Avenue At Brooklyn
Inspection history, citations, penalties and survey trends for this long-term care facility in Brooklyn, Ohio.
- Location
- 4700 Idlewood Drive, Brooklyn, Ohio 44144
- CMS Provider Number
- 366495
- Inspections on file
- 17
- Latest survey
- June 2, 2025
- Citations (last 12 mo.)
- 0
Citation history
Health deficiencies cited at Avenue At Brooklyn during CMS and state inspections, most recent first.
A resident with type 1 diabetes and multiple comorbidities reported low blood glucose to a CNA, who provided a snack but failed to notify the nurse or monitor the resident further. The nurse did not verify blood glucose readings or perform required rounds throughout the night. The resident was later found unresponsive by a family member, and resuscitation was unsuccessful. Staff did not follow policies for reporting, assessment, or monitoring of changes in condition, resulting in the resident's death.
Three residents experienced lapses in dignity and respect, including being left exposed in bed, having an uncovered drainage bag visible from the hallway, and receiving a meal tray placed next to a full urinal. Staff observed these situations but did not take appropriate action to maintain resident dignity, despite facility policy requiring such standards.
Surveyors found that the facility did not maintain a medication error rate below 5%, with three errors observed among twenty-nine opportunities. Errors included an LPN crushing and administering the wrong form of Aspirin to a resident, a resident missing a scheduled dose of Phenobarbital due to unavailability, and an RN administering a chewable Aspirin tablet not in accordance with the physician's order. These actions were not consistent with facility policy requiring medications to be given as prescribed.
A resident with epilepsy and other medical conditions experienced multiple missed doses of prescribed Phenobarbital due to medication unavailability, incomplete documentation, and staff not utilizing available medication in the facility's automated dispensing system. Staff interviews and record reviews confirmed that the medication was not administered as ordered, and facility policy for medication administration was not followed.
The facility failed to maintain cleanliness and sanitation in the kitchen and nursing unit refrigerators, as observed during a survey. Issues included oil spills, food debris, and grease stains in various areas, as well as unlabeled food items and standing water in a refrigerator. The Mobile Dietary Manager verified these findings, which were contrary to the facility's sanitation policy.
The facility failed to maintain a sanitary dumpster area, potentially affecting all 105 residents. Observations revealed open dumpster lids, a trash bag on the ground, and scattered debris, including an empty cigarette package and used latex gloves. The Mobile Dietary Manager confirmed the observation, noting maintenance was responsible for the area. Facility policy required the area to be clean and debris-free.
The facility's arbitration agreement failed to include a clause allowing residents or their representatives to communicate with federal, state, or local officials, affecting all residents. This omission was confirmed by a corporate nurse during an interview.
The facility's arbitration agreement failed to ensure a neutral and fair process for residents by mandating arbitration through the National Arbitration Forum (NAF) and not allowing other counsel except the American Arbitrators Association (AAA). The agreement also lacked provisions for selecting a neutral arbitrator or venue, affecting all 105 residents. This was confirmed by a review of records and an interview with a corporate nurse.
The facility failed to provide trauma-informed and culturally competent care to five residents with PTSD, as there were no assessments or care plans documented in their medical records. Despite the facility's policy requiring such documentation, it was confirmed by the Regional Director that no evidence of compliance existed.
A resident with a history of diabetes and related complications did not receive a timely ENT referral after an audiologist recommended it due to hearing issues. The Social Services Director was responsible for scheduling but failed to ensure the referral was completed, and the Director of Nursing was unaware of the issue until months later.
A facility failed to maintain consistent communication with a dialysis center for a resident requiring dialysis services. The resident, with complex medical conditions including type I diabetes and end-stage renal disease, had missing dialysis communication forms for two months, despite physician orders requiring regular completion. The DON confirmed the deficiency, acknowledging the lapse in communication as per facility policy.
A resident received incorrect medication dosages due to errors in administration by an LPN, leading to a medication error rate of 13.8%. The resident, with a history of multiple medical conditions, was given 400 mg of magnesium oxide instead of the prescribed 500 mg, and other medications lacked specified dosages. The facility's policy on medication administration was not followed.
A facility failed to ensure proper communication between the facility and hospice services for a resident admitted with a stroke and pneumonia. The resident's POA reported a lack of updates on hospice services and medical care. The hospice contract did not specify a designated staff member or hospice representative for coordination of care, nor did it provide medical director information. The hospice agreement stated the resident's right to know caregivers and receive effective communication.
A resident with multiple health conditions experienced a delay in receiving incontinence care due to staffing shortages. The resident waited 53 minutes for assistance after using the call light, as staff were occupied with other duties and one aide was unavailable due to a fire watch. The resident was eventually found with a heavily wetted brief, though no skin damage was observed.
The facility failed to provide the required SNF ABN to three residents before discontinuing their skilled services under Medicare Part A. A resident with dementia, another with fractures and dementia, and a third with end-stage renal disease and diabetes did not receive the necessary financial liability notices. This was confirmed by a social worker who acknowledged the oversight.
A CNA improperly handled soiled linens after providing incontinence care to a resident by discarding them into a trash can and then carrying them unbagged against her body to the utility room. This was against the facility's policy, which required contaminated laundry to be bagged at the point of collection. The resident had multiple medical conditions and was always incontinent, requiring assistance for toileting and hygiene.
A resident with multiple diagnoses, including osteomyelitis, did not receive all prescribed IV antibiotics due to lapses in administration and documentation. Despite having RNs on duty, several doses of Vancomycin and Zosyn were missed, and communication issues among staff contributed to the deficiency. The facility's policy required proper documentation and administration, which was not followed, leading to a deficiency.
The facility did not maintain RN coverage for eight consecutive hours on two days, potentially affecting all 96 residents. This was confirmed by reviewing nursing schedules and an interview with the HR Director.
A resident experienced a cardiac emergency, and the facility failed to provide effective CPR. The resident was found vomiting and later lost consciousness. An LPN initiated CPR on the resident's mattress without a backboard or ambu bag, compromising the effectiveness of the chest compressions. The crash cart was not immediately accessible, arriving only when EMS did. The resident, who had a Full Code status, was transferred to the hospital and subsequently expired.
A facility failed to provide timely care for two residents experiencing changes in condition. One resident, with a history of diabetes and dementia, showed difficulty swallowing and became unresponsive, yet the physician was not notified, and medications were improperly administered. Another resident experienced high blood pressure and rapid breathing, but the physician was not informed, and oxygen therapy was mismanaged. These failures violated the facility's Change in Condition Policy, leading to Immediate Jeopardy for one resident.
An LPN in a long-term care facility failed to clean and disinfect a shared glucometer between uses for multiple residents with diabetes mellitus. The facility's policy required cleaning before and after each use to prevent infection transmission, but the LPN did not adhere to this, using the same glucometer for three residents without cleaning it. The LPN confirmed the lack of cleaning, stating she would clean the device at the end of her shift.
The facility failed to provide timely toileting and incontinence care, affecting several residents. One resident waited over an hour for bathroom assistance, leading to soiling herself, while another wore improperly fitted briefs due to a lack of appropriate sizes. A third resident, needing help with toileting, was left unattended despite repeated calls for assistance. Staffing issues contributed to these deficiencies, with police involvement due to unresponsive staff.
Two residents in a LTC facility experienced significant medication errors. One resident with a seizure disorder did not receive their prescribed vimpat due to unavailability, while another resident with diabetes received insulin after eating, contrary to physician orders. The LPN involved admitted to checking blood sugar levels during or after meals, leading to incorrect insulin administration. Facility policy on medication administration was not followed.
The facility failed to securely administer medications, leaving pills unattended on bedside tables for residents unable to self-administer. Staff interviews confirmed this practice, and the facility's policy lacked guidance on monitoring residents during medication administration.
The facility failed to ensure phone calls were timely answered and addressed when transferred to nursing staff, potentially affecting all residents. A resident's daughter reported that her calls were not answered or returned. Observations and staff interviews confirmed that nursing staff were occupied with residents and unable to answer phone calls, and messages left by the BOM were not returned. The Administrator acknowledged that this issue had been previously discussed in staff meetings.
A resident with hemiplegia reported an incident where an STNA refused to give her the bed remote control, leading to a physical struggle and derogatory comments. Despite the resident's daughter communicating the incident to the DON, no immediate action was taken, and the DON failed to properly identify herself when addressing the issue, leaving the resident feeling unsupported and disrespected.
The facility failed to implement their abuse policy after a resident reported an incident involving a state tested nurse aide (STNA). Despite the resident's daughter communicating the incident to the Director of Nursing (DON) via text, no immediate action was taken to investigate or address the allegation. The alleged perpetrator continued to work shifts, and the investigation was delayed, breaching the facility's abuse prohibition policy.
A resident reported an incident involving two STNAs, where one STNA refused to give her the bed remote control, leading to a physical altercation and derogatory comments. The incident was communicated to the DON via text by the resident's daughter, but no immediate action was taken to investigate or report the incident. The facility's self-reported incident was not created until after surveyor intervention, indicating a delay in reporting the abuse allegation to the state agency.
A resident with hemiplegia and hemiparesis reported an incident where an STNA wrestled with her over a bed remote control, threw the remote at her, and made derogatory comments. Despite the resident's daughter communicating the incident to the DON via text, the DON did not initiate an investigation or speak to the resident until the following day. The facility failed to immediately suspend the alleged perpetrators and start an investigation, contrary to their abuse prohibition policy.
The facility failed to consistently get a resident with severe cognitive impairment out of bed, despite his medical history and care plan indicating the need for frequent engagement. Staff interviews revealed inconsistencies in care, with some STNAs unwilling to get the resident up and a lack of awareness among LPNs about the resident's recent activities.
The facility failed to ensure a resident with severe cognitive impairments and multiple diagnoses was consistently provided with activities that met his needs. Despite having a care plan that included music and reading, the resident was often observed lying in bed without engagement, and staff interviews revealed inconsistencies in following the care plan.
Failure to Respond to Acute Change in Condition for Diabetic Resident
Penalty
Summary
A deficiency occurred when staff failed to timely identify and respond to an acute change in condition for a resident with type 1 diabetes, chronic kidney disease, and other significant comorbidities. The resident, known to be a brittle diabetic, activated her call light during the night and reported to a CNA that her blood glucose was low and requested a snack. The CNA provided a snack but did not notify the nurse on duty of the resident's report of low blood glucose, nor did she return to check on the resident after the initial interaction. No further nursing assessment or monitoring was performed for the resident throughout the night. The nurse on duty, an LPN, had last seen the resident earlier in the evening when administering scheduled medications and insulin, relying solely on the resident's verbal report of her blood glucose reading from a continuous glucose monitoring device, without verifying the reading herself. The LPN did not make any rounds or assessments of the resident for the remainder of the night shift. The resident was not checked on again until her husband arrived in the morning and found her unresponsive, not breathing, and without a pulse. Resuscitative efforts were initiated, and EMS was called, but the resident was pronounced deceased at the facility. During the code, a blood glucose check revealed a critically low reading. Interviews and record reviews confirmed that staff failed to follow facility policy regarding timely reporting and assessment of changes in condition, as well as routine rounding and verification of blood glucose readings, directly contributing to the resident's lack of care and subsequent death.
Failure to Maintain Resident Dignity and Respect
Penalty
Summary
The facility failed to ensure that residents were treated with respect and dignity, as evidenced by multiple observations and interviews involving three residents. One resident, who was alert and oriented but required assistance with activities of daily living (ADLs) due to physical impairments, was observed lying in bed uncovered and naked from the waist down, visible from the hallway. A CNA who noticed the situation did not intervene, stating the resident was not assigned to her care, and confirmed the resident's exposed state. Another resident, who was alert but cognitively impaired and dependent on staff for ADLs, was observed sitting in her room with her cholecystostomy drainage bag exposed and visible from the hallway. The resident reported that her drainage bag was never covered. An LPN confirmed that elimination bags should be covered for resident dignity and verified the observation at the time. A third resident, with quadriplegia and other significant medical conditions, required staff assistance for ADLs. A CNA delivered this resident's breakfast tray and placed it next to a urinal that was three-quarters full of urine, then left the room without emptying the urinal. The resident expressed discomfort with eating near the full urinal and stated he would not eat his breakfast because of it. The CNA and the LPN/Unit Manager both confirmed that the urinal should have been emptied before placing the meal tray nearby. Facility policy requires the maintenance of residents' personal dignity, well-being, and self-determination.
Medication Error Rate Exceeds Acceptable Threshold
Penalty
Summary
The facility failed to maintain a medication error rate below 5%, with three errors observed out of twenty-nine opportunities, resulting in a 10.34% error rate. For one resident with Alzheimer's Disease, chronic kidney disease, and hypertension, a physician order specified Aspirin 81 mg delayed release, not to be crushed. However, an LPN crushed and administered a chewable Aspirin 81 mg tablet instead, contrary to the order. Another resident with a history of femur fracture, diabetes, epilepsy, and failure to thrive did not receive a scheduled dose of Phenobarbital 32.4 mg in the morning because the medication was not available in the narcotic drawer, and the nurse confirmed it could not be administered as ordered. A third resident, diagnosed with malignant neoplasm, secondary bone neoplasm, fibromyalgia, and chronic kidney disease, was ordered to receive Aspirin 81 mg by mouth in the morning. During medication administration, an RN provided a chewable Aspirin 81 mg tablet, which the resident swallowed, and later confirmed this was not in accordance with the physician's order. In all cases, facility policy required medications to be administered as per written physician orders, but these were not followed, leading to the cited deficiency.
Failure to Administer Seizure Medication as Ordered
Penalty
Summary
The facility failed to ensure that a resident was free from significant medication errors, specifically regarding the administration of Phenobarbital for seizure control. The resident, who had diagnoses including epilepsy, left femur fracture, type 2 diabetes mellitus, and adult failure to thrive, had multiple missed doses of Phenobarbital as ordered by the physician. Review of the medication administration records (MAR) for May revealed nine missed morning doses and four missed bedtime doses, with documentation inconsistencies and incomplete nursing notes regarding the reasons for the missed doses. In several instances, the medication was not available in the facility, and pharmacy delivery delays or prescription issues were cited, but not always clearly documented. Observations confirmed that the medication was not present in the locked narcotic drawer during medication pass, and staff interviews revealed a lack of awareness and follow-up regarding the missed doses. The nurse practitioner was not informed of the extent of the missed doses and expressed concern, noting that the medication is critical for seizure prevention. Further review indicated that the medication was actually available in the facility's AlixaRX system and could have been administered, but this resource was not utilized by staff. Facility policy requires medications to be administered in accordance with physician orders and established schedules, but these protocols were not followed in this case. The resident's Phenobarbital blood level was found to be at the lower end of the therapeutic range, and the facility's own records showed that the medication was available but not accessed. The deficiency was substantiated by interviews, record reviews, and direct observation, confirming that the resident was not protected from significant medication errors as required.
Sanitation Deficiencies in Kitchen and Refrigerators
Penalty
Summary
The facility failed to maintain the kitchen and nursing unit refrigerators in a clean and sanitary manner, as observed during a survey. During an initial tour of the kitchen, several issues were noted, including a large oil spill under a container of cooking oil, food debris on top of the oven, and an oven mitt on the floor. The deep fryer had food crumbs and grease stains, and the floor beneath it had a brownish substance and food crumbs. Shelves under the steam table, which held clean steam table pans, had various crumbs and food debris. The reach-in freezer and refrigerator under the steam table contained food debris, and a sliced tomato and lettuce leaf were found wrapped in saran without a date or label. Additionally, the side of the steam table had crumbs and food debris, and a container holding utensils had food debris and stains. An unattached tubing for the juice/pop machine was on the floor, and the ice machine had a moderate amount of dried whitish substance on its exterior. Further observations revealed that the reach-in refrigerator near the juice/pop machine had standing water inside, and there was food splatter on the doors of the refrigerator. The nursing unit refrigerator had a dried reddish substance on the bottom of the freezer and running down the inside door. These findings were verified by the Mobile Dietary Manager, who acknowledged the issues, including the lime buildup on the ice machine. The facility's policy on general sanitation of the kitchen, which was undated, stated that food and nutrition services staff would maintain kitchen sanitation through compliance with a written comprehensive cleaning schedule.
Unsanitary Dumpster Area
Penalty
Summary
The facility failed to maintain the outside dumpster area in a sanitary condition, which had the potential to affect all 105 residents. During an observation, two dumpsters were found with their lids open, and a large clear trash bag was on the ground next to one of the dumpsters. Additionally, various trash items, including an empty cigarette package and several used latex gloves, were scattered on the ground around and between the dumpsters. An interview with the Mobile Dietary Manager confirmed the observation and indicated that maintenance was responsible for the upkeep of the dumpster area. The facility's undated policy on Trash Handling stated that outside dumpsters and their surrounding areas should be kept clean and free of debris.
Arbitration Agreement Lacks Required Communication Clause
Penalty
Summary
The facility failed to ensure its arbitration agreement contained all required information, affecting all residents with a census of 105. Upon reviewing the facility's admission packet, it was found that the arbitration agreement and requirements were included on pages nine and ten of the admission agreement. However, the agreement did not state that residents or their representatives could communicate with federal, state, or local officials, including federal and state surveyors, health department employees, and representatives of the Office of the State Long-Term Care Ombudsman. This omission was confirmed during an interview with Corporate Nurse #999, who acknowledged that the agreement should have included this information.
Lack of Neutral Arbitration Process in Facility Agreements
Penalty
Summary
The facility failed to provide a neutral and fair arbitration process for its residents. The arbitration agreement, included in the admission packet on pages nine and ten, mandated arbitration through the National Arbitration Forum (NAF) and did not allow residents or their representatives to seek other counsel except the American Arbitrators Association (AAA) for binding arbitration disputes. Additionally, the agreement lacked provisions for selecting a neutral arbitrator or a mutually agreed-upon venue for arbitration proceedings. This deficiency affected all 105 residents of the facility, as confirmed by a review of resident medical records and an interview with Corporate Nurse #999, who verified the absence of information related to a neutrally agreed-upon arbitrator or venue in the agreement.
Failure to Provide Trauma-Informed and Culturally Competent Care
Penalty
Summary
The facility failed to provide trauma-informed and culturally competent care to residents diagnosed with PTSD, affecting five residents. These residents, who had various cognitive impairments and required different levels of assistance with activities of daily living, did not have any assessments, care plans, or documentation related to their trauma diagnoses or culturally competent care in their medical records. This lack of documentation was confirmed by the Regional Director during an interview. The facility's policy on Trauma Informed Care, dated October 4, 2022, mandates the completion of assessments to identify residents with mental and psychosocial disorders, including PTSD, and the development of resident-specific care plans addressing cultural preferences. However, the facility did not adhere to this policy, as evidenced by the absence of relevant documentation for the affected residents.
Failure to Schedule ENT Referral for Resident
Penalty
Summary
The facility failed to ensure a timely referral for an ear, nose, and throat (ENT) appointment for a resident, which was identified during a review of records and interviews. The resident, who had a history of type I diabetes mellitus with multiple complications, including diabetic retinopathy and neuropathy, was seen by an audiologist who recommended an ENT consult due to asymmetrical hearing loss, tinnitus, and dizziness. This recommendation was communicated to the Social Services Director (SSD), who was responsible for scheduling the appointment. However, the referral process was not completed as expected. The SSD stated that the referral was passed to a nurse, but she was unsure which nurse received it, and no appointment was made. The Director of Nursing (DON) was only made aware of the issue months later and was uncertain about the referral's status since it occurred before her tenure at the facility. This oversight affected the resident's access to necessary ENT services, as no appointment was scheduled following the audiologist's recommendation.
Failure in Dialysis Communication for a Resident
Penalty
Summary
The facility failed to ensure consistent communication between the facility and the dialysis center for a resident requiring dialysis services. This deficiency was identified through a review of medical records, staff interviews, and facility policy and procedures. The resident involved had multiple complex medical conditions, including type I diabetes mellitus with various complications, chronic pancreatitis, hypotension, cardiomegaly, dependence on renal dialysis, end-stage renal disease, and epilepsy. The resident was noted to have intact cognition and was independent with activities of daily living, receiving dialysis as part of their care. The deficiency was specifically related to the lack of completed dialysis communication forms, which are essential for maintaining ongoing communication and collaboration with the dialysis facility. The physician orders required that dialysis monitoring forms be completed every day shift on Mondays, Wednesdays, and Fridays. However, the review revealed missing communication forms for January and February 2025, despite having forms completed in the previous months. The Director of Nursing confirmed the absence of these forms, acknowledging the deficiency in maintaining proper communication as per the facility's policy revised in December 2022.
Medication Administration Errors Result in High Error Rate
Penalty
Summary
The facility failed to administer medications as ordered, resulting in a medication error rate above 5%. During an observation of medication administration for a resident, an LPN prepared and administered medications that did not match the prescribed orders. Specifically, the resident was given 400 mg of magnesium oxide instead of the prescribed 500 mg. Additionally, the orders for vitamin D-3, cranberry, and Gas-X did not specify the correct dosages, leading to further medication errors. The resident involved had a medical history that included a femur fracture, major depressive disorder, dementia, and a gastric ulcer. The errors were confirmed through an interview with the LPN, who acknowledged the discrepancies between the administered medications and the prescribed orders. The facility's medication administration policy, which emphasizes the five rights of medication administration, was not adhered to, resulting in four errors out of 29 observed opportunities, equating to a 13.8% error rate.
Lack of Communication Between Facility and Hospice Services
Penalty
Summary
The facility failed to provide appropriate and timely ongoing communication between the facility and hospice services for Resident #63, who was one of three residents reviewed for hospice services. Resident #63 was admitted to hospice services with diagnoses including a stroke affecting the left side and pneumonia. The resident's power of attorney (POA) reported a lack of communication between the facility and hospice services, stating that the facility did not designate a staff member to address the resident's medical care and did not provide updates on hospice services or the resident's medical condition. The review of Resident #63's hospice contract revealed that it did not specify a designated staff member, hospice representative, or medical director information for coordination of care and communication between the hospice provider and the facility. The Regional Nurse confirmed that the hospice contract lacked this information. The hospice agreement stated that the resident and/or guardian has the right to know who the caregivers are, their professional titles, and their roles, as well as the right to effective verbal and written communication.
Delayed Incontinence Care Due to Staffing Shortages
Penalty
Summary
The facility failed to provide timely incontinence care for a resident, identified as Resident #22, who was occasionally incontinent and required substantial assistance for toileting. The resident, who had a history of cerebral infarction, hemiplegia, hemiparesis, HIV disease, aphasia, and neurogenic bowels, reported waiting up to 30 minutes for assistance after using the call light. On one occasion, the resident's call light was observed to be on for 53 minutes before receiving incontinence care, during which time multiple staff members entered and left the room without providing the necessary care. The delay in care was attributed to staffing shortages, as confirmed by a CNA who was responsible for over 20 residents and noted that the facility was working short-staffed with only four aides available. The CNA mentioned that one aide was unavailable due to a fire watch requirement. The resident was eventually found with a heavily wetted brief, although there was no clear evidence of moisture-related skin damage. This incident was part of a broader investigation under specific complaint numbers.
Failure to Provide Required SNF ABN Notices
Penalty
Summary
The facility failed to provide the required Skilled Nursing Facility Advance Beneficiary Notice of Non-coverage (SNF ABN) to three residents prior to the discontinuation of their skilled services under Medicare Part A. This deficiency affected three residents, each with significant medical conditions. Resident #85, diagnosed with dementia, protein malnutrition, and high blood pressure, was discharged from skilled services and returned to his community residence. Resident #95, with diagnoses including fractures of both femurs, dementia, and visual hallucinations, transitioned to hospice services at the facility. Resident #304, suffering from end-stage renal disease, type two diabetes, and major depressive disorder, was discharged and returned to her community residence. A review of their financial liability notices revealed that none of these residents received the SNF ABN as required. This was confirmed during an interview with Social Worker #400, who acknowledged that the forms were not provided to the residents as mandated.
Improper Handling of Soiled Linens by CNA
Penalty
Summary
The facility failed to ensure proper handling and transport of soiled linens after providing incontinence care to Resident #37. During an observation, CNA #300 was seen discarding a urine-soaked brief and soiled washcloths, towels, and draw sheets into a trash can lined with a plastic bag. CNA #300 then used gloved hands to retrieve the soiled linens from the trash can, cradled them in her bare arm against her chest, and carried them unbagged into the hallway to the soiled utility room. This action was contrary to the facility's policy, which required contaminated laundry to be bagged or contained at the point of collection and not held close to the body during transport. Resident #37, who was cognitively intact, had a range of medical conditions including cerebral infarction, atherosclerotic heart disease, and flaccid hemiplegia, and was always incontinent of bowel and bladder, requiring assistance for toileting and hygiene. Interviews with CNA #300 and CNA #359 confirmed the improper handling of soiled linens, with CNA #300 stating there were not enough plastic bags available and that staff were not allowed to bring soiled linen barrels to resident rooms. The deficiency was identified during a complaint investigation and had the potential to affect additional residents receiving care from CNA #300.
Failure to Administer IV Antibiotics as Ordered
Penalty
Summary
The facility failed to ensure that all intravenous (IV) antibiotics were administered to a resident as ordered by the physician. The resident, who was admitted with multiple diagnoses including osteomyelitis, pressure ulcers, and quadriplegia, was receiving antibiotic therapy as part of their treatment plan. However, a review of the medical records revealed that several doses of Vancomycin and Zosyn were not documented as administered on multiple occasions in November and December. The medication administration records (MAR) and progress notes lacked evidence of administration for specific dates and times, indicating a failure to follow the physician's orders. Interviews with nursing staff, including Licensed Practical Nurses (LPNs) and the Director of Nursing (DON), confirmed the lapses in medication administration. LPNs reported that there were instances when no Registered Nurse (RN) was available to administer the IV antibiotics, leading to missed doses. The DON acknowledged communication issues among staff regarding RN availability for IV administration and confirmed that there were RNs on duty during some of the times when doses were missed. However, the DON could not verify that all undocumented doses had been administered, as there was no documentation to support this. The facility's policy on medication administration required that medications be administered according to prescriber orders and documented in the MAR by the administering nurse. The policy also stipulated that staff should not end their work duty without ensuring all administered medications were documented. The failure to adhere to these guidelines resulted in a deficiency, as the facility did not ensure that the resident received their prescribed IV antibiotics as ordered, and there was a lack of documentation to confirm administration.
Failure to Maintain RN Coverage
Penalty
Summary
The facility failed to ensure the presence of a registered nurse (RN) for at least eight consecutive hours a day, seven days a week, as required by regulations. This deficiency was identified through a review of nursing schedules and an interview with the Human Resources Director. Specifically, there was no RN coverage for eight consecutive hours on two days, 08/31/24 and 09/01/24, which had the potential to affect all 96 residents residing in the facility. The Human Resources Director confirmed the lack of RN coverage on these dates during an interview conducted on 09/11/24.
Failure to Provide Effective CPR During Cardiac Emergency
Penalty
Summary
The facility failed to provide effective cardiopulmonary resuscitation (CPR) to a resident who experienced a cardiac emergency. During the incident, the resident was found vomiting and later lost consciousness and pulse. Licensed Practical Nurse (LPN) #207 initiated CPR on the resident while she was still on her mattress, which decreased the effectiveness of the chest compressions. Additionally, there was a failure to provide mechanical ventilation as the ambu bag was not available, and the crash cart was not immediately accessible. The staff's response to the emergency was inadequate, as LPN #206 left the room to call 911, and State Tested Nursing Assistant (STNA) #310 left to have another LPN print transfer documents instead of assisting with CPR. STNA #310 was unable to locate the crash cart promptly, and it only arrived at the resident's room simultaneously with the Emergency Medical Services (EMS). The absence of a backboard and ambu bag during the CPR attempt compromised the quality of care provided to the resident. The resident, who had a Full Code status, was admitted to the facility for surgical aftercare following digestive system surgery and was cognitively intact. Despite the staff's efforts, the resident remained without a pulse or respirations upon EMS arrival and was subsequently transferred to the hospital, where she expired. The facility's failure to ensure the availability of necessary emergency equipment and adequately trained staff to perform CPR effectively resulted in Immediate Jeopardy and actual harm to the resident.
Failure to Respond to Residents' Change in Condition
Penalty
Summary
The facility failed to timely identify and provide adequate care for a resident who experienced an acute change in condition. The resident, who had a history of type two diabetes mellitus, unspecified dementia, aneurism of the ascending aorta without rupture, and hypertension, began showing signs of difficulty swallowing and had their diet downgraded to pureed. Despite these changes, the physician was not notified, and no nursing assessments or monitoring were completed. Over the course of two days, the resident's oral intake was poor, and they eventually became unresponsive. A nursing assistant found the resident unresponsive and notified an LPN, who failed to assess the resident or notify the physician. The LPN continued to administer medications by placing them in the resident's mouth despite their unresponsive state. Another resident experienced a change in condition characterized by high blood pressure, rapid respirations, and shortness of breath, requiring oxygen therapy outside of physician-ordered parameters. The resident's condition was not typical, and the LPN on duty failed to notify the physician of the change in condition. The resident's oxygen was set at a higher level than ordered, and the LPN did not adjust it or notify the physician. The LPN only notified another LPN, who also did not inform the physician or nurse practitioner of the resident's condition. The facility's failure to follow its Change in Condition Policy and Procedure resulted in Immediate Jeopardy for one resident and a significant deficiency for another. The lack of timely assessments, monitoring, and physician notification contributed to the residents' deteriorating conditions. The facility's policy required prompt notification of the physician and responsible party when a resident experienced a significant change in condition, but this was not adhered to in these cases.
Failure to Disinfect Shared Glucometer
Penalty
Summary
The facility failed to ensure proper infection prevention and control practices were followed during blood glucose monitoring. Specifically, a shared glucometer was not cleaned and disinfected between uses for different residents. This deficiency was observed during medication administration by an LPN, who used the same glucometer for multiple residents without cleaning it between uses. The LPN confirmed that the glucometer was not cleaned before, between, or after use for three residents, and stated that she would clean it at the end of her shift. The deficiency affected three residents who were observed for blood sugar assessment, all of whom had a diagnosis of diabetes mellitus. The facility's policy required that glucometers be cleaned and disinfected before and after each use to prevent infection transmission. However, the LPN did not adhere to this policy, as confirmed by her actions and statements. The facility's policy was reviewed, and it was noted that the glucometer should be cleaned with a disinfectant wipe and allowed to sit for five minutes between uses.
Inadequate Incontinence Care and Staffing Issues
Penalty
Summary
The facility failed to provide timely and appropriate toileting and incontinence care for several residents, leading to significant distress and discomfort. One resident, who was cognitively intact, reported having to wait over an hour for assistance to use the bathroom, resulting in soiling herself. The staff was understaffed due to a no-show nurse, and the resident's daughter had to call the police for a wellness check after multiple unanswered calls to the facility. The police confirmed the resident's call light had been on for an extended period without response, and the facility was unable to provide call log audits for the incident. Another resident, who was always incontinent of urine, reported discomfort due to the facility not providing the correct size of incontinence briefs. The staff had to use multiple smaller briefs, which were bulky and uncomfortable for the resident. Observations confirmed the resident was wearing multiple improperly fitted briefs, and the staff acknowledged the lack of appropriately sized briefs, leading to the use of multiple smaller ones. A third resident, who required assistance with toileting, was observed sitting in her doorway, repeatedly calling for help. The toilet in her bathroom was covered with diarrhea, and despite her requests, staff did not assist her promptly. An STNA left the resident's room without providing help, and the resident attempted to clean the bathroom herself. Eventually, an LPN was requested to assist, finding the resident sitting on the toilet unassisted. This incident was part of a broader issue, as the police had received multiple calls from the facility regarding unresponsive staff.
Medication Administration Errors in LTC Facility
Penalty
Summary
The facility failed to ensure that residents were free from significant medication errors, affecting two residents. Resident #6, who was moderately cognitively impaired and had a seizure disorder, did not receive the prescribed morning dose of vimpat due to the medication being unavailable. The LPN responsible for administering the medication confirmed that she did not know why the medication was unavailable, and the Medication Administration Record corroborated that the dose was missed. Resident #8, also moderately cognitively impaired and diagnosed with diabetes mellitus, received insulin outside of the physician-ordered parameters. The LPN checked Resident #8's blood sugar after the resident had already consumed part of her breakfast, which was contrary to the physician's order to check blood sugar levels before meals. The LPN admitted to performing blood sugar checks during or after meals, which led to the administration of insulin based on incorrect timing. The facility's policy on medication administration was not adhered to, contributing to these errors.
Medication Administration Deficiency
Penalty
Summary
The facility failed to securely administer medications according to professional standards, affecting four residents. Observations revealed that medication cups containing pills were left unattended on bedside tables for residents who were either asleep or unable to self-administer medications. Specifically, Resident #78 had six pills left on her table, which she could not reach, despite having an order not to self-administer medications. Resident #18 also had six pills left unattended, with no orders allowing self-administration, and an assessment indicating she could not safely self-administer medications. Resident #54 had two pills left unattended, with an order prohibiting self-administration. Resident #84 had five pills left on her table and required applesauce to swallow her medication, which was not provided, despite an order against self-administration. Interviews with staff confirmed these practices. RN #401 admitted to leaving medications at the bedside, believing it necessary as many residents would not take their pills before breakfast. He was unaware of any orders or assessments regarding the residents' ability to self-administer medications. The Director of Nursing confirmed that nurses were supposed to monitor residents during medication administration. A review of the facility's medication administration policy revealed it did not specify the need for nurses to observe residents when administering medications. This deficiency was investigated under Complaint Numbers OH00154232 and OH00154160.
Failure to Answer and Return Phone Calls
Penalty
Summary
The facility failed to ensure phone calls were timely answered and addressed when transferred to nursing staff, potentially affecting all residents. Resident #42's daughter reported that her calls to the facility were transferred to the nurse's station but were never answered, and her messages were not returned. An observation confirmed that calls to the nursing station were not answered, and messages left by the Business Office Manager (BOM) were not returned. Interviews with nursing staff revealed that they were occupied with residents and unable to answer phone calls. The BOM confirmed that written messages were left at the nurses' station, and the Administrator acknowledged that this issue had been previously discussed in staff meetings. This deficiency was investigated under Complaint Number OH00152016.
Failure to Treat Resident with Dignity and Respect
Penalty
Summary
The facility failed to treat Resident #24 with dignity and respect during an incident involving two State Tested Nurse Aides (STNAs). Resident #24, who has hemiplegia and hemiparesis following a cerebral infarction, reported that one STNA refused to give her the bed remote control, leading to a physical struggle over the remote. The STNA then threw the remote at Resident #24 and made derogatory comments, which were laughed at by the second STNA. This incident left Resident #24 tearful and upset, feeling humiliated and disrespected. Despite the resident's daughter communicating the incident to the Director of Nursing (DON) via text, no immediate action was taken to address the concern. The daughter had been at the facility for an extended period without anyone coming to discuss the incident with her or Resident #24. When the DON finally addressed the issue, she did not identify herself properly to Resident #24, leading to further confusion and distress for the resident. The facility's policy on abuse prohibition, which includes physical, mental, and verbal abuse, was not adhered to in this case. The DON's failure to properly communicate and address the resident's and her daughter's concerns exacerbated the situation, leaving Resident #24 feeling unsupported and disrespected. The lack of documentation in the nursing progress notes further indicates a failure in proper reporting and follow-up on the incident.
Failure to Implement Abuse Policy
Penalty
Summary
The facility failed to implement their abuse policy after allegations of staff-to-resident abuse involving a resident with hemiplegia and hemiparesis following a cerebral infarction. The resident, who was cognitively intact and usually understood, reported an incident where a state tested nurse aide (STNA) wrestled with her over a bed remote control, threw the remote at her, and made derogatory comments. Despite the resident's daughter communicating the incident to the Director of Nursing (DON) via text, no immediate action was taken to investigate or address the allegation on the same day. The DON confirmed awareness of the text messages but did not initiate an investigation or speak to the resident until the following day. The facility's policy required immediate assessment and protection of the resident, removal of the alleged perpetrator, and timely reporting of the incident to the state agency. However, the alleged perpetrator continued to work shifts after the incident, and the investigation was delayed. Interviews with the DON and review of facility time sheets confirmed the presence of the two STNAs involved in the incident on the specified dates. The facility's failure to timely report the allegation, suspend the alleged perpetrators, and start an immediate investigation constituted a breach of their abuse prohibition policy. This deficiency was identified during a complaint investigation and affected one resident out of three reviewed for abuse, with a facility census of 98.
Failure to Timely Report Abuse Allegation
Penalty
Summary
The facility failed to timely report an allegation of staff-to-resident abuse to the state agency, affecting one resident. Resident #24, who was cognitively intact and had hemiplegia and hemiparesis following a cerebral infarction, reported an incident involving two state-tested nurse aides (STNAs) on a Sunday night. The resident claimed that one STNA refused to give her the bed remote control, leading to a physical altercation where the STNA threw the remote at her and made derogatory comments. The incident was communicated to the Director of Nursing (DON) via text by the resident's daughter, but no immediate action was taken by the DON to investigate or report the incident on the same day. The DON received a text message from the resident's daughter on the following day, detailing the incident and requesting a meeting. Despite acknowledging the message, the DON did not speak to the resident or her daughter until the next morning. The facility's self-reported incident (SRI) was not created until after surveyor intervention, indicating a delay in reporting the abuse allegation to the state agency. The facility's policy requires all alleged violations of abuse to be reported immediately, but this protocol was not followed. Interviews with the DON confirmed that the two STNAs involved were identified, and one of them continued to work shifts after the incident. The facility's failure to timely report the abuse allegation and initiate an investigation violated their own abuse prohibition policy, which mandates immediate reporting of such incidents. The deficiency was identified during a complaint investigation, highlighting a significant lapse in the facility's response to abuse allegations.
Failure to Timely Investigate Allegation of Staff-to-Resident Abuse
Penalty
Summary
The facility failed to timely investigate an allegation of staff-to-resident abuse involving a resident with hemiplegia and hemiparesis following a cerebral infarction. The resident, who was cognitively intact and usually understood, reported an incident where a state-tested nurse aide (STNA) wrestled with her over a bed remote control, threw the remote at her, and made derogatory comments. The resident's daughter communicated the incident to the Director of Nursing (DON) via text, but the DON did not initiate an investigation or speak to the resident until the following day. The resident's daughter expressed her concerns to the DON through text messages, indicating that her mother had been involved in a fight with an aide. Despite receiving these messages, the DON did not take immediate action to investigate the allegation or ensure the resident's safety. The DON confirmed that she was aware of the text messages and the allegation but did not speak to the resident or her daughter until the next day, delaying the investigation process. Interviews with the DON revealed that the two STNAs involved in the incident were not immediately suspended, and an investigation was not promptly initiated. The facility's policy on abuse prohibition requires immediate assessment and protection of the resident, notification of the attending physician and legal responsible party, and interviews with all involved parties. The facility failed to adhere to these guidelines, resulting in a delay in addressing the abuse allegation and ensuring the resident's safety.
Inconsistent Care for Resident with Severe Cognitive Impairment
Penalty
Summary
The facility failed to ensure that Resident #57 was consistently gotten out of bed, affecting one of three residents reviewed for activities of daily living. Resident #57, who has diagnoses including encephalopathy, gastrostomy, dysphagia, pneumonia, blindness in the left eye, and a genetic-related intellectual disability, was observed lying in bed on multiple occasions without attempts to engage or communicate with him. The resident's medical record indicated severe cognitive impairment and a preference for not being touched due to irritability and discomfort. Despite a care meeting discussing the importance of getting Resident #57 up frequently, observations revealed that he was often left in bed with minimal interaction or engagement from staff. Interviews with various staff members, including State Tested Nurse Aides (STNAs) and Licensed Practical Nurses (LPNs), revealed inconsistencies in the care provided to Resident #57. Some staff members admitted that whether the resident was gotten out of bed depended on which STNA was working, with some STNAs unwilling to get him up. It was noted that Resident #57 never refused to get up and was rarely taken to any activities or out of his room when he was up. The Unit Manager and other LPNs were unsure of the last time Resident #57 was out of bed, indicating a lack of consistent care and attention to his needs. This deficiency was investigated under Master Complaint Number OH00152261 and Complaint Number OH00152016.
Failure to Provide Consistent Activities for Resident
Penalty
Summary
The facility failed to ensure Resident #57 was consistently provided with activities that met his needs. Resident #57, who has diagnoses including encephalopathy, gastrostomy, dysphagia, pneumonia, blindness in the left eye, and a genetic-related intellectual disability, was observed lying in bed on multiple occasions without engaging in any activities. Despite having a care plan that included activities he enjoyed, such as listening to music and having books read to him, these activities were not consistently provided. The resident's cognitive skills for daily decision-making were severely impaired, and he was rarely or never understood, making it crucial for the facility to adhere to his care plan to meet his needs. Interviews with staff revealed inconsistencies in getting Resident #57 out of bed and engaging him in activities. The State Tested Nurse Aide (STNA) mentioned that it depended on which STNA was working whether the resident got up or not, and that he never went to any activities. The Activities Director admitted to trying music but not reading books to the resident, and noted that the resident was on the room visits list but had not been consistently engaged. The Unit Manager was also unsure when the resident was last out of bed. These observations and interviews indicate a failure to provide Resident #57 with the necessary activities to meet his needs, as outlined in his care plan.
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.
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