Ayden Healthcare Of Oregon
Inspection history, citations, penalties and survey trends for this long-term care facility in Oregon, Ohio.
- Location
- 3953 Navarre Ave, Oregon, Ohio 43616
- CMS Provider Number
- 365453
- Inspections on file
- 41
- Latest survey
- March 19, 2026
- Citations (last 12 mo.)
- 11
Citation history
Health deficiencies cited at Ayden Healthcare Of Oregon during CMS and state inspections, most recent first.
Two residents at high risk for skin breakdown did not receive wound and incontinence care as ordered. One resident with a stage II sacral pressure injury and MASD remained on the back for several hours without the two-hourly checks, incontinence care, or repositioning that staff later described as expected, and was found heavily soiled with urine; when CNAs finally provided care, they noted MASD and a sacral wound but did not apply the ordered dressing, which an LPN later confirmed should have been in place. Another resident with paraplegia, chronic osteomyelitis, and a right posterior thigh/gluteal wound had a physician order for cleansing with liquid antibacterial soap and water and application of Prisma with a silicone border dressing, but an LPN instead used wound cleanser spray, applied a different collagen product, and performed the entire dressing change without changing soiled gloves between removing contaminated dressings and handling clean supplies, which the LPN and DON acknowledged did not follow the physician’s orders or clean technique.
Surveyors found that staff failed to provide timely and complete incontinence care for two residents. One resident with paraplegia and stage IV pressure ulcers had a soiled brief removed, but the CNA did not cleanse urine from the anterior perineum before applying a new brief. Another resident in a persistent vegetative state, fully dependent and incontinent, was left on the back for several hours without incontinence checks; an LPN discovered the resident heavily soiled with urine while providing G-tube care but did not address the incontinence, and the resident was not changed until later by CNAs. Staff reported residents were to be checked and changed every two hours, and the DON stated there was no formal incontinence care policy, with the task treated as standard practice.
A resident with multiple complex conditions, including dementia, dysphagia, and dependence on G-tube feeding, had physician orders for continuous tube feeding, scheduled water flushes, and daily cleansing of the G-tube site with application of a sponge dressing. During observation, an LPN found the G-tube site without the ordered dressing and cleaned brown/red dried drainage from the insertion area, acknowledging that a dressing should have been in place. The DON later reported there was no formal facility policy or procedure for G-tube care and maintenance, even though additional residents also had G-tubes.
Surveyors found that the facility failed to implement Enhanced Barrier Precautions (EBP) for two residents with complex medical conditions, including one with a G-tube and skin breakdown and another with HIV and stage III–IV pressure ulcers, both fully dependent for ADLs and incontinent. For these residents, there were no physician orders or care plan entries documenting EBP, no EBP signage or PPE at room entrances, and CNAs performed incontinence care and repositioning without donning gowns or gloves. Staff interviews confirmed unawareness that EBP were required and the lack of visual cues or readily available PPE, while the DON acknowledged that the facility’s EBP policy did not require a physician order or care plan entry to initiate or maintain EBP.
Surveyors found that cigarettes were not properly contained or extinguished in approved receptacles in and around a designated independent smoking area. Extinguished cigarette butts were observed on a carpeted community room floor, inside a plastic trash can containing paper and styrofoam items near the smoking exit, and scattered outside near a combustible wood exterior. An LPN confirmed these findings, and facility leadership identified multiple independent, unsupervised smokers and numerous other residents living on the affected end of the building.
Staff failed to follow hand hygiene and single-use glove policies during meal preparation and service for residents. One dietary aide handled empty and soiled trays, operated the dishwasher, then handled clean utensils and meal tickets without changing gloves or washing hands, and picked meal tickets up from the floor and placed them on clean trays without handwashing. Another dietary staff member repeatedly left and re-entered the kitchen wearing the same gloves, touched door handles and the walk-in cooler, then handled food items, plates, tuna sandwiches, and grilled sandwiches without changing gloves or washing hands. Both staff later acknowledged not following required handwashing and glove-change procedures, and the dietary manager confirmed that facility policy requires handwashing between glove changes and after contact with soiled or contaminated surfaces.
Surveyors found that common shower rooms and multiple corridors were not properly cleaned or maintained, with black and brown residues on floors and walls, missing and broken tiles, exposed backing board and wall holes, a soiled brief on a shower room floor, peeling caulk around a toilet, and a broken soap dispenser with jagged edges. An LPN reported the floors had been in this condition since their employment, and the Director of Housekeeping Services confirmed the persistent stains and damage despite unsuccessful cleaning attempts. These conditions affected most residents in the facility, excluding those on the Medbridge unit.
Staff did not consistently record daily medication refrigerator temperatures and failed to secure medication cards during administration, leaving them unattended on a cart in the hallway. A resident with cognitive impairment was also found with two inhalers in his room, despite not being permitted to self-administer medications. The DON and LPN confirmed these lapses in medication security and storage.
Two residents, both cognitively intact, were affected by unaddressed environmental issues on the 200 hall, including a hanging metal ceiling tile support track, stained ceiling tiles, and excessive dust buildup on vents. An LPN confirmed these conditions, and both residents reported finding them bothersome and not homelike, in violation of the facility's policy for a safe and clean environment.
A resident with multiple chronic conditions was not instructed or encouraged by an LPN to rinse their mouth after receiving an inhaled corticosteroid medication, despite physician orders and manufacturer instructions requiring this step. Both the LPN and an RN confirmed the omission during interviews, and the deficiency was identified during a complaint investigation.
The facility did not ensure that all new hire employees had complete TB testing results in their files, with one LPN lacking any TB test documentation and a housekeeper and CNA missing the second step of the required two-step TB skin test. This failure to follow the facility's TB screening policy had the potential to affect all 80 residents.
A resident with quadriplegia and multiple pressure ulcers did not receive wound care treatments as ordered by the physician. Despite being cognitively intact, the resident's treatments were not documented as completed on several occasions, and observations confirmed that dressings were not changed daily. The facility's policy on skin management was not effectively implemented, as verified by the DON.
The facility failed to maintain cleanliness in the North and South shower rooms, affecting most residents. Debris and a dark-colored substance were observed on the shower floor tiles, confirmed by the Housekeeping and Laundry Supervisor. Facility policies required floors to be clean and sanitary, but these standards were not met, leading to a deficiency investigation.
A resident with intact cognition and multiple diagnoses, including diabetes and osteoarthritis, was not provided timely pharmacy services for pain management. The facility used the resident's personal supply of oxycodone-acetaminophen without her permission, despite having a policy for accessing controlled substances. Interviews revealed that nursing staff used the resident's home medications instead of the facility's stock, leading to a deficiency investigation.
The facility failed to ensure safe food handling, proper sanitization of the thermometer, and correct operation of the high-temperature dishwasher. A cook used a cloth from a sanitizer bucket with inadequate sanitizing levels to wipe the thermometer and did not change gloves before handling ready-to-eat food for two residents. The dishwasher also operated below the required wash temperature, affecting all 82 residents.
The facility failed to provide adequate protein portions for residents on a mechanical soft diet. During meal service, it was observed that a cook used a size 20 scoop, equivalent to 1.52 ounces, to serve mechanical soft pork chops, whereas the dietary menu indicated that the portion should have been six ounces. The Dietary Manager confirmed the discrepancy.
The facility failed to maintain clean resident rooms, affecting four residents. Observations revealed dirty and sticky floors in two rooms and a stool-soiled bedpan under a resident's bed. These conditions were confirmed by staff and violated the facility's cleaning policies.
The facility failed to ensure residents had access to their call lights and bed mobility equipment. One resident's call light was under the bed, another's was clipped to the top of the bed, and a third resident did not have an overbed trapeze for a month, despite needing it for bed mobility. These deficiencies were confirmed by staff and violated the facility's policies.
The facility failed to consistently implement the bowel movement plan for a resident with constipation, leading to multiple days without documented bowel movements and only one administration of Miralax despite physician orders. The DON confirmed that the physician was not notified after 72 hours of no bowel movements.
A resident with severe cognitive impairment and multiple medical conditions did not receive timely incontinence care, leading to a moisture-associated skin breakdown (MASD) on the sacrum. The nursing plan of care lacked specific documentation for monitoring incontinence frequency and protective products, and staff failed to communicate the resident's condition and refusal of care.
The facility failed to manage a resident's pain and administer pain medications as ordered by the physician. An LPN administered only 100 mg of gabapentin instead of the prescribed 300 mg, despite the updated order. The resident questioned the dosage, but the LPN did not verify the updated order until after the medication was given.
The facility failed to ensure ongoing communication and collaboration with the dialysis facility for a resident with ESRD, as there was no documentation of dialysis communication from 04/24/24 to 05/01/24. Staff interviews revealed inconsistent practices in sending dialysis communication forms, and the DON confirmed the absence of such documentation in the resident's records.
The facility failed to ensure timely physician response to pharmacy recommendations for a resident prescribed PRN Clonazepam for major depressive disorder and generalized anxiety disorder. Despite pharmacy reviews identifying the need for anticipated duration and continued use rationale, there was no physician response until the date of the survey. Interviews confirmed the facility did not follow its policy on monthly reassessment of sedative medications.
The facility failed to administer medications as ordered, resulting in a 15% medication error rate. An LPN administered a resident's morning medications late and omitted a dose, leading to incorrect documentation.
A resident with diabetes did not receive the prescribed insulin before breakfast, and the LPN documented the administration without actually giving it. Later, the LPN administered the insulin without priming the needle, contrary to the manufacturer's guidelines.
The facility failed to ensure accurate documentation and administration of medications for two residents. An LPN omitted a morning dose of Buspirone for one resident and documented it as given, and did not administer lispro insulin to another resident despite documenting it as administered. These actions were against the facility's policy requiring accurate and complete medical records.
The facility failed to ensure that STNAs received the required twelve hours of annual training and annual performance reviews. STNA #571, STNA #624, and STNA #629 did not meet the training requirements, and their performance evaluations were either missing or outdated. The Administrator confirmed these deficiencies, which were identified through a review of personnel files, staff interviews, and facility policy.
A resident with multiple diagnoses reported being verbally assaulted by an LPN, who used curse words and yelled during a verbal altercation. The incident was corroborated by interviews with the resident, the LPN, a nursing assistant, and a police officer. The altercation began over a schedule book the resident had removed from the nurse's station desk, escalating to the point where the nursing assistant had to intervene to separate the two parties.
Failure to Follow Physician Orders and Aseptic Technique for Wound and Incontinence Care
Penalty
Summary
The deficiency involves the facility’s failure to provide ordered pressure ulcer care, moisture-associated skin damage (MASD) care, and timely incontinence care and repositioning for residents at high risk for skin breakdown. One resident with dementia, a persistent vegetative state, total dependence for ADLs, incontinence, and tube feeding was assessed as high risk for pressure ulcer development with a Braden score of 11. After readmission from the hospital, this resident had a stage II coccyx pressure injury and excoriation/MASD to the groin and thighs, with physician and wound specialist orders for cleansing with wound cleanser or normal saline, application of zinc barrier cream to the wound bed and buttocks, coverage with a dry or foam dressing, and dressing changes every shift and as needed. The plan of care also included barrier cream after incontinence episodes, routine skin inspection, and use of a pressure-reducing mattress. On the observed day, CNAs provided incontinence care and repositioned this resident onto his back at 7:45 A.M. Continued observation from 8:00 A.M. to 11:13 A.M. showed the resident remained on his back without further checks for incontinence care or repositioning, despite staff later stating the resident was to be checked, changed, and repositioned every two hours. At 11:13 A.M., an LPN entered the room, exposed the G-tube site, and found the resident heavily soiled with urine in an adult brief but did not address the incontinence care needs while completing G-tube and tube feeding care. At 11:58 A.M., two CNAs removed the brief and again found the resident heavily soiled with urine; they cleansed the resident with disposable wipes and incontinence spray cleanser and noted MASD and a sacral wound, but no dressing was applied to these wounds at that time, despite a current physician order for a dressing. The LPN later verified that a physician order for a dressing to the MASD and sacral wound was in place and that no dressing was present. A second resident with paraplegia, chronic osteomyelitis, stage IV pressure ulcers to the right buttock and sacral region, incontinence, and dependence for ADLs also experienced deficient wound care. This resident had an order for an open area on the right posterior thigh to be cleansed with liquid antibacterial soap and water, patted dry, and treated with Prisma and a silicone border Zetuvit dressing once daily and as needed. During observation of wound care, an LPN gathered supplies, donned gloves and a gown, and exposed the right posterior gluteal fold wound, where the dressing was dislodged. The LPN removed the soiled dressing and packing, then, without changing soiled gloves, opened gauze packaging, cleansed the wound with wound cleanser spray instead of the ordered liquid antibacterial soap and water, and patted the wound dry with gauze. The LPN then opened and applied a collagen purcol pad instead of the ordered Prisma, and covered the wound with a silicone border dressing, all while continuing to use the same soiled gloves. The LPN confirmed that gloves were not changed between handling soiled dressings and clean supplies and that the products used did not match the physician’s orders. The DON verified that the wound treatment was not administered as ordered by the physician.
Failure to Provide Timely and Complete Incontinence Care for Two Residents
Penalty
Summary
The deficiency involves the facility’s failure to provide timely and effective incontinence care to two residents. One resident with paraplegia, chronic osteomyelitis, two stage IV pressure ulcers, urinary incontinence, and dependence on staff for ADLs had a care plan that included monitoring for UTI signs and providing incontinence care as needed. During observed incontinence care, a CNA removed a urine- and bowel-movement–soiled brief, cleansed only the fecal matter, applied a new brief, and did not cleanse the resident’s anterior perineum of urine. The CNA confirmed in interview that the urine was not cleansed from the anterior perineum during this incontinence care episode. Another resident, in a persistent vegetative state, severely cognitively impaired, incontinent of bowel and bladder, dependent for all ADLs, and at risk for pressure ulcer development, had a care plan intervention to provide incontinence care as needed. Two CNAs were observed to perform incontinence care and reposition the resident, after which the resident remained on his back for several hours. From the time of that care until late morning, no staff were observed checking the resident for incontinence needs. When an LPN later entered the room and exposed the G-tube site, the resident was found to be heavily soiled with urine in the brief, but the LPN did not address the incontinence at that time and proceeded only with G-tube care. The resident was not changed until nearly an hour later, when two CNAs entered, found the resident heavily soiled with urine, and then provided cleansing and repositioning. Staff interviews indicated residents were to be checked, changed, and repositioned every two hours, and the DON stated there was no written policy, with incontinence care considered a standard practice task.
Failure to Provide Ordered G-Tube Care and Dressing
Penalty
Summary
The deficiency involves the facility’s failure to provide gastrostomy tube (G-tube) care and maintenance as ordered for a resident who was fully dependent on tube feeding. The resident had multiple diagnoses including dementia, acute respiratory failure, Type II diabetes mellitus with diabetic neuropathy, dysphagia, history of aspiration pneumonia, a G-tube, and hypertension, and was documented on the MDS as being in a persistent vegetative state, severely cognitively impaired, unable to make needs known, dependent for all ADLs, incontinent, and receiving all nutrition via feeding tube. The care plan identified potential for altered nutrition/hydration, with the resident ordered NPO and dependent on tube feeding and flushes, and included interventions such as administering medications as ordered, elevating the head of bed, and evaluating tube feed tolerance. Physician orders specified continuous tube feeding with Glucerna 1.2 via G-tube for up to 20 hours per day with scheduled water flushes, and a treatment order to cleanse the area around the G-tube with soap and water and apply a new sponge dressing daily and as needed. During an observation, an LPN entered the resident’s room and exposed the G-tube site, at which time no dressing (sponge) was in place despite the physician’s order for a daily dressing. The LPN cleansed a small amount of brown/red dried drainage from the G-tube insertion site and confirmed that a dressing should have been applied. In an interview, the DON stated that the facility did not have a policy or procedure in place regarding the provision of G-tube care and maintenance, and that the procedure was considered a standard of practice task. The facility also identified two additional residents with G-tubes, indicating that more than one resident required such care, but the cited deficiency specifically involved the failure to follow ordered G-tube care for this resident.
Failure to Implement Enhanced Barrier Precautions for Residents Requiring High-Contact Care
Penalty
Summary
The deficiency involves the facility’s failure to implement its infection prevention and control program by not applying Enhanced Barrier Precautions (EBP) for residents who met criteria and were identified by the facility as being on EBP. The facility had identified 26 residents as requiring EBP, yet for at least two of three residents reviewed, there were no physician orders or nursing care plan entries documenting EBP, and no visual cues or supplies at the room entrances to support their use. The facility’s EBP policy, dated August 2022, stated that gowns and gloves were to be used for high-contact resident care activities for residents with wounds or indwelling medical devices when contact precautions did not otherwise apply. One resident had multiple significant medical conditions including dementia, acute respiratory failure, Type II diabetes with neuropathy, dysphagia, a history of aspiration pneumonia, a G-tube, and hypertension, and was in a persistent vegetative state, fully dependent for ADLs, incontinent of bowel and bladder, and at risk for pressure ulcer development with existing moisture-associated skin damage and a sacral wound requiring treatment. Despite this, the medical record lacked any physician order or nursing plan of care for EBP. During observation, the resident was receiving tube feeding, and there was no EBP signage or PPE at the room entry. Two CNAs entered the room and performed incontinence care and repositioning without donning PPE, and one CNA later confirmed they were unaware the resident was on EBP or that PPE was required during direct care. The DON also verified there was no signage or PPE at the room entry. Another resident had diagnoses including HIV, Type II diabetes with neuropathy, COPD, necrotizing fasciitis, peripheral vascular disease, lymphedema, and nutritional anemia, with moderately impaired cognition, dependence for ADLs, incontinence of bowel and bladder, and risk for pressure ulcer development, and was admitted with one stage III and one stage IV pressure ulcer requiring daily wound care. Observation showed the resident’s call light active and, again, no EBP signage or PPE at the room entrance. Two CNAs entered to perform incontinence care and repositioning without donning PPE. A CNA who had assumed care earlier verified they were unaware the resident required EBP and confirmed the absence of signage and readily accessible PPE. The DON stated that the facility’s policy did not include instructions to obtain or require a physician order or plan of care to place or maintain a resident on EBP.
Improper Containment and Disposal of Cigarettes in Smoking Area
Penalty
Summary
Surveyors identified a deficiency related to accident hazards and inadequate supervision in the facility’s management of resident smoking and cigarette disposal. During observation of the south 300 resident community room, four extinguished cigarette butts were found on the carpeted floor. A plastic trash can located inside the building near the exit door to the designated independent smoking area contained multiple paper and styrofoam items along with multiple extinguished cigarettes. Additional observation outside the community room exit door revealed more than 17 extinguished cigarettes on the ground in close proximity to the combustible wood exterior of the building. On-site verification of these conditions was conducted with a Unit Manager LPN, who confirmed the presence of the discarded cigarettes in the community room, in the plastic trash can, and outside the designated independent smoking area. The Administrator later provided a list identifying 17 residents as independent or unsupervised smokers and an additional 32 residents residing on the south end of the building, the area where the unsafe cigarette disposal practices were observed. The facility census at the time was 79 residents.
Improper Hand Hygiene and Glove Use During Food Preparation and Service
Penalty
Summary
The deficiency involves failure to maintain proper hand hygiene and glove use during meal preparation and service for 78 residents receiving food from the facility kitchen. During a lunch meal service, a dietary aide was observed wearing single-use gloves while handling empty meal trays, then handling soiled trays and operating the commercial dishwasher without changing gloves or washing hands. The same staff member then handled clean utensils and placed meal tickets on clean trays without changing gloves. When meal tickets fell to the floor, the aide picked them up and placed them back on clean trays, changed gloves, but did not wash hands. In a subsequent interview, this aide confirmed that facility policy requires staff to remove soiled gloves and wash hands before donning a new pair when gloves are cross-contaminated. Additional observations during the same lunch meal service showed another dietary staff member repeatedly exiting and re-entering the kitchen wearing the same single-use gloves while touching multiple potentially contaminated surfaces, including the kitchen entry door handles and the walk-in cooler door, and then handling food and clean plates without changing gloves or washing hands. This staff member obtained various food items from the cooler, carried trays of tuna fish sandwiches, and prepared grilled sandwiches while continuing to use the same soiled gloves. In an interview, this staff member acknowledged not changing gloves and not performing required hand washing when handling food. The dietary manager confirmed that facility policies require hands to be washed between glove changes and after handling soiled items or contaminated surfaces, and that gloved hands are considered a food contact surface that must be changed and followed by hand washing when contamination occurs.
Failure to Maintain Clean and Safe Common Showers and Corridors
Penalty
Summary
The deficiency involves the facility’s failure to ensure that resident common shower rooms and common area corridors were properly cleaned and maintained for the majority of the resident population. Surveyor observation of the north common shower room found a black substance along the edge of the floor and wall in the left stall, as well as an approximately one foot by eight inch section of missing ceramic tile next to the wall-mounted seat, exposing the structural backing or board and a one-inch diameter hole through the wall. In the south common shower room, surveyors observed a soiled brief on the floor in front of the sink, a brown substance with peeling caulk around the base of the toilet, a black substance between the shower stall floor and tile, and a black substance between the wall shower tiles. Four holes were noted penetrating the wall through the ceramic tile with a black-brown substance around the holes, and a broken soap dispenser in the stall with jagged edges. Additional observations between multiple resident room corridors (rooms 101–109, 110–122, 201–210, 301–312, and 314–326) revealed brown/black residue covering various floor tiles, along corridor walls, and at resident room thresholds. Multiple broken floor tiles were also identified in corridors between rooms 206–208 and 314–327. During an interview, an LPN stated that the floors had been in this condition since the start of their employment. A tour with the Director of Housekeeping Services confirmed the condition of the facility flooring and resident common showers, and the Director reported that attempts to remove the flooring stains had been unsuccessful. These conditions affected 68 current residents, excluding 11 residents on the Medbridge unit, and were investigated under a complaint.
Failure to Securely Store Medications and Monitor Refrigerator Temperatures
Penalty
Summary
Facility staff failed to ensure that drugs and biologicals were stored in a safe and secure manner, as required by facility policy and professional standards. Observations and review of temperature logs for medication refrigerators at both the North and South nurse stations revealed multiple dates across October, November, and December where daily temperature checks were not recorded. The Director of Nursing confirmed that temperatures had not been monitored and logged daily, despite facility policy requiring daily monitoring of medication refrigerator temperatures. Additionally, during medication administration for a resident with multiple diagnoses including emphysema, hypertension, hepatitis C, and cognitive impairment, an LPN left three medication cards unsecured on top of a medication cart in the hallway, out of view, while administering medications in the resident's room. Later, the same resident was found with two inhalers (Ventolin and Symbicort) by his pillow, despite not being permitted to self-administer medications. Both the LPN and the DON confirmed that these medications should not have been accessible to the resident and should have been securely stored.
Failure to Maintain Clean and Homelike Environment on 200 Hall
Penalty
Summary
Surveyors identified a failure by the facility to maintain a clean and homelike environment on the 200 hall, affecting two residents who were both cognitively intact and did not exhibit behavioral issues at the time of assessment. Observations revealed a metal ceiling tile support track hanging down approximately three inches, multiple ceiling tiles with round orange-brown stains ranging from three to six inches in diameter, and an excessive buildup of dust on vents and surrounding ceiling tiles. These conditions were confirmed by an LPN during an interview. Both affected residents reported being aware of the ceiling conditions and expressed that they found them bothersome and not homelike. Review of the facility's policy on providing a safe, clean, and homelike environment indicated that the observed conditions were not in compliance with established standards. The deficiency was documented under a specific complaint number and was based on direct observation, interviews, and policy review.
Failure to Encourage Oral Rinse After Steroid Inhaler Administration
Penalty
Summary
A deficiency was identified when a resident with multiple diagnoses, including emphysema, hypertension, viral hepatitis C, alcohol dependence, cocaine use, and toxic encephalopathy, was not encouraged or offered an oral rinse after receiving an inhaled medication containing a steroid (Symbicort). The resident, who was cognitively impaired and required moderate assistance with activities of daily living, had a physician's order for Symbicort to be administered twice daily for shortness of breath. During medication administration, observation revealed that the LPN administered the inhaled medication but did not instruct or encourage the resident to rinse his mouth afterward. Interviews with both the LPN and an RN confirmed that residents should rinse their mouths after using a steroid inhaler, and that this step was omitted for the resident in question. Review of the manufacturer's instructions for Symbicort also indicated that users should rinse their mouths with water and spit it out after inhalation. This failure to follow proper administration protocol was discovered during a complaint investigation and affected one of three residents reviewed for medication administration.
Incomplete TB Screening for New Employees
Penalty
Summary
The facility failed to ensure that all new hire employees had current and complete TB testing results in their personnel files, as required by the facility's own Tuberculin (TB) Risk Assessment and policy. Specifically, the personnel file for an LPN did not contain any TB skin test results, and the files for a housekeeper and a CNA showed that only the first step of the required two-step TB skin test was completed, with no documentation of the second step. The facility's policy required a baseline two-step skin test for all healthcare workers prior to employment, but this was not consistently followed. Interviews with the Human Resource Director confirmed the absence or incompleteness of TB testing documentation in the employee files. The Regional Director of Operations also acknowledged that new employees should have completed the two-step TB skin test upon hire. The facility census at the time was 80 residents, and the deficiency had the potential to affect all residents. There were no reported TB infections in the facility at the time of the review.
Failure to Complete Pressure Wound Treatments as Ordered
Penalty
Summary
The facility failed to ensure that treatments for pressure wounds were completed as ordered by the physician for a resident with multiple pressure ulcers. The resident, who was cognitively intact and dependent on staff for all activities of daily living due to quadriplegia, had a history of non-compliance with wound care treatments. Despite this, there was no documentation of the resident refusing treatment on specific dates in February 2025 when the treatments were not completed. Observations and interviews confirmed that the wound dressings were not changed daily as required, with one dressing being left unchanged for three days. The facility's policy on skin management aimed to prevent and manage pressure injuries, but the lack of adherence to the treatment schedule for the resident's pressure ulcers indicated a failure in implementation. The Director of Nursing verified the absence of documentation for the completion or refusal of wound treatments on several dates, highlighting a gap in the facility's compliance with physician orders and internal policies. This deficiency was identified during an investigation under a specific complaint number.
Unsanitary Conditions in Shower Rooms
Penalty
Summary
The facility failed to maintain the North and South shower rooms in a clean and sanitary manner, which had the potential to affect all residents except for 24 who were identified as not using the shower rooms. During an observation, debris and a buildup of a dark-colored substance were found around the perimeter of the shower floor tiles in both shower rooms. This observation was confirmed by an interview with the Housekeeping and Laundry Supervisor. A review of the facility's policies revealed that the floors were supposed to be maintained in a clean, safe, and sanitary manner, and the environment was to be kept clean, sanitary, and orderly. This deficiency was investigated under Complaint Number OH00154998.
Failure to Provide Timely Pharmacy Services
Penalty
Summary
The facility failed to provide timely pharmacy services for a resident, identified as Resident #73, who required medication for pain management. Upon admission, the resident had intact cognition and was diagnosed with type two diabetes mellitus, osteoarthritis of the knee, and chronic obstructive pulmonary disease. The hospital discharge orders included a prescription for oxycodone-acetaminophen to be taken as needed for pain. However, the facility did not have the medication available and used the resident's personal supply without her permission. The resident had brought 20 tablets from home, and the facility administered ten doses from this supply before sending the remaining medication home with a family member. Interviews with the Director of Nursing and the Unit Manager Registered Nurse revealed that the nursing staff used the resident's home medications instead of the facility's contingent stock, which was against the facility's policy. The policy required a specialized code from the pharmacist to access controlled substances from the emergency medication kit. The resident expressed that her medications were used without her consent, and the Unit Manager confirmed that the resident was informed she could not keep medications in her room. This deficiency was investigated under Complaint Number OH00155011.
Food Handling and Sanitization Deficiencies
Penalty
Summary
The facility failed to ensure safe food handling during meal service, proper sanitization of the thermometer used to check food temperatures, and correct operation of the high-temperature dishwasher. Cook #553 was observed using a cloth from a sanitizer bucket with inadequate sanitizing levels to wipe the thermometer between checking different food items. The sanitizer solution was found to be at 100 parts per million (PPM) instead of the required 200 PPM. Additionally, Cook #553 did not change gloves or perform hand hygiene before handling ready-to-eat food items, such as cheese and buns, for two residents. This was confirmed by the Dietary Manager, who stated that gloves should be changed after each use and that ready-to-eat food should be handled with clean gloves. The high-temperature dishwasher was also found to be operating below the required wash temperature of 160 degrees Fahrenheit, reaching only 142 degrees Fahrenheit during a wash cycle. Although the rinse temperature was adequate, the wash temperature did not meet the necessary standards. The facility had to use disposable plates and utensils temporarily while the dishwasher was being repaired. These deficiencies affected two residents directly and had the potential to affect all 82 residents in the facility who received food from the kitchen.
Inadequate Protein Portions for Mechanical Soft Diet
Penalty
Summary
The facility failed to provide adequate protein portions for residents on a mechanical soft diet. This deficiency affected five residents identified on a mechanical soft diet. During meal service, it was observed that Cook #553 used a size 20 scoop, equivalent to 1.52 ounces, to serve mechanical soft pork chops, whereas the dietary menu spreadsheet indicated that the portion should have been six ounces. Cook #553 confirmed that some mechanical soft pork chop was leftover because some residents chose the alternative menu option. The Dietary Manager (DM) #569 confirmed that the size 20 scoop held 1 5/8 ounces and that the correct serving size should have been six ounces.
Failure to Maintain Clean Resident Rooms
Penalty
Summary
The facility failed to provide clean resident rooms, affecting four residents. Observations revealed that Resident #27 was sitting in a room with a dirty and sticky floor, and a dried yellowish fluid was noted under the bed. This was confirmed by an Occupational Therapy Assistant. Additionally, the room shared by Residents #55 and #59 was observed to have a dirty and sticky floor on two separate occasions, which was verified by a State Tested Nursing Assistant. The facility's policy on cleaning and disinfecting residents' rooms, dated August 2013, states that housekeeping surfaces should be cleaned regularly, when spills occur, and when visibly soiled. Another observation revealed a stool-soiled and uncovered bedpan under Resident #21's bed, which the resident stated had been there since the previous day. This was confirmed by a State Tested Nursing Aide. The facility's policy on maintaining a homelike environment, revised in May 2017, requires that the facility staff and management ensure a clean, sanitary, and orderly environment. The facility census at the time was 82 residents.
Failure to Ensure Accessibility of Call Lights and Bed Mobility Equipment
Penalty
Summary
The facility failed to ensure residents had access to their call lights and bed mobility equipment, affecting three residents. Resident #12, who was cognitively intact and dependent on staff for various activities, was observed sitting in a wheelchair with her call light inaccessible under the bed. This was verified by a State tested Nursing Assistant (STNA). Similarly, Resident #67, who was severely cognitively impaired and required assistance for mobility, had his call light clipped to the top of the bed, making it inaccessible. This was also confirmed by an STNA. The facility's policy mandates that staff ensure the call light is within reach before leaving the resident's room, which was not followed in these cases. Resident #48, who had multiple diagnoses including COPD, PVD, and CHF, and was cognitively intact, did not have an overbed trapeze for approximately one month. The resident indicated that she extensively used the trapeze for bed mobility. The Director of Rehabilitation confirmed that Resident #48 had participated in 23 sessions of Occupational Therapy and was discharged from OT, but the trapeze was not present in her room. An STNA also verified the absence of the overbed trapeze. These deficiencies highlight the facility's failure to accommodate the needs and preferences of the residents as per their care plans and facility policies.
Failure to Implement Bowel Movement Plan
Penalty
Summary
The facility failed to consistently implement the bowel movement plan for a resident who had not had a bowel movement for several days. The resident, who had diagnoses including MRSA infection, viral infection of the urogenital system, and constipation, was found to have multiple days without documented bowel movements in April 2024. Despite having a physician's order for Miralax to be administered every six hours as needed for constipation, the medication was only administered once on 04/04/24. The resident's Bowel and Bladder Elimination Record showed no bowel movements for several days, and there was no evidence of physician notification after 72 hours of no bowel movements, as verified by the Director of Nursing (DON). This affected one of two residents reviewed for bowel incontinence, with the facility census being 82. The Minimum Data Set (MDS) assessment indicated that the resident had mild cognitive impairment and was always incontinent of bowel and bladder. The resident's plan of care included administering medications as ordered to manage the risk of alteration in elimination. However, the facility did not adhere to this plan, leading to the deficiency. The DON confirmed that the physician should have been notified after 72 hours of no bowel movements, but this protocol was not followed, and the resident did not receive the necessary medication consistently.
Failure to Provide Timely Incontinence Care
Penalty
Summary
The facility failed to ensure timely incontinence care and services for a resident with severe cognitive impairment and multiple medical conditions, including type II diabetes mellitus, gastrointestinal hemorrhage, anemia, coronary artery disease, and depression. The resident was always incontinent of bowel and bladder and required partial to moderate assistance for daily activities. The nursing plan of care lacked specific documentation for monitoring incontinence frequency and the use of protective incontinence products. Additionally, the plan did not address the resident's ability to use the bathroom or the frequency of toileting offers. On the day of observation, the resident was found seated in a wheelchair with a saturated seat cushion and incontinence brief, indicating a lack of timely incontinence care. The State Tested Nurse Aide (STNA) responsible for the resident's care did not inform the nurse about the resident's skin breakdown or the resident's refusal of incontinence care. The Licensed Practical Nurse (LPN) on duty was also unaware of the skin breakdown and the resident's refusal of care. When the resident was finally moved to the bed, an area of moisture-associated skin breakdown (MASD) was discovered on the sacrum, causing the resident pain. The facility's Urinary Continence and Incontinence Assessment and Management policy required staff to document continence details, identify risk factors, and implement a toileting plan. However, these steps were not adequately followed, leading to the resident's skin breakdown and pain. The wound specialist later assessed the resident and confirmed the presence of a non-pressure partial thickness sacrum wound, which had been present for more than seven days without appropriate treatment or intervention.
Failure to Administer Pain Medication as Ordered
Penalty
Summary
The facility failed to manage a resident's pain and administer pain medications as ordered by the physician. Resident #287, diagnosed with polyneuropathy, had a physician's order for gabapentin 300 mg three times daily. However, on 05/01/24, an LPN administered only 100 mg of gabapentin to the resident, despite the updated order for 300 mg. The LPN did not read the entire order on the Medication Administration Record (MAR) and only administered the lower dose. The resident questioned the dosage, but the LPN did not verify the updated order until after the medication was given. The facility's policy on Medication Administration and General Guidelines requires that medications be administered according to the physician's written orders, and any discrepancies between the MAR and medication label should be checked against the physician's order. Additionally, the facility's Pain Assessment and Management policy emphasizes a commitment to appropriate pain assessment and treatment. The failure to follow these policies resulted in inadequate pain management for Resident #287.
Failure to Ensure Ongoing Communication for Dialysis Care
Penalty
Summary
The facility failed to ensure ongoing communication and collaboration with the dialysis facility regarding dialysis care and services for Resident #287, who was admitted with end-stage renal disease (ESRD) and dependence on dialysis. The medical record review revealed that from 04/24/24 to 05/01/24, there was no documentation of dialysis communication. Interviews with staff, including a Registered Nurse (RN) and Licensed Practical Nurses (LPNs), indicated that the facility did not consistently send dialysis communication forms. One LPN mentioned that she had just learned about a red dialysis book, which was newly created and kept in the unit manager's office, but there was no dialysis communication information in the resident's hard chart or electronic medical record. The Director of Nursing (DON) confirmed the absence of dialysis communication forms in both the hard chart and electronic medical record for Resident #287. The facility's policy on the care of residents with ESRD, revised in 09/10, stated that residents with ESRD would be cared for according to currently recognized standards of care. However, the lack of documented communication between the facility and the dialysis center indicates a failure to adhere to this policy, potentially compromising the quality of care provided to the resident.
Failure to Ensure Timely Physician Response to Pharmacy Recommendations
Penalty
Summary
The facility failed to ensure timely physician response to pharmacy recommendations regarding the use of as-needed (PRN) psychotropic medications for a resident. Resident #7, who was admitted with diagnoses of major depressive disorder and generalized anxiety disorder, was prescribed Clonazepam 0.5 mg to be taken every twelve hours as needed. The pharmacy identified the need for anticipated duration and continued use rationale in their reviews dated 02/19/24 and 03/27/24, but there was no physician response until the date of the survey on 05/02/24. Interviews with the Registered Nurse Regional Support and the Director of Nursing confirmed that the pharmacy's recommendations for the PRN psychotropic medication were not addressed in a timely manner. The facility's policy on medication monitoring, which requires monthly reassessment of the need for sedative medications by the responsible physician, was not followed. This resulted in a failure to comply with the monitoring standards for the prescribed dose of Clonazepam for Resident #7.
Medication Administration Errors
Penalty
Summary
The facility failed to ensure medications were administered as ordered by the physician, resulting in a medication error rate of 15%, which is above the acceptable threshold of 5%. Specifically, six medication errors were observed out of 40 opportunities. This affected one resident who had multiple diagnoses, including chronic respiratory failure, anxiety, COPD, chronic kidney disease, GERD, and PVD. The resident's medical record indicated that medications were to be administered within specific time frames, but these were not adhered to by the LPN responsible for the resident's care. On the day of observation, the LPN administered the resident's morning medications late and omitted the morning dose of Buspirone, instead giving the noon dose. The LPN also incorrectly documented that the medications had been administered earlier in the morning. The resident confirmed that she had not requested to hold her morning medications. The facility's policy requires medications to be administered within one hour of the scheduled time and documented accurately, which was not followed in this instance.
Failure to Administer Insulin as Prescribed
Penalty
Summary
The facility failed to ensure medications were administered to residents without significant medication errors, specifically affecting Resident #287. Resident #287, who has a diagnosis of diabetes mellitus and uses long-term insulin, did not receive the prescribed lispro insulin before breakfast as ordered. The LPN documented the administration of the insulin on the MAR without actually administering it. Later, the LPN administered the insulin without priming the needle, which is against the manufacturer's guidelines for proper insulin administration. The deficiency was identified through medical record review, observation, and interviews with both the resident and the LPN. The resident confirmed that he did not receive his insulin that morning, and the LPN admitted to not administering the insulin as ordered. The facility's policy and the manufacturer's guidelines for insulin administration were not followed, leading to a significant medication error for Resident #287.
Medication Administration and Documentation Failures
Penalty
Summary
The facility failed to ensure accurate documentation and administration of medications for two residents. For Resident #4, who has multiple diagnoses including chronic respiratory failure and anxiety, the Licensed Practical Nurse (LPN) administered medications but omitted the morning dose of Buspirone and instead gave the noon dose. The LPN had already initialed the morning dose as administered in the medical record, and there was no documentation of the resident refusing the medication or any notification to the physician about the missed dose. This discrepancy was observed during a review of the medical record and medication administration records (MAR) and confirmed through an interview with the LPN. For Resident #287, who has diabetes mellitus and uses long-term insulin, the LPN documented the administration of lispro insulin on the MAR but did not actually administer the insulin. The resident, who is cognitively intact, reported not receiving the insulin, and this was confirmed by the LPN during an interview. The facility's policy requires that medical records be accurate and complete, and that medication administration be recorded at the time the medication is given. However, these policies were not followed, leading to inaccuracies in the medical records for both residents.
Failure to Ensure Annual Training and Performance Reviews for STNAs
Penalty
Summary
The facility failed to ensure that state tested nurse aides (STNAs) received the required twelve hours of annual training and annual performance reviews. This deficiency was identified through a review of personnel files, staff interviews, and facility policy. Specifically, STNA #571, STNA #624, and STNA #629 did not meet the annual training requirements, and their performance evaluations were either missing or outdated. The training records lacked documentation of the amount of time spent on each training session, and the topics covered were either vague or unspecified. The personnel file for STNA #571 showed only three trainings with no documented time and no annual performance evaluation. Similarly, STNA #624 had three trainings with no documented time and no performance evaluation since September 2022. STNA #629 had four trainings with no documented time and no performance evaluation since September 2022. The Administrator confirmed these deficiencies during an interview. The facility's policy mandates that all personnel attend regularly scheduled in-service training classes and that performance reviews be conducted annually, with in-service training based on these reviews. However, these requirements were not met for the STNAs in question.
Failure to Ensure Resident Dignity and Respect
Penalty
Summary
The facility failed to ensure residents were treated in a dignified manner, specifically affecting one resident with multiple diagnoses including major depressive disorder, PTSD, and paraplegia. The resident reported being verbally assaulted by an LPN, who used curse words and yelled during a verbal altercation. The incident was corroborated by interviews with the resident, the LPN, a nursing assistant, and a police officer. The altercation began over a schedule book the resident had removed from the nurse's station desk, escalating to the point where the nursing assistant had to intervene to separate the two parties. Further investigation revealed that the LPN had a history of disciplinary issues related to poor customer service and had received prior education on resident rights and abuse prevention. The Resident Council meeting minutes also indicated ongoing concerns about staff behavior, including disrespect and lack of mindfulness towards residents and their property. The facility's policies on abuse prevention and resident rights were reviewed, highlighting the requirement for staff to treat residents with kindness, respect, and dignity.
Latest citations in Ohio
A resident with intact cognition receiving Medicare Part A skilled services for metabolic encephalopathy had services discontinued while benefit days remained, but the facility did not issue the required Skilled Nursing Facility Advance Beneficiary Notice (SNF ABN). The Social Services Director later confirmed that no SNF ABN was provided and reported she believed only a Notice of Medicare Non-Coverage (NOMNC) was needed when all skilled services were stopped. This practice conflicted with the facility’s written policy, which required SNF ABNs to be issued when extended care items or services were initiated, reduced, or terminated due to expected non-coverage by Medicare.
Surveyors identified that the facility exceeded the acceptable medication error rate when two residents with type 2 DM received insulin doses that were not administered according to orders or manufacturer instructions. In two separate observations, an LPN administered Novolog and another LPN administered insulin glargine and insulin lispro without priming the insulin pens, and the insulin lispro and Novolog were given after the residents had already consumed a significant portion of their breakfast meals, despite orders for administration before meals. Manufacturer information for both insulin products required priming before each injection to ensure accurate dosing, and facility policy required medications, including insulin, to be administered safely, timely, and in accordance with prescriber orders and specified time frames.
Surveyors found that the facility failed to document tray line food temperatures for multiple meals served from two dining room kitchenettes, despite having a “Trayline Taste & Temperature Log” and a policy requiring food to be stored, prepared, distributed, and served according to professional food safety standards. Review of logs showed repeated missing entries for breakfast, lunch, and dinner services in both the Harrison and McClellan dining areas, and the Senior Director of Culinary Services confirmed that temperatures had not been recorded for those meals, potentially affecting all residents receiving meals from those kitchenettes.
The facility failed to conduct and document required periodic care conferences for two residents, despite multiple comprehensive, quarterly, and significant change MDS assessments and a policy requiring periodic care conferences with resident and/or family participation. One resident with Parkinson’s disease, post-stroke hemiplegia, TIA, DMII, and depression had only two documented care conferences over a year, while another resident with aphasia, cerebrovascular disease, DMII, gait difficulty, coagulation defect, depression, and muscle weakness had no documented care conferences in the past year, aside from a declined invitation to the representative. The UCC confirmed that care conferences were expected to occur quarterly and that no additional documentation existed for either resident.
A resident with Alzheimer's disease and type II DM, who required extensive assistance with ADLs and was receiving scheduled Lantus and sliding-scale Humalog, experienced a severely elevated blood glucose level. The on-call provider was notified and ordered an additional dose of lispro insulin with a directive to recheck the blood glucose after administration. Nursing staff administered the extra insulin but did not document any follow-up blood glucose check, and the DON confirmed that this reevaluation was required by the facility's abnormal blood glucose policy and was not completed or documented.
A resident with Parkinson’s disease, dementia, and hypothyroidism was prescribed levothyroxine once daily along with other medications. A consultant pharmacist’s monthly drug regimen review recommended that levothyroxine be given in the morning on an empty stomach, 30–60 minutes before food, per manufacturer instructions. The medical record contained no documented physician response to this recommendation, and the MAR showed the drug scheduled for morning administration while the resident was observed eating breakfast and receiving the medication at the same time. An LPN confirmed administering levothyroxine during the meal, and the DON verified there was no documentation explaining whether or why the pharmacist’s recommendation was or was not followed, resulting in a failure to act on and document the identified irregularity.
A resident with severe cognitive impairment, multiple comorbidities, documented gait and balance abnormalities, and a high fall risk was care planned and assessed by therapy to require contact guard assistance and use of a gait belt for transfers and ambulation. While being assisted by a CNA from a recliner to the bathroom with a walker, the CNA did not apply a gait belt, even though the resident had a known tendency to lean backward when standing. As the CNA reached to open the bathroom door, the resident lost balance and fell backward, striking the back of the head, and was later found by an LPN without a gait belt in place, contrary to the facility’s gait belt policy and the resident’s assessed needs.
A resident with CKD stage five requiring peritoneal dialysis (PD) was admitted with pre-admission physician orders for three daily PD exchanges and monitoring for peritonitis (fever, abdominal pain, cloudy effluent), but these monitoring orders were not entered into the facility’s physician orders. The care plan referenced PD and general monitoring but did not specifically address peritonitis monitoring. Paper PD flowsheets showed incomplete and inconsistent documentation of exchanges and resident condition, including missing condition/comments for individual treatments and no record of one ordered PD exchange. The PD cycler flowsheet lacked effluent descriptions on multiple days. The PD nurse reported facility staff were expected to monitor effluent and symptoms, and the DON confirmed the absence of specific peritonitis monitoring orders, lack of an order for the PD cycler, and documentation gaps, despite a facility policy requiring ongoing assessment and monitoring for complications before, during, and after dialysis treatments.
A nurse was observed preparing multiple oral medications for a resident with depression, traumatic brain injury, anxiety, and impaired cognition by pushing tablets and capsules from unit-dose cards directly into her ungloved hand and then using her fingers to place them into a medication cup. In a follow-up interview, the RN confirmed this practice and acknowledged that the correct procedure is to dispense medications directly from the card into the cup, contrary to the facility’s medication administration policy requiring adherence to good nursing principles and practices.
A resident with Alzheimer’s disease, diabetes, anxiety, significant ADL dependence, and behavioral symptoms was observed seated in a chair positioned against the nursing station with a locked wheelchair placed directly in front, also against the nursing station, effectively restricting movement. An LPN confirmed both wheelchair wheels were locked and that it should not have been placed there, while a CNA stated she had positioned the wheelchair to prepare for lunch, was unable to complete the transfer, and left it in place, acknowledging this was wrong. This arrangement conflicted with the facility’s restraint policy, which prohibits physical restraints except when alternatives are ineffective for treating a medical symptom and defines restraints as devices adjacent to the body that cannot be easily removed and that restrict freedom of movement or access to the body.
Failure to Issue Required SNF ABN When Discontinuing Medicare Part A Services
Penalty
Summary
The deficiency involves the facility’s failure to issue a Skilled Nursing Facility Advance Beneficiary Notice (SNF ABN) when Medicare Part A services were discontinued for a resident who still had available benefit days. The resident was admitted with a diagnosis of metabolic encephalopathy and had intact cognition per the Minimum Data Set assessment. The facility’s own SNF Beneficiary Notification Review documented that Medicare Part A skilled services began on 02/11/26 and the last covered day was 03/11/26, and that the facility initiated discharge from Medicare Part A services before the resident’s benefit days were exhausted. Despite this, no SNF ABN was provided to the resident or the resident’s representative. During interviews, the Social Services Director stated that the SNF ABN was issued hours prior to the last covered day but, upon reviewing her files, confirmed that no SNF ABN had actually been issued for this resident. She further explained that she believed an SNF ABN was only required if one skilled service remained and that if all skilled services were being discontinued, only the Notice of Medicare Non-Coverage (NOMNC) needed to be issued. The Administrator, however, stated that a resident should always receive both a SNF ABN and a NOMNC when Medicare Part A services are discontinued and benefit days remain. Review of the facility’s written policy dated 03/28/23 showed that the facility was required to issue SNF ABNs for initiation, reduction, or termination of extended care items or services when Medicare payment was not expected, which did not occur in this case.
Plan Of Correction
This Plan of Correction is submitted as required under State and Federal law. This Plan of Correction does not constitute an admission on the part of the Facility that the findings cited are accurate, that the findings constitute a deficiency or that the scope and severity regarding the deficiency cited are correctly applied. Any changes to the Facility's policies and procedures should be inadmissible in any proceeding on that basis. Without admitting or denying the validity or the existence of the alleged noncompliance, the Facility submits this Plan of Correction with the intention that it be inadmissible by any third party in any civil or other action against the facility or any employee, agent, officer, director or shareholder of the Facility. The Facility is utilizing this Plan of Correction as its allegation of substantial compliance as of 05/29/2026 F-0582 Corrective action for resident/s: On 5/14/26 Resident #34 was informed of rights and responsibilities related to Advanced Beneficiary Notice and voiced understanding of information for future reference by administrator. Identification of other residents who may be affected: Any resident receiving skilled services from nursing or therapy services. The Administrator audited all residents who were discharged from skilled services in the past 30 days to ensure they were issued a Notice of Non-Coverage and Advanced Beneficiary Notice on 5/29/26. No non-compliance was noted. Measures for systemic change: On 5/14/2026 Business Office Manager, Director of Rehab, Minimum Data Set nurse, Director of Nursing and Social Services Director were educated on proper procedure of issuing of Notice Of Medicare Non Coverage and Advanced Beneficiary Notice by administrator. All upcoming discharges from skilled services will be reviewed weekly at Utilization Review meeting to ensure notices will be delivered timely. How Corrective Action will be monitored: Administrator or designee to complete audits of all residents being discharged from skilled services to ensure they were issued a Notice of Non-Coverage and Advanced Beneficiary. This audit will be completed weekly x 4 weeks, then monthly x 2 months. Corrective action will be initiated for any noted non-compliance. Audit findings will be reviewed as part of the monthly quality assurance process to determine the need for further monitoring. Date of Compliance 5/29/26
Insulin Administration Errors and Failure to Prime Insulin Pens
Penalty
Summary
The deficiency involves the facility’s failure to maintain a medication error rate below 5%, with surveyors identifying 3 errors out of 28 medication administration opportunities, resulting in a 10.71% error rate. For one resident with type 2 diabetes mellitus and moderate cognitive impairment, the physician’s order directed Novolog insulin 10 units via subcutaneous pen-injector to be given before meals. During an observed medication pass, the LPN administered 10 units of Novolog insulin without priming the pen and did so after the resident had already consumed approximately 50% of the breakfast meal. The LPN later confirmed she did not prime the pen and acknowledged that the insulin was ordered to be administered prior to meals. Manufacturer instructions for the Novolog FlexPen specified that an air shot (priming) must be performed before each injection to ensure proper dosing. Another resident, also diagnosed with type 2 diabetes mellitus and with intact cognition, had orders for insulin glargine 35 units subcutaneously twice daily and insulin lispro 20 units subcutaneously before meals, plus 12 units subcutaneously if blood glucose was between 251 mg/dL and 300 mg/dL. During an observed medication administration, an LPN administered 35 units of insulin glargine and 32 units of insulin lispro without priming the insulin pens and after the resident had consumed approximately 90% of the breakfast meal, despite orders for insulin lispro to be given before meals. The LPN later stated she could not remember if she had primed the pen and acknowledged that the insulin was ordered to be administered prior to meals. Manufacturer information for insulin lispro stated that the pen must be primed before each injection to confirm insulin delivery and remove air, and that failure to prime could result in too much or too little insulin. The DON confirmed the expectation that insulin be administered as ordered, including priming each pen with two units before dialing the prescribed dose, and facility policy required medications, including insulin, to be administered safely, timely, and in accordance with prescriber orders and required time frames.
Plan Of Correction
This Plan of Correction is submitted as required under State and Federal law. This Plan of Correction does not constitute an admission on the part of the Facility that the findings cited are accurate, that the findings constitute a deficiency or that the scope and severity regarding the deficiency cited are correctly applied. Any changes to the Facility's policies and procedures should be inadmissible in any proceeding on that basis. Without admitting or denying the validity or the existence of the alleged noncompliance, the Facility submits this Plan of Correction with the intention that it be inadmissible by any third party in any civil or other action against the facility or any employee, agent, officer, director or shareholder of the Facility. The Facility is utilizing this Plan of Correction as an allegation of substantial compliance as of 5/29/2026. F-0759 Corrective action for resident/s: Residents #21 and #22 were assessed and evaluated by nurse and Director of Nursing 5/14/26. Resident #21 and #22 both denied any adverse effects and none were noted upon assessment by the Director of Nursing on 5/14/2026. Notification made to physician on 5/14/2026. LPN # 2 competency Eval on insulin administration with the Director of Nursing completed 5/14/2026. Identification of other residents who may be affected: Diabetic residents on assignment of LPN #2/station 2 have the potential to be affected and were assessed by the DON/Designee on 5/14/26 and found to be within normal limits. Measures for systemic change: All Nurses were educated by the Director of Nursing on the steps for Insulin administration per competency, diabetes clinical protocol policy, Medication and treatment orders policy, administering medications policy, and Obtaining fingerstick Glucose Level policy On 5/14/2026. How Corrective Action will be monitored: Director of Nursing and Assistant Director of Nursing will complete insulin administration audits on 5 nurses. This audit will be completed weekly x 4 weeks, then monthly x 2 months. Corrective action will be initiated for any noted non-compliance. Audit findings will be reviewed as part of the monthly quality assurance process to determine the need for further monitoring. Date of Compliance: 5/29/2026
Failure to Document Tray Line Food Temperatures in Dining Room Kitchenettes
Penalty
Summary
The deficiency involves the facility’s failure to document tray line food temperatures for meals served from the Harrison and McClellan Dining Room kitchenettes, as required by professional standards for food service safety and the facility’s own policy. Review of the “Trayline Taste & Temperature Log” (revised September 2018) showed missing temperature documentation for multiple meals from the Harrison Dining Room kitchenette, including dinner on 03/30/26 and 03/31/26, lunch and dinner on 04/01/26 and 04/02/26, dinner on 04/07/26, and lunch and dinner on 04/08/26 and 04/10/26. The Senior Director of Culinary Services confirmed during interview that tray line food temperatures were not documented on the log for these meals. Similarly, review of the same log for the McClellan Dining Room kitchenette revealed that tray line food temperatures were not documented for dinner on 04/01/26, breakfast and lunch on 04/02/26, and lunch and dinner on 04/07/26. The Senior Director of Culinary Services also verified these omissions during interview. The facility census at the time was 27 residents, and the governing “Food and Nutrition” policy, approved on 09/07/21, stated that the facility must store, prepare, distribute, and serve food in accordance with professional standards for food service safety.
Plan Of Correction
F812 The facility will continue to ensure food temperatures are completed before meals are served for all residents. To ensure compliance with this standard the following measures have been taken: 1. Immediately 4/15/26 culinary supervisor #224 was re-educated by Dietary Manager to this standard and policy "Food and Nutrition" which includes documentation of food temperatures. 2. All dietary staff have been re-educated to the standard and policy "Food and Nutrition" during the month of April 2026. 3. Audits of food temperature documentation to be completed by Dietary Manager 4 x per week for 4 weeks then weekly for 4 weeks. 4. Administrator to validate audits/compliance and provide additional training as needed. Administrator will present to QAPI committee for ongoing monitoring and further direction.
Failure to Conduct and Document Required Care Conferences
Penalty
Summary
The deficiency involves the facility’s failure to complete and document comprehensive care conferences at required intervals in accordance with care plan regulations and facility policy. For one resident with Parkinson’s disease with dyskinesia, cognitive communication deficit, hemiplegia and hemiparesis following cerebral infarction, transient cerebral ischemic attack, type II diabetes mellitus, and major depressive disorder, the record showed multiple MDS assessments over a one-year period, including annual, quarterly, and significant change assessments. However, only two care conferences were documented during the last 12 months, despite the expectation that care conferences be conducted quarterly with the resident and family when possible. The Unit Care Coordinator confirmed that no additional care conference documentation existed for this resident beyond the notes dated 04/21/25 and 01/02/26. A second resident, with diagnoses including aphasia following cerebrovascular disease, cerebral infarction, type II diabetes mellitus, unsteadiness on feet, difficulty in walking, coagulation defect, depression, and muscle weakness, also had multiple MDS assessments completed over the review period, including quarterly and annual assessments. The record contained a note that a care conference was offered to the resident’s representative, who declined to attend, but there was no documentation of any care conferences for the most recent 12 months. The Unit Care Coordinator confirmed that no other care conference documentation was available for this resident. Facility policy stated that periodic care conferences involving the resident, family, and the interdisciplinary team are part of the care planning process, but the required periodic care conferences and corresponding documentation were not completed for these two residents.
Plan Of Correction
THIS PLAN OF CORRECTION SERVES AS BERKELEY SQUARE'S CREDIBLE ALLEGATION OF SUBSTANTIAL COMPLIANCE AS OF June 1, 2026. Without admitting or denying the validity or existence of the alleged deficiencies, Berkeley Square provides the following Plan of Correction: F657 The facility will continue to document completion of care conferences at the required intervals for all residents, including residents #04 & #15. To ensure compliance with this standard the following measures have be taken: 1. The social service designee and the inter- disciplinary team were re-educated by the administrator to the facility policy "Care Conference" on 4/29/26 and verbalized understanding. 2. Care conferences for resident #04 and resident #15 were conducted on or before 4/29/2026 by the interdisciplinary team. 3. Review of all other residents was conducted by the social service designee to validate and ensure that care conference schedule is up to date with timely care conferences scheduled for them on 4/15/2026. Audits of care conferences to be completed weekly for four weeks and then monthly after that by the social service designee. Documentation of the care conference including any identified concerns in the medical record. Administrator to validate audits/compliance and provide additional training as needed. Administrator will present results of these audits to QAPI committee for ongoing monitoring and further direction.
Failure to Reevaluate Blood Glucose After Treatment for Hyperglycemia
Penalty
Summary
The facility failed to ensure that a resident with diabetes received treatment in accordance with professional standards of practice when nursing staff did not reevaluate the resident's blood glucose after treatment for severe hyperglycemia. The resident, admitted with diagnoses including Alzheimer's disease, type II diabetes mellitus, and depression, had physician orders for Humalog insulin on a sliding scale before meals, Lantus insulin 25 units daily, and lisinopril 5 mg daily. The resident required extensive assistance with activities of daily living, including transfers, toileting hygiene, eating, and bathing. On the evening in question, the resident's blood glucose was documented as 532 mg/dL, and the on-call provider was notified. The provider gave a new order to administer an additional 8 units of lispro (Humalog) and to recheck the blood glucose in 30 minutes. The electronic medication administration record showed that the blood glucose of 532 mg/dL was obtained at 9:00 p.m. and that the additional 8 units of lispro were administered at 9:21 p.m. However, there was no documentation in the resident's chart that the blood glucose was rechecked after the additional insulin was given. In an interview, the DON confirmed there was no evidence of reevaluation and verified that, according to the facility's "Abnormal Blood Glucose Procedure" policy, the resident should have been reevaluated and that the evaluation step should have been included in the progress note documentation.
Plan Of Correction
F684 The facility will continue to ensure all residents, including #03, receive treatment in accordance with professional standards of practice and reevaluated for hyperglycemia. To ensure compliance with this standard the following measures have been taken: 1. The director of nursing assessed resident #03, reviewed documentation and orders and found no ill effects immediately 4/16/26. 2. All licensed nurses were re-educated to facility policy "Blood Glucose Monitoring" by the Director of Nursing/designee in April 2026. 3. Audits of like-residents that require blood sugar checks to be completed by the director of nursing/designee two times a week for 4 weeks and then monthly after that to validate correct follow through when there is abnormally high blood glucose result. The Administrator will bring results of these audits to the QAPI committee for ongoing monitoring and further direction.
Failure to Act on Pharmacist Drug Regimen Recommendation for Thyroid Medication
Penalty
Summary
The deficiency involves the facility’s failure to ensure that pharmacy recommendations from the monthly drug regimen review were acted upon and documented for a resident. The resident was admitted with diagnoses including Parkinson’s disease, dementia, and hypothyroidism, and had current physician orders for levothyroxine 150 mcg once daily, buspirone 50 mg twice daily, and losartan 100 mg once daily. A medication regimen review dated 11/25/2025 included a consultant pharmacist recommendation that levothyroxine be administered consistently in the morning on an empty stomach, at least 30–60 minutes before food, per manufacturer instructions. There was no specific physician response in the medical record to this recommendation, and the facility’s policy stated that consulting pharmacist reviews are sent to nursing and addressed with the primary care provider or consulting specialist for review and follow-up. Review of the resident’s medication administration record for April 2026 showed levothyroxine scheduled for 9:00 a.m. On observation, the resident was seen eating breakfast in the dining area at 8:03 a.m., and an LPN reported administering the levothyroxine 150 mcg to the resident while the resident was in the dining area eating breakfast. The DON confirmed there was no evidence in the resident’s medical record explaining why the consultant pharmacist’s recommendation from 11/25/2025 was or was not acted upon. This lack of documented physician review and action on the pharmacist’s identified irregularity constituted noncompliance with the drug regimen review requirements.
Plan Of Correction
F756 The facility will continue to ensure the pharmacy recommendations from the monthly drug regimen review by a licensed pharmacist are acted upon for all residents, including #08. To ensure compliance with this standard the following measures have been taken: 1. Resident #08 was assessed by the registered nurse and med review completed by 4/28/26. After review of resident's drug regime's, it was discovered that resident #8 had 2 separate medication recommendations on the same form, to be reviewed by two separate practitioners, pharmacy has been instructed and agreed to separate meds on individual forms. 2. Licensed nurses re-educated to facility policy "Drug Regimen Review" by Director of nursing/designee in April 2026 and no later than 5/8/26. Licensed nurses are responsible for ensuring the reviews and recommendations are given to the physician for timely review. 3. Review of all other current residents Drug Regimen orders completed by Director of nursing/designee on 4/16/26 to ensure recommendations were followed up on/reviewed by the physician and address concerns if needed. 4. Audit of drug regime recommendations, pharmacy recommendations, and physician follow up to be completed weekly for four weeks by the Director of nursing/designee. Administrator will present results of these audits to the QAPI committee for ongoing monitoring and further direction.
Failure to Use Required Gait Belt During Ambulation Resulting in Resident Fall
Penalty
Summary
The deficiency involves the facility’s failure to ensure that a required gait belt was used while assisting a high fall‑risk resident with ambulation, resulting in a fall with head injury. The resident had multiple diagnoses including metabolic encephalopathy, hypertension, osteoarthritis, muscle weakness, gait and mobility abnormalities, major depressive disorder, anxiety, and visual hallucinations. Admission and subsequent MDS and fall risk assessments documented that the resident was severely cognitively impaired, required moderate to maximal assistance with transfers and ambulation, could not independently come to a standing position, exhibited loss of balance while standing, used an assistive device, and had decreased muscle coordination. The resident had a history of falls prior to admission and was assessed as being at high, later moderate, risk for falls. The resident’s fall care plan identified her as at risk for falls and included interventions such as providing maximum to moderate assistance with transfers and walking short distances, use of a walker and wheelchair, and following the facility’s fall protocol. Therapy notes and care conference documentation indicated that the resident leaned backwards when standing, required contact guard to minimal assistance for bed mobility and transfers, and needed constant verbal cueing for safe sequencing during toilet transfers. The physical therapist confirmed that the resident was to use a gait belt with staff when ambulating, and the DON verified that therapy had assessed the resident as requiring contact guard assistance and a gait belt for ambulation and transfers. On the day of the incident, a CNA was assisting the resident from her recliner to the bathroom using a walker. The CNA walked beside the resident, providing guidance and support, and reported having a hand on the resident while assisting her. As they approached the bathroom door, the CNA reached for the doorknob to open it, and at that moment the resident began to lose her balance and fell backwards to the floor, striking the back of her head. The nurse who responded found the resident on her back at the foot of the bed with her feet near the bathroom, noted a red raised area on the back of the head, and documented that the resident was not wearing a gait belt and that the gait belt was on the dresser. In the facility’s investigative summary and in interviews, the CNA acknowledged that she did not have a gait belt on the resident while ambulating her, despite the resident’s assessed need for hands‑on assistance and gait belt use per facility policy and the resident’s care and therapy plans.
Failure to Implement PD Orders and Monitor Resident Receiving Peritoneal Dialysis
Penalty
Summary
The deficiency involves the facility’s failure to implement pre-admission physician orders for peritoneal dialysis (PD) and to provide ongoing monitoring for a resident with chronic kidney disease (CKD) stage five who required PD. Pre-admission orders dated 11/14/25 specified three daily PD exchanges at 6:00 A.M., 2:00 P.M., and 10:00 P.M., and directed staff to monitor for signs and symptoms of peritonitis, including fever, abdominal pain, and cloudy effluent. These monitoring orders were not entered into the facility’s physician orders. The resident’s care plan noted the need for PD and included general monitoring interventions (labs, signs of bleeding, bacteremia, septic shock, and significant vital sign changes), but did not specifically address the ordered monitoring for peritonitis. Review of PD documentation showed incomplete and inconsistent charting of treatments and resident condition. The paper peritoneal flowsheet had columns for time of PD and condition/comments, including instructions to call the nurse immediately for cloudy fluid, abdominal pain, or fever. However, the first entry on 11/15/26 at 2:00 P.M. only noted that the PD nurse completed the exchange, and the 10:00 P.M. entry that day had no condition/comment documentation. Subsequent days (11/16/25, 11/17/25, and 11/18/25) contained only one condition/comment entry per day rather than for each exchange, and there was no documentation that the 6:00 A.M. PD on 11/18/25 was completed. The PD cycler flowsheet starting 11/19/25 lacked any description of the effluent on multiple days. The PD nurse from the dialysis company stated facility staff were expected to monitor effluent for cloudiness and assess for abdominal pain and fever, and the DON confirmed there was no electronic physician order for peritonitis monitoring or for use of the PD cycler, that the paper charting did not allow for effluent description or symptom documentation for each treatment, and that PD was not documented at one ordered time. The facility’s dialysis policy required ongoing assessment and monitoring for complications before, during, and after treatments, which was not reflected in the documentation for this resident.
Improper Infection Control During Medication Administration
Penalty
Summary
Surveyors identified a deficiency in infection prevention and control related to medication administration for Resident #29. The resident was admitted on 02/28/14 with diagnoses including depression, traumatic brain injury, and anxiety, and had impaired cognition per a quarterly MDS assessment. During an observation on 03/25/26 at 6:58 A.M., RN #281 prepared the resident’s medications by removing an Amoxicillin-Pot Clavulanate tablet from the medication card and pushing it directly into her ungloved hand, then using her fingers to place the pill into a medication cup. The same process was observed for multiple other medications, including Escitalopram Oxalate, Furosemide, Sennosides, Lyrica, and Vitamin D, each being pushed from the card into the RN’s ungloved hand and then transferred by her fingers into the medication cup before administration to Resident #29. In a subsequent interview at 7:27 A.M. the same day, RN #281 confirmed she had placed each medication into her ungloved hands prior to administration and acknowledged that the proper procedure was to push the pills directly from the card into the medication cup. Review of the facility’s “Medication Administration – General guidelines” policy, revised 10/08/25, stated that medications are to be administered in accordance with good nursing principles and practices. This practice failure was cited as a deficiency under Complaint Number 2681777.
Improper Use of Wheelchair as a Physical Restraint
Penalty
Summary
Surveyors identified a deficiency related to the facility’s failure to ensure a resident was free from physical restraints. Resident #7, admitted with diagnoses including Alzheimer’s disease, diabetes mellitus, and anxiety disorder, was documented on a recent MDS as rarely understood and dependent for ADLs except eating. The resident ambulated independently on the unit without an assistive device and had documented verbal and other behaviors occurring one to three days during the look-back period. The care plan noted the resident had potential to be physically aggressive, chase staff, throw objects, and be combative with care, with interventions such as offering choices, administering medications as ordered, and intervening early when agitation occurred. During an observation and interview, Resident #7 was found sitting in a chair with the right arm of the chair positioned against the nursing station and a wheelchair placed directly in front of him. The left arm of the wheelchair was also against the nursing station, and both wheelchair wheels were locked, creating a barrier that appeared to restrain the resident, who was sleeping with his knees touching the locked wheelchair. An LPN confirmed both wheelchair wheels were locked and that the wheelchair should not have been placed in front of the resident. A CNA reported she had placed the wheelchair there in preparation to get the resident up for lunch, was unable to transfer him, and left the wheelchair in that position, acknowledging it was wrong to keep it there. The facility’s physical restraint policy stated that physical restraints are not used except when alternatives are not appropriate or effective for treating a medical symptom and defined physical restraints as any device attached or adjacent to the body that the individual cannot easily remove and that restricts freedom of movement or access to the body.
Trusted data from CMS and state health departments
Every citation, penalty and Plan of Correction is sourced from public CMS records (latest release May 27, 2026) and official state health department websites — never guesswork.
Trusted by long-term care providers and associations.
