Crystal Care Center Of Ashland
Inspection history, citations, penalties and survey trends for this long-term care facility in Ashland, Ohio.
- Location
- 1251 East Main Street, Ashland, Ohio 44805
- CMS Provider Number
- 366239
- Inspections on file
- 22
- Latest survey
- August 6, 2025
- Citations (last 12 mo.)
- 1
Citation history
Health deficiencies cited at Crystal Care Center Of Ashland during CMS and state inspections, most recent first.
The facility failed to adequately monitor and notify a physician about a resident's worsening cellulitis, resulting in actual harm and hospital admission. Additionally, two other residents were not provided with ordered interventions for constipation and heel protection, as confirmed by record review, interviews, and observations.
The facility did not provide enough CNA staff on certain shifts, as identified in its own Facility Assessment, leading to delayed responses to call lights and untimely care for residents. Multiple residents reported waiting over 30 minutes for assistance, resulting in incidents such as incontinence and self-care attempts. Staff and administrative review confirmed that CNA staffing levels were below what was needed to meet resident needs.
Surveyors found that the kitchen was not maintained in a clean and sanitary condition, with food items such as crates of onions stored directly on the floor, mold present behind the dishwashing machine, and buildup and debris under tables and behind equipment. These conditions were verified by the Dietary Manager and were not in accordance with the facility's food safety policy.
Surveyors found that the facility did not maintain a safe, clean, and homelike environment, with issues including a hallway door with a gap allowing outside elements in, a poorly installed window AC unit leaving an open space to the outdoors, broken tiles and unsanitary conditions in a shower room, and damaged or unclean areas in resident rooms and bathrooms. These deficiencies were confirmed by residents, nursing staff, and maintenance personnel.
A resident with significant mobility impairments and a history of chronic wounds did not receive the ordered alternating pressure/low air loss mattress as recommended by wound care. Despite being at high risk for pressure ulcers and having care plans specifying this intervention, observation and staff interviews confirmed the mattress was not in place, indicating a failure to implement necessary pressure ulcer prevention measures.
The facility did not consistently provide or document physician-ordered catheter care for three residents with indwelling or suprapubic catheters. This included missed catheter site cleaning, dressing changes, and application of prescribed ointment, as confirmed by medical records and staff interviews.
A resident with a PEG tube did not have current physician orders or documentation for site care, cleansing, or dressing changes. Staff failed to inspect or document care for the PEG tube site over several weeks, and a visitor observed dried blood around the site that was not addressed. Facility policy requiring daily checks and physician-specified dressing orders was not followed.
A resident with a central line did not have appropriate physician orders for dressing changes or site monitoring, and the dressing was not changed since admission. Observation revealed the dressing was rolled back, discolored, and the line was exposed. Staff confirmed the lack of orders and dressing changes, which did not meet facility policy requiring regular sterile dressing changes and documentation.
A resident with a recent leg fracture and chronic pain did not receive prescribed oxycodone-acetaminophen for severe pain due to pharmacy and administrative delays, resulting in inadequate pain control with only Tylenol provided. Nursing staff communicated the issue but did not administer the stronger medication when it became available, and pain levels were inaccurately documented.
A resident with multiple chronic conditions did not have pharmacy recommendations for medication adjustments reviewed by the physician within the facility's required 30-day timeframe. The pharmacist's recommendations, including a dosage reduction and regulatory compliance for as-needed psychoactive medications, were not addressed by the physician until over a month later, contrary to facility policy as confirmed by staff and policy review.
A resident with pain management needs was found with an unattended dose of Xtampza ER (oxycodone) left at the bedside, after a night shift LPN provided the medication without a physician's order for self-administration or bedside storage. Facility policy requires nurses to observe medication consumption, but this protocol was not followed.
A resident on contact precautions for an MSSA wound infection required staff to don PPE for care. After medication administration, an LPN and a surveyor found no receptacle for contaminated PPE near the room exit, forcing them to walk back through the room to dispose of used PPE in a bin placed across the room. Staff interviews confirmed the bin's placement was due to space limitations, and CDC guidance was not followed regarding PPE disposal.
A resident's family member made multiple requests for medical records, but the facility failed to respond or inform the family of the process, resulting in a delay. The staff responsible was unaware of the request due to absence, and the Administrator was not notified, contrary to facility policy requiring prompt handling of such requests.
Failure to Monitor and Intervene for Skin Integrity, Constipation, and Heel Protection
Penalty
Summary
The facility failed to provide appropriate monitoring and timely intervention for a resident with cellulitis, resulting in actual harm. The resident, who had a history of right tibia fracture, atrial fibrillation, COPD, and cellulitis, developed new redness and pain in the right lower leg. Although a nurse practitioner assessed the resident and ordered antibiotics with instructions for close monitoring and physician notification if the condition worsened, there was no documented evidence that the resident's skin condition was monitored or that the physician was notified of the decline. The resident's family member discovered the worsening condition, which had spread up the leg and onto the buttocks, and requested hospital transfer, where the resident was admitted and treated with IV antibiotics. Additionally, the facility failed to implement interventions for constipation for another resident who had a physician's order for lactulose as needed and a care plan indicating risk for constipation. Despite documentation showing no bowel movements for several days, there was no evidence that the ordered medication was administered or that the bowel protocol was initiated, as required by facility policy. The administrator confirmed the lack of intervention during this period. A third resident, who had orders for heel protection devices (Prevalon boots) while in bed due to risk factors such as atherosclerosis, end stage renal disease, and diabetes, was not provided with these devices. Multiple observations and interviews confirmed that the resident never received the ordered heel protectors since admission, despite being willing to use them. These failures affected three residents and were identified through medical record review, staff and resident interviews, and direct observation.
Insufficient CNA Staffing Resulting in Delayed Resident Care
Penalty
Summary
The facility failed to provide sufficient nursing staff to meet the needs of all residents as identified in its Facility Assessment (FA). Multiple residents reported that call lights were not answered in a timely manner, with some waiting over 30 minutes for assistance, resulting in incidents such as incontinence and residents attempting to care for themselves against staff instructions. Residents specifically noted delays during the second and third shifts, and staff interviews confirmed that CNA staffing was inadequate to handle the workload and respond to resident needs promptly. A review of staffing records revealed that on the date in question, the number of CNAs working during the second and third shifts was below the minimum required by the facility's own FA. During the second shift, only four CNAs were present for part of the shift when six were needed, and during the third shift, only three CNAs were present for part of the shift when four were required. The facility administrator confirmed the staffing shortfall during a review of the clock in and out reports.
Unsanitary Kitchen Conditions and Improper Food Storage
Penalty
Summary
Surveyors observed that the facility failed to maintain a clean and sanitary kitchen environment and did not store food items according to professional standards. Specifically, three crates of onions were found stacked directly on the floor in the dry storage area of the main kitchen. Additionally, there was an unknown black substance, identified as mold by the Dietary Manager, present on the wall behind the dishwashing machine, extending from mid-wall to the floor. Further observations revealed buildup and debris under a metal table, as well as against a wall and behind a refrigerator in the kitchen. The facility's policy required that food items in dry storage be kept off the floor and that food safety standards be followed, but these standards were not met during the survey. All 59 residents who received meals from the kitchen were potentially affected by these conditions. No specific medical history or condition of individual residents was mentioned in the report.
Failure to Maintain Safe, Clean, and Homelike Environment
Penalty
Summary
The facility failed to maintain a safe, clean, comfortable, and homelike environment for its residents, as evidenced by multiple observations and resident and staff interviews. One door at the end of a hallway had a visible gap at the bottom, allowing outside elements such as heat, cold air, and potentially insects to enter, which was confirmed by a resident who reported discomfort and concern, especially during winter. Another resident's room had a window air conditioning unit that was not properly installed, leaving an open space to the outdoors, which the resident believed allowed spiders and insects to enter. The Director of Maintenance confirmed the improper installation. Further deficiencies were observed in the shower room, where broken tiles surrounded the drain, a blood-soaked item was found on the floor, a dried red substance was present on the wall, and the door had multiple scuffed and chipped areas. Additionally, in a shared bathroom, the baseboard was unattached, and in a resident's room, there was a large area of scraped paint and food particles scattered on the floor. These findings were verified by staff interviews. Facility policies reviewed indicated that residents have the right to a safe, clean, and comfortable environment, which was not upheld in these instances.
Failure to Provide Ordered Pressure-Relieving Mattress for High-Risk Resident
Penalty
Summary
The facility failed to implement wound care recommendations for a resident who was at high risk for pressure ulcer development. The resident, who had diagnoses including lymphedema, chronic kidney disease, and obstructive uropathy, required substantial to maximal assistance for bed mobility and had impairments in both lower extremities. The care plan and wound care progress notes specified the need for an alternating pressure/low air loss mattress to prevent skin breakdown and pressure ulcers, with instructions to ensure the mattress settings were appropriate for the resident's needs. Despite these documented interventions, observation and staff interviews confirmed that the resident did not have the recommended mattress in place. The resident had a history of chronic wounds and pressure ulcers, and was noted to be at high risk for further pressure ulcer formation due to decreased mobility, incontinence, and limited ability to reposition. Facility policy required regular review of skin assessments and compliance with interventions, but the lack of the prescribed mattress indicated a failure to follow these protocols. The deficiency was identified through observation, interviews, and medical record review, affecting one of three residents reviewed for pressure ulcers.
Failure to Provide and Document Physician-Ordered Catheter Care
Penalty
Summary
The facility failed to ensure that physician-ordered catheter care was provided and properly documented for three residents with indwelling or suprapubic catheters. For one resident with a suprapubic catheter and diagnoses including lymphedema, chronic kidney disease, and obstructive uropathy, there were multiple instances where the Treatment Administration Record (TAR) showed no documentation of required catheter site cleaning and dressing changes, as ordered by the physician. The resident reported that staff sometimes went several days without changing the dressing, and facility staff confirmed the lack of documentation for these treatments. Another resident with an indwelling urinary catheter and diagnoses of type II diabetes mellitus and obstructive and reflux uropathy also had missing documentation of catheter care on several shifts, as confirmed by nursing staff. A third resident with a suprapubic catheter and diagnoses including diabetes mellitus type II, peripheral vascular disease, and congestive heart failure had no documentation of required catheter care and application of prescribed Mupirocin ointment on multiple occasions. Facility policy required catheter care every shift, but records and staff interviews confirmed that care was not consistently provided or documented as ordered.
Failure to Obtain Physician Orders and Document PEG Tube Care
Penalty
Summary
The facility failed to obtain and maintain current physician orders for the care and monitoring of a resident's percutaneous endoscopic gastrostomy (PEG) tube. The resident, who was severely cognitively impaired and had multiple diagnoses including dysphagia and muscle weakness, was admitted with a PEG tube in place. The care plan included interventions such as cleansing the PEG tube site, applying a dressing, and daily inspection for signs of infection or skin breakdown. However, a review of physician orders for the relevant month revealed there were no active orders for cleansing, inspecting, or dressing the PEG tube site, and a previous order did not specify the type of dressing required. Further review of the Treatment Administration Record showed no documentation that staff had inspected, cleansed, or dressed the PEG tube site for a period of nearly three weeks. A visitor reported observing dried blood around the PEG tube and noted that staff did not return to clean the site after being informed. Observation confirmed the presence of a dressing only on the day of the survey, and an LPN verified the absence of physician orders and documentation for PEG tube care. Facility policies required daily checks of feeding tube sites and physician-specified dressing orders, which were not followed in this case.
Failure to Maintain and Monitor Central Line Dressing
Penalty
Summary
The facility failed to ensure proper care and management of a central line for a resident who was admitted with multiple diagnoses, including end stage renal disease and diabetes mellitus. The resident had a central line in place, and the plan of care included interventions such as changing the dressing as ordered and per facility policy, and monitoring for signs of infiltration and infection. However, there were no physician orders for monitoring the IV site or for dressing changes, including the type or frequency. Medical record review showed no evidence that the central line dressing had been changed since admission. During observation, the central line dressing was found to be rolled back, discolored, and the line was completely uncovered and exposed, with the date on the dressing illegible. Staff interviews confirmed that there were no orders for dressing changes or site monitoring, and that the dressing had not been changed since admission. Facility policy required sterile dressings to be maintained and changed every five to seven days or when compromised, with documentation of dressing changes and site assessments, but these standards were not met for this resident.
Failure to Provide Timely and Effective Pain Management
Penalty
Summary
The facility failed to ensure effective pain management for a resident admitted with a left lower leg fracture, chronic pain, and anxiety. Upon admission, the resident had physician orders for Tylenol and oxycodone-acetaminophen as needed for pain. However, due to an issue with obtaining a resident identification number, the pharmacy was unable to fill the oxycodone-acetaminophen prescription, resulting in the resident only receiving Tylenol for pain management. Documentation shows that Tylenol was administered when the resident reported significant pain, but the stronger pain medication was not given until much later, despite the resident experiencing severe pain that was not adequately controlled by Tylenol alone. Interviews with the resident and nursing staff confirmed that the resident experienced severe pain, rating it as high as ten out of ten, and that the Tylenol provided only minimal and short-lived relief. Nursing staff communicated the medication issue to administration and the DON, but delays persisted in providing the prescribed pain medication. Additionally, there was inaccurate documentation of the resident's pain level in the medical record. The facility's pain management policy requires that pain management be consistent with professional standards and resident preferences, which was not met in this instance.
Delayed Physician Review of Pharmacy Recommendations
Penalty
Summary
The facility failed to ensure that pharmacy recommendations were reviewed by the physician within the required timeframe, as outlined in facility policy. Specifically, for one resident with multiple diagnoses including asthma, type II diabetes mellitus, schizoaffective disorder, depression, anxiety disorder, schizophrenia, and insomnia, pharmacy recommendations regarding medication adjustments were not reviewed and signed by the physician until more than 30 days after the recommendations were made. The facility's policy required that such recommendations be reviewed by the medical provider within 30 days. Medical record review showed that the pharmacist recommended a dosage reduction for Famotidine and highlighted regulatory requirements for limiting as-needed psychoactive medications to 14 days unless reassessed and justified by the provider. In both instances, the physician did not review and sign the recommendations until 31 and 34 days after they were made, respectively. Staff interview confirmed the facility's policy for timely review, and policy documentation supported this requirement.
Unattended Controlled Medication Left at Bedside
Penalty
Summary
A deficiency occurred when a medication, specifically Xtampza ER (extended release oxycodone), was left unattended at a resident's bedside without a physician's order permitting self-administration or bedside storage. The resident, who was cognitively intact and had diagnoses including neuromuscular dysfunction of the bladder, benign prostatic hyperplasia, and unspecified pain, was observed with a medication cup containing an unknown pill on his bedside table. The resident reported that the night shift nurse had given him the medication, but he fell asleep and forgot to take it. Further investigation confirmed that the medication was left by the night shift LPN, who acknowledged that there was no order to leave medications at the bedside for this resident. Facility policy requires that nurses observe residents consuming their medications to ensure compliance with medication administration protocols. The unattended medication was verified by another LPN during the morning shift, confirming a failure to properly store and administer medications as required.
Improper Placement of Contaminated PPE Receptacle During Contact Precautions
Penalty
Summary
Staff failed to ensure that receptacles for contaminated personal protective equipment (PPE) were appropriately placed to prevent the transmission of pathogens. During an observation of medication administration for a resident with a history of methicillin susceptible Staphylococcus aureus (MSSA) infection of the left hip joint, it was noted that both the LPN and the surveyor donned PPE to enter the resident's room, which was under contact precautions. After administering IV medication, they exited the room and found there was no receptacle available near the exit to dispose of contaminated PPE. Instead, the only available bin for contaminated PPE was located on the opposite side of the room, near the window, requiring staff to walk back through the room to dispose of their used PPE. Interviews with the LPN and the Infection Control Preventionist confirmed that the placement of the contaminated PPE bin was due to space constraints, as the room was small and the bin did not fit by the door. Review of CDC guidance indicated that proper discarding of PPE should occur before exiting the patient room to contain pathogens. The facility's failure to provide an appropriately placed receptacle for contaminated PPE resulted in staff having to traverse the resident's environment with used PPE, contrary to recommended infection control practices.
Failure to Timely Address Medical Record Request
Penalty
Summary
The facility failed to address a request for medical records in a timely manner for a resident with severe cognitive impairment and multiple diagnoses, including altered mental status, psychosis, encephalopathy, anxiety, restlessness and agitation, depression, sepsis, hypertension, and a history of cerebral infarction. The resident's family member initially requested the medical records via email, followed by a second email one week later, but did not receive a response from the facility regarding the process for obtaining the records. Staff interviews revealed that the Social Service Designee (SSD) was unaware of the request until after returning from vacation, and the Administrator had not been notified of the request at all. Facility policy required that requests for records be referred to the DON, Administrator, or another designated staff member, with records to be provided within two days after payment. The lack of response and failure to follow policy resulted in the deficiency.
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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