Astoria Place Of Cincinnati
Inspection history, citations, penalties and survey trends for this long-term care facility in Cincinnati, Ohio.
- Location
- 3627 Harvey Avenue, Cincinnati, Ohio 45229
- CMS Provider Number
- 366150
- Inspections on file
- 51
- Latest survey
- February 19, 2026
- Citations (last 12 mo.)
- 16
Citation history
Health deficiencies cited at Astoria Place Of Cincinnati during CMS and state inspections, most recent first.
Surveyors found that meals served did not match tray tickets or the posted menus. A resident with multiple medical conditions received a breakfast tray that differed from both the ticket and the planned menu when a cook failed to prepare a listed item. During lunch, residents were given additional sandwich toppings not on the menu, some residents later did not receive those toppings when the kitchen ran out, and all residents were served chocolate pudding instead of the chocolate cake specified on the menu, despite cake being available. These issues affected all residents receiving meals from the kitchen.
Surveyors found that meals, including pureed diets, were not prepared or served according to facility recipes or standards for palatability and temperature. The Dietary Manager blended chicken patties, lettuce, tomatoes, mayonnaise, and bread with hot water without using recipe cards, made gravy using only oil, flour, and water, and pureed rice with hot water instead of using cream of rice as specified. A test tray showed a cold chicken sandwich, bland broccoli without required lemon seasoning, and food items at non-appetizing temperatures. The RD confirmed staff should follow recipe cards and that the gravy formulation used would not taste good, and facility recipes and policy required more complete ingredients and palatable, well-balanced diets for all residents.
Surveyors found multiple failures to maintain sanitary food storage and preparation practices, including dirty soda equipment, a soiled cutting block, and dirty knives stored as clean. In the walk-in cooler and dry storage, various opened foods such as cheeses, bologna, pudding, pasta, and raw eggs were undated, and raw eggs were stored above other foods. The walk-in freezer was too warm, with food not fully frozen and an icicle from the condenser dripping over an open box of peas. The kitchen ice machine was leaking due to overfilling, and during a lunch meal service, broccoli on the steam table was held below the required hot-holding temperature because part of the steam table was not functioning, affecting all residents receiving meals.
The facility did not maintain a safe, functional, and homelike environment when two cognitively intact residents sharing a semi-private room had a bathroom door that would not close completely, compromising privacy despite facility Resident Rights guaranteeing privacy. In a separate room, a resident with significant cognitive impairment and multiple medical conditions was found with an unmonitored portable space heater plugged in and running on the floor, even though facility policy prohibits portable space heaters. These conditions were inconsistent with the facility’s own policies requiring a safe, clean, comfortable, and homelike environment.
A resident with cognitive impairment and multiple diagnoses reported verbal abuse by two CNAs. After the allegation was brought to the Administrator's attention, both staff members remained on duty and continued caring for residents, despite facility policy requiring immediate removal of accused employees pending investigation.
A resident with dementia and other medical conditions reported being sexually assaulted by a roommate, which was communicated to hospital staff and the facility's Director. Although the incident was discussed and a police report had previously been filed for similar allegations, the facility did not create a Self-Reported Incident (SRI) or ensure timely reporting to the state agency as required by policy.
A resident with dementia and other medical conditions reported to EMS and ER staff that he was fondled by his roommate. Despite the allegation and prior similar reports, facility staff did not initiate or document a required investigation or Self-Reported Incident (SRI), as confirmed by the Administrator. This failure was not in accordance with facility policy for abuse investigations.
A CNA did not change gloves or perform hand hygiene after providing incontinence care to a resident with severe cognitive impairment and urinary incontinence, instead applying a new incontinence brief immediately after cleaning the resident. This action was not in accordance with facility policy, which requires hand hygiene after contact with body fluids.
Surveyors found that an LPN had pre-pulled and stored loose pills for all residents on a unit in individual cups on the medication cart, rather than preparing and administering each resident's medication separately as required by facility policy. The DON confirmed this was not the correct procedure.
A resident with paraplegia and intact cognition was the subject of an unreported allegation of sexual abuse involving a staff member. Multiple staff reported the suspected relationship to the Administrator, but the facility did not notify the state agency until several months later, contrary to policy requiring reporting within 24 hours.
Two residents, one cognitively intact and one with mild cognitive deficits, had their cigarettes confiscated and discarded by the Administrator after being found smoking in a non-designated area. The cigarettes were not returned or replaced, constituting misappropriation of personal property as defined by facility policy.
The facility did not promptly report suspected abuse, neglect, or theft, nor did it communicate the results of its investigation to the proper authorities as required.
A deficiency was cited when a resident was not protected from various forms of abuse and neglect, as the facility failed to ensure adequate safeguards against physical, mental, sexual abuse, physical punishment, and neglect by any individual.
A deficiency was cited when the facility did not provide a safe, clean, comfortable, and homelike environment, nor did it ensure that treatment and supports for daily living were delivered safely to residents.
Staff did not follow Enhanced Barrier Precautions (EBP) during incontinence and wound care for a resident with EBP orders. Observations showed that staff failed to don gowns and did not change gloves or perform hand hygiene after cleaning feces, then touched clean items. The DON and involved staff confirmed these infection control measures were not followed as required by facility policy and physician orders.
A resident with multiple complex medical conditions was subject to an emergency discharge after being accused by two other residents of possessing a firearm, though no weapon was found. The resident was denied re-entry, police were called, and the resident was discharged without a safe destination or arrangements for ongoing wound care. The resident's belongings were placed by the dumpster, and the individual left the property in a wheelchair without transportation or a coat, later spending two days in a car before being hospitalized.
A resident with a history of schizoaffective disorder, cognitive impairment, and exit-seeking behavior was not adequately supervised after expressing threats to leave and self-harm. Despite being placed on one-on-one supervision and later assessed as not suicidal, supervision was discontinued, and the care plan lacked specific interventions for elopement risk. The resident subsequently removed a windowpane, exited the building undetected, and sustained serious injuries after falling from a second-story window.
The facility did not inform residents of a lunch menu substitution when beef pot roast was replaced with hamburgers due to the pot roast not being ready. The dietary manager confirmed that no notification was provided to residents, contrary to facility policy, affecting all residents who received meals from the kitchen.
A resident with multiple health conditions was unable to control the temperature in their room due to a missing air conditioner knob and lack of instruction, resulting in discomfort. Additionally, several shower rooms were found to be unsanitary, with water damage, mildew, a non-functioning toilet, and feces on the floor, and these issues were not promptly reported or addressed by staff.
A resident with multiple chronic conditions and a history of falls suffered an unwitnessed fall resulting in a shoulder fracture. The LPN received the X-ray results but did not notify the physician directly, instead passing the information to the DON. The Medical Director was not made aware of the injury until two days later, delaying necessary evaluation and treatment, despite facility policy requiring immediate provider notification for significant injuries.
Two residents were involved in an incident where one resident with behavioral issues was struck and scratched by another resident with a history of aggression. Although the event was documented and investigated internally, it was not reported to the State Agency as required by facility policy, resulting in noncompliance.
A resident with multiple mental health diagnoses was admitted without documentation of a required PASRR screening. The social worker confirmed that PASRR screening should have occurred prior to admission, and facility policy required such screening for major mental disabilities before admission.
A resident with multiple medical and mental health diagnoses was not reassessed for PASRR after receiving new mental health diagnoses and being prescribed additional psychotropic medications. The social worker did not complete the required reassessment due to being unaware of these changes, despite facility policy requiring coordination of PASRR assessments after significant changes.
The facility did not consistently conduct quarterly care conferences with participation from the full interdisciplinary team for three residents with complex medical and psychiatric conditions. In some cases, care conferences were either not held, not documented, or conducted without the required team members or resident involvement, contrary to facility policy.
A resident with a history of falls and cognitive impairment suffered a shoulder injury after an unwitnessed fall. Despite X-ray confirmation of a fracture dislocation, staff did not promptly notify the physician or obtain timely treatment, resulting in a delay of care until the resident was eventually sent to the hospital two days later.
A resident with multiple psychiatric diagnoses did not attend a scheduled telemedicine mental health appointment because the clinical team failed to review the admission and communicate the appointment details, despite the information being present in the hospital paperwork. The oversight occurred when the ADON was assigned to the floor and the usual morning meeting did not take place.
Three residents did not receive medications as prescribed when an LPN borrowed medications from other residents to administer to a resident whose medications were unavailable, contrary to facility policy prohibiting such practice. The incident involved residents with complex medical conditions and was confirmed through record review and staff interview.
The facility failed to maintain accurate medical records for three residents, including incorrect discharge documentation for a resident with complex needs, lack of timely physician notification regarding a resident's fracture, and false documentation by an LPN about provider notification for discontinuation of one-to-one supervision. These actions did not meet the facility's policy for objective, complete, and accurate documentation.
The facility failed to maintain a sanitary kitchen environment, affecting 60 residents. Observations revealed issues such as debris from a floor fan, grease buildup on exhaust louvers, and mold in the dishwashing area. The ice machine had mold, and there was no temperature monitoring for the freezer and milk cooler. Foods were unlabeled, undated, and expired in resident refrigerators. The Dietary Manager confirmed these issues, which violated the facility's sanitation policy.
The facility failed to maintain a safe and comfortable environment for residents, with issues including vulgar writing on walls, excessively hot rooms without air-cooling equipment, and a poorly maintained smoke room. Residents experienced discomfort and inadequate living conditions, with no alternative accommodations or temperature monitoring provided.
The facility failed to provide visual privacy for residents, affecting several individuals on a secured women's unit. Observations showed incomplete privacy curtains and a lack of window blinds in some rooms. Interviews with staff and residents confirmed the need for adequate privacy measures, which were not in place, violating the facility's privacy policy.
The facility failed to provide a safe and sanitary environment for residents on the women's secured unit, affecting 19 residents. Observations revealed mold-like substances in the shower room, a non-operational exhaust fan, and a torn shower curtain compromising privacy. Additionally, a missing span of drywall in the chemical room and a leaking shower head in a storage room were noted. Staff confirmed these issues, and the facility's maintenance policy was reviewed.
A resident with multiple diagnoses, including dementia and anxiety disorder, was recommended eyeglasses by an optometrist, but the facility failed to ensure the order was completed. Despite being cognitively intact, the resident did not receive the eyeglasses, as confirmed by an LPN and a Social Worker Designee. Observations showed the resident squinting to read a clock, highlighting the deficiency in providing necessary vision services.
The facility did not submit the required PBJ staffing data to CMS for the first quarter of 2024. The omission was due to a contractor responsible for the submission not providing the necessary login credentials after his contract was terminated. The facility had to create a new profile to ensure future submissions.
Meals Served Did Not Match Posted Menus or Tray Tickets
Penalty
Summary
The deficiency involves the facility’s failure to ensure that meals served matched residents’ tray tickets and the posted menus, as required by facility policy. For one resident, admitted with diagnoses including COPD, history of TIA and cerebral infarction without residual deficits, left bundle-branch block, mood disorder, acute kidney failure, toxic encephalopathy, and cocaine abuse, surveyors observed a breakfast tray containing milk, grape juice, hot oatmeal, breakfast ham, and scrambled eggs. The tray ticket for this meal specified cold or hot cereal, juice of choice, waffles, breakfast ham, milk, and coffee or hot tea. The resident reported that tray tickets and menus often did not match the meals served, and confirmed that the breakfast provided did not match the ticket or menu that day. A CNA verified the discrepancy between the tray ticket and the items actually on the tray. The Dietary Manager confirmed that the written breakfast menu for that date included cold or hot cereal, juice of choice, waffles, breakfast ham slice, milk of choice, and coffee or hot tea, and stated that the cook forgot to make and serve the waffles listed on the menu. At lunch on the same date, the written menu indicated residents were to receive lemon zest broccoli, chocolate cake with icing, a chicken patty on a bun, and rice. During observation of lunch service with the Dietary Manager, residents’ trays were seen to include lettuce and tomatoes on their chicken patties, items not listed on the menu. Later in the meal service, the kitchen ran out of lettuce, and the Dietary Manager confirmed that 17 residents did not receive lettuce and tomatoes on their chicken sandwiches because the facility did not have enough of these items. Further observation showed that all residents received chocolate pudding instead of the chocolate cake with icing specified on the menu. The Dietary Manager verified that chocolate cake was available but a cook followed an incorrect menu and served chocolate pudding instead. Review of the facility’s “Menus” policy stated that menus are to be developed and prepared in advance to meet residents’ needs, but the observed meal service did not consistently follow the planned menus or tray tickets for all 84 residents receiving food from the kitchen.
Failure to Provide Palatable, Properly Prepared, and Appetizing-Temperature Meals
Penalty
Summary
The deficiency involves the facility’s failure to ensure that food was palatable, properly prepared according to recipes, and served at appetizing temperatures for all residents receiving meals from the kitchen. During lunch service, the posted menu included lemon zest broccoli, chocolate cake with icing, chicken patty on a bun, and rice. Observation of pureed diet preparation showed the Dietary Manager placing chicken patties, lettuce, tomatoes, mayonnaise, and slices of bread into a blender, then adding hot water to thin the mixture to a pudding-like consistency. The Dietary Manager acknowledged he did not use the facility’s recipe cards, relying instead on his own judgment of the desired consistency. He also prepared gravy for puree and mechanical soft diets using only oil, flour, and water, and prepared a rice puree by blending scoops of rice with hot water to a thick, sticky consistency. Review of the lunch spreadsheet showed that cream of rice should have been substituted for rice for residents on a puree diet. A test tray taken later that lunch period showed the chicken sandwich at 106°F, broccoli at 139°F, rice at 120°F, and chocolate pudding at 58°F. The surveyor tasted the items and found the broccoli bland and the chicken sandwich cold; the Dietary Manager confirmed the chicken sandwich was cold and that lemon seasoning, which should have been added to the broccoli, was missing. The Registered Dietician stated that kitchen staff should follow recipe cards and spreadsheets and verified that gravy made only with oil, flour, and water would not taste very good, noting that a chicken or beef base would be expected for flavoring. Review of the facility’s recipe cards showed that the chicken patty on bun for puree diets should have the meat, mayonnaise, and bread pureed together, with gravy added gradually to achieve a smooth consistency, and that gravy should be made with flour, fat from meat drippings, black pepper, chicken or beef base, and water. The facility’s Food and Nutrition Services policy stated that each resident is to be provided a nourishing, palatable, well-balanced diet that meets daily nutritional and special dietary needs.
Unsanitary Food Storage, Preparation, and Temperature Control in Dietary Services
Penalty
Summary
Surveyors identified a deficiency in the facility’s failure to store and prepare food in a sanitary manner consistent with its own policies and professional standards. During kitchen observation, the soda gun nozzle was found dirty with a red buildup, and a white cutting block attached to the steam table had black residue on its surface. In the food prep area, five dirty knives were stored in a case designated for clean knives. The Dietary Manager confirmed each of these items was dirty despite facility policies stating that all kitchen equipment, counters, and utensils should be kept clean. Additional observations showed multiple food storage and temperature control issues. In the walk-in cooler, vanilla pudding, several types of cheese, bologna, and opened raw eggs were undated, and the raw eggs were stored on the top shelf above potatoes, contrary to policy requiring food to be dated and raw eggs to be stored on the bottom shelf. The walk-in freezer registered 25°F, and food inside was soft rather than frozen solid, despite policy requiring frozen food to be maintained in a solid state; an icicle was also observed hanging from the condenser above an open box of peas. In dry storage, opened bags of spaghetti and egg noodles were undated. The ice machine in the kitchen was leaking due to overfilling, and during a lunch meal service, broccoli on the steam table was held at 123°F while part of the steam table was not working, even though facility policy required hot foods to be held above 135°F. These conditions had the potential to affect all 84 residents in the facility.
Failure to Maintain Resident Privacy and Safe Environmental Conditions
Penalty
Summary
The facility failed to ensure a safe, functional, and homelike environment by not maintaining resident privacy and by allowing the use of prohibited electrical equipment. For two cognitively intact residents sharing a semi-private room, surveyors observed that the shared bathroom door did not close completely, which did not provide adequate privacy while using the bathroom adjacent to their sleeping quarters. Both residents expressed concerns that the bathroom door’s inability to close fully did not provide enough privacy for either of them. A Human Resources staff member confirmed that the bathroom door adjacent to each resident’s sleeping quarters did not close completely. Facility documentation on Resident Rights stated that residents are guaranteed rights to privacy under Federal and State laws. In another room, a resident with severe problems with thinking and memory, and diagnoses including hemiplegia following cerebral infarction, type II diabetes mellitus, anxiety disorder, polyneuropathy, muscle weakness, major depressive disorder, and alcohol-induced persisting dementia, was found with an unmonitored portable space heater plugged in and running on the floor, with the room door standing open. A CNA verified that the space heater was running in the resident’s room, and the DON stated that the heater was being used because the room’s heat was not working properly. Review of the facility’s Electrical Safety for Residents policy, revised January 2011, stated that portable space heaters are not permitted in the facility. The facility’s Quality of Life–Homelike Environment policy stated that residents are to be provided with a safe, clean, comfortable, and homelike environment, including a clean, sanitary, and orderly environment.
Failure to Remove Staff Accused of Abuse Pending Investigation
Penalty
Summary
The facility failed to follow its abuse policy in response to an allegation of verbal abuse by staff towards a resident. The resident, who had a history of diffuse traumatic brain injury, vascular dementia, mood disorder, and major depressive disorder, reported being verbally abused by two CNAs. The resident had moderate cognitive impairment and was independent with activities of daily living. The incident was not reported by the resident at the time it occurred. Upon being informed of the allegation by a surveyor, the Administrator acknowledged not being previously aware of the abuse claim. Despite the facility's policy requiring immediate removal of staff accused of abuse pending investigation, both CNAs remained on duty and continued caring for residents after the allegation was reported. Review of time sheets confirmed that the accused staff members were present and working during this period, contrary to facility policy.
Failure to Timely Report Alleged Sexual Abuse to State Agency
Penalty
Summary
The facility failed to report an allegation of sexual abuse involving a resident to the state agency as required by policy. The incident involved a resident with dementia, type II diabetes mellitus, and bipolar disorder, who was admitted to the emergency room after EMS was called for a hyperglycemic event. During the EMS response, the resident reported that his roommate had fondled him in the bathroom. The hospital social worker communicated with the facility's Director, who acknowledged that the resident was more distraught than usual and that similar allegations had previously been made against the same roommate, with a police report already filed. Despite these events, a review of the facility's Self-Reported Incidents (SRI) revealed that no SRI was created for the alleged sexual abuse. The Administrator stated that he had sent an email to the Ohio Department of Health to report the issue but did not follow up after receiving no response, and confirmed that no SRI was filed. Facility policy requires that all allegations of abuse, neglect, exploitation, or mistreatment be reported immediately, but no later than two hours after the allegation is made, to the State Agency.
Failure to Investigate Alleged Sexual Abuse
Penalty
Summary
The facility failed to conduct a thorough investigation into an alleged sexual abuse incident involving a resident with dementia, type II diabetes mellitus, and bipolar disorder. The resident was admitted to the emergency room after EMS was called for a hyperglycemic event, during which the resident reported to EMS that his roommate had fondled him in the bathroom. The ER records indicated that the resident was visibly distressed, and the facility Director acknowledged that similar allegations had previously been made against the same roommate, with a police report already filed. Despite these circumstances, the facility did not initiate or document a Self-Reported Incident (SRI) for this allegation. A review of facility records confirmed that no investigation was conducted regarding the reported sexual abuse. The Administrator verified that there was no documentation or evidence of an investigation into the incident. Facility policy requires immediate initiation of an investigation into any abuse allegations, including a root cause analysis and cooperation from all staff to ensure resident protection. However, these procedures were not followed in this case, resulting in non-compliance with the facility's abuse investigation policy.
Failure to Follow Hand Hygiene Protocol During Incontinence Care
Penalty
Summary
During a review of infection control practices, it was observed that a certified nursing assistant (CNA) failed to follow proper hand hygiene protocols while providing incontinence care to a resident with severe cognitive impairment and functional urinary incontinence. After cleaning the resident and removing a soiled incontinence brief, the CNA did not change gloves or perform hand hygiene before applying a new brief. This was confirmed during an interview with the CNA, who acknowledged not changing gloves or performing hand hygiene after contact with urine. Facility policy requires hand hygiene with soap and water when hands are visibly soiled or contaminated with body fluids, in accordance with CDC and WHO standards.
Improper Pre-Pulling and Storage of Medications on Medication Cart
Penalty
Summary
Surveyors observed that the medication cart on the 200-unit contained 18 cups of loose pills, each labeled with the names of all residents on the unit. An LPN confirmed that she had pre-pulled all morning medications for these residents in advance of administration. The DON verified that this practice was not in accordance with facility policy, which requires medications to be prepared, administered, and signed off for each resident individually before proceeding to the next. The facility's policy also specifies that the person administering medications should initial the Medication Administration Record (MAR) after giving each resident's medication and before administering the next.
Failure to Timely Report Allegation of Sexual Abuse
Penalty
Summary
The facility failed to report an allegation of sexual abuse involving a resident with paraplegia and intact cognition in a timely manner to the Ohio Department of Health. The resident was admitted in early January and discharged in early April. Multiple staff members, including a staff member and a social worker, reported to the previous Administrator in early April that there was a suspected sexual relationship between the Housekeeping Supervisor and the resident. Despite these reports, the allegation was not reported to the state agency until mid-October, several months after the resident had been discharged. Interviews with facility staff and review of the facility's Self-Reported Incidents (SRIs) confirmed that the required notification to authorities did not occur within the 24-hour timeframe outlined in the facility's Abuse and Neglect Protocol. The facility's investigation, initiated only after the delayed report, did not substantiate the abuse. The deficiency centers on the facility's failure to promptly report the allegation as required by policy and regulation.
Misappropriation of Residents' Personal Property by Administrator
Penalty
Summary
The facility failed to prevent the misappropriation of residents' personal property, specifically cigarettes, for two residents. One resident, who was cognitively intact and independent with activities of daily living, and another resident, who had mild cognitive deficits and required extensive staff assistance, were both found smoking in a non-designated area outside the facility. The Administrator observed the residents smoking in this area and, after informing them that smoking was not permitted there, confiscated their cigarettes and disposed of them in the garbage. The Administrator did not return or replace the cigarettes for either resident. Interviews with both residents confirmed that their cigarettes were taken and discarded by the Administrator after being found smoking in a non-designated area. The facility's policy defines misappropriation of resident property as the deliberate misplacement, exploitation, or wrongful, temporary or permanent use of a resident's belongings or money without the resident's consent. The Administrator acknowledged taking and discarding the cigarettes and confirmed that the items were not replaced, which constituted a failure to protect residents from the wrongful use of their belongings.
Failure to Timely Report Suspected Abuse, Neglect, or Theft
Penalty
Summary
The facility failed to timely report suspected abuse, neglect, or theft and did not report the results of the investigation to the proper authorities. This deficiency was identified based on the facility's lack of prompt action in notifying the appropriate agencies when an incident of suspected abuse, neglect, or theft occurred. The report indicates that the required notifications and investigation results were not communicated as mandated.
Failure to Protect Residents from Abuse and Neglect
Penalty
Summary
A deficiency was identified regarding the facility's failure to protect each resident from all types of abuse, including physical, mental, sexual abuse, physical punishment, and neglect by any individual. The report notes that residents were not adequately safeguarded from these forms of mistreatment, indicating lapses in the facility's protective measures and oversight.
Failure to Ensure Safe and Homelike Environment
Penalty
Summary
A deficiency was identified regarding the failure to honor the resident's right to a safe, clean, comfortable, and homelike environment. The report notes that the facility did not ensure residents received treatment and supports for daily living in a manner that maintained their safety and comfort. Specific details about the actions or inactions leading to this deficiency, as well as information about the residents involved or their medical conditions at the time, are not provided in the report.
Failure to Implement Enhanced Barrier Precautions During Resident Care
Penalty
Summary
Staff failed to implement Enhanced Barrier Precautions (EBP) during incontinence and wound care for a resident with orders for EBP. Observations revealed that staff did not don gowns prior to providing incontinence care and wound care, despite signage and physician orders indicating the need for EBP. During incontinence care, a certified nursing assistant (CNA) cleansed feces from the resident's buttocks but did not remove gloves, perform hand hygiene, or don new gloves before proceeding to touch clean items such as the resident's brief, pajama bottoms, sheets, and wash basin. The same lack of gown use was observed during wound care. The resident involved had diagnoses including dementia, hypertension, and chronic kidney disease, and was frequently incontinent of bowel and occasionally incontinent of bladder. The resident required varying levels of assistance with personal care activities. Interviews with the staff involved and the Director of Nursing confirmed that the required infection control measures, including donning gowns and changing gloves with appropriate hand hygiene, were not followed as per facility policy and physician orders.
Failure to Provide Safe and Orderly Discharge for Resident
Penalty
Summary
The facility failed to provide a safe and orderly discharge for a resident who was subject to an emergency discharge following allegations from two other residents that the individual possessed a firearm and had made threats. The resident, who had diagnoses including unspecified paraplegia, a stage III pressure ulcer, chronic pain syndrome, malnutrition, morbid obesity, bipolar disorder, and neuromuscular bladder dysfunction, left the facility without signing out and was later refused re-entry. Despite multiple attempts by the social worker to secure alternative placement and community resources, no emergency housing or LTC facility would accept the resident, and the resident was unavailable to participate in discharge planning. When the resident returned to the facility, staff, following instructions from administration and police, did not allow entry and called law enforcement. Police searched the resident and found no weapon. The resident was given discharge paperwork, a face sheet, a medication list, and routine medications (excluding narcotics), but was not provided with a safe discharge destination or arrangements for ongoing wound care. The resident's belongings were packed in trash bags and placed by the dumpster, and the resident left the property in a wheelchair without a coat or transportation, ultimately spending two days in a car before being hospitalized for a stomach infection. Interviews with staff, the Ombudsman, and police confirmed that the resident was discharged without a safe destination, and that the facility's discharge notice inaccurately listed a destination. The resident did not take any belongings with him, and staff were unclear about his whereabouts after leaving. The facility's own policy required advance preparation for discharge, including assistance with transportation and ensuring a safe discharge location, but these steps were not followed in this case.
Failure to Prevent Elopement Results in Resident Injury
Penalty
Summary
A deficiency occurred when a resident, identified as an elopement risk with a history of schizoaffective disorder, suicidal ideation, substance abuse, and cognitive impairment, was not adequately supervised, resulting in an elopement event. The resident had previously expressed a desire to leave the facility and made explicit threats to jump out of a window if not allowed to leave. Staff responded by placing the resident on one-on-one supervision and sending him to the hospital for evaluation of suicidal ideation. Upon return from the hospital, documentation indicated the resident did not have suicidal ideation but continued to express a strong desire to leave the facility. Despite the resident's ongoing exit-seeking behaviors and recent threats, one-on-one supervision was discontinued after a period of observed calmness. The care plan did not include specific interventions related to placement on a secured unit for increased elopement risk, and there was a lack of clear communication among staff regarding the resident's supervision status. On the morning following the removal of one-on-one supervision, the resident was able to remove a windowpane from his room and exit the building undetected by staff, ultimately falling two stories to the pavement below and sustaining serious injuries. Interviews and record reviews revealed that staff were aware of the resident's history and behaviors, including his repeated requests to leave, agitation, and threats of self-harm. However, the facility failed to maintain adequate supervision and did not implement or communicate effective interventions to prevent the resident's elopement, despite clear indications of risk. The incident resulted in significant physical harm to the resident and was determined to be a result of insufficient supervision and failure to address known hazards.
Failure to Notify Residents of Menu Changes
Penalty
Summary
The facility failed to notify residents of a change to the lunch menu in a timely manner, as required by facility policy. On the specified date, the posted menu indicated that beef pot roast, brown gravy, mashed potatoes, glazed carrots, and pineapple tidbits would be served for lunch. However, during meal preparation, dietary staff substituted hamburgers on wheat bread for the pot roast because the pot roast was not ready. The Dietary Manager confirmed that residents were not informed of this substitution, either verbally or by posted notice, despite the facility's policy requiring notification of menu changes at the earliest convenience. This deficiency affected all residents who accepted food from the kitchen, with the exception of two residents who did not receive food from the kitchen.
Failure to Maintain Room Temperature Controls and Sanitary Shower Facilities
Penalty
Summary
The facility failed to ensure residents had control over their room temperature and did not maintain sanitary shower rooms. One resident, who had multiple diagnoses including congestive heart failure, bipolar disorder, anxiety disorder, noncompliance with medical treatment, and cellulitis, was unable to adjust the air conditioning in their room due to a missing temperature control knob. The resident reported being cold throughout the night and not knowing how to operate the unit, as no instructions were provided. The Maintenance Director confirmed the absence of the knob on the air conditioner control. Additionally, observations revealed unsanitary conditions in multiple shower rooms. The women's locked unit shower room had significant water damage causing the sheet rock to pull away from the wall and a mildewed shower curtain. The 100-unit shower room had a non-flushing toilet filled with brown water, which had not been reported to maintenance for at least a week. The 300-unit shower room had pieces of stool on the floor near the drain. Staff interviews confirmed these issues, and the Maintenance Director and Administrator acknowledged the unsanitary conditions and lack of timely repairs.
Failure to Timely Notify Physician of Significant Injury After Resident Fall
Penalty
Summary
The facility failed to ensure timely physician notification of diagnostic results for a resident who experienced an unwitnessed fall resulting in a shoulder fracture. The resident, who had multiple diagnoses including chronic obstructive pulmonary disease, type II diabetes, schizoaffective disorder, and a history of repeated falls, was found to have a fracture dislocation of the left shoulder on X-ray. The care plan required immediate provider notification for falls with significant injury. However, after the X-ray results were received, the LPN did not notify the physician directly but instead gave the results to the DON, as per protocol at the time. The Medical Director later stated he was not informed of the X-ray findings until two days after the results were available and indicated that, had he been notified, he would have sent the resident to the hospital for evaluation and treatment. The facility's policy required immediate practitioner notification by phone when a fall resulted in significant injury. The failure to notify the physician promptly led to a delay in appropriate medical evaluation and intervention for the resident's injury.
Failure to Timely Report Alleged Resident-to-Resident Abuse
Penalty
Summary
The facility failed to report allegations of abuse to the State Agency in a timely manner, as required by policy. Two residents were involved in an incident where one resident, who had a history of wandering and behavioral issues, was struck and scratched by another resident with a history of aggression and multiple psychiatric diagnoses. The incident occurred when a staff member witnessed one resident hitting another in the face and scratching her arms and face while attempting to remove her from another resident's room. The affected resident sustained three superficial scratches on the right side of her face. The incident was documented, and appropriate notifications within the facility were made, but the event was not reported to the State Agency. During interviews, the Administrator confirmed that the incident was investigated internally and determined not to be abuse, and therefore was not reported to the State Agency. The facility's policy required reporting abuse allegations to the state survey agency within 24 hours if the event did not involve abuse or result in serious bodily injury. Despite this, the incident was not reported, resulting in noncompliance with regulatory requirements.
Failure to Complete PASRR Screening Prior to Admission
Penalty
Summary
The facility failed to ensure that a resident received the required Pre-Admission Screening and Resident Review (PASRR) prior to admission. Record review showed that the resident, who had diagnoses including paraplegia, opioid dependence, chronic post-traumatic stress disorder, schizoaffective disorder bipolar type, dependent personality disorder, and generalized anxiety disorder, was admitted without documentation of a PASRR screening in the medical record. The most recent MDS assessment indicated the resident was cognitively intact, had no behaviors, did not reject care, and did not wander. During an interview, the social worker confirmed that residents coming from the hospital should have been screened for PASRR before admission and verified that there was no evidence of PASRR screening for this resident. Facility policy required screening for major mental disability before admission, with Level II PASRR screens sent to Behavioral Consulting Services prior to admission.
Failure to Reassess for PASRR After New Mental Health Diagnoses and Psychotropic Medications
Penalty
Summary
The facility failed to ensure that a resident was reassessed for the Pre-Admission Screening and Resident Review (PASRR) following significant changes in mental health diagnoses and the initiation of new psychotropic medications. Specifically, the resident was admitted with multiple diagnoses, including hemiplegia, type II diabetes, unspecified anxiety disorder, unspecified persistent mood disorder, and chronic systolic heart failure. The medical record showed that the resident received new diagnoses of unspecified anxiety disorder and persistent mood (affective) disorder, and was prescribed several psychotropic medications, including Divalproex sodium, Ativan, and Lexapro, on multiple occasions. Despite these significant changes, there was no evidence in the medical record that a significant change PASRR assessment was completed after the new diagnoses or after the psychotropic medications were ordered. During an interview, the social worker confirmed that she had not reassessed the resident for PASRR because she was unaware of the changes in diagnoses and medications. Facility policy required the social worker to coordinate PASRR assessments and notify appropriate services if Level II services were needed, but this process was not followed in this case.
Failure to Hold Interdisciplinary Quarterly Care Conferences
Penalty
Summary
The facility failed to ensure that residents received quarterly care conferences attended by members of the interdisciplinary team (IDT), as required. For three residents reviewed, care conferences were either not held quarterly or, when held, did not include participation from the full IDT. In one case, a resident with multiple diagnoses including hemiplegia, diabetes, and heart failure had only a single care conference documented with the social worker present and no other IDT members. In another instance, a resident with cognitive intactness and multiple psychiatric and neurological diagnoses had not had a documented care conference since the previous year, and while the social worker communicated with the resident's guardian, these interactions were not documented as care conferences nor did they include the IDT. For a third resident with chronic illnesses and moderate cognitive impairment, the last care conference was conducted by phone between the social worker and the legal representative, without the resident or other IDT members present. Interviews with the social worker confirmed that quarterly care conferences were not consistently held and that the IDT was not routinely involved. The social worker cited reasons such as the resident's cognitive status, lack of response from other team members, and challenges in reaching legal representatives. Facility policy indicated that residents and their representatives should be encouraged to participate in the care planning process and be given advance notice of care conferences, but this was not consistently followed for the residents reviewed.
Failure to Timely Treat Displaced Shoulder Joint After Fall
Penalty
Summary
The facility failed to provide timely treatment and care for a resident who sustained a displaced shoulder joint following a fall. The resident, who had multiple diagnoses including repeated falls, impaired cognition, and psychiatric disorders, experienced an unwitnessed fall resulting in a shoulder injury. Although the resident later reported increasing pain in her arm, and an X-ray confirmed a fracture dislocation with abnormal positioning and fracture fragments, there was no immediate action taken to address the injury. The X-ray results were reviewed, but no new orders were given, and the physician was not notified promptly as required by facility policy. The delay in notifying the attending physician and obtaining appropriate medical treatment resulted in the resident continuing to experience pain, swelling, and functional impairment for two days before being sent to the hospital. Interviews revealed that the LPN provided the X-ray results to the DON, who did not notify the medical director. The medical director confirmed he was unaware of the injury until his next visit, at which point he ordered the resident to be sent to the hospital for evaluation and treatment. Facility policy required timely physician notification and immediate medical treatment for injuries after a fall, which was not followed in this case.
Failure to Facilitate Scheduled Mental Health Appointment
Penalty
Summary
The facility failed to ensure that a resident received necessary behavioral health care and services by not facilitating attendance at a scheduled mental health telemedicine appointment. The resident, who was admitted with multiple psychiatric diagnoses including schizoaffective disorder bipolar type, suicidal ideations, substance abuse, antisocial personality disorder, and mild neurocognitive disorder with behavioral disturbance, was cognitively intact at the time of admission. Hospital records indicated that a telemedicine appointment with psychiatry was scheduled for the resident, and the hospital's Licensed Social Worker was to call the resident at the facility for this consult. The deficiency occurred because the clinical team did not review the resident's admission in the morning meeting as usual, due to the Assistant Director of Nursing being assigned to the floor. As a result, the scheduled mental health appointment was not communicated or facilitated, and the ADON was unaware of the appointment. The administrator later confirmed that the appointment was clearly documented in the hospital paperwork provided at admission. Facility policy required timely communication of admission information to appropriate departments, but this did not occur in this instance.
Failure to Administer Medications as Prescribed and Improper Borrowing of Resident Medications
Penalty
Summary
The facility failed to ensure that medications were administered as prescribed for three residents out of eight reviewed for medication administration. Specifically, one resident with multiple diagnoses, including a humerus fracture, diabetes, malnutrition, hypertension, and intracerebral hemorrhage, had a physician order for Carvedilol 25 mg twice daily. Another resident with congestive heart failure, interstitial lung disease, diabetes, psychotic disorder, and dementia had an order for Fenofibrate 145 mg at bedtime. A third resident with diastolic heart failure, bipolar disorder, anxiety, noncompliance with medical treatment, and cellulitis had multiple medication orders, including Depakote ER, Fenofibrate, Valsartan, Colace, Digoxin, Carvedilol, Spironolactone, Eliquis, and Flomax. On a specific date, the Medication Administration Record showed that the third resident was scheduled to receive several medications at 9:00 PM but only received a partial dose of Colace and refused the rest. During an interview, an LPN admitted to borrowing medications from other residents, including Fenofibrate and Carvedilol, to administer to the third resident because the resident's own medications were unavailable. The LPN stated it was easier to obtain medications from other residents than from the emergency drug supply. Facility policy explicitly prohibited administering medications ordered for one resident to another. This practice was confirmed as a deficiency under the cited complaint numbers.
Inaccurate Medical Record Documentation for Multiple Residents
Penalty
Summary
The facility failed to ensure that information documented in the medical records was accurate for three residents. For one resident with paraplegia, a stage III pressure ulcer, and other complex diagnoses, the discharge documentation inaccurately stated that the resident was discharged to another nursing facility, when in fact the resident was observed leaving the facility independently in a wheelchair and was not admitted to another facility. The discharge notice also included allegations that the resident had threatened others, but the actual discharge location was not as documented. Another resident with multiple medical and psychiatric diagnoses, including a recent shoulder fracture from a fall, had an X-ray confirming a fracture dislocation. The LPN documented that the X-ray results were reviewed and that there were no new orders, but during interviews, it was revealed that the physician was not notified of the results as required. The medical director confirmed he was unaware of the X-ray findings until two days later and would have sent the resident to the hospital had he been informed. A third resident with psychiatric and substance use diagnoses had a late entry progress note indicating that the provider was notified about discontinuation of one-to-one supervision. However, the LPN later admitted that this documentation was false and that no provider was actually notified. Facility policy required that documentation in the medical record be objective, complete, and accurate, which was not followed in these cases.
Sanitation Deficiencies in Kitchen and Food Storage Areas
Penalty
Summary
The facility failed to maintain a sanitary kitchen environment, which had the potential to affect 60 of 60 residents who received food from the kitchen. Observations revealed multiple sanitation issues, including a four-foot diameter floor fan with gray fuzzy debris blowing across the kitchen area, exhaust louvers with heavy grease buildup, and ceiling fan louvers with a heavy buildup of gray fuzzy debris. Additionally, there was a three-foot-wide exhaust fan louver with a heavy buildup of a black wet substance, and the ceiling above the stove had splatters of a brown substance. The kitchen also had missing, exposed, broken, and heavily soiled ceiling tiles, and the flooring had a heavy buildup of black debris. Further issues included heavily soiled meal plate warmer equipment, missing caulking in the dishwashing area, and blackened dish table walls consistent with mold. The ice machine had a pink wet substance consistent with mold, and there was no thermometer or temperature log for the food storage freezer chest and milk cooler. Multiple foods were unlabeled, undated, and expired in the resident-designated refrigerators. The Dietary Manager confirmed these issues and acknowledged the need for cleaning and repairs. The facility's policy required the food service area to be maintained in a clean and sanitary manner, which was not adhered to.
Facility Fails to Maintain Safe and Comfortable Environment
Penalty
Summary
The facility failed to provide a safe, comfortable, and clean environment for its residents, affecting 13 out of 19 residents on the women's secured unit. One resident, who had been residing in a room for several months, was subjected to vulgar handwritten statements on the walls, which were left by a previous occupant. Despite the resident's complaints, the facility did not remove the offensive writing. Another resident's room was excessively hot, reaching 83 degrees Fahrenheit, with no air-cooling equipment provided, causing discomfort and sleep disturbances. The facility did not offer alternative accommodations or monitor the room temperature. Several residents, including those with severely impaired cognition, were found in rooms with temperatures at the upper limit of the acceptable range, without any air-cooling equipment. These residents were not provided with adequate means to cool their rooms, and there was no documentation of temperature monitoring. One resident was only moved to a cooler room after the issue was identified by a maintenance assistant. Additionally, the interior smoke room on the women's secured unit was in disrepair, with insufficient ashtrays, a non-operational air fan, and walls discolored with nicotine. The room was not cleaned or maintained, leading to a buildup of cigarette ashes on the floor and inadequate ventilation. The facility's policy on maintenance and storage areas was not adhered to, as the smoke room was not kept in a clean and safe manner.
Facility Fails to Ensure Visual Privacy for Residents
Penalty
Summary
The facility failed to ensure that resident bedrooms provided visual privacy, affecting eight residents on the secured women's unit. Observations revealed that privacy curtains did not completely encircle the beds for some residents, and one resident had no privacy curtain at all. Interviews with staff and residents confirmed the lack of adequate privacy measures, with residents expressing a desire for privacy from their roommates during care. The facility's policy on privacy, dated September 2019, stated that privacy would be provided in all aspects of care, which was not adhered to in these instances. Additionally, the facility did not provide window blinds in certain resident rooms, further compromising visual privacy. This affected five residents who were observed to have no window blinds, and interviews with staff and residents confirmed the need for window coverings to ensure privacy during care. The deficiency was investigated under Complaint Number OH00155399, highlighting the facility's noncompliance with its own privacy policy.
Facility Fails to Maintain Safe and Sanitary Environment
Penalty
Summary
The facility failed to maintain a safe, functional, sanitary, and comfortable environment for residents on the women's secured unit, affecting 19 residents. Observations revealed that the shower room had a blackened substance resembling mold at the base of the shower stall and adjacent walls. The shower exhaust fan was covered with a gray fuzzy layer and was not operational. Additionally, the shower privacy curtain was torn and not fully attached, compromising privacy. Interviews with staff confirmed these issues, and it was noted that all residents on the women's unit used this main shower room. Further observations identified a missing span of drywall around the faucets in the chemical room, exposing the interior wall. A room labeled as a whirlpool room was being used for storage and was filled with files and paperwork. This room also had a leaking shower head, resulting in mold-like substance on the floor. Staff interviews confirmed the disrepair of the chemical room wall and the leaking shower head. The facility's policy on storage areas and maintenance, dated December 2009, was reviewed and indicated that storage areas should be maintained in a clean and safe manner, and maintenance services should ensure the building is in good repair and free from hazards.
Failure to Provide Vision Services
Penalty
Summary
The facility failed to ensure that a resident received the necessary vision services and assistive devices. Resident #23, who was admitted with diagnoses including chronic obstructive pulmonary disease, schizoaffective disorder, dementia, and generalized anxiety disorder, was recommended eyeglasses by an optometrist on 11/15/23. Despite being cognitively intact as per the Minimum Data Set assessment dated 06/06/24, the resident did not have eyeglasses. An interview with a Licensed Practical Nurse on 08/06/24 confirmed the absence of eyeglasses for the resident. An observation on the same day revealed the resident squinting to read a clock, and the resident confirmed his need for eyeglasses. A Social Worker Designee confirmed that the optometrist was supposed to order the eyeglasses, but this had not been done, resulting in the resident not receiving them.
Failure to Submit PBJ Staffing Data
Penalty
Summary
The facility failed to submit complete and accurate staffing information for the Payroll-Based Journal (PBJ) staffing report to the Centers for Medicare and Medicaid Services (CMS) for the first quarter of 2024. This deficiency was identified through a review of the PBJ staffing data report, which revealed that no data had been submitted for that period. During an interview, the Regional Operations Manager and the Administrator confirmed the omission. The Administrator had submitted the necessary information to the facility's corporate office, expecting them to forward it to CMS. However, the individual responsible for the submission was a contractor whose contract was terminated, and he did not provide the login credentials needed for submission. Consequently, the facility had to create a new profile to ensure future compliance.
Latest citations in Ohio
A resident with intact cognition receiving Medicare Part A skilled services for metabolic encephalopathy had services discontinued while benefit days remained, but the facility did not issue the required Skilled Nursing Facility Advance Beneficiary Notice (SNF ABN). The Social Services Director later confirmed that no SNF ABN was provided and reported she believed only a Notice of Medicare Non-Coverage (NOMNC) was needed when all skilled services were stopped. This practice conflicted with the facility’s written policy, which required SNF ABNs to be issued when extended care items or services were initiated, reduced, or terminated due to expected non-coverage by Medicare.
Surveyors identified that the facility exceeded the acceptable medication error rate when two residents with type 2 DM received insulin doses that were not administered according to orders or manufacturer instructions. In two separate observations, an LPN administered Novolog and another LPN administered insulin glargine and insulin lispro without priming the insulin pens, and the insulin lispro and Novolog were given after the residents had already consumed a significant portion of their breakfast meals, despite orders for administration before meals. Manufacturer information for both insulin products required priming before each injection to ensure accurate dosing, and facility policy required medications, including insulin, to be administered safely, timely, and in accordance with prescriber orders and specified time frames.
Surveyors found that the facility failed to document tray line food temperatures for multiple meals served from two dining room kitchenettes, despite having a “Trayline Taste & Temperature Log” and a policy requiring food to be stored, prepared, distributed, and served according to professional food safety standards. Review of logs showed repeated missing entries for breakfast, lunch, and dinner services in both the Harrison and McClellan dining areas, and the Senior Director of Culinary Services confirmed that temperatures had not been recorded for those meals, potentially affecting all residents receiving meals from those kitchenettes.
The facility failed to conduct and document required periodic care conferences for two residents, despite multiple comprehensive, quarterly, and significant change MDS assessments and a policy requiring periodic care conferences with resident and/or family participation. One resident with Parkinson’s disease, post-stroke hemiplegia, TIA, DMII, and depression had only two documented care conferences over a year, while another resident with aphasia, cerebrovascular disease, DMII, gait difficulty, coagulation defect, depression, and muscle weakness had no documented care conferences in the past year, aside from a declined invitation to the representative. The UCC confirmed that care conferences were expected to occur quarterly and that no additional documentation existed for either resident.
A resident with Alzheimer's disease and type II DM, who required extensive assistance with ADLs and was receiving scheduled Lantus and sliding-scale Humalog, experienced a severely elevated blood glucose level. The on-call provider was notified and ordered an additional dose of lispro insulin with a directive to recheck the blood glucose after administration. Nursing staff administered the extra insulin but did not document any follow-up blood glucose check, and the DON confirmed that this reevaluation was required by the facility's abnormal blood glucose policy and was not completed or documented.
A resident with Parkinson’s disease, dementia, and hypothyroidism was prescribed levothyroxine once daily along with other medications. A consultant pharmacist’s monthly drug regimen review recommended that levothyroxine be given in the morning on an empty stomach, 30–60 minutes before food, per manufacturer instructions. The medical record contained no documented physician response to this recommendation, and the MAR showed the drug scheduled for morning administration while the resident was observed eating breakfast and receiving the medication at the same time. An LPN confirmed administering levothyroxine during the meal, and the DON verified there was no documentation explaining whether or why the pharmacist’s recommendation was or was not followed, resulting in a failure to act on and document the identified irregularity.
A resident with severe cognitive impairment, multiple comorbidities, documented gait and balance abnormalities, and a high fall risk was care planned and assessed by therapy to require contact guard assistance and use of a gait belt for transfers and ambulation. While being assisted by a CNA from a recliner to the bathroom with a walker, the CNA did not apply a gait belt, even though the resident had a known tendency to lean backward when standing. As the CNA reached to open the bathroom door, the resident lost balance and fell backward, striking the back of the head, and was later found by an LPN without a gait belt in place, contrary to the facility’s gait belt policy and the resident’s assessed needs.
A resident with CKD stage five requiring peritoneal dialysis (PD) was admitted with pre-admission physician orders for three daily PD exchanges and monitoring for peritonitis (fever, abdominal pain, cloudy effluent), but these monitoring orders were not entered into the facility’s physician orders. The care plan referenced PD and general monitoring but did not specifically address peritonitis monitoring. Paper PD flowsheets showed incomplete and inconsistent documentation of exchanges and resident condition, including missing condition/comments for individual treatments and no record of one ordered PD exchange. The PD cycler flowsheet lacked effluent descriptions on multiple days. The PD nurse reported facility staff were expected to monitor effluent and symptoms, and the DON confirmed the absence of specific peritonitis monitoring orders, lack of an order for the PD cycler, and documentation gaps, despite a facility policy requiring ongoing assessment and monitoring for complications before, during, and after dialysis treatments.
A nurse was observed preparing multiple oral medications for a resident with depression, traumatic brain injury, anxiety, and impaired cognition by pushing tablets and capsules from unit-dose cards directly into her ungloved hand and then using her fingers to place them into a medication cup. In a follow-up interview, the RN confirmed this practice and acknowledged that the correct procedure is to dispense medications directly from the card into the cup, contrary to the facility’s medication administration policy requiring adherence to good nursing principles and practices.
A resident with Alzheimer’s disease, diabetes, anxiety, significant ADL dependence, and behavioral symptoms was observed seated in a chair positioned against the nursing station with a locked wheelchair placed directly in front, also against the nursing station, effectively restricting movement. An LPN confirmed both wheelchair wheels were locked and that it should not have been placed there, while a CNA stated she had positioned the wheelchair to prepare for lunch, was unable to complete the transfer, and left it in place, acknowledging this was wrong. This arrangement conflicted with the facility’s restraint policy, which prohibits physical restraints except when alternatives are ineffective for treating a medical symptom and defines restraints as devices adjacent to the body that cannot be easily removed and that restrict freedom of movement or access to the body.
Failure to Issue Required SNF ABN When Discontinuing Medicare Part A Services
Penalty
Summary
The deficiency involves the facility’s failure to issue a Skilled Nursing Facility Advance Beneficiary Notice (SNF ABN) when Medicare Part A services were discontinued for a resident who still had available benefit days. The resident was admitted with a diagnosis of metabolic encephalopathy and had intact cognition per the Minimum Data Set assessment. The facility’s own SNF Beneficiary Notification Review documented that Medicare Part A skilled services began on 02/11/26 and the last covered day was 03/11/26, and that the facility initiated discharge from Medicare Part A services before the resident’s benefit days were exhausted. Despite this, no SNF ABN was provided to the resident or the resident’s representative. During interviews, the Social Services Director stated that the SNF ABN was issued hours prior to the last covered day but, upon reviewing her files, confirmed that no SNF ABN had actually been issued for this resident. She further explained that she believed an SNF ABN was only required if one skilled service remained and that if all skilled services were being discontinued, only the Notice of Medicare Non-Coverage (NOMNC) needed to be issued. The Administrator, however, stated that a resident should always receive both a SNF ABN and a NOMNC when Medicare Part A services are discontinued and benefit days remain. Review of the facility’s written policy dated 03/28/23 showed that the facility was required to issue SNF ABNs for initiation, reduction, or termination of extended care items or services when Medicare payment was not expected, which did not occur in this case.
Plan Of Correction
This Plan of Correction is submitted as required under State and Federal law. This Plan of Correction does not constitute an admission on the part of the Facility that the findings cited are accurate, that the findings constitute a deficiency or that the scope and severity regarding the deficiency cited are correctly applied. Any changes to the Facility's policies and procedures should be inadmissible in any proceeding on that basis. Without admitting or denying the validity or the existence of the alleged noncompliance, the Facility submits this Plan of Correction with the intention that it be inadmissible by any third party in any civil or other action against the facility or any employee, agent, officer, director or shareholder of the Facility. The Facility is utilizing this Plan of Correction as its allegation of substantial compliance as of 05/29/2026 F-0582 Corrective action for resident/s: On 5/14/26 Resident #34 was informed of rights and responsibilities related to Advanced Beneficiary Notice and voiced understanding of information for future reference by administrator. Identification of other residents who may be affected: Any resident receiving skilled services from nursing or therapy services. The Administrator audited all residents who were discharged from skilled services in the past 30 days to ensure they were issued a Notice of Non-Coverage and Advanced Beneficiary Notice on 5/29/26. No non-compliance was noted. Measures for systemic change: On 5/14/2026 Business Office Manager, Director of Rehab, Minimum Data Set nurse, Director of Nursing and Social Services Director were educated on proper procedure of issuing of Notice Of Medicare Non Coverage and Advanced Beneficiary Notice by administrator. All upcoming discharges from skilled services will be reviewed weekly at Utilization Review meeting to ensure notices will be delivered timely. How Corrective Action will be monitored: Administrator or designee to complete audits of all residents being discharged from skilled services to ensure they were issued a Notice of Non-Coverage and Advanced Beneficiary. This audit will be completed weekly x 4 weeks, then monthly x 2 months. Corrective action will be initiated for any noted non-compliance. Audit findings will be reviewed as part of the monthly quality assurance process to determine the need for further monitoring. Date of Compliance 5/29/26
Insulin Administration Errors and Failure to Prime Insulin Pens
Penalty
Summary
The deficiency involves the facility’s failure to maintain a medication error rate below 5%, with surveyors identifying 3 errors out of 28 medication administration opportunities, resulting in a 10.71% error rate. For one resident with type 2 diabetes mellitus and moderate cognitive impairment, the physician’s order directed Novolog insulin 10 units via subcutaneous pen-injector to be given before meals. During an observed medication pass, the LPN administered 10 units of Novolog insulin without priming the pen and did so after the resident had already consumed approximately 50% of the breakfast meal. The LPN later confirmed she did not prime the pen and acknowledged that the insulin was ordered to be administered prior to meals. Manufacturer instructions for the Novolog FlexPen specified that an air shot (priming) must be performed before each injection to ensure proper dosing. Another resident, also diagnosed with type 2 diabetes mellitus and with intact cognition, had orders for insulin glargine 35 units subcutaneously twice daily and insulin lispro 20 units subcutaneously before meals, plus 12 units subcutaneously if blood glucose was between 251 mg/dL and 300 mg/dL. During an observed medication administration, an LPN administered 35 units of insulin glargine and 32 units of insulin lispro without priming the insulin pens and after the resident had consumed approximately 90% of the breakfast meal, despite orders for insulin lispro to be given before meals. The LPN later stated she could not remember if she had primed the pen and acknowledged that the insulin was ordered to be administered prior to meals. Manufacturer information for insulin lispro stated that the pen must be primed before each injection to confirm insulin delivery and remove air, and that failure to prime could result in too much or too little insulin. The DON confirmed the expectation that insulin be administered as ordered, including priming each pen with two units before dialing the prescribed dose, and facility policy required medications, including insulin, to be administered safely, timely, and in accordance with prescriber orders and required time frames.
Plan Of Correction
This Plan of Correction is submitted as required under State and Federal law. This Plan of Correction does not constitute an admission on the part of the Facility that the findings cited are accurate, that the findings constitute a deficiency or that the scope and severity regarding the deficiency cited are correctly applied. Any changes to the Facility's policies and procedures should be inadmissible in any proceeding on that basis. Without admitting or denying the validity or the existence of the alleged noncompliance, the Facility submits this Plan of Correction with the intention that it be inadmissible by any third party in any civil or other action against the facility or any employee, agent, officer, director or shareholder of the Facility. The Facility is utilizing this Plan of Correction as an allegation of substantial compliance as of 5/29/2026. F-0759 Corrective action for resident/s: Residents #21 and #22 were assessed and evaluated by nurse and Director of Nursing 5/14/26. Resident #21 and #22 both denied any adverse effects and none were noted upon assessment by the Director of Nursing on 5/14/2026. Notification made to physician on 5/14/2026. LPN # 2 competency Eval on insulin administration with the Director of Nursing completed 5/14/2026. Identification of other residents who may be affected: Diabetic residents on assignment of LPN #2/station 2 have the potential to be affected and were assessed by the DON/Designee on 5/14/26 and found to be within normal limits. Measures for systemic change: All Nurses were educated by the Director of Nursing on the steps for Insulin administration per competency, diabetes clinical protocol policy, Medication and treatment orders policy, administering medications policy, and Obtaining fingerstick Glucose Level policy On 5/14/2026. How Corrective Action will be monitored: Director of Nursing and Assistant Director of Nursing will complete insulin administration audits on 5 nurses. This audit will be completed weekly x 4 weeks, then monthly x 2 months. Corrective action will be initiated for any noted non-compliance. Audit findings will be reviewed as part of the monthly quality assurance process to determine the need for further monitoring. Date of Compliance: 5/29/2026
Failure to Document Tray Line Food Temperatures in Dining Room Kitchenettes
Penalty
Summary
The deficiency involves the facility’s failure to document tray line food temperatures for meals served from the Harrison and McClellan Dining Room kitchenettes, as required by professional standards for food service safety and the facility’s own policy. Review of the “Trayline Taste & Temperature Log” (revised September 2018) showed missing temperature documentation for multiple meals from the Harrison Dining Room kitchenette, including dinner on 03/30/26 and 03/31/26, lunch and dinner on 04/01/26 and 04/02/26, dinner on 04/07/26, and lunch and dinner on 04/08/26 and 04/10/26. The Senior Director of Culinary Services confirmed during interview that tray line food temperatures were not documented on the log for these meals. Similarly, review of the same log for the McClellan Dining Room kitchenette revealed that tray line food temperatures were not documented for dinner on 04/01/26, breakfast and lunch on 04/02/26, and lunch and dinner on 04/07/26. The Senior Director of Culinary Services also verified these omissions during interview. The facility census at the time was 27 residents, and the governing “Food and Nutrition” policy, approved on 09/07/21, stated that the facility must store, prepare, distribute, and serve food in accordance with professional standards for food service safety.
Plan Of Correction
F812 The facility will continue to ensure food temperatures are completed before meals are served for all residents. To ensure compliance with this standard the following measures have been taken: 1. Immediately 4/15/26 culinary supervisor #224 was re-educated by Dietary Manager to this standard and policy "Food and Nutrition" which includes documentation of food temperatures. 2. All dietary staff have been re-educated to the standard and policy "Food and Nutrition" during the month of April 2026. 3. Audits of food temperature documentation to be completed by Dietary Manager 4 x per week for 4 weeks then weekly for 4 weeks. 4. Administrator to validate audits/compliance and provide additional training as needed. Administrator will present to QAPI committee for ongoing monitoring and further direction.
Failure to Conduct and Document Required Care Conferences
Penalty
Summary
The deficiency involves the facility’s failure to complete and document comprehensive care conferences at required intervals in accordance with care plan regulations and facility policy. For one resident with Parkinson’s disease with dyskinesia, cognitive communication deficit, hemiplegia and hemiparesis following cerebral infarction, transient cerebral ischemic attack, type II diabetes mellitus, and major depressive disorder, the record showed multiple MDS assessments over a one-year period, including annual, quarterly, and significant change assessments. However, only two care conferences were documented during the last 12 months, despite the expectation that care conferences be conducted quarterly with the resident and family when possible. The Unit Care Coordinator confirmed that no additional care conference documentation existed for this resident beyond the notes dated 04/21/25 and 01/02/26. A second resident, with diagnoses including aphasia following cerebrovascular disease, cerebral infarction, type II diabetes mellitus, unsteadiness on feet, difficulty in walking, coagulation defect, depression, and muscle weakness, also had multiple MDS assessments completed over the review period, including quarterly and annual assessments. The record contained a note that a care conference was offered to the resident’s representative, who declined to attend, but there was no documentation of any care conferences for the most recent 12 months. The Unit Care Coordinator confirmed that no other care conference documentation was available for this resident. Facility policy stated that periodic care conferences involving the resident, family, and the interdisciplinary team are part of the care planning process, but the required periodic care conferences and corresponding documentation were not completed for these two residents.
Plan Of Correction
THIS PLAN OF CORRECTION SERVES AS BERKELEY SQUARE'S CREDIBLE ALLEGATION OF SUBSTANTIAL COMPLIANCE AS OF June 1, 2026. Without admitting or denying the validity or existence of the alleged deficiencies, Berkeley Square provides the following Plan of Correction: F657 The facility will continue to document completion of care conferences at the required intervals for all residents, including residents #04 & #15. To ensure compliance with this standard the following measures have be taken: 1. The social service designee and the inter- disciplinary team were re-educated by the administrator to the facility policy "Care Conference" on 4/29/26 and verbalized understanding. 2. Care conferences for resident #04 and resident #15 were conducted on or before 4/29/2026 by the interdisciplinary team. 3. Review of all other residents was conducted by the social service designee to validate and ensure that care conference schedule is up to date with timely care conferences scheduled for them on 4/15/2026. Audits of care conferences to be completed weekly for four weeks and then monthly after that by the social service designee. Documentation of the care conference including any identified concerns in the medical record. Administrator to validate audits/compliance and provide additional training as needed. Administrator will present results of these audits to QAPI committee for ongoing monitoring and further direction.
Failure to Reevaluate Blood Glucose After Treatment for Hyperglycemia
Penalty
Summary
The facility failed to ensure that a resident with diabetes received treatment in accordance with professional standards of practice when nursing staff did not reevaluate the resident's blood glucose after treatment for severe hyperglycemia. The resident, admitted with diagnoses including Alzheimer's disease, type II diabetes mellitus, and depression, had physician orders for Humalog insulin on a sliding scale before meals, Lantus insulin 25 units daily, and lisinopril 5 mg daily. The resident required extensive assistance with activities of daily living, including transfers, toileting hygiene, eating, and bathing. On the evening in question, the resident's blood glucose was documented as 532 mg/dL, and the on-call provider was notified. The provider gave a new order to administer an additional 8 units of lispro (Humalog) and to recheck the blood glucose in 30 minutes. The electronic medication administration record showed that the blood glucose of 532 mg/dL was obtained at 9:00 p.m. and that the additional 8 units of lispro were administered at 9:21 p.m. However, there was no documentation in the resident's chart that the blood glucose was rechecked after the additional insulin was given. In an interview, the DON confirmed there was no evidence of reevaluation and verified that, according to the facility's "Abnormal Blood Glucose Procedure" policy, the resident should have been reevaluated and that the evaluation step should have been included in the progress note documentation.
Plan Of Correction
F684 The facility will continue to ensure all residents, including #03, receive treatment in accordance with professional standards of practice and reevaluated for hyperglycemia. To ensure compliance with this standard the following measures have been taken: 1. The director of nursing assessed resident #03, reviewed documentation and orders and found no ill effects immediately 4/16/26. 2. All licensed nurses were re-educated to facility policy "Blood Glucose Monitoring" by the Director of Nursing/designee in April 2026. 3. Audits of like-residents that require blood sugar checks to be completed by the director of nursing/designee two times a week for 4 weeks and then monthly after that to validate correct follow through when there is abnormally high blood glucose result. The Administrator will bring results of these audits to the QAPI committee for ongoing monitoring and further direction.
Failure to Act on Pharmacist Drug Regimen Recommendation for Thyroid Medication
Penalty
Summary
The deficiency involves the facility’s failure to ensure that pharmacy recommendations from the monthly drug regimen review were acted upon and documented for a resident. The resident was admitted with diagnoses including Parkinson’s disease, dementia, and hypothyroidism, and had current physician orders for levothyroxine 150 mcg once daily, buspirone 50 mg twice daily, and losartan 100 mg once daily. A medication regimen review dated 11/25/2025 included a consultant pharmacist recommendation that levothyroxine be administered consistently in the morning on an empty stomach, at least 30–60 minutes before food, per manufacturer instructions. There was no specific physician response in the medical record to this recommendation, and the facility’s policy stated that consulting pharmacist reviews are sent to nursing and addressed with the primary care provider or consulting specialist for review and follow-up. Review of the resident’s medication administration record for April 2026 showed levothyroxine scheduled for 9:00 a.m. On observation, the resident was seen eating breakfast in the dining area at 8:03 a.m., and an LPN reported administering the levothyroxine 150 mcg to the resident while the resident was in the dining area eating breakfast. The DON confirmed there was no evidence in the resident’s medical record explaining why the consultant pharmacist’s recommendation from 11/25/2025 was or was not acted upon. This lack of documented physician review and action on the pharmacist’s identified irregularity constituted noncompliance with the drug regimen review requirements.
Plan Of Correction
F756 The facility will continue to ensure the pharmacy recommendations from the monthly drug regimen review by a licensed pharmacist are acted upon for all residents, including #08. To ensure compliance with this standard the following measures have been taken: 1. Resident #08 was assessed by the registered nurse and med review completed by 4/28/26. After review of resident's drug regime's, it was discovered that resident #8 had 2 separate medication recommendations on the same form, to be reviewed by two separate practitioners, pharmacy has been instructed and agreed to separate meds on individual forms. 2. Licensed nurses re-educated to facility policy "Drug Regimen Review" by Director of nursing/designee in April 2026 and no later than 5/8/26. Licensed nurses are responsible for ensuring the reviews and recommendations are given to the physician for timely review. 3. Review of all other current residents Drug Regimen orders completed by Director of nursing/designee on 4/16/26 to ensure recommendations were followed up on/reviewed by the physician and address concerns if needed. 4. Audit of drug regime recommendations, pharmacy recommendations, and physician follow up to be completed weekly for four weeks by the Director of nursing/designee. Administrator will present results of these audits to the QAPI committee for ongoing monitoring and further direction.
Failure to Use Required Gait Belt During Ambulation Resulting in Resident Fall
Penalty
Summary
The deficiency involves the facility’s failure to ensure that a required gait belt was used while assisting a high fall‑risk resident with ambulation, resulting in a fall with head injury. The resident had multiple diagnoses including metabolic encephalopathy, hypertension, osteoarthritis, muscle weakness, gait and mobility abnormalities, major depressive disorder, anxiety, and visual hallucinations. Admission and subsequent MDS and fall risk assessments documented that the resident was severely cognitively impaired, required moderate to maximal assistance with transfers and ambulation, could not independently come to a standing position, exhibited loss of balance while standing, used an assistive device, and had decreased muscle coordination. The resident had a history of falls prior to admission and was assessed as being at high, later moderate, risk for falls. The resident’s fall care plan identified her as at risk for falls and included interventions such as providing maximum to moderate assistance with transfers and walking short distances, use of a walker and wheelchair, and following the facility’s fall protocol. Therapy notes and care conference documentation indicated that the resident leaned backwards when standing, required contact guard to minimal assistance for bed mobility and transfers, and needed constant verbal cueing for safe sequencing during toilet transfers. The physical therapist confirmed that the resident was to use a gait belt with staff when ambulating, and the DON verified that therapy had assessed the resident as requiring contact guard assistance and a gait belt for ambulation and transfers. On the day of the incident, a CNA was assisting the resident from her recliner to the bathroom using a walker. The CNA walked beside the resident, providing guidance and support, and reported having a hand on the resident while assisting her. As they approached the bathroom door, the CNA reached for the doorknob to open it, and at that moment the resident began to lose her balance and fell backwards to the floor, striking the back of her head. The nurse who responded found the resident on her back at the foot of the bed with her feet near the bathroom, noted a red raised area on the back of the head, and documented that the resident was not wearing a gait belt and that the gait belt was on the dresser. In the facility’s investigative summary and in interviews, the CNA acknowledged that she did not have a gait belt on the resident while ambulating her, despite the resident’s assessed need for hands‑on assistance and gait belt use per facility policy and the resident’s care and therapy plans.
Failure to Implement PD Orders and Monitor Resident Receiving Peritoneal Dialysis
Penalty
Summary
The deficiency involves the facility’s failure to implement pre-admission physician orders for peritoneal dialysis (PD) and to provide ongoing monitoring for a resident with chronic kidney disease (CKD) stage five who required PD. Pre-admission orders dated 11/14/25 specified three daily PD exchanges at 6:00 A.M., 2:00 P.M., and 10:00 P.M., and directed staff to monitor for signs and symptoms of peritonitis, including fever, abdominal pain, and cloudy effluent. These monitoring orders were not entered into the facility’s physician orders. The resident’s care plan noted the need for PD and included general monitoring interventions (labs, signs of bleeding, bacteremia, septic shock, and significant vital sign changes), but did not specifically address the ordered monitoring for peritonitis. Review of PD documentation showed incomplete and inconsistent charting of treatments and resident condition. The paper peritoneal flowsheet had columns for time of PD and condition/comments, including instructions to call the nurse immediately for cloudy fluid, abdominal pain, or fever. However, the first entry on 11/15/26 at 2:00 P.M. only noted that the PD nurse completed the exchange, and the 10:00 P.M. entry that day had no condition/comment documentation. Subsequent days (11/16/25, 11/17/25, and 11/18/25) contained only one condition/comment entry per day rather than for each exchange, and there was no documentation that the 6:00 A.M. PD on 11/18/25 was completed. The PD cycler flowsheet starting 11/19/25 lacked any description of the effluent on multiple days. The PD nurse from the dialysis company stated facility staff were expected to monitor effluent for cloudiness and assess for abdominal pain and fever, and the DON confirmed there was no electronic physician order for peritonitis monitoring or for use of the PD cycler, that the paper charting did not allow for effluent description or symptom documentation for each treatment, and that PD was not documented at one ordered time. The facility’s dialysis policy required ongoing assessment and monitoring for complications before, during, and after treatments, which was not reflected in the documentation for this resident.
Improper Infection Control During Medication Administration
Penalty
Summary
Surveyors identified a deficiency in infection prevention and control related to medication administration for Resident #29. The resident was admitted on 02/28/14 with diagnoses including depression, traumatic brain injury, and anxiety, and had impaired cognition per a quarterly MDS assessment. During an observation on 03/25/26 at 6:58 A.M., RN #281 prepared the resident’s medications by removing an Amoxicillin-Pot Clavulanate tablet from the medication card and pushing it directly into her ungloved hand, then using her fingers to place the pill into a medication cup. The same process was observed for multiple other medications, including Escitalopram Oxalate, Furosemide, Sennosides, Lyrica, and Vitamin D, each being pushed from the card into the RN’s ungloved hand and then transferred by her fingers into the medication cup before administration to Resident #29. In a subsequent interview at 7:27 A.M. the same day, RN #281 confirmed she had placed each medication into her ungloved hands prior to administration and acknowledged that the proper procedure was to push the pills directly from the card into the medication cup. Review of the facility’s “Medication Administration – General guidelines” policy, revised 10/08/25, stated that medications are to be administered in accordance with good nursing principles and practices. This practice failure was cited as a deficiency under Complaint Number 2681777.
Improper Use of Wheelchair as a Physical Restraint
Penalty
Summary
Surveyors identified a deficiency related to the facility’s failure to ensure a resident was free from physical restraints. Resident #7, admitted with diagnoses including Alzheimer’s disease, diabetes mellitus, and anxiety disorder, was documented on a recent MDS as rarely understood and dependent for ADLs except eating. The resident ambulated independently on the unit without an assistive device and had documented verbal and other behaviors occurring one to three days during the look-back period. The care plan noted the resident had potential to be physically aggressive, chase staff, throw objects, and be combative with care, with interventions such as offering choices, administering medications as ordered, and intervening early when agitation occurred. During an observation and interview, Resident #7 was found sitting in a chair with the right arm of the chair positioned against the nursing station and a wheelchair placed directly in front of him. The left arm of the wheelchair was also against the nursing station, and both wheelchair wheels were locked, creating a barrier that appeared to restrain the resident, who was sleeping with his knees touching the locked wheelchair. An LPN confirmed both wheelchair wheels were locked and that the wheelchair should not have been placed in front of the resident. A CNA reported she had placed the wheelchair there in preparation to get the resident up for lunch, was unable to transfer him, and left the wheelchair in that position, acknowledging it was wrong to keep it there. The facility’s physical restraint policy stated that physical restraints are not used except when alternatives are not appropriate or effective for treating a medical symptom and defined physical restraints as any device attached or adjacent to the body that the individual cannot easily remove and that restricts freedom of movement or access to the body.
Trusted data from CMS and state health departments
Every citation, penalty and Plan of Correction is sourced from public CMS records (latest release May 27, 2026) and official state health department websites — never guesswork.
Trusted by long-term care providers and associations.
