Ayden Healthcare Of Rosemount Pavilion
Inspection history, citations, penalties and survey trends for this long-term care facility in Portsmouth, Ohio.
- Location
- 20 Easter Drive, Portsmouth, Ohio 45662
- CMS Provider Number
- 365584
- Inspections on file
- 22
- Latest survey
- May 16, 2025
- Citations (last 12 mo.)
- 0
Citation history
Health deficiencies cited at Ayden Healthcare Of Rosemount Pavilion during CMS and state inspections, most recent first.
Surveyors found that the facility did not develop or implement comprehensive, individualized care plans for several residents, resulting in generic interventions that failed to address specific needs such as pressure ulcers, trauma histories, mental health conditions, and complex medical diagnoses. Staff and the DON confirmed that care plans were incomplete or not tailored to each resident, and observations showed that important aspects of care, including use of medical devices and management of comorbidities, were not addressed in the care plans.
The facility did not appropriately assess or develop care plans for residents with PTSD or trauma histories, failing to identify causes, triggers, or implement interventions to minimize re-traumatization. Several residents with trauma-related diagnoses did not have individualized trauma-informed care plans, and staff confirmed that necessary assessments and interventions were not completed.
A resident with significant medical and cognitive needs was observed with an uncovered foley catheter drainage bag lying on the floor. The facility's care plan and catheter policy did not address the use of a dignity bag to cover the catheter, resulting in a failure to support the resident's right to privacy and dignity.
Surveyors found that MDS assessments did not accurately reflect the use of pressure relieving devices and mechanically altered diets for three residents. One resident with a pressure ulcer was not documented as having a specialty mattress, another was receiving a mechanical soft diet not reflected in the MDS, and a third with multiple wounds and an amputation was not recorded as having pressure relieving devices or scheduled repositioning, despite evidence to the contrary.
A resident with PTSD, insomnia, and Parkinson's disease was care planned for fall risk with a commode or urinal at bedside, but this intervention was not present during observation. An LPN confirmed the absence, and the DON stated the intervention had been removed from the care plan, though this was not updated at the time of review.
A resident with diabetes, chronic kidney failure, and pruritis did not receive wound care as ordered by the physician. An LPN applied Optifoam bandages and Kerlix wraps not specified in the orders, used wound cleanser instead of soap and water, and failed to date or initial some dressings. The dressings were also not changed as scheduled, and the LPN confirmed the care provided did not follow physician orders or facility policy.
A resident with multiple complex wounds and significant care needs did not have complete or adequate physician orders for pressure ulcer care. Recommendations from a wound care NP for nutritional supplements and vitamins were not transcribed, and the facility could not provide a policy for wound care orders. The DON confirmed the inadequacy of the orders, contributing to insufficient wound management.
A resident with multiple medical conditions was inaccurately assessed as a non-smoker on two facility smoking assessments, despite being listed as a supervised smoker and observed smoking with staff supervision. The DON confirmed the assessments were incorrect, and facility policy required accurate smoking assessments for all smokers.
A resident with multiple chronic conditions and a physician order for a fortified foods diet with regular texture and thin liquids was instead served a mechanical soft diet with double protein portions and fortified mashed potatoes. Staff interviews revealed confusion about the resident's correct diet order, and there was no documentation of a physician order for the diet change. The facility could not provide a policy on dietary orders, and the MDS did not reflect the altered diet.
A resident with complex cardiac and hypertensive conditions received both Metoprolol and Midodrine despite physician orders specifying to hold these medications based on specific blood pressure parameters. Nursing staff and leadership confirmed that the medications were not held as required, resulting in significant medication errors.
A resident with multiple chronic conditions had physician orders for quarterly CBC, BMP, and HgbA1C lab tests, but these were not obtained as scheduled over several months. An LPN confirmed that the required labs were missed during the specified periods.
Surveyors found that two residents with indwelling Foley catheters had their drainage bags lying uncovered on the floor, as confirmed by staff. One resident was non-compliant with catheter care instructions, and facility policies did not address infection prevention for Foley catheters.
A resident with advanced dementia and on hospice care continued to receive scheduled tramadol despite family concerns about overmedication, excessive sedation, and weight loss. The family requested limiting pain medication to nighttime or as needed, but staff did not adjust the regimen or communicate directly with the family. The facility lacked a policy for opioid use or over-sedation management, and the resident’s condition and family concerns were not promptly or adequately addressed.
Failure to Develop and Implement Comprehensive, Individualized Care Plans
Penalty
Summary
The facility failed to develop and implement comprehensive, resident-centered care plans that addressed all identified needs for seven residents out of twenty reviewed during the annual survey. Surveyors found that care plans often contained only generic interventions and did not include individualized strategies based on each resident's diagnoses, conditions, or personal history. For example, one resident with a stage three pressure ulcer and orders for specific interventions such as a specialty mattress and heel protectors had a care plan that lacked individualized interventions and did not address the resident's inability to use certain equipment as intended. Several residents with mental health diagnoses, trauma histories, or complex medical conditions did not have care plans that addressed the full scope of their needs. One resident with PTSD had a care plan that only referenced access to psychiatry and psychosocial services, without identifying triggers or specific interventions to prevent re-traumatization. Another resident with a history of trauma and anxiety related to loud noises had no care plan addressing these issues, despite the resident's own report of distress and coping strategies. Additionally, residents with multiple comorbidities, such as heart failure, hypertension, diabetes, and recent fractures, had care plans that omitted key diagnoses and related interventions, such as cardiovascular disease management, pain control, or pressure ulcer prevention. Observations and interviews confirmed that care plans were incomplete or not individualized, and that staff, including the DON, acknowledged these deficiencies. In some cases, care plans did not address significant medical issues such as viral hepatitis, cirrhosis, depression, insomnia, or the use of medical devices like indwelling catheters and wound vacs. The lack of comprehensive care planning was evident through both documentation review and direct observation of residents and their care environments.
Failure to Assess and Care Plan for Trauma and PTSD in Residents
Penalty
Summary
The facility failed to ensure that residents with Post Traumatic Stress Disorder (PTSD) or a history of trauma were appropriately assessed to identify the causes of their trauma, potential triggers, and to implement care plans aimed at minimizing re-traumatization. Record reviews and interviews revealed that for five residents with PTSD or trauma histories, there were no comprehensive assessments conducted to determine the specific causes of their trauma or to identify triggers that could lead to re-traumatization. In several cases, care plans either did not exist or lacked interventions tailored to the residents' trauma-related needs. For example, one resident with multiple diagnoses including PTSD and severely impaired cognition had no care plan addressing the cause of PTSD, potential triggers, or interventions to reduce re-traumatization. Another resident, cognitively intact and reporting symptoms consistent with trauma, was not provided with a care plan that addressed her trauma or included interventions for staff to use in case of adverse reactions. Similarly, a resident who experienced a traumatic motor vehicle accident and exhibited emotional distress had no further assessment or care plan related to trauma triggers or symptoms. Additional residents with trauma histories, including one with PTSD and another with acute pain due to trauma and anxiety disorder, were not adequately assessed for causes or triggers of their trauma. Their care plans either lacked trauma-specific interventions or were entirely absent. Interviews with the DON confirmed that these assessments and care plans had not been completed, and that the facility had not taken steps to minimize the risk of re-traumatization for these residents.
Failure to Provide Dignity Bag for Foley Catheter
Penalty
Summary
Resident #233, who was admitted with multiple complex medical conditions including a right leg amputation, stage four sacral pressure ulcer, diabetes mellitus type two, and cognitive impairment, was observed to have an indwelling foley catheter. The resident was dependent on staff for activities of daily living and had a care plan in place for catheter management, which included positioning the catheter bag and tubing below the bladder and away from the entrance room door, as well as monitoring for signs of infection and documenting intake and output. However, the care plan and facility policy did not address the use of a dignity bag to cover the catheter drainage bag. On two separate occasions, the resident's foley catheter drainage bag was observed uncovered and lying on the floor. This was confirmed by a CNA during an interview. The facility's catheter policy, revised recently, did not include any guidance on covering the catheter bag with a dignity bag to enhance the resident's privacy. This omission resulted in a failure to honor the resident's right to dignity and privacy as required.
Inaccurate MDS Assessments for Pressure Devices and Diet Orders
Penalty
Summary
The facility failed to ensure that Minimum Data Set (MDS) assessments accurately reflected the use of pressure relieving devices and mechanically altered diets for three residents. For one resident with a history of pressure ulcer, morbid obesity, and diabetes, the MDS did not indicate the presence of a specialty mattress, despite documentation and observation confirming its use for several months. The Director of Nursing confirmed that the MDS assessment did not accurately reflect the use of the pressure reducing device. Another resident with Alzheimer's disease, malnutrition, and other chronic conditions was assessed on the MDS as not receiving a mechanically altered diet, even though dietary records, meal tickets, and staff interviews confirmed the resident was receiving a mechanical soft diet with double protein portions and fortified foods. There was also a lack of clear documentation regarding the diet order change, and staff were uncertain about the current diet order until it was updated in the electronic medical record during the survey. A third resident with multiple pressure ulcers, a recent amputation, and cognitive impairment was not documented on the MDS as having pressure relieving devices or being scheduled for turning and repositioning, despite observations and staff interviews confirming the use of a low air loss mattress, pressure relieving cushion, heel protector, and regular repositioning. The MDS Coordinator acknowledged that the MDS did not accurately reflect the resident's use of these devices and interventions.
Failure to Update and Implement Fall Prevention Interventions on Care Plan
Penalty
Summary
The facility failed to ensure that fall prevention interventions on a resident's care plan were reviewed and revised for accuracy. A resident with diagnoses including PTSD, insomnia, and Parkinson's disease was identified as being at risk for falls, with a care plan intervention specifying the use of a commode or urinal at bedside. During observation, it was noted that neither a commode nor a urinal was present at the resident's bedside. This was confirmed by an LPN, who acknowledged the absence of the intervention. The DON later confirmed that the intervention was no longer appropriate and had been removed from the care plan, but this update was not reflected in the care plan at the time of the survey.
Failure to Provide Wound Care as Ordered by Physician
Penalty
Summary
The facility failed to provide wound care treatments as ordered by the physician for a resident with multiple medical conditions, including diabetes mellitus, chronic kidney failure, and pruritis. The resident's care plan included interventions for eczematous areas and skin tears, with specific physician orders for cleansing and treating the left shoulder, left arm, and right forearm using designated products and techniques. However, observations revealed that the resident had an Optifoam bandage applied to the arm below the right elbow and the left shoulder, which were not ordered by the physician. Additionally, Kerlix dressings on both lower arms were saturated with blood and had not been changed according to the prescribed schedule, as indicated by the dates and staff initials on the dressings. During wound care treatment, an LPN was observed using wound cleanser instead of soap and water, applying Optifoam bandages and Kerlix wraps not specified in the physician's orders, and failing to date or initial some dressings as required by facility policy. The LPN confirmed that the wound care provided did not follow the physician's orders, acknowledging that Xeroform and a non-adherent bandage should have been used on the right arm and Triad cream with open air exposure on the left arm. Review of facility policy confirmed that treatments were to be applied as ordered and dressings were to be properly labeled, which was not done in this case.
Incomplete Physician Orders for Pressure Ulcer Care
Penalty
Summary
The facility failed to ensure that physician orders for pressure ulcer care contained sufficient information to provide adequate care for a resident with multiple complex wounds. The resident, who had a history of right leg amputation, stage four sacral pressure ulcer, diabetes, and other comorbidities, was dependent on staff for activities of daily living and had cognitive impairment. Upon review, the physician orders for wound care lacked complete and specific instructions, and recommendations from the wound care nurse practitioner for nutritional supplements and vitamins to aid wound healing were not transcribed into the physician orders. Additionally, the assessment did not document the use of pressure-reducing devices or repositioning interventions at admission. Observations confirmed the resident had a low air loss mattress and pressure-reducing cushion in use, and was positioned appropriately. However, the Director of Nursing acknowledged that the wound care orders were incomplete and inadequate for the resident's needs. The facility was unable to provide a policy for wound care orders and treatment, further contributing to the deficiency in ensuring proper pressure ulcer care and prevention.
Inaccurate Smoking Assessments for Supervised Smoker
Penalty
Summary
The facility failed to ensure that smoking assessments were accurately completed for a resident who smoked, resulting in a deficiency related to accident hazards and supervision. Record review showed that the resident, who had diagnoses including a pressure ulcer, morbid obesity, and diabetes mellitus, was admitted to the facility and assessed as having intact cognition. The resident's care plan identified a risk for injury related to smoking, with interventions requiring supervision at all times and storage of smoking items at the nurses station. However, facility Smoking and Safety assessments completed on two occasions inaccurately indicated that the resident did not smoke, despite the resident being listed as a supervised smoker on the facility's list and being observed smoking with staff supervision in the designated area. Interviews confirmed that the resident had been smoking at the facility since admission, with staff assisting her outside to smoke daily. The DON acknowledged that the completed assessments were inaccurate, as the resident was indeed a supervised smoker. Facility policy required that all residents who smoke be assessed using a smoking assessment and only allowed to smoke in designated areas if determined to be safe smokers. The inaccurate completion of the smoking assessments for this resident constituted a failure to ensure the area was free from accident hazards and that adequate supervision and assessment were provided to prevent accidents.
Failure to Provide Physician-Ordered Diet to Resident
Penalty
Summary
The facility failed to ensure that a resident's meals were provided as ordered by the physician. A review of the medical record for a resident with multiple diagnoses, including Alzheimer's disease, protein calorie malnutrition, and dementia, showed a physician order for a fortified foods diet with regular texture and thin liquids, along with a house supplement three times daily. However, observation of a lunch meal revealed the resident received a mechanical soft diet with double portions of protein and fortified mashed potatoes, which did not match the physician's order. The resident's meal ticket and dietary manager both confirmed the mechanical soft diet, but there was no documentation of a physician order for this change in the medical record or nursing notes. Interviews with staff revealed confusion regarding the resident's current diet order. The MDS Coordinator confirmed the MDS did not reflect a mechanically altered diet, and an LPN admitted to changing the diet order in the electronic medical record without clear documentation of the source of the order. The Director of Nursing also confirmed the absence of documentation for the diet change. The facility was unable to provide a policy related to dietary orders, further highlighting the lack of proper documentation and communication regarding dietary changes for the resident.
Failure to Hold Blood Pressure Medications per Physician Parameters
Penalty
Summary
The facility failed to ensure that blood pressure medications were administered according to physician-ordered parameters for a resident with multiple diagnoses, including congestive heart failure, atrial fibrillation, diabetes, and hypertension. The resident was prescribed Metoprolol tartrate with instructions to hold the medication if systolic blood pressure was less than 120 mmHg or pulse was less than 60 bpm, and Midodrine hydrochloride with instructions to hold if systolic blood pressure was greater than 120 mmHg. Medical record review showed that these parameters were not followed on multiple occasions, with Metoprolol administered when the resident's systolic blood pressure was below 120 mmHg and Midodrine given when systolic blood pressure was above 120 mmHg. Interviews with nursing staff and facility leadership confirmed that both medications were administered despite blood pressure readings that met the criteria for holding the medications. The medication administration record documented several instances where the medications were not held as ordered, and both the LPN and DON acknowledged that the medications should have been held based on the resident's blood pressure readings. This failure resulted in significant medication errors for the resident.
Failure to Perform Physician-Ordered Laboratory Tests
Penalty
Summary
The facility failed to ensure that laboratory tests ordered by a physician were performed as required for one resident. The resident, who had diagnoses including a pressure ulcer of the right heel, morbid obesity, and diabetes mellitus, was admitted to the facility and assessed to have intact cognition. Physician orders specified that a Complete Blood Count (CBC) with differential, Basic Metabolic Panel (BMP), and Hemoglobin A1C (HgbA1C) were to be drawn and resulted every three months in January, April, July, and October. However, a review of laboratory results showed that none of these tests were obtained for the resident from January through May of the review year. This was confirmed by an LPN during an interview, who acknowledged that the required laboratory tests had not been completed as ordered in January or April.
Failure to Keep Foley Catheter Drainage Bags Off the Floor
Penalty
Summary
Surveyors observed that the facility failed to ensure that indwelling Foley catheter drainage bags were kept off the floor for two of three residents reviewed with indwelling catheters. For one resident with a history of neurogenic bladder, cirrhosis, BPH, and other conditions, repeated observations showed the catheter bag lying on the floor without a dignity cover. The resident was noted to be non-compliant with keeping the catheter bag off the floor and not using the cover, as confirmed by an LPN who stated the resident drags the bag on the floor. The resident's care plan documented non-compliance with catheter care, including not hanging the bag and not keeping the cover on, with interventions focused on education and documentation of non-compliance. Another resident with a history of traumatic amputation, stage four pressure ulcer, diabetes, and cognitive impairment was also observed with a Foley catheter drainage bag lying uncovered on the floor. Staff confirmed the observation. The resident's care plan included instructions to position the catheter bag and tubing below the bladder and away from the entrance, but did not specifically address keeping the bag off the floor. Additionally, facility policies on infection control and catheter care did not address infection prevention measures related to Foley catheters.
Failure to Address Family Concerns of Overmedication and Opioid Side Effects
Penalty
Summary
The facility failed to ensure that a resident’s drug regimen was free from unnecessary drugs by not timely and appropriately assessing family concerns regarding possible overmedication. The resident, who had diagnoses including Alzheimer's disease, dementia, bipolar disorder, and was on hospice care with a prognosis of less than six months, was prescribed tramadol 50 mg twice daily for pain, along with non-pharmacological interventions as tolerated. Despite documentation in the medical record and pain assessments indicating the resident had no pain, the resident continued to receive scheduled opioid medication. Observations showed the resident was frequently sleeping and difficult to arouse, and the family reported concerns about excessive sedation and weight loss, requesting that pain medication be limited to nighttime or as needed for pain. Interviews with staff confirmed that the resident continued to receive tramadol twice daily, and the DON acknowledged awareness of the family’s concerns but had not directly communicated with the family or adjusted the medication regimen. The facility lacked a policy related to opioid medication or management of over-sedation, and there was no evidence that the family’s request or the resident’s condition was promptly or adequately addressed.
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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