Ayden Healthcare Of Greenville
Inspection history, citations, penalties and survey trends for this long-term care facility in Greenville, Ohio.
- Location
- 243 Marion Drive, Greenville, Ohio 45331
- CMS Provider Number
- 365532
- Inspections on file
- 25
- Latest survey
- December 4, 2025
- Citations (last 12 mo.)
- 14
Citation history
Health deficiencies cited at Ayden Healthcare Of Greenville during CMS and state inspections, most recent first.
Staff did not allow a food processor to air dry after sanitizing before use, placed food in the still-wet processor, and served sandwiches below the required hot holding temperature. Additionally, silverware was handled without gloves, with mouth-contact surfaces touched during tray preparation, contrary to facility policy.
Surveyors found that several opened eye drop bottles and ointments were either missing open dates or being used beyond the recommended four-week period after opening. LPNs confirmed these issues during interviews, and the deficiency affected multiple residents whose medications were stored on the observed medication carts.
A resident was found to have a made bed with a top blanket containing two large, light brown stains. The resident did not know the origin of the stains and expressed not wanting dirty bedding. A CNA confirmed the bed was made with the stained blanket.
A resident who was fully dependent on staff was found with a hematoma and blood on her pillow, and staff were unable to explain the cause of the injury. There were inconsistencies in staff accounts regarding who assisted with the resident's transfer, and the assigned LPN did not immediately assess the injury, deferring to the DON. The facility did not follow its abuse policy, which required immediate assessment and documentation for injuries of unknown origin.
A resident who was dependent on staff for all ADLs and had multiple chronic conditions was found with a hematoma and blood on her pillow, with no explanation for the injury. The incident was documented and reported internally, but the DON confirmed it was not reported to the state agency as required by facility policy.
A resident who was dependent on staff for all ADLs and had multiple medical conditions was found with a head hematoma and bleeding, with staff providing inconsistent accounts of when and how the injury was discovered and whether proper transfer procedures were followed. The facility's investigation was incomplete, missing key witness statements and documentation, and did not adhere to policy requirements for investigating injuries of unknown origin.
A resident with multiple complex medical conditions and dependence on staff for oral hygiene experienced ongoing mouth pain and required dental extractions. Despite documented dental issues and interventions, the facility did not develop a care plan to address the resident's dental needs, pain, or required extractions, as confirmed by staff and record review.
A resident with hemiplegia and muscle weakness, who required staff assistance for ADLs, did not consistently receive oral care twice daily as recommended by a dentist. Documentation and interviews confirmed that oral care was often only provided on shower days, contrary to facility policy and care recommendations.
A resident with multiple chronic conditions and intact cognition was not provided with an activities program that supported their preferences, including not being invited to desired group activities. Documentation showed the resident was frequently marked as unavailable despite being present in the facility, and participation was limited to independent activities, contrary to facility policy requiring individualized activity offerings.
During a meal service, several residents on a puree diet were served food items that did not match the prescribed menu, including regular tomato soup without crackers and cottage cheese instead of pureed cantaloupe. The Dietary Director confirmed these substitutions, which were not supported by a written order as required by facility policy.
Staff did not wear required PPE, specifically gowns, while providing high-contact care to a resident on Enhanced Barrier Precautions due to a stage IV pressure ulcer and indwelling catheter. This occurred despite facility policy and CDC guidance mandating gown use for such care activities.
A resident with cognitive impairment and high dependence on staff was found to have a non-functional call light in their room, which did not activate in the room, hallway, or nursing station. The issue was confirmed by the Maintenance Director, and facility policy required staff to notify maintenance of such problems.
A CNA failed to follow infection control protocols during incontinence care for a resident with multiple chronic conditions, including removing a soiled dressing, using the same wipe on both the anal area and an open wound, and not performing hand hygiene immediately after care. The DON confirmed that these actions were not in line with facility policy and expectations.
Two residents received PRN psychotropic medications without proper documentation of medical indications, re-evaluation dates, or duration of use. Orders for antianxiety and antipsychotic medications were administered over multiple days without required monitoring or justification, and pharmacy recommendations for review were not acted upon in a timely manner.
A resident with severe cognitive impairment and multiple medical conditions had two distinct pressure ulcers, but only one was treated as ordered due to incomplete wound documentation. During wound care, an LPN treated only one wound because records did not specify both ulcers, and the wound care clinician confirmed that assessments combined both wounds into a single measurement, contrary to facility policy.
A resident with multiple medical conditions, including depression and bipolar disorder, did not receive a prescribed dose of Venlafaxine ER 150 mg because the medication was not available during a medication pass. A nurse confirmed the medication could not be found in the medication cart, overflow, or emergency box, contrary to facility policy requiring timely and safe administration of medications.
A resident receiving insulin injections for diabetes was administered doses from two insulin pens that were not dated when opened, contrary to facility policy requiring multi-dose containers to be labeled with the date of first use. The administering RN confirmed the absence of opening dates on both pens.
The facility failed to pay its contracted extermination services, resulting in the cessation of monthly treatments for infestations. This affected a resident whose belongings were infested with bed bugs, as no extermination services were provided to address the issue. The administrator confirmed the non-payment and lack of services since August 2024.
A facility failed to ensure all nurses had active licenses, resulting in an LPN working with an expired license. The issue was discovered during a complaint investigation, and the IDON confirmed the LPN worked post-expiration. An assessment of residents and medication audits showed no issues.
The facility failed to maintain its pest control program due to nonpayment, affecting all 67 residents. Services were discontinued after August 2024, confirmed by the extermination service and the facility's administrator. A resident's belongings were infested with bed bugs, and without extermination services, the facility could not treat them, violating the facility's pest control policy.
A resident with a prosthetic leg was admitted to a facility with a bed bug infestation. The facility failed to treat the prosthetic for bed bugs due to unpaid extermination services, leaving the resident without the prosthetic and impacting therapy sessions. Staff attempts to clean the prosthetic were unsuccessful, and the resident expressed agitation over the missing prosthetic.
A resident with dementia and other conditions was found with a laceration on the right lower leg, and the cause was unknown. Despite finding scissors with apparent blood in the room, the facility did not investigate or report the incident to the state as required by their policy. Staff confirmed the incident was reported internally, but no further action was taken.
A resident with dementia and other conditions was found with a leg laceration of unknown origin. Despite the presence of scissors with apparent blood in the room, the facility did not investigate or report the incident as required by policy. Staff confirmed the incident was reported to the DON, but no further action was taken, leading to non-compliance with regulations.
Failure to Maintain Safe and Sanitary Food Preparation and Handling
Penalty
Summary
Staff failed to prepare and handle food in a safe and sanitary manner, as observed during the preparation of puree diets. A staff member was seen cleaning a food processor in a three-compartment sink, then immediately assembling it and adding sandwiches without allowing the processor to air dry. The staff member confirmed that the inside of the food processor was still wet with sanitizer when food was placed inside. Additionally, ham and cheese sandwiches stored on the steam table were found to be at 125 degrees Fahrenheit, below the required minimum hot holding temperature of 135 degrees Fahrenheit. The staff member verified the temperature was below standard and later checked the sandwiches again, finding them at 132.8 degrees Fahrenheit, still not meeting the minimum requirement. Further observations revealed another staff member placing silverware on residents' lunch trays without wearing gloves and touching the mouth-contact surfaces of other spoons while removing a spoon from an unorganized container. This was confirmed by another staff member, who then reorganized the spoons to prevent contamination. The facility's policy on food preparation and handling requires food to be kept free of harmful organisms and substances, which was not followed in these instances.
Failure to Properly Label and Dispose of Ophthalmic Medications
Penalty
Summary
Surveyors observed that the facility failed to ensure proper labeling and timely disposal of ophthalmic medications, specifically eye drops and ointments, in accordance with professional standards. During inspection of two medication carts, several opened eye drop bottles were found either lacking an open date or being used beyond the recommended four-week period after opening. For example, one resident's artificial tears were open and dated over three months prior, while another resident's latanoprost solution had no open date but was nearly empty. Additional observations revealed other eye drop bottles and ointments with either missing open dates or open dates exceeding the four-week usage guideline. Interviews with LPNs confirmed the absence of open dates on some medications and the use of products past the recommended timeframe. The review of The International Pharmacopoeia guidance indicated that multidose ophthalmic drop preparations should be used for up to four weeks after opening. These findings affected six residents whose medications were stored on the observed carts, and the facility census at the time was 65.
Failure to Ensure Clean Bed Linens for Resident
Penalty
Summary
A deficiency was identified when a resident's bed was observed to have a large, oblong light brown stain, approximately 12 inches by 6 inches, and a second similar stain below it, on the top white blanket. The bed was made with the sides and end of the blanket tucked under the mattress. During an interview, the resident was unable to identify the source of the stain but expressed a desire not to have stained or dirty bedding. A certified nursing assistant confirmed the presence of the stains and that the bed had been made in this condition.
Failure to Follow Abuse Policy for Injury of Unknown Origin
Penalty
Summary
The facility failed to follow its abuse policy in response to an injury of unknown origin involving one resident. The resident, who was dependent on staff for all activities of daily living and had diagnoses including chronic obstructive pulmonary disease, type 2 diabetes mellitus, and hypertension, was found during morning care with a small amount of blood on her pillow and a hematoma on the side of her head. The source of the injury was not observed, and the resident was unable to explain what happened. Staff interviews and witness statements revealed inconsistencies regarding who assisted with the resident's transfer and the sequence of events, with some staff unable to provide details or denying involvement. The nurse assigned to the resident did not immediately assess the injury, stating that the DON was handling the incident. Review of the facility's policy indicated that staff should immediately report all incidents and not move a resident with a suspected injury until assessed by a nurse supervisor. The policy also required documentation of the assessment, physician and representative notification, and treatment provided. In this case, the required immediate assessment and clear documentation were not completed as specified, and the incident was not managed in accordance with the established abuse policy for injuries of unknown origin.
Failure to Report Injury of Unknown Origin
Penalty
Summary
The facility failed to report an injury of unknown origin to the state surveying agency as required by policy. Medical record review showed that a resident with chronic obstructive pulmonary disease, type 2 diabetes mellitus, and hypertension, who was dependent on staff for all activities of daily living, was found with a hematoma and a small amount of blood on her pillow during morning care. The source of the injury was not observed, and the resident was unable to explain what happened. The incident was documented in the facility's incident log, and staff reported the findings to nursing. Despite the facility's policy requiring immediate reporting of all injuries of unknown source to the Administrator or designee and notification of the state agency within two hours if serious bodily injury is identified, the Director of Nursing confirmed that the incident was not reported to the State Surveying Agency. The failure to report was identified through medical record review, incident log review, staff interview, and policy review, and affected one resident out of five reviewed during the survey.
Failure to Thoroughly Investigate Resident Injury of Unknown Origin
Penalty
Summary
The facility failed to conduct a thorough and timely investigation into an injury of unknown source involving a resident who was dependent on staff for all activities of daily living and had significant medical conditions, including chronic obstructive pulmonary disease and type 2 diabetes mellitus. The resident was found with a hematoma and bleeding on her head during morning care, with staff noting blood on her pillow and a bump on her head. The resident was unable to communicate what had happened, and staff provided inconsistent accounts regarding when the injury was first identified, who was present during transfers, and whether proper two-person assistance was provided during mechanical lift transfers. The facility's incident investigation was incomplete and did not adhere to its own policy, which required interviewing all relevant witnesses, including staff from prior shifts and family members who had contact with the resident. Key witness statements were missing, such as from the staff member who assisted with the transfer the previous evening and from the resident's husband, who was present the night before the injury was discovered. Additionally, the investigation did not document important details, such as the placement and condition of the Hoyer lift, or whether there was any blood on the equipment or elsewhere in the room. Staff interviews revealed confusion and lack of clarity about the events leading up to the injury, with some staff unable to confirm who assisted with transfers or whether proper procedures were followed. The facility prematurely concluded that the Hoyer lift bar caused the injury before gathering all necessary statements and evidence. The investigation was not completed within the required timeframe, and documentation was insufficient to determine the cause of the injury, resulting in a deficiency for failure to thoroughly investigate an injury of unknown origin.
Failure to Address Dental Needs in Care Plan
Penalty
Summary
The facility failed to develop and implement a care plan addressing the dental needs of a resident who was dependent on staff for all activities of daily living, including oral hygiene. The resident had multiple diagnoses, including Parkinson's disease, malnutrition, HIV, diabetes, and a history of adult physical abuse. Medical record review showed the resident was moderately cognitively impaired and required supervision with eating, as well as full assistance with personal care. The resident experienced mouth and facial pain, discomfort with chewing, and specifically reported a toothache in the right lower jaw. Hospice was notified, and the resident was started on antibiotics for a bacterial infection. A dental visit resulted in a referral for extractions, but review of the care plan revealed there was no documentation addressing the resident's dental needs, mouth pain, or the need for extractions. Staff interviews confirmed the absence of a care plan for these issues, despite the resident's ongoing dental pain and the need for intervention. Facility policy required care plans to be based on comprehensive assessments and developed by the interdisciplinary team, but this was not followed in the resident's case.
Failure to Provide Consistent Oral Care Assistance
Penalty
Summary
The facility failed to provide appropriate oral care to a resident who was unable to perform oral hygiene independently. The resident, who had a history of hemiplegia and hemiparesis following a cerebral infarction and muscle weakness, was cognitively intact and required assistance with activities of daily living. According to the medical record and oral care log, staff did not consistently offer or provide oral care twice daily as recommended by the dentist. Documentation showed that on multiple dates, oral care was only offered once per day, and the resident confirmed that staff typically only brushed his teeth on days when he received a shower. Interviews with the resident and the Director of Nursing verified the lack of documentation and the inconsistency in providing oral care as required by facility policy. The facility's policy stated that appropriate care and services would be provided to residents unable to carry out activities of daily living independently, but this was not followed in the case of this resident.
Failure to Provide Resident-Directed Activities Program
Penalty
Summary
The facility failed to provide an activities program that supported residents in their choice of activities, as evidenced by the experience of one resident. This resident, who had multiple significant diagnoses including cancer, chronic heart failure, COPD, Parkinson's disease, diabetes, and chronic kidney disease, was cognitively intact and required substantial to maximum assistance with mobility and dressing. The resident's care plan included interventions such as monitoring for changes in activity participation, providing 1:1 activities as needed, offering items for self-directed activities, encouraging new activities, and reassessing activity interests. Despite these interventions, the resident reported not being invited to desired activities such as bingo and expressed dissatisfaction with the lack of available activities. Review of activity participation documentation showed the resident was marked as unavailable for activities 71 times and refused 15 times over a two-month period, with participation limited to independent activities like current events, socializing, and television. The administrator confirmed the resident was almost always present in the facility and could not explain why the resident was repeatedly marked as unavailable. Facility policy required activities to be offered based on individual preferences and needs, with participation documented in the medical record, but this was not followed in the resident's case.
Failure to Follow Prescribed Puree Diet Menu
Penalty
Summary
The facility failed to follow the prescribed menu for residents on a puree diet, as observed during a lunch service. Specifically, three residents who required a puree diet were served regular tomato soup without crackers and cottage cheese instead of the menu-specified pureed tomato soup with crackers and pureed cantaloupe. Additionally, apple sauce was served in place of pureed cantaloupe. The Dietary Director confirmed these deviations from the menu, and a review of the facility's policy indicated that texture modification diets should be followed as ordered, with no changes made without a written order.
Failure to Use Required PPE During Enhanced Barrier Precautions
Penalty
Summary
Staff failed to follow infection prevention and control protocols for a resident who was under Enhanced Barrier Precautions (EBP) due to a stage IV pressure ulcer and an indwelling catheter. Specifically, observation revealed that a Certified Nursing Assistant (CNA) exited the resident's area after changing the resident's brief and performing peri-care without wearing a gown, which is required under EBP for high-contact care activities. The CNA confirmed during an interview that neither they nor the assisting CNA wore a gown during the procedure, despite being aware of the EBP requirements. Record review showed that the resident had significant medical conditions, including active primary progressive multiple sclerosis and epilepsy, and had an active physician order for EBP. Facility policy and CDC guidance both require the use of gowns and gloves during high-contact care activities for residents with wounds or indwelling medical devices. The failure to use appropriate PPE during these activities constituted a breach of the facility's infection control policy and CDC recommendations.
Non-Functional Call Light in Resident Room
Penalty
Summary
A deficiency was identified when a resident's call light was found to be non-functional during an observation. The resident, who had diagnoses including Parkinson's disease and major depressive disorder, was moderately cognitively impaired and dependent on staff for toileting, personal hygiene, and transfers. The resident's fall care plan included an intervention to ensure the call light was within reach. However, on the date of observation, the call light in the resident's room was not working and did not activate in the room, hallway, or nursing station. This was confirmed by the Maintenance Director. The facility's policy required staff to notify maintenance if call lights were not functioning.
Infection Control Lapse During Incontinence Care
Penalty
Summary
During incontinence care for a resident with multiple diagnoses including diabetes mellitus type II, morbid obesity, depression, and chronic obstructive pulmonary disease, a Certified Nursing Assistant (CNA) failed to follow proper infection control practices. The resident, who was cognitively intact and dependent on staff for bed mobility, transfers, and toileting hygiene, was observed lying in bed when the CNA donned personal protective equipment and began care. The CNA removed the resident's incontinence product, cleansed the peri area, and then removed a soiled bordered dressing from the resident's left buttock, revealing a shallow open area. The CNA continued to cleanse the resident, using wipes to clean stool from both the anal area and the open wound, sometimes using the same wipe for both areas before disposal. The CNA did not perform hand hygiene immediately after providing care and before leaving the resident's room, instead applying hand sanitizer only after returning from disposing of soiled items in the utility room. The CNA confirmed during an interview that she had removed the dressing, which was not her responsibility, and acknowledged not performing hand hygiene at the appropriate time. The Director of Nursing confirmed that CNAs are expected to provide incontinence care but not to remove dressings, and that hand hygiene should be performed immediately after care and before leaving the resident's room. Facility policy also requires thorough cleansing and hand hygiene after incontinence care, which was not followed in this instance.
Lack of Documentation and Monitoring for Psychotropic Medication Use
Penalty
Summary
The facility failed to ensure that psychotropic medications prescribed to residents had appropriate documentation for medical use, including clear indications, re-evaluation dates, and duration of use. For one resident with diagnoses including dysphagia, tremors, dementia, osteoarthritis, and adult failure to thrive, a physician order for Lorazepam as needed (PRN) for anxiety did not specify a re-evaluation or duration date. The medication was administered daily over multiple days, and the order was only later changed to include a 14-day duration. For another resident with encephalopathy, hypotension, Alzheimer's disease, and atrial fibrillation, a PRN order for Haloperidol for agitation also lacked a re-evaluation or duration date, and the resident did not have a documented medical diagnosis supporting the use of this antipsychotic. The medication was administered on multiple days across two months. A pharmacy medication regimen review recommended re-evaluation and the addition of a stop date for the Haloperidol order, but this recommendation was not reviewed or signed by the physician until the resident was about to be discharged. The Director of Nursing confirmed that both residents' PRN psychotropic medication orders lacked required re-evaluation and duration dates, and that the medical record did not show adequate indications for the use of Haloperidol. Facility policy required that each resident's medication regimen be managed and monitored for dose, duration, indication, and clinical need, but these requirements were not met for the residents reviewed.
Failure to Properly Assess and Treat Multiple Pressure Ulcers
Penalty
Summary
The facility failed to properly assess and treat pressure ulcers for a resident with multiple complex medical diagnoses, including multiple sclerosis, quadriplegia, and myelodysplastic syndrome. Medical record review showed that the resident had a Stage IV pressure ulcer present upon admission, and weekly wound assessments were being conducted. However, the documentation only included measurements for the entire affected area and did not provide separate descriptions or measurements for each distinct pressure ulcer. During wound care observation, two separate wounds were identified on the resident's right buttock/sacrum area, but only one wound received the prescribed treatment. The LPN performing the care stated that the documentation did not indicate a second pressure ulcer, so treatment was only applied to one wound. Further interviews confirmed that the wound care clinician was aware of two distinct pressure ulcers but had only documented the area as a whole, not individually. The facility's policy required individualized treatment and assessment for each pressure injury, but this was not followed. As a result, one of the resident's pressure ulcers did not receive the ordered treatment, and the documentation failed to accurately reflect the resident's wound status. This deficiency was identified during a complaint investigation and affected one resident reviewed for wound care.
Medication Not Available for Administration
Penalty
Summary
The facility failed to ensure that medications were available for administration as prescribed, resulting in a deficiency affecting one resident. Medical record review showed that the resident, who had diagnoses including heart disease, diabetes mellitus, atrial fibrillation, depression, and bipolar disorder, was admitted and had a physician's order for Venlafaxine ER 150 mg daily for depression. During a medication pass observation, a registered nurse was unable to locate the resident's prescribed Venlafaxine ER 150 mg tablet in the medication cart, overflow, or emergency box, confirming the medication was not available for administration. Facility policy required medications to be administered safely, timely, and as prescribed, which was not followed in this instance.
Insulin Pens Not Dated Upon Opening
Penalty
Summary
The facility failed to ensure that insulin injector pens were properly dated when opened, as required by professional standards and facility policy. During medication administration for a resident with multiple diagnoses including diabetes mellitus, gas gangrene, chronic osteomyelitis, peripheral vascular disease, and hypertension, it was observed that both the Insulin Glargine and Insulin Lispro pens used for the resident did not have an opening date indicated on them. The registered nurse who administered the insulin confirmed that neither pen was dated to show when it was first opened. Review of the facility's medication administration policy revealed that staff are required to record the date on multi-dose containers when they are opened and to check expiration or beyond-use dates prior to administration. Despite this policy, the insulin pens in use for the resident were not dated, representing a failure to follow established procedures for medication labeling and storage.
Facility's Non-payment Leads to Cessation of Extermination Services
Penalty
Summary
The facility failed to maintain financial solvency by not paying its contracted extermination services, which were scheduled to provide monthly treatments for infestations. The contract with the extermination service began in February 2024, but the facility had not received any invoices after August 20, 2024. This non-payment led to the cessation of extermination services, as confirmed by the exterminator's receptionist during an interview on December 26, 2024. The lack of extermination services directly impacted the care of a resident who was admitted from the hospital on September 25, 2024, and subsequently readmitted. The resident's personal belongings, which were infested with bed bugs, were bagged and stored outside the facility. Due to the outstanding balance with the exterminator, no services were provided to eradicate the bed bugs from the resident's belongings. The facility administrator confirmed the non-payment and the absence of extermination services since August 2024. This deficiency was identified during a complaint investigation.
Expired Nursing License Deficiency
Penalty
Summary
The facility failed to ensure that all nurses providing care to residents had active licenses, as required by state law. Specifically, a Licensed Practical Nurse (LPN) was found to have an expired license while continuing to work at the facility. The Ohio Board of Nursing License Verification database confirmed that the LPN's license had expired, and the facility's daily nursing schedules showed that the LPN was scheduled to work after the expiration date. The Human Resource Manager confirmed that the LPN worked with an expired license on her last day of work. The Interim Director of Nursing (IDON) verified that the LPN had worked after her license expired and stated that the issue was discovered and addressed by management. The IDON conducted an assessment of all residents cared for by the LPN and found no issues or concerns with the nursing care provided. Additionally, an audit of medications administered by the LPN revealed no errors. The deficiency was identified during a complaint investigation related to specific complaint numbers.
Failure to Maintain Pest Control Program
Penalty
Summary
The facility failed to maintain a pest control program in accordance with its policy, which had the potential to affect all 67 residents. The facility had a contract with an extermination service to provide monthly pest control services, but the services were discontinued after August 2024 due to nonpayment. This lapse in service was confirmed through interviews with the extermination service's receptionist and the facility's administrator, who acknowledged the unpaid balance and the cessation of services. The deficiency was further highlighted by an incident involving a resident who was admitted from the hospital and had their personal belongings infested with bed bugs. Due to the lack of extermination services, the facility was unable to treat the resident's belongings, which were instead bagged and stored outside. The facility's pest control policy, dated October 2019, mandates an ongoing pest control program to keep the building free of pests, but this was not adhered to, leading to the deficiency noted in the complaint investigation.
Failure to Provide Prosthetic Due to Untreated Bed Bug Infestation
Penalty
Summary
The facility failed to provide appropriate care and assistance for a resident with a prosthesis by not timely treating the prosthetic device for bed bugs. The resident, who had a traumatic leg amputation and other medical conditions, was admitted with a prosthetic leg infested with bed bugs. Upon admission, the resident's belongings, including the prosthetic, were bagged and placed in a contained area outside the facility due to the infestation. However, the facility did not contact an exterminator to treat the items because of an unpaid balance with the extermination service provider. The resident's medical records and therapy notes indicated that the absence of the prosthetic leg was a barrier to the resident's therapy sessions and independence. Despite the resident's need for the prosthetic to improve mobility and independence, the facility did not ensure the prosthetic was decontaminated and returned to the resident. The resident expressed agitation over the missing prosthetic, and therapy sessions were impacted due to its unavailability. Interviews with facility staff revealed that attempts to clean the prosthetic with insecticide were unsuccessful, and the facility's environmental manager confirmed that no extermination efforts had been made. The facility's administrator acknowledged the unpaid extermination services and the lack of extermination since August 2024. The facility's failure to address the bed bug infestation and provide the resident with a usable prosthetic leg resulted in a deficiency during the complaint investigation.
Failure to Report Injury of Unknown Origin
Penalty
Summary
The facility failed to report an injury of unknown origin involving a resident to the State Agency, as required by their policy and regulations. The resident, who has dementia, retrograde amnesia, falls, and asthma, was found with a laceration on the right lower leg. The injury was discovered by a nurse during bed rounds, and the resident was unable to explain how it occurred. The wound was assessed, and the resident was sent to the hospital for treatment. Despite the presence of scissors with apparent blood on them found in the room, the facility did not conduct a thorough investigation or report the incident to the state. Interviews with staff, including LPNs and RNs, confirmed that the injury's cause was unknown and that the incident was reported to the Director of Nursing. However, the facility did not follow through with an investigation or report the injury as required by their policy. The facility's policy mandates that all reports of abuse, including injuries of unknown source, must be reported to state agencies and thoroughly investigated, which was not done in this case.
Failure to Investigate Injury of Unknown Origin
Penalty
Summary
The facility failed to investigate an injury of unknown origin for Resident #15, who was admitted with diagnoses including dementia, retrograde amnesia, falls, and asthma. The resident, who required complete assistance for activities of daily living, was found with a laceration on the right lower leg. The injury was discovered during a bed round by an aide, and the resident was unable to explain how it occurred. The nurse assessed the wound, notified the physician and family, and sent the resident to the hospital for treatment. Despite the presence of scissors with apparent blood on them found in the room, the facility did not document or investigate the cause of the injury. Interviews with staff, including LPN #111 and RN #400, confirmed the presence of scissors and the reporting of the incident to the Director of Nursing (DON). However, the DON acknowledged that the facility did not investigate or report the injury as required by their policy. The facility's policy mandates that all reports of abuse, including injuries of unknown source, must be reported to state agencies and thoroughly investigated. The failure to investigate and report the incident represents non-compliance with the facility's policy and regulations.
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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