Franklin Plaza Extended Care
Inspection history, citations, penalties and survey trends for this long-term care facility in Cleveland, Ohio.
- Location
- 3600 Franklin Boulevard, Cleveland, Ohio 44113
- CMS Provider Number
- 365388
- Inspections on file
- 35
- Latest survey
- March 3, 2026
- Citations (last 12 mo.)
- 64
Citation history
Health deficiencies cited at Franklin Plaza Extended Care during CMS and state inspections, most recent first.
Two residents experienced accidents due to inadequate assistance and supervision. A quadriplegic, nonverbal resident who was totally dependent for care and identified as a fall risk was provided personal care by a single CNA, contrary to staff understanding that two staff were needed for all care. During this one-person care, the resident rolled from bed to the floor and was later found in a fetal position on the floor with visible injuries; hospital evaluation documented multiple fractures and other trauma. In a separate incident, a cognitively impaired resident with vascular dementia and impaired mobility, whose care plan did not address wandering or elopement and who had no LOA orders, left the building without staff knowledge or sign-out, wandered outside looking for a spouse, fell on a curb, and sustained lacerations, with police and hospital staff later notifying facility staff of the event.
Surveyors found widespread environmental and sanitation issues, including multiple unsecured cleaning supply closets, a dirty medication cart, and extensive disrepair in resident rooms and shower areas. Several residents’ rooms had non-functioning equipment such as beds and over-bed lights, peeling paint, water-stained ceiling tiles, holes in walls and floors, leaks under sinks, dirty floors, and dusty fans and air-conditioning units. Women’s and men’s shower rooms contained clogged toilets with feces and urine, clothing on the floor, missing or non-working light fixtures, cracked and missing tiles exposing wall structures, mildew and rust buildup, peeling paint, visible ceiling leaks, and stained or water-filled ceiling tiles. In addition, ceiling tiles near a nurses’ station were heavily water-stained, and one of the main elevators was repeatedly out of service, with staff reporting frequent breakdowns and ongoing efforts to identify the cause.
Surveyors found that the facility did not follow its posted menus for multiple meals, including substituting beef stew and ice cream for a planned beef tips entrée and strawberry pretzel dessert, and serving turkey burgers instead of bratwurst patties. A dietary manager reported making substitutions due to resident preferences, cost concerns, and an internal policy about choking hazards, but these changes were not reflected on the menu. On another observed meal, residents on pureed diets did not receive the planned pureed confetti cake bar; instead, the cake was not pureed and an alternate dessert was planned, despite confirmation from dietary leadership that pureed-diet residents should receive the same items in pureed form. A resident reported that food was often cold and that the menu was often not followed.
Surveyors found widespread sanitation failures in the kitchen and dining areas, including dirty refrigerators with food debris and moldy produce, dusty fans and ceilings, sticky and debris-covered floors, and water accumulation near the dishwasher. Kitchen equipment and surfaces such as walls, ceiling tiles, vents, prep areas, shelving, lights, warming ovens, tray carts, and trash cans were observed to be dirty or poorly maintained, with staff personal items stored in food service areas. Dining room tables used by residents were visibly soiled and felt dirty to the touch, and although an ADON acknowledged the issue, the tables were not cleaned at that time. These conditions occurred despite a facility policy requiring kitchen sanitation through a comprehensive cleaning schedule.
The facility failed to enforce its safe smoking policies, allowing multiple residents to possess cigarettes and lighters in their rooms or on their person instead of in required lockboxes, and to smoke outside designated areas. A resident with extensive medical conditions and nicotine dependence was documented smoking and drinking alcohol in her room and later found with a lighter, despite being classified as a supervised smoker who could not safely use a lighter. Other residents were observed with smoking materials at bedside while oxygen equipment was in use, with burn holes in clothing, storing cigarettes in trash or under bedding, and smoking at the facility entrance rather than in the designated smoking area. Staff acknowledged that residents sometimes obtained smoking materials from families or store trips and that room sweeps occurred, but unsecured smoking materials and noncompliance with smoking rules remained widespread.
Two residents did not receive appropriate wound and skin care according to orders and care plans. A resident with peripheral vascular disease and a chronic heel ulcer, who was dependent for ADLs, did not have every-shift skin checks or documented bathing as ordered, and staff failed to identify and report multiple new vascular wounds on the legs and right heel despite a strong foul odor and visible open areas. The resident’s heel boots were tattered, heavily soiled, and improperly applied, and a sock was found adhered to skin over a large necrotic heel wound that had not been reported to the wound NP. Another resident’s hand/wrist splint, ordered to be monitored and removable for hygiene, was heavily soiled with dried dark debris; a CNA recognized the soiling yet still applied the splint and stated it had been that way for some time.
The facility failed to provide timely incontinence care and adequate catheter care for two residents. One resident with intact cognition, non-ambulatory status, and bowel/bladder incontinence reported not being changed since the previous evening despite requesting help; observation later showed urine had soaked through the brief, clothing, and wheelchair, and the CNA acknowledged not providing incontinence care during the shift. Another resident with urinary retention, stroke-related weakness, and an indwelling Foley catheter, whose care plan and MD orders required catheter care every shift, was found calling out while lying in a soiled brief; although a CNA reported providing incontinence care about an hour earlier, subsequent care revealed stool incontinence and a large amount of brown dried debris on the catheter tubing, and the CNA stated catheter care had not been done and was unsure when it was last provided.
A facility failed to conduct a thorough investigation after a resident with cognitive impairment alleged that another resident pulled down her pants in a common area. The investigation did not include statements from staff or other residents who may have witnessed the incident, nor did it identify which staff supervised the area at the time. The facility's policy required interviews with all potential witnesses, but this was not completed, and the incident was deemed unsubstantiated without a comprehensive review.
Surveyors found that the facility did not keep the kitchen clean or ensure food items were labeled and dated as required. Multiple undated containers of milk, pudding, juice, and Jell-O were found in the walk-in cooler, along with chocolate pies in packaging with broken seals. Dirty containers, greasy residue on an oven, and possible mold in the ice bin were also observed, with the Dietary Manager unable to confirm cleaning schedules. These issues were not in line with facility policy and had the potential to affect all residents except those not receiving food from the kitchen.
Multiple residents were affected by environmental and infection control deficiencies, including stained and missing ceiling tiles, running faucets, exposed wires, soiled linens placed on the floor, pervasive odors, and unaddressed maintenance issues. Staff interviews confirmed awareness of some issues, while others went unnoticed until pointed out by surveyors. Facility policies requiring cleanliness and safety were not consistently followed.
Multiple residents experienced prolonged lack of access to functional toilets due to plumbing failures and restricted access to alternative restrooms. Some residents, including those with cognitive impairments, were unable to use their assigned bathrooms for extended periods, leading to distress and incontinence. Staff and maintenance were aware of the issues, but repairs were delayed, and alternative restrooms were not readily accessible to residents.
A resident who was fully dependent on staff for toileting and hygiene was found with dried urine stains and a saturated incontinence brief, indicating a lack of timely incontinence care. Staff interviews confirmed that the assigned CNA had not changed the resident since starting her shift and was unaware of the last time care was provided. The DON verified that care should have been given earlier and that the facility's policy did not specify care frequency.
A resident with severe cognitive impairment and multiple psychiatric and physical diagnoses did not receive necessary medically related social services after the resignation of their legal guardian. Staff were unaware of who was responsible for the resident's care decisions, financial matters, or Medicaid redetermination, and the medical record contained outdated contact information and instructions. This resulted in the resident lacking appropriate representation and support.
The facility did not provide appropriate food items to residents on controlled carbohydrate, liberalized renal, and renal diets, as required by their dietary orders. During a meal service, all residents on regular or mechanically altered diets received the same menu items, regardless of their dietary restrictions, due to the absence of required alternatives and failure to follow diet spreadsheets. Dietary staff and management confirmed that the correct procedures were not followed, impacting numerous residents with special dietary needs.
Surveyors observed that food and drink served to residents was not palatable, attractive, or at a safe and appetizing temperature, resulting in a deficiency.
Two residents with tracheostomies and feeding tubes, both requiring Enhanced Barrier Precautions, received high-contact care from an LPN who did not don the required gown and gloves. The LPN confirmed awareness of the PPE requirement and signage but reported that PPE was not available in the rooms at the time of care, resulting in non-compliance with facility policy and physician orders.
A facility failed to timely order and implement care for a resident with a suprapubic catheter and ileostomy, resulting in a deficiency. The resident was admitted with these devices but lacked physician orders for their care for several weeks. Despite having a care plan outlining necessary interventions, the orders were not obtained until after the deficiency was identified. Observations showed the resident's catheter bag was not emptied as needed, and the unit manager confirmed the oversight.
A resident with a PEG tube did not receive appropriate care as per physician orders. The dressing on the PEG tube was not changed daily, and there was crusty brownish-red drainage and redness around the site, which was not documented in the progress notes. The resident, who relied on tube feeding for more than 51% of their caloric intake, had diagnoses including epilepsy and chronic respiratory failure.
A resident with a tracheostomy did not receive proper care, as observed by an LPN. The trach dressing was undated with crusty drainage, and the skin was purplish-red. The facility's policy for trach care was not followed, as documentation of skin integrity and changes in secretions was missing.
The facility failed to administer medications according to nursing standards, affecting two residents. An LPN prepared medications for a resident, but a UM administered them, omitting a prescribed inhalation powder. Another resident's medications were signed off before administration. The DON confirmed these actions violated facility policy.
The facility failed to ensure staff donned appropriate PPE for two residents, leading to infection control deficiencies. One resident with multiple medical devices did not have timely Enhanced Barrier Precautions (EBP) implemented, and an LPN did not wear an isolation gown while providing care. Another resident with a tracheostomy and PEG tube also did not receive proper EBP, as an LPN provided care without a gown, despite posted EBP signs. These actions breached the facility's infection control policy.
The facility failed to maintain a sanitary condition in its garbage and refuse area, potentially affecting all 157 residents. Observations revealed multiple plastic trash bags, used Styrofoam food containers, and various debris scattered around the dumpster area. These findings were confirmed by the DM during a complaint investigation.
Failure to Provide Safe ADL Assistance and Adequate Supervision Resulting in Fall Injuries and Unauthorized Exit
Penalty
Summary
The deficiency involves the facility’s failure to provide adequate, safe assistance during ADLs/personal care for a quadriplegic resident and failure to provide sufficient supervision to prevent another cognitively impaired resident from leaving the facility unsupervised. One resident, who was cognitively impaired, quadriplegic, and had multiple contractures, was dependent on staff for toileting, bathing, personal hygiene, bed mobility, and transfers. His care plan identified him as at risk for falls related to immobility and paralytic syndrome and required mechanical lift transfers with assistance of two staff members for transfers and mobility, but it did not specify the number of staff required for bathing, bed mobility, dressing, or incontinence care. Staff interviews, including an RN and LPN, indicated that this resident required two staff members for all care because he was unable to move himself. On the evening of the incident, a CNA provided personal care to this quadriplegic resident alone. According to the CNA’s written statement, the resident was placed on his right side during care and rolled off the bed. The LPN who responded reported that the CNA told her he had lost his grip on the resident during care. The LPN observed the resident on the floor in a fetal position with his head against equipment, and another CNA later described the resident as wedged between the floor and the nightstand with blood around his mouth. Initial nursing documentation noted shearing to the right knee and a new pain level of 3–4 out of 10 after the fall, and pain medication was administered. The fall investigation documented that the resident rolled from bed during care but did not identify the root cause, did not clarify the level of assistance that should have been used, did not document whether the resident hit his head, and did not show that neurological checks were completed. Hospital records from the subsequent emergency department visit documented that the resident had sustained a four-foot fall from bed during care and arrived with multiple fractures to the left pelvis and left hand, a hematoma to the left eyebrow, and abrasions to the right knee and left ankle and toes. EMS reported that facility staff were initially hesitant to send the resident to the hospital and that he was transported after family request. The DON later acknowledged being informed that the CNA had provided care unassisted and that the care plan did not specify that two staff were required for ADLs, although it did indicate the resident was total care. The facility’s falls policy required staff to identify risk factors and define possible causes for falls and to identify pertinent interventions to prevent subsequent falls, but the investigation for this event did not fully address these elements. The second component of the deficiency concerns a resident with vascular dementia, impaired cognition, difficulty walking, and lack of coordination, who required supervision with ambulation and bed mobility. The resident’s care plan identified fall risk and impaired cognition, with interventions to assist with transfers and mobility and to encourage participation in daily decisions, but it did not address wandering or elopement. An elopement assessment rated the resident at low risk for elopement, and there were no physician orders authorizing leave of absence (LOA) privileges during the period reviewed. On the date of the incident, the resident left the facility without staff awareness or a documented sign-out. Nursing staff, including the assigned LPN and an RN on duty later in the day, reported they were unaware the resident had left until notified by a supervisor or by police. The receptionist recalled seeing the resident earlier in the afternoon but did not recall seeing her leave or having visitors and later received a call from police indicating the resident was at the police station. Hospital documentation stated that the resident had escaped from the facility, was wandering outside looking for her husband, tripped on a curb, fell, and struck her head, resulting in a skin tear to the right elbow and superficial lacerations to multiple digits of the right hand. The DON confirmed that the resident had impaired cognition, that no LOA orders were in place, and that the administrator reported the event to the state as an unauthorized LOA. The facility’s LOA policy required that residents who are not their own responsible party leave only with a responsible party who signs them out at the front desk, but this process was not followed in this case. The combination of these events—providing one-person assistance during personal care to a quadriplegic, totally dependent resident whose care needs effectively required two staff, and allowing a cognitively impaired resident to leave the building unsupervised without LOA authorization or staff awareness—formed the basis of the cited deficiency for failure to ensure the environment was free from accident hazards and that residents received adequate supervision and assistance to prevent accidents.
Environmental Disrepair, Unsecured Chemicals, and Poor Sanitation Throughout Facility
Penalty
Summary
The deficiency involves the facility’s failure to maintain a safe, clean, and homelike environment, including unsecured cleaning supplies and multiple environmental disrepairs. Surveyors observed several unlocked cleaning supply closets on multiple floors, with housekeeping staff confirming that the closets remained unlocked because there were no keys, despite expectations that cleaning supplies be secured at all times. A dirty medication cart with dried brown splatter was also observed. These conditions affected multiple residents and had the potential to affect all residents in the facility. Additional deficiencies were identified in resident rooms and common shower areas. One resident’s room had an extremely dusty wall air-conditioning unit, damaged floor trim with flaking drywall, and a bed that did not work and was missing electric plugins. Another resident’s room had a non-functioning over-bed light despite multiple requests for repair, yellow-green splatter on the wall, a dirty floor, chipped paint, a dusty standing fan, water stains on the wall from a leak, and a hole in the drywall behind the bed. Other rooms had large amounts of paint chipping by windows, multiple ceiling tiles with large brown water stains above beds, a large hole near a wall air-conditioning unit stuffed with a towel, and floors with holes and large pieces of floor tiles missing. Two residents’ room sink was leaking into a basin placed underneath. Common shower and corridor areas also showed significant deterioration and unclean conditions. On one floor, a women’s shower room had a clogged toilet with feces and urine, clothing items on the floor, peeling paint above the shower, and water-stained ceilings. Another women’s shower room lacked a light fixture cover, had non-functioning bulbs with debris flaking from the fixture, cracked tiles, mildew and rust buildup, missing wall tiles exposing a large hole and wall structure, peeling paint, visible water leaking from the ceiling, and rust on the floor. A men’s shower room had a used towel left on a bench and large brown water stains and a water-filled bubble in ceiling tiles, with wet ceiling tiles and missing wall tiles in a standing shower. Surveyors also observed multiple stained ceiling tiles near a nurses’ station and repeated outages of one of the main elevators, which staff reported frequently broke down and required ongoing troubleshooting.
Failure to Follow Posted Menus and Provide Appropriate Pureed Diet Desserts
Penalty
Summary
The facility failed to ensure that menus were followed as written, affecting nearly all residents who received meals from the kitchen. On a specified lunch date, the posted menu called for braised beef tips, rice pilaf, buttered carrots, a dinner roll, and strawberry pretzel dessert. Instead, during observation of the lunch tray line, dietary staff served beef stew with rice mixed into it, carrots, pears, a dinner roll, and ice cream. The dietary manager reported substituting beef tips with beef stew and adding rice to the stew based on resident preferences, and also substituting the strawberry pretzel dessert due to its high cost. A resident interviewed that afternoon stated the food was “so/so,” was often cold, and that the menu was often not followed. For dinner on the same date, the menu specified a bratwurst patty on a bun, but observation of the dinner tray line showed that a turkey burger was served instead. The dietary manager stated that facility policy did not allow hot dog–shaped bratwurst because of choking hazard concerns and that she was unable to obtain a non–hot dog–shaped bratwurst. On another dinner date, the menu and spreadsheet indicated that residents on a pureed diet were to receive a pureed confetti cake bar for dessert. Observation of the dinner tray line revealed that the confetti cake had not been pureed, and the dietary manager acknowledged she had not pureed the cake, was unsure if there was enough, and had planned to give residents on pureed diets a different dessert. The dietician and regional director of food services confirmed that residents on pureed diets should receive the same food as those on regular diets, in pureed form. These findings were inconsistent with the facility’s policy stating that individuals will be provided with nourishing, palatable, attractive meals that support each individual’s daily nutritional and special dietary needs.
Widespread Kitchen and Dining Sanitation Failures
Penalty
Summary
The facility failed to maintain the kitchen in a clean and sanitary manner, affecting food procurement, storage, preparation, and service for most residents who received meals from the kitchen. Surveyors observed that a refrigerator across from the stove contained food debris, splatter, and dirt along the bottom, with black residue on the back wall. The walk-in refrigerator had dust on the fans and ceiling, an undated container of lemonade, a bag of expired arugula, four moldy cucumbers, and staff food items, despite the Dietary Manager (DM) stating staff food was not typically kept there. The kitchen floor was extremely sticky and slippery with dried black debris buildup, tape, and trash near the stove and tray line. A freezer panel was falling off, and there was a large accumulation of water on the floor around the dishwasher extending toward the ice machine. Walls behind the dishwasher and 3-part sink were extremely dirty with dust and dirt, and ceiling tiles were heavily soiled with brown and black spots, which the DM reported had not been wiped down in six months. Further observations during the lunch tray line revealed large amounts of black dust on a vent and where ceiling tiles met the wall, dust strands hanging from ceiling tiles, and heavy dust buildup on ceiling grids. The floor under a prep table had wet, matted dust, and a steel shelf holding clean food containers was itself dirty. Dust buildup was also noted behind the ice machine and on pipes, wires, and the ceiling, with splatter on multiple kitchen lights. Trash cans lacked lids, a window near the freezer and stove was dirty and cluttered with staff clothing, bags, and a water bottle, and the warming oven and tray carts had visible spills and food debris despite expectations for daily wiping. In a dining room, tables had visible debris and liquid stains and felt dirty to the touch, and although the Assistant DON acknowledged the condition and stated she would wipe them down, this was not done. Additional issues included a convection steamer door that did not close and two non-functioning light bulbs in the stove hood. The facility’s own policy required maintenance of kitchen sanitation through compliance with a written, comprehensive cleaning schedule.
Failure to Enforce Safe Smoking Policies and Control Smoking Materials
Penalty
Summary
The deficiency involves the facility’s failure to implement and enforce its own safe smoking policies and procedures for residents who smoke. The facility’s smoking policy required that smoking occur only in designated areas and times, that all smoking materials (including cigarettes and lighters) be locked when not in use, and that supervised smokers not be given personal possession of smoking materials. Despite this, multiple residents were observed with cigarettes and lighters in their rooms or on their person, and smoking paraphernalia was found in inappropriate locations within the facility. The facility census included 37 smokers out of 164 residents. One resident with multiple medical diagnoses including hypertensive heart and chronic kidney disease, type 2 diabetes, end stage renal disease, atrial fibrillation, vascular dementia, post-traumatic stress disorder, anxiety, and nicotine dependence had a care plan addressing potential tobacco-related injuries and infection control issues. This resident was documented as having been found drinking vodka and smoking in her room, and later having a lighter in her room, despite being care planned as a supervised smoker who could not safely use a lighter and was to smoke only in designated areas. Other residents were observed with cigarettes and lighters not stored in lockboxes as required. One resident’s room contained a pack of cigarettes and a lighter on the bedside table while an oxygen concentrator was running, and this situation was observed on more than one occasion. Another resident was reported by CNAs to have smoked in his room while his roommate, who used oxygen, was present. Additional observations showed residents keeping cigarettes and lighters at bedside or on their person, including a resident in the hallway with cigarettes and a lighter and clothing with multiple burn holes, and another resident with cigarettes and a lighter at bedside who stated she could not access the designated outdoor smoking area due to a damaged sidewalk. Cigarettes and lighters were also found on the floor of a resident’s room across from a room where oxygen was in use, and smoked smoking paraphernalia was found placed on a vitals machine at a nursing station. Other residents were seen with cigarette packs on the floor or hidden in trash or under bedding, refusing to relinquish them, and one resident was observed smoking in front of the facility rather than in the designated smoking area. Staff interviews confirmed that residents sometimes obtained cigarettes and lighters from family or store trips and that room sweeps were done, but these measures did not prevent the widespread presence of unsecured smoking materials and smoking outside of designated areas, contrary to facility policy.
Failure to Provide Comprehensive Wound Care and Maintain Clean Assistive Devices
Penalty
Summary
The deficiency involves the facility’s failure to provide comprehensive wound management and skin care as ordered and care-planned for a resident with vascular disease and chronic ulcers. One resident with chronic left heel vascular ulcer, peripheral vascular disease, and significant mobility and self-care deficits was care-planned to receive heel lift suspension boots at all times (removed only for bathing/hygiene and shift skin checks), weekly wound documentation, and monitoring for infection and changes in wound size. Physician orders also required nightly wound treatments and every-shift skin checks. Record review showed that skin checks were not documented every shift as ordered, and there was no evidence that showers or bathing had been provided during the review period. Surveyor observations on multiple occasions noted a strong foul odor in the resident’s room. During ADL care, staff confirmed the odor and described it as smelling like a “rotten wound.” The resident’s left heel Kerlix dressing appeared clean and intact, but the heel boots were tattered, heavily soiled, flattened, and one was applied upside down; CNAs stated they were unaware of a red open area on the resident’s left mid-calf until it was observed during care. The wound nurse later confirmed this new area and documented it as a skin tear, with subsequent weekly wound documentation identifying additional vascular ulcers on the left posterior calf, left distal calf, and right heel. Progress notes earlier in the same period had stated there were no new skin issues identified. When the wound nurse practitioner arrived for wound rounds, she reported that she had only been informed of one new wound that morning. On assessment, removal of the resident’s sock revealed that a large amount of skin was adhered to the sock and a large open right heel wound with slough and necrotic tissue was present, accompanied by foul odor; the practitioner stated this was a new wound she had not previously been made aware of. Removal of the Kerlix dressing on the left foot revealed another new wound on the left posterior calf several inches above the chronic heel wound, which neither the wound nurse nor the practitioner had known about. The practitioner stated the three new wounds were vascular in nature and did not develop overnight. The resident could not recall when he last had a shower, when his sock was last removed, or when his foot was last cleaned. In a separate finding, another resident’s hand/wrist splint, which was ordered to be monitored for redness and open areas and removable for hygiene, was observed to be heavily soiled with dried dark debris; a CNA acknowledged seeing the soiling and stated it had been that way for a while, yet still applied the splint to the resident’s hand.
Failure to Provide Timely Incontinence and Adequate Catheter Care
Penalty
Summary
The facility failed to provide timely incontinence care to Resident #64, who was admitted on 10/05/21 with diagnoses including muscle weakness, lack of coordination, and diabetes. The resident had intact cognition, was non-ambulatory, dependent for transfers and bed mobility, and was incontinent of bowel and bladder. The care plan dated 12/22/25 indicated the resident was dependent with toileting and required staff assistance with ADLs, including checking for incontinence, offering toileting assistance, and removing wet or soiled clothing to provide incontinence care. On 02/19/26 at 1:59 P.M., the resident reported he was incontinent of urine, had asked to be changed, and had not been changed since the previous evening. He stated he had recently asked a CNA for incontinence care, but the CNA told him she was going on break and would change him upon return. During the interview, a strong urine odor was noted. At 2:20 P.M., CNA #303 confirmed the resident had requested incontinence care prior to her break and that she told him she would change him when she returned. Observation of incontinence care at that time revealed the resident was heavily soiled with urine that had soaked through his brief, clothing, and onto his wheelchair. CNA #303 stated she had not provided incontinence care during her shift and was unaware he required care until he informed her shortly before. The facility also failed to provide adequate catheter care to Resident #153, admitted on 01/30/26 with diagnoses including urinary retention, stroke with right-sided weakness, and muscle weakness. The care plan dated 02/01/26 identified the resident as being at risk for infection related to use of a urinary catheter, with interventions including Foley catheter care every shift. The MDS indicated intact cognition, dependence with toileting, and an indwelling urinary catheter, and current physician orders directed catheter care every shift and as needed. On 02/26/26 at 11:38 A.M., the resident was observed calling out for assistance and stated he was upset and lying in a dirty brief. At 11:48 A.M., CNA #409 reported having provided incontinence care approximately an hour earlier and was unaware the resident required additional care. CNA #409 then provided incontinence care due to stool incontinence, and further observation revealed a large amount of brown dried debris around the catheter tubing. CNA #409 stated he had not provided catheter care during the earlier incontinence care and was unsure when catheter care had last been provided.
Failure to Thoroughly Investigate Resident-to-Resident Sexual Abuse Allegation
Penalty
Summary
The facility failed to thoroughly investigate an allegation of resident-to-resident sexual abuse involving a moderately cognitively impaired resident with hemiplegia and muscle weakness. The incident was reported after the resident's husband received a voicemail from another resident stating that a male resident had pulled down his wife's pants and touched her. The resident herself reported that her pants were pulled down in a common area after a smoke break, but she denied being touched in her private area and refused a hospital evaluation. The accused resident denied the incident, stating they were only joking, and there were no staff or other residents present according to his account. The facility's investigation was incomplete, lacking statements from staff who supervised or assisted with the smoke break, as well as from other residents who may have witnessed the event. Notably, the investigation did not include a statement from the roommate who initially reported the incident to the resident's husband, nor did it identify which staff members were present during the relevant time. The Director of Nursing and Administrator confirmed that no staff or additional residents were interviewed regarding the incident or any similar behaviors by the accused resident. Facility policy required that all alleged violations involving abuse be thoroughly investigated, including interviews with the resident, the accused, and all potential witnesses, such as staff and other residents present at the time. However, the investigation did not meet these requirements, as it failed to identify or interview key individuals who may have had relevant information about the incident. The police were not contacted, and the incident was ultimately deemed unsubstantiated without a comprehensive investigation.
Failure to Maintain Kitchen Sanitation and Proper Food Labeling
Penalty
Summary
The facility failed to maintain the kitchen area in a clean and sanitary condition and did not ensure that food items were properly labeled and dated. During a kitchen tour with the Dietary Manager, surveyors observed multiple undated containers of milk, chocolate pudding, prune juice, and Jell-O in the walk-in cooler, as well as two chocolate pies in original packaging with broken seals. Additionally, a brown, crusty substance was found on the outside of several cups and bowls, and a large amount of greasy food residue was present on the outside wall of an oven, with the Dietary Manager unable to state when it was last cleaned. A black spotted substance, identified as possible mold, was also observed on the inside wall of the ice bin. These findings were confirmed by the Dietary Manager and were not in accordance with the facility's policy on food preparation and storage. The deficiency had the potential to affect all residents except those identified as receiving nothing by mouth.
Environmental and Infection Control Deficiencies Identified
Penalty
Summary
The facility failed to maintain a safe, functional, sanitary, and comfortable environment for its residents, as evidenced by multiple observations and interviews. Several rooms had significant maintenance issues, such as stained and missing ceiling tiles exposing plumbing, running faucets that could not be turned off, and exposed wires from a detached telephone outlet cover. In one instance, a resident's room had a large brown stain above the bed from an old water leak, and the maintenance director was unaware of the issue. Other rooms had missing ceiling tiles in bathrooms, exposing large holes and plumbing pipes, with these conditions persisting over multiple days of observation. In addition to maintenance concerns, there were notable lapses in infection control and cleanliness. Dirty linens, towels, and incontinence pads were placed directly on the floor during care for a resident who was always incontinent and dependent on staff for hygiene. The CNA involved acknowledged this practice was improper but cited a lack of available bags. The DON confirmed that placing soiled linens on the floor was an infection control issue. Other observations included soiled incontinence briefs left on the bathroom floor, which attracted gnats, and a strong urine odor in the hallway, further indicating lapses in cleanliness and timely waste removal. Additional environmental deficiencies included a loose floor tile in a common area, a section of baseboard peeling away from the wall, chipped paint on a resident's door, and the presence of empty oxygen tanks in a resident's room. Shower rooms were found with dark mildew, rust-like stains, and ceiling tiles with blackish substances. Facility policies reviewed required clean and sanitary conditions, but these were not consistently followed, as evidenced by the ongoing issues observed and verified by staff and administration.
Failure to Maintain Safe and Accessible Restroom Facilities
Penalty
Summary
The facility failed to provide a safe, clean, comfortable, and homelike environment for six residents, as evidenced by multiple nonfunctional toilets and inadequate access to alternative restroom facilities. Several residents, including those with intact cognition and those with cognitive impairments, experienced prolonged periods without access to a working toilet in their rooms. In one instance, a resident was unable to use her bathroom for two months due to a nonfunctional toilet and damaged tiles, and was directed to use a shower room or a bedside commode. However, the shower room required a code that only staff knew, and the alternative common area restroom was labeled for visitors only, further restricting access. The resident reported episodes of incontinence as a result of these barriers. Other residents also faced similar issues, with reports of toilets that would not flush and required maintenance intervention. In some cases, residents had to wait for staff to unlock alternative restrooms, and in one instance, a toilet in a shared bathroom was found to be nonfunctional and contained unflushed fecal matter. Staff interviews confirmed awareness of the plumbing issues, but repairs were delayed due to the unavailability of maintenance personnel. Some residents expressed distress and frustration over the lack of access to functional restroom facilities, and staff verified that these issues had persisted for days or even since admission for certain individuals. Facility policy review indicated that residents have the right to a safe and clean living environment, including general maintenance of sanitary interiors. Despite this, observations and interviews revealed ongoing problems with restroom accessibility and cleanliness, affecting residents' dignity and comfort. The deficiency was identified through record review, observation, and interviews, and was determined to have the potential to impact all residents in the facility.
Failure to Provide Timely Incontinence Care
Penalty
Summary
A deficiency was identified when a resident with a history of congestive heart failure, diabetes, dementia, and adult failure to thrive was not provided timely incontinence care. The resident was fully dependent on staff for toileting and hygiene due to impaired cognition and mobility. Observations revealed a strong foul urine odor in the resident's room, and the resident was found lying in bed with yellow-brownish stains on her gown and underpad, indicating prolonged exposure to urine. The incontinence brief was moderately saturated, and the stains extended from the resident's hip to her shoulder, suggesting she had not been changed for an extended period. Interviews with staff confirmed that the assigned CNA had not provided incontinence care since starting her shift and was unaware of when the resident was last changed. The CNA also did not receive a report regarding the resident's previous care. The Director of Nursing verified that the CNA should have provided incontinence care earlier and acknowledged that the resident should not have had dried urine stains if care had been provided in a timely manner. Review of the facility's incontinence care policy showed it aimed to keep residents clean and dry but did not specify the required frequency of care.
Failure to Provide Medically Related Social Services Due to Lack of Legal Representation
Penalty
Summary
The facility failed to provide medically related social services necessary for a resident to attain or maintain the highest practicable physical, mental, and psychosocial well-being. The resident in question had multiple complex diagnoses, including schizoaffective disorder, alcohol-induced dementia, bipolar disorder, delusional disorders, hearing loss, and legal blindness. The resident was severely cognitively impaired, dependent on staff for all activities of daily living, and unable to participate in meaningful conversation or provide reliable information. Despite these needs, the facility did not ensure that the resident's legal and social service needs were met, as evidenced by outdated and incorrect emergency contact information and a lack of clarity regarding who was responsible for making decisions on the resident's behalf. Interviews and record reviews revealed that the social worker and other staff were unaware of who was responsible for the resident's care decisions, financial matters, or Medicaid redetermination after the resignation of the legal guardian. The medical record still directed staff to refer to a legal guardian who was no longer in place, and there was no active case with Adult Protective Services. The social worker confirmed that multiple staff failed to update the resident's records and ensure appropriate representation, resulting in a lack of necessary social services and support for the resident.
Failure to Provide Appropriate Diets for Residents with Special Dietary Needs
Penalty
Summary
The facility failed to ensure that residents on specialized diets, including controlled carbohydrate diets (CCD), liberalized renal diets, and renal diets with regular or mechanically altered consistency, received the appropriate food items as specified in the facility's diet spreadsheets and menu guidelines. During a lunch meal service, observations revealed that all residents on regular or mechanically altered diets were served the same items—herb roasted pork loin, candied sweet potatoes, and buttered cabbage—regardless of their prescribed dietary restrictions. There were no plain sweet potatoes or buttered noodles available on the steam table for those requiring alternatives, and the dietary staff confirmed that brown sugar had been added to all sweet potatoes, making them unsuitable for CCD and renal diets. Interviews with dietary staff and the dietary manager revealed that the diet spreadsheets, which detailed the specific meal modifications required for each diet type, were not accessible or followed during meal service. The dietary manager admitted to not double-checking that residents received the correct items and stated that the facility typically had liberal diets. The dietitian confirmed that the spreadsheets should have been followed. Additionally, the facility's policy did not include guidance on following diet spreadsheets. This deficiency affected a significant number of residents identified as requiring specialized diets.
Failure to Provide Palatable and Properly Tempered Food and Drink
Penalty
Summary
The facility failed to ensure that food and drink provided to residents was palatable, attractive, and served at a safe and appetizing temperature. Surveyors observed that the food and beverages did not meet these standards during their review. The deficiency was identified based on direct observation of the meals and drinks served to residents.
Failure to Use PPE for Residents on Enhanced Barrier Precautions
Penalty
Summary
The facility failed to ensure proper infection control techniques were used for residents on Enhanced Barrier Precautions (EBP). Two residents with significant medical needs, including tracheostomies and feeding tubes, were identified as requiring EBP, which included the use of gowns and gloves during high-contact care. Both residents were dependent on staff for eating, toileting, and personal hygiene, and their care plans and physician orders specified the need for PPE during care involving their feeding tubes and tracheostomies. Despite these requirements, observations revealed that an LPN provided tube feeding and checked feeding tube sites for both residents without donning the required PPE. The LPN acknowledged that signs indicating EBP were posted outside the residents' rooms and confirmed awareness of the PPE requirement, but stated that PPE was not available in the rooms at the time care was provided. Facility policy also required PPE use for residents with indwelling medical devices, such as feeding tubes, during high-contact care.
Failure to Timely Order and Implement Catheter and Ostomy Care
Penalty
Summary
The facility failed to timely order and implement care for a resident with a suprapubic catheter and ileostomy, leading to a deficiency in providing appropriate catheter and ostomy care. The resident, who was admitted with a suprapubic catheter, ileostomy bag, and 28 staples to the abdomen, did not have physician orders for the care of these devices from the time of admission until several weeks later. Despite having a care plan in place that outlined the necessary interventions to prevent infection and ensure proper catheter and ostomy care, the orders were not obtained until after the deficiency was identified. The resident's medical records and care plan indicated a risk for infection and trauma related to the use of a suprapubic catheter and ileostomy. However, the lack of timely physician orders meant that the necessary treatments and monitoring were not documented or completed as required. Observations revealed that the resident's catheter bag was not emptied as frequently as needed, and there was a delay in obtaining the appropriate care orders. The unit manager acknowledged the oversight and confirmed that the admission nurse did not ensure the orders were in place, leading to the deficiency being cited.
Failure to Provide Appropriate PEG Tube Care
Penalty
Summary
The facility failed to provide appropriate care and services for a resident with a PEG tube, as per physician orders. The resident, who was dependent on tube feeding for more than 51% of their total caloric intake, had specific orders for routine care of the PEG tube site, including cleansing with normal saline, applying a dry clean dressing, and monitoring for irritation every shift. However, during an observation, it was found that the dressing on the resident's PEG tube was not changed daily as required, and there was a moderate amount of crusty brownish-red drainage on the tube and dressing. Additionally, the surrounding skin was reddened, indicating potential irritation or infection, which was not documented in the resident's progress notes. The resident's medical record showed diagnoses of epilepsy, type two diabetes mellitus with hyperglycemia, and chronic respiratory failure with hypoxia. Despite the physician's orders and the facility's policy, the care provided did not adhere to the required standards, as evidenced by the outdated dressing and lack of documentation regarding the condition of the PEG tube site. This deficiency was identified during a complaint investigation and affected one resident out of three reviewed for appropriate PEG tube care, with the facility census being 167.
Inadequate Tracheostomy Care for a Resident
Penalty
Summary
The facility failed to provide proper respiratory care for a resident with a tracheostomy, leading to a deficiency. Resident #158, who has a history of epilepsy, type two diabetes mellitus with hyperglycemia, and chronic respiratory failure with hypoxia, was observed to have inadequate tracheostomy care. The resident's medical records indicated orders for trach care every shift and as needed, which were documented as completed. However, during an observation, the resident's trach dressing was found to be undated and had a moderate amount of greenish-brown crusty drainage. The skin around the tracheostomy was purplish-red, and the suction canister was half full with mucousy greenish-yellow fluid. The facility's policy on tracheostomy care, which aims to keep the surrounding tissue clean and free from infection, was not adhered to. The policy requires daily trach care, cleaning and inspecting the skin under the trach ties, and documenting the integrity of the skin and any changes in secretions. However, the progress notes for the resident did not document the skin integrity under the trach ties or any redness around the trach tube. This lack of proper documentation and care led to the deficiency being identified during the survey.
Medication Administration Deficiency
Penalty
Summary
The facility failed to ensure medications were administered according to current nursing standards of practice, affecting two residents. Resident #4, who had a history of a fibula fracture, type two diabetes with diabetic neuropathy, and shortness of breath, did not receive their prescribed Fluticasone Proprionate Diskus inhalation powder with their morning medications. The Licensed Practical Nurse (LPN) #400 prepared the medications, but Unit Manager (UM) #401 administered them without verifying the completeness of the medication list, leading to the omission of the inhalation powder. The facility policy requires that the person who prepares the medication should also administer it, which was not followed in this instance. Resident #158, diagnosed with epilepsy, type two diabetes mellitus with hyperglycemia, and chronic respiratory failure with hypoxia, was also affected by improper medication administration practices. LPN #400 signed off on the Medication Administration Record (MAR) for medications that had not yet been administered, including levetiracetam for seizures. This premature documentation occurred because LPN #400 had to interrupt the preparation of Resident #158's medications to prepare medications for Resident #4, which were then administered by UM #401. The Director of Nursing (DON) confirmed that the actions of LPN #400 and UM #401 were not in compliance with the facility's medication administration policy. The policy stipulates that medications should be administered as prescribed and documented immediately after administration. The deficiency was identified during an investigation under Complaint Number OH00158785.
Infection Control Deficiencies Due to Improper PPE Use
Penalty
Summary
The facility failed to ensure that staff donned appropriate personal protective equipment (PPE) when providing care for two residents, leading to deficiencies in infection prevention and control. Resident #62, who was admitted with multiple medical devices including a suprapubic catheter, ileostomy, and JP drain, was at risk for infection. Despite having physician orders for Enhanced Barrier Precautions (EBP) that required the use of gowns and gloves for high-contact care, these precautions were not implemented in a timely manner. An observation revealed that an LPN did not wear an isolation gown while emptying Resident #62's catheter bag, despite the presence of a CDC EBP sign at the room entrance. Resident #158, who had diagnoses including epilepsy, diabetes, and chronic respiratory failure, also required EBP due to the presence of a tracheostomy and PEG tube. The resident was dependent on staff for all activities of daily living and received a significant portion of nutrition through tube feeding. During an observation, an LPN provided tracheostomy and PEG tube care without donning an isolation gown, even though an EBP sign was posted at the room entrance. The LPN's clothing came into contact with the resident's bed linens and gown, further indicating a breach in infection control protocols. The facility's policy on Enhanced Barrier Precautions, which was reviewed in November 2023, outlined the necessity of using gowns and gloves for high-contact resident care activities to prevent the transmission of multidrug-resistant organisms. However, the failure to adhere to these precautions for residents with indwelling medical devices and other risk factors for infection led to the identified deficiencies. The non-compliance was investigated under a specific complaint number, highlighting the facility's lapses in infection control practices.
Improper Disposal of Garbage and Refuse
Penalty
Summary
The facility failed to maintain its garbage and refuse area in a sanitary condition, which had the potential to affect all 157 residents. During an observation of the facility's outside dumpster area, multiple plastic trash bags full of refuse were found on the sides of the dumpster. Additionally, used Styrofoam food containers, plastic gloves, straws, disposable masks, and various food particles were scattered on the ground outside the dumpster area. These findings were verified by the Dietary Manager during the observation. This deficiency was identified as an incidental finding during a complaint investigation.
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 metabolic encephalopathy, muscle weakness, and a history of CVA experienced a fall in his room that was not documented in the medical record until the following morning as a late entry. Two RNs acknowledged that the fall was not recorded at the time it occurred and stated that fall incidents should be documented as soon as possible after the event, resulting in a deficiency for failure to maintain timely, professionally standard medical records.
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.
A resident with cirrhosis, ascites, mood disorder, and alcohol-induced major neurocognitive disorder, and with moderately impaired cognition, was observed sitting on a shower chair in a gown with buttocks exposed and visible from the hallway through an open room door. A CNA left the room quickly after hearing another resident yell and forgot to close the door or pull the privacy curtain, and an RN confirmed the exposure, demonstrating a failure to maintain the resident’s dignity and privacy.
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.
Untimely Documentation of Resident Fall Incident in Medical Record
Penalty
Summary
The deficiency involves the facility’s failure to document a resident’s fall incident in the medical record in a timely manner, in accordance with accepted professional standards. The resident was admitted with diagnoses including metabolic encephalopathy, muscle weakness, and cerebrovascular accident. According to the medical record, a progress note was entered as a late entry on 02/20/26 at 8:21 A.M., stating that the resident had suffered a fall in his room on 02/19/26 at 8:00 P.M. There was no evidence of any documentation of the fall incident entered in the medical record at the time of, or shortly after, the fall on 02/19/26 at 8:00 P.M. During an interview on 03/30/26 at 12:05 P.M., two RNs confirmed that the fall incident was not documented until the following morning and stated that fall incidents should be entered in the medical record as soon as possible following the event. This lack of timely documentation of the fall incident constituted non-compliance with requirements to safeguard resident-identifiable information and maintain medical records in accordance with professional standards.
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.
Resident Left Exposed and Visible From Hallway Due to Failure to Maintain Privacy
Penalty
Summary
The facility failed to ensure resident dignity and privacy when a cognitively impaired resident was left exposed and visible from the hallway. The resident, who had diagnoses including cirrhosis with ascites, mood disorder, and alcohol-induced major neurocognitive disorder, had a BIMS score of eight, indicating moderately impaired cognition. During an observation, the resident was seen sitting on a shower chair in a gown with buttocks exposed, and this exposure was visible from the open room door in the hallway. A Certified Resident Care Associate and a Registered Nurse confirmed that the resident’s buttocks were visible from the hallway. The Certified Resident Care Associate reported that she had left the resident’s room quickly after hearing a resident in an adjacent room yell and, in her haste, forgot to close the door or pull the privacy curtain, resulting in the resident’s exposed state being visible to others. This incident involved one resident out of three reviewed for dignity, in a facility with a census of 52 residents, and was identified through record review, observation, and staff interviews.
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