Norwood Towers Post-acute
Inspection history, citations, penalties and survey trends for this long-term care facility in Cincinnati, Ohio.
- Location
- 1500 Sherman Avenue, Cincinnati, Ohio 45212
- CMS Provider Number
- 366238
- Inspections on file
- 34
- Latest survey
- February 26, 2026
- Citations (last 12 mo.)
- 15
Citation history
Health deficiencies cited at Norwood Towers Post-acute during CMS and state inspections, most recent first.
A resident with severe cognitive impairment and multiple comorbidities was given several medications not prescribed for her when a medication technician, distracted during a med pass, administered drugs that had been pulled for another resident without properly verifying identity as required by facility policy. The resident received Clozapine, Depakote, Niacin, and Haldol, subsequently became lethargic, difficult to rouse, drooled, had tachycardia, and vomited multiple times, leading to notification of the provider and transfer to the hospital, where she was treated for unintentional ingestion of non-prescribed medications and returned to baseline mental status after about a day.
A resident with chronic pain syndrome and multiple serious conditions did not receive prescribed PRN oxycodone for nearly 24 hours due to the facility running out of medication. Despite repeated requests and reports of severe pain, staff did not notify hospice or obtain an emergency supply in a timely manner, and failed to document the resident's pain or communicate the shortage as required by facility policy. This resulted in actual harm, with the resident experiencing uncontrolled pain until an emergency supply was provided by hospice.
The facility did not provide residents with information about the grievance process or how to file a grievance. Multiple residents, including those who were cognitively intact and involved in resident council, were unaware of their rights or the process, and staff also lacked knowledge. No information was posted in the facility, despite policies requiring residents be informed and assisted in filing grievances.
Surveyors identified multiple deficiencies in the facility's environment, including unclean and damaged equipment in resident rooms, persistent odors in the memory care unit, and a dirty, poorly lit elevator. Staff confirmed these issues had not been addressed, resulting in a failure to provide a clean, comfortable, and homelike setting as required by facility policy.
Surveyors found that three residents did not receive adequate privacy and dignity during personal care. One resident had visible facial hair that staff had not addressed despite her request. Another was left in a public area wearing a thin hospital gown that exposed her breast, with staff unaware of how long she had been exposed. A third resident was left exposed in bed with the door open while a CNA provided hygiene care, allowing direct hallway view. Staff confirmed these lapses in privacy and dignity.
The facility did not ensure that three residents with varying cognitive and physical impairments received necessary assistance with ADLs, including bathing and hygiene. One resident was found with unclean feet and bedding, another did not receive the required number of baths, and a third had to bathe independently despite needing help, with documentation and interviews confirming missed care.
Two residents with cognitive and physical impairments were observed smoking without the required protective smoking aprons during supervised smoke breaks. Staff were unaware of the need for these safety measures, and one resident had burns on his clothing. Facility policy and care plans specified the use of adaptive equipment and supervision, but these were not consistently implemented.
The facility failed to dispose of medications in a timely manner, potentially affecting all 110 residents. A room was found with a large quantity of medications, including blister packs and daily envelopes, stored improperly. The DON was unaware of who was responsible for disposal, and only two employees had access to the room. The facility's policy on medication disposal was not followed.
A facility failed to ensure medications were not left unattended at the bedside in a secured memory care unit, affecting a resident who was cognitively intact and required supervision. The resident was observed to have medications left on the bedside table, despite an LPN claiming to have witnessed the resident taking them. A medication technician later found the medications on the table, indicating they had not been taken. The facility's policy requires licensed individuals to administer and document medications, which was not followed in this case.
The facility failed to store medications properly, with unlocked doors and expired medications found in the storage room and central supply. An LPN confirmed the inability to lock the nurse's station and the presence of expired medications, violating the facility's policy requiring locked compartments for drugs and biologicals.
A resident with multiple health conditions, including diabetes, was observed with long, dirty fingernails despite being dependent on staff for personal hygiene. The care plan required weekly nail trimming, but staff interviews confirmed the resident did not refuse care, and his nails remained untrimmed over several days.
The facility failed to implement pharmacy recommendations for two residents, leading to deficiencies in medication management. A resident's orders for Rizatriptan and Diclofenac gel were not updated as recommended, and another resident continued receiving Ibuprofen and Benadryl despite agreements to discontinue. These oversights were confirmed by a Regional RN.
Significant Medication Error Due to Failure to Verify Resident Identity
Penalty
Summary
The deficiency involves the facility’s failure to ensure a resident was free from significant medication errors when staff administered multiple medications that were not prescribed for the resident. The resident had been admitted with diagnoses including cerebral infarction, type 2 diabetes, and dementia, and a recent MDS assessment documented severe cognitive impairment and dependence on staff for ADLs. During an evening medication pass, a medication technician pulled medications intended for another resident and, after becoming distracted by another resident, administered those medications to this resident at the medication cart. As a result of this error, the resident received Clozapine 200 mg, Depakote 250 mg, Niacin 250 mg, and Haldol (dose not specified), none of which were ordered for her. The facility’s own medication administration policy required the individual administering medications to verify the resident’s identity before giving medications and to check the label three times to ensure the right resident, medication, dose, time, and method. The medication technician acknowledged that she did not correctly verify the resident’s identity before administration and only realized the error after the medications had been given. Following the administration of the wrong medications, the resident developed lethargy, was difficult to rouse, was drooling, had an elevated heart rate, and experienced three episodes of emesis the next morning. Nursing staff notified the nurse practitioner, who contacted poison control, and the resident was sent to the emergency department for evaluation. Hospital records documented that the resident was admitted for unintentional ingestion of medications not prescribed for her, underwent a CT scan that showed no acute intracranial abnormality, and that her mental status returned to baseline after approximately 24 hours.
Failure to Provide Timely PRN Pain Medication for Resident with Chronic Pain
Penalty
Summary
A deficiency occurred when staff failed to provide appropriate pain management for a resident with chronic pain syndrome and multiple serious diagnoses, including malignant neoplasm of the larynx, osteomyelitis, fibromyalgia, and a bowel rupture with colostomy. The resident was cognitively intact, independent in most activities of daily living, and under hospice care. Physician orders specified that oxycodone 10 mg tablets were to be administered every three hours as needed for pain. However, documentation revealed that the resident did not receive her PRN pain medication for nearly 24 hours, despite multiple requests and reports of severe pain. Medical record review and interviews indicated that the facility ran out of the prescribed oxycodone, and staff did not notify hospice or obtain an emergency supply in a timely manner. The controlled drug record showed the medication was depleted, and the resident reported to both staff and hospice that she was in significant pain and unable to receive her medication. The hospice nurse confirmed being notified by the resident via text message that the medication was unavailable, and subsequently arranged for an emergency supply, which was not administered until the following day. There was no documentation that the hospice nurse was notified by facility staff when the medication first became unavailable. Facility policy required that medication administration be based on resident need and that medication errors be documented and reported. The pain management policy also required immediate notification of the provider if pain was not adequately controlled. Despite these policies, staff did not ensure the resident received her ordered pain medication, did not document the resident's repeated requests for pain relief, and failed to communicate the medication shortage to hospice in a timely manner. This resulted in actual harm to the resident, who experienced severe, uncontrolled pain for an extended period.
Failure to Inform Residents of Grievance Process
Penalty
Summary
The facility failed to provide residents with information regarding the grievance process and how to file a grievance, as required by policy. Record review and interviews revealed that three residents, including one who was cognitively intact and served as the presiding president of the Resident Council, were unaware of their right to file a grievance or the process for doing so. These residents reported that the grievance process had never been explained to them individually or during resident council meetings. One resident with moderate cognitive impairment also indicated he was unaware of the process and could not recall it being discussed at meetings he attended. Further investigation showed that there was no posted information about the grievance process in the facility, and the Assistant Director of Nursing confirmed a lack of knowledge about how the process worked. Although the Administrator was able to provide a written policy and the names of the grievance committee members, there was no evidence that this information was communicated to residents. The facility's own policies stated that residents have the right to file grievances orally or in writing and that the facility should assist residents in exercising this right, but these procedures were not being followed or made known to residents.
Failure to Maintain Clean, Safe, and Homelike Environment
Penalty
Summary
Surveyors found that the facility failed to provide a homelike environment for its residents, as evidenced by multiple observations of unclean and damaged equipment and furnishings in resident rooms. Specific findings included tube feeding poles with dried brownish substances, broken window blinds, privacy curtains with brown stains or hanging off tracks, and walls with brown splashes and holes. Housekeeping and maintenance staff confirmed these issues had not been addressed. Additionally, the elevator was observed to be dirty, with stains on the floor, dirt in the corners, dim lighting, and light panels containing bugs and a black substance. The memory care unit (MCU) was also found to have persistent, pungent odors of urine and feces in the hallway and resident rooms, with staff unable to immediately identify or resolve the source of the smell. The facility's own policy requires a clean, comfortable, and homelike environment, but these conditions were not met for several residents and areas, affecting both the safety and comfort of residents, staff, and visitors.
Failure to Maintain Resident Privacy and Dignity During Personal Care
Penalty
Summary
Surveyors identified that the facility failed to provide privacy and dignity for three residents out of seven reviewed for dignity. One resident with moderate cognitive impairment and multiple diagnoses, including dementia and depression, was observed to have noticeable facial hair under her chin. The resident stated that staff had previously addressed this issue and expressed a desire for staff to remove the facial hair. An LPN confirmed the presence and visibility of the facial hair. Another resident with severe cognitive impairment and a history of stroke and diabetes was observed sitting in a lounge area wearing a thin hospital gown, pants, and shoes. The gown was so worn that the resident's breast was visible through the fabric, and several other residents were present in the area. A CNA confirmed the visibility of the resident's breast and stated she was unaware of how long the resident had been exposed in this manner, noting that the resident had no other clothes available at the time. A third resident, who required substantial assistance with personal hygiene due to multiple medical conditions, was observed lying in bed with the door wide open while a CNA applied deodorant under his arms. The resident's chest was exposed, and the open door allowed direct view from the hallway. The CNA acknowledged that the resident was exposed with the door open, and the resident confirmed that privacy was not maintained during this care activity.
Failure to Provide Required Assistance with Activities of Daily Living
Penalty
Summary
The facility failed to provide necessary assistance with Activities of Daily Living (ADLs) for three residents who required varying levels of support. One resident with severe cognitive impairment and multiple medical conditions, including diabetes and cerebrovascular attack, was found lying in bed with feet encrusted in a yellow substance and a dirty mattress, indicating a lack of proper hygiene care. Staff confirmed the resident's condition and the failure to maintain cleanliness. Another resident, who was cognitively intact but required supervision or assistance for bathing, did not receive the required twice-weekly bathing as documented, with staff confirming the missed care opportunities. A third resident, admitted with multiple diagnoses such as atrial fibrillation, diabetes, and cancer, required moderate assistance with bathing but reported having to perform showers independently after regaining some strength through therapy. Initially, this resident received no regular bathing, and both the resident and a family member expressed uncertainty and concern about the bathing schedule and lack of assistance when the resident was too weak to bathe independently. Documentation revealed several periods where the resident was not scheduled for any showers, further confirming the deficiency in providing necessary ADL support.
Failure to Ensure Safe Smoking Practices for Supervised Residents
Penalty
Summary
The facility failed to ensure safe smoking practices for residents who required supervision and adaptive equipment during smoking breaks. Two residents with cognitive and physical impairments, including visual impairment and dexterity issues, were observed smoking without the required protective smoking aprons, despite care plans specifying the need for supervision and use of adaptive devices. One resident was noted to have burns on his clothing, and neither resident was offered or wearing a smoking apron during supervised smoke breaks. Staff interviews confirmed a lack of awareness regarding the requirement for smoking aprons for these residents. Review of facility policy indicated that residents should be evaluated for safe smoking practices and that care plans should reflect any restrictions or necessary adaptive equipment. However, observations and interviews revealed that these protocols were not consistently followed, resulting in residents with identified risks smoking without appropriate safety measures in place. The facility had identified fifteen residents requiring assistance with smoking, but the deficiency was observed in the two residents reviewed.
Failure to Timely Dispose of Medications
Penalty
Summary
The facility failed to ensure timely disposal of medications, which could potentially affect all 110 residents. During an observation, a room on the second floor was found to contain a large quantity of medications, including individual blister packs and daily envelopes, stored in an overflowing cardboard box and plastic tubs. A large trash bag was also noted to be half full of empty plastic bottles and envelopes. The Director of Nursing (DON) indicated that these medications were not taken back by the pharmacy after residents were discharged or medications were discontinued. The DON was unaware of who was responsible for disposing of these medications and believed they had been in the room for two to three weeks. Further investigation revealed that only two employees, the Maintenance Director and Central Supply, currently had keys to the room, with a new Administrator set to receive a key soon. A review of the facility's policy on discarding and destroying medications showed that medications should be mixed with an undesirable substance and placed in a sealable container to prevent leakage. However, this procedure was not followed, as evidenced by the medications found in the room, some of which had fill dates as far back as October of the previous year.
Medications Left Unattended in Memory Care Unit
Penalty
Summary
The facility failed to ensure that medications were not left unattended at the bedside in a secured memory care unit, affecting a resident who was reviewed for accidents. The resident, who was cognitively intact and required supervision for activities of daily living, was observed to have medications left on the bedside table. The medications were supposed to be administered by an LPN, who claimed to have witnessed the resident taking them. However, a medication technician later found the medications on the resident's table, indicating that they had not been taken. The resident, who had a history of convulsions, schizoaffective disorder, mood disorder, vascular dementia, major depressive disorder, personal history of traumatic brain injury, and hypertension, denied pocketing or spitting out the medications, stating that he always takes them when given. The facility's policy requires that only licensed individuals administer medications and document their administration, which was not adhered to in this instance, as the medications were left unattended, posing a potential risk to the resident and others in the secured unit.
Improper Medication Storage
Penalty
Summary
The facility failed to ensure medications were stored in a proper and safe manner, which had the potential to affect all residents except those on the secure unit. During an observation of the medication storage room on the third floor, it was found that the door was unlocked and accessible to anyone. Expired medications were present, including two bottles of aspirin with an expiration date of January 2024, a bottle of Senna plus with an expiration date of June 2024 but marked as April 2023, and a bottle of stool softeners with an expiration date of August 2023. Additionally, the nurse's station on the third floor could not be locked, and a grey plastic bag containing daily medication packs for residents was stored under the desk. The LPN verified the inability to lock the door and the presence of expired medications. Further observation revealed that a room identified as central supply on the lower level was also unlocked and contained numerous bottles of over-the-counter medications, including aspirin, acetaminophen, stool softeners, and vitamins. The LPN confirmed that these medications were stored in an unlocked room. The facility's policy on the storage of medications requires that drugs and biologicals be stored in locked compartments, which was not adhered to in these instances.
Failure to Provide Adequate Nail Care for Dependent Resident
Penalty
Summary
The facility failed to provide adequate nail care for a resident who was dependent on staff for personal hygiene. The resident, who had diagnoses including hemiplegia, hemiparesis following cerebral infarction, type II diabetes mellitus, anxiety, schizophrenia, and major depressive disorder, was observed with long fingernails that extended approximately three-fourth inches beyond the fingertip, with brown debris underneath. Despite the care plan indicating that the resident's nails should be trimmed weekly and as needed, there was no documentation of the resident refusing care, and the resident expressed a desire to have his nails trimmed. Interviews with staff, including the Director of Nursing, a State tested Nursing Assistant, and a Licensed Practical Nurse, confirmed that the resident did not refuse care and that his nails should be trimmed by a nurse due to his diabetic condition. However, observations over several days showed that the resident's nails remained untrimmed and dirty, indicating a failure to follow the care plan and provide necessary assistance with activities of daily living as per the facility's policy.
Failure to Implement Pharmacy Recommendations
Penalty
Summary
The facility failed to act timely on pharmacy recommendations for two residents, leading to deficiencies in medication management. For Resident #32, the pharmacist recommended adding a maximum daily dose to the order for Rizatriptan Benzoate and specifying the amount for Diclofenac gel application. Additionally, there was a need to establish a pain scale for administering Meloxicam and Oxycodone. Despite these recommendations being agreed upon by the prescriber, the necessary changes were not reflected in the medication administration record (MAR) or physician orders over several months. This oversight was confirmed by a Regional Registered Nurse during an interview. For Resident #16, the pharmacist suggested discontinuing Ibuprofen for a trial period and replacing Benadryl with an alternative sleep aid. Although the physician initially agreed to these recommendations, the Ibuprofen was not discontinued, and Benadryl continued to be administered until months later. The physician's change of mind regarding Ibuprofen was not documented, and the delay in discontinuing Benadryl was acknowledged by the Regional Registered Nurse. These lapses in following through with pharmacy recommendations resulted in deficiencies in the facility's medication management practices.
Latest citations in Ohio
Surveyors found that multiple hazardous storage areas, including a closet near medical records, a beauty salon used to store chemical cases, a supply room in one nursing station, a room leading to a smoking area, a housekeeping room near therapy, and a lobby storage room, lacked required self-closing or automatic-closing doors. These conditions did not comply with NFPA 101 requirements for hazardous area enclosure and had the potential to affect all residents and staff in an emergency.
Surveyors found that the facility did not conduct fire drills on every shift each quarter and did not vary drill conditions as required by NFPA 101. Record review showed that one shift lacked a documented drill for an entire quarter, and the pattern of drill times and dates did not demonstrate varied conditions. The Maintenance Director confirmed the incomplete and noncompliant fire drill schedule, which affected all residents and staff emergency preparedness.
Surveyors found that the facility did not maintain clear egress corridors as required by NFPA 101, with a TV/video cart plugged into a corridor outlet and multiple unsecured chairs placed in the hallway near resident rooms and the secured unit dining room, including directly in front of a fire extinguisher. These items projected about 29 inches into an approximately eight-foot-wide corridor and were located in front of the handrail, potentially affecting 28 residents and staff’s ability to assist in an emergency. The Maintenance Director confirmed these corridor obstructions during the survey.
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.
The facility failed to maintain accurate and complete crash cart audits for multiple full-code residents. Surveyors, accompanied by the DON, found that daily crash cart checks did not include verification of supply expiration dates, and that an extension cord documented as present on several audit dates was not actually in the cart. Audit logs also conflicted with the cart’s contents by indicating that required items such as eye protection, saline, and clear plastic were present when they were not. These findings were inconsistent with the facility’s policy requiring the crash cart to be checked every 24 hours and after each use, with prompt replacement of equipment and supplies.
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.
Failure to Maintain Self-Closing Doors for Multiple Hazardous Storage Areas
Penalty
Summary
Surveyors identified a deficiency related to hazardous area protection and door requirements under NFPA 101, 2012 Edition. During facility tours, they observed that multiple hazardous storage areas did not have self-closing or automatic-closing doors as required for hazardous areas such as combustible storage and chemical storage. These areas included a closet next to medical records, a beauty salon being used to store cases of chemicals, a supply room in Station #2, and the room leading to the smoking area in Station #3. On a subsequent tour, surveyors observed additional hazardous areas without self-closing doors. The housekeeping room across from therapy and the lobby storage room were both noted to lack self-closing door mechanisms. The facility census at the time was 59 residents, and the surveyors stated that this deficient practice had the potential to affect all residents and staff's ability to assist in an emergency. The Maintenance Director verified these findings at the time they were observed.
Plan Of Correction
K 0321 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 admissible 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 06/12/2026 K-0321 Doors with Self-Closing Devices Corrective action for resident/s: 1. The closet door next to medical records was lacking a self-closing door on 5/19/2026. Maintenance director to add self-closing device to closet door next to medical records on or before 06/12/2026 in accordance with applicable code. 2. The beauty salon had chemicals stored in it on 5/19/2026. Maintenance director moved chemicals from beauty salon on 05/20/2026 in accordance with applicable code. 3. The supply room on station 2 was lacking a self-closing door on 5/19/2026. Maintenance director to add self-closing door to supply room on station 2 on or before 06/12/2026 in accordance with applicable code. 4. The room to the smoking area on station 3 was lacking a self-closing door on 5/19/2026. Maintenance director to add a self-closing door to the smoking are on station 3 on or before 06/12/2026 in accordance with applicable code. 4. The housekeeping room across from therapy was lacking a self-closing door on 5/19/2026. Maintenance director to add a self-closing door to the housekeeping room across from therapy gym on or before 06/12/2026 in accordance with applicable code. 5. The lobby storage room was lacking a self-closing door on 5/19/2026. Maintenance director to add a self-closing door to the lobby storage room on or before 06/12/2026 in accordance with applicable code. Identification of other residents who may be affected: LNHA and Maintenance director/designee completed a full facility audit for doors with self-closing devices on 05/26/2026. Any corrective action, including, doors identified as needing self-closures will be added on or before 06/09/2026 in accordance with applicable code. Measures for systemic change: LNHA educated Maintenance Director on 05/26/2026 regarding NFPA 101-2012 sections 19.3.2.1 and 19.3.5.9 specifically regarding doors with self-closing devices. How Corrective Action will be monitored Ongoing "Doors with Self-Closing device audit" to be completed weekly x 2 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 06/12/2026
Failure to Conduct Required Quarterly Fire Drills on All Shifts
Penalty
Summary
The facility failed to conduct fire drills in accordance with NFPA 101, 2012 Edition, sections 19.7.1 through 19.7.1.8, specifically by not holding drills every shift each quarter and not varying drill conditions as required. Record review on 06/09/25 at approximately 10:32 A.M. showed there was no fire drill conducted for the first shift during the third quarter. The documented first-shift fire drills occurred on 01/30/26 at 2:42 P.M., 04/30/26 at 1:51 P.M., and 10/31/25 at 10:58 A.M., indicating a missed quarter. Second-shift fire drills were recorded on 02/26/26 at 5:20 P.M., 06/03/25 at 4:35 P.M., 08/29/25 at 3:46 P.M., and 11/25/25 at 5:09 P.M., and third-shift drills on 02/28/26 at 11:47 P.M., 05/30/25 at 12:18 A.M., 07/22/25 at 11:34 P.M., 09/26/25 at 11:40 P.M., and 12/15/25 at 5:17 A.M. The surveyor determined that drills were not conducted under varied conditions and that the required quarterly drill on each shift was not consistently performed. The Maintenance Director confirmed these findings at the time they were identified, and the deficiency had the potential to affect all 59 residents and staff response in an emergency. No specific residents, medical histories, or clinical conditions were described in the report; the deficiency related to facility-wide emergency preparedness practices and documentation of fire drills.
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 05/29/2026 K-0712 Fire Drills Corrective action for resident/s: There were no records of a fire drill for the first shift of the third quarter of 2025. First shift fire drill completed on 5/24/2026 by maintenance director/designee with no findings or corrective action necessary. Identification of other residents who may be affected: On 5/26/2026 Maintenance director/designee completed 100% audit of the scheduled fire drills to ensure a drill is scheduled quarterly each shift with no findings or corrective action necessary. Measures for systemic change: LNHA educated Maintenance Director on 05/26/2026 regarding NFPA 101-2012 section 19.7.1.4 through 19.7.1.7. specifically including fire drill frequency requirements. How Corrective Action will be monitored Ongoing "Fire Drill Audit" to be completed weekly x 2 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 05/29/2026
Obstructed Egress Corridors Due to Equipment and Chairs
Penalty
Summary
The facility failed to maintain required clear egress widths in corridors in accordance with NFPA 101, 2012 Edition, sections 19.2.3.4 through 19.2.3.5 and 7.3.2 through 7.3.2.3, creating projections into the egress corridor that exceeded allowable limits. Surveyors observed that on one day in Station #3, a cart with a television and video equipment was plugged into an outlet in the corridor by room 38, and five activity room chairs were placed in the corridor near the secured unit dining room directly in front of a fire extinguisher. On the following day, surveyors again observed chairs in the Station #3 corridor, with four by room 35 and four by the activities room, and the same television cart still in the corridor; the chairs were not secured. The corridor was approximately eight feet wide, and the projections extended approximately 29 inches into the corridor in front of the handrail. These conditions had the potential to affect 28 residents in the facility and the staff’s ability to assist in an emergency, and the Maintenance Director confirmed the observations at the time of discovery. No specific resident medical histories or conditions were described in the report, only that 28 residents were potentially affected and the facility census was 59.
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 subsequent remedial measures and 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 05/29/2026 K-0232 Clear path of egress Corrective action for resident/s: 1. On 05/18/2026 station 3 had a cart with a television parked in the corridor by room 38 that exceeded allowable limits. Maintenance director/designee moved the TV cart into the activity room, out to the corridor on 05/18/2026 in accordance with applicable code. 2. On 5/18/2026 station 3 had 5 chairs in the corridor near the dining room directly in front of the fire extinguisher. Maintenance director/designee moved the chairs into the dining room, out of the corridor on 5/18/2026 in accordance with applicable code. 3. On 5/19/2026 station 3 had 4 chairs by the activity room and 4 by room 35. In addition, the TV cart was in the corridor. The maintenance director/designee moved the chairs and TV cart into the dining room, out of the corridor on 5/19/2026 in accordance with applicable code. Identification of other residents who may be affected: Maintenance director/designee completed a 100% facility audit for clear paths of egress on 5/26/26 with no findings or corrective action necessary. Measures for systemic change: Maintenance Director/designee educated staff on 5/26/2026 regarding NFPA 101-2012 section 19.2.3.4 and 19.2.3.5 specifically including maintaining a clear path of egress. How Corrective Action will be monitored Ongoing "Path of Egress Audit" to be completed weekly x 2 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 05/29/2026
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
Inaccurate Crash Cart Audits and Missing Emergency Equipment
Penalty
Summary
The facility failed to ensure accurate and complete crash cart audits for residents requiring basic life support, affecting eighteen of thirty-five residents who were designated as full code. During an observation of the crash cart with the DON, surveyors found that the daily audit documentation for the month did not include verification of expiration dates for crash cart supplies. Review of the crash cart audit logs showed that an extension cord was documented as being in the cart on multiple dates, but the extension cord was not present in the cart at the time of inspection. Additionally, the audit documentation indicated that required items, including eye protection, saline, and clear plastic, were not present in the crash cart, yet they were documented as being in the cart. The facility’s undated “Emergency Crash Cart” policy stated that the crash cart is to be checked every 24 hours and after every use, and that equipment and supplies are to be noted and replaced promptly, but the observed documentation and contents of the cart did not match these requirements. This deficiency was verified with the DON at the time of the survey and was cited under the requirement that personnel provide basic life support, including CPR, to residents requiring emergency care, subject to physician orders and advance directives, and was investigated under Complaint Number 2687380.
Plan Of Correction
Cridersville Care Center Provider Number:366171 Survey Type: Complaint Survey Survey Date: 04/29/26 This Plan of Correction (PoC) outlines the actions completed by the facility with regards to the deficiency citation. This Plan of correction does not constitute any admission of guilt or liability by the facility and is submitted only in response to the regulatory requirements. Please accept the following as the facility's credible allegation of compliance as of 4/30/26. F678 CPR All Full Code residents #18 have the potential to be affected by the alleged deficiency. On 4/27/26 the DON/ADON re-stocked the crash cart per the inventory sheet for all missing items. Crash cart inventory sheet updated and new one will go into effect on 5/1/26. All licensed nursing staff provided with training related to crash cart inventory being a daily audit review using inventory sheet on 4/27/26 per DON/designee. The DON/designee will conduct clinical rounds and conduct a random audit of crash cart three times per week for 4 (four) weeks to ensure compliance. The results of the audit will be documented. The facility conducted an Ad-Hoc QAPI meeting on 4/27/26 and discussed the alleged deficiency and corrective actions. Date when corrective action will be completed: 4/30/26
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.
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