that garbage and refuse containers be covered when not in use.
Surveyors observed mouse droppings between the deep fryer and stove and on a rack below the steamer, as well as three cockroaches on the floor by the dry storage area. Dietary staff confirmed these findings. Pest control records indicated routine monthly treatments with no issues previously noted, despite the facility's policy requiring food service areas to be kept clean and free from pests.
Staff served meals in Styrofoam containers due to staffing shortages, and the main dining room was found with significant dust, debris, and a dead fly on the curtains. Multiple resident rooms and bathrooms were heavily soiled with black substances and unclean toilets, with staff confirming these conditions. Facility policy requires a clean, homelike environment, but these standards were not met in both dining and resident areas.
The facility did not consistently update care plans after changes in condition or complete required care conferences. For example, a resident with a new stage III pressure ulcer did not have this reflected in their care plan, and several residents with complex medical histories had no documented care conferences or incomplete documentation, despite facility policy requiring these actions.
Staff did not maintain safe and sanitary conditions in common areas, as evidenced by torn cove base, missing floor tiles creating trip hazards, a non-functioning ceiling light with a broken cover, and dusty ceiling vents with debris. These issues were confirmed by a CNA and the Maintenance Supervisor and had the potential to affect all residents, staff, and visitors.
A resident with multiple medical conditions expired in the facility, and the facility did not transfer the remaining balance of the resident's personal funds to the estate within the required thirty-day period, as confirmed by record review and staff interview.
A resident with multiple chronic conditions was found with several medications and supplements at her bedside, none of which had physician orders or documentation of administration. An LPN confirmed these items should have been secured in the medication cart, in accordance with facility policy requiring all drugs and biologicals to be stored in locked compartments.
A resident with multiple medical conditions did not receive her ordered meal and was instead given a peanut butter sandwich without being consulted, as kitchen staff failed to discuss alternative options when the requested item was unavailable. The resident confirmed this was a recurring issue, and facility policy requiring support of dietary choices was not followed.
A resident did not receive prescribed Percocet on multiple occasions due to unavailability, despite a physician's order. The resident, with a history of amputation and other medical conditions, was cognitively intact and required assistance with daily activities. Nurses' notes revealed communication issues with the pharmacy and lack of access to the Pyxis system, leading to missed doses. The facility's policy mandates timely administration of medications, which was not followed.
A resident with multiple medical conditions did not receive Insulin Glargine, Insulin Lispro, and Zoloft as ordered on several occasions, as confirmed by the MAR and a Regional Clinical Nurse. Despite the lack of documentation, the resident did not experience negative effects. The facility's policy requires medications to be administered safely and timely.
A resident at risk for pressure ulcers developed an unstageable ulcer on the right heel and a stage II ulcer on the left heel due to the facility's failure to implement preventive measures and conduct thorough skin assessments. The care plan lacked specific interventions for heel protection, and staff did not report early signs of skin breakdown. The ulcers were only identified during a wound assessment by a CNP, highlighting lapses in communication and documentation.
A resident with a surgical incision on the right knee showed signs of possible infection. Despite instructions from a CNP to notify the orthopedic surgeon, the facility staff only left a message and did not follow up. The resident was later transferred to the hospital for complications. The facility failed to adhere to its policy requiring prompt physician notification of significant changes.
The facility failed to follow a resident's enteral tube feeding orders, administering continuous feeding with incorrect flush amounts and not changing the enteral feed bag after 24 hours, as confirmed by the DON.
The facility failed to administer medications as ordered, resulting in a 9.67% medication error rate. A resident with multiple diagnoses had three medications omitted during a medication pass because the LPN could not locate them in the medication cart.
Failure to Respond Timely to Resident’s Repeated ICD Shock Complaints
Penalty
Summary
The deficiency involves the facility’s failure to provide timely, adequate, and necessary care, monitoring, and treatment following an acute change in condition for a resident with an implanted cardioverter defibrillator (ICD). The resident, who had a history of stroke, COPD, acute respiratory failure with hypoxia, coronary artery disease from ischemic cardiomyopathy, a low ejection fraction, prior coronary artery bypass grafting, and ICD placement, was alert and oriented per a recent MDS. On the day in question, the resident repeatedly complained of being shocked and screamed out in pain throughout the day. One LPN reported that the resident stated a man or the bed was shocking him; she suspected a UTI, unplugged and checked the bed, took vital signs, and wrote a note in a provider binder for follow-up the next day, but did not document the event in the medical record or notify a physician. She also stated she did not know the resident had an ICD. Later that evening, an RN received report that the resident had been screaming all day about being shocked. When the RN assessed the resident around 9:30 P.M., the resident reported being shocked by his pacemaker. The RN, who stated he was unaware of the pacemaker until the resident mentioned it, reviewed the record and confirmed the device, noted an irregular and elevated heart rhythm, and documented that the resident complained of a shocking feeling in his chest with heart rates of 64 and 69 bpm. The RN attempted to contact the on-call provider but received no answer and awaited a return call; he did not obtain further orders or send the resident to the hospital before the end of his shift. He reported to the oncoming LPN that the resident had complained of being shocked and instructed that the resident should be sent out if it occurred again. About an hour into the night shift, the oncoming LPN heard the resident screaming in pain, assessed him, and documented that the resident complained of ICD shocks that had been occurring for the last four hours. At that time, the resident’s vital signs included a BP of 94/59 mmHg, HR 92, RR 22, and O2 saturation of 96%, and the resident requested to go to the emergency room because the shocks were scaring him. The LPN contacted the on-call provider, who agreed to send the resident to the hospital, and EMS was called. EMS documented that the resident reported 12–15 ICD shocks in the prior three hours, with heart rates rising to 225 bpm and atrial fibrillation with rapid ventricular response. Hospital records and the medical director’s note later indicated the resident had been in ventricular tachycardia with repeated ICD defibrillations, hypokalemia, and more than 35 shocks per ICD report, requiring antiarrhythmic medications, IV drips, and ICU admission. The facility’s change in condition policy required vigilant monitoring, comprehensive assessment, documentation in the medical record, and immediate physician notification for significant changes, which were not consistently followed in this case.
Unlicensed CNA Allowed to Provide Resident Care
Penalty
Summary
The deficiency involves the facility’s failure to ensure that employed CNAs were properly certified with the State of Ohio, as required by facility policy and state regulations. Personnel record review showed that CNA #13 was originally hired as a housekeeper and later completed an online Nurse Aide Competency Evaluation Program (NATCEP), but there was no evidence she had obtained state certification. Timecard review for February 2026 showed CNA #13 worked multiple 12-hour shifts providing care. Review of the Ohio Nurse Aide Registry confirmed there was no current or expired CNA license for CNA #13. The facility’s policy on required training and certification stated that nurse aides must have successfully completed a state-approved NATCEP and either be awaiting certification results or be enrolled in a state-approved NATCEP within the first four months of employment, with certification to be verified through the state registry. Interviews further confirmed that CNA #13 was not licensed and was nonetheless providing personal care to residents. The DON acknowledged that CNA #13 had completed an online CNA program but never took the state test for licensure and verified that she was not licensed as a CNA. CNA #13 herself confirmed she was not licensed, was providing personal care, and reported that her scheduled state test had been cancelled during a government shutdown, and that the DON and Human Resources were not aware she had not completed the state test. Human Resources staff confirmed CNA #13 was not licensed and stated they failed to follow up after her test was cancelled. The facility census at the time was 65 residents, and the failure to ensure proper CNA licensure had the ability to affect all residents.
Failure to Notify Provider of Acute Change in Condition Related to ICD Shocks
Penalty
Summary
The deficiency involves the facility’s failure to notify a physician or non-physician provider when a resident experienced an acute change in condition. Resident #52, admitted with diagnoses including cerebral infarction, COPD, and acute respiratory failure with hypoxia, had intact cognition per a recent MDS with a BIMS score of 15. On 01/31/26, between 11:00 A.M. and 10:55 P.M., there was no documented evidence that the physician or on-call provider was contacted when the resident had an acute change in condition around 1:00 P.M. Later that evening at 10:56 P.M., an RN documented that the resident complained of a shocking feeling in his chest; assessment showed a pacemaker with heart rates of 64 and then 69 bpm, and the on-call provider was contacted but did not answer, with the nurse awaiting a return call. In the early hours of 02/01/26 at 12:55 A.M., an LPN documented that the resident complained his ICD had been shocking him for the last four hours, with vital signs including BP 94/59 mmHg, HR 92, RR 22, and O2 sat 96%. The resident requested transfer to the emergency room due to fear from the shocks, and the on-call provider then agreed to send him to the hospital; EMS later recorded elevated heart rates up to 225 and documented that the resident reported 12–15 ICD shocks in the prior three hours and was in A-fib with RVR. Hospital records showed the resident, with significant cardiac history including CAD, ischemic cardiomyopathy with EF 20–25%, prior CABG, and ICD placement, required cardiology consultation, initiation of amiodarone, and ICU admission. In an interview, the resident stated he had been shocked and initially was not sent out despite significant discomfort. An LPN who worked the 7:00 A.M. to 8:00 P.M. shift on 01/31/26 reported the resident was screaming and saying a man or the bed was shocking him; she suspected a UTI, unplugged and checked the bed, took vital signs but did not document them, did not know he had an ICD, and only placed a written note in the provider binder without calling the provider about the acute change. The DON confirmed staff should document and notify the provider for acute changes and verified the provider was not notified of the change in condition on 01/31/26, contrary to the facility’s Change in Condition policy requiring immediate physician notification for significant changes.
Failure to Document Resident’s Acute Change in Condition and Cardiac Symptoms
Penalty
Summary
The deficiency involves the facility’s failure to maintain a complete and accurate medical record for a resident who experienced an acute change in condition. The resident, admitted with diagnoses including cerebral infarction, COPD, and acute respiratory failure with hypoxia, had intact cognition as shown by a BIMS score of 15. On the date in question, there was no nursing documentation between 11:00 A.M. and 10:55 P.M. regarding the resident’s complaints of being shocked and screaming in pain, despite multiple reports that these symptoms occurred throughout the day. According to interviews, a day-shift LPN reported that the resident was screaming and saying that a man or the bed was shocking him. Believing the resident might have a UTI because he “was not making any sense,” the LPN unplugged and checked the bed, took vital signs, and wrote a note in the provider’s binder for follow-up, but did not document the assessment or the resident’s complaints in the medical record and did not notify a physician. The LPN also stated she did not know the resident had an ICD. Later, an RN who relieved the day-shift nurse received report that the resident had been screaming all day about being shocked. When the resident again screamed out and reported being shocked by his pacemaker, the RN assessed him, noted an irregular and elevated heart rhythm, and attempted to contact the on-call provider, but the first related entry in the medical record was not made until 10:56 P.M. Subsequently, the night-shift LPN received report that the resident had been screaming in pain most of the day due to being shocked. About an hour into that shift, the resident again screamed out in pain, was assessed, and EMS was called. EMS documented that the resident complained of shocking chest pain and was in A-fib with RVR, and he was transported to the hospital. Hospital records showed the resident reported repeated ICD firings and had a significant cardiac history including CAD from ischemic cardiomyopathy, low ejection fraction, prior CABG, and ICD placement, and he required cardiology consultation, initiation of amiodarone, and ICU admission. The DON confirmed that staff are required by policy to document changes in condition in the medical record and verified that the resident’s record lacked documentation from the day-shift LPN regarding the acute change in condition.
Failure to Complete Timely Skin Assessments Resulting in Advanced Pressure Ulcer
Penalty
Summary
The facility failed to thoroughly assess and monitor the skin integrity of a resident who was admitted without pressure ulcers and assessed as low risk for their development. Despite having a care plan in place that included interventions such as regular repositioning, use of pressure-relieving devices, nutritional support, and weekly skin assessments by a licensed nurse, there were significant lapses in the execution and documentation of these interventions. Specifically, weekly skin assessments were not completed for three consecutive weeks, and shower sheets did not document any wounds or open areas during this period. A new skin issue was first identified as moisture-associated skin damage (MASD) with scabbing, but no detailed assessment or measurements were performed at that time. Subsequently, a wound nurse practitioner assessed the area and classified it as an unstageable, facility-acquired pressure ulcer with 100% slough tissue, requiring sharp debridement. The resident's care plan was updated to reflect the presence of the pressure ulcer, and dietary notes indicated an increased need for nutrition to promote wound healing. However, the pressure ulcer risk assessment continued to rate the resident as low risk, with no noted limitations in mobility. Interviews with facility staff confirmed the missed weekly skin assessments and the failure to identify the wound until it had reached an advanced stage. The facility's own wound management policy required weekly wound and skin assessments, and national guidelines emphasized the importance of comprehensive and ongoing skin assessments to detect early signs of pressure damage. The lack of timely and thorough skin assessments directly contributed to the development and progression of the resident's pressure ulcer.
Failure to Provide Required RN Coverage
Penalty
Summary
The facility failed to ensure that a Registered Nurse (RN) was scheduled for at least eight consecutive hours daily, as required by both facility policy and regulatory standards. Review of staffing schedules for a specified period revealed that on one date, there was no RN present in the facility for the required duration. This was confirmed during an interview with the Clinical Director, who acknowledged the absence of an RN on that day. The facility's own policy mandates the presence of an RN for at least eight consecutive hours each day, seven days a week. The census at the time was 68 residents, all of whom had the potential to be affected by this lapse.
Widespread Food Safety and Sanitation Deficiencies in Dietary Services
Penalty
Summary
The facility failed to ensure that food was prepared, stored, and served in accordance with professional standards, resulting in multiple deficiencies observed during survey. Staff were observed not following required hygiene practices, such as a CNA assisting with food preparation without wearing a hair net and other staff handling ready-to-eat foods with bare hands instead of gloves. Additionally, clean plates were dried with a rag after being washed, and food preparation utensils, such as spatulas, were found to be burnt and blackened. Sanitation and food storage practices were also deficient. The kitchen and storage areas contained evidence of pest infestation, including mouse droppings and large insects. Food items in both coolers and freezers were found to be unlabeled, undated, unsealed, and in some cases, expired. There was also a foul odor and a puddle of reddish-brown liquid in the walk-in cooler, attributed to meat thawing, with staff unable to confirm how long the liquid had been present. Dry storage areas had food stored directly on the floor and opened items without proper labeling or dating. Physical conditions in the kitchen further contributed to the deficiencies, with open windows and damaged screens allowing potential pest entry, and oven hood vents caked with a fuzzy white substance. These observations were confirmed by staff interviews, and a review of facility policies indicated that the observed practices were not in compliance with established food safety and sanitation requirements. The facility census at the time was 68 residents, with one resident identified as not receiving food from the kitchen.
Uncovered Garbage Cans in Kitchen Food Preparation Area
Penalty
Summary
Staff failed to ensure that garbage cans in the kitchen food preparation area were covered, as required by facility policy. On two separate observations, surveyors noted that two garbage cans in the food preparation area were left uncovered. This was confirmed in an interview with a dietary staff member, who acknowledged that the garbage cans were not covered. Review of the facility's policy indicated that garbage and refuse containers should be covered when not in use. The facility census at the time was 68 residents. No information was provided regarding any specific residents' medical history or condition at the time of the deficiency.
Failure to Maintain Effective Pest Control in Kitchen
Penalty
Summary
The facility failed to maintain effective pest control in the kitchen area, as evidenced by direct observations and staff interviews. On the morning of 05/18/25, several black specs, later confirmed by dietary staff as mouse droppings, were found on the floor between the deep fryer and stove, as well as on a rack below the steamer. Additionally, three cockroaches were observed on the floor by the dry storage area, which was also confirmed by dietary staff. Review of pest control documentation showed that routine monthly services had been performed in the preceding months, with no issues noted during those visits. The facility's policy requires all food service areas to be kept clean, sanitary, and protected from rodents and insects, but these conditions were not met at the time of the survey.
Failure to Maintain Clean and Homelike Environment in Dining and Resident Areas
Penalty
Summary
The facility failed to provide a clean and homelike environment for its residents, as evidenced by multiple observations and staff interviews. During breakfast, residents were served meals in Styrofoam containers due to staff shortages, as confirmed by dietary staff. The main dining room was found to have significant cleanliness issues, including a large ceiling vent, curtains, curtain rods, and sprinkler heads all covered in a thick, gray, fuzzy material, with some of it visibly blowing through the air. A dead house fly was observed stuck to the curtains, and a long string of the gray material was hanging from a ceiling tile. The dining room floor was also heavily soiled with food debris and liquid stains, and staff confirmed that the area had not been cleaned due to short staffing. Additionally, three resident rooms were observed to be heavily soiled, with floors and walls covered in an unknown black substance, and bathrooms containing heavily soiled floors and toilets with black rings. These conditions were confirmed by a CNA during the observations. The facility's own policy requires a safe, clean, and homelike environment, but these standards were not met in the dining area or resident rooms, affecting both the overall environment and the daily living experience of the residents.
Failure to Update Care Plans and Complete Required Care Conferences
Penalty
Summary
The facility failed to ensure that care plans were updated in a timely manner following changes in residents' conditions and did not consistently complete or document required care conferences. For one resident with diabetes, mood disturbance, dementia, and a pressure ulcer, the care plan was not updated to reflect the development of a stage III pressure ulcer, despite a physician's order for treatment and confirmation by nursing staff. The facility's policy required care plans to be revised as needed, but this was not followed. Multiple residents did not have evidence of care conferences being held or documented as required. One resident with congestive heart failure, diabetes, COPD, depression, and schizoaffective disorder had no documented care conferences, and the care plan was not updated to include a new diagnosis of schizoaffective disorder. Another resident with a fracture, PTSD, depression, and glaucoma had no care conference documented for over a year. Additional residents with various diagnoses, including cognitive impairment and physical disabilities, either had no care conferences documented or had incomplete documentation, such as missing signatures or dates. Interviews with residents and clinical staff confirmed the lack of care conferences and incomplete or outdated care plans. Facility policy required care plan discussions with residents and/or their representatives at regular intervals and after significant changes, with proper documentation and signatures, but these procedures were not consistently followed for several residents reviewed.
Failure to Maintain Safe and Sanitary Common Areas
Penalty
Summary
Facility staff failed to maintain a safe, functional, and sanitary environment in the common areas, as evidenced by several direct observations and staff interviews. On one occasion, the cove base at the entrance to the rehab hallway was found to be ripped and torn, with multiple missing floor tiles, which a CNA confirmed as being in disrepair and presenting a trip hazard to residents, staff, and visitors. Additionally, the ceiling light at the entrance to the rehab unit was not working, and its cover was broken, as confirmed by the Maintenance Supervisor. Further observation revealed that ceiling vents on the Sea Side Lane unit were dusty with debris hanging down, which was also acknowledged by the Maintenance Supervisor. These deficiencies had the potential to affect all 68 residents residing in the facility.
Failure to Timely Transfer Deceased Resident's Personal Funds
Penalty
Summary
The facility failed to transfer the personal funds of a deceased resident to the resident's estate within the required thirty-day period. Medical record review showed that the resident, who had diagnoses including anemia, atrial fibrillation, hypertension, dementia, and depression, expired in the facility. Review of the resident fund account records indicated that the facility sent a check for the remaining balance of $245.51 to the estate, but this was not completed within the mandated timeframe. An interview with the Business Office Manager confirmed that the refund was not processed within thirty days as required by facility policy and regulations.
Medications Improperly Stored at Bedside Without Orders or Documentation
Penalty
Summary
A deficiency was identified when a resident was found to have multiple medications and supplements, including cranberry supplement, probiotic tablets, Refresh Tears eye drops, Replenish eye drops, Ketorolac eye drops, multivitamin capsules, and Tums tablets, stored in bottles on her bedside table. Review of the resident's medical record and Medication Administration Record (MAR) revealed there were no physician's orders or documentation for administration of these medications and supplements. The resident was cognitively intact and required staff assistance with activities of daily living, with diagnoses including polyneuropathy, congestive heart failure, hypertension, and acute respiratory failure with hypoxia. Observation and interview with an LPN confirmed that these medications should not have been at the resident's bedside and should have been locked in the medication cart. The facility's policy required all medications to be stored in locked compartments, medication carts, cabinets, drawers, or refrigerators, and to be housed according to manufacturer recommendations to ensure security and proper storage conditions. The failure to store medications securely and the presence of medications without physician orders or documentation constituted a violation of the facility's medication storage policy.
Resident Meal Preferences Not Honored
Penalty
Summary
A deficiency occurred when a cognitively intact resident with multiple diagnoses, including a left humerus fracture, PTSD, depression, and glaucoma, did not receive her ordered meal. The resident had ordered a hot dog, mashed potatoes, and fruit for lunch, but instead received mashed potatoes, fruit, and a peanut butter sandwich. The resident confirmed that she often did not receive what was listed on the menu and would instead be given a peanut butter and jelly sandwich. Observation during lunch service confirmed the resident received a peanut butter sandwich instead of the hot dog she had ordered. The Director of Nutritional Services verified that the kitchen did not have hot dogs available and that staff did not discuss alternative menu options with the resident. Instead, staff assumed the resident would want a peanut butter sandwich without confirming her preference. Facility policy stated that residents' rights to make personal dietary choices would be supported, but this was not followed in this instance.
Medication Availability Deficiency
Penalty
Summary
The facility failed to ensure that a medication, Percocet, was available for administration as ordered for a resident. The resident, who was admitted with medical diagnoses including acquired absence of left below knee amputation, peripheral vascular disease, diabetes mellitus, and hypertension, was cognitively intact and required varying levels of staff assistance for daily activities. A physician order dated 09/12/24 prescribed Percocet 5-325 mg to be given every four hours for pain. However, the Medication Administration Record (MAR) showed that the resident did not receive the medication on several occasions, specifically on 10/12/24, 10/13/24, 10/18/24, 10/28/24, and 12/04/24. Nurses' notes indicated communication issues with the pharmacy and lack of access to the Pyxis system, which contributed to the medication not being available. On 10/18/24, a nurse noted that the pharmacy promised delivery of the medication in the evening, but by 10/19/24, the resident was still out of Percocet. The nurse and the on-call supervisor both lacked access to the Pyxis system to obtain the medication. On 12/04/24, another note stated that the medication was not available in the medication cart and had to be reordered. Interviews with the resident and the Regional Clinical Nurse confirmed the lack of documentation for the administration of Percocet on the specified dates. The facility's policy required medications to be administered safely and timely, as prescribed, which was not adhered to in this case.
Failure to Administer Medications as Ordered
Penalty
Summary
The facility failed to ensure that a resident was free from significant medication errors, affecting one resident out of the three reviewed for medication administration. The resident, who was cognitively intact and required supervision with certain activities, had medical diagnoses including myocardial infarction, cerebral infarctions, diabetes mellitus with neuropathy, spinal stenosis, and congestive heart failure. The resident had physician orders for Insulin Glargine, Insulin Lispro, and Zoloft, but the November 2024 Medication Administration Record (MAR) lacked documentation to support that these medications were administered as ordered on multiple dates. An interview with the Regional Clinical Nurse confirmed the absence of documentation for the administration of the resident's medications as ordered in November 2024. Despite the lack of documentation, it was confirmed that the resident did not experience any negative effects from the medications not being administered as ordered. The facility's policy on administering medications stated that medications should be administered in a safe and timely manner, as prescribed, and in accordance with the orders, including any required time frame. This deficiency was investigated under a specific complaint number.
Failure to Prevent and Treat Pressure Ulcers
Penalty
Summary
The facility failed to adequately assess and implement preventive measures for pressure ulcers, resulting in actual harm to a resident. The resident was admitted without pressure sores but was at risk for developing them due to impaired mobility and incontinence. Despite being identified as at risk, the care plan did not include specific interventions for heel protection, such as offloading or using heel protectors. The facility's Treatment Administration Record (TAR) lacked orders for heel protection, and the resident's heels were not offloaded, leading to the development of an unstageable pressure ulcer on the right heel and a stage II ulcer on the left heel. The facility's staff did not conduct thorough skin assessments as required. Although the resident's care plan included daily skin assessments and weekly checks by a licensed nurse, the only documented weekly skin assessment indicated no pressure ulcers. However, an occupational therapist noted reddened areas on the resident's heels, which were not reported to the nursing staff. The pressure ulcers were only identified during a wound assessment by a Certified Nurse Practitioner (CNP) several days later, by which time the ulcers had progressed significantly. Interviews with facility staff confirmed lapses in communication and documentation. The CNP reported the pressure ulcers to the Director of Nursing (DON) and provided treatment orders, but the facility's nursing staff failed to identify the ulcers in a timely manner. The DON acknowledged that the facility's policy required weekly skin assessments and that the resident's care plan lacked necessary interventions for heel protection. The facility's policy emphasized the prevention of avoidable pressure injuries, but the lack of adherence to these protocols contributed to the resident's harm.
Failure to Communicate Significant Change in Resident's Condition
Penalty
Summary
The facility failed to ensure proper communication between nursing staff and resident physicians regarding significant changes in a resident's condition. This deficiency affected a resident who was admitted with multiple diagnoses, including a periprosthetic fracture and a history of falling. The resident had undergone surgical revision of a right total knee replacement and was noted to have a surgical incision on the right knee. Initially, the incision was healing well, but later showed signs of possible infection. Despite instructions from a Certified Nurse Practitioner (CNP) to notify the orthopedic surgeon about the changes in the wound, the facility staff only left a message with the surgeon's office and did not follow up further. The resident was scheduled for a follow-up appointment with the orthopedic surgeon, but due to the lack of additional communication from the facility, the resident was not seen earlier than the scheduled date. Upon attending the appointment, the surgeon transferred the resident to the hospital for evaluation of complications related to the knee surgery. The facility's policy required prompt notification of physicians when significant changes occurred, but this was not adhered to, resulting in a deficiency noted during the investigation.
Failure to Follow Enteral Tube Feeding Orders
Penalty
Summary
The facility failed to ensure that a resident's enteral tube feeding orders were implemented as prescribed. Resident #82, who has diagnoses including chronic obstructive pulmonary disease, lupus, gastrostomy tube, and West Nile virus, had physician orders for Jevity 1.5 calories at 70 milliliters per hour for 22 hours and a 50 ml free water flush for the same duration. However, the Licensed Practical Nurse (LPN) responsible for the resident on 04/30/24 did not follow these orders, instead administering the enteral nutrition continuously with a 250 ml flush every four hours. This discrepancy was confirmed by the Director of Nursing (DON) during an interview and observation on 05/01/24, where it was also noted that the enteral feed bag had not been changed after 24 hours as required by the facility's policy. The DON verified that the enteral nutrition and fluid flush order for Resident #82 was not followed as ordered and that the enteral bag was still in use beyond the 24-hour limit. The facility's policy on the care and treatment of feeding tubes, dated 05/01/24, mandates that feeding tubes be utilized according to physician orders. This deficiency was identified during an investigation under Complaint Number OH00152784.
Medication Administration Deficiency
Penalty
Summary
The facility failed to ensure medications were administered as physician ordered, resulting in a 9.67% medication error rate. This affected one resident observed for medication administration pass. The resident, who has diagnoses including end-stage renal disease, chronic obstructive pulmonary disease, and stroke, had physician orders for ProRenal + D Oral Tablet, Acidophilus Capsule, and Olopatadine Ophthalmic Solution. During a medication pass observation, an LPN was unable to locate these medications in the medication cart, leading to their omission. The LPN verified that the medications were unavailable and were being omitted.
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A resident with intact cognition receiving Medicare Part A skilled services for metabolic encephalopathy had services discontinued while benefit days remained, but the facility did not issue the required Skilled Nursing Facility Advance Beneficiary Notice (SNF ABN). The Social Services Director later confirmed that no SNF ABN was provided and reported she believed only a Notice of Medicare Non-Coverage (NOMNC) was needed when all skilled services were stopped. This practice conflicted with the facility’s written policy, which required SNF ABNs to be issued when extended care items or services were initiated, reduced, or terminated due to expected non-coverage by Medicare.
Surveyors identified that the facility exceeded the acceptable medication error rate when two residents with type 2 DM received insulin doses that were not administered according to orders or manufacturer instructions. In two separate observations, an LPN administered Novolog and another LPN administered insulin glargine and insulin lispro without priming the insulin pens, and the insulin lispro and Novolog were given after the residents had already consumed a significant portion of their breakfast meals, despite orders for administration before meals. Manufacturer information for both insulin products required priming before each injection to ensure accurate dosing, and facility policy required medications, including insulin, to be administered safely, timely, and in accordance with prescriber orders and specified time frames.
Surveyors found that the facility failed to document tray line food temperatures for multiple meals served from two dining room kitchenettes, despite having a “Trayline Taste & Temperature Log” and a policy requiring food to be stored, prepared, distributed, and served according to professional food safety standards. Review of logs showed repeated missing entries for breakfast, lunch, and dinner services in both the Harrison and McClellan dining areas, and the Senior Director of Culinary Services confirmed that temperatures had not been recorded for those meals, potentially affecting all residents receiving meals from those kitchenettes.
The facility failed to conduct and document required periodic care conferences for two residents, despite multiple comprehensive, quarterly, and significant change MDS assessments and a policy requiring periodic care conferences with resident and/or family participation. One resident with Parkinson’s disease, post-stroke hemiplegia, TIA, DMII, and depression had only two documented care conferences over a year, while another resident with aphasia, cerebrovascular disease, DMII, gait difficulty, coagulation defect, depression, and muscle weakness had no documented care conferences in the past year, aside from a declined invitation to the representative. The UCC confirmed that care conferences were expected to occur quarterly and that no additional documentation existed for either resident.
A resident with Alzheimer's disease and type II DM, who required extensive assistance with ADLs and was receiving scheduled Lantus and sliding-scale Humalog, experienced a severely elevated blood glucose level. The on-call provider was notified and ordered an additional dose of lispro insulin with a directive to recheck the blood glucose after administration. Nursing staff administered the extra insulin but did not document any follow-up blood glucose check, and the DON confirmed that this reevaluation was required by the facility's abnormal blood glucose policy and was not completed or documented.
A resident with Parkinson’s disease, dementia, and hypothyroidism was prescribed levothyroxine once daily along with other medications. A consultant pharmacist’s monthly drug regimen review recommended that levothyroxine be given in the morning on an empty stomach, 30–60 minutes before food, per manufacturer instructions. The medical record contained no documented physician response to this recommendation, and the MAR showed the drug scheduled for morning administration while the resident was observed eating breakfast and receiving the medication at the same time. An LPN confirmed administering levothyroxine during the meal, and the DON verified there was no documentation explaining whether or why the pharmacist’s recommendation was or was not followed, resulting in a failure to act on and document the identified irregularity.
A resident with severe cognitive impairment, multiple comorbidities, documented gait and balance abnormalities, and a high fall risk was care planned and assessed by therapy to require contact guard assistance and use of a gait belt for transfers and ambulation. While being assisted by a CNA from a recliner to the bathroom with a walker, the CNA did not apply a gait belt, even though the resident had a known tendency to lean backward when standing. As the CNA reached to open the bathroom door, the resident lost balance and fell backward, striking the back of the head, and was later found by an LPN without a gait belt in place, contrary to the facility’s gait belt policy and the resident’s assessed needs.
A resident with CKD stage five requiring peritoneal dialysis (PD) was admitted with pre-admission physician orders for three daily PD exchanges and monitoring for peritonitis (fever, abdominal pain, cloudy effluent), but these monitoring orders were not entered into the facility’s physician orders. The care plan referenced PD and general monitoring but did not specifically address peritonitis monitoring. Paper PD flowsheets showed incomplete and inconsistent documentation of exchanges and resident condition, including missing condition/comments for individual treatments and no record of one ordered PD exchange. The PD cycler flowsheet lacked effluent descriptions on multiple days. The PD nurse reported facility staff were expected to monitor effluent and symptoms, and the DON confirmed the absence of specific peritonitis monitoring orders, lack of an order for the PD cycler, and documentation gaps, despite a facility policy requiring ongoing assessment and monitoring for complications before, during, and after dialysis treatments.
A nurse was observed preparing multiple oral medications for a resident with depression, traumatic brain injury, anxiety, and impaired cognition by pushing tablets and capsules from unit-dose cards directly into her ungloved hand and then using her fingers to place them into a medication cup. In a follow-up interview, the RN confirmed this practice and acknowledged that the correct procedure is to dispense medications directly from the card into the cup, contrary to the facility’s medication administration policy requiring adherence to good nursing principles and practices.
A resident with Alzheimer’s disease, diabetes, anxiety, significant ADL dependence, and behavioral symptoms was observed seated in a chair positioned against the nursing station with a locked wheelchair placed directly in front, also against the nursing station, effectively restricting movement. An LPN confirmed both wheelchair wheels were locked and that it should not have been placed there, while a CNA stated she had positioned the wheelchair to prepare for lunch, was unable to complete the transfer, and left it in place, acknowledging this was wrong. This arrangement conflicted with the facility’s restraint policy, which prohibits physical restraints except when alternatives are ineffective for treating a medical symptom and defines restraints as devices adjacent to the body that cannot be easily removed and that restrict freedom of movement or access to the body.
Failure to Issue Required SNF ABN When Discontinuing Medicare Part A Services
Penalty
Summary
The deficiency involves the facility’s failure to issue a Skilled Nursing Facility Advance Beneficiary Notice (SNF ABN) when Medicare Part A services were discontinued for a resident who still had available benefit days. The resident was admitted with a diagnosis of metabolic encephalopathy and had intact cognition per the Minimum Data Set assessment. The facility’s own SNF Beneficiary Notification Review documented that Medicare Part A skilled services began on 02/11/26 and the last covered day was 03/11/26, and that the facility initiated discharge from Medicare Part A services before the resident’s benefit days were exhausted. Despite this, no SNF ABN was provided to the resident or the resident’s representative. During interviews, the Social Services Director stated that the SNF ABN was issued hours prior to the last covered day but, upon reviewing her files, confirmed that no SNF ABN had actually been issued for this resident. She further explained that she believed an SNF ABN was only required if one skilled service remained and that if all skilled services were being discontinued, only the Notice of Medicare Non-Coverage (NOMNC) needed to be issued. The Administrator, however, stated that a resident should always receive both a SNF ABN and a NOMNC when Medicare Part A services are discontinued and benefit days remain. Review of the facility’s written policy dated 03/28/23 showed that the facility was required to issue SNF ABNs for initiation, reduction, or termination of extended care items or services when Medicare payment was not expected, which did not occur in this case.
Plan Of Correction
This Plan of Correction is submitted as required under State and Federal law. This Plan of Correction does not constitute an admission on the part of the Facility that the findings cited are accurate, that the findings constitute a deficiency or that the scope and severity regarding the deficiency cited are correctly applied. Any changes to the Facility's policies and procedures should be inadmissible in any proceeding on that basis. Without admitting or denying the validity or the existence of the alleged noncompliance, the Facility submits this Plan of Correction with the intention that it be inadmissible by any third party in any civil or other action against the facility or any employee, agent, officer, director or shareholder of the Facility. The Facility is utilizing this Plan of Correction as its allegation of substantial compliance as of 05/29/2026 F-0582 Corrective action for resident/s: On 5/14/26 Resident #34 was informed of rights and responsibilities related to Advanced Beneficiary Notice and voiced understanding of information for future reference by administrator. Identification of other residents who may be affected: Any resident receiving skilled services from nursing or therapy services. The Administrator audited all residents who were discharged from skilled services in the past 30 days to ensure they were issued a Notice of Non-Coverage and Advanced Beneficiary Notice on 5/29/26. No non-compliance was noted. Measures for systemic change: On 5/14/2026 Business Office Manager, Director of Rehab, Minimum Data Set nurse, Director of Nursing and Social Services Director were educated on proper procedure of issuing of Notice Of Medicare Non Coverage and Advanced Beneficiary Notice by administrator. All upcoming discharges from skilled services will be reviewed weekly at Utilization Review meeting to ensure notices will be delivered timely. How Corrective Action will be monitored: Administrator or designee to complete audits of all residents being discharged from skilled services to ensure they were issued a Notice of Non-Coverage and Advanced Beneficiary. This audit will be completed weekly x 4 weeks, then monthly x 2 months. Corrective action will be initiated for any noted non-compliance. Audit findings will be reviewed as part of the monthly quality assurance process to determine the need for further monitoring. Date of Compliance 5/29/26
Insulin Administration Errors and Failure to Prime Insulin Pens
Penalty
Summary
The deficiency involves the facility’s failure to maintain a medication error rate below 5%, with surveyors identifying 3 errors out of 28 medication administration opportunities, resulting in a 10.71% error rate. For one resident with type 2 diabetes mellitus and moderate cognitive impairment, the physician’s order directed Novolog insulin 10 units via subcutaneous pen-injector to be given before meals. During an observed medication pass, the LPN administered 10 units of Novolog insulin without priming the pen and did so after the resident had already consumed approximately 50% of the breakfast meal. The LPN later confirmed she did not prime the pen and acknowledged that the insulin was ordered to be administered prior to meals. Manufacturer instructions for the Novolog FlexPen specified that an air shot (priming) must be performed before each injection to ensure proper dosing. Another resident, also diagnosed with type 2 diabetes mellitus and with intact cognition, had orders for insulin glargine 35 units subcutaneously twice daily and insulin lispro 20 units subcutaneously before meals, plus 12 units subcutaneously if blood glucose was between 251 mg/dL and 300 mg/dL. During an observed medication administration, an LPN administered 35 units of insulin glargine and 32 units of insulin lispro without priming the insulin pens and after the resident had consumed approximately 90% of the breakfast meal, despite orders for insulin lispro to be given before meals. The LPN later stated she could not remember if she had primed the pen and acknowledged that the insulin was ordered to be administered prior to meals. Manufacturer information for insulin lispro stated that the pen must be primed before each injection to confirm insulin delivery and remove air, and that failure to prime could result in too much or too little insulin. The DON confirmed the expectation that insulin be administered as ordered, including priming each pen with two units before dialing the prescribed dose, and facility policy required medications, including insulin, to be administered safely, timely, and in accordance with prescriber orders and required time frames.
Plan Of Correction
This Plan of Correction is submitted as required under State and Federal law. This Plan of Correction does not constitute an admission on the part of the Facility that the findings cited are accurate, that the findings constitute a deficiency or that the scope and severity regarding the deficiency cited are correctly applied. Any changes to the Facility's policies and procedures should be inadmissible in any proceeding on that basis. Without admitting or denying the validity or the existence of the alleged noncompliance, the Facility submits this Plan of Correction with the intention that it be inadmissible by any third party in any civil or other action against the facility or any employee, agent, officer, director or shareholder of the Facility. The Facility is utilizing this Plan of Correction as an allegation of substantial compliance as of 5/29/2026. F-0759 Corrective action for resident/s: Residents #21 and #22 were assessed and evaluated by nurse and Director of Nursing 5/14/26. Resident #21 and #22 both denied any adverse effects and none were noted upon assessment by the Director of Nursing on 5/14/2026. Notification made to physician on 5/14/2026. LPN # 2 competency Eval on insulin administration with the Director of Nursing completed 5/14/2026. Identification of other residents who may be affected: Diabetic residents on assignment of LPN #2/station 2 have the potential to be affected and were assessed by the DON/Designee on 5/14/26 and found to be within normal limits. Measures for systemic change: All Nurses were educated by the Director of Nursing on the steps for Insulin administration per competency, diabetes clinical protocol policy, Medication and treatment orders policy, administering medications policy, and Obtaining fingerstick Glucose Level policy On 5/14/2026. How Corrective Action will be monitored: Director of Nursing and Assistant Director of Nursing will complete insulin administration audits on 5 nurses. This audit will be completed weekly x 4 weeks, then monthly x 2 months. Corrective action will be initiated for any noted non-compliance. Audit findings will be reviewed as part of the monthly quality assurance process to determine the need for further monitoring. Date of Compliance: 5/29/2026
Failure to Document Tray Line Food Temperatures in Dining Room Kitchenettes
Penalty
Summary
The deficiency involves the facility’s failure to document tray line food temperatures for meals served from the Harrison and McClellan Dining Room kitchenettes, as required by professional standards for food service safety and the facility’s own policy. Review of the “Trayline Taste & Temperature Log” (revised September 2018) showed missing temperature documentation for multiple meals from the Harrison Dining Room kitchenette, including dinner on 03/30/26 and 03/31/26, lunch and dinner on 04/01/26 and 04/02/26, dinner on 04/07/26, and lunch and dinner on 04/08/26 and 04/10/26. The Senior Director of Culinary Services confirmed during interview that tray line food temperatures were not documented on the log for these meals. Similarly, review of the same log for the McClellan Dining Room kitchenette revealed that tray line food temperatures were not documented for dinner on 04/01/26, breakfast and lunch on 04/02/26, and lunch and dinner on 04/07/26. The Senior Director of Culinary Services also verified these omissions during interview. The facility census at the time was 27 residents, and the governing “Food and Nutrition” policy, approved on 09/07/21, stated that the facility must store, prepare, distribute, and serve food in accordance with professional standards for food service safety.
Plan Of Correction
F812 The facility will continue to ensure food temperatures are completed before meals are served for all residents. To ensure compliance with this standard the following measures have been taken: 1. Immediately 4/15/26 culinary supervisor #224 was re-educated by Dietary Manager to this standard and policy "Food and Nutrition" which includes documentation of food temperatures. 2. All dietary staff have been re-educated to the standard and policy "Food and Nutrition" during the month of April 2026. 3. Audits of food temperature documentation to be completed by Dietary Manager 4 x per week for 4 weeks then weekly for 4 weeks. 4. Administrator to validate audits/compliance and provide additional training as needed. Administrator will present to QAPI committee for ongoing monitoring and further direction.
Failure to Conduct and Document Required Care Conferences
Penalty
Summary
The deficiency involves the facility’s failure to complete and document comprehensive care conferences at required intervals in accordance with care plan regulations and facility policy. For one resident with Parkinson’s disease with dyskinesia, cognitive communication deficit, hemiplegia and hemiparesis following cerebral infarction, transient cerebral ischemic attack, type II diabetes mellitus, and major depressive disorder, the record showed multiple MDS assessments over a one-year period, including annual, quarterly, and significant change assessments. However, only two care conferences were documented during the last 12 months, despite the expectation that care conferences be conducted quarterly with the resident and family when possible. The Unit Care Coordinator confirmed that no additional care conference documentation existed for this resident beyond the notes dated 04/21/25 and 01/02/26. A second resident, with diagnoses including aphasia following cerebrovascular disease, cerebral infarction, type II diabetes mellitus, unsteadiness on feet, difficulty in walking, coagulation defect, depression, and muscle weakness, also had multiple MDS assessments completed over the review period, including quarterly and annual assessments. The record contained a note that a care conference was offered to the resident’s representative, who declined to attend, but there was no documentation of any care conferences for the most recent 12 months. The Unit Care Coordinator confirmed that no other care conference documentation was available for this resident. Facility policy stated that periodic care conferences involving the resident, family, and the interdisciplinary team are part of the care planning process, but the required periodic care conferences and corresponding documentation were not completed for these two residents.
Plan Of Correction
THIS PLAN OF CORRECTION SERVES AS BERKELEY SQUARE'S CREDIBLE ALLEGATION OF SUBSTANTIAL COMPLIANCE AS OF June 1, 2026. Without admitting or denying the validity or existence of the alleged deficiencies, Berkeley Square provides the following Plan of Correction: F657 The facility will continue to document completion of care conferences at the required intervals for all residents, including residents #04 & #15. To ensure compliance with this standard the following measures have be taken: 1. The social service designee and the inter- disciplinary team were re-educated by the administrator to the facility policy "Care Conference" on 4/29/26 and verbalized understanding. 2. Care conferences for resident #04 and resident #15 were conducted on or before 4/29/2026 by the interdisciplinary team. 3. Review of all other residents was conducted by the social service designee to validate and ensure that care conference schedule is up to date with timely care conferences scheduled for them on 4/15/2026. Audits of care conferences to be completed weekly for four weeks and then monthly after that by the social service designee. Documentation of the care conference including any identified concerns in the medical record. Administrator to validate audits/compliance and provide additional training as needed. Administrator will present results of these audits to QAPI committee for ongoing monitoring and further direction.
Failure to Reevaluate Blood Glucose After Treatment for Hyperglycemia
Penalty
Summary
The facility failed to ensure that a resident with diabetes received treatment in accordance with professional standards of practice when nursing staff did not reevaluate the resident's blood glucose after treatment for severe hyperglycemia. The resident, admitted with diagnoses including Alzheimer's disease, type II diabetes mellitus, and depression, had physician orders for Humalog insulin on a sliding scale before meals, Lantus insulin 25 units daily, and lisinopril 5 mg daily. The resident required extensive assistance with activities of daily living, including transfers, toileting hygiene, eating, and bathing. On the evening in question, the resident's blood glucose was documented as 532 mg/dL, and the on-call provider was notified. The provider gave a new order to administer an additional 8 units of lispro (Humalog) and to recheck the blood glucose in 30 minutes. The electronic medication administration record showed that the blood glucose of 532 mg/dL was obtained at 9:00 p.m. and that the additional 8 units of lispro were administered at 9:21 p.m. However, there was no documentation in the resident's chart that the blood glucose was rechecked after the additional insulin was given. In an interview, the DON confirmed there was no evidence of reevaluation and verified that, according to the facility's "Abnormal Blood Glucose Procedure" policy, the resident should have been reevaluated and that the evaluation step should have been included in the progress note documentation.
Plan Of Correction
F684 The facility will continue to ensure all residents, including #03, receive treatment in accordance with professional standards of practice and reevaluated for hyperglycemia. To ensure compliance with this standard the following measures have been taken: 1. The director of nursing assessed resident #03, reviewed documentation and orders and found no ill effects immediately 4/16/26. 2. All licensed nurses were re-educated to facility policy "Blood Glucose Monitoring" by the Director of Nursing/designee in April 2026. 3. Audits of like-residents that require blood sugar checks to be completed by the director of nursing/designee two times a week for 4 weeks and then monthly after that to validate correct follow through when there is abnormally high blood glucose result. The Administrator will bring results of these audits to the QAPI committee for ongoing monitoring and further direction.
Failure to Act on Pharmacist Drug Regimen Recommendation for Thyroid Medication
Penalty
Summary
The deficiency involves the facility’s failure to ensure that pharmacy recommendations from the monthly drug regimen review were acted upon and documented for a resident. The resident was admitted with diagnoses including Parkinson’s disease, dementia, and hypothyroidism, and had current physician orders for levothyroxine 150 mcg once daily, buspirone 50 mg twice daily, and losartan 100 mg once daily. A medication regimen review dated 11/25/2025 included a consultant pharmacist recommendation that levothyroxine be administered consistently in the morning on an empty stomach, at least 30–60 minutes before food, per manufacturer instructions. There was no specific physician response in the medical record to this recommendation, and the facility’s policy stated that consulting pharmacist reviews are sent to nursing and addressed with the primary care provider or consulting specialist for review and follow-up. Review of the resident’s medication administration record for April 2026 showed levothyroxine scheduled for 9:00 a.m. On observation, the resident was seen eating breakfast in the dining area at 8:03 a.m., and an LPN reported administering the levothyroxine 150 mcg to the resident while the resident was in the dining area eating breakfast. The DON confirmed there was no evidence in the resident’s medical record explaining why the consultant pharmacist’s recommendation from 11/25/2025 was or was not acted upon. This lack of documented physician review and action on the pharmacist’s identified irregularity constituted noncompliance with the drug regimen review requirements.
Plan Of Correction
F756 The facility will continue to ensure the pharmacy recommendations from the monthly drug regimen review by a licensed pharmacist are acted upon for all residents, including #08. To ensure compliance with this standard the following measures have been taken: 1. Resident #08 was assessed by the registered nurse and med review completed by 4/28/26. After review of resident's drug regime's, it was discovered that resident #8 had 2 separate medication recommendations on the same form, to be reviewed by two separate practitioners, pharmacy has been instructed and agreed to separate meds on individual forms. 2. Licensed nurses re-educated to facility policy "Drug Regimen Review" by Director of nursing/designee in April 2026 and no later than 5/8/26. Licensed nurses are responsible for ensuring the reviews and recommendations are given to the physician for timely review. 3. Review of all other current residents Drug Regimen orders completed by Director of nursing/designee on 4/16/26 to ensure recommendations were followed up on/reviewed by the physician and address concerns if needed. 4. Audit of drug regime recommendations, pharmacy recommendations, and physician follow up to be completed weekly for four weeks by the Director of nursing/designee. Administrator will present results of these audits to the QAPI committee for ongoing monitoring and further direction.
Failure to Use Required Gait Belt During Ambulation Resulting in Resident Fall
Penalty
Summary
The deficiency involves the facility’s failure to ensure that a required gait belt was used while assisting a high fall‑risk resident with ambulation, resulting in a fall with head injury. The resident had multiple diagnoses including metabolic encephalopathy, hypertension, osteoarthritis, muscle weakness, gait and mobility abnormalities, major depressive disorder, anxiety, and visual hallucinations. Admission and subsequent MDS and fall risk assessments documented that the resident was severely cognitively impaired, required moderate to maximal assistance with transfers and ambulation, could not independently come to a standing position, exhibited loss of balance while standing, used an assistive device, and had decreased muscle coordination. The resident had a history of falls prior to admission and was assessed as being at high, later moderate, risk for falls. The resident’s fall care plan identified her as at risk for falls and included interventions such as providing maximum to moderate assistance with transfers and walking short distances, use of a walker and wheelchair, and following the facility’s fall protocol. Therapy notes and care conference documentation indicated that the resident leaned backwards when standing, required contact guard to minimal assistance for bed mobility and transfers, and needed constant verbal cueing for safe sequencing during toilet transfers. The physical therapist confirmed that the resident was to use a gait belt with staff when ambulating, and the DON verified that therapy had assessed the resident as requiring contact guard assistance and a gait belt for ambulation and transfers. On the day of the incident, a CNA was assisting the resident from her recliner to the bathroom using a walker. The CNA walked beside the resident, providing guidance and support, and reported having a hand on the resident while assisting her. As they approached the bathroom door, the CNA reached for the doorknob to open it, and at that moment the resident began to lose her balance and fell backwards to the floor, striking the back of her head. The nurse who responded found the resident on her back at the foot of the bed with her feet near the bathroom, noted a red raised area on the back of the head, and documented that the resident was not wearing a gait belt and that the gait belt was on the dresser. In the facility’s investigative summary and in interviews, the CNA acknowledged that she did not have a gait belt on the resident while ambulating her, despite the resident’s assessed need for hands‑on assistance and gait belt use per facility policy and the resident’s care and therapy plans.
Failure to Implement PD Orders and Monitor Resident Receiving Peritoneal Dialysis
Penalty
Summary
The deficiency involves the facility’s failure to implement pre-admission physician orders for peritoneal dialysis (PD) and to provide ongoing monitoring for a resident with chronic kidney disease (CKD) stage five who required PD. Pre-admission orders dated 11/14/25 specified three daily PD exchanges at 6:00 A.M., 2:00 P.M., and 10:00 P.M., and directed staff to monitor for signs and symptoms of peritonitis, including fever, abdominal pain, and cloudy effluent. These monitoring orders were not entered into the facility’s physician orders. The resident’s care plan noted the need for PD and included general monitoring interventions (labs, signs of bleeding, bacteremia, septic shock, and significant vital sign changes), but did not specifically address the ordered monitoring for peritonitis. Review of PD documentation showed incomplete and inconsistent charting of treatments and resident condition. The paper peritoneal flowsheet had columns for time of PD and condition/comments, including instructions to call the nurse immediately for cloudy fluid, abdominal pain, or fever. However, the first entry on 11/15/26 at 2:00 P.M. only noted that the PD nurse completed the exchange, and the 10:00 P.M. entry that day had no condition/comment documentation. Subsequent days (11/16/25, 11/17/25, and 11/18/25) contained only one condition/comment entry per day rather than for each exchange, and there was no documentation that the 6:00 A.M. PD on 11/18/25 was completed. The PD cycler flowsheet starting 11/19/25 lacked any description of the effluent on multiple days. The PD nurse from the dialysis company stated facility staff were expected to monitor effluent for cloudiness and assess for abdominal pain and fever, and the DON confirmed there was no electronic physician order for peritonitis monitoring or for use of the PD cycler, that the paper charting did not allow for effluent description or symptom documentation for each treatment, and that PD was not documented at one ordered time. The facility’s dialysis policy required ongoing assessment and monitoring for complications before, during, and after treatments, which was not reflected in the documentation for this resident.
Improper Infection Control During Medication Administration
Penalty
Summary
Surveyors identified a deficiency in infection prevention and control related to medication administration for Resident #29. The resident was admitted on 02/28/14 with diagnoses including depression, traumatic brain injury, and anxiety, and had impaired cognition per a quarterly MDS assessment. During an observation on 03/25/26 at 6:58 A.M., RN #281 prepared the resident’s medications by removing an Amoxicillin-Pot Clavulanate tablet from the medication card and pushing it directly into her ungloved hand, then using her fingers to place the pill into a medication cup. The same process was observed for multiple other medications, including Escitalopram Oxalate, Furosemide, Sennosides, Lyrica, and Vitamin D, each being pushed from the card into the RN’s ungloved hand and then transferred by her fingers into the medication cup before administration to Resident #29. In a subsequent interview at 7:27 A.M. the same day, RN #281 confirmed she had placed each medication into her ungloved hands prior to administration and acknowledged that the proper procedure was to push the pills directly from the card into the medication cup. Review of the facility’s “Medication Administration – General guidelines” policy, revised 10/08/25, stated that medications are to be administered in accordance with good nursing principles and practices. This practice failure was cited as a deficiency under Complaint Number 2681777.
Improper Use of Wheelchair as a Physical Restraint
Penalty
Summary
Surveyors identified a deficiency related to the facility’s failure to ensure a resident was free from physical restraints. Resident #7, admitted with diagnoses including Alzheimer’s disease, diabetes mellitus, and anxiety disorder, was documented on a recent MDS as rarely understood and dependent for ADLs except eating. The resident ambulated independently on the unit without an assistive device and had documented verbal and other behaviors occurring one to three days during the look-back period. The care plan noted the resident had potential to be physically aggressive, chase staff, throw objects, and be combative with care, with interventions such as offering choices, administering medications as ordered, and intervening early when agitation occurred. During an observation and interview, Resident #7 was found sitting in a chair with the right arm of the chair positioned against the nursing station and a wheelchair placed directly in front of him. The left arm of the wheelchair was also against the nursing station, and both wheelchair wheels were locked, creating a barrier that appeared to restrain the resident, who was sleeping with his knees touching the locked wheelchair. An LPN confirmed both wheelchair wheels were locked and that the wheelchair should not have been placed in front of the resident. A CNA reported she had placed the wheelchair there in preparation to get the resident up for lunch, was unable to transfer him, and left the wheelchair in that position, acknowledging it was wrong to keep it there. The facility’s physical restraint policy stated that physical restraints are not used except when alternatives are not appropriate or effective for treating a medical symptom and defined physical restraints as any device attached or adjacent to the body that the individual cannot easily remove and that restricts freedom of movement or access to the body.
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