Shawnee Manor
Inspection history, citations, penalties and survey trends for this long-term care facility in Lima, Ohio.
- Location
- 2535 Fort Amanda Road, Lima, Ohio 45804
- CMS Provider Number
- 365361
- Inspections on file
- 32
- Latest survey
- February 26, 2026
- Citations (last 12 mo.)
- 1
Citation history
Health deficiencies cited at Shawnee Manor during CMS and state inspections, most recent first.
A resident with multiple respiratory and cardiac diagnoses, including CHF, OSA, bronchiectasis, and chronic respiratory failure, had a care plan directing nightly BiPAP/CPAP use, but the facility lacked corresponding physician orders for the therapy and did not document nightly administration in the TARs, task worksheets, or nursing notes. The only related order was for weekly cleansing of the BiPAP mask. The resident’s family reported that CPAP had been ordered on admission and that the resident was not consistently using the device as ordered, nor was the family informed of refusals. The Administrator and DON confirmed the absence of necessary BiPAP/CPAP orders and documentation, resulting in a cited deficiency.
The facility failed to properly store medications, with issues including undated opened medications, food stored with biologicals, and medications not labeled with resident names. Observations revealed opened ear drops without a date, an insulin pen without an open date, and outdated tuberculin derivative. Food items were found in a medication cart with biologicals, and Cymbalta packages lacked resident identification.
The facility failed to ensure call lights were within reach for three residents, affecting their ability to communicate needs. A resident with spastic hemiplegia had a call light stuck between the mattress and handrail, another with cerebral palsy had a touch call light on the nightstand, and a third with cognitive deficits had a call light on the floor. Staff confirmed these observations and repositioned the call lights.
A resident dependent on staff for bathing did not receive proper hygiene care, as CNAs placed soiled washcloths back into the basin of warm water during the bathing process, violating infection control measures. The resident had multiple medical conditions, including pressure ulcers, and required assistance for bathing. The facility's policy was not followed, compromising the resident's care.
A facility failed to follow a physician's orders for treating a resident's skin tear. The resident, who was cognitively intact and had a history of several medical conditions, had a skin tear on the left forearm. The physician ordered daily cleansing and dressing changes, but the treatment was not performed as documented. An LPN confirmed the discrepancy, noting the dressing was incorrectly dated and not changed as ordered.
A facility failed to apply hand and foot splints per physician orders for a resident with dementia and contractures. The care plan required specific orthoses and braces to be applied by CNAs, but documentation showed a lack of compliance over the past 30 days. Observations confirmed the absence of required splints, and no refusal by the resident was documented, indicating non-adherence to the care plan.
A facility failed to follow physician orders for a resident's respiratory care, specifically regarding the weekly change of oxygen equipment. The resident, who was cognitively intact and had heart failure and depression, had an oxygen humidification bottle that had not been changed since late December, despite orders for weekly changes. This was confirmed by an LPN and was against the facility's policy.
A facility failed to implement enhanced barrier precautions during catheter and ostomy care for a resident with multiple diagnoses, including a urinary tract infection and dementia. Despite the care plan and facility policy indicating the use of gowns and gloves for high-contact activities, staff were observed performing care without gowns. Both a nurse and a CNA confirmed the lack of gown use, citing that the resident was no longer on any kind of precaution.
A resident with severe cognitive impairment and a history of falls was not provided with appropriate fall interventions. Despite a previous fall due to fatigue, the resident was placed in the wrong wheelchair, leading to another fall and injury. The facility's Fall Reduction Policy was not adequately followed.
The facility failed to provide showers twice weekly to two residents as required by their care plans. One resident, with diagnoses including dementia and diabetes, received showers only three times in 30 days, while another severely cognitively impaired resident received showers only twice. The DON confirmed the lack of documentation for these showers, indicating non-compliance with the facility's policy on activities of daily living.
The facility failed to maintain infection control during incontinence care for two residents. A CNA did not change gloves or perform hand hygiene while providing care to a cognitively impaired resident, and another CNA used the same gloves throughout the care process for a cognitively intact resident. These actions violated the facility's glove use policy, which requires hand cleaning after glove removal.
Failure to Implement and Document Ordered BiPAP/CPAP Therapy
Penalty
Summary
The facility failed to ensure that a resident’s BiPAP/CPAP therapy was implemented and documented according to physician recommendations and the resident’s care plan. The resident, who had diagnoses including congestive heart failure, obstructive sleep apnea, bronchiectasis, and chronic respiratory failure, was care planned on 05/18/22 as being at risk for altered respiratory status, with an intervention to assist in ensuring the BiPAP/CPAP mask was in place nightly per order. The quarterly MDS showed the resident had intact cognition and was receiving non-invasive oxygen therapy. However, review of physician orders from 08/11/22 through discharge on 10/14/25 revealed no physician order for BiPAP/CPAP therapy, aside from an order dated 05/04/24 directing staff to cleanse the BiPAP mask weekly on Sundays. Review of the resident’s medical record, including TARs, task worksheets, and nursing progress notes, showed no evidence that BiPAP/CPAP therapy was administered nightly as indicated in the care plan. The resident’s family representative reported that there had been an order for CPAP upon admission and stated the facility did not ensure the resident was using the CPAP machine as ordered, and that she was not informed when the resident refused the therapy. In an interview, the Administrator and DON confirmed that the medical record lacked documentation of BiPAP/CPAP administration and acknowledged there were no physician orders to administer it nightly, although there should have been. This deficiency was cited under Complaint Number 2705837.
Medication Storage Deficiencies
Penalty
Summary
The facility failed to adhere to proper medication storage protocols, as evidenced by several observations and interviews. In the F-hall medication cart, an opened bottle of generic ear drops was found without an open date, which was confirmed by an LPN. Similarly, the A-hall medication cart contained an unmarked medication cup with various tablets and an opened insulin pen without an open date, as verified by another LPN. Additionally, the memory care unit's medication room had an opened vial of tuberculin derivative dated over 30 days prior, which should have been disposed of according to the staff developer. Further deficiencies were noted in the D-hall medication cart, where food items were stored alongside biologicals, including hemorrhoidal cream. Eleven packages of Cymbalta without resident names and undated artificial tears were also found. These findings were confirmed by an LPN. The facility's policy on medication storage, which requires medications to be stored in legally compliant containers and outdated medications to be removed immediately, was not followed, leading to these deficiencies.
Failure to Ensure Call Lights Within Reach for Residents
Penalty
Summary
The facility failed to ensure that call lights were within reach for three residents, leading to a deficiency in accommodating the needs and preferences of each resident. Resident #31, who was admitted with diagnoses including spastic hemiplegia and cognitive impairment, was observed with her call light stuck between the mattress and handrail, making it inaccessible. This was confirmed by a Certified Nursing Assistant (CNA) who verified the call light was out of reach. Similarly, Resident #235, with a history of cerebral palsy and intellectual disabilities, was found with her touch call light placed on the nightstand, out of her reach. A Registered Nurse confirmed this observation and repositioned the call light. Additionally, Resident #104, diagnosed with cognitive communication deficit and mood disorders, was observed with her call light on the floor at the foot of the bed, out of reach. A CNA verified this and placed the call light within reach. These observations indicate a failure to adhere to care plans that required call lights to be accessible to prevent falls and ensure residents could communicate their needs effectively.
Failure to Maintain Hygiene and Infection Control During Bathing
Penalty
Summary
The facility failed to ensure that a resident who was dependent on staff for bathing received the necessary services to maintain good hygiene. The resident, who was cognitively intact, had multiple medical conditions including skin infection, diabetes mellitus, and pressure ulcers on the buttocks. The resident required assistance from staff for bathing due to impaired bilateral lower extremities and was at risk for decline in activities of daily living (ADL) due to various health issues. The plan of care indicated that the resident was totally dependent on staff for toileting and required one to two staff members for bathing. During an observation, two CNAs were performing a bath for the resident. CNA #623 washed the resident's back and legs, which had open wounds, using a washcloth that was then placed back into the basin of warm water, potentially contaminating it. This process was repeated for washing the resident's buttocks. The CNAs later confirmed that the soiled washcloths should not have been placed back into the basin, as this action did not adhere to infection control measures. The facility's policy stated that each resident should receive care to maintain their highest practical well-being, but the actions observed during the bathing process did not align with this policy.
Failure to Follow Physician's Orders for Skin Tear Treatment
Penalty
Summary
The facility failed to ensure that a resident's treatment for a skin tear was completed as ordered by the physician. The resident, who was cognitively intact and had a medical history including carpal tunnel syndrome, type two diabetes mellitus, cognitive heart failure, and major depressive disorder, had a skin tear on the left forearm. The physician's order required the skin tear to be cleansed with normal saline, treated with triple-antibiotic ointment, and covered with bordered gauze every day shift. However, the treatment administration record indicated that the dressing was documented as completed on three consecutive days, but an observation revealed that the dressing was dated incorrectly and had not been changed as ordered. An LPN confirmed that the treatment was documented as completed but had not been performed, and the dressing was not changed as per the physician's order.
Failure to Apply Splints as Ordered for Resident with Contractures
Penalty
Summary
The facility failed to ensure that hand and foot splints were applied per physician orders for a resident with multiple diagnoses, including dementia, schizoaffective disorder, and contractures. The resident's care plan required the use of a left wrist hand finger orthosis, a right c-splint elbow brace, PRAFO boots, and palm protectors due to muscle weakness, contractures, and pain. The care plan also specified that certified nursing assistants (CNAs) were to apply these braces as ordered and provide passive range of motion exercises before and after application. However, a review of the electronic medical record revealed a lack of documentation regarding the application of bilateral hand splints for the past 30 days. On the day of observation, the resident was seen in a wheelchair without any braces or splints on their hands, elbows, or lower extremities. This was confirmed by a Business Office Manager who verified the absence of the required splints and braces. The facility's policy on range of motion, revised in 2016, mandates that residents with limited range of motion receive appropriate treatment to increase or prevent further decrease in range of motion. Despite this policy, there was no documentation of the resident refusing the braces, indicating a failure to adhere to the prescribed care plan and physician orders.
Failure to Change Respiratory Equipment as Ordered
Penalty
Summary
The facility failed to adhere to physician orders regarding the maintenance of respiratory equipment for a resident. Resident #12, who was cognitively intact and had diagnoses including cognitive heart failure and major depressive disorder, was affected by this deficiency. The physician's orders, dated 04/07/24, specified that the resident's oxygen tubing, supply bag, and water jug should be changed weekly, and the concentrator should be wiped down and its filter cleaned weekly. However, an observation on 02/11/25 revealed that the oxygen concentrator's humidification bottle was last changed on 12/29/24, indicating a failure to follow the weekly change order. This was confirmed by an LPN during an interview. The facility's policy also required that disposable supplies be dated when changed, and that O2 humidifier bottles be changed weekly or as needed.
Failure to Implement Enhanced Barrier Precautions During Care
Penalty
Summary
The facility failed to ensure staff implemented enhanced barrier precautions (EBP) during catheter and ostomy care for Resident #79, who was admitted with multiple diagnoses including urinary tract infection, multiple sclerosis, and dementia. The resident required extensive assistance for bed mobility and was totally dependent on staff for toileting, with an indwelling catheter and ostomy. Despite the care plan indicating that Resident #79 may be in EBP and staff may wear appropriate personal protective equipment (PPE) during high-contact care activities, observations and interviews revealed that staff did not consistently wear gowns during catheter and ostomy care. During an observation, RN #402 performed ostomy replacement without wearing a gown, despite the sign above the resident's bed indicating that gowns and gloves should be used for high-contact activities. Similarly, CNA #520 performed catheter care without wearing a gown, only using gloves. Both staff members confirmed the lack of gown use, with RN #402 stating that the resident was no longer on any kind of precaution. The facility's policy on standard precautions indicated that an impervious gown should be worn during high-contact activities, including care for indwelling medical devices, regardless of MDRO colonization status.
Failure to Implement Fall Interventions for a Resident
Penalty
Summary
The facility failed to ensure a fall intervention was in place for Resident #335, who was severely cognitively impaired and had a history of repeated falls. The resident was admitted with diagnoses including depression, chronic kidney disease, malnutrition, atrial fibrillation, and seizures. On 01/12/25, Resident #335 was found lying on the floor in her room, and a root cause analysis determined the fall was due to fatigue after lunch. The interdisciplinary team decided to change the resident's wheelchair and encourage rest after lunch as interventions. However, on 01/18/25, Resident #335 was found on the floor in the dining room with a small abrasion and bleeding to the corner of her right eye, requiring an ER visit. It was determined that the resident was not in the correct tilt wheelchair, as staff had mistakenly placed her in the wrong one. The facility's Fall Reduction Policy mandates identifying residents at risk for falls and implementing a fall reduction program, which was not adequately followed in this case.
Failure to Provide Scheduled Showers to Residents
Penalty
Summary
The facility failed to provide showers twice weekly to two residents, #25 and #40, as required by their care plans. Resident #25, who was admitted with diagnoses including disorders of the bladder, repeated falls, dementia, and diabetes mellitus type II, was cognitively impaired and dependent on staff for personal hygiene. The Certified Nursing Assistant (CNA) documentation indicated that Resident #25 received showers on only three occasions over a 30-day period, with one refusal noted. Similarly, Resident #40, who was severely cognitively impaired and dependent for all activities of daily living, received showers on only two occasions in the same timeframe. The Director of Nursing confirmed that the showers were not documented as having been provided to these residents, indicating a lapse in adherence to the facility's policy on activities of daily living. The policy, dated April 29, 2016, mandates that the facility provide necessary care and services to maintain the highest practicable physical, mental, and psychosocial well-being of residents, including personal hygiene. This deficiency was identified during an investigation under Complaint Number OH00159551.
Infection Control Deficiency in Incontinence Care
Penalty
Summary
The facility failed to ensure clean and sanitary incontinence care for two residents, leading to a deficiency in infection prevention and control. Resident #25, who is cognitively impaired and dependent on staff for transfers and toileting, was observed receiving incontinence care from CNA #221. During this care, CNA #221 did not remove soiled gloves or perform hand hygiene before adjusting bed linens and personal items on the overbed table, which is a breach of sanitary protocol. Similarly, Resident #63, who is cognitively intact but dependent on staff for toileting hygiene, was observed receiving morning and incontinence care from CNA #227. CNA #227 used the same gloves throughout the care process, including washing the resident's body, assisting with clothing, and handling personal items, without changing gloves or performing hand hygiene. This was confirmed in an interview with CNA #227, who acknowledged the failure to remove soiled gloves and perform hand hygiene. The facility's policy on glove use, which requires hand cleaning after glove removal, was not followed, contributing to the deficiency.
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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