Kingston Of Ashland
Inspection history, citations, penalties and survey trends for this long-term care facility in Ashland, Ohio.
- Location
- 20 Amberwood Pkwy, Ashland, Ohio 44805
- CMS Provider Number
- 365646
- Inspections on file
- 23
- Latest survey
- October 30, 2025
- Citations (last 12 mo.)
- 3
Citation history
Health deficiencies cited at Kingston Of Ashland during CMS and state inspections, most recent first.
A resident with multiple medical conditions and impaired cognition experienced a fall while transferring from bed to wheelchair, witnessed by a family member. Facility staff did not notify the physician or nurse practitioner of the incident as required by policy, and there was no documentation of such notification in the medical record. Interviews confirmed that medical providers were not made aware of the fall until several days later.
A resident with multiple chronic conditions and moderately impaired cognition experienced a fall while transferring from bed to wheelchair, witnessed by his son. The incident was not documented in the medical record, as confirmed by interviews with nursing staff, the DON, and the administrator.
Two residents with indwelling urinary catheters were found with their drainage bags lying directly on the floor, contrary to facility policy requiring catheter bags to be kept off the floor. These incidents were confirmed by an LPN and a CNA during interviews.
A resident recovering from a recent below-the-knee amputation experienced severe pain when their prescribed Oxycodone was not renewed in time, leaving no narcotic pain medication available. Despite repeated reports of high pain levels and a care plan identifying pain risk, the on-call NP declined to renew the prescription overnight, offering only extra strength Tylenol, which the resident refused. The resident was ultimately transferred to the hospital for pain control.
Three residents experienced significant medication errors when staff failed to follow physician orders and facility protocols. One resident with diabetes was given insulin despite an order to hold it for low blood glucose, resulting in severe hypoglycemia and emergency intervention. Another resident received the wrong medications, including an anticoagulant not prescribed for them. A third resident was administered a diuretic at the wrong frequency due to a transcription error. These incidents demonstrate failures in medication administration and order verification.
A resident with multiple chronic conditions was prescribed Ergocalciferol to be given weekly, but the order was incorrectly transcribed as a daily dose during admission. The MAR reflected daily administration until an LPN identified the error and obtained clarification from the physician. The DON confirmed the transcription mistake, resulting in inaccurate medical records.
A facility failed to document the clinical status of a resident with multiple health conditions, including anemia and congestive heart failure. Despite a physician's order to monitor the resident's confusion and altered mental status, no vital signs or clinical assessments were recorded on a specified day. Interviews confirmed the lack of documentation, which was against the facility's policy.
A resident experienced a significant delay in receiving toileting assistance, with a call light left unanswered for 44 minutes. Despite initial staff acknowledgment, the resident was not attended to promptly, leading to a delay in care. Other residents reported similar issues with call light response times.
A resident with multiple health conditions did not have daily weights documented as ordered, and significant weight changes were not reported to the physician. Additionally, a wound culture was delayed in being sent to the lab, resulting in a delay in identifying an infection. The DON confirmed the delays, citing lab staffing issues.
A resident with severe medical conditions fell out of bed, but the incident was not documented or reported to the family. Despite being a high fall risk, no neurological assessment was conducted, and the family was informed days later. The resident's condition declined, leading to hospitalization and eventual death. The nurse involved was terminated.
A resident did not receive her prescribed Entresto for several days due to a billing issue with the pharmacy, as she was incorrectly listed as deceased in the Medicare system. Despite the LPN contacting the pharmacy multiple times, the medication was not delivered, and the physician was not notified of the issue. The resident developed non-pitting edema in both legs during this period.
Failure to Notify Physician of Resident Fall
Penalty
Summary
The facility failed to notify the physician of a resident's fall, as required by policy. A resident with multiple complex diagnoses, including metabolic encephalopathy, osteomyelitis, endocarditis, diabetes, heart failure, and impaired cognition, experienced a fall while attempting to transfer from bed to wheelchair. The fall was witnessed by the resident's son, but there was no documentation in the medical record indicating that the physician was notified of the incident. Interviews with nursing staff, the Director of Nursing, and the resident's son confirmed that the fall occurred and that the physician and nurse practitioner were not informed at the time of the event. Further interviews with the nurse practitioner and physician revealed that neither was aware of the fall until several days later. Review of the facility's policy on changes in a resident's condition or status indicated that the nurse supervisor or charge nurse is responsible for notifying the attending physician or nurse practitioner in the event of an accident or injury. The lack of timely notification to the physician following the resident's fall constituted a deficiency as identified during the complaint investigation.
Failure to Document Resident Fall Incident in Medical Record
Penalty
Summary
The facility failed to ensure a complete and accurate medical record for a resident regarding documentation of a fall incident. A resident with multiple complex diagnoses, including metabolic encephalopathy, osteomyelitis, endocarditis, diabetes, heart failure, and other chronic conditions, experienced a fall while attempting to transfer from bed to wheelchair. The fall was witnessed by the resident's son, who was present in the room at the time. The resident had been assessed as having moderately impaired cognition. Despite the fall occurring in the presence of a family member, there was no documentation of the incident in the resident's medical record. Multiple interviews with facility staff, including an RN, the DON, and a Regional Quality Assurance RN, confirmed that the fall was not recorded in the medical record. The lack of documentation was verified by both the DON and the facility administrator, as well as the resident's son, who provided details of the incident.
Failure to Maintain Urinary Catheter Drainage Bags Off the Floor
Penalty
Summary
The facility failed to maintain indwelling urinary catheter drainage bags in a manner that would prevent infections, as observed in two out of three residents reviewed for urinary catheters. For one resident with multiple chronic conditions including chronic respiratory failure, heart disease, diabetes, and impaired cognition, the urinary drainage bag was observed lying directly on the floor of the resident's room. This observation was confirmed by an LPN during an interview. Similarly, another resident with a history of aphasia, heart disease, neuromuscular bladder dysfunction, and other significant medical issues was found with their urinary drainage bag also lying directly on the floor. This was verified by a CNA during an interview. Review of the facility's urinary catheter care policy indicated that catheter tubing and drainage bags should be kept off the floor, but this protocol was not followed in these instances.
Failure to Provide Timely Post-Surgical Pain Management
Penalty
Summary
A deficiency occurred when a resident who had recently undergone a below-the-knee amputation was not provided with adequate post-surgical pain management. The resident had a physician's order for Oxycodone 10 mg every four hours as needed for moderate pain, and acetaminophen scheduled every eight hours. The resident consistently reported significant pain, with pain levels ranging from 7 to 10, and had received 17 doses of Oxycodone prior to the incident. The care plan identified the resident as being at risk for pain due to the recent surgical procedure, with interventions including medication and repositioning. On the night of the incident, the resident experienced severe pain rated at 10 out of 10 and requested narcotic pain medication. However, the Oxycodone prescription had expired and was not renewed in a timely manner, resulting in no narcotic pain medication being available. The on-call nurse practitioner declined to renew the prescription during the night and instead ordered extra strength Tylenol, which the resident refused. As a result, the resident requested transfer to the hospital for pain management and was subsequently transported by EMS. Interviews with staff confirmed that the failure to renew the Oxycodone prescription led to the unavailability of the medication when the resident was in severe pain. The DON acknowledged that the prescription had expired and was not renewed, which directly resulted in the resident's transfer to the hospital for pain control. The facility's pain management policy defined pain management as alleviating pain to a level acceptable to the resident, but this standard was not met in this case.
Plan Of Correction
This Plan of Correction is being prepared and executed because it is required by the provisions of the State and Federal regulations and not because Kingston of Ashland agrees with the allegations and citations listed on the statement of deficiencies. Kingston of Ashland maintains that the alleged deficiencies do not individually or collectively jeopardize the health and safety of the residents, nor are they of such character as to limit our capacity to render adequate care as prescribed by regulation. This plan of correction shall operate as Kingston of Ashland's written credible allegations of compliance. This plan of correction is not meant to establish any standard of care, contract, obligation, or position, and Kingston of Ashland reserves all possible contentions and defenses in any civil or criminal actions or proceeding. Please accept the date of correction 4/17/2025 as the facility's credible allegation of compliance. F697 Resident #93 no longer resides in the center. Resident #93 was sent to the ER on 3/7 and script for Percocet obtained at that time. Nurse practitioner #339 was provided education on 4/3 and 4/4 on the pain assessment and management policy, controlled substance prescription policy, and receiving controlled substances policy. The Director of Nursing or designee will review current residents on narcotic pain medications to ensure that the narcotic medication regimen is effective for treating pain and that the narcotic pain medications are available for use. This will be completed on or before 4/17/2025. Issues identified will be addressed at the time of discovery. The Director of Nursing or designee will educate licensed nurses and Certified Medication Aides on the controlled substance prescription policy and receiving controlled substance policy, which includes reordering of controlled medications, on or before 4/17/2025. The Director of Nursing or designee with educated licensed nurses on the pain assessment and management policy on or before 4/17/2025. The Director of Advanced Nurse Practitioners will educate the nurse practitioners on the controlled substance prescription policy and receiving controlled substance policy, which includes reordering of controlled medications, on or before 4/17/2025. The Director of Nursing or designee will complete an audit on 5 residents weekly for 4 weeks that receive narcotic pain medications to ensure that the narcotic medication regimen is effective for treating pain and that narcotic pain medication is available for use. The results will be presented to the QAA committee for review and consideration for further corrective actions.
Significant Medication Errors Affecting Multiple Residents
Penalty
Summary
Surveyors identified that the facility failed to ensure residents were free from significant medication errors, as required by regulation. One resident with Type II diabetes was administered a long-acting insulin injection despite a physician order to hold the medication if the blood glucose level was below 200 mg/dL. At the time of administration, the resident's blood glucose was 109 mg/dL. This error led to the resident experiencing severe hypoglycemia, becoming unresponsive, and requiring emergency intervention with glucagon and close monitoring. In another instance, a resident was given the wrong morning medications by an LPN, including a lower dose of an antihypertensive and an anticoagulant that were not prescribed for them. The error was discovered after administration, and the resident was assessed for adverse effects. The facility's policy requires that medications be administered only as prescribed and that staff verify resident identity and orders prior to administration, which was not followed in this case. A third resident received a diuretic medication at an incorrect frequency due to a transcription error of a hospital discharge order. Instead of receiving the medication two times per week as ordered, the resident was given it two times per day for four days. This error was identified during a review of laboratory results and the original discharge paperwork. In each case, the facility's failure to follow physician orders and established medication administration protocols resulted in significant medication errors affecting three residents.
Plan Of Correction
This Plan of Correction is being prepared and executed because it is required by the provisions of the State and Federal regulations and not because Kingston of Ashland agrees with the allegations and citations listed on the statement of deficiencies. Kingston of Ashland maintains that the alleged deficiencies do not individually or collectively jeopardize the health and safety of the residents, nor are they of such character as to limit our capacity to render adequate care as prescribed by regulation. This plan of correction shall operate as Kingston of Ashland's written credible allegations of compliance. This plan of correction is not meant to establish any standard of care, contract, obligation, or position, and Kingston of Ashland reserves all possible contentions and defenses in any civil or criminal actions or proceedings. Please accept the date of correction 4/17/2025 as the facility's credible allegation of compliance. Resident #111 was treated at the time of the error in the center with no outstanding negative outcomes noted after treatment for low blood sugar. Resident #111 was assessed by nurse at the time of change in condition on 2/17/2024 with blood sugars being checked hourly until blood sugars were within normal range. Resident #111 was assessed by CNP on 2/24/2025. Resident #111 remains in the center. Resident #404's Lasix order was corrected at the time of discovery with no negative outcome noted. Resident #404 was assessed at the time of discovery by nurse on 2/24/2025. Resident #404 was assessed by CNP on 2/25/2025. Resident #404 remains in the center. Resident #302's had no negative outcome related to being administered another resident's medications. Resident #302 was assessed at the time of discovery by the nurse on 3/14/2025. Resident #302 remains in the center. The Director of Nursing or designee will review current residents with orders for insulin to ensure that the medication is being given per order. This will be completed on or before 4/17/2025. Issues identified will be addressed at the time of discovery. The Director of Nursing or designee will review medication orders for residents that have been admitted since the date of survey exit through the date of compliance to ensure that medication orders were transcribed appropriately upon admission. This will be completed on or before 4/17/2025. Issues identified will be addressed at the time of discovery. The Director of Nursing or designee will complete medication administration observations on current residents to ensure that medications are given per order. This will be completed on or before 4/17/2025. Issues identified will be addressed at the time of discovery. The Director of Nursing or designee will educate licensed nurses and certified medication aides on the administering medications policy on or before 4/17/2025. The Director of Nursing or designee will educate licensed nurses on the electronic order entry process and transcription policy on or before 4/17/2025. The Director of Nursing or designee will complete an audit on 5 residents weekly for 4 weeks that receive insulin to ensure medication was given per order. The Director of Nursing or designee will complete medication order audits on 5 new admissions weekly for 4 weeks to ensure that medication orders are transcribed appropriately upon admission. The Director of Nursing or designee will complete medication administration observations on 5 residents weekly for 4 weeks to ensure that medications are given per order. The results will be presented to the QAA committee for review and consideration for further corrective actions. This Plan of Correction is being prepared and executed because it is required by the provisions of the State and Federal regulations and not because Kingston of Ashland agrees with the allegations and citations listed on the statement of deficiencies. Kingston of Ashland maintains that the alleged deficiencies do not individually or collectively jeopardize the health and safety of the residents, nor are they of such character as to limit our capacity to render adequate care as prescribed by regulation. This plan of correction shall operate as Kingston of Ashland's written credible allegations of compliance. This plan of correction is not meant to establish any standard of care, contract, obligation, or position, and Kingston of Ashland reserves all possible contentions and defenses in any civil or criminal actions or proceedings. Please accept the date of correction 4/17/2025 as the facility's credible allegation of compliance. Resident #348's orders for ergocalciferol and calcitriol were corrected at the time of discovery with no negative outcome noted. Resident #348 no longer resides in the center. The Director of Nursing or designee will review medication orders for residents that have been admitted since the date of survey exit through the date of compliance to ensure that medication orders were transcribed appropriately upon admission. This will be completed on or before 4/17/2025. Issues identified will be addressed at the time of discovery. The Director of Nursing or designee will educate licensed nurses on the electronic order entry process and transcription policy on or before 4/17/2025.
Incorrect Transcription of Physician Order for Medication
Penalty
Summary
A deficiency occurred when a facility failed to maintain accurate medical records by not correctly transcribing a physician's order for a resident. The resident, who was admitted with diagnoses including high blood pressure, type 2 diabetes, congestive heart failure, and osteoporosis, had a hospital discharge order for Ergocalciferol (vitamin D2) to be administered once weekly on Mondays. However, during the admission process, the order was incorrectly transcribed as a daily administration instead of weekly. This transcription error was reflected in the resident's Medication Administration Record (MAR), which showed the medication being administered daily. On one occasion, the medication was not administered, and this was documented by an LPN. During a subsequent medication pass, the LPN identified the discrepancy in the order and sought clarification from the physician, after which the correct weekly order was entered. Interviews with the LPN and the Director of Nursing confirmed that the error originated during the admission process and resulted in the resident's medical record not being accurate or complete as required. The facility's policy on administering medications states that medications should be administered as prescribed, which was not followed in this instance.
Plan Of Correction
This Plan of Correction is being prepared and executed because it is required by the provisions of the State and Federal regulations and not because Kingston of Ashland agrees with the allegations and citations listed on the statement of deficiencies. Kingston of Ashland maintains that the alleged deficiencies do not individually or collectively jeopardize the health and safety of the residents, nor are they of such character as to limit our capacity to render adequate care as prescribed by regulation. This plan of correction shall operate as Kingston of Ashland's written credible allegations of compliance. This plan of correction is not meant to establish any standard of care, contract, obligation, or position, and Kingston of Ashland reserves all possible contentions and defenses in any civil or criminal actions or proceeding. Please accept the date of correction 4/17/2025 as the facility's credible allegation of compliance. Resident #348's orders for ergocalciferol and calcitriol were corrected at the time of discovery with no negative outcome noted. Resident #348 no longer resides in the center. Director of Nursing or designee will review medication orders for residents that have been admitted since the date of survey exit through the date of compliance to ensure that medication orders were transcribed appropriately upon admission. This will be completed on or before 4/17/2025. Issues identified will be addressed at the time of discovery. Director of Nursing or designee will educate licensed nurses on the electronic order entry process and transcription policy on or before 4/17/2025. Director of Nursing or designee will complete a medication order audit on 5 new admissions weekly for 4 weeks to ensure that medication orders are transcribed appropriately upon admission. The results will be presented to the QAA committee for review and consideration for further corrective actions.
Failure to Document Resident's Clinical Status
Penalty
Summary
The facility failed to complete the medical record and accurately document the clinical status for a resident, identified as Resident #105, among a sample of four residents. Resident #105 had a complex medical history, including anemia, type two diabetes, paroxysmal atrial fibrillation, congestive heart failure, protein calorie malnutrition, macular degeneration, spinal stenosis, presence of a cardiac pacemaker, chronic kidney disease stage three, and cardiomyopathy. The resident expired on a specified date. A review of the vital sign record revealed that vital signs were documented on one date, but no vital signs were recorded on the following day. Additionally, there was a physician's order to monitor the resident's confusion and altered mental status, with instructions to send the resident to the Emergency Department if the condition progressed. However, no clinical assessments were documented on the specified date. Interviews with Registered Nurse #150 and the facility's Administrator and Director of Nursing confirmed that vital signs and assessments were not recorded in the electronic medical record on the specified date. The facility's policy titled 'Change in a Resident's Condition or Status' required the nurse supervisor or charge nurse to record information related to changes in the resident's medical or mental condition. The failure to document vital signs and assessments as per the facility's policy contributed to the deficiency identified during the survey.
Delayed Response to Call Lights
Penalty
Summary
The facility failed to provide timely toileting assistance to a resident who required staff assistance for activities of daily living. The resident, who had intact cognition and was occasionally incontinent of bladder, had a call light on for 44 minutes without receiving assistance. The resident had turned on the call light at around 8:00 A.M. for toileting and dressing assistance before a scheduled speech therapy session at 9:00 A.M. Despite a nursing assistant initially responding and promising to return, the resident was left unattended, leading to a delay in care. This incident was corroborated by observations and interviews with staff and the resident. Additional interviews with other residents revealed similar issues with delayed responses to call lights, with reports of waiting for hours for assistance and staff failing to return after promising to do so. The Director of Nursing acknowledged the complaint and indicated that staff had been educated on the issue. The facility's policy on answering call lights was reviewed, highlighting the purpose of responding to residents' requests and needs. This deficiency was part of a complaint investigation.
Failure to Monitor Weight and Process Lab Tests Timely
Penalty
Summary
The facility failed to ensure that daily weights and laboratory tests were obtained and reported as ordered for a resident. The resident, who had multiple diagnoses including congestive heart failure and chronic kidney disease, was ordered to have daily weights taken and to notify the provider of significant weight changes. However, there were multiple days where weights were not documented, and significant weight gains were not reported to the physician as required. This oversight in monitoring the resident's weight could have impacted the management of her health conditions. Additionally, the facility did not timely process a wound culture for the same resident. The culture, ordered due to a change in drainage color, was collected but not sent to the lab until two days later, resulting in a delay in identifying a pseudomonas aeruginosa infection. The delay in processing the lab test and the subsequent delay in treatment could have affected the resident's care. The DON confirmed the delay but attributed it to staffing issues at the lab.
Failure to Document and Assess Post-Fall Incident
Penalty
Summary
The facility failed to complete a thorough and timely post-fall assessment and notify the family of a fall for Resident #109. Resident #109, who had a history of severe medical conditions including hemiplegia, cerebral infarction, and a brain bleed, was found on the floor next to his bed. Despite being a high fall risk and having fall prevention measures in place, such as a low bed and fall mats, the resident rolled out of bed. The incident was not documented, and no neurological assessment was conducted immediately following the fall. Interviews with staff revealed that the nurse on duty did not consider the incident a fall and therefore did not document it or notify the family. The resident was found by a State tested Nursing Assistant (STNA) and was assisted back to bed using a Hoyer lift. The nurse checked the resident for injuries but did not perform a neurological assessment or document the incident. The family was not informed of the fall until days later, after the resident's condition had declined significantly. The family expressed concerns about the resident's care, noting delays in response to call lights and the resident's deteriorating condition. The resident was eventually sent to the hospital at the family's request, where a head scan confirmed a brain bleed. The resident was placed on comfort care and later passed away. The facility's Director of Nursing confirmed the lack of documentation and assessment following the fall, and the nurse involved was terminated.
Failure to Provide Timely Medication for Resident
Penalty
Summary
The facility failed to ensure timely procurement of medication for Resident #20, who was admitted with multiple diagnoses including chronic obstructive pulmonary disease, heart conditions, and chronic pain syndrome. Despite having intact cognition, Resident #20 did not receive her prescribed Entresto, a heart failure medication, from the time of admission until several days later. The Medication Administration Record (MAR) indicated that the medication was not administered, and progress notes showed the resident developed non-pitting edema in both legs during this period. Interviews with staff revealed that the Licensed Practical Nurse (LPN) contacted the pharmacy multiple times regarding the medication, but it was not delivered due to a billing issue. The Director of Nursing (DON) confirmed that the pharmacy withheld the medication because Resident #20 was incorrectly listed as deceased in the Medicare system, affecting her insurance status. There was no documentation of the physician being notified about the unavailability of the medication, which contributed to the delay in addressing the resident's medical needs.
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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