Ayden Healthcare Of Fairfield
Inspection history, citations, penalties and survey trends for this long-term care facility in Fairfield, Ohio.
- Location
- 3801 Woodridge Boulevard, Fairfield, Ohio 45014
- CMS Provider Number
- 365738
- Inspections on file
- 32
- Latest survey
- January 12, 2026
- Citations (last 12 mo.)
- 5
Citation history
Health deficiencies cited at Ayden Healthcare Of Fairfield during CMS and state inspections, most recent first.
Surveyors observed a shower room where a single shower chair with a fixed toilet seat had a section of PVC pipe underneath that was smeared with brown fecal matter, despite staff indicating the chair had been cleaned. An LPN confirmed the substance was feces and acknowledged that shower equipment and the room were supposed to be cleaned after each use, while the DON stated that staff providing showers were responsible for cleaning equipment between residents. This failure to maintain clean shower equipment had the potential to affect multiple residents who used the second-floor shower room.
The facility failed to notify residents and their representatives and invite them to participate in care conferences, and lacked documentation of such notifications. One resident with COPD, anxiety, hemiplegia, and osteoarthritis, who was cognitively intact and identified as full code, had a care plan calling for education of the resident and responsible party, yet neither the resident nor the power-of-attorney daughter were listed as attendees on the care conference sheet, and both reported not being informed of care conferences. Another cognitively intact resident with type 2 DM, morbid obesity, and mental health diagnoses had no record in progress notes of any care conference notification and stated he was not invited. A third resident with hypertension, COPD, stroke, and impaired cognition had a care plan requiring communication with family about needs, but progress notes showed no evidence that the resident or emergency contacts were notified of quarterly care conferences. The DON and Administrator confirmed for all three cases that there was no documentation of notifications or invitations.
A resident with type 2 DM, morbid obesity, and mental health diagnoses was admitted on insulin therapy with existing orders from a prior facility for BID blood sugar monitoring. On admission, these blood glucose monitoring orders were not transcribed into the EHR, and admission physician orders were silent regarding blood sugar checks. Active orders did not include glucose monitoring until a daily fasting blood sugar order was entered more than a month later. The DON confirmed that the monitoring order should have been transcribed at admission and that no blood sugar checks were performed for the resident during this interval.
A resident with intact cognition, hemiplegia, bowel and bladder incontinence, and a care plan requiring maximal assistance for toileting was documented as incontinent almost daily, yet the medical record lacked evidence that staff consistently provided or attempted incontinent and toileting care or recorded refusals. Electronic documentation showed multiple days when toileting tasks did not occur and other days when the resident was marked as needing only supervision, contrary to the care plan. Surveyors observed CNAs offer toileting once, after which the resident refused and no further attempts were made over more than two hours. Later, the resident was seen with visibly wet clothing and reported going outside repeatedly without staff offering toileting reminders or assistance, despite being unable to transfer independently. Leadership confirmed that documentation of offers of care, refusals, and incontinent care was incomplete and that facility ADL policy expectations for managing resisted care were not followed.
Two residents receiving antianxiety medications experienced multiple medication administration errors when staff failed to follow physician orders and facility policy. One resident with anxiety and depression had clonazepam ordered twice daily, but controlled drug records showed missed doses, incorrect dosing (splitting a 2 mg dose into two 1 mg tablets), and administration of the bedtime dose in the morning, as well as a missed morning dose when the facility lacked medication. Another resident with COPD, respiratory failure, and anxiety had Xanax ordered three times daily, yet controlled records documented doses given at inconsistent times and more frequently than ordered. The DON confirmed that these medications were not administered as ordered and that multiple errors occurred for both residents.
A resident with multiple medical conditions fell during a transfer using a Hoyer lift due to a CNA conducting the transfer alone and failing to properly secure the lift pad. The facility's protocol requires two aides for such transfers, which was not followed, leading to the resident landing on her shoulders.
A resident with a history of opioid abuse and other conditions did not receive prescribed Methadone on multiple occasions due to unavailability and lack of timely prescription processing. The facility's procedure for handling unavailable medications was not adequately followed or documented, leading to a significant medication error.
The facility failed to maintain effective pest control, with multiple observations of flies and gnats in resident rooms and the kitchen. Flies were seen on meal trays, food, and residents' sheets, confirmed by residents and staff. In the kitchen, flies were observed on the steam table and around the dishwasher, verified by dietary staff. The facility's Pest Control Policy was not effectively implemented, leading to a deficiency.
The facility did not provide resolutions for issues raised in Resident Council meetings, affecting all attending residents. Meeting minutes from over a year showed no documented resolutions. The new Activity Director could not find past resolutions, and residents reported that their complaints were not addressed. The Administrator admitted to not following up on concerns or documenting actions, despite a policy requiring a response form to track issues.
The facility failed to conduct proper medication regimen reviews for five residents, missing documentation for March 2024. Residents with various medical conditions, including cerebral infarction, diabetes, and spinal stenosis, were affected. Additionally, a delay in physician response to a pharmacy recommendation for a resident with duplicate Mirtazepine orders was noted, exceeding the facility's 30-day policy.
The facility failed to provide residents with daily menus, leaving them unaware of their meal options. Interviews with several residents revealed they did not receive menus and were unsure of their daily meals. Staff confirmed that while preferences were recorded, residents did not have access to choose from the menu, leading to a deficiency in communication and meal planning.
The facility failed to provide residents with meal alternatives, affecting several residents who were unable to choose different meals if they disliked the ones served. Observations and interviews revealed a lack of posted alternative menus and staff unawareness of available options. In one case, a resident requested a hot dog but received a hamburger due to unavailability, highlighting a disconnect between the facility's policy and its implementation.
The facility's kitchen was found to be unsanitary, with a large puddle of dirty water under the dishwasher and a dusty vent above the steam table. Ceiling tiles near the steam table were drooping and discolored due to a leaking roof. These issues were confirmed by dietary staff, and the facility's policy required maintaining cleanliness and sanitation in dining and food service areas.
The facility failed to maintain essential kitchen equipment, affecting nearly all residents. Observations revealed a non-functional garbage disposal, leaking dishwasher, broken oven and refrigerator, and a malfunctioning three-compartment sink. Dietary staff confirmed these issues, with the dishwasher leaking for months and requiring a wet vacuum for drainage. Rags were used to keep the sink filled, and the broken oven and refrigerator remained in the kitchen.
The facility failed to provide adequate nutritional care to several residents, leading to significant weight loss and unimplemented dietary recommendations. Residents did not receive prescribed supplements during meals, and weekly weights were not documented as ordered. The facility ran out of dietary supplements, and the Registered Dietitian confirmed concerns about the implementation of dietary recommendations and weight monitoring.
The facility failed to serve meals at safe and palatable temperatures, affecting nearly all residents. Observations showed that food temperatures dropped significantly from the kitchen to the residents, with items like chicken and mashed potatoes falling to 100°F. Breakfast trays were delayed in distribution, resulting in scrambled eggs and grits being served at unpalatable temperatures. The Dietary Supervisor confirmed these deficiencies, which violated the facility's policy requiring hot food to be served at a minimum of 135°F.
The facility failed to maintain a clean and homelike environment, with residents reporting sticky floors, rust in showers, and cobwebs. A resident's room had a strong urine odor and a damaged mattress, while another room had food debris and exposed wall space. Staff confirmed these issues, indicating inadequate cleaning practices.
The facility failed to maintain accurate advance directives for two residents, resulting in unclear code status for one and incomplete admission documentation for another. This was confirmed by the DON and Regional Director of Clinical Services, indicating a breach in the facility's policy on advance care planning.
A facility failed to hold care conferences for a resident with multiple diagnoses, including diabetes and dementia, as required. The resident had not had a care conference documented in over a year, despite needing assistance with daily activities. Interviews confirmed the absence of care conferences, contrary to the facility's policy.
A resident with impaired vision and feeding difficulties did not receive necessary assistance with meals, leading to significant food spillage. Despite a care plan requiring meal assistance, staff set up meals and left the resident unattended, failing to provide the needed support.
The facility failed to invite residents to participate in activities, affecting three residents who expressed interest but were not invited. Despite care plans indicating a risk for alteration in activity participation, observations showed no activities taking place as scheduled, and staff interviews revealed a lack of effort in inviting residents. The facility's policy to promote well-being through activities was not effectively implemented.
The facility failed to supervise residents and store smoking materials properly, affecting resident safety. A resident with cognitive impairment was left unattended after a fall, while two others had smoking materials in their rooms against policy. Smoking areas lacked safety equipment, and staff did not adhere to supervision requirements.
A facility failed to maintain communication with a dialysis center for a resident requiring dialysis. Despite the resident's care plan and facility policy mandating communication forms for each dialysis visit, many forms were missing over a three-month period. The ADON confirmed the lapse in completing required documentation, which was against the facility's policy for ensuring safe and coordinated care.
A resident in a facility was affected by inaccurate documentation of medication administration, with duplicate orders for several medications. The MAR showed discrepancies in the administration of Potassium, Tamsulosin, and Omeprazole. Staff interviews confirmed the errors, with an LPN acknowledging the documentation inaccuracies and the DON recognizing the need to correct duplicate orders.
The facility did not conduct 90-day evaluations for STNAs, affecting all residents. Personnel records for two STNAs showed no evidence of evaluations, and the HR Director confirmed they were not completed due to her being new to the position.
The facility did not post daily staffing information for residents and visitors, affecting all 66 residents. An RN confirmed the absence of the staffing posting in its usual location, and it remained unposted throughout the morning.
Unclean Shower Chair and Inadequate Cleaning Practices in Shower Room
Penalty
Summary
Surveyors found that the facility failed to ensure the second-floor shower room equipment was clean and in good repair for residents who used that area. Observation of the shower room revealed a single shower chair with a non-movable toilet seat, and under the seat was a section of white PVC pipe covered with brown smeared matter. An LPN confirmed that the chair had been cleaned and verified that the brown smeared matter was fecal matter, and also stated that the shower room and equipment were supposed to be cleaned after each use. In a separate observation and interview, the DON stated that staff providing showers were responsible for cleaning the equipment between residents. This deficiency had the potential to affect 17 identified residents who used the second-floor shower room. The facility census at the time was 72 residents, and the issue was investigated under a specific complaint number related to this non-compliance.
Failure to Notify Residents and Representatives of Care Conferences
Penalty
Summary
The deficiency involves the facility’s failure to notify residents or their representatives and invite them to participate in care conferences, as required for development and review of the comprehensive care plan. For one resident with COPD, anxiety, hemiplegia, abnormal posture, and bilateral osteoarthritis, the quarterly MDS showed intact cognition and a need for assistance with ADLs, and the care plan identified the resident as full code with interventions including education of the resident and responsible party and review of advance directives. The face sheet listed the resident as responsible party and identified an emergency contact with power of attorney, yet the care conference signature sheet did not include the resident or representative, and progress notes over several months contained no documentation that the family was notified of the quarterly care conference. The resident reported that only once had the facility called the daughter to talk by phone and otherwise had not invited them to care conferences, and the daughter confirmed she had not received information regarding care conferences. The DON acknowledged awareness that the family wanted notification and that they had reported not being notified of recent care conferences, and the Administrator confirmed there was no documentation of notifications or invitations. For a second resident with type 2 diabetes mellitus, morbid obesity, depressive disorder, panic disorder, and anxiety, the admission MDS showed intact cognition and a need for set-up assistance with eating, toileting, bed mobility, and transfers. Progress notes over several weeks were silent regarding any notification to the resident or representative about participation in care conferences. The DON and Administrator both verified there was no documentation of notification or invitation for this resident, and the resident stated he was not notified of or invited to participate in a care conference. For a third resident with hypertension, COPD, and stroke, the quarterly MDS showed impaired cognition and a need for assistance with eating, bed mobility, transfers, and toileting; the care plan noted impaired cognitive functioning and included interventions to communicate with the resident and family regarding capabilities and needs. The face sheet listed the resident as responsible party with three emergency contacts, but progress notes over several months contained no documentation that the resident or representative was notified of the quarterly care conference. The resident stated the facility would let his family know if something was going on with his health but could not recall receiving notification of care conferences or invitations to participate. The DON and Administrator again verified there was no documentation of notification or invitations for this resident.
Failure to Transcribe and Implement Blood Glucose Monitoring Orders
Penalty
Summary
The facility failed to follow physician orders for blood glucose monitoring for one resident with type 2 diabetes mellitus, morbid obesity, depressive disorder, panic disorder, and anxiety. The resident was admitted from another LTC facility with a discharging physician order dated 10/01/25 for blood sugar monitoring two times a day. The admission MDS showed the resident had intact cognition, required setup assistance for eating, toileting, bed mobility, and transfers, and received insulin injections during the assessment period. However, review of the admission physician orders dated 10/31/25 showed no order for blood sugar monitoring, and the active physician orders did not include blood glucose checks until an order for a daily fasting blood sugar was written on 12/04/25. On interview, the DON confirmed that the blood sugar monitoring order from the prior facility was not transcribed into the electronic health record at admission and acknowledged that it should have been. The DON also verified that no blood sugar checks were completed for this resident from admission until 12/04/25, when the daily fasting blood sugar order was entered. This failure to transcribe and implement blood glucose monitoring orders resulted in the resident not receiving ordered blood sugar checks during that period, as identified under Complaint Number 2662752.
Failure to Provide and Document Toileting and Incontinent Care for Dependent Resident
Penalty
Summary
The deficiency involves the facility’s failure to ensure staff consistently offered and documented incontinent and toileting care, including refusals, for a dependent resident with bowel and bladder incontinence. The resident had diagnoses including COPD, anxiety, hemiplegia, hemiparesis, abnormal posture, and bilateral osteoarthritis, with intact cognition and a care plan indicating maximal assistance for toileting hygiene using a stand-up lift with two staff. The care plan also included interventions such as application of barrier cream after perineal care, use of disposable briefs, and monitoring for UTIs. The physician orders contained no specific toileting orders. Electronic health record review showed the resident was incontinent daily over a one‑month period with only four continent episodes, and behavior documentation was silent for any refusals or rejection of care. Toileting task documentation showed multiple days where the task was marked as not occurring, and several days where the resident was documented as completing toileting tasks with only supervision, despite the care plan indicating a need for maximal assistance. On the day of surveyor observation, two CNAs offered to take the resident to the toilet, and the resident refused; no further attempts to provide care were observed over the following 2 hours and 15 minutes. The ADON and DON confirmed that toileting documentation for the resident was incomplete, that nurses’ notes lacked detail about what care was refused, and that there was no other documentation showing staff offers of toileting assistance or refusals, despite daily documentation of incontinence without corresponding incontinent care entries. Later that day, the resident was observed wearing jeans with a large wet area from the perineal area to mid‑thighs and reported having been in and out of the facility all day to smoke, stating that staff did not come outside to remind or offer toileting and that she could not transfer herself from the wheelchair to the commode due to left‑sided weakness. Review of the facility’s Activities of Daily Living policy showed that staff were expected to attempt alternative approaches when residents resist care, but this was not followed as written for this resident.
Multiple Medication Administration Errors with Antianxiety Drugs
Penalty
Summary
The deficiency involves the facility’s failure to ensure medications were administered in accordance with physician orders and its own medication administration policy for two residents receiving antianxiety medications. One resident with type 2 diabetes, morbid obesity, depressive disorder, panic disorder, and anxiety had intact cognition and required setup assistance for activities of daily living. This resident had physician orders for clonazepam 1 mg every morning and 2 mg every night. Record review showed clonazepam was generally documented on the MAR as given twice daily in November, but the controlled narcotic count sheets revealed multiple missed and incorrect doses. The 1 mg morning dose was not administered on a specific date when the last available tablet had been given the prior evening, and a refill was pending. The 2 mg bedtime dose was not signed out as administered on several dates, and on another date the resident received two separate 1 mg doses at bedtime instead of the ordered 2 mg tablet. Additionally, the 2 mg clonazepam dose was signed out as administered in the morning on multiple dates, contrary to the bedtime order. The resident reported receiving clonazepam on one night but not at the correct dose and stated the facility did not have the ordered morning dose the following day while waiting for a new prescription. Another resident with chronic obstructive pulmonary disease, respiratory failure, and an anxiety disorder, and with impaired cognition, had an order for Xanax 1 mg by mouth three times daily for anxiety. The MAR for this resident showed Xanax as administered as ordered, but the controlled drug administration record documented administration at times and frequencies that did not match the three-times-daily order. On multiple dates, Xanax 1 mg was given four times in a day or at times inconsistent with the ordered schedule. In interviews, the DON confirmed that for both residents, clonazepam and Xanax were not administered as ordered and that multiple medication administration errors occurred. Review of the facility’s “Administration Procedures for all Medication” policy indicated staff were required to complete the five rights of medication administration, but the facility failed to follow this policy in these instances.
Improper Mechanical Lift Transfer Leads to Resident Fall
Penalty
Summary
The facility failed to ensure proper transfer procedures using a mechanical lift, specifically a Hoyer lift, for a resident. The resident, who was cognitively intact and required substantial assistance for daily activities, experienced a fall during a transfer. The resident's medical history included conditions such as cerebral infarction, hemiplegia, epilepsy, and major depressive disorder. During the incident, the resident was being transferred from a wheelchair to a bed when the CNA, who was alone, did not properly secure the Hoyer pad, resulting in the resident falling backward and landing on her shoulders. The facility's investigation revealed that the CNA conducted the transfer without assistance, which was against the protocol that required two aides to be present for mechanical lift transfers. The Director of Nursing confirmed that the CNA admitted to performing the transfer alone and that the resident reported being dropped due to improper clipping of the Hoyer pad. The incident was documented in a progress note and a post-fall evaluation, both indicating the lack of adherence to safety procedures during the transfer.
Failure to Administer Methadone as Prescribed
Penalty
Summary
The facility failed to administer Methadone as prescribed to a resident, resulting in a significant medication error. The resident, who had a history of paraplegia, opioid abuse, auditory hallucinations, delusional disorders, and congestive obstructive pulmonary disease, was admitted with an order for Methadone 10 mg to be given every 12 hours for pain. However, the medication was not administered on several occasions, specifically on 11/13/24 at 9:00 P.M., 11/23/24 at 9:00 A.M. and 9:00 P.M., 11/24/24 at 9:00 A.M. and 9:00 P.M., and 11/25/24 at 9:00 A.M. and 9:00 P.M. The nursing notes indicated that the Methadone was unavailable and required a signed prescription, which was sent to the physician but not promptly returned. The Director of Nursing confirmed that the medication was not administered as ordered and explained the procedure for when medications are unavailable, which includes checking the Pyxis machine and notifying the practitioner. However, there was a lack of documentation regarding these actions in the resident's record, contributing to the deficiency.
Pest Control Deficiency in Facility
Penalty
Summary
The facility failed to maintain effective pest control, as evidenced by multiple observations of flies and gnats in resident rooms and the kitchen area. On several occasions, flies were seen crawling on meal trays and landing on food, tray tables, and residents' sheets. Residents confirmed the persistent presence of flies and gnats, which interfered with their ability to eat meals without insects landing on their food. Staff members, including a State Tested Nursing Assistant (STNA), also acknowledged the issue, indicating a widespread problem throughout the facility. In the kitchen, flies were observed flying and landing on the steam table during tray line service, and around the dishwasher and three-compartment sink. These observations were verified by the Dietary Supervisor and a Dietary Aide. The facility's Pest Control Policy, dated August 2016, emphasizes the importance of pest control in maintaining a safe and healthy living environment for residents. However, the facility's failure to adhere to this policy resulted in a deficiency that was investigated under specific complaint numbers.
Failure to Provide Resolutions for Resident Council Meetings
Penalty
Summary
The facility failed to ensure that resolutions were provided to residents following Resident Council meetings, potentially affecting all residents who attended these meetings. A review of the Resident Council Minutes from August 28, 2023, through August 30, 2024, showed that while meetings were held, no resolutions to the problems discussed were documented. An interview with the Activity Director (AD) revealed that she had been in her position for three weeks and could not find any resolutions for past meetings. During a Resident Council Meeting, two residents expressed that although meetings were held, their complaints were not addressed, and they did not receive feedback on their concerns in subsequent meetings. The Administrator confirmed that she had not followed up on all concerns from the meetings and had not documented any actions taken. The facility's policy required the use of a Resident Council Response Form to track issues and resolutions, but this process was not followed.
Failure in Medication Regimen Reviews and Physician Response
Penalty
Summary
The facility failed to conduct proper medication regimen reviews by a licensed pharmacist as required, affecting five residents. For Residents #27, #44, #57, #51, and #13, the facility could not provide evidence of a medication regimen review being completed for March 2024. Interviews with the Director of Nursing (DON) confirmed the absence of these reviews, indicating a lapse in the facility's adherence to its medication review policies. Resident #27, with multiple medical diagnoses including cerebral infarction and epilepsy, was found to have no documented medication review for March 2024. Similarly, Resident #44, diagnosed with conditions such as diabetes mellitus type II and Alzheimer's disease, also lacked evidence of a medication review for the same month. Resident #57, who had severe cognitive impairment and a history of chronic conditions like congestive heart failure and myocardial infarction, was similarly affected by the absence of a documented review. Additionally, Resident #51's case highlighted a delay in physician response to a pharmacy recommendation. The resident, with diagnoses including spinal stenosis and feeding difficulties, had a pharmacy recommendation to discontinue a duplicate order for Mirtazepine, which was not reviewed by the physician until 38 days later, exceeding the facility's policy of a 30-day response time. Resident #13, with a range of diagnoses including type two diabetes mellitus and vascular dementia, also had no documented medication review for March 2024, further underscoring the facility's failure to comply with its medication review protocols.
Failure to Provide Residents with Daily Menus
Penalty
Summary
The facility failed to ensure that residents were informed about their daily meals, as evidenced by interviews and observations involving six residents. These residents reported not receiving menus and being unaware of what meals they would be served each day. Observations confirmed the absence of menus in their rooms. This issue was identified during interviews conducted over several days, with residents expressing their lack of knowledge about their meal plans. Staff interviews revealed that the dietary manager and nursing staff were responsible for gathering residents' food preferences and ensuring meals were served according to the menu. However, it was noted that residents did not have the opportunity to choose from the menu, and there was no system in place to provide them with daily menus. This lack of communication and transparency regarding meal options contributed to the deficiency identified by the surveyors.
Failure to Provide Meal Alternatives
Penalty
Summary
The facility failed to ensure that residents were able to choose alternative meals, affecting six out of eight residents reviewed for food alternatives. Observations and interviews revealed that there were no postings for meal alternatives, and residents were not provided with options if they did not like the meals served. Several residents, including Resident #59, #64, #4, #38, #58, and #319, reported being unable to choose from an alternative menu, and no alternatives were observed in their rooms. Staff members, including an LPN and an STNA, were unaware of where the list of alternatives was located, and it was confirmed that it was not posted for residents to see. Additionally, a new admission, Resident #319, did not receive the alternative menu upon admission. In another instance, an STNA delivered a meal tray to a resident who requested an alternative meal. The STNA informed the resident that hamburgers and hot dogs were available as alternatives, but upon returning, only a hamburger was provided as the kitchen did not have hot dogs available. The residents involved confirmed they did not want a hamburger but ate it due to uncertainty about other available options. The facility's policy on offering food replacements at meal times was reviewed, revealing that the director of food and nutrition services is responsible for maintaining a list of meal alternates, which should be provided to the nursing staff. However, the nursing staff was not aware of the available alternatives.
Sanitation Deficiency in Kitchen
Penalty
Summary
The facility failed to maintain a clean and sanitary kitchen, which had the potential to affect 65 out of 66 residents, as one resident had not consumed food from the kitchen. During an observation of the kitchen, a large puddle of dirty water was found bubbling and pooling under the dishwasher, extending to the middle of the walkway between the dishwasher and the three-compartment sink. This was verified by a dietary aide present at the time. Additionally, a dusty vent was observed above the steam table where food is served, and ceiling tiles near the steam table were drooping and discolored. The dietary director confirmed these observations and stated that a leaking roof caused the issues with the ceiling tiles. A review of the facility's undated policy on cleaning and sanitation revealed that staff were expected to maintain the cleanliness and sanitation of dining and food service areas.
Kitchen Equipment Malfunction
Penalty
Summary
The facility failed to ensure that essential kitchen equipment was functioning properly, which had the potential to affect 65 out of 66 residents. Observations made on September 18, 2024, revealed several issues in the kitchen, including a non-functional garbage disposal, a leaking dishwasher, a broken oven and refrigerator, and a three-compartment sink that did not fill and drain properly. Interviews with the dietary staff confirmed these malfunctions. The Dietary Aide mentioned that the dishwasher had been leaking for months, requiring the use of a wet vacuum to drain the sink. The Dietary Supervisor reported that rags were used to keep the sink filled, and the Dietary Director confirmed the broken oven and refrigerator, as well as the non-functional garbage disposal, necessitating the use of trash cans or a wet vacuum for food waste cleanup.
Failure to Provide Adequate Nutritional Care
Penalty
Summary
The facility failed to provide adequate nutritional care and services to prevent a decline in the nutritional status of several residents. Resident #20 experienced significant weight loss and was supposed to receive a health shake three times a day as per physician orders. However, observations revealed that the resident did not receive the prescribed nutritional supplements during meals, and there were no records of weekly weights being obtained as recommended by the Registered Dietitian. The facility had run out of dietary supplements, and the Director of Nursing confirmed that the recommendations for re-weighing and obtaining weekly weights were not implemented. Resident #51 also experienced significant weight loss and was ordered to receive supplements such as Magic Cup and Boost with meals. Observations showed that these supplements were not provided during meals, and weekly weights were not documented as ordered. The facility's dietary staff failed to supply the necessary supplements, and the Registered Dietitian confirmed concerns about the implementation of dietary recommendations and weight monitoring. Resident #44 was ordered a regular diet with double portions and house supplements due to weight loss concerns. However, observations indicated that the resident was served single portions without the required supplements. Similar issues were noted for Resident #3 and Resident #34, where nutritional recommendations, including supplements and weekly weights, were not implemented. Interviews with the Registered Dietitian and the Director of Nursing confirmed the facility's failure to follow through with nutritional care plans and recommendations.
Failure to Serve Meals at Safe and Palatable Temperatures
Penalty
Summary
The facility failed to ensure that meals were palatable and served at appropriate temperatures, affecting 65 out of 66 residents. Observations and interviews with several residents revealed that the food was often cold and not cooked properly. On one occasion, meal temperatures were recorded before the start of meal service, showing that the chicken thigh, mashed potatoes, and green beans were initially at safe temperatures of 184, 183, and 181 degrees Fahrenheit, respectively. However, a subsequent test tray observation showed these items had dropped to 100 degrees Fahrenheit, which was verified by the Dietary Supervisor as below the required 135 degrees Fahrenheit. Additionally, the rice served was found to be undercooked, as confirmed by the Dietary Supervisor. Further observations highlighted delays in meal service, with breakfast trays left unattended in the hallway for an extended period. The meal cart was observed sitting at the end of the hallway without staff present to distribute the trays promptly. It took several minutes before staff began passing out the trays, resulting in scrambled eggs and grits being served at temperatures of 80 and 98 degrees Fahrenheit, respectively. These temperatures were confirmed by the Dietary Supervisor to be unpalatable for residents. The facility's policy required all hot food items to be served at a minimum of 135 degrees Fahrenheit, which was not adhered to in these instances.
Facility Fails to Maintain Clean and Homelike Environment
Penalty
Summary
The facility failed to maintain a clean and homelike environment for its residents, as evidenced by numerous observations and interviews. Residents reported sticky floors, rust in showers, peeling wallpaper, and cobwebs in their rooms. Several rooms had issues with water damage, improper sealing of windows, and broken blinds. Maintenance and housekeeping staff confirmed these observations, indicating a lack of proper upkeep and cleaning in the facility. In one instance, a resident's room was found to have a strong odor of urine and a mattress with large cuts on its surface. Despite multiple observations over several days, the room's condition remained unchanged, and the Director of Nursing verified the issues. This suggests a failure to address basic hygiene and maintenance needs in a timely manner. Another room shared by two residents was observed to have a large amount of food debris on the floor, black film, and dirt in various areas. The cobase behind one resident's bed had fallen off, exposing the empty space behind the wall. A State tested Nursing Assistant confirmed the room's unclean state, highlighting the facility's inadequate cleaning practices.
Failure to Ensure Accurate Advance Directives
Penalty
Summary
The facility failed to ensure accurate advance directives were in place for two residents, leading to a deficiency in honoring residents' rights to make decisions about their care. For one resident, the medical record showed conflicting information regarding their code status, with both a Do Not Resuscitate (DNR) order and a full code status present in different parts of the record. This discrepancy was confirmed by the Director of Nursing, indicating a lack of clarity in the resident's advance directive documentation. Another resident's records revealed that the facility did not complete the necessary screening for advance directives upon admission. The resident's electronic health record indicated a full code status, but there was no documentation in the paper chart to confirm the resident's preferences or any completed admission documents. This oversight was verified by the Regional Director of Clinical Services, highlighting a failure to adhere to the facility's policy on advance care planning and documentation.
Failure to Hold Required Care Conferences
Penalty
Summary
The facility failed to hold care conferences as required, affecting one resident. Resident #13, who was admitted with multiple diagnoses including type two diabetes mellitus, myasthenia gravis, cardiac murmur, and vascular dementia, had not had a care conference documented in over a year. The quarterly Minimum Data Set (MDS) assessment indicated that Resident #13 had moderately impaired cognition and required assistance with various activities of daily living. Interviews with the resident and the Director of Nursing confirmed the absence of care conferences for months, despite the facility's policy stating that care plan meetings should be scheduled at convenient times for residents and their families.
Failure to Assist Resident with Meals
Penalty
Summary
The facility failed to provide timely and necessary assistance with meals to a resident, identified as Resident #51, who required limited assistance due to impaired vision and feeding difficulties. The resident, who had diagnoses including spinal stenosis and serous retinal detachment, was observed on multiple occasions struggling to eat meals independently. Despite having a care plan that included interventions such as explaining tray setup using a clock as a guideline and offering assistance with meals, these measures were not adequately implemented. On several occasions, Resident #51 was observed eating with his fingers or using a regular fork, resulting in significant food spillage on his lap and the floor. Staff members, including a State tested Nursing Assistant (STNA), were noted to set up meals and leave the resident without providing the necessary assistance, despite the resident's confirmed inability to see well enough to feed himself without dropping food. This lack of assistance was confirmed by an STNA who acknowledged the resident's visual impairment and feeding difficulties.
Failure to Invite Residents to Activities
Penalty
Summary
The facility failed to ensure that residents were invited and able to participate in activities outside of their rooms, affecting three residents. Resident #38, who was cognitively intact and dependent on transfers, expressed a desire to participate in activities but was not invited. His care plan indicated a risk for alteration in activity participation, with interventions to familiarize him with the nursing home environment and activity programs. However, his activity participation documentation only included computer, news, and television, and he stated he needed a slide board to get out of bed. Resident #58, also cognitively intact and requiring a two-person assist for transfers, was not invited to activities despite expressing interest. Her care plan similarly noted a risk for alteration in activity participation. Resident #319, who required limited assistance for transfers, was not assessed for activities and had not been invited to participate. Observations revealed no activities taking place as scheduled, and staff interviews indicated a lack of effort in inviting residents to participate. The facility's policy emphasized promoting residents' well-being through activity programming, but this was not effectively implemented.
Inadequate Supervision and Smoking Policy Violations
Penalty
Summary
The facility failed to provide adequate supervision and proper storage of smoking materials for two residents, leading to potential safety hazards. Resident #27, who has a history of cerebral infarction, epilepsy, and other medical conditions, was observed with multiple smoking materials in her room, despite her care plan requiring these to be kept at the nurse's station. Additionally, the designated smoking areas lacked necessary safety equipment, such as fire extinguishers, and Resident #27, a supervised smoker, was found smoking unsupervised in an area designated for independent smokers. Resident #44, who has severe cognitive impairment and a history of repeated falls, was found on the floor in the dining/activity room without staff assistance for eight minutes. Despite multiple staff members walking by, no one responded until a surveyor intervened. The resident was eventually assessed and sent to the emergency room, where no significant injuries were found, but a skin tear was treated upon return. Resident #65, who is cognitively intact, was observed with smoking materials in his room, contrary to the facility's smoking policy that requires such items to be stored at the nurse's station. Although the resident claimed to be an unsupervised smoker, a staff member later confirmed that smoking materials should be kept at the nursing station. These incidents highlight lapses in supervision and adherence to smoking policies, affecting the safety and well-being of the residents involved.
Failure to Maintain Communication for Dialysis Care
Penalty
Summary
The facility failed to maintain proper communication between the facility and the dialysis center for a resident who required dialysis services. The resident, who had diagnoses including pleural effusion, dependence on renal dialysis, and moderate protein-calorie malnutrition, was admitted to the facility and assessed to have moderately impaired cognition. The care plan indicated that the resident was to attend dialysis sessions on specific days of the week. However, a review of the dialysis communication forms revealed that forms were only completed for a few of the dialysis appointments attended by the resident over a three-month period. The Assistant Director of Nursing confirmed that the facility's policy required the completion of dialysis communication forms for each dialysis appointment, which was not adhered to in this case. The facility's policy, reviewed in August 2024, emphasized the importance of collaboration with the dialysis center and required an assessment of the resident before and after each dialysis visit. Despite this policy, numerous communication forms were missing, indicating a lapse in the facility's adherence to its own procedures for ensuring safe and coordinated dialysis care.
Medication Administration Documentation Deficiency
Penalty
Summary
The facility failed to ensure accurate documentation of medications administered to a resident, which was identified during an annual survey. This deficiency affected one resident who had duplicate medication orders for Guaifenesin, Glucagon, Loperamide, Omeprazole, Potassium, and Tamsulosin. The resident, who had diagnoses including spinal stenosis, serous retinal detachment of the right eye, and feeding difficulties, was assessed to have intact cognition. The Medication Administration Record (MAR) showed that Potassium and Tamsulosin were documented as being administered twice at the same time each day, and Omeprazole was documented as being administered at both 6:00 A.M. and 7:30 A.M. each day. Interviews with staff confirmed the discrepancies in medication administration. An LPN confirmed that only one dose of Potassium and Tamsulosin was administered, despite documentation indicating two doses. Additionally, the LPN confirmed that Omeprazole was administered and documented twice due to shifts overlapping. The Director of Nursing acknowledged the presence of duplicate orders for the medications and confirmed the need for correction.
Failure to Conduct 90-Day Evaluations for STNAs
Penalty
Summary
The facility failed to ensure that State tested Nurse Aides (STNA) received a 90-day evaluation, affecting all residents in the facility with a census of 66. Personnel records for two STNAs, both hired on the same date, showed no evidence of a 90-day evaluation being conducted. An interview with the Human Resource Director confirmed that the evaluations had not been completed, as she was new to the position.
Failure to Post Daily Staffing Information
Penalty
Summary
The facility failed to ensure that daily staffing information was posted for residents and visitors to view, which had the potential to affect all 66 residents residing in the facility. On the morning of September 15, 2024, an observation revealed that no daily staffing information was posted in the facility. A subsequent observation and interview with a registered nurse confirmed that the plastic holder, where the staffing information is usually placed, was empty, and the nurse was unable to locate the staffing posting to place in the holder. Further observation later that morning confirmed that the staffing information had still not been posted in the designated holder or any other conspicuous area of the facility.
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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