Astoria Place Of Silverton
Inspection history, citations, penalties and survey trends for this long-term care facility in Cincinnati, Ohio.
- Location
- 6922 Ohio Avenue, Cincinnati, Ohio 45236
- CMS Provider Number
- 365476
- Inspections on file
- 39
- Latest survey
- March 17, 2026
- Citations (last 12 mo.)
- 14
Citation history
Health deficiencies cited at Astoria Place Of Silverton during CMS and state inspections, most recent first.
The facility did not maintain its dishwasher in working order over multiple extended periods, as documented in temperature logs and confirmed by staff interviews and surveyor observations. Due to recurring mechanical and chemical-dispensing problems, the dishwasher was frequently out of service, and technicians were repeatedly called for repairs. As a result, all meals were served in disposable Styrofoam containers with plastic utensils, and a resident reported difficulty cutting food and cutting through the container while eating. These conditions were inconsistent with the facility’s sanitization policy requiring equipment to be kept in good repair.
Surveyors found that the facility failed to maintain resident dignity by serving meals in Styrofoam containers with plastic cutlery for an extended period due to a malfunctioning dishwasher that left reusable dishes unclean. All but three NPO residents were affected, and a resident reported difficulty cutting food because the utensil would cut through the Styrofoam. Observations on multiple meal services confirmed ongoing use of disposable dishware, which conflicted with the facility’s written dignity policy requiring care that promotes quality of life, respect, and individuality.
The facility failed to follow its own policy requiring prompt notification of the attending physician or provider when residents left against medical advice (AMA). In two separate cases, a resident with multiple chronic conditions and cognitive impairment who later tested cognitively intact signed out AMA, and another resident with cerebrovascular disease, COPD, major depressive disorder, and essential HTN was taken out AMA by a Guardian. In both instances, documentation showed the residents left AMA, but there was no evidence that the Medical Director or provider was notified, and leadership later confirmed that no such notifications occurred.
Surveyors found that the facility failed to prevent significant medication errors, including administration of morphine and lorazepam without active orders to a hospice resident with severe psychiatric and neurological conditions, as documented in narcotic logs, hospice notes, and electronic messages. Other residents with glaucoma, heart failure, chronic pain, epilepsy, hemiplegia, and vascular dementia missed multiple scheduled 9 p.m. doses of ophthalmic agents, an anticoagulant (Eliquis), and an antiepileptic (topiramate), as shown on MARs and confirmed by a regional clinical director. These actions and omissions occurred despite a facility policy requiring verification of the right resident, medication, dose, time, and route before administration.
Surveyors found multiple unsecured controlled substances, including lorazepam concentrate and morphine sulfate oral solution, lying on the DON’s desk instead of being stored in locked, permanently affixed compartments as required. These medications belonged to a current resident and several discharged residents and still contained varying amounts of narcotics. Facility policies required that controlled substances be kept in a securely locked area with restricted access and destroyed within a few days of discontinuation, but the DON acknowledged being behind on destruction. This failure affected several identified residents and had the potential to impact many independently mobile residents in the facility.
Surveyors found that the facility did not maintain an adequate food supply or consistently follow posted menus, affecting most residents. The Dietary Manager acknowledged low food stock, lack of a required emergency supply, and reliance on weekly deliveries and local store purchases. During one observed meal, residents on regular diets received only one cookie instead of the two listed on the menu, and those on mechanical soft or puree diets received pudding instead of the posted dessert. A review showed that menu substitution logs had not been completed for many months, and the Dietary Manager confirmed that substitutions and served meals were not documented, despite facility policy requiring such records. Residents reported not always receiving items on their meal tickets and feeling they did not get enough food to meet daily calorie needs.
Surveyors identified multiple unsanitary food handling and environmental conditions, including a leaking ceiling vent near an active prep area with splashing onto clean dishes, dust and black residue in the walk-in cooler, and an unclean wooden floor cover that could not be sanitized. Staff were observed using an unclean taped water dispenser for resident drinks, storing damaged and chipped knives, handling food after touching eyeglasses without changing gloves or handwashing, and using utensils that had not met required sanitizer contact time or air-drying. Food and utensils were also placed on wet trays still coated with sanitizer, all in violation of the facility’s own sanitization policy.
Surveyors found that the facility did not conduct required care conferences for two residents with multiple psychiatric and medical diagnoses, including one who was cognitively intact and another with severely impaired cognition requiring ADL assistance. Record reviews with SS staff showed no documentation of any care conferences for either resident, and SS confirmed that none were held. This was inconsistent with the facility’s Comprehensive Care Plans policy, which requires resident participation in person-centered care planning or documented reasons and efforts when participation is not practicable.
Surveyors found that the facility failed to notify the Medical Director or attending provider when two residents left Against Medical Advice, despite a policy requiring prompt provider notification for AMA discharges. One cognitively intact resident with multiple chronic conditions signed an unauthorized discharge release after staff discussed the risks and attempted to persuade the resident to stay, but the provider was never informed. In another case, a resident with significant medical diagnoses was signed out AMA by a guardian, with no documentation of provider notification. These omissions were confirmed through record review and staff and Medical Director interviews.
The facility failed to administer multiple scheduled medications as ordered for three residents with conditions including hemiplegia, GERD, chronic pain, hypertensive heart disease with heart failure, epileptic seizures, and vascular dementia. Over numerous days, morning, evening, and bedtime doses of pain medications, muscle relaxants, GERD treatments, thyroid replacement, psychotropic agents, inhalers, ophthalmic drops, laxatives, supplements, and other chronic medications were not given as documented on the MARs. The Regional Clinical Director confirmed that these medications were not administered, despite a facility policy requiring verification of the right resident, medication, dose, time, and route before administration.
Surveyors observed pooling water with a brownish tint on the floor of the walk-in refrigerator, which was confirmed by the Dietary Manager, who was new to the role and unaware of the issue's cause. This unsanitary condition had the potential to affect nearly all residents, except for a resident not consuming food from the kitchen per diet order.
Surveyors identified multiple deficiencies in the facility's environment, including missing and broken handrails, stained and damaged ceiling tiles, water damage with blankets on the floor, a broken shower chair still in use, and significant wall and flooring damage in a resident's room. These issues were confirmed by staff and affected a resident with complex medical needs.
A resident with Alzheimer's disease and dementia was assessed as a moderate fall risk but did not have a fall prevention care plan or interventions implemented until four days after experiencing a fall. Staff interviews and record review confirmed the delay, which was not in accordance with the facility's fall prevention policy.
A medication technician prepared and administered oral medications to a resident with multiple medical conditions by handling the medications with bare hands and failing to perform hand hygiene before or after the process. This action was in direct violation of the facility's infection control policy, which requires hand hygiene prior to handling medications.
A resident's family did not receive a timely refund of advance payments after the resident's death, despite multiple requests and facility policy requiring refunds within thirty days. The facility's business office and administration were aware of the issue but did not provide documentation of the refund being issued.
A facility failed to properly document and justify the transfer of a resident with a history of psychosis and dementia, citing incompatibility with other residents. The resident's guardian was not involved in the discharge process and was unaware of the transfer until after it occurred. Interviews with facility staff confirmed the lack of documentation, despite policy requirements.
A facility failed to notify a resident's guardian before transferring the resident due to behavioral issues. The resident, with a history of psychosis and dementia, was independent in daily activities. Despite multiple conversations with the guardian, no formal discharge notice was given, and documentation was lacking, violating the facility's policy.
The facility failed to provide palatable food, as observed during a lunch meal where the menu items were not as described, and the food was unappealing and bland. Residents reported the vegetables were soggy and the entree was unappealing, leading them to order substitutes. The Dietary Manager acknowledged the issues with the food quality.
A resident with multiple diagnoses, including COPD and diabetes, did not have their wound treatments documented in the Treatment Administration Record (TAR) on several dates. Interviews with the DON and nursing staff confirmed that treatments were completed but not recorded, violating the facility's documentation policy.
The facility failed to maintain an effective pest control program, affecting all 53 residents. Multiple residents and a visitor reported seeing various bugs in their rooms. The Administrator acknowledged the ongoing issue with large water bugs and admitted that current pest control procedures were not effective.
A facility failed to provide a written discharge notice and appeal rights to a resident discharged to a local hotel. The resident, who had multiple medical conditions and was cognitively intact, was discharged without documented evidence of a discharge summary or written notice, contrary to facility policy.
A resident with multiple diagnoses was discharged to a local hotel without proper follow-up services or a documented discharge summary. The discharge was initiated due to the resident's desire to leave and the discovery of his status as a registered sex offender. The facility paid for the resident's hotel room for seven days but failed to follow its own discharge documentation policy.
The facility failed to provide a clean, safe, and sanitary environment, affecting three residents and potentially impacting all 18 residents in the memory care unit. Issues included damaged walls, stains, unknown substances, and poor maintenance in residents' rooms and the shower room, as confirmed by staff and residents.
Facility staff failed to perform proper hand hygiene after providing incontinence care and before applying barrier cream, repositioning, and adjusting clothing for two residents. STNAs continued to use soiled gloves during these procedures, contrary to the facility's hand hygiene policy.
Failure to Maintain Dishwasher in Working Order
Penalty
Summary
The facility failed to maintain the dishwasher in working order, resulting in prolonged periods when it was non-operational or not functioning correctly. During a kitchen observation with the Dietary Manager, the dishwasher was found to be out of service, and the manager reported ongoing problems since February, including incorrect chemical dispensing during the wash cycle and dishes not coming out clean. The manager stated that technicians had been called frequently and that the machine would work briefly after repairs and then break again. A technician was observed working on the dishwasher during the survey, and the Regional Director of Operations later confirmed that although the dishwasher had worked the previous day, it had again stopped functioning. Because the dishwasher was not operational, the facility used disposable dishware and utensils for all meals, and residents were observed receiving meals in Styrofoam containers with plastic cutlery on multiple days. A resident reported dissatisfaction with the Styrofoam containers, stating that they made it difficult to cut food and that she would cut through the container while trying to eat. Review of the dishwasher temperature log showed the dish machine was documented as broken for multiple extended periods: from 11/21/25 through 11/31/25, 01/24/26 through 02/01/26, 02/07/26 through 03/01/26, and 03/04/26 through 03/17/26. Facility policy on sanitization required all equipment to be maintained in good repair, which was not met during these documented breakdowns.
Failure to Maintain Dignity by Serving Meals on Disposable Dishware
Penalty
Summary
The deficiency involves the facility’s failure to honor residents’ rights to dignity and respect by serving meals on disposable Styrofoam dishware with plastic cutlery for an extended period. Surveyors observed that the facility’s dishwasher had been malfunctioning since February, dispensing chemicals at incorrect times and leaving dishes unclean. As a result, the facility had been using disposable dishware for all meals, affecting 67 residents, while three residents who were NPO did not receive food from the kitchen. During a kitchen observation, the dishwasher was noted to be non-operational and under repair by a technician, and subsequent meal service observations showed residents receiving their meals in Styrofoam containers with plastic utensils. A resident reported dissatisfaction with the Styrofoam containers, stating that it was difficult to cut food and that attempts to do so resulted in cutting through the container itself. Multiple observations of lunch services confirmed that residents continued to be served meals in Styrofoam containers with plastic utensils. Review of the facility’s “Quality of Life – Dignity” policy, dated August 2009, indicated that each resident should be cared for in a manner that promotes and enhances quality of life, dignity, respect, and individuality, and that staff should promote, maintain, and protect resident privacy. The use of disposable dishware and cutlery during meal services was determined to be inconsistent with these dignity standards, leading to the cited deficiency under the referenced complaint number.
Failure to Notify Physician of Residents’ AMA Discharges
Penalty
Summary
The deficiency involves the facility’s failure to follow its policy requiring prompt notification of the attending physician or provider when a resident leaves against medical advice (AMA). For one resident admitted with chronic viral hepatitis C, polyneuropathy, dementia, manic episode without psychotic symptoms, bipolar disorder, depression, and venous insufficiency, the record showed moderately impaired cognition on the most recent MDS, with independence in eating, partial assistance with toileting, substantial assistance with bathing, and setup for personal hygiene. On the day of discharge, the resident’s BIMS score was 13, indicating cognitively intact status, and the resident signed an Unauthorized Discharge Release of Responsibility form to leave AMA after the facility documented discussion of the risks and attempts to have the resident remain. However, the Medical Director/provider was not notified of this AMA discharge, and the Medical Director later confirmed he had never been informed. A second resident, admitted with cerebrovascular disease, COPD, major depressive disorder, and essential HTN, had an MDS indicating independence with eating, dependence on staff for toileting and bathing, and partial assistance with personal hygiene. This resident was discharged AMA by the resident’s Guardian, as documented in a progress note. Review of the medical record revealed no documentation that the Medical Director/provider was notified when the resident left AMA, and the Regional Clinical Director confirmed that the provider was not notified at that time. The facility’s written policy titled “Discharging a Resident Without a Physician’s Approval” states that when a resident or representative requests discharge earlier than outlined in the care plan and without physician approval (AMA), the attending physician or provider is to be promptly notified. The failure to notify the physician/provider for both AMA discharges constituted non-compliance and was cited under Complaint Number 2699059.
Failure to Prevent Significant Medication Errors and Missed Doses
Penalty
Summary
The deficiency involves the facility’s failure to ensure residents were free from significant medication errors, including administering controlled substances without active orders and failing to administer ordered medications on multiple occasions. One resident with severe psychiatric and neurological diagnoses had PRN orders for morphine sulfate and lorazepam that were discontinued early in the month, with no subsequent active orders. Despite this, controlled substance records showed lorazepam doses documented on two dates later in the month and morphine doses documented on three dates, including the day of the resident’s death, all without active physician orders. Entries on the narcotic logs were illegible. Hospice documentation indicated that a hospice RN visited the resident due to lethargy and minimal responsiveness, discussed medication administration with an LPN, and noted that lorazepam and morphine were administered during the visit. Electronic triage messages showed the LPN informed the hospice NP that the lorazepam order was not active, requested that it be reinstated and increased, and acknowledged that the resident had not been receiving the medication, yet also indicated that medications were on hand and had been given on specific dates. Additional deficiencies were identified for a resident with glaucoma and related eye pressure issues whose multiple ophthalmic medications and an oral medication for high eye pressure were ordered for administration at 9:00 P.M. and twice daily. Review of the MAR for this resident showed that several 9:00 P.M. doses of Latanoprost, Rhopressa, Brimonidine Tartrate, Dorzolamide-Timolol, and Methazolamide were not administered on multiple dates in the same month. The Regional Clinical Director confirmed that these medications were not given at the ordered times on the identified dates. The resident was documented as cognitively intact on the MDS assessment. A further deficiency involved a cognitively intact resident with hypertensive heart disease with heart failure, intervertebral disc degeneration, and chronic pain syndrome who had an order for Eliquis 5 mg at 9:00 P.M. The MAR showed that this anticoagulant was not administered on multiple specified 9:00 P.M. doses in the same month, and the Regional Clinical Director verified the missed doses. Another resident with hemiplegia, epileptic seizures, vascular dementia, and severe cognitive impairment had a long-standing order for topiramate 50 mg daily at 9:00 P.M. for epilepsy. The MAR revealed that the 9:00 P.M. doses of topiramate were not administered on multiple dates in the same month, and the Regional Clinical Director confirmed these missed doses. The facility’s medication administration policy required staff to verify the right resident, medication, dosage, time, and route before administration, but the documented omissions and administration of medications without active orders demonstrate that this process was not consistently followed.
Unsecured and Undestroyed Controlled Substances Left on DON’s Desk
Penalty
Summary
Surveyors identified a deficiency in the facility’s handling of controlled substances when multiple unsecured narcotic medications were observed lying on the DON’s desk during an interview with the DON and the Regional Clinical Director. The medications included lorazepam oral concentrate and morphine sulfate oral solution prescribed for one resident who still resided in the facility, with significant amounts remaining in the bottles, as well as multiple bottles of morphine sulfate and lorazepam concentrate for several residents who had been discharged. The DON confirmed that these controlled medications were unsecured and acknowledged that controlled substances should be stored in a permanently affixed, locked compartment. The facility’s written policies titled “Controlled Substances” and “Discarding and Destroying Medications” required that controlled substances be separately locked in permanently affixed compartments and that any remaining controlled substances after discharge or discontinuation be securely locked in an area with restricted access until destruction, with disposal to occur immediately and no longer than three days after discontinuation. Contrary to these policies, the controlled medications for discharged residents were kept on the DON’s desk rather than in a securely locked area, and the DON stated she was behind in destroying the controlled substances. This failure to secure and timely destroy controlled substances affected four identified residents and had the potential to affect 56 independently mobile residents in a facility census of 70.
Failure to Maintain Adequate Food Supply and Follow Posted Menus
Penalty
Summary
The facility failed to ensure menus were followed and that an adequate food supply was maintained to meet residents' nutritional needs. Surveyors observed the dry stock area with the Dietary Manager and found a low stock of food, with the Dietary Manager confirming that food deliveries occurred once a week, that she shopped locally if food ran out, and that there was no emergency stock of food available, despite facility policy requiring a minimum seven-day supply. Review of the lunch meal service showed that the posted menu for that day called for beef and noodles, broccoli florets, and two baked cookies, but residents on regular diets received only one cookie, and residents on mechanical soft and puree diets received pudding instead of the listed dessert. The Dietary Manager confirmed there were not enough cookies prepared to follow the menu and acknowledged that the menu indicated residents should have received two cookies. Resident interviews further supported that the menu was not consistently followed. One resident reported not always receiving everything listed on their meal tickets, and another resident stated that the facility did not follow the meal tickets and that they felt they were not getting enough food to meet their daily calorie needs. Review of the substitution logs with the Dietary Manager showed that the log had not been filled out since July 2025, and the Dietary Manager verified that she did not keep a substitution log or documentation of meals served. This was inconsistent with the facility’s written menu policy, which required that menus be followed and that any deviations from the menu be recorded and archived. The deficiency affected 67 residents, with three residents identified as NPO and therefore not receiving food from the kitchen.
Unsanitary Food Storage, Preparation, and Serving Practices
Penalty
Summary
The deficiency involves the facility’s failure to store, prepare, and serve food in a safe and sanitary manner in accordance with professional standards, affecting 67 residents who received food from the kitchen. Surveyors observed an air vent in the kitchen ceiling leaking condensation water from the air conditioning unit, with droplets falling onto the floor adjacent to an actively used food preparation table and splashing onto clean dishes stored below. Additional observations in the kitchen included dust on the ceiling and black residue on the fan shields in the walk-in cooler, as well as an unclean sheet of wood with black residue covering a hole in the floor under a preparation area, which staff acknowledged could not be cleaned. Two knives with broken tips and two knives with chipped paint on the blades were stored on the magnetic knife strip, and the dietary manager confirmed these knives were not safe to use and should not have been stored in the kitchen. Surveyors also observed unsanitary practices related to food and utensil handling. An activities assistant was seen passing drinks using a metal water dispenser that was unclean, with brown residue and discolored tape on the lid; the assistant stated the tape was used because the lid frequently came off and acknowledged the dispenser was difficult to clean due to the tape. A staff member preparing food was observed adjusting his glasses with gloved hands and then pureeing steamed broccoli without changing gloves or washing hands, and later using a rubber spatula that had been dipped briefly in sanitizer and not allowed the required contact time or air-drying before returning it to food preparation. During tray line observation, food and utensils were placed on wet trays that still had sanitizer on them because the trays were stacked while wet and there was no place to allow them to air dry. These conditions and practices were inconsistent with the facility’s sanitization policy, which required kitchen areas, utensils, and equipment to be kept clean, in good repair, free from damage, and allowed to air dry.
Failure to Conduct Care Conferences and Involve Residents in Care Planning
Penalty
Summary
The facility failed to ensure residents were allowed to participate in the development and implementation of their person-centered plans of care by not conducting required care conferences. For one resident with chronic viral hepatitis C, polyneuropathy, dementia, manic episode without psychotic symptoms, bipolar disorder, depression, and venous insufficiency, record review showed admission and subsequent discharge against medical advice with no guardian at the time of discharge. The most recent MDS 3.0 assessment documented moderately impaired cognition with varying levels of assistance needed for ADLs, and a later BIMS score of 13 indicated the resident was cognitively intact. Review of this resident’s medical record with Social Services staff revealed no evidence of any care conferences, and the Social Services staff member confirmed that none had been conducted. For another resident with diagnoses including mood disorder, bipolar disorder, cauda equina syndrome, catatonic schizophrenia, and major depressive disorder, the most recent MDS assessment showed severely impaired cognition and a need for assistance with ADLs. Review of this resident’s medical record with Social Services staff likewise revealed no documentation of any care conferences, and the Social Services staff member verified that none had been held. The facility’s Comprehensive Care Plans policy states that each resident’s comprehensive person-centered care plan must be consistent with the resident’s right to participate in the planning process, and that if resident or representative participation is not practicable, an explanation and the steps taken to include them must be documented in the medical record. Such documentation was not present for these residents. This deficiency was cited under Complaint Number 2691577.
Failure to Notify Provider of Residents Leaving Against Medical Advice
Penalty
Summary
The deficiency involves the facility’s failure to notify the Medical Director or attending provider when residents left the facility Against Medical Advice (AMA), contrary to facility policy. For one resident admitted with diagnoses including chronic viral hepatitis C, polyneuropathy, dementia, manic episode without psychotic symptoms, bipolar disorder, depression, and venous insufficiency, the record showed the resident was discharged AMA. The most recent MDS indicated moderately impaired cognition with varying levels of assistance needed for ADLs, and a reassessment on the day of discharge documented a BIMS score of 13, indicating the resident was cognitively intact. An "Unauthorized Discharge Release of Responsibility" form dated the day of discharge showed the resident signed out AMA and that staff discussed the risks of leaving and attempted to get the resident to stay. However, interviews with the Regional Clinical Director and the Medical Director confirmed that the Medical Director/provider was not notified of this AMA discharge. A second resident, admitted with cerebrovascular disease, COPD, major depressive disorder, and essential hypertension, was also discharged AMA. The most recent MDS showed the resident was independent with eating but dependent on staff for toileting and bathing and required partial assistance with personal hygiene. A progress note documented that this resident was signed out AMA by the resident’s Guardian. Review of the medical record revealed no documentation that the Medical Director/provider was notified when this resident left AMA, and the Regional Clinical Director confirmed that no such notification occurred. Facility policy titled "Discharging a Resident Without a Physician's Approval" required that the attending physician or provider be promptly notified when a resident or representative requests discharge AMA, but this notification did not occur for these two residents.
Failure to Administer Multiple Medications as Ordered for Three Residents
Penalty
Summary
The deficiency involves the facility’s failure to administer medications according to physician orders for three residents. For one cognitively intact resident with hemiplegia, GERD, and chronic pain, multiple scheduled medications were not given on numerous documented dates in February. Missed medications included cyclobenzaprine, methocarbamol, and acetaminophen at 6:00 A.M. and 10:00 P.M., omeprazole at 5:00 A.M., and several 9:00 P.M. medications such as a Lidocaine patch, diclofenac gel, Senna S, atorvastatin, and melatonin. The Regional Clinical Director confirmed that these medications were not administered as ordered. A second cognitively intact resident with hypertensive heart disease with heart failure, intervertebral disc degeneration, and chronic pain syndrome also had multiple missed doses of ordered medications. Review of the MAR showed that several 9:00 P.M. medications, including atorvastatin, trazodone, tamsulosin, Advair Diskus, Biotene, Lyrica, Mucinex ER, naproxen, omeprazole, Senna S, sodium chloride, and valsartan, were not administered on multiple evenings in February. Additionally, buspirone and cyclobenzaprine were not administered at 6:00 A.M. and 10:00 P.M. on multiple dates, and levothyroxine at 6:00 A.M. and Pataday ophthalmic solution at 5:00 A.M. were also not given on several dates. The Regional Clinical Director verified these missed medications. A third resident with hemiplegia, epileptic seizures, and vascular dementia, who was assessed as severely cognitively impaired, had numerous missed doses of ordered medications as well. The February MAR showed that famotidine, melatonin, artificial tears, baclofen, Depakote sprinkles, and a house nutritional supplement were not administered at 9:00 P.M. on multiple dates. Levothyroxine at 6:00 A.M. and hydrocodone-acetaminophen at 6:00 A.M. and 10:00 P.M. were also not administered on several dates. The facility’s medication administration policy required staff to verify the right resident, medication, dosage, time, and route before administration, but the documented omissions show that medications were not given as ordered. The Regional Clinical Director confirmed the missed medications for this resident as well.
Unsanitary Kitchen Conditions Due to Pooling Water in Walk-In Refrigerator
Penalty
Summary
The facility failed to maintain the kitchen in a clean and sanitary condition, as evidenced by the observation of pooling water with a brownish tint on the floor of the walk-in refrigerator. This issue was identified during a kitchen inspection and was confirmed by the Dietary Manager, who acknowledged the presence of the pooling water but was unable to provide information about the cause due to being new in the position. The unsanitary condition in the kitchen had the potential to affect 70 out of 71 residents, as one resident was not consuming food from the kitchen per their diet order.
Failure to Maintain Safe, Clean, and Homelike Environment
Penalty
Summary
The facility failed to maintain a clean, safe, and homelike environment, as evidenced by multiple observations throughout the building. Surveyors found a missing section of handrail on one hall, with a wooden box containing plumbing parts only partially secured to the wall, and another hall with a broken handrail that had a sharp, exposed edge. Several ceiling tiles in different areas, including near the shower room and on a secured unit, were observed to have brown stains, black spots, cracks, and missing pieces. In the 300 hall, blankets were found pressed against a ventilation unit on the floor, with a puddle of water and brownish water seeping from under the flooring. The shower room contained a broken shower chair that was still in use, black discoloration between wall tiles, a cracked and damaged shower frame, and a hole in the ceiling near the toilet. A resident with multiple diagnoses, including congestive heart failure, pneumonia, kidney failure, diabetes, COPD, anxiety, depression, and schizophrenia, was found to have a room with significant physical damage. The wall between the closet and dresser was missing pieces, partially covered by a screwed-in material, but still rough and incomplete. The edge of the wall near the door frame was breaking off, and the flooring outside the room was missing a section. These deficiencies were confirmed by various staff members during the survey. The facility's policy requires a safe, clean, and comfortable environment, but these conditions were not met.
Failure to Timely Implement Fall Prevention Measures
Penalty
Summary
The facility failed to implement timely and appropriate care and services to prevent falls for a resident who was assessed to be at moderate risk. The resident, who had diagnoses including Alzheimer's disease, dementia with behavioral disturbances, and hypertension, was admitted to the facility and assessed for fall risk. Despite being identified as at risk, the resident did not have a fall prevention plan of care or interventions implemented until four days after experiencing a fall in the facility. Record review and staff interviews confirmed that the plan of care and interventions to prevent falls were not put in place until several days after the incident. The facility's own Fall Policy requires that all residents be evaluated for safety risks and that care plans be created and implemented based on individual risk factors to prevent falls. This lapse in timely implementation of fall prevention measures was identified during the investigation of multiple complaints.
Failure to Follow Infection Control Procedures During Medication Administration
Penalty
Summary
During a medication administration observation, a medication technician prepared and administered oral medications to a resident without adhering to proper infection control procedures. The technician handled all eight medications with bare hands, transferring them from their individual packaging directly into a medication cup. No hand hygiene was performed before or after the medication administration process. The resident involved had multiple medical diagnoses, including Alzheimer's disease, seizures, depression, dysphagia, supraventricular tachycardia, atrial fibrillation, and benign prostatic hyperplasia, and was assessed as having minimal cognitive impairment. The facility's medication administration policy, revised earlier in the year, requires hand hygiene to be performed prior to handling any medication and mandates that contaminated medications be discarded. The medication technician confirmed during an interview that she did not wash her hands at any point during the process and acknowledged that she should not have touched the medications with her bare hands. This failure to follow established infection control protocols was directly observed and verified during the survey.
Failure to Timely Refund Resident Funds After Discharge or Death
Penalty
Summary
The facility failed to provide evidence of issuing a refund within thirty days of discharge, as required by policy, for a resident who had passed away. The resident, who had diagnoses including lung cancer and depression and required partial to moderate assistance with ADLs, had a payment posted to their account for the month of their death. After the resident's passing, the resident's daughter reported not receiving a refund for the funds paid in advance, despite multiple attempts to contact the facility for resolution. Record review showed that a payment was made for the full month, but only a portion of the month was billed for room and board, leaving a credit balance. Interviews with facility staff revealed that the request for a refund was forwarded to the corporate office, but no documented evidence of a payment being issued was found. The facility's policy required refunds and a final accounting to be provided within thirty days of discharge or death, but this was not completed for the resident in question.
Improper Resident Transfer Without Documentation
Penalty
Summary
The facility failed to comply with regulations regarding the transfer or discharge of a resident without adequate justification and proper documentation. This deficiency affected one resident, who had a history of unspecified psychosis, vascular dementia, anxiety disorder, bipolar disorder, and alcohol-induced persisting dementia. The resident was assessed to have moderately impaired cognition but was independent in daily activities. Despite this, the facility discharged the resident to another nursing home, citing incompatibility with other residents as the reason. However, there was no documentation in the medical record regarding discussions of the transfer or discharge with the resident's guardian. Interviews with the resident's guardian revealed that he was not involved in the discharge process and was unaware of the transfer until after it occurred. The guardian reported that the facility had expressed concerns about the resident's behavior but did not inform him of the transfer until the resident refused to stay at the new facility. The Director of Nursing and the Administrator confirmed the lack of documentation and stated that the decision to transfer was made for safety reasons. The facility's policy required all transfers or discharges to be documented, which was not adhered to in this case.
Failure to Provide Proper Notification Before Resident Transfer
Penalty
Summary
The facility failed to provide proper notification before transferring or discharging a resident, specifically affecting one resident out of three reviewed for such actions. The resident in question had a history of unspecified psychosis, vascular dementia, anxiety disorders, bipolar disorder, and alcohol-induced persisting dementia. Despite having moderately impaired cognition, the resident was independent in daily activities. The medical record review revealed no documentation of discussions regarding the transfer or discharge with the resident's guardian, and the discharge summary was incomplete, indicating the resident was moved due to incompatibility with other residents. Interviews with the resident's guardian and facility staff highlighted a lack of communication and documentation. The guardian was not involved in the discharge process and was unaware of the transfer until after it occurred. The Director of Nursing and the Administrator confirmed the absence of formal discharge notice and documentation, despite multiple conversations with the guardian about the resident's behavior and desire to leave. The facility's policy required written notice and documentation of the reasons for transfer or discharge, which was not adhered to in this case.
Deficiency in Food Quality and Palatability
Penalty
Summary
The facility failed to provide palatable food to meet the nutritional needs of its residents, as evidenced by a review of the menu, observations, and interviews. On the date in question, the lunch menu included creamy Maryland chicken with mushroom sauce, egg noodles, yellow squash, chilled peach, and a choice of cold beverage. However, the test tray observation revealed discrepancies, such as the use of penne noodles instead of egg noodles, and the yellow squash was green, mushy, and lacked flavor. Additionally, the chicken dish contained a hard substance resembling a chicken bone and was described as bland and flavorless. Residents interviewed during the lunch meal expressed dissatisfaction with the food, noting that the vegetables were soggy and distasteful, and the entree was unappealing, leading them to order substitute items. The Dietary Manager confirmed the issues with the squash and zucchini, acknowledging that they frequently became mushy during cooking and expressed a desire to remove them from the menu. The facility's policy on food preparation and service was reviewed, indicating that food should be prepared and served in compliance with safe food handling practices. This deficiency was investigated under Complaint Number OH00155100.
Failure to Document Wound Treatments
Penalty
Summary
The facility failed to accurately and timely document wound treatments for a resident, identified as Resident #48, who was admitted with diagnoses including chronic obstructive pulmonary disease, cellulitis, lymphedema, and type two diabetes mellitus. The care plan for this resident required staff to perform wound treatments with documentation of measurements, type of tissue, and any exudate noted. However, the Treatment Administration Record (TAR) for June 2024 showed that the treatment was not documented as completed on multiple dates. Interviews with the Director of Nursing and several nursing staff confirmed that the treatments were completed as ordered but were not documented in the TAR. Specifically, an LPN and two RNs admitted to not documenting the completion of treatments on various dates in June 2024. The facility's policy on Charting and Documentation required all services provided to residents to be documented in their medical records, which was not adhered to in this case.
Failure to Maintain Effective Pest Control Program
Penalty
Summary
The facility failed to maintain an effective pest control program, which had the potential to affect all 53 residents. Multiple residents and a visitor reported observing various bugs in their rooms. Resident #35 and Resident #42 both mentioned seeing bugs recently. A visitor showed the surveyor pictures of large bugs she had observed in the facility. Resident #47 reported having large bugs in her room, and during the interview, a dead bug was observed inside her door frame and a live one under her sink. The Activity Director confirmed the presence of bugs in Resident #47's room, including three large bugs around the base of the toilet. The Housekeeper also observed bugs in the resident's rooms and hallways while cleaning. A State tested Nurse Aide confirmed the ongoing issue with pests and mentioned that residents had voiced concerns about pest control. The Administrator acknowledged the ongoing issue with large water bugs for several months and admitted that the current pest control procedures were not effective. The facility's policy on pest control, dated May 2008, stated that the facility would maintain an effective pest control program to ensure it was kept free of pests and rodents. However, the observations and interviews indicated that the facility had not adhered to this policy, leading to the deficiency.
Failure to Provide Written Discharge Notice and Appeal Rights
Penalty
Summary
The facility failed to ensure a written discharge notice with provision of the discharge was provided to a resident upon discharge to the community. This deficiency affected one resident who was admitted with multiple diagnoses including spondylosis, chronic obstructive pulmonary disease, coronary artery dissection, major depressive disorder, insomnia, hypertension, and alcohol abuse. The resident was cognitively intact and dependent on facility staff for medication administration. The resident was discharged to a local hotel with personal belongings, a courtesy bag, and a list of medications, but there was no documented evidence of a written discharge notice or discharge appeal being offered to the resident. Interviews with the Social Service Designee, Administrator, Director of Nursing, and Medical Director revealed that the discharge was initiated due to the resident's desire to leave and the discovery of the resident being a sexual offender. The facility paid for a hotel room for seven days, but there was no documented evidence of a discharge summary or written discharge notice in the medical record. The facility policy confirmed that a written discharge notice and the right to appeal should be provided to the resident, which was not done in this case.
Failure to Ensure Safe and Orderly Discharge
Penalty
Summary
The facility failed to ensure a safe and orderly discharge for a resident, identified as Resident #56, who was discharged to a local hotel without proper follow-up services. The resident, who had multiple diagnoses including spondylosis, chronic obstructive pulmonary disease, coronary artery dissection, major depressive disorder, insomnia, hypertension, and alcohol abuse, was cognitively intact and dependent on facility staff for medication administration. Despite being given a list of medications and a courtesy bag, there was no documented evidence of a discharge summary or any follow-up services being set up for the resident. The Social Service Designee (SSD) was on vacation at the time of discharge and had only referred the resident to a program that could help with finding an apartment, but nothing was set up. The discharge was initiated due to the resident's desire to sign himself out and stay with a friend, as well as the discovery of the resident's status as a registered sex offender. The facility paid for the resident's hotel room for seven days but failed to document the discharge summary in the medical record or provide it to the resident. The Medical Director was not aware of the resident's sex offender status at the time of discharge. The facility's policy required screening new admissions through the Dru National Sex Offender Public Website, but the facility had only used the national listing and not the local one. The facility's policy also required detailed documentation of the discharge, which was not followed in this case.
Facility Fails to Maintain Clean and Safe Environment
Penalty
Summary
The facility failed to provide a clean, safe, and sanitary environment, directly affecting three residents and potentially impacting all 18 residents in the memory care unit. Resident #14's room had multiple issues, including a hanging cove base, drywall mud splatter, a large brownish/red stain on the bed sheet, an unknown brown liquid on the floor, black smudges, a removed metal electric box, and a rusted baseboard heater. Resident #14 reported that the unknown brown liquid had been on the floor for two days, and staff confirmed the room's condition. Resident #25's room had a large crack running the entire length of the wall and peeling, exposed drywall under the window, which was verified by the Maintenance Supervisor (MS). Resident #42's room had damaged drywall and black marks on the walls, which had been present for a while, as confirmed by the resident and MS. Additionally, the Memory Care Unit shower room was found to be in poor condition, with a large white chunky substance on the floor, black fuzzy substance in the tile grout, a non-functional overhead light, missing ceiling tiles, a missing toilet tank, and uneven floor edges. The MS confirmed that the white substance on the floor was floor leveler. The facility's policy titled 'Quality of Life - Homelike Environment' states that residents are to be provided with a safe, clean, comfortable, and homelike environment, which was not upheld in these instances.
Failure to Perform Proper Hand Hygiene During Incontinence Care
Penalty
Summary
The facility staff failed to perform proper hand hygiene after providing incontinence care and before applying barrier cream, repositioning, and adjusting clothing for two residents. For Resident #26, who has diagnoses including hemiplegia and functional urinary incontinence, the State tested Nursing Assistant (STNA) #256 did not change gloves after performing peri care. Instead, the STNA continued to wear the soiled gloves while applying barrier cream, a new incontinence brief, repositioning, and covering the resident with a sheet. This was confirmed during an interview with STNA #256, who acknowledged the failure to change gloves after performing peri care. Similarly, for Resident #4, who has diagnoses including Parkinson's disease and irritant contact dermatitis, STNAs #235 and #248 did not change their gloves after performing peri care. They continued to use the soiled gloves while applying a clean incontinence brief, barrier cream, repositioning, straightening the resident's clothes, and covering the resident with a sheet. This was confirmed during an interview with both STNAs. The facility's hand hygiene policy, which requires hand hygiene after glove removal and after contact with body fluids, was not followed in these instances.
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A resident with intact cognition receiving Medicare Part A skilled services for metabolic encephalopathy had services discontinued while benefit days remained, but the facility did not issue the required Skilled Nursing Facility Advance Beneficiary Notice (SNF ABN). The Social Services Director later confirmed that no SNF ABN was provided and reported she believed only a Notice of Medicare Non-Coverage (NOMNC) was needed when all skilled services were stopped. This practice conflicted with the facility’s written policy, which required SNF ABNs to be issued when extended care items or services were initiated, reduced, or terminated due to expected non-coverage by Medicare.
Surveyors identified that the facility exceeded the acceptable medication error rate when two residents with type 2 DM received insulin doses that were not administered according to orders or manufacturer instructions. In two separate observations, an LPN administered Novolog and another LPN administered insulin glargine and insulin lispro without priming the insulin pens, and the insulin lispro and Novolog were given after the residents had already consumed a significant portion of their breakfast meals, despite orders for administration before meals. Manufacturer information for both insulin products required priming before each injection to ensure accurate dosing, and facility policy required medications, including insulin, to be administered safely, timely, and in accordance with prescriber orders and specified time frames.
Surveyors found that the facility failed to document tray line food temperatures for multiple meals served from two dining room kitchenettes, despite having a “Trayline Taste & Temperature Log” and a policy requiring food to be stored, prepared, distributed, and served according to professional food safety standards. Review of logs showed repeated missing entries for breakfast, lunch, and dinner services in both the Harrison and McClellan dining areas, and the Senior Director of Culinary Services confirmed that temperatures had not been recorded for those meals, potentially affecting all residents receiving meals from those kitchenettes.
The facility failed to conduct and document required periodic care conferences for two residents, despite multiple comprehensive, quarterly, and significant change MDS assessments and a policy requiring periodic care conferences with resident and/or family participation. One resident with Parkinson’s disease, post-stroke hemiplegia, TIA, DMII, and depression had only two documented care conferences over a year, while another resident with aphasia, cerebrovascular disease, DMII, gait difficulty, coagulation defect, depression, and muscle weakness had no documented care conferences in the past year, aside from a declined invitation to the representative. The UCC confirmed that care conferences were expected to occur quarterly and that no additional documentation existed for either resident.
A resident with Alzheimer's disease and type II DM, who required extensive assistance with ADLs and was receiving scheduled Lantus and sliding-scale Humalog, experienced a severely elevated blood glucose level. The on-call provider was notified and ordered an additional dose of lispro insulin with a directive to recheck the blood glucose after administration. Nursing staff administered the extra insulin but did not document any follow-up blood glucose check, and the DON confirmed that this reevaluation was required by the facility's abnormal blood glucose policy and was not completed or documented.
A resident with Parkinson’s disease, dementia, and hypothyroidism was prescribed levothyroxine once daily along with other medications. A consultant pharmacist’s monthly drug regimen review recommended that levothyroxine be given in the morning on an empty stomach, 30–60 minutes before food, per manufacturer instructions. The medical record contained no documented physician response to this recommendation, and the MAR showed the drug scheduled for morning administration while the resident was observed eating breakfast and receiving the medication at the same time. An LPN confirmed administering levothyroxine during the meal, and the DON verified there was no documentation explaining whether or why the pharmacist’s recommendation was or was not followed, resulting in a failure to act on and document the identified irregularity.
A resident with severe cognitive impairment, multiple comorbidities, documented gait and balance abnormalities, and a high fall risk was care planned and assessed by therapy to require contact guard assistance and use of a gait belt for transfers and ambulation. While being assisted by a CNA from a recliner to the bathroom with a walker, the CNA did not apply a gait belt, even though the resident had a known tendency to lean backward when standing. As the CNA reached to open the bathroom door, the resident lost balance and fell backward, striking the back of the head, and was later found by an LPN without a gait belt in place, contrary to the facility’s gait belt policy and the resident’s assessed needs.
A resident with CKD stage five requiring peritoneal dialysis (PD) was admitted with pre-admission physician orders for three daily PD exchanges and monitoring for peritonitis (fever, abdominal pain, cloudy effluent), but these monitoring orders were not entered into the facility’s physician orders. The care plan referenced PD and general monitoring but did not specifically address peritonitis monitoring. Paper PD flowsheets showed incomplete and inconsistent documentation of exchanges and resident condition, including missing condition/comments for individual treatments and no record of one ordered PD exchange. The PD cycler flowsheet lacked effluent descriptions on multiple days. The PD nurse reported facility staff were expected to monitor effluent and symptoms, and the DON confirmed the absence of specific peritonitis monitoring orders, lack of an order for the PD cycler, and documentation gaps, despite a facility policy requiring ongoing assessment and monitoring for complications before, during, and after dialysis treatments.
A nurse was observed preparing multiple oral medications for a resident with depression, traumatic brain injury, anxiety, and impaired cognition by pushing tablets and capsules from unit-dose cards directly into her ungloved hand and then using her fingers to place them into a medication cup. In a follow-up interview, the RN confirmed this practice and acknowledged that the correct procedure is to dispense medications directly from the card into the cup, contrary to the facility’s medication administration policy requiring adherence to good nursing principles and practices.
A resident with Alzheimer’s disease, diabetes, anxiety, significant ADL dependence, and behavioral symptoms was observed seated in a chair positioned against the nursing station with a locked wheelchair placed directly in front, also against the nursing station, effectively restricting movement. An LPN confirmed both wheelchair wheels were locked and that it should not have been placed there, while a CNA stated she had positioned the wheelchair to prepare for lunch, was unable to complete the transfer, and left it in place, acknowledging this was wrong. This arrangement conflicted with the facility’s restraint policy, which prohibits physical restraints except when alternatives are ineffective for treating a medical symptom and defines restraints as devices adjacent to the body that cannot be easily removed and that restrict freedom of movement or access to the body.
Failure to Issue Required SNF ABN When Discontinuing Medicare Part A Services
Penalty
Summary
The deficiency involves the facility’s failure to issue a Skilled Nursing Facility Advance Beneficiary Notice (SNF ABN) when Medicare Part A services were discontinued for a resident who still had available benefit days. The resident was admitted with a diagnosis of metabolic encephalopathy and had intact cognition per the Minimum Data Set assessment. The facility’s own SNF Beneficiary Notification Review documented that Medicare Part A skilled services began on 02/11/26 and the last covered day was 03/11/26, and that the facility initiated discharge from Medicare Part A services before the resident’s benefit days were exhausted. Despite this, no SNF ABN was provided to the resident or the resident’s representative. During interviews, the Social Services Director stated that the SNF ABN was issued hours prior to the last covered day but, upon reviewing her files, confirmed that no SNF ABN had actually been issued for this resident. She further explained that she believed an SNF ABN was only required if one skilled service remained and that if all skilled services were being discontinued, only the Notice of Medicare Non-Coverage (NOMNC) needed to be issued. The Administrator, however, stated that a resident should always receive both a SNF ABN and a NOMNC when Medicare Part A services are discontinued and benefit days remain. Review of the facility’s written policy dated 03/28/23 showed that the facility was required to issue SNF ABNs for initiation, reduction, or termination of extended care items or services when Medicare payment was not expected, which did not occur in this case.
Plan Of Correction
This Plan of Correction is submitted as required under State and Federal law. This Plan of Correction does not constitute an admission on the part of the Facility that the findings cited are accurate, that the findings constitute a deficiency or that the scope and severity regarding the deficiency cited are correctly applied. Any changes to the Facility's policies and procedures should be inadmissible in any proceeding on that basis. Without admitting or denying the validity or the existence of the alleged noncompliance, the Facility submits this Plan of Correction with the intention that it be inadmissible by any third party in any civil or other action against the facility or any employee, agent, officer, director or shareholder of the Facility. The Facility is utilizing this Plan of Correction as its allegation of substantial compliance as of 05/29/2026 F-0582 Corrective action for resident/s: On 5/14/26 Resident #34 was informed of rights and responsibilities related to Advanced Beneficiary Notice and voiced understanding of information for future reference by administrator. Identification of other residents who may be affected: Any resident receiving skilled services from nursing or therapy services. The Administrator audited all residents who were discharged from skilled services in the past 30 days to ensure they were issued a Notice of Non-Coverage and Advanced Beneficiary Notice on 5/29/26. No non-compliance was noted. Measures for systemic change: On 5/14/2026 Business Office Manager, Director of Rehab, Minimum Data Set nurse, Director of Nursing and Social Services Director were educated on proper procedure of issuing of Notice Of Medicare Non Coverage and Advanced Beneficiary Notice by administrator. All upcoming discharges from skilled services will be reviewed weekly at Utilization Review meeting to ensure notices will be delivered timely. How Corrective Action will be monitored: Administrator or designee to complete audits of all residents being discharged from skilled services to ensure they were issued a Notice of Non-Coverage and Advanced Beneficiary. This audit will be completed weekly x 4 weeks, then monthly x 2 months. Corrective action will be initiated for any noted non-compliance. Audit findings will be reviewed as part of the monthly quality assurance process to determine the need for further monitoring. Date of Compliance 5/29/26
Insulin Administration Errors and Failure to Prime Insulin Pens
Penalty
Summary
The deficiency involves the facility’s failure to maintain a medication error rate below 5%, with surveyors identifying 3 errors out of 28 medication administration opportunities, resulting in a 10.71% error rate. For one resident with type 2 diabetes mellitus and moderate cognitive impairment, the physician’s order directed Novolog insulin 10 units via subcutaneous pen-injector to be given before meals. During an observed medication pass, the LPN administered 10 units of Novolog insulin without priming the pen and did so after the resident had already consumed approximately 50% of the breakfast meal. The LPN later confirmed she did not prime the pen and acknowledged that the insulin was ordered to be administered prior to meals. Manufacturer instructions for the Novolog FlexPen specified that an air shot (priming) must be performed before each injection to ensure proper dosing. Another resident, also diagnosed with type 2 diabetes mellitus and with intact cognition, had orders for insulin glargine 35 units subcutaneously twice daily and insulin lispro 20 units subcutaneously before meals, plus 12 units subcutaneously if blood glucose was between 251 mg/dL and 300 mg/dL. During an observed medication administration, an LPN administered 35 units of insulin glargine and 32 units of insulin lispro without priming the insulin pens and after the resident had consumed approximately 90% of the breakfast meal, despite orders for insulin lispro to be given before meals. The LPN later stated she could not remember if she had primed the pen and acknowledged that the insulin was ordered to be administered prior to meals. Manufacturer information for insulin lispro stated that the pen must be primed before each injection to confirm insulin delivery and remove air, and that failure to prime could result in too much or too little insulin. The DON confirmed the expectation that insulin be administered as ordered, including priming each pen with two units before dialing the prescribed dose, and facility policy required medications, including insulin, to be administered safely, timely, and in accordance with prescriber orders and required time frames.
Plan Of Correction
This Plan of Correction is submitted as required under State and Federal law. This Plan of Correction does not constitute an admission on the part of the Facility that the findings cited are accurate, that the findings constitute a deficiency or that the scope and severity regarding the deficiency cited are correctly applied. Any changes to the Facility's policies and procedures should be inadmissible in any proceeding on that basis. Without admitting or denying the validity or the existence of the alleged noncompliance, the Facility submits this Plan of Correction with the intention that it be inadmissible by any third party in any civil or other action against the facility or any employee, agent, officer, director or shareholder of the Facility. The Facility is utilizing this Plan of Correction as an allegation of substantial compliance as of 5/29/2026. F-0759 Corrective action for resident/s: Residents #21 and #22 were assessed and evaluated by nurse and Director of Nursing 5/14/26. Resident #21 and #22 both denied any adverse effects and none were noted upon assessment by the Director of Nursing on 5/14/2026. Notification made to physician on 5/14/2026. LPN # 2 competency Eval on insulin administration with the Director of Nursing completed 5/14/2026. Identification of other residents who may be affected: Diabetic residents on assignment of LPN #2/station 2 have the potential to be affected and were assessed by the DON/Designee on 5/14/26 and found to be within normal limits. Measures for systemic change: All Nurses were educated by the Director of Nursing on the steps for Insulin administration per competency, diabetes clinical protocol policy, Medication and treatment orders policy, administering medications policy, and Obtaining fingerstick Glucose Level policy On 5/14/2026. How Corrective Action will be monitored: Director of Nursing and Assistant Director of Nursing will complete insulin administration audits on 5 nurses. This audit will be completed weekly x 4 weeks, then monthly x 2 months. Corrective action will be initiated for any noted non-compliance. Audit findings will be reviewed as part of the monthly quality assurance process to determine the need for further monitoring. Date of Compliance: 5/29/2026
Failure to Document Tray Line Food Temperatures in Dining Room Kitchenettes
Penalty
Summary
The deficiency involves the facility’s failure to document tray line food temperatures for meals served from the Harrison and McClellan Dining Room kitchenettes, as required by professional standards for food service safety and the facility’s own policy. Review of the “Trayline Taste & Temperature Log” (revised September 2018) showed missing temperature documentation for multiple meals from the Harrison Dining Room kitchenette, including dinner on 03/30/26 and 03/31/26, lunch and dinner on 04/01/26 and 04/02/26, dinner on 04/07/26, and lunch and dinner on 04/08/26 and 04/10/26. The Senior Director of Culinary Services confirmed during interview that tray line food temperatures were not documented on the log for these meals. Similarly, review of the same log for the McClellan Dining Room kitchenette revealed that tray line food temperatures were not documented for dinner on 04/01/26, breakfast and lunch on 04/02/26, and lunch and dinner on 04/07/26. The Senior Director of Culinary Services also verified these omissions during interview. The facility census at the time was 27 residents, and the governing “Food and Nutrition” policy, approved on 09/07/21, stated that the facility must store, prepare, distribute, and serve food in accordance with professional standards for food service safety.
Plan Of Correction
F812 The facility will continue to ensure food temperatures are completed before meals are served for all residents. To ensure compliance with this standard the following measures have been taken: 1. Immediately 4/15/26 culinary supervisor #224 was re-educated by Dietary Manager to this standard and policy "Food and Nutrition" which includes documentation of food temperatures. 2. All dietary staff have been re-educated to the standard and policy "Food and Nutrition" during the month of April 2026. 3. Audits of food temperature documentation to be completed by Dietary Manager 4 x per week for 4 weeks then weekly for 4 weeks. 4. Administrator to validate audits/compliance and provide additional training as needed. Administrator will present to QAPI committee for ongoing monitoring and further direction.
Failure to Conduct and Document Required Care Conferences
Penalty
Summary
The deficiency involves the facility’s failure to complete and document comprehensive care conferences at required intervals in accordance with care plan regulations and facility policy. For one resident with Parkinson’s disease with dyskinesia, cognitive communication deficit, hemiplegia and hemiparesis following cerebral infarction, transient cerebral ischemic attack, type II diabetes mellitus, and major depressive disorder, the record showed multiple MDS assessments over a one-year period, including annual, quarterly, and significant change assessments. However, only two care conferences were documented during the last 12 months, despite the expectation that care conferences be conducted quarterly with the resident and family when possible. The Unit Care Coordinator confirmed that no additional care conference documentation existed for this resident beyond the notes dated 04/21/25 and 01/02/26. A second resident, with diagnoses including aphasia following cerebrovascular disease, cerebral infarction, type II diabetes mellitus, unsteadiness on feet, difficulty in walking, coagulation defect, depression, and muscle weakness, also had multiple MDS assessments completed over the review period, including quarterly and annual assessments. The record contained a note that a care conference was offered to the resident’s representative, who declined to attend, but there was no documentation of any care conferences for the most recent 12 months. The Unit Care Coordinator confirmed that no other care conference documentation was available for this resident. Facility policy stated that periodic care conferences involving the resident, family, and the interdisciplinary team are part of the care planning process, but the required periodic care conferences and corresponding documentation were not completed for these two residents.
Plan Of Correction
THIS PLAN OF CORRECTION SERVES AS BERKELEY SQUARE'S CREDIBLE ALLEGATION OF SUBSTANTIAL COMPLIANCE AS OF June 1, 2026. Without admitting or denying the validity or existence of the alleged deficiencies, Berkeley Square provides the following Plan of Correction: F657 The facility will continue to document completion of care conferences at the required intervals for all residents, including residents #04 & #15. To ensure compliance with this standard the following measures have be taken: 1. The social service designee and the inter- disciplinary team were re-educated by the administrator to the facility policy "Care Conference" on 4/29/26 and verbalized understanding. 2. Care conferences for resident #04 and resident #15 were conducted on or before 4/29/2026 by the interdisciplinary team. 3. Review of all other residents was conducted by the social service designee to validate and ensure that care conference schedule is up to date with timely care conferences scheduled for them on 4/15/2026. Audits of care conferences to be completed weekly for four weeks and then monthly after that by the social service designee. Documentation of the care conference including any identified concerns in the medical record. Administrator to validate audits/compliance and provide additional training as needed. Administrator will present results of these audits to QAPI committee for ongoing monitoring and further direction.
Failure to Reevaluate Blood Glucose After Treatment for Hyperglycemia
Penalty
Summary
The facility failed to ensure that a resident with diabetes received treatment in accordance with professional standards of practice when nursing staff did not reevaluate the resident's blood glucose after treatment for severe hyperglycemia. The resident, admitted with diagnoses including Alzheimer's disease, type II diabetes mellitus, and depression, had physician orders for Humalog insulin on a sliding scale before meals, Lantus insulin 25 units daily, and lisinopril 5 mg daily. The resident required extensive assistance with activities of daily living, including transfers, toileting hygiene, eating, and bathing. On the evening in question, the resident's blood glucose was documented as 532 mg/dL, and the on-call provider was notified. The provider gave a new order to administer an additional 8 units of lispro (Humalog) and to recheck the blood glucose in 30 minutes. The electronic medication administration record showed that the blood glucose of 532 mg/dL was obtained at 9:00 p.m. and that the additional 8 units of lispro were administered at 9:21 p.m. However, there was no documentation in the resident's chart that the blood glucose was rechecked after the additional insulin was given. In an interview, the DON confirmed there was no evidence of reevaluation and verified that, according to the facility's "Abnormal Blood Glucose Procedure" policy, the resident should have been reevaluated and that the evaluation step should have been included in the progress note documentation.
Plan Of Correction
F684 The facility will continue to ensure all residents, including #03, receive treatment in accordance with professional standards of practice and reevaluated for hyperglycemia. To ensure compliance with this standard the following measures have been taken: 1. The director of nursing assessed resident #03, reviewed documentation and orders and found no ill effects immediately 4/16/26. 2. All licensed nurses were re-educated to facility policy "Blood Glucose Monitoring" by the Director of Nursing/designee in April 2026. 3. Audits of like-residents that require blood sugar checks to be completed by the director of nursing/designee two times a week for 4 weeks and then monthly after that to validate correct follow through when there is abnormally high blood glucose result. The Administrator will bring results of these audits to the QAPI committee for ongoing monitoring and further direction.
Failure to Act on Pharmacist Drug Regimen Recommendation for Thyroid Medication
Penalty
Summary
The deficiency involves the facility’s failure to ensure that pharmacy recommendations from the monthly drug regimen review were acted upon and documented for a resident. The resident was admitted with diagnoses including Parkinson’s disease, dementia, and hypothyroidism, and had current physician orders for levothyroxine 150 mcg once daily, buspirone 50 mg twice daily, and losartan 100 mg once daily. A medication regimen review dated 11/25/2025 included a consultant pharmacist recommendation that levothyroxine be administered consistently in the morning on an empty stomach, at least 30–60 minutes before food, per manufacturer instructions. There was no specific physician response in the medical record to this recommendation, and the facility’s policy stated that consulting pharmacist reviews are sent to nursing and addressed with the primary care provider or consulting specialist for review and follow-up. Review of the resident’s medication administration record for April 2026 showed levothyroxine scheduled for 9:00 a.m. On observation, the resident was seen eating breakfast in the dining area at 8:03 a.m., and an LPN reported administering the levothyroxine 150 mcg to the resident while the resident was in the dining area eating breakfast. The DON confirmed there was no evidence in the resident’s medical record explaining why the consultant pharmacist’s recommendation from 11/25/2025 was or was not acted upon. This lack of documented physician review and action on the pharmacist’s identified irregularity constituted noncompliance with the drug regimen review requirements.
Plan Of Correction
F756 The facility will continue to ensure the pharmacy recommendations from the monthly drug regimen review by a licensed pharmacist are acted upon for all residents, including #08. To ensure compliance with this standard the following measures have been taken: 1. Resident #08 was assessed by the registered nurse and med review completed by 4/28/26. After review of resident's drug regime's, it was discovered that resident #8 had 2 separate medication recommendations on the same form, to be reviewed by two separate practitioners, pharmacy has been instructed and agreed to separate meds on individual forms. 2. Licensed nurses re-educated to facility policy "Drug Regimen Review" by Director of nursing/designee in April 2026 and no later than 5/8/26. Licensed nurses are responsible for ensuring the reviews and recommendations are given to the physician for timely review. 3. Review of all other current residents Drug Regimen orders completed by Director of nursing/designee on 4/16/26 to ensure recommendations were followed up on/reviewed by the physician and address concerns if needed. 4. Audit of drug regime recommendations, pharmacy recommendations, and physician follow up to be completed weekly for four weeks by the Director of nursing/designee. Administrator will present results of these audits to the QAPI committee for ongoing monitoring and further direction.
Failure to Use Required Gait Belt During Ambulation Resulting in Resident Fall
Penalty
Summary
The deficiency involves the facility’s failure to ensure that a required gait belt was used while assisting a high fall‑risk resident with ambulation, resulting in a fall with head injury. The resident had multiple diagnoses including metabolic encephalopathy, hypertension, osteoarthritis, muscle weakness, gait and mobility abnormalities, major depressive disorder, anxiety, and visual hallucinations. Admission and subsequent MDS and fall risk assessments documented that the resident was severely cognitively impaired, required moderate to maximal assistance with transfers and ambulation, could not independently come to a standing position, exhibited loss of balance while standing, used an assistive device, and had decreased muscle coordination. The resident had a history of falls prior to admission and was assessed as being at high, later moderate, risk for falls. The resident’s fall care plan identified her as at risk for falls and included interventions such as providing maximum to moderate assistance with transfers and walking short distances, use of a walker and wheelchair, and following the facility’s fall protocol. Therapy notes and care conference documentation indicated that the resident leaned backwards when standing, required contact guard to minimal assistance for bed mobility and transfers, and needed constant verbal cueing for safe sequencing during toilet transfers. The physical therapist confirmed that the resident was to use a gait belt with staff when ambulating, and the DON verified that therapy had assessed the resident as requiring contact guard assistance and a gait belt for ambulation and transfers. On the day of the incident, a CNA was assisting the resident from her recliner to the bathroom using a walker. The CNA walked beside the resident, providing guidance and support, and reported having a hand on the resident while assisting her. As they approached the bathroom door, the CNA reached for the doorknob to open it, and at that moment the resident began to lose her balance and fell backwards to the floor, striking the back of her head. The nurse who responded found the resident on her back at the foot of the bed with her feet near the bathroom, noted a red raised area on the back of the head, and documented that the resident was not wearing a gait belt and that the gait belt was on the dresser. In the facility’s investigative summary and in interviews, the CNA acknowledged that she did not have a gait belt on the resident while ambulating her, despite the resident’s assessed need for hands‑on assistance and gait belt use per facility policy and the resident’s care and therapy plans.
Failure to Implement PD Orders and Monitor Resident Receiving Peritoneal Dialysis
Penalty
Summary
The deficiency involves the facility’s failure to implement pre-admission physician orders for peritoneal dialysis (PD) and to provide ongoing monitoring for a resident with chronic kidney disease (CKD) stage five who required PD. Pre-admission orders dated 11/14/25 specified three daily PD exchanges at 6:00 A.M., 2:00 P.M., and 10:00 P.M., and directed staff to monitor for signs and symptoms of peritonitis, including fever, abdominal pain, and cloudy effluent. These monitoring orders were not entered into the facility’s physician orders. The resident’s care plan noted the need for PD and included general monitoring interventions (labs, signs of bleeding, bacteremia, septic shock, and significant vital sign changes), but did not specifically address the ordered monitoring for peritonitis. Review of PD documentation showed incomplete and inconsistent charting of treatments and resident condition. The paper peritoneal flowsheet had columns for time of PD and condition/comments, including instructions to call the nurse immediately for cloudy fluid, abdominal pain, or fever. However, the first entry on 11/15/26 at 2:00 P.M. only noted that the PD nurse completed the exchange, and the 10:00 P.M. entry that day had no condition/comment documentation. Subsequent days (11/16/25, 11/17/25, and 11/18/25) contained only one condition/comment entry per day rather than for each exchange, and there was no documentation that the 6:00 A.M. PD on 11/18/25 was completed. The PD cycler flowsheet starting 11/19/25 lacked any description of the effluent on multiple days. The PD nurse from the dialysis company stated facility staff were expected to monitor effluent for cloudiness and assess for abdominal pain and fever, and the DON confirmed there was no electronic physician order for peritonitis monitoring or for use of the PD cycler, that the paper charting did not allow for effluent description or symptom documentation for each treatment, and that PD was not documented at one ordered time. The facility’s dialysis policy required ongoing assessment and monitoring for complications before, during, and after treatments, which was not reflected in the documentation for this resident.
Improper Infection Control During Medication Administration
Penalty
Summary
Surveyors identified a deficiency in infection prevention and control related to medication administration for Resident #29. The resident was admitted on 02/28/14 with diagnoses including depression, traumatic brain injury, and anxiety, and had impaired cognition per a quarterly MDS assessment. During an observation on 03/25/26 at 6:58 A.M., RN #281 prepared the resident’s medications by removing an Amoxicillin-Pot Clavulanate tablet from the medication card and pushing it directly into her ungloved hand, then using her fingers to place the pill into a medication cup. The same process was observed for multiple other medications, including Escitalopram Oxalate, Furosemide, Sennosides, Lyrica, and Vitamin D, each being pushed from the card into the RN’s ungloved hand and then transferred by her fingers into the medication cup before administration to Resident #29. In a subsequent interview at 7:27 A.M. the same day, RN #281 confirmed she had placed each medication into her ungloved hands prior to administration and acknowledged that the proper procedure was to push the pills directly from the card into the medication cup. Review of the facility’s “Medication Administration – General guidelines” policy, revised 10/08/25, stated that medications are to be administered in accordance with good nursing principles and practices. This practice failure was cited as a deficiency under Complaint Number 2681777.
Improper Use of Wheelchair as a Physical Restraint
Penalty
Summary
Surveyors identified a deficiency related to the facility’s failure to ensure a resident was free from physical restraints. Resident #7, admitted with diagnoses including Alzheimer’s disease, diabetes mellitus, and anxiety disorder, was documented on a recent MDS as rarely understood and dependent for ADLs except eating. The resident ambulated independently on the unit without an assistive device and had documented verbal and other behaviors occurring one to three days during the look-back period. The care plan noted the resident had potential to be physically aggressive, chase staff, throw objects, and be combative with care, with interventions such as offering choices, administering medications as ordered, and intervening early when agitation occurred. During an observation and interview, Resident #7 was found sitting in a chair with the right arm of the chair positioned against the nursing station and a wheelchair placed directly in front of him. The left arm of the wheelchair was also against the nursing station, and both wheelchair wheels were locked, creating a barrier that appeared to restrain the resident, who was sleeping with his knees touching the locked wheelchair. An LPN confirmed both wheelchair wheels were locked and that the wheelchair should not have been placed in front of the resident. A CNA reported she had placed the wheelchair there in preparation to get the resident up for lunch, was unable to transfer him, and left the wheelchair in that position, acknowledging it was wrong to keep it there. The facility’s physical restraint policy stated that physical restraints are not used except when alternatives are not appropriate or effective for treating a medical symptom and defined physical restraints as any device attached or adjacent to the body that the individual cannot easily remove and that restricts freedom of movement or access to the body.
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