Addison Heights Health And Rehabilitation Center
Inspection history, citations, penalties and survey trends for this long-term care facility in Maumee, Ohio.
- Location
- 3600 Butz Rd, Maumee, Ohio 43537
- CMS Provider Number
- 366041
- Inspections on file
- 45
- Latest survey
- February 18, 2026
- Citations (last 12 mo.)
- 45
Citation history
Health deficiencies cited at Addison Heights Health And Rehabilitation Center during CMS and state inspections, most recent first.
The facility failed to protect residents’ personal belongings by not maintaining accurate, complete, and updated inventories and by not ensuring clothing was labeled before being sent to laundry. Several residents with both impaired and intact cognition reported missing clothing such as underwear, pajamas, pants, shoes, and sentimental items, and stated they had notified staff without receiving follow-up. Surveyors found undated and unsigned inventory forms that listed only general categories of items without quantities, while room checks revealed many more, often unlabeled, clothing items than documented. Laundry staff and the Laundry Account Manager reported that most inventory sheets were incomplete, clothing was routinely sent to laundry in unlabeled bags, and the process for tracking missing items was not functioning, as no missing item forms had been received for months. Observations showed large amounts of unlabeled clothing in the laundry room and on racks in the social worker’s office, including items matching residents’ descriptions of missing garments, while the DON, ADON, CNAs, and receptionist gave inconsistent accounts of who was responsible for inventorying and labeling, and the Resident Council President reported ongoing problems with clothing not being returned from laundry.
A resident with multiple serious diagnoses and intact cognition became agitated, searched through belongings, and loudly claimed that personal accounts were hacked and all money was stolen while staff and a hospice nurse attempted to calm the situation. The resident tried to leave the building, police and EMS were called, and the resident was combative with officers and arrested. Despite the clear allegation that the resident’s account was hacked and money was gone, the facility did not submit a self-reported incident to the state agency or initiate an investigation, contrary to its abuse, neglect, exploitation, and misappropriation policy, and there were conflicting staff reports about whether leadership had been informed of the allegation.
A resident with paraplegia, stage 4 pressure ulcers, an indwelling urinary catheter, and an ostomy had physician orders and a care plan requiring enhanced barrier precautions (EBPs), including gown and glove use for high-contact care such as hygiene, bed mobility, linen changes, and device care. Despite EBP signage on the door and PPE supplies available outside the room, a CNA provided oral care, adjusted bed linens, repositioned the resident, and emptied the urinary catheter drainage bag while wearing only gloves and no gown. The CNA reported being unaware the resident was on EBPs, stated staff were not in the habit of wearing gowns, and indicated she had not received EBP training, while the DON confirmed staff should wear PPE for residents on EBPs during high-contact care, as required by facility policy.
A resident with severe cognitive impairment and multiple comorbidities developed left arm swelling, leading to a STAT x-ray that revealed a non-displaced distal radial fracture. Nursing staff notified the NP and implemented orders for imaging and ice, and later a splint was ordered for the affected extremity. However, there was no documentation that the resident’s representative was promptly informed of the fracture when it was first identified, and the family was ultimately notified days later by a hospice nurse rather than facility staff, contrary to facility policy requiring prompt notification of changes in condition.
A resident with cancer, COPD, liver malignancy, low back pain, intact cognition, and frequent pain had multiple Oxycodone orders, including a change from 30 mg PRN to 20 mg scheduled and PRN, but the facility failed to maintain accurate controlled substance records. MARs showed numerous Oxycodone doses given, yet corresponding controlled substance monitoring records were missing for several days, and discontinued 30 mg tablets were removed from the card without documentation of administration, waste, or disposal. On another occasion, Oxycodone 20 mg was charted as administered without a matching removal on the control record, and destruction records for 30 mg tablets contained conflicting counts and altered entries. The resident reported not receiving pain medication when requested, and interviews with the DON, ADON, and other staff confirmed missing control records, improper combining of scheduled and PRN orders on one card, incomplete shift-change inventory documentation, and failure to follow required documentation and review procedures for controlled substances.
During a COVID-19 outbreak, staff failed to consistently use required PPE such as N95 masks, gowns, gloves, and face shields when caring for residents in isolation or under droplet precautions. Several staff members entered rooms of COVID-19 positive residents or provided care in affected areas without following posted PPE requirements, and some reported confusion or lack of education regarding proper protocols. The facility's own policy mandated specific PPE for suspected or confirmed COVID-19 cases, but these measures were not reliably implemented, affecting both infected and non-infected residents.
A resident with multiple medical conditions was found to have a low air loss mattress that overhung the bed frame by about five inches, preventing the installation of a grab bar on one side. The Maintenance Director confirmed the mattress was too large for the frame and not fully supported.
A resident with impaired mobility and multiple medical conditions did not have the required bilateral bed rails in place as ordered and care planned, due to the absence of a grab bar on one side of the bed. The Maintenance Director confirmed the missing grab bar and stated that no assessment or adjustment of the bedframe or mattress had been performed to ensure proper fit and compliance with the resident's needs.
A resident with severe cognitive impairment and total dependence on staff was found in a wheelchair in a common area with another cognitively impaired resident kneeling beside her and making inappropriate contact inside her brief. The incident occurred when the area was unsupervised, as staff were occupied elsewhere. A CNA witnessed the event and reported it, but the written account was less detailed than the verbal description provided later. The facility's lack of supervision in the lounge area led to this incident of sexual abuse.
A resident with severe cognitive impairment and multiple diagnoses was found with another resident's hand in her brief. Although staff intervened immediately, the Administrator did not report the alleged sexual abuse to the State Agency within the required timeframe, citing a belief that no abuse had occurred. This failure to report was not in accordance with facility policy.
Two residents did not receive multiple doses of their prescribed medications, including antibiotics, antipsychotics, muscle relaxers, and pain medications, because the medications were not available at the facility. Documentation and interviews confirmed that these medications were missed as they were either awaiting delivery or a new prescription, resulting in deviations from physician orders.
Staff did not label opened thickened liquid cartons with open dates and were unaware that these products were only safe for seven days after opening, resulting in improper storage and monitoring of beverages for a resident with impaired cognition and special dietary needs.
A resident with complex medical and psychological needs was subjected to repeated removal of a comfort item by an LPN, resulting in distress. Although staff reported the incident internally, the facility did not notify the State Survey Agency of the abuse allegation within the required timeframe, as confirmed by staff interviews and review of facility records.
Surveyors found that multiple rooms and restrooms had significant maintenance and cleanliness issues, including damaged walls, peeling paint, broken fixtures, missing hygiene supplies, and non-functional lighting. Staff interviews confirmed these conditions, and only one of three showers in the memory care unit was operational. These deficiencies affected at least ten residents and did not meet the facility's policy for a safe, clean, and homelike environment.
A resident with multiple complex diagnoses and cognitive impairment had only one care conference during their admission, despite requiring regular care conferences at admission, quarterly, and with significant changes in condition. Staff interviews and facility policy review confirmed that the required schedule for care conferences was not followed.
A resident with significant risk factors for skin breakdown, including impaired mobility and incontinence, was not provided with physician-ordered pressure-relieving devices such as a wheelchair cushion and offloading boots. Observations and staff interviews confirmed that these devices were not in use or available, and care instructions for CNAs did not include their application, despite the resident's recent history of a healed stage III pressure ulcer.
Surveyors found that several residents were exposed to uncomfortably cold temperatures, requiring them to wear heavy coats and blankets, while multiple rooms had significant maintenance issues such as damaged walls, peeling paint, unsecured toilets, and broken window sills. Staff confirmed these conditions, which did not meet the facility's own standards for a safe and homelike environment.
Staff left open canisters of hazardous Sani-Cloth wipes on a linen cart accessible to residents, including several who were cognitively impaired and independently mobile. An LPN confirmed these chemicals should have been locked away according to facility policy, but they were left unsecured in a resident area, contrary to safety protocols.
The facility failed to maintain a homelike environment due to pervasive foul odors throughout the facility, excluding the secured memory care unit. Observations and interviews with staff and visitors confirmed the presence of strong, unpleasant odors, particularly near the nurses' station and certain resident rooms. The facility's policy on minimizing institutional odors was not followed, leading to this deficiency.
A facility failed to ensure timely follow-up by a physician for a resident with elevated sodium levels. The resident, with multiple health issues, had a lab report showing abnormal sodium levels, which the MD reviewed but did not act upon until days later. Interviews revealed a lack of awareness and follow-up, despite facility policy requiring timely medical assessments.
A facility failed to notify a physician in a timely manner about a resident's abnormal lab results, which included an elevated sodium level. The resident had multiple health conditions, and the facility's policy required prompt notification of the physician for significant changes in medical treatment. Interviews revealed uncertainty and lack of documentation regarding the notification timeline.
The facility failed to maintain air temperatures at a comfortable level, affecting 18 residents. Observations revealed that the memory care unit's ambient air temperatures were below the required 71 degrees Fahrenheit, with readings ranging from 65.3 to 70.1 degrees Fahrenheit. CNAs confirmed the cool temperatures during resident bathing, and the Maintenance Director was unaware of the issue despite weekly checks. The facility's policy requires maintaining temperatures between 71 to 81 degrees Fahrenheit.
A resident with multiple health conditions did not receive ordered weekly lab work for CBC and BMP, as confirmed by the DON. The facility's records lacked evidence of completed lab work, despite orders being in the lab system. This deficiency was found during a complaint investigation.
A resident with dementia and pressure ulcers did not receive proper infection control during wound care. An LPN failed to don a gown and did not change gloves or perform hand hygiene between dressing changes, contrary to facility policy and CDC guidelines. The facility lacked a specific EBP policy, relying on CDC guidelines instead.
The facility failed to maintain a clean and sanitary environment, affecting several residents. Observations revealed issues such as peeling floors, broken wall bumpers, and unclean bathrooms in the Memory Care Unit. Interviews with staff and residents confirmed the poor condition, with reports of inadequate housekeeping services and unresolved maintenance issues. The Director of Housekeeping verified these problems during a walkthrough, indicating non-compliance with maintaining a safe and homelike environment.
A resident with a history of migraines did not receive prescribed medications due to a failure to transcribe physician orders into the EMAR. Despite the medications being delivered, they were not administered, leading to continued severe pain for the resident.
Systemic Failure to Inventory, Label, and Track Residents’ Personal Clothing and Belongings
Penalty
Summary
The deficiency involves the facility’s failure to implement effective procedures to safeguard residents’ personal belongings, particularly clothing, as required by its own policies. Multiple residents with varying cognitive statuses reported missing clothing and personal items, and surveyors found that inventory forms were incomplete, inaccurate, undated, and often unsigned. For one resident with Alzheimer’s disease and impaired cognition, the admission inventory listed general categories of clothing and photographs but no quantities and did not include a recliner chair that remained in the facility after discharge. A concern form documented that this resident’s representative reported missing slippers, pajamas, and a shirt; some items were later found among unlabeled clothing, and one pair of slippers remained missing. The Administrator confirmed the recliner was not on the inventory sheet. Another resident with Huntington’s disease and moderately impaired cognition reported missing underwear, stating she had informed staff but received no follow-up. Her inventory form was undated and unsigned, listing only a few clothing items and a cell phone with charger. When surveyors and the ADON later checked her belongings, they found more clothing items than were documented, and several items were unlabeled. A resident with hemiplegia, schizoaffective disorder, and intact cognition reported missing shoes, leggings, jogging pants, a sentimental t‑shirt, and a hoodie, and stated she had reported these losses without staff follow-up. Her inventory form, completed by a social worker, listed only broad categories of clothing and a few specific items, with almost no quantities recorded. Observation showed she had numerous clothing items not accurately reflected on the inventory form, and some items were unlabeled. A resident admitted with a femur fracture and intact cognition reported missing three pairs of pajamas and said he had notified laundry staff, who did not follow up. His undated, unsigned inventory form listed only a small number of clothing items and dentures, while observation later revealed multiple additional clothing items, most of which were unlabeled and not on the inventory. Another resident with cerebral infarction, bipolar disorder, and intact cognition reported missing pajama pants, undershorts, dress pants, and shirts, and said staff told him he would need to sort through bags of clothes himself, which he refused. His inventory form, signed by therapy staff, listed general clothing and personal items without quantities. Subsequent observation showed numerous clothing items, including unlabeled pants the resident said he received as gifts, and the inventory remained inaccurate. Surveyors later observed racks of unlabeled clothing in the social worker’s office, including pajama pants matching this resident’s description. Staff interviews and laundry observations showed systemic failures in the processes for inventorying, labeling, and tracking clothing. The Laundry Account Manager stated that about 90% of inventory sheets had not been completed and clothing was not being labeled, with CNAs sending bags of unlabeled clothing to laundry. Laundry staff reported the tracking process was “broken,” that they lacked descriptions and sizes on inventory sheets, and that they had not received missing item forms for months. Surveyors observed large quantities of unlabeled clothing in the laundry room and on racks in the social worker’s office. CNAs and the DON gave inconsistent descriptions of who completes inventories, what details should be documented, and who is responsible for labeling clothing. The receptionist, who had labeling equipment, was unsure of her responsibility. The DON and ADON acknowledged that inventory sheets were not consistently completed, updated, or reviewed after admission, that many items were unlabeled, and that new items brought in by families were not routinely added to inventories. Despite facility policies requiring inventory of belongings, prompt investigation of complaints, and maintenance of lost-and-found records, there were no documented concern forms or nurse notes for the missing items reported by several residents, and the Resident Council President reported ongoing issues with clothing not being returned from laundry.
Failure to Report and Investigate Allegation of Misappropriation
Penalty
Summary
The deficiency involves the facility’s failure to timely report an allegation of misappropriation of a resident’s funds to the state agency and to initiate an investigation. The resident involved had diagnoses including malignant carcinoid tumor of the bronchus and lung, COPD, malignant neoplasm of the liver, depressive disorder, neoplasm of the brain, and anxiety, and was documented as having intact cognition on a recent quarterly MDS. On one morning, nursing documentation showed the resident was in his room going through his belongings, then moved into the hallway with belongings on his rollator, loudly stating he was leaving, that his accounts were hacked, and that all his money was stolen. The resident was yelling, not redirectable, and ultimately shoved his belongings to the ground and attempted to leave through the front doors while the hospice nurse and a facility nurse followed. Police and EMS were called, and the resident became combative with officers and was arrested. Review of the facility’s Self-Reported Incidents through the day after the event showed that no SRI had been submitted to the state agency regarding the resident’s allegation of misappropriation, and no investigation into the allegation had been started. The DON acknowledged the resident had called the sheriff and reported his account had been hacked, and confirmed the resident was combative with an officer and arrested, but did not indicate that an abuse/misappropriation report or investigation had been initiated. The Administrator stated she was not informed that the resident had alleged his account was hacked or that his money was stolen, and verified that no SRI had been submitted, stating she would have filed one if she had been aware. In contrast, the ADON reported that on the day of the incident the resident stated his account was hacked and his money was gone, and that this allegation was reported to the Administrator, DON, and Regional on call. Facility policy required that all alleged violations involving abuse, neglect, exploitation, or misappropriation of resident property be reported within required timeframes and investigated, which did not occur in this case.
Failure to Implement Enhanced Barrier Precautions per Physician Orders
Penalty
Summary
The deficiency involves the facility’s failure to implement physician-ordered enhanced barrier precautions (EBPs) for a resident with multiple high-risk conditions. The resident, admitted with paraplegia, hypertension, neuromuscular bladder dysfunction, and stage four pressure ulcers on both hips, had an indwelling urinary catheter, an ostomy, and two stage four pressure ulcers present on admission. The quarterly MDS showed the resident had intact cognition. Physician orders dated 08/05/25 required staff to use gowns and gloves for high-contact resident care activities, including dressing, bathing/showering, transfers, hygiene, toileting, changing linens, changing briefs, dressing changes, and care of any device such as wounds, catheters, or ostomies. The resident’s care plan also specified the need for EBPs related to wounds, colostomy, and indwelling urinary catheter, with interventions directing staff to wear EBP PPE during high-contact care. During observation, the resident was in bed with a sign posted on the door indicating EBPs and instructing staff to wear a gown and gloves during care, and a PPE bin with gowns was available outside the room. A CNA was observed providing care while wearing gloves but no gown. The CNA performed multiple high-contact activities, including oral care, placing a pillowcase on a pillow, repositioning the resident in bed, and emptying the urinary catheter drainage bag, all without donning a gown. In interview, the CNA confirmed these care activities, stated she was unaware the resident was on EBPs, reported she had not noticed the sign, and indicated that staff were not in the habit of wearing gowns and that she had not received training on EBPs. The DON confirmed that staff should be wearing PPE for residents on EBPs during high-contact care. Review of the facility’s Enhanced Barrier Precautions policy, revised 12/2024, showed that EBPs require gown and glove use for high-contact care for residents with wounds or indwelling devices and that staff were to be trained prior to caring for residents on EBPs, with signage used to communicate required PPE.
Failure to Promptly Notify Resident Representative of Fracture
Penalty
Summary
The deficiency involves the facility’s failure to promptly notify a resident’s representative of a significant change in condition, specifically a left radial fracture. The resident had diagnoses including cerebral infarction, Alzheimer’s disease, anxiety, and depressive disorder, and was documented as having severe cognitive impairment and dependence on staff for activities of daily living. On 01/22/26, a STAT x-ray of the resident’s left arm was ordered due to edema, along with an order for ice application. Nursing documentation that morning indicated the nurse practitioner was notified of the edema and that all parties were notified of the new x-ray and ice orders. An x-ray was completed that evening, and the radiology report later that night showed a non-displaced fracture of the distal left radius. On the following day, a nurse’s note documented that the nurse practitioner reviewed the x-ray results with no new orders, but there was no documentation that the resident’s representative was notified of the fracture at that time. Several days later, on 01/27/26, the nurse practitioner evaluated the resident onsite, reviewed the abnormal x-ray results, and new orders were written for a left wrist/hand splint; the nurse’s note again stated that all parties were notified. A hospice progress note that same day showed that hospice staff initially believed the x-ray was negative and only learned of the radial fracture when a staff member entered with a splint and stated the resident had a fracture. The hospice nurse then spoke with facility staff, who confirmed the nondisplaced radial fracture and indicated the resident’s representative would be updated. Documentation shows that the hospice nurse, not facility staff, notified the family of the x-ray results and treatment on 01/29/26. The unit manager LPN confirmed there was no documentation that the family was notified of the fracture when it was identified on 01/22/26, despite facility policy requiring prompt notification of the resident, physician, and resident representative of changes in condition.
Failure to Accurately Manage and Document Controlled Substance Use for a Resident in Pain
Penalty
Summary
The deficiency involves the facility’s failure to maintain an accurate and compliant system for dispensing, administering, reconciling, and destroying controlled substances, specifically Oxycodone, for a resident with significant pain needs. The resident was admitted with malignant carcinoid tumor of the bronchus and lung, COPD, malignant neoplasm of the liver, and low back pain, and had intact cognition, independence in ADLs, and frequent pain. Physician orders initially included Oxycodone 30 mg every four hours as needed, later changed to Oxycodone 20 mg scheduled three times daily with additional 20 mg doses every four hours as needed. The scheduled and PRN Oxycodone 20 mg orders were placed on the same medication card, contrary to facility policy requiring one prescription per control record page. Review of the MARs and controlled substance records showed multiple discrepancies and missing documentation. The MARs indicated that the resident received 26 Oxycodone tablets over several days and an additional 28 tablets over a later period, but there were no corresponding controlled substance monitoring/control records for those administrations. On one date, two tablets of discontinued Oxycodone 30 mg were removed from the medication card at 3:00 A.M., with no documentation on the MAR or in nurse’s notes that the medication was administered, disposed of, or wasted. On another date, the MAR showed administration of two Oxycodone 20 mg tablets, but the control record did not show that the medication had been removed from the card, and there was no nursing documentation explaining why the medication was charted as given when it had not been pulled according to the control record. Further record review revealed inconsistencies in the documented counts and destruction of Oxycodone 30 mg tablets. A disposal record showed nine tablets documented as destroyed, while the corresponding control record indicated only four tablets remained, and the entry for destruction of nine tablets was crossed out and changed to four. The DON verified that nine tablets had been incorrectly documented as destroyed. Facility leadership and nursing staff acknowledged they could not locate all of the resident’s Oxycodone control records and that nurses were not consistently documenting and initialing shift-change controlled substance inventory count sheets when medication cards and control records were removed from the controlled substance binder. The resident reported that pain medication was not administered when requested and stated that management had been notified. Interviews with the ADON and other staff confirmed that required documentation practices, including progress notes when medications were not given and proper witnessing and recording of destruction, were not followed, and that the ADON had not reviewed the missing control records as required by policy.
Failure to Implement Proper PPE Protocols During COVID-19 Outbreak
Penalty
Summary
The facility failed to implement proper infection prevention and control practices during a COVID-19 outbreak, specifically regarding the use of personal protective equipment (PPE). Observations revealed that staff and residents were generally wearing surgical masks, but multiple instances occurred where staff did not don the required PPE, such as N95 masks, gowns, gloves, and face shields, when entering rooms of residents with confirmed COVID-19 or when providing care in areas under droplet precautions. In several cases, staff entered rooms of residents in isolation without appropriate PPE, and some staff were unaware of or did not follow posted PPE requirements. For example, a certified nursing assistant (CNA) entered a room shared by a COVID-19 positive resident without donning any PPE, and another CNA provided care to COVID-19 positive residents while only wearing a surgical mask, despite signage indicating the need for an N95 mask and other protective equipment. Interviews with staff indicated confusion and lack of consistent education regarding PPE protocols. Some staff reported not receiving education on proper donning and doffing procedures, while others were unsure about mask requirements or believed that wearing a face shield alone was sufficient. There were also reports of staff being unable to locate N95 masks on the memory care unit (MCU), despite the facility stating that adequate stock was available. This led to staff providing care to COVID-19 positive residents without the recommended respiratory protection. Additionally, staff sometimes failed to review or follow the PPE instructions posted on isolation signage before entering resident rooms. The deficiency affected both residents diagnosed with COVID-19 and those not diagnosed, as improper PPE use increased the potential for transmission. The facility census was 68, with 14 residents identified as having COVID-19 during the outbreak. The facility's own policy required staff to use a NIOSH-approved N95 respirator, gown, gloves, and eye protection when entering the room of a resident with suspected or confirmed COVID-19, but these protocols were not consistently followed as observed and confirmed through staff interviews.
Incompatible Mattress and Bed Frame Resulting in Unsafe Bed Setup
Penalty
Summary
The facility failed to ensure that a mattress and bed frame were compatible for a resident with morbid obesity, muscle weakness, and Type II Diabetes Mellitus. The resident, who was cognitively intact and required a low air loss mattress at all times, reported that the mattress was too large for the bed frame. Observation confirmed that the mattress overhung the bed frame by approximately five inches, and a grab bar could not be installed on one side of the bed due to the mattress's size. The Maintenance Director acknowledged that the mattress was not fully supported by the frame and confirmed awareness of the issue.
Failure to Provide Ordered Bed Rails for Resident Mobility
Penalty
Summary
The facility failed to ensure that bed rails were in place as ordered to assist a resident with bed mobility. The resident, who had diagnoses including morbid obesity, muscle weakness, and Type II Diabetes Mellitus, was care planned and assessed to require bilateral half side rails to promote independence with bed mobility, self-positioning, and transfers. The physician order also specified half side rails on both sides of the bed. However, during observation, it was noted that only the left side of the bed had a grab bar, while the right side, which was against the wall, did not have one installed. The resident reported that both grab bars were necessary to assist with mobility during personal care in bed. The Maintenance Director confirmed the absence of the right-side grab bar, attributing it to the way the mattress fit the bedframe. Further interview revealed that the Maintenance Director had not assessed the mattress or bedframe for proper fit since beginning employment and had not made any changes to the resident's bed setup. This resulted in the resident not having the necessary equipment in place as indicated by their care plan and physician order.
Failure to Supervise Resulting in Resident-to-Resident Sexual Abuse
Penalty
Summary
The facility failed to provide adequate supervision, resulting in an incident of sexual abuse involving two residents with dementia. One resident, who had severely impaired cognition and was dependent on staff for all activities of daily living, was found in a wheelchair in the lounge area with another resident kneeling beside her and his hand inside her brief at the peri area. The incident was witnessed by a CNA, who observed the resident's hand entering the brief from the side and making contact with the peri area. The CNA described the resident's posture as appearing to enjoy the interaction, and the event occurred in a common area near the nurse's station. At the time of the incident, staffing in the area included a nurse passing medication and another CNA providing care in a different room, leaving the lounge area unsupervised. The resident who initiated the contact had impaired cognition but was physically able to move independently. The incident was discovered when the CNA exited another resident's room and observed the inappropriate contact. The written statement provided by the CNA was brief, as directed by the DON, but during a subsequent interview, the CNA provided more detailed observations about the nature and extent of the contact. The facility's investigation included review of witness statements, medical records, and interviews with staff. The administrator acknowledged the discrepancy between the CNA's written and verbal statements but maintained that the investigation did not indicate sexual abuse. However, the facility's policy required monitoring for sexually aggressive behavior and potential abuse in resident-to-resident altercations. The lack of supervision in the lounge area directly contributed to the incident, as staff were not present to prevent or immediately intervene in the inappropriate contact.
Failure to Timely Report Alleged Sexual Abuse
Penalty
Summary
The facility failed to ensure timely reporting of an allegation of sexual abuse to the State Agency, as required by federal and state regulations. A resident with severe cognitive impairment, dependent on staff for all activities of daily living and diagnosed with Alzheimer's disease, cerebral infarction, depression, anxiety, and cerebrovascular disease, was found in her wheelchair in the lounge with another resident's hand in her brief. The incident was documented by the DON, and the residents were immediately separated and placed on 15-minute checks. Despite the immediate intervention, the Administrator did not report the incident to the State Agency within the required two-hour timeframe. The Administrator stated that the delay was due to his belief that no abuse had occurred. Facility policy mandates that all alleged violations involving abuse must be reported within the proper time frame, but this procedure was not followed in this case.
Failure to Administer Medications as Ordered Due to Unavailability
Penalty
Summary
The facility failed to ensure that medications were administered according to physician orders for two residents. For one resident with multiple diagnoses including a fractured femur, osteoarthritis, anxiety, schizoaffective disorder, and venous thrombosis, several prescribed medications such as Senna, Cefuroxime Axetil, Eliquis, Risperidone, and Methocarbamol were not administered upon admission due to the medications not being available. Documentation in the Medication Administration Record (MAR) and nurses' progress notes confirmed that these medications were missed, and the provider was notified of the missed doses, but no new orders were received. Additionally, the resident received only nine out of ten ordered doses of Cefuroxime Axetil. Another resident with a history of spondylolisthesis, chronic pain, and cervical disc disorder did not receive multiple doses of Lyrica (pregabalin) as ordered for nerve pain. The MAR and nursing notes indicated that the medication was not available on several occasions, resulting in missed doses. The resident reported experiencing neck pain and confirmed that the facility ran out of his medication for six doses during the previous week. The DON confirmed the missed doses upon review of the MARs for both October and November.
Failure to Properly Label and Monitor Expiration of Thickened Liquids
Penalty
Summary
Staff failed to properly label food items with open dates and did not demonstrate knowledge regarding the expiration of packaged foods. During an observation of food storage, several opened cartons of nectar thickened beverages were found in a reach-in cooler, each with only a handwritten date indicating when the product was received into inventory, not when it was opened. The Dietary Manager confirmed that no other date was written to indicate the opening of the product and believed the product was safe to consume until the manufacturer’s stamped date. However, the cartons were labeled to be used within seven days of opening if refrigerated, a fact the Dietary Manager was unaware of. This deficiency affected a resident with impaired cognition and multiple diagnoses, who was the only individual in the facility on thickened liquids. Review of facility training records showed that dietary staff, including the Dietary Manager, had been educated on expired food disposal and labeling and dating foods, but the facility’s policy did not provide guidance on dating food items with multiple servings in original containers. The lack of proper labeling and staff knowledge led to the failure to ensure food safety standards were met for the resident requiring thickened liquids.
Failure to Timely Report Alleged Staff-to-Resident Abuse
Penalty
Summary
The facility failed to immediately report an allegation of staff-to-resident abuse to the State Survey Agency, as required by regulation and facility policy. A resident with multiple diagnoses, including sepsis, seizures, bipolar disorder, and major depressive disorder, who was rarely or never understood by staff, was at risk for falls and had interventions in place for safety and engagement. On the evening in question, a CNA and an LPN witnessed another LPN repeatedly snatch a stuffed animal from the resident, refuse to return it unless the resident complied with demands, and make statements such as the toy being in 'jail' and the resident being 'bad.' These actions caused the resident to become visibly upset and agitated, prompting staff to report the incident to the unit manager immediately. Despite the immediate internal reporting, the facility did not notify the State Survey Agency of the abuse allegation until two days after the incident. Review of the facility's self-reported incidents and interviews with staff and the administrator confirmed the delay in reporting. Facility policy required that allegations of abuse and the results of investigations be reported within required timeframes, which was not followed in this case. This deficiency was identified during a complaint investigation and affected one of three residents reviewed for abuse.
Failure to Maintain Safe, Clean, and Homelike Environment
Penalty
Summary
Surveyors identified multiple failures by facility staff to maintain a safe, clean, and homelike environment for residents, as evidenced by direct observations and staff interviews. Numerous resident rooms and restrooms were found with significant maintenance and cleanliness issues, including spider webs, broken or missing laminate on window sills, cracked and damaged walls, peeling paint, exposed drywall, holes in doors and walls, loose or non-functional electrical outlets, and broken or missing shower fixtures. In several cases, attempts to repair damage were incomplete or used unidentified substances, and some areas had unidentified stains or substances present. Additional deficiencies included the absence of basic hygiene supplies, such as hand soap or sanitizer in shared restrooms, and non-functional lighting in resident restrooms. In the memory care unit, only one of three showers was operational, with the others having broken or non-functioning components. Several restrooms and resident rooms had missing or damaged shower curtains, cracked flooring, and loose or broken radiant heater covers. These conditions were consistently verified by interviews with LPNs, CNAs, and housekeeping staff, who confirmed the observations made by surveyors. The facility's own policy, dated February 2021, requires the provision of a safe, clean, comfortable, and homelike environment, but the observed conditions did not meet these standards. The issues affected at least ten residents, as confirmed by the facility administrator, and were investigated under two complaint numbers. No information was provided regarding the medical history or specific conditions of the affected residents at the time of the deficiency.
Failure to Hold Required Care Conferences for Resident
Penalty
Summary
The facility failed to ensure that care conferences were held as required for a resident during their admission. Medical record review showed that the resident, who was admitted with multiple diagnoses including encephalitis, dementia, abnormal lung findings, latent tuberculosis, hypokalemia, and restlessness/agitation, had only one care conference documented during their stay. The resident was cognitively impaired, with a BIMS score of 03, and required assistance with all functional abilities. Interviews with the Social Services Designee and the Administrator confirmed that only one care conference was held for the resident, despite facility policy and regulatory requirements for care conferences to occur at admission, quarterly, and with significant changes in condition. The Social Services Designee indicated she was trying to catch up on overdue care conferences due to a staffing change. Review of facility policy also confirmed the expectation for regular care conferences, which was not met in this case.
Failure to Implement Physician-Ordered Pressure Ulcer Prevention Interventions
Penalty
Summary
The facility failed to implement physician-ordered interventions to prevent skin breakdown for a resident with multiple risk factors, including multiple sclerosis, coronary artery disease, hypertension, major depressive disorder, metabolic encephalopathy, muscle weakness, and dementia. The resident was assessed as having moderately impaired cognition, was dependent on staff for activities of daily living, incontinent of bowel and bladder, and at moderate risk for pressure ulcer development. Physician orders included the use of a pressure-reducing cushion in the wheelchair at all times and offloading boots to both lower extremities. The care plan was updated to address these risks and included specific interventions such as the use of a Roho cushion and offloading boots. Despite these orders and care plan interventions, observations revealed that the resident was repeatedly found seated in a geri-chair without the required pressure-relieving cushion or offloading boots in place. Staff interviews confirmed that the devices were not in use and could not be located in the resident's room. Additionally, review of the CNA's electronic resident-specific information lacked instructions regarding the use of these devices. The nursing supervisor verified that the devices were ordered and not in place, and acknowledged the resident's recent history of a healed stage III pressure ulcer to the coccyx.
Failure to Maintain Safe, Comfortable, and Homelike Environment
Penalty
Summary
Surveyors identified that the facility failed to provide a comfortable and homelike environment for residents, as evidenced by multiple observations and interviews. In the memory care unit, two residents were found wearing heavy winter clothing and blankets due to cold temperatures, with the thermostat set at 69°F, below the facility's policy range of 71°F to 81°F. Staff confirmed the temperature was uncomfortably low and adjusted the thermostat during the survey. The facility's policy requires maintaining comfortable and safe temperatures, which was not adhered to at the time of observation. Additional deficiencies were observed in resident rooms, including significant physical damage and lack of maintenance. One resident's room had a large area of wall damage present since admission, another had peeling paint behind the bed, and a third had both peeling paint and a window sill with broken and chipped laminate. In the same room, the toilet was not properly secured and moved when used, and there was missing drywall at the base of the shower exit. Staff interviews confirmed these environmental issues, which were inconsistent with the facility's policy to provide a safe, clean, and homelike environment.
Unsafe Storage of Hazardous Chemicals
Penalty
Summary
Facility staff failed to store chemicals in a safe and secure manner, resulting in open and accessible canisters of Sani-Cloth germicidal disposable wipes and Sani-Cloth bleach germicidal disposable wipes being left on a linen cart near resident rooms. Both canisters were observed to be open and within reach of residents, including four individuals identified as cognitively impaired and independently mobile who resided outside of the memory care unit. Product labels and Safety Data Sheets (SDS) for these chemicals indicated they are hazardous, with warnings to keep them out of reach of children, use personal protective equipment, and avoid contact with skin and eyes. An LPN confirmed during interview that the chemicals were accessible to residents and stated that facility protocol required such items to be stored in a locked room or compartment. Facility policies reviewed emphasized the importance of maintaining an environment free from accident hazards and providing a safe, clean, and comfortable setting for residents. The failure to secure hazardous chemicals was found to be inconsistent with these policies and had the potential to affect the safety of cognitively impaired residents.
Facility Fails to Maintain Odor-Free Environment
Penalty
Summary
The facility failed to maintain a safe, clean, and homelike environment as required, due to pervasive foul odors throughout the facility, excluding the secured memory care unit. Observations made on February 19, 2025, revealed that the reception area and resident halls had a strong, unpleasant odor, particularly near the nurses' station. Interviews with staff, including a Certified Nursing Assistant and Licensed Practical Nurses, confirmed the presence of the odor, which was attributed to certain resident rooms where individuals declined assistance with care. The odor was noticeable from the nurses' station, approximately 20 feet from the affected resident rooms. Family members visiting a resident also reported the persistent foul odor from the entrance to the resident's room, indicating that the issue was ongoing and noticeable to visitors. A resident interviewed on February 20, 2025, corroborated the presence of the foul odor in the facility's halls. The facility's policy on maintaining a homelike environment, which includes minimizing institutional odors, was not adhered to, leading to this deficiency. This issue was investigated under Complaint Number OH00161393.
Failure to Ensure Timely Physician Follow-Up for Elevated Sodium Levels
Penalty
Summary
The facility failed to ensure timely and adequate follow-up by the physician for a resident's care needs, specifically regarding elevated sodium levels. Resident #19, who had multiple diagnoses including dementia, anxiety, and chronic kidney disease, had a lab report showing an abnormal sodium level of 156 mEq/L, which was outside the normal range. The lab results were reported to the facility, and the Medical Director (MD) reviewed them but did not provide any new orders or follow-up until several days later. The illegible handwriting on the lab report was confirmed to be the MD's signature, dated the day after the lab results were received. Interviews with the MD and the Nephrology Nurse Practitioner (NNP) revealed a lack of awareness and follow-up on the elevated sodium levels. The MD was unable to recall reviewing the lab results or providing any subsequent treatment, and the NNP was not informed of the elevated sodium level until several days later. The facility's Director of Nursing (DON) confirmed that the lab report was placed in the MD's folder for review, but no action was taken until days later, despite the facility's policy requiring timely medical assessments and information sharing. This deficiency was identified during a complaint investigation.
Failure to Notify Physician of Abnormal Lab Results
Penalty
Summary
The facility failed to notify the physician in a timely manner regarding abnormal laboratory results for a resident. The resident, who had multiple diagnoses including dementia, anxiety, psychotic disorder, hypertension, chronic kidney disease stage 3B, and schizoaffective disorder, had routine labs drawn. The results, which included an elevated sodium level, were reported to the facility, but there was no evidence that the physician was notified of these abnormal values on the day they were received. Interviews with the Medical Director and the Director of Nursing revealed uncertainty and lack of documentation regarding when the physician was informed of the lab results. The Medical Director was unsure of the notification timeline, and the Director of Nursing confirmed that there was no evidence of notification on the day the results were received. The facility's policy required timely notification of the physician when there was a need to alter the resident's medical treatment significantly, which was not adhered to in this case.
Facility Fails to Maintain Required Air Temperatures
Penalty
Summary
The facility failed to maintain air temperatures at a comfortable and acceptable level, affecting 18 out of 68 residents. During an observation tour, it was noted that the heating, ventilation, and air conditioning system was provided by forced air and multiple room furnaces, with each room equipped with an electric radiant heat baseboard local control unit. However, the ambient air temperature readings in the memory care unit common corridors and resident rooms were below the required temperature of 71 degrees Fahrenheit. Specifically, temperatures ranged from 65.3 to 70.1 degrees Fahrenheit, with the common shower room also recording low temperatures and non-operational electric radiant heat wall heaters. Interviews with CNAs assigned to the memory care unit confirmed that the temperatures were cool during resident bathing, and they had no access to adjust the heat. The Maintenance Director verified that the ambient air temperatures in the memory care unit were below the required level and was unaware of the issue despite conducting weekly random temperature checks. The facility's homelike environment policy, revised in February 2021, mandates maintaining comfortable and safe temperatures between 71 to 81 degrees Fahrenheit, which was not adhered to, leading to this deficiency.
Failure to Complete Ordered Lab Services
Penalty
Summary
The facility failed to ensure that laboratory services were collected and completed according to physician orders for a resident. The resident, who had been re-admitted and later discharged, had diagnoses including chronic obstructive pulmonary disease (COPD), congestive heart failure (CHF), right-sided heart failure, cerebral vascular accident (CVA), and alcohol abuse. The physician had ordered weekly laboratory work for a complete blood count (CBC) and basic metabolic panel (BMP) to monitor the resident's condition. However, a review of the Medication Administration Record (MAR) revealed that the lab work was not completed on the specified dates, and there were no results for the CBC and BMP from the specified period. An interview with the Director of Nursing (DON) confirmed that the orders were in the lab system, but the medical record lacked evidence of the lab work being completed. This deficiency was discovered during a complaint investigation, indicating a lapse in following the facility's policy for prevention and screening.
Infection Control Lapses During Wound Care
Penalty
Summary
The facility failed to adhere to infection control practices during wound care for a resident with dementia and pressure ulcers. The resident was admitted with unhealed pressure ulcers and was care planned for wound care with enhanced barrier precautions (EBP). However, during an observation, an LPN did not don a gown as required by EBP before performing wound care. The LPN removed the old dressing from the resident's left knee without changing gloves or performing hand hygiene before applying a new dressing, which is against the facility's wound care policy and CDC guidelines. Additionally, the LPN repeated the same procedure on the resident's left outer leg wound, again failing to change gloves or perform hand hygiene between removing the soiled dressing and applying a new one. The facility's Director of Nursing confirmed that there was no specific EBP policy in place, and the facility was following CDC guidelines. The facility's policy and CDC guidelines both emphasize the importance of hand hygiene and proper use of personal protective equipment to prevent the spread of infections.
Facility Fails to Maintain Clean and Sanitary Environment
Penalty
Summary
The facility failed to maintain a clean and sanitary environment, affecting four out of six residents sampled for the environment. Observations in the Memory Care Unit revealed several issues, including a peeling and bulging laminate floor, broken wall bumpers with jagged edges, peeling carpeting, holes in the wall, and a thick layer of dust on fan paddles. Additionally, there were food items on the floor, deep grooves in the paint exposing drywall, and a missing electrical plate over an active outlet. The shower room had a constant stream of water running from a shower hose, black slimy substances on grout and flooring, and a missing tile exposing drywall. The main dining room had peeling and missing paint on the ceiling. Interviews with staff and residents confirmed the poor condition of the facility. A State Tested Nursing Assistant (STNA) described the environment as awful and not clean. A family member of a resident expressed dissatisfaction with the facility's physical appearance and lack of response to concerns. Residents reported issues such as missing laminate on window ledges, missing heater vent covers, and unclean bathrooms with strong odors of urine. One resident mentioned having to sweep their own room due to inadequate housekeeping services. The Director of Housekeeping verified the presence of gnats, unclean bathrooms, and other maintenance issues during a walkthrough with the Administrator. The housekeeping job routine checklist indicated that resident rooms and bathrooms should be cleaned daily using a specified process, but these procedures were not followed. The deficiency was investigated under Complaint Number OH00155465, highlighting the facility's non-compliance with maintaining a safe, clean, and homelike environment for residents.
Failure to Administer Prescribed Migraine Medications
Penalty
Summary
The facility failed to ensure medications to treat migraine headaches were provided as ordered by the physician, resulting in a significant medication error for Resident #12. The resident, who was admitted with diagnoses including anxiety disorder, mononeuropathy, major depression, and cervicalgia, had a nursing plan of care that included interventions for pain management. Despite attending a neurology appointment and receiving new medication orders for Nurtec and Aimovig, these orders were not transcribed into the electronic medication administration record (EMAR), and the medications were not administered as required. The resident reported experiencing daily migraine headaches with pain levels reaching eight out of ten, and the previously administered medications were not consistently effective. Interviews with the resident, the Director of Nursing (DON), and a Licensed Practical Nurse (LPN) revealed that the medications were delivered to the facility but were not made available for administration due to the lack of transcription into the EMAR. The facility's policy on administering medications, which requires medications to be administered in accordance with prescriber orders, was not followed. This oversight resulted in the resident not receiving the prescribed medications for migraine treatment, highlighting a significant lapse in medication management and adherence to physician orders.
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 metabolic encephalopathy, muscle weakness, and a history of CVA experienced a fall in his room that was not documented in the medical record until the following morning as a late entry. Two RNs acknowledged that the fall was not recorded at the time it occurred and stated that fall incidents should be documented as soon as possible after the event, resulting in a deficiency for failure to maintain timely, professionally standard medical records.
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.
A resident with cirrhosis, ascites, mood disorder, and alcohol-induced major neurocognitive disorder, and with moderately impaired cognition, was observed sitting on a shower chair in a gown with buttocks exposed and visible from the hallway through an open room door. A CNA left the room quickly after hearing another resident yell and forgot to close the door or pull the privacy curtain, and an RN confirmed the exposure, demonstrating a failure to maintain the resident’s dignity and privacy.
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.
Untimely Documentation of Resident Fall Incident in Medical Record
Penalty
Summary
The deficiency involves the facility’s failure to document a resident’s fall incident in the medical record in a timely manner, in accordance with accepted professional standards. The resident was admitted with diagnoses including metabolic encephalopathy, muscle weakness, and cerebrovascular accident. According to the medical record, a progress note was entered as a late entry on 02/20/26 at 8:21 A.M., stating that the resident had suffered a fall in his room on 02/19/26 at 8:00 P.M. There was no evidence of any documentation of the fall incident entered in the medical record at the time of, or shortly after, the fall on 02/19/26 at 8:00 P.M. During an interview on 03/30/26 at 12:05 P.M., two RNs confirmed that the fall incident was not documented until the following morning and stated that fall incidents should be entered in the medical record as soon as possible following the event. This lack of timely documentation of the fall incident constituted non-compliance with requirements to safeguard resident-identifiable information and maintain medical records in accordance with professional standards.
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.
Resident Left Exposed and Visible From Hallway Due to Failure to Maintain Privacy
Penalty
Summary
The facility failed to ensure resident dignity and privacy when a cognitively impaired resident was left exposed and visible from the hallway. The resident, who had diagnoses including cirrhosis with ascites, mood disorder, and alcohol-induced major neurocognitive disorder, had a BIMS score of eight, indicating moderately impaired cognition. During an observation, the resident was seen sitting on a shower chair in a gown with buttocks exposed, and this exposure was visible from the open room door in the hallway. A Certified Resident Care Associate and a Registered Nurse confirmed that the resident’s buttocks were visible from the hallway. The Certified Resident Care Associate reported that she had left the resident’s room quickly after hearing a resident in an adjacent room yell and, in her haste, forgot to close the door or pull the privacy curtain, resulting in the resident’s exposed state being visible to others. This incident involved one resident out of three reviewed for dignity, in a facility with a census of 52 residents, and was identified through record review, observation, and staff interviews.
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.
