Ayden Healthcare Of Toledo
Inspection history, citations, penalties and survey trends for this long-term care facility in Toledo, Ohio.
- Location
- 4293 Monroe St, Toledo, Ohio 43606
- CMS Provider Number
- 365849
- Inspections on file
- 32
- Latest survey
- March 27, 2025
- Citations (last 12 mo.)
- 0
Citation history
Health deficiencies cited at Ayden Healthcare Of Toledo during CMS and state inspections, most recent first.
The facility failed to assist residents with ADL care, affecting three individuals. A resident with cognitive impairment was found with lice due to inadequate hygiene assistance. Another resident with quadriplegia was improperly fed by a fellow resident instead of staff. A third resident reported not receiving proper bathing, leading to poor hygiene. These incidents highlight a lack of adherence to facility policies on resident care.
The facility failed to provide adequate pressure ulcer care for two residents. One resident had a dressing come off, leading to fecal contamination of a wound, while another resident returned from the hospital with pressure injuries but lacked documented wound care orders. Interviews confirmed the absence of proper documentation and care, violating the facility's skin management policy.
The facility failed to provide adequate toenail care for two residents, leading to a deficiency in activities of daily living. One resident had long, thick, and discolored toenails, while another had long, jagged toenails that were uncomfortable. Both residents had signed consent for podiatry care but were not timely added to the podiatry list, as confirmed by staff interviews.
A facility failed to properly document medical records for a resident with skin issues. Despite being at risk for impaired skin integrity, the resident's weekly body audits inaccurately reported intact skin, while progress notes indicated refusals of showers and treatment for body lice. Interviews revealed non-compliance with bathing and skin assessments, and the facility staff did not verify the inaccurate assessments.
An LPN failed to maintain infection control standards during medication administration for a resident with chronic conditions. The LPN did not perform hand hygiene between residents and handled medication with ungloved hands, contrary to facility policy requiring universal precautions.
The facility failed to provide the required twelve hours of annual training and timely performance reviews for its STNAs, potentially affecting all 67 residents. Personnel files showed that three STNAs did not meet the training requirements, and two lacked timely performance evaluations. The Human Resource Director confirmed these deficiencies, which were contrary to the facility's policies outlined in the Employee Handbook and the Nurse Aide In-Service Training Program.
The facility failed to store medications safely and allowed expired medications to remain in storage, affecting all 67 residents. Observations revealed a brown liquid in the South hall medication refrigerator soaking an expired influenza vaccine, and an expired bottle of epinephrine in the North medication refrigerator. These findings were confirmed by LPNs, despite facility policy requiring the removal and proper disposal of outdated medications.
The facility failed to ensure cleanliness and proper labeling of food in refrigerators at the nurses' stations, affecting all 67 residents. Observations revealed undated sandwiches, a baggy of watered-down food, and unlabeled takeout items. A foul odor and a towel with a brown substance were also noted. The facility's policy requires perishable foods to be labeled with the resident's name, item, and use-by date.
The facility failed to address and resolve concerns raised by the Resident Council, including slow call light response times and delays in meal delivery, over several months. Despite repeated issues documented in the Resident Council minutes, there was a lack of documented follow-up or resolution. Interviews confirmed insufficient follow-through on addressing these concerns, affecting 18 residents.
The facility failed to conduct timely care conferences for several residents, as required by their policy. Residents with various health conditions, including chronic diseases and cognitive impairments, did not receive quarterly care conferences in conjunction with their MDS assessments. Interviews confirmed that these conferences were missed due to scheduling issues.
The facility failed to maintain a safe and homelike environment, affecting all 67 residents. Water was observed leaking from fire dampers in the South halls, with some areas lacking proper containment. Interviews revealed rainwater was entering through the roof, and caulking attempts were ineffective. A black substance was noted on the dampers. Additionally, a bathroom wall had missing wallpaper and exposed drywall, requiring repair. The facility's policy emphasized a clean and orderly environment, which was not maintained.
The facility failed to enforce smoking policies and fall prevention measures, affecting several residents. A resident was found with cigarettes and a lighter in their room, contrary to the policy requiring these items to be kept at the nurse's station. Another resident, at risk for falls, did not have the required interventions in place, such as a perimeter mattress and floor mat. Staff interviews confirmed the lack of adherence to care plans, posing potential safety risks.
A facility failed to accommodate a resident's religious fasting preferences, impacting their nutritional intake. Despite the resident's intact cognition and need for assistance with eating, the care plan lacked guidance for fasting, and meals were not provided after dark. This oversight led to a decline in the resident's health, resulting in hospitalization for hyponatremia and hypokalemia due to poor oral intake.
The facility failed to complete and transmit MDS assessments within required timeframes for two residents. One resident, with multiple diagnoses including HIV and Alzheimer's, had no MDS completed for their death, while another resident's MDS for death was completed but not transmitted. An MDS nurse confirmed these deficiencies.
A facility failed to accurately reflect a resident's status in the MDS assessment. The resident, with chronic respiratory conditions, was receiving oxygen therapy, as noted in medical records and staff interviews. However, the MDS assessment incorrectly indicated the resident was not on oxygen therapy, an error confirmed by a Corporate RN.
A facility failed to implement a care plan for a resident's smoking needs, despite the resident being assessed as safe to smoke with supervision. The resident, with multiple medical conditions, did not have a smoking care plan in place, as confirmed by the DON. This was contrary to the facility's policy requiring comprehensive, person-centered care plans.
A resident with a history of cerebral infarction and other chronic conditions experienced a delay in accessing vision services after his glasses broke. Despite being cognitively intact and needing corrective lenses, the resident's glasses remained unusable for one to two months. Facility staff were unaware of the issue, and the resident was not scheduled for a recent optometrist visit, contrary to the facility's policies on sensory impairments and social services referrals.
A resident with chronic conditions and nutritional deficiency did not receive recommended nutritional supplements and weekly weight monitoring. Despite dietitian and physician recommendations, these were not implemented, leading to hospitalization for hyponatremia and hypokalemia. Interviews confirmed the facility's failure to follow through with necessary care actions.
Two residents were receiving oxygen therapy without current physician orders, contrary to facility policy. One resident with chronic respiratory failure was observed receiving oxygen at five liters per minute without an order after returning from the hospital. Another resident with COPD was receiving oxygen at four liters per minute without an order since admission. The facility's policy requires a physician's order for oxygen, which was not followed.
The facility did not timely implement pharmacy recommendations for two residents. One resident experienced delays in adjusting the dosing frequency of Eliquis and clarifying hemorrhoidal cream application. Another resident's recommendations for adding acetaminophen and reducing doses of duloxetine and risperidone were not timely addressed. The DON confirmed these delays.
A facility failed to implement a timely gradual dose reduction for a resident's psychotropic medication, risperidone, despite a physician's order. The resident, with a history of cerebral infarction, heart failure, and schizoaffective disorder, was on a 1 mg dose at bedtime, which was supposed to be reduced to 0.5 mg. The delay in executing this order was confirmed by the DON.
A facility failed to complete laboratory orders from a wound care specialist for a resident with type II diabetes and a cutaneous abscess. The resident required substantial assistance and had an infection of a diabetic foot ulcer. Despite orders for specific lab tests on certain days, the facility did not complete these tests on multiple occasions, as confirmed by a Corporate RN.
A facility failed to maintain accurate medical records for a resident who was ordered a Velcro wrist brace/splint for arthritis. The resident found the brace uncomfortable and did not wear it, but an LPN mistakenly signed off that the splint was in place due to confusion with a surgical bandage. This discrepancy violated the facility's policy requiring objective, complete, and accurate documentation.
The facility failed to practice proper antibiotic stewardship for three residents with UTIs, administering antibiotics without conducting necessary culture or sensitivity testing. Despite urinalysis results indicating bacteria, antibiotics were prescribed without confirming the specific infectious agent or appropriate treatment. The facility's policy on infection control was not followed, as confirmed by the DON.
The facility did not ensure that two residents were offered pneumococcal and influenza vaccinations as per CDC guidelines. One resident, with diabetes and heart disease, lacked documentation of being offered the pneumococcal vaccine. Another resident, with schizophrenia and depression, had not received the influenza vaccine since 2022 and had refused the pneumococcal vaccine, with no further documented attempts to offer it. Facility policies required offering and documenting vaccine refusals, but these were not followed.
The facility failed to offer COVID-19 vaccinations to two residents as per CDC recommendations. One resident, with type two diabetes and heart disease, last received a vaccine in 2022, with no further attempts documented. Another resident, with schizophrenia and depression, lacked documentation of a booster, despite an attempt to contact their responsible party. The facility's policy required offering vaccines and documenting refusals, which was not followed.
A facility failed to implement a wound care specialist's orders for a resident with diabetes and a foot ulcer. The resident required substantial assistance and had irritant dermatitis. Despite orders for zinc oxide cream, the treatment was not initiated, and the DON confirmed the lapse, citing undocumented use of an alternative cream. This issue was a repeat deficiency.
The facility failed to provide adequate pressure ulcer care and equipment maintenance for two residents. One resident did not receive wound care as ordered, with heel boots not in use and a dressing not changed as scheduled. Another resident's air mattress was non-functional for over a week, leaving her without proper support. Staff were unaware of these issues, indicating a lapse in following the facility's policy on assistive devices.
A resident with multiple health issues, including cancer and a pressure ulcer, did not receive timely incontinence care, resulting in prolonged exposure to wet conditions. Despite having high cognitive function and requiring assistance, the resident was not checked or changed overnight. Observations revealed a strong odor and significant soiling, and interviews confirmed the lack of care, contrary to facility policy.
Two residents experienced medication administration deficiencies. One resident received Tylenol without a physician's order, while another missed doses of several medications due to delivery issues. The facility's policy requires medications to be administered according to prescriber orders, which was not followed.
The facility did not post a notice of the availability of survey results from the past three years in prominent and accessible areas. Observations and interviews revealed that residents and staff were unaware of the survey results binder's location, which was placed outside the locked doors at the facility entrance without any signage. This affected all 67 residents.
A facility failed to document blood sugar levels for a resident with diabetes receiving Mounjaro, despite physician orders for monitoring. The MAR showed checks were done, but no results were recorded. The DON confirmed the lack of documentation, which violated the facility's diabetes care policy.
A resident in an LTC facility did not receive medications as ordered, leading to significant errors. An LPN administered insulin after the resident's meal, outside the prescribed timeframe, and failed to prime the insulin pen or hold the injection for the required time. Additionally, the resident did not receive their prescribed Paxil, affecting their mood. The facility's policies on medication administration were not followed, resulting in the resident not receiving necessary medications appropriately.
Failure to Assist Residents with ADL Care
Penalty
Summary
The facility failed to assist dependent residents with activities of daily living (ADL) care, affecting three residents. Resident #26, who was severely cognitively impaired, was found with multiple bug bites and lice infestation due to inadequate personal hygiene assistance. The resident had not received a bath or shower for an unknown period, and the staff accepted her refusals for showers without further intervention. This lack of care led to a lice infestation, with multiple bites and dead bugs found on her body and bedding. Resident #78, who required assistance with eating due to quadriplegia, was observed being fed by another resident instead of a staff member. The CNA responsible for assisting him was occupied with other residents, leading to Resident #78 being fed by his tablemate. Both residents confirmed that this was a regular occurrence, and the CNA admitted to allowing it, despite the facility's policy that no residents are approved or trained to feed others. Resident #94, who required substantial assistance with bathing and personal hygiene, reported not always receiving showers and noted that when she did, soap and shampoo were not used. Observations confirmed her hair appeared greasy, and she had body odor. The facility's policy stated that residents unable to perform ADLs independently should receive necessary services to maintain hygiene, which was not adhered to in this case.
Failure to Provide Adequate Pressure Ulcer Care
Penalty
Summary
The facility failed to provide adequate treatment for pressure ulcers for two residents, Resident #43 and Former Resident #9. Resident #43, who was admitted with paraplegia and stage four pressure ulcers, did not have a wound dressing on his thigh wound for several hours, during which fecal matter contaminated the wound. This occurred after the dressing came off during incontinence care, and although the aide informed the nurse, the dressing was not reapplied until later. This was confirmed by both the resident and the Licensed Practical Nurse (LPN) during interviews. Former Resident #9, who had a history of paraplegia and other health issues, was admitted with a risk for impaired skin integrity. Despite this, the facility failed to document or obtain orders for wound care for pressure injuries on the resident's left heel and right ankle after returning from a hospital visit. The wounds were identified as stage three pressure ulcers, but the facility's records lacked documentation of the necessary wound care. Interviews with the Corporate Nurse and the Director of Nursing (DON) confirmed that there were no orders or documentation for the wound care, although they claimed care was provided. The facility's policy on skin management requires an initial assessment and obtaining physician orders for treatment when skin integrity issues are identified. However, this policy was not followed for both residents, leading to inadequate care and documentation of their pressure ulcers. This deficiency was investigated under multiple complaint numbers, indicating a pattern of non-compliance with pressure ulcer care protocols.
Deficiency in Toenail Care for Residents
Penalty
Summary
The facility failed to provide adequate toenail care for two residents, leading to a deficiency in the care of activities of daily living. Resident #15, who was admitted with multiple diagnoses including lymphedema, venous insufficiency, and heart failure, was observed with long, thick, and discolored toenails. Despite being cognitively intact and requiring assistance with personal hygiene, the resident's toenails were overdue for trimming, as confirmed by an LPN. The resident had signed consent for podiatry care, indicating a need for attention to thickened and painful nails, yet was not placed on the podiatry list until after the observation. Similarly, Resident #94, who was also cognitively intact and required substantial assistance with personal hygiene, was found with long, jagged toenails that were uncomfortable and snagged on items. Despite having signed consent for podiatry care, the resident was not added to the podiatry list. Interviews with a CNA and Social Services confirmed the oversight, as the residents were only approved for podiatry services after the deficiency was noted. This lack of timely podiatry care for both residents was identified during a complaint investigation, highlighting a failure in the facility's process for managing podiatry services.
Failure to Document Accurate Skin Assessments
Penalty
Summary
The facility failed to ensure proper documentation of medical records for a resident with skin issues. The resident, who had diagnoses including schizophrenia and metabolic disorders, was noted to have intact cognition and was independent in dressing but required supervision for hygiene. Despite being at risk for impaired skin integrity due to various factors such as weakness, difficulty ambulating, and non-compliance with personal care, the resident's weekly body audits consistently reported intact skin with no new concerns. However, progress notes indicated the resident's refusal of weekly showers, skin sweeps, and treatment for body lice, which was not accurately reflected in the skin assessments. Interviews with the Corporate Nurse and the Director of Nursing revealed that the resident had been non-compliant with bathing and skin assessments for an extended period, and the facility staff did not verify the inaccurate skin assessments. The facility's policy required weekly skin evaluations to be documented in the electronic medical record, but this was not adhered to, leading to the deficiency. This issue was investigated under Complaint Number OH00163858.
Infection Control Breach During Medication Administration
Penalty
Summary
The facility failed to maintain infection control standards during medication administration for Resident #60. The resident, who was cognitively intact, had a medical history including chronic respiratory failure, cerebral vascular accident, quadriplegia, and chronic kidney disease. On the morning of March 27, 2025, an LPN was observed administering medication to Resident #60 without performing hand hygiene after completing medication administration for another resident. The LPN moved the medication cart and began preparing medication for Resident #60 without washing her hands. During the medication preparation, the LPN was observed counting 11 pills by dumping them into her ungloved hand, counting them, and then returning them to the medication cup before administering them to Resident #60. The LPN confirmed in an interview that she did not perform hand hygiene between residents and handled the medication with her ungloved, uncleaned hand. The facility's policy requires adherence to universal precautions, including proper hand hygiene and glove use, which was not followed in this instance.
Deficiency in 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 that performance reviews were completed at least once every twelve months. This deficiency had the potential to affect all 67 residents in the facility. The personnel files of three STNAs were reviewed, revealing that STNA #113, hired on February 9, 2023, had only seven hours of annual training. STNA #116, hired on August 2, 2022, also had seven hours of annual training and lacked a performance evaluation. STNA #119, hired on February 21, 2023, had five hours of annual training, with a performance evaluation completed on June 17, 2024. The Human Resource Director confirmed the deficiencies in training hours and performance reviews for the STNAs mentioned. The facility's Employee Handbook and policy on the Nurse Aide In-Service Training Program outlined the requirements for annual training and performance evaluations, which were not met. The handbook specified that direct patient care employees must have at least an annual skills evaluation and competency check, while the policy required a minimum of twelve hours of in-service training annually, based on the outcomes of performance reviews. These requirements were not fulfilled, leading to the identified deficiencies.
Medication Storage and Expiration Deficiencies
Penalty
Summary
The facility failed to store medications in a safe and sanitary manner and did not ensure that medications were not used past their expiration dates, potentially affecting all 67 residents. During an observation of the South hall medication refrigerator, a brown liquid substance was found on the bottom shelf, soaking an expired vial of influenza vaccine. This was confirmed by an LPN. Additionally, an inspection of the North medication storage refrigerator revealed an expired bottle of epinephrine, which was also verified by another LPN. The facility's policy requires that outdated, contaminated, or deteriorated medications be immediately removed from stock and disposed of according to procedures, and that medication storage areas be kept clean and free of clutter.
Improper Food Storage and Labeling in Facility Refrigerators
Penalty
Summary
The facility failed to maintain cleanliness and proper labeling of food stored in the refrigerators at the nurses' stations, which could potentially affect all 67 residents. During an observation at the North nurse's station, seven sandwiches were found in plastic wrap without dates, and a baggy containing lettuce, tomato, meat, and onion appeared watered down and was also undated. Additionally, a carton of oat milk was found without a label or date. The Unit Manager confirmed these findings and acknowledged that the food should have been dated. At the South nurse's station, six sandwiches, a bowl of chili, and two takeout bags of Chinese food were found undated and unlabeled, with no indication of which resident the food belonged to. The freezer contained a towel with a brown substance, and the refrigerator emitted a foul odor when opened. The Unit Manager verified these observations, including the foul odor. The facility's policy, dated October 2017, requires perishable foods to be stored in re-sealable containers with labels indicating the resident's name, the item, and the use-by date.
Failure to Address Resident Council Concerns
Penalty
Summary
The facility failed to adequately address and resolve concerns raised by the Resident Council in a timely manner, as evidenced by repeated issues documented in the Resident Council minutes over several months. Concerns included slow call light response times, delays in meal cart delivery leading to cold food, and other issues such as medication administration, staffing, noise levels, and smoking times. Despite these recurring concerns, there was a lack of documented follow-up or resolution for the months prior to January 2024 and after March 2024. Interviews with residents and staff confirmed that the facility did not consistently act on the concerns raised by the Resident Council, and there was insufficient follow-through on addressing these issues. The facility's policy required the use of a Resident Council Response form to track issues and their resolution, with the relevant department responsible for addressing the concerns. However, the review of audits for call lights and meal tray passes revealed limited monitoring, with only a few instances of call light audits conducted over several months. The Activities Director confirmed that many concerns were repeated at each meeting, and there was a lack of awareness regarding the follow-up actions taken. This deficiency in addressing Resident Council concerns had the potential to affect 18 residents who regularly attended the meetings, out of a facility census of 67.
Failure to Conduct Timely Care Conferences
Penalty
Summary
The facility failed to conduct care conferences as required, affecting eight out of 26 residents reviewed for care conferences. The facility's policy mandates that care conferences be held quarterly in conjunction with the Minimum Data Set (MDS) assessments. However, the review of medical records and interviews with residents revealed that care conferences were not held timely for several residents, including those with high cognitive function and significant health issues. Resident #9, who has multiple diagnoses including chronic obstructive pulmonary disease and chronic kidney disease, expressed that care conferences were not held quarterly as desired. Similarly, Resident #34, with diagnoses such as congestive heart failure and bipolar disorder, had care conferences that were not conducted in a timely manner. Resident #57, who has a speech deficit, also experienced delays in care conferences, with the last ones held several months apart. Other residents, such as Resident #62 with cancer and malnutrition, and Resident #14 with diabetes and heart disease, also faced similar issues with untimely care conferences. Interviews with residents and staff confirmed that care conferences were missed due to them not being scheduled in conjunction with the MDS assessments. The facility's policy, which requires the interdisciplinary team to develop and implement a comprehensive care plan at least quarterly, was not adhered to, leading to this deficiency.
Facility Fails to Maintain Safe and Homelike Environment
Penalty
Summary
The facility failed to maintain a safe and homelike environment, which had the potential to affect all 67 residents. During an observation, water was found running out of the fire dampers from the ceiling onto the floor in the South halls of the facility. Although buckets and wet floor signs were placed in four areas, three additional areas had water sitting on the floor. Interviews with the Maintenance Assistant and Maintenance Supervisor revealed that rainwater was entering through the fire dampers from the roof, and attempts to caulk them were unsuccessful. Additionally, a black substance was observed on the fire dampers. Further observations revealed a bathroom wall between two rooms with a large portion of wallpaper missing and broken drywall exposed. A tour with the Maintenance Supervisor confirmed the need for repair. The facility's policy on maintaining a homelike environment emphasized the importance of a clean, sanitary, and orderly setting, which was not upheld in these instances.
Failure to Enforce Smoking Policies and Fall Prevention Measures
Penalty
Summary
The facility failed to maintain safe smoking practices as outlined in their care plans and smoking policy, affecting several residents. Resident #59, who was cognitively intact and required moderate assistance for daily activities, was found to have his own cigarettes and did not hand them over to the nurse after smoking, contrary to the care plan and smoking policy. Similarly, Resident #64, who required extensive assistance, kept cigarettes and a lighter in his room, which was against the facility's policy that required smoking items to be kept at the nurse's station. Observations revealed that multiple residents, including Resident #328, were in possession of cigarettes and lighters, and staff did not collect these items after smoking sessions, despite the policy requiring supervision and storage of smoking materials at the nurse's station. Additionally, the facility failed to implement fall prevention interventions for Resident #14, who was at risk for falls due to multiple health conditions, including diabetes and heart disease. The care plan for Resident #14 included specific interventions such as placing the bed against the wall, using a perimeter mattress, and having a floor mat, none of which were observed to be in place during the survey. Interviews with staff confirmed the absence of these interventions, and the staff was unaware of what a perimeter mattress was, indicating a lack of adherence to the care plan. These deficiencies were identified during a complaint investigation, highlighting non-compliance with the facility's policies and care plans designed to prevent accidents and ensure resident safety. The facility's failure to enforce smoking policies and implement fall prevention measures posed potential risks to the residents' safety and well-being.
Failure to Accommodate Religious Fasting Preferences
Penalty
Summary
The facility failed to accommodate a resident's religious fasting preferences, impacting their nutritional intake. The resident, who had intact cognition and required assistance with eating, was admitted with chronic obstructive pulmonary disease, type II diabetes mellitus, and nutritional deficiency. Despite recommendations for weekly weights and nutritional supplements due to decreased meal intake, the resident experienced a decline in health, leading to hospitalization for hyponatremia and hypokalemia attributed to poor oral intake. The resident fasted for religious reasons from sun up to sun down during a specific period, but the facility did not provide meals after dark to accommodate this practice. The care plan lacked guidance or interventions to support the resident's fasting preferences. The dietary supervisor acknowledged awareness of the fasting but continued to send meal trays during regular meal service hours, without adjustments for the resident's needs. An email from a corporate registered nurse confirmed the absence of care plan interventions for fasting, highlighting the facility's failure to honor the resident's religious preferences.
Failure to Complete and Transmit MDS Assessments Timely
Penalty
Summary
The facility failed to ensure that completed Minimum Data Set (MDS) assessments were completed and transmitted within the required timeframes, affecting two residents. Resident #43, who had diagnoses including HIV, malignant neoplasm of the rectum and anal canal, Alzheimer's disease, and Parkinson's disease, was admitted and later died in the facility. However, no MDS assessment was completed for the death, with the last completed assessment being for admission. Resident #61, with diagnoses such as acute kidney failure, congestive heart failure, and cognitive communication deficit, also died in the facility. Although the MDS assessment for death was completed, it was not transmitted. An interview with MDS Nurse #164 confirmed these deficiencies, verifying that the assessments for both residents were not completed or transmitted as required.
Inaccurate MDS Assessment for Oxygen Therapy
Penalty
Summary
The facility failed to ensure that the Minimum Data Set (MDS) assessments accurately reflected the resident's status, specifically affecting one resident out of 26 reviewed. The resident, who was admitted with chronic obstructive pulmonary disease and chronic respiratory failure, was receiving oxygen therapy at three liters per minute via nasal cannula as documented in the admission nursing observation and provider progress notes. However, the comprehensive admission MDS assessment inaccurately indicated that the resident was not on oxygen therapy. This discrepancy was confirmed by a Corporate Registered Nurse during an interview, highlighting an error in the MDS assessment coding.
Failure to Implement Smoking Care Plan
Penalty
Summary
The facility failed to implement a care plan to address a resident's desire to smoke, which was identified during a survey. The resident, who was re-admitted with multiple diagnoses including intestinal obstruction, dislocation, fractures, hypertension, cognitive communication deficit, and PTSD, was assessed as a current smoker and deemed safe to smoke with supervision. Despite this assessment, the resident's care plan did not include a smoking care plan as of the survey date. The Director of Nursing confirmed the absence of a smoking care plan for the resident. The facility's policy on comprehensive, person-centered care plans requires that they include measurable objectives, timeframes, and reflect the resident's expressed wishes, which was not adhered to in this case.
Failure to Provide Timely Vision Services
Penalty
Summary
The facility failed to ensure timely access to vision services for a resident, identified as Resident #17, who was cognitively intact and had corrective lenses. The resident's medical record indicated a history of cerebral infarction, chronic heart failure, chronic obstructive pulmonary disease, diabetes mellitus, major depressive disorder, and schizoaffective disorder. During an interview, the resident reported that his glasses had been broken for at least one to two months, with a missing screw and temple, rendering them unusable. An observation confirmed the glasses' condition, as they were found on the bedside table with the described damages. Interviews with facility staff revealed a lack of awareness and action regarding the resident's need for vision services. The Social Services Director stated that the optometrist had visited the facility recently, but the resident was not scheduled for an appointment. Additionally, the Activities Director, who was reportedly present when the glasses broke, denied knowledge of the incident and was unsure when the resident stopped wearing glasses. The facility's policy on sensory impairments and social services referrals outlined procedures for addressing sensory deficits, including vision evaluations and coordination with outside agencies, which were not followed in this case.
Failure to Implement Nutritional Recommendations and Orders
Penalty
Summary
The facility failed to implement physician orders and dietitian recommendations for a resident with chronic obstructive pulmonary disease, type II diabetes mellitus, and nutritional deficiency. The resident was admitted with these diagnoses and had intact cognition, requiring assistance for eating. Despite recommendations from a dietetic technician for weekly weights and nutritional supplements due to decreased meal intake, these were not ordered or implemented. The resident experienced a decline in health, leading to hospitalization for hyponatremia and hypokalemia, attributed to poor oral intake. Upon returning from the hospital, the resident had a significant weight gain, prompting a physician to order weekly weights, which were also not completed. Further recommendations for nutritional supplements were made but not ordered. Interviews with the Director of Nursing and a Corporate Registered Nurse confirmed the failure to implement these recommendations and orders, highlighting a deficiency in the facility's care for the resident's nutritional needs.
Oxygen Administration Without Physician Orders
Penalty
Summary
The facility failed to ensure physician orders for oxygen administration were in place before administering oxygen to residents. This deficiency affected two residents who were receiving oxygen therapy without current physician orders. Resident #26, diagnosed with chronic respiratory failure with hypoxia and asthma, was observed receiving oxygen at five liters per minute via nasal cannula without a current physician order. The resident had been discharged to the hospital and returned to the facility, but the oxygen order was not resumed upon her return. The Director of Nursing confirmed that there was no physician order for oxygen administration for Resident #26 since her return until it was updated. Similarly, Resident #33, with diagnoses of chronic obstructive pulmonary disease and chronic respiratory failure, was receiving oxygen therapy at four liters per minute via nasal cannula without a physician order. The resident had been receiving oxygen since admission, but no order was documented until it was obtained after the surveyor's observation. The facility's policy on oxygen administration, which requires a physician's order to be verified prior to providing oxygen, was not followed in these cases.
Delayed Implementation of Pharmacy Recommendations
Penalty
Summary
The facility failed to ensure timely review and implementation of pharmacy recommendations for two residents regarding their medication regimens. For Resident #14, the pharmacy recommended a change in the dosing frequency of the anticoagulant Eliquis from once daily to twice daily, which was not implemented until over two months later. Additionally, there was a delay in clarifying the frequency of hemorrhoidal cream application. The Director of Nursing confirmed that these pharmacy recommendations were not timely implemented. For Resident #17, the pharmacy suggested adding acetaminophen for less severe pain alongside tramadol and recommended gradual dose reductions for the antidepressant duloxetine and the antipsychotic risperidone. The physician agreed to the acetaminophen addition but did not respond to the dose reduction recommendations for duloxetine and risperidone. The Director of Nursing verified that the physician's orders for these recommendations were not implemented in a timely manner, and there was no physician response to the dose reduction suggestions.
Failure to Implement Timely Gradual Dose Reduction for Psychotropic Medication
Penalty
Summary
The facility failed to ensure timely implementation of physician orders for gradual dose reductions of psychotropic medications, specifically affecting one resident. The resident, who was cognitively intact, had a medical history that included cerebral infarction, heart failure, chronic obstructive pulmonary disease, diabetes mellitus, major depressive disorder, and schizoaffective disorder. A medication regimen review recommended a gradual dose reduction for risperidone, which the physician agreed to, but the reduction was not implemented in a timely manner. The resident had been on a 1 mg dose of risperidone at bedtime since late the previous year, and the physician agreed to reduce the dose to 0.5 mg. However, the order to decrease the dose was not executed promptly, as confirmed by the Director of Nursing during an interview. This oversight in implementing the physician's order for a gradual dose reduction of risperidone was identified as a deficiency during the survey.
Failure to Complete Laboratory Orders for Wound Care
Penalty
Summary
The facility failed to ensure that laboratory orders from a consulted wound care specialist were completed for Resident #175, who was one of three residents reviewed for wounds. Resident #175, who had diagnoses including type II diabetes mellitus and a cutaneous abscess of the left foot, was admitted on an unspecified date and discharged to home on 06/13/24. The comprehensive admission Minimum Data Set (MDS) assessment indicated that the resident had intact cognition and required substantial/maximal assistance for toileting. The resident also had an infection of a diabetic foot ulcer, a surgical wound, and moisture-associated skin damage. A consultant wound care physician's progress note dated 05/07/24 included orders for specific laboratory tests to be conducted on Mondays and Thursdays. However, an interview with Corporate Regional Nurse (RN) #260 on 07/15/24 confirmed that the facility did not complete the laboratory tests as ordered on multiple dates, including 05/20/24, 05/27/24, 05/30/24, 06/03/24, 06/06/24, and 06/10/24. The Corporate RN confirmed that the consultant physician's orders should have been implemented.
Inaccurate Medical Record Keeping for Resident's Splint
Penalty
Summary
The facility failed to maintain accurate medical records for a resident, which was identified during a review of medical records, resident and staff interviews, and a facility policy review. The deficiency involved a resident who had an order for a Velcro wrist brace/splint for comfort due to arthritis. The resident found the brace uncomfortable and refused to wear it, storing it in a bedside drawer. However, an LPN mistakenly believed the splint was in place and had been signing off on the treatment administration record (TAR) that the splint was in place, including on a specific date, when it was not. This discrepancy was discovered during an interview with the LPN, who admitted to confusion between the splint and a gauze bandage on the resident's right hand from surgery. The facility's policy on charting and documentation requires that medical records be objective, complete, and accurate, which was not adhered to in this case.
Failure in Antibiotic Stewardship for UTI Treatment
Penalty
Summary
The facility failed to ensure proper antibiotic stewardship when treating residents with urinary tract infections (UTIs). This deficiency affected three residents, all of whom were treated with antibiotics without appropriate culture or sensitivity testing to determine the specific infectious agent or the most suitable antibiotic. Resident #12, diagnosed with type II diabetes mellitus and morbid obesity, received cephalexin for a presumed UTI before a urinalysis was conducted, which later showed few bacteria. The Director of Nursing (DON) confirmed that no culture or sensitivity testing was performed, and the urine sample was collected four days after the antibiotic treatment began. Similarly, Resident #18, with diagnoses of rhabdomyolysis and obstructive and reflux uropathy, was treated with Keflex for a UTI without prior culture or sensitivity testing, despite having an indwelling catheter and a urinalysis showing few bacteria. Resident #50, diagnosed with anxiety and fibromyalgia, also received Keflex for a UTI without appropriate testing, even though the urinalysis indicated moderate bacteria. The DON confirmed that no cultures or sensitivity tests were ordered for any of the three residents before initiating antibiotic treatment. The facility's policy, which references the use of McGeer criteria or NHSN criteria for defining infections, was not adhered to in these cases.
Failure to Offer Vaccinations per CDC Recommendations
Penalty
Summary
The facility failed to ensure that residents were offered pneumococcal and influenza vaccinations according to CDC recommendations. This deficiency was identified during a review of medical records, immunization records, staff interviews, and facility policies. Specifically, Resident #14, who was admitted with diagnoses including type two diabetes mellitus and heart disease, was not documented as having been offered the pneumococcal vaccine. The Director of Nursing (DON) confirmed the absence of documentation verifying the offer of this vaccine. Additionally, Resident #30, who was admitted with schizophrenia and depression, had not received the influenza vaccine since October 2022 and had previously refused the pneumococcal vaccine. Despite an attempt to contact the resident's responsible party regarding needed immunizations, there was no further documentation of refusals or attempts to provide the vaccines. The facility's policies, last revised in 2019, required that all residents be offered vaccines to prevent infectious diseases and that refusals be documented, but these procedures were not adequately followed for the residents in question.
Failure to Offer COVID-19 Vaccinations per CDC Recommendations
Penalty
Summary
The facility failed to ensure COVID-19 vaccinations were offered to residents in accordance with CDC recommendations. This deficiency was identified during a review of medical records, immunization records, staff interviews, and facility policies. Specifically, Resident #14, who was cognitively intact and had diagnoses including type two diabetes mellitus and heart disease, was last documented to have received a COVID-19 vaccine on 08/11/22. There were no further documented refusals or attempts to provide this resident with a COVID-19 vaccination booster, as confirmed by an interview with the Director of Nursing (DON). Similarly, Resident #30, who was also cognitively intact and had diagnoses including schizophrenia and depression, did not have documentation of receiving a COVID-19 vaccine booster. A nursing progress note indicated an attempt to contact the responsible party regarding needed immunizations, but there were no further documented refusals or attempts to provide the booster. The facility's policy on vaccination, revised in 2019, stated that all residents should be offered vaccines to prevent infectious diseases, and any refusals should be documented. The CDC guidance recommended that individuals aged 65 and older receive an additional dose of the updated COVID-19 vaccine, which was not adhered to in these cases.
Failure to Implement Wound Care Orders
Penalty
Summary
The facility failed to ensure that the orders from a consulted wound care specialist were completed for a resident with type II diabetes mellitus and a cutaneous abscess of the left foot. The resident, who required substantial assistance for toileting, had an infection of a diabetic foot ulcer, a surgical wound, and moisture-associated skin damage. A wound care physician identified irritant dermatitis on the resident's buttocks and ordered zinc oxide barrier cream to be applied three times per day for at least ten days. However, a review of the resident's physician orders and treatment administration records for April and May 2024 revealed that the treatment orders for the zinc oxide barrier cream were not initiated. The Director of Nursing confirmed the orders were not followed and stated that the facility used their own barrier cream, but could not provide documentation of its application. This deficiency was a recite to a previous complaint survey.
Failure in Pressure Ulcer Care and Equipment Maintenance
Penalty
Summary
The facility failed to ensure proper pressure ulcer care and prevention for two residents. Resident #16, who had a stage four pressure ulcer and was diagnosed with bullous pemphigoid and type II diabetes mellitus, did not receive wound care as ordered. The resident's care plan included the use of heel boots to protect the skin, but during an observation, the boots were found on a dresser instead of on the resident. Additionally, the wound dressing was not changed as per the physician's order, as it was dated two days prior to the observation. The Assistant Director of Nursing confirmed that the wound care was not completed as ordered. Resident #56, who had multiple diagnoses including atrial fibrillation and rheumatoid arthritis, was at risk for impaired skin integrity and required a pressure-reducing mattress. However, the resident reported that her air mattress had not been functioning for over a week, leaving her lying in a hole. An observation confirmed that the mattress was flat and not providing the necessary support. The Licensed Practical Nurse and the Assistant Director of Nursing were unaware of the mattress issue, and the facility's policy on maintaining assistive devices was not followed.
Inadequate Incontinence Care for Resident
Penalty
Summary
The facility failed to provide timely and adequate incontinence care for Resident #62, who was affected by multiple serious health conditions including osteomyelitis, liver and lung cancer, malnutrition, and a pressure ulcer. The resident, who had high cognitive function and required substantial assistance for toileting, reported not being checked or changed for incontinence since the previous night. Despite requesting assistance, the resident did not receive timely care, leading to prolonged exposure to wet conditions. During an observation, it was noted that the resident had a strong odor in the room and a large amount of urine and dark liquid on his body and bedding, indicating a lack of incontinence care. Interviews with the Administrator and the Director of Nursing confirmed that the resident had not been checked or changed throughout the night. The facility's policy on incontinence care emphasized individualized care to maintain comfort and skin integrity, which was not adhered to in this case.
Medication Administration Deficiencies
Penalty
Summary
The facility failed to ensure medications were administered with a physician's order and were available for administration, affecting two residents. Resident #55, diagnosed with HIV and bacteremia, was administered Tylenol for leg pain without a physician's order. The resident's medical record lacked documentation of the Tylenol administration, and the Director of Nursing (DON) confirmed the medication was given without an order. Resident #175, with diagnoses including diabetes, a cutaneous abscess, hyperlipidemia, hypertension, and depression, did not receive several prescribed medications due to delivery issues. The resident's progress notes indicated that Flagyl, Lisinopril, Synthroid, and vancomycin were not administered as they were not delivered on time. The DON verified that the medications were unavailable, resulting in missed doses. The facility's policy requires medications to be administered according to prescriber orders, which was not adhered to in these cases.
Failure to Post Survey Results Notice
Penalty
Summary
The facility failed to post a notice of the availability of survey results from the preceding three years in areas that are prominent and accessible to the public. This deficiency was identified through observations and interviews conducted with residents and staff. During an observation on July 15, 2024, it was noted that there was no signage in the hallways regarding the location of the survey results binder or how to access it. Interviews with several residents revealed that they were unaware of the location of the survey results binder. Additionally, a State Tested Nurse Aide (STNA) confirmed that the binder was located on a bookshelf outside the locked doors at the facility entrance, but there was no posting indicating its location. Further interviews with the receptionist and the administrator verified the absence of signage or postings to inform residents or the public about the location of the survey binder. The receptionist mentioned that people would ask for the binder if they wanted to see it, while the administrator confirmed the binder's location at the front entrance but acknowledged the lack of signage. This oversight had the potential to affect all 67 residents of the facility, as the facility census was 67 at the time of the survey.
Failure to Document Blood Sugar Monitoring for Diabetic Resident
Penalty
Summary
The facility failed to ensure proper monitoring of blood sugar levels for a resident receiving the medication Mounjaro, as ordered by the physician. The resident, who had a history of type 2 diabetes mellitus, morbid obesity, and other health conditions, was prescribed Mounjaro for diabetes management and later for weight loss. The physician's order required blood sugar monitoring every Monday and Thursday while the resident was on this medication. Although the Medication Administration Records (MAR) indicated that blood sugar checks were performed twice weekly, there was no documented evidence of the actual blood sugar results in the medical record. An interview with the Director of Nursing confirmed the absence of documented blood sugar results, despite the MAR showing nurse initials for the checks. The facility's policy on the care of residents with diabetes mellitus emphasized the need for documentation of blood sugar results and other pertinent laboratory studies. This deficiency was identified during an investigation under Complaint Number OH00154139, highlighting non-compliance with the physician's orders and the facility's own policy.
Medication Administration Errors in LTC Facility
Penalty
Summary
The facility failed to ensure medications were administered as ordered by the physician and within prescribed time frames, leading to significant medication errors. During an observation, an LPN administered insulin to a resident after the resident had already consumed 50-75% of their breakfast, which was outside the prescribed timeframe. The LPN also failed to prime the insulin pen and did not hold the injection for the required 10 seconds, which are necessary steps to ensure the correct dosage is delivered. This resulted in a delay in the administration of insulin, which was supposed to be given before meals. Additionally, the resident did not receive their prescribed antidepressant medication, Paxil, as ordered. The resident reported a change in mood and lack of tolerance with staff due to not receiving the medication. A review of the medication administration record revealed that Paxil was not administered from the time of the resident's admission until a new order was obtained, which changed the administration time to once daily in the morning. This oversight in medication administration was confirmed by the LPN and further verified by the Director of Nursing and the Administrator. The resident involved had a complex medical history, including type 2 diabetes mellitus, major depression, and other significant health conditions. The facility's policies on medication administration and diabetes management were not followed, as evidenced by the lack of documentation for the administration of Paxil and the improper administration of insulin. The facility's failure to adhere to these policies and physician orders resulted in the resident not receiving necessary medications in a timely and appropriate manner.
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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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