Altercare Of Canal Winchester Post-acute Rc
Inspection history, citations, penalties and survey trends for this long-term care facility in Canal Winchester, Ohio.
- Location
- 6725 Thrush Drive, Canal Winchester, Ohio 43110
- CMS Provider Number
- 366367
- Inspections on file
- 25
- Latest survey
- November 17, 2025
- Citations (last 12 mo.)
- 8
Citation history
Health deficiencies cited at Altercare Of Canal Winchester Post-acute Rc during CMS and state inspections, most recent first.
A resident with multiple stage 4 pressure ulcers and significant comorbidities was not provided with a recommended protein supplement for wound healing, despite a dietician's documented recommendation and care plan update. The recommendation was not communicated to the physician, resulting in no supplement order or administration. The resident experienced notable weight loss, and both the wound physician and the resident's spouse identified nutrition as a key factor in delayed wound healing.
The facility failed to implement a comprehensive pressure ulcer prevention program, resulting in harm to two residents. One resident developed a Stage IV ulcer due to inadequate assessments and interventions, while another did not receive prescribed off-loading boots, increasing their risk of skin breakdown. Staff interviews confirmed the lack of timely interventions and adherence to facility policies.
A facility failed to ensure proper hand hygiene during medication administration and did not implement enhanced barrier precautions (EBP) for residents with chronic wounds. An RN did not perform hand hygiene before or after entering rooms, and EBP was not in place for residents with pressure ulcers. The facility's policies require hand hygiene and EBP for infection control.
A resident with intact cognition and requiring assistance to reposition in bed experienced a 29-minute delay in call light response, despite facility policy requiring a response within three to five minutes. The delay occurred because other aides were busy, affecting one resident in a facility with a census of 61.
The facility failed to maintain the confidentiality of residents' medical records during medication administration. An RN Supervisor left MARs open and unattended, exposing sensitive information to passersby. This affected two residents, both moderately cognitively impaired, with various medical conditions. The Assistant Director of Nursing confirmed that such exposure violated the facility's confidentiality policy.
A resident with severe cognitive impairment and limited mobility did not receive necessary meal setup assistance, despite physician orders and therapy assessments indicating the need. The resident struggled to eat breakfast due to improperly set up meals, highlighting a deficiency in care.
The facility failed to implement fall interventions and conduct timely investigations for three residents, leading to deficiencies in accident prevention and supervision. A resident experienced multiple falls without timely interventions, another was observed with their bed not in the lowest position, and a third had a fall report completed late. These lapses highlight the facility's failure to adhere to prescribed safety measures and policies.
A facility failed to ensure adequate hydration for a resident with severe cognitive impairment, as fluids were not consistently provided and no hydration care plan was in place. Another resident experienced significant weight loss, which was not addressed by the facility, and dietary needs were not accurately assessed or met. Additionally, a third resident was not weighed monthly as required, with no documentation of refusal or notification to the physician, leading to deficiencies in monitoring nutritional status.
A facility failed to document nonpharmacological interventions before administering PRN Lorazepam to a resident with dementia and anxiety. Despite multiple administrations over a month, interventions were only documented once. The DON confirmed the lack of required documentation.
A resident with a history of dysphagia and other medical conditions experienced a delay in receiving speech therapy services after a diet change due to swallowing difficulties. Despite documentation of the issue, the SLP was not informed until over two months later, revealing a communication breakdown in the facility's protocol for notifying therapy staff.
A resident's prescribed narcotics were misappropriated due to altered medication inventory logs and poor documentation. An agency RN was suspected of taking the medications, as discrepancies occurred during their shifts. The resident did not report any missed doses, but a pharmacy audit revealed a missing card of Hydrocodone-Acetaminophen.
A facility failed to timely investigate a misappropriation allegation involving a resident's Hydrocodone-Acetaminophen medication. Discrepancies in the medication inventory log and a pharmacy audit revealed missing narcotics, with RN suspected but unreachable. The facility's delayed response violated its policy requiring immediate reporting and investigation of such incidents.
Failure to Implement Care Planned Nutritional Supplementation for Wound Healing
Penalty
Summary
The facility failed to implement care planned interventions for nutritional supplements for a resident with multiple stage 4 pressure ulcers and significant comorbidities, including hemiplegia, chronic kidney disease, and obesity. Upon admission, the resident was identified as being at high risk for skin breakdown and poor nutritional intake, and the care plan included recommendations for nutritional assessment and supplementation to support wound healing. The dietician specifically recommended a protein supplement (prosource) to aid in wound healing, and this intervention was documented in the care plan. Despite the dietician's recommendation and the care plan update, there were no physician orders for the recommended supplement, and the intervention was not implemented. The dietician's recommendation was communicated via email to the Administrator, DON, and ADON, but the message was not relayed to the resident's physician. As a result, the physician was unaware of the recommendation and did not order the supplement. The resident experienced significant weight loss over a short period, and both the resident and her spouse expressed concern that the weight loss was contributing to poor wound healing. The wound physician also identified nutrition as the primary barrier to wound healing for this resident. Interviews with facility staff confirmed that the breakdown in communication led to the failure to implement the recommended nutritional intervention. The facility's policy required that dietician referrals and recommendations for supplements be administered in accordance with physician orders, but this process was not followed. The deficiency was identified through observation, interviews, and record review, and it affected one resident reviewed for wounds.
Failure to Implement Pressure Ulcer Prevention Program
Penalty
Summary
The facility failed to develop and implement a comprehensive and individualized pressure ulcer prevention program, resulting in harm to two residents. Resident #216, who was at risk for pressure ulcer development and dependent on staff for activities of daily living, developed an unstageable pressure ulcer on the sacrum, which later progressed to a Stage IV ulcer. The resident was admitted with intact skin, and the facility did not implement adequate interventions to prevent the development of the ulcer or identify it in a timely manner. The admitting nurse did not thoroughly assess the resident's buttocks area, and a second skin assessment was not completed as required by facility policy. Resident #213, who was at moderate risk for skin breakdown due to impaired mobility and cognitive challenges, did not receive the necessary interventions to prevent pressure ulcers. Despite physician orders for off-loading boots to be used while the resident was in bed, observations revealed that the boots were not in place during multiple checks. The resident's family expressed concerns about the lack of support boots, and staff confirmed the need for these interventions due to the resident's high risk of skin issues. Interviews with facility staff, including the Director of Nursing and a Regional Nurse Consultant, confirmed the lack of timely interventions and assessments for both residents. The facility's policies on pressure injury prevention and admission skin assessments were not followed, contributing to the development and progression of pressure ulcers in these residents. The facility's failure to adhere to its own policies and implement necessary preventive measures led to the deficiencies identified in the report.
Inadequate Hand Hygiene and EBP Implementation
Penalty
Summary
The facility failed to ensure appropriate hand hygiene during medication administration for Resident #105. The RN Supervisor #207 did not perform hand hygiene before preparing medications or after exiting the resident's room. This was confirmed through observation and interviews with the RN Supervisor and the Assistant Director of Nursing. The facility's hand hygiene policy requires hand hygiene before direct contact with residents, before preparing or handling medications, and after contact with residents or inanimate objects. The facility also failed to implement and follow enhanced barrier precautions (EBP) for Residents #2, #19, and #104. For Resident #104, the RN Supervisor did not perform hand hygiene before entering or after exiting the room, despite the presence of an EBP sign. The resident's care plan required EBP due to a chronic wound, and the facility's policy mandates frequent hand hygiene and the use of gowns and gloves during high-contact care activities. Resident #2 had a stage three pressure ulcer but did not have EBP in place, as observed over several days. The Director of Nursing confirmed that EBP should have been implemented. Similarly, Resident #19 had a stage three pressure ulcer, but EBP was not in place until after the surveyor's observation. The facility's policy on EBP requires the use of PPE and signage for residents with chronic wounds to prevent the transmission of multidrug-resistant organisms.
Delayed Response to Call Light
Penalty
Summary
The facility failed to address the needs of a resident in a timely manner, as evidenced by a 29-minute delay in responding to a call light. The resident, who had intact cognition and required substantial or maximal assistance to reposition in bed, triggered the call light because she was uncomfortable and needed help adjusting her position. Despite the facility's policy stating that call lights should be answered within three to five minutes, the call light remained unanswered for 29 minutes. An STNA eventually responded, explaining that other aides were busy assisting other residents. This incident affected one resident out of a facility census of 61.
Confidentiality Breach During Medication Administration
Penalty
Summary
The facility failed to ensure the confidentiality of residents' medical records during routine medication administration, affecting two residents. During the medication administration process, the Registered Nurse (RN) Supervisor left the medication administration records (MAR) open and unattended on the computer screen, making sensitive information visible to passersby. This occurred while the RN was obtaining blood pressure readings for the residents, which was required before administering medications. The information exposed included medication details, scheduled timings, residents' dates of birth, and room numbers. The incident involved two residents, both of whom were moderately cognitively impaired. One resident had a medical history including metabolic encephalopathy, vascular dementia, hypertension, pneumonia, and gastro-esophageal disease, while the other had osteoarthritis, cognitive communication deficit, bradycardia, and acute kidney failure. The RN Supervisor confirmed that the medical records were visible to the public during the medication administration process. The Assistant Director of Nursing also acknowledged that residents' medical records should not be visible or accessible to the public, as per the facility's confidentiality policy.
Failure to Provide Meal Setup Assistance
Penalty
Summary
The facility failed to provide necessary meal setup assistance to a resident with limited range of motion, resulting in a deficiency. Resident #213, who was admitted with severe cognitive impairment and multiple fractures, required setup assistance with eating due to her limited mobility and strength in both upper extremities. Despite physician orders and occupational therapy assessments indicating the need for assistance, the resident did not receive the required help during meals. On the morning of the observation, Resident #213 was seen struggling to eat her breakfast because her meal was not properly set up. She had difficulty cutting her food and removing lids due to her limited arm movement. A nursing assistant denied that any residents, including Resident #213, required meal assistance, which was confirmed as incorrect by the Regional Nurse Consultant. This lack of assistance directly contributed to the resident's inability to perform activities of daily living independently.
Failure to Implement Fall Interventions and Timely Investigations
Penalty
Summary
The facility failed to ensure fall interventions were in place for three residents, leading to deficiencies in accident prevention and supervision. Resident #2 experienced multiple falls, with the facility failing to implement timely and appropriate interventions. Despite orders for a low bed and a fall mat, these were not consistently in place, and neurological assessments were incomplete. The fall investigation for an incident on 09/05/24 was not completed until 09/23/24, indicating a delay in addressing the resident's fall risk. Resident #38 was observed with his bed not in the lowest position, contrary to physician orders and care plan interventions aimed at reducing fall risk. This oversight was confirmed by a nursing assistant, highlighting a lapse in adherence to prescribed safety measures. The facility's policy on fall investigation was not effectively followed, as assessments and interventions were not consistently implemented. Resident #205 had a fall on 09/21/24, with the fall report not completed in a timely manner. The resident's care plan identified a high risk for falls, yet interventions such as non-skid strips were not promptly implemented. The Director of Nursing confirmed the delay in completing the fall report and implementing preventive measures, further underscoring the facility's failure to adequately address fall risks and ensure resident safety.
Deficiencies in Hydration and Nutrition Monitoring
Penalty
Summary
The facility failed to ensure adequate hydration for Resident #38, who had severe cognitive impairment and required assistance with eating. Observations over several days revealed that the resident was frequently without fluids in various locations, including the activities room, dining room, and in bed. Interviews with staff confirmed that fluids were not consistently provided, and there was no hydration care plan in place for the resident, despite the facility's policy to pass fluids once a shift and as needed. Resident #2 experienced a significant weight loss of 6.2% within six days, which was not addressed by the facility. The resident, who was on hospice care and had a stage three pressure ulcer, had dietary needs that were not accurately assessed or met. The Registered Dietitian failed to recognize the weight change and did not make necessary dietary recommendations, such as supplements, to address the resident's increased protein needs due to the pressure ulcer. The facility's policy required addressing weight loss within a week, but this was not followed, and the physician and dietitian were not notified of the weight loss. Resident #19 was not weighed monthly as required, and there was no documentation of the resident refusing weights or the physician being notified of such refusals. The resident had a history of refusing care, but this was not documented, and the facility failed to ensure that the resident's weight was monitored according to policy. The lack of documentation and communication regarding the resident's refusal to be weighed contributed to the deficiency in monitoring the resident's nutritional status.
Failure to Document Nonpharmacological Interventions Before PRN Medication
Penalty
Summary
The facility failed to ensure that nonpharmacological interventions were attempted and documented before administering 'as needed' anxiety medication to a resident. This deficiency was identified during a review of the medical records and interviews. The resident in question had a range of diagnoses, including senile degeneration of the brain, unspecified dementia, and anxiety disorder, among others. The resident's care plan included the use of psychotropic medications, specifically an antidepressant and an antianxiety medication, with interventions requiring physician and pharmacist review for potential dosage reduction and monitoring for side effects. The resident had a physician's order for Lorazepam, an antianxiety medication, to be administered as needed. The Medication Administration Record (MAR) showed that Lorazepam was administered multiple times over a period of approximately one month. However, documentation of nonpharmacological interventions was only present for one instance, despite the medication being administered on numerous occasions. The Director of Nursing confirmed that nonpharmacological interventions were not documented as required, indicating a lapse in following the established protocol for medication administration.
Failure to Provide Timely Speech Therapy Services
Penalty
Summary
The facility failed to ensure that a resident received timely speech therapy services following a change in their nutritional condition. The resident, who had a history of chronic obstructive pulmonary disease, hemiplegia, dysphagia, diabetes, and a gastrostomy tube, was noted to have difficulty swallowing a mechanically altered diet. As a result, the resident's diet was downgraded to a pureed diet until a speech language pathologist (SLP) could provide a recommendation. However, despite the change in diet and the resident's swallowing issues being documented, there was no evidence of evaluation or treatment by the SLP from the time of the diet change until over two months later. Interviews with facility staff revealed a breakdown in communication and process. The SLP was not made aware of the resident's swallowing issues and diet change until much later, indicating a failure in the facility's protocol for notifying therapy staff of such changes. The Director of Nursing (DON) explained that the usual process involved the nurse entering the diet change order, which the DON would then print and provide to therapy during the next morning meeting. However, the order from July was missed, leading to the delay in the resident receiving necessary speech therapy services.
Misappropriation of Resident's Narcotics
Penalty
Summary
The facility failed to prevent the misappropriation of a resident's prescribed narcotics, specifically Hydrocodone-Acetaminophen. The resident, who was cognitively intact and on a scheduled pain medication regime, did not report any missed doses or pain. However, discrepancies were found in the controlled medication inventory log, with entries being altered and made illegible without proper documentation or signatures indicating who made the changes. This affected one resident out of three reviewed for misappropriation. The issue was identified when a pharmacy audit revealed poor documentation and a missing card of Hydrocodone-Acetaminophen. The audit was conducted after staff attempted to refill the resident's prescription and were informed it was too early, indicating that the medication should still have been available in the facility. The investigation pointed to an agency RN as the suspected perpetrator, who had signed the medication inventory log during the shifts when the discrepancies occurred. Attempts to contact the RN for clarification were unsuccessful. The facility's investigation involved reviewing witness statements and contacting the staffing agency. A police report was filed, and the facility determined that the RN was responsible for the missing medications based on the timing of the medication delivery and the altered narcotic sheet documentation. The facility's policy defined misappropriation as the wrongful use of a resident's belongings without consent, which was applicable in this case.
Delayed Investigation of Medication Misappropriation
Penalty
Summary
The facility failed to timely investigate an allegation of misappropriation involving a resident's medication. Resident #21, who was cognitively intact and on a scheduled pain regimen, was affected by this incident. The resident's medical record indicated a prescription for Hydrocodone-Acetaminophen, which was documented as administered without any concerns of missing doses. However, discrepancies were found in the controlled medication inventory log, with altered entries and missing documentation of who made these changes. The issue came to light when a pharmacy audit revealed poor documentation and a missing card of Hydrocodone-Acetaminophen. The Director of Nursing reached out to the staffing agency regarding RN #122, who was suspected of misappropriating the narcotics. Despite attempts to contact RN #122, the agency was unable to reach her. The facility's investigation, initiated after the pharmacy audit, was delayed, and the missing medication was reported to the police. Interviews with staff and review of the facility's policy on misappropriation highlighted a delay in reporting and investigating the incident. The policy required immediate reporting of misappropriation allegations to the Administrator, with an investigation to be completed within five working days. The deficiency was identified under Complaint Number OH00155403, indicating non-compliance with the facility's policy and procedures.
Latest citations in Ohio
A resident with intact cognition receiving Medicare Part A skilled services for metabolic encephalopathy had services discontinued while benefit days remained, but the facility did not issue the required Skilled Nursing Facility Advance Beneficiary Notice (SNF ABN). The Social Services Director later confirmed that no SNF ABN was provided and reported she believed only a Notice of Medicare Non-Coverage (NOMNC) was needed when all skilled services were stopped. This practice conflicted with the facility’s written policy, which required SNF ABNs to be issued when extended care items or services were initiated, reduced, or terminated due to expected non-coverage by Medicare.
Surveyors identified that the facility exceeded the acceptable medication error rate when two residents with type 2 DM received insulin doses that were not administered according to orders or manufacturer instructions. In two separate observations, an LPN administered Novolog and another LPN administered insulin glargine and insulin lispro without priming the insulin pens, and the insulin lispro and Novolog were given after the residents had already consumed a significant portion of their breakfast meals, despite orders for administration before meals. Manufacturer information for both insulin products required priming before each injection to ensure accurate dosing, and facility policy required medications, including insulin, to be administered safely, timely, and in accordance with prescriber orders and specified time frames.
Surveyors found that the facility failed to document tray line food temperatures for multiple meals served from two dining room kitchenettes, despite having a “Trayline Taste & Temperature Log” and a policy requiring food to be stored, prepared, distributed, and served according to professional food safety standards. Review of logs showed repeated missing entries for breakfast, lunch, and dinner services in both the Harrison and McClellan dining areas, and the Senior Director of Culinary Services confirmed that temperatures had not been recorded for those meals, potentially affecting all residents receiving meals from those kitchenettes.
The facility failed to conduct and document required periodic care conferences for two residents, despite multiple comprehensive, quarterly, and significant change MDS assessments and a policy requiring periodic care conferences with resident and/or family participation. One resident with Parkinson’s disease, post-stroke hemiplegia, TIA, DMII, and depression had only two documented care conferences over a year, while another resident with aphasia, cerebrovascular disease, DMII, gait difficulty, coagulation defect, depression, and muscle weakness had no documented care conferences in the past year, aside from a declined invitation to the representative. The UCC confirmed that care conferences were expected to occur quarterly and that no additional documentation existed for either resident.
A resident with Alzheimer's disease and type II DM, who required extensive assistance with ADLs and was receiving scheduled Lantus and sliding-scale Humalog, experienced a severely elevated blood glucose level. The on-call provider was notified and ordered an additional dose of lispro insulin with a directive to recheck the blood glucose after administration. Nursing staff administered the extra insulin but did not document any follow-up blood glucose check, and the DON confirmed that this reevaluation was required by the facility's abnormal blood glucose policy and was not completed or documented.
A resident with Parkinson’s disease, dementia, and hypothyroidism was prescribed levothyroxine once daily along with other medications. A consultant pharmacist’s monthly drug regimen review recommended that levothyroxine be given in the morning on an empty stomach, 30–60 minutes before food, per manufacturer instructions. The medical record contained no documented physician response to this recommendation, and the MAR showed the drug scheduled for morning administration while the resident was observed eating breakfast and receiving the medication at the same time. An LPN confirmed administering levothyroxine during the meal, and the DON verified there was no documentation explaining whether or why the pharmacist’s recommendation was or was not followed, resulting in a failure to act on and document the identified irregularity.
A resident with severe cognitive impairment, multiple comorbidities, documented gait and balance abnormalities, and a high fall risk was care planned and assessed by therapy to require contact guard assistance and use of a gait belt for transfers and ambulation. While being assisted by a CNA from a recliner to the bathroom with a walker, the CNA did not apply a gait belt, even though the resident had a known tendency to lean backward when standing. As the CNA reached to open the bathroom door, the resident lost balance and fell backward, striking the back of the head, and was later found by an LPN without a gait belt in place, contrary to the facility’s gait belt policy and the resident’s assessed needs.
A resident with CKD stage five requiring peritoneal dialysis (PD) was admitted with pre-admission physician orders for three daily PD exchanges and monitoring for peritonitis (fever, abdominal pain, cloudy effluent), but these monitoring orders were not entered into the facility’s physician orders. The care plan referenced PD and general monitoring but did not specifically address peritonitis monitoring. Paper PD flowsheets showed incomplete and inconsistent documentation of exchanges and resident condition, including missing condition/comments for individual treatments and no record of one ordered PD exchange. The PD cycler flowsheet lacked effluent descriptions on multiple days. The PD nurse reported facility staff were expected to monitor effluent and symptoms, and the DON confirmed the absence of specific peritonitis monitoring orders, lack of an order for the PD cycler, and documentation gaps, despite a facility policy requiring ongoing assessment and monitoring for complications before, during, and after dialysis treatments.
A nurse was observed preparing multiple oral medications for a resident with depression, traumatic brain injury, anxiety, and impaired cognition by pushing tablets and capsules from unit-dose cards directly into her ungloved hand and then using her fingers to place them into a medication cup. In a follow-up interview, the RN confirmed this practice and acknowledged that the correct procedure is to dispense medications directly from the card into the cup, contrary to the facility’s medication administration policy requiring adherence to good nursing principles and practices.
A resident with Alzheimer’s disease, diabetes, anxiety, significant ADL dependence, and behavioral symptoms was observed seated in a chair positioned against the nursing station with a locked wheelchair placed directly in front, also against the nursing station, effectively restricting movement. An LPN confirmed both wheelchair wheels were locked and that it should not have been placed there, while a CNA stated she had positioned the wheelchair to prepare for lunch, was unable to complete the transfer, and left it in place, acknowledging this was wrong. This arrangement conflicted with the facility’s restraint policy, which prohibits physical restraints except when alternatives are ineffective for treating a medical symptom and defines restraints as devices adjacent to the body that cannot be easily removed and that restrict freedom of movement or access to the body.
Failure to Issue Required SNF ABN When Discontinuing Medicare Part A Services
Penalty
Summary
The deficiency involves the facility’s failure to issue a Skilled Nursing Facility Advance Beneficiary Notice (SNF ABN) when Medicare Part A services were discontinued for a resident who still had available benefit days. The resident was admitted with a diagnosis of metabolic encephalopathy and had intact cognition per the Minimum Data Set assessment. The facility’s own SNF Beneficiary Notification Review documented that Medicare Part A skilled services began on 02/11/26 and the last covered day was 03/11/26, and that the facility initiated discharge from Medicare Part A services before the resident’s benefit days were exhausted. Despite this, no SNF ABN was provided to the resident or the resident’s representative. During interviews, the Social Services Director stated that the SNF ABN was issued hours prior to the last covered day but, upon reviewing her files, confirmed that no SNF ABN had actually been issued for this resident. She further explained that she believed an SNF ABN was only required if one skilled service remained and that if all skilled services were being discontinued, only the Notice of Medicare Non-Coverage (NOMNC) needed to be issued. The Administrator, however, stated that a resident should always receive both a SNF ABN and a NOMNC when Medicare Part A services are discontinued and benefit days remain. Review of the facility’s written policy dated 03/28/23 showed that the facility was required to issue SNF ABNs for initiation, reduction, or termination of extended care items or services when Medicare payment was not expected, which did not occur in this case.
Plan Of Correction
This Plan of Correction is submitted as required under State and Federal law. This Plan of Correction does not constitute an admission on the part of the Facility that the findings cited are accurate, that the findings constitute a deficiency or that the scope and severity regarding the deficiency cited are correctly applied. Any changes to the Facility's policies and procedures should be inadmissible in any proceeding on that basis. Without admitting or denying the validity or the existence of the alleged noncompliance, the Facility submits this Plan of Correction with the intention that it be inadmissible by any third party in any civil or other action against the facility or any employee, agent, officer, director or shareholder of the Facility. The Facility is utilizing this Plan of Correction as its allegation of substantial compliance as of 05/29/2026 F-0582 Corrective action for resident/s: On 5/14/26 Resident #34 was informed of rights and responsibilities related to Advanced Beneficiary Notice and voiced understanding of information for future reference by administrator. Identification of other residents who may be affected: Any resident receiving skilled services from nursing or therapy services. The Administrator audited all residents who were discharged from skilled services in the past 30 days to ensure they were issued a Notice of Non-Coverage and Advanced Beneficiary Notice on 5/29/26. No non-compliance was noted. Measures for systemic change: On 5/14/2026 Business Office Manager, Director of Rehab, Minimum Data Set nurse, Director of Nursing and Social Services Director were educated on proper procedure of issuing of Notice Of Medicare Non Coverage and Advanced Beneficiary Notice by administrator. All upcoming discharges from skilled services will be reviewed weekly at Utilization Review meeting to ensure notices will be delivered timely. How Corrective Action will be monitored: Administrator or designee to complete audits of all residents being discharged from skilled services to ensure they were issued a Notice of Non-Coverage and Advanced Beneficiary. This audit will be completed weekly x 4 weeks, then monthly x 2 months. Corrective action will be initiated for any noted non-compliance. Audit findings will be reviewed as part of the monthly quality assurance process to determine the need for further monitoring. Date of Compliance 5/29/26
Insulin Administration Errors and Failure to Prime Insulin Pens
Penalty
Summary
The deficiency involves the facility’s failure to maintain a medication error rate below 5%, with surveyors identifying 3 errors out of 28 medication administration opportunities, resulting in a 10.71% error rate. For one resident with type 2 diabetes mellitus and moderate cognitive impairment, the physician’s order directed Novolog insulin 10 units via subcutaneous pen-injector to be given before meals. During an observed medication pass, the LPN administered 10 units of Novolog insulin without priming the pen and did so after the resident had already consumed approximately 50% of the breakfast meal. The LPN later confirmed she did not prime the pen and acknowledged that the insulin was ordered to be administered prior to meals. Manufacturer instructions for the Novolog FlexPen specified that an air shot (priming) must be performed before each injection to ensure proper dosing. Another resident, also diagnosed with type 2 diabetes mellitus and with intact cognition, had orders for insulin glargine 35 units subcutaneously twice daily and insulin lispro 20 units subcutaneously before meals, plus 12 units subcutaneously if blood glucose was between 251 mg/dL and 300 mg/dL. During an observed medication administration, an LPN administered 35 units of insulin glargine and 32 units of insulin lispro without priming the insulin pens and after the resident had consumed approximately 90% of the breakfast meal, despite orders for insulin lispro to be given before meals. The LPN later stated she could not remember if she had primed the pen and acknowledged that the insulin was ordered to be administered prior to meals. Manufacturer information for insulin lispro stated that the pen must be primed before each injection to confirm insulin delivery and remove air, and that failure to prime could result in too much or too little insulin. The DON confirmed the expectation that insulin be administered as ordered, including priming each pen with two units before dialing the prescribed dose, and facility policy required medications, including insulin, to be administered safely, timely, and in accordance with prescriber orders and required time frames.
Plan Of Correction
This Plan of Correction is submitted as required under State and Federal law. This Plan of Correction does not constitute an admission on the part of the Facility that the findings cited are accurate, that the findings constitute a deficiency or that the scope and severity regarding the deficiency cited are correctly applied. Any changes to the Facility's policies and procedures should be inadmissible in any proceeding on that basis. Without admitting or denying the validity or the existence of the alleged noncompliance, the Facility submits this Plan of Correction with the intention that it be inadmissible by any third party in any civil or other action against the facility or any employee, agent, officer, director or shareholder of the Facility. The Facility is utilizing this Plan of Correction as an allegation of substantial compliance as of 5/29/2026. F-0759 Corrective action for resident/s: Residents #21 and #22 were assessed and evaluated by nurse and Director of Nursing 5/14/26. Resident #21 and #22 both denied any adverse effects and none were noted upon assessment by the Director of Nursing on 5/14/2026. Notification made to physician on 5/14/2026. LPN # 2 competency Eval on insulin administration with the Director of Nursing completed 5/14/2026. Identification of other residents who may be affected: Diabetic residents on assignment of LPN #2/station 2 have the potential to be affected and were assessed by the DON/Designee on 5/14/26 and found to be within normal limits. Measures for systemic change: All Nurses were educated by the Director of Nursing on the steps for Insulin administration per competency, diabetes clinical protocol policy, Medication and treatment orders policy, administering medications policy, and Obtaining fingerstick Glucose Level policy On 5/14/2026. How Corrective Action will be monitored: Director of Nursing and Assistant Director of Nursing will complete insulin administration audits on 5 nurses. This audit will be completed weekly x 4 weeks, then monthly x 2 months. Corrective action will be initiated for any noted non-compliance. Audit findings will be reviewed as part of the monthly quality assurance process to determine the need for further monitoring. Date of Compliance: 5/29/2026
Failure to Document Tray Line Food Temperatures in Dining Room Kitchenettes
Penalty
Summary
The deficiency involves the facility’s failure to document tray line food temperatures for meals served from the Harrison and McClellan Dining Room kitchenettes, as required by professional standards for food service safety and the facility’s own policy. Review of the “Trayline Taste & Temperature Log” (revised September 2018) showed missing temperature documentation for multiple meals from the Harrison Dining Room kitchenette, including dinner on 03/30/26 and 03/31/26, lunch and dinner on 04/01/26 and 04/02/26, dinner on 04/07/26, and lunch and dinner on 04/08/26 and 04/10/26. The Senior Director of Culinary Services confirmed during interview that tray line food temperatures were not documented on the log for these meals. Similarly, review of the same log for the McClellan Dining Room kitchenette revealed that tray line food temperatures were not documented for dinner on 04/01/26, breakfast and lunch on 04/02/26, and lunch and dinner on 04/07/26. The Senior Director of Culinary Services also verified these omissions during interview. The facility census at the time was 27 residents, and the governing “Food and Nutrition” policy, approved on 09/07/21, stated that the facility must store, prepare, distribute, and serve food in accordance with professional standards for food service safety.
Plan Of Correction
F812 The facility will continue to ensure food temperatures are completed before meals are served for all residents. To ensure compliance with this standard the following measures have been taken: 1. Immediately 4/15/26 culinary supervisor #224 was re-educated by Dietary Manager to this standard and policy "Food and Nutrition" which includes documentation of food temperatures. 2. All dietary staff have been re-educated to the standard and policy "Food and Nutrition" during the month of April 2026. 3. Audits of food temperature documentation to be completed by Dietary Manager 4 x per week for 4 weeks then weekly for 4 weeks. 4. Administrator to validate audits/compliance and provide additional training as needed. Administrator will present to QAPI committee for ongoing monitoring and further direction.
Failure to Conduct and Document Required Care Conferences
Penalty
Summary
The deficiency involves the facility’s failure to complete and document comprehensive care conferences at required intervals in accordance with care plan regulations and facility policy. For one resident with Parkinson’s disease with dyskinesia, cognitive communication deficit, hemiplegia and hemiparesis following cerebral infarction, transient cerebral ischemic attack, type II diabetes mellitus, and major depressive disorder, the record showed multiple MDS assessments over a one-year period, including annual, quarterly, and significant change assessments. However, only two care conferences were documented during the last 12 months, despite the expectation that care conferences be conducted quarterly with the resident and family when possible. The Unit Care Coordinator confirmed that no additional care conference documentation existed for this resident beyond the notes dated 04/21/25 and 01/02/26. A second resident, with diagnoses including aphasia following cerebrovascular disease, cerebral infarction, type II diabetes mellitus, unsteadiness on feet, difficulty in walking, coagulation defect, depression, and muscle weakness, also had multiple MDS assessments completed over the review period, including quarterly and annual assessments. The record contained a note that a care conference was offered to the resident’s representative, who declined to attend, but there was no documentation of any care conferences for the most recent 12 months. The Unit Care Coordinator confirmed that no other care conference documentation was available for this resident. Facility policy stated that periodic care conferences involving the resident, family, and the interdisciplinary team are part of the care planning process, but the required periodic care conferences and corresponding documentation were not completed for these two residents.
Plan Of Correction
THIS PLAN OF CORRECTION SERVES AS BERKELEY SQUARE'S CREDIBLE ALLEGATION OF SUBSTANTIAL COMPLIANCE AS OF June 1, 2026. Without admitting or denying the validity or existence of the alleged deficiencies, Berkeley Square provides the following Plan of Correction: F657 The facility will continue to document completion of care conferences at the required intervals for all residents, including residents #04 & #15. To ensure compliance with this standard the following measures have be taken: 1. The social service designee and the inter- disciplinary team were re-educated by the administrator to the facility policy "Care Conference" on 4/29/26 and verbalized understanding. 2. Care conferences for resident #04 and resident #15 were conducted on or before 4/29/2026 by the interdisciplinary team. 3. Review of all other residents was conducted by the social service designee to validate and ensure that care conference schedule is up to date with timely care conferences scheduled for them on 4/15/2026. Audits of care conferences to be completed weekly for four weeks and then monthly after that by the social service designee. Documentation of the care conference including any identified concerns in the medical record. Administrator to validate audits/compliance and provide additional training as needed. Administrator will present results of these audits to QAPI committee for ongoing monitoring and further direction.
Failure to Reevaluate Blood Glucose After Treatment for Hyperglycemia
Penalty
Summary
The facility failed to ensure that a resident with diabetes received treatment in accordance with professional standards of practice when nursing staff did not reevaluate the resident's blood glucose after treatment for severe hyperglycemia. The resident, admitted with diagnoses including Alzheimer's disease, type II diabetes mellitus, and depression, had physician orders for Humalog insulin on a sliding scale before meals, Lantus insulin 25 units daily, and lisinopril 5 mg daily. The resident required extensive assistance with activities of daily living, including transfers, toileting hygiene, eating, and bathing. On the evening in question, the resident's blood glucose was documented as 532 mg/dL, and the on-call provider was notified. The provider gave a new order to administer an additional 8 units of lispro (Humalog) and to recheck the blood glucose in 30 minutes. The electronic medication administration record showed that the blood glucose of 532 mg/dL was obtained at 9:00 p.m. and that the additional 8 units of lispro were administered at 9:21 p.m. However, there was no documentation in the resident's chart that the blood glucose was rechecked after the additional insulin was given. In an interview, the DON confirmed there was no evidence of reevaluation and verified that, according to the facility's "Abnormal Blood Glucose Procedure" policy, the resident should have been reevaluated and that the evaluation step should have been included in the progress note documentation.
Plan Of Correction
F684 The facility will continue to ensure all residents, including #03, receive treatment in accordance with professional standards of practice and reevaluated for hyperglycemia. To ensure compliance with this standard the following measures have been taken: 1. The director of nursing assessed resident #03, reviewed documentation and orders and found no ill effects immediately 4/16/26. 2. All licensed nurses were re-educated to facility policy "Blood Glucose Monitoring" by the Director of Nursing/designee in April 2026. 3. Audits of like-residents that require blood sugar checks to be completed by the director of nursing/designee two times a week for 4 weeks and then monthly after that to validate correct follow through when there is abnormally high blood glucose result. The Administrator will bring results of these audits to the QAPI committee for ongoing monitoring and further direction.
Failure to Act on Pharmacist Drug Regimen Recommendation for Thyroid Medication
Penalty
Summary
The deficiency involves the facility’s failure to ensure that pharmacy recommendations from the monthly drug regimen review were acted upon and documented for a resident. The resident was admitted with diagnoses including Parkinson’s disease, dementia, and hypothyroidism, and had current physician orders for levothyroxine 150 mcg once daily, buspirone 50 mg twice daily, and losartan 100 mg once daily. A medication regimen review dated 11/25/2025 included a consultant pharmacist recommendation that levothyroxine be administered consistently in the morning on an empty stomach, at least 30–60 minutes before food, per manufacturer instructions. There was no specific physician response in the medical record to this recommendation, and the facility’s policy stated that consulting pharmacist reviews are sent to nursing and addressed with the primary care provider or consulting specialist for review and follow-up. Review of the resident’s medication administration record for April 2026 showed levothyroxine scheduled for 9:00 a.m. On observation, the resident was seen eating breakfast in the dining area at 8:03 a.m., and an LPN reported administering the levothyroxine 150 mcg to the resident while the resident was in the dining area eating breakfast. The DON confirmed there was no evidence in the resident’s medical record explaining why the consultant pharmacist’s recommendation from 11/25/2025 was or was not acted upon. This lack of documented physician review and action on the pharmacist’s identified irregularity constituted noncompliance with the drug regimen review requirements.
Plan Of Correction
F756 The facility will continue to ensure the pharmacy recommendations from the monthly drug regimen review by a licensed pharmacist are acted upon for all residents, including #08. To ensure compliance with this standard the following measures have been taken: 1. Resident #08 was assessed by the registered nurse and med review completed by 4/28/26. After review of resident's drug regime's, it was discovered that resident #8 had 2 separate medication recommendations on the same form, to be reviewed by two separate practitioners, pharmacy has been instructed and agreed to separate meds on individual forms. 2. Licensed nurses re-educated to facility policy "Drug Regimen Review" by Director of nursing/designee in April 2026 and no later than 5/8/26. Licensed nurses are responsible for ensuring the reviews and recommendations are given to the physician for timely review. 3. Review of all other current residents Drug Regimen orders completed by Director of nursing/designee on 4/16/26 to ensure recommendations were followed up on/reviewed by the physician and address concerns if needed. 4. Audit of drug regime recommendations, pharmacy recommendations, and physician follow up to be completed weekly for four weeks by the Director of nursing/designee. Administrator will present results of these audits to the QAPI committee for ongoing monitoring and further direction.
Failure to Use Required Gait Belt During Ambulation Resulting in Resident Fall
Penalty
Summary
The deficiency involves the facility’s failure to ensure that a required gait belt was used while assisting a high fall‑risk resident with ambulation, resulting in a fall with head injury. The resident had multiple diagnoses including metabolic encephalopathy, hypertension, osteoarthritis, muscle weakness, gait and mobility abnormalities, major depressive disorder, anxiety, and visual hallucinations. Admission and subsequent MDS and fall risk assessments documented that the resident was severely cognitively impaired, required moderate to maximal assistance with transfers and ambulation, could not independently come to a standing position, exhibited loss of balance while standing, used an assistive device, and had decreased muscle coordination. The resident had a history of falls prior to admission and was assessed as being at high, later moderate, risk for falls. The resident’s fall care plan identified her as at risk for falls and included interventions such as providing maximum to moderate assistance with transfers and walking short distances, use of a walker and wheelchair, and following the facility’s fall protocol. Therapy notes and care conference documentation indicated that the resident leaned backwards when standing, required contact guard to minimal assistance for bed mobility and transfers, and needed constant verbal cueing for safe sequencing during toilet transfers. The physical therapist confirmed that the resident was to use a gait belt with staff when ambulating, and the DON verified that therapy had assessed the resident as requiring contact guard assistance and a gait belt for ambulation and transfers. On the day of the incident, a CNA was assisting the resident from her recliner to the bathroom using a walker. The CNA walked beside the resident, providing guidance and support, and reported having a hand on the resident while assisting her. As they approached the bathroom door, the CNA reached for the doorknob to open it, and at that moment the resident began to lose her balance and fell backwards to the floor, striking the back of her head. The nurse who responded found the resident on her back at the foot of the bed with her feet near the bathroom, noted a red raised area on the back of the head, and documented that the resident was not wearing a gait belt and that the gait belt was on the dresser. In the facility’s investigative summary and in interviews, the CNA acknowledged that she did not have a gait belt on the resident while ambulating her, despite the resident’s assessed need for hands‑on assistance and gait belt use per facility policy and the resident’s care and therapy plans.
Failure to Implement PD Orders and Monitor Resident Receiving Peritoneal Dialysis
Penalty
Summary
The deficiency involves the facility’s failure to implement pre-admission physician orders for peritoneal dialysis (PD) and to provide ongoing monitoring for a resident with chronic kidney disease (CKD) stage five who required PD. Pre-admission orders dated 11/14/25 specified three daily PD exchanges at 6:00 A.M., 2:00 P.M., and 10:00 P.M., and directed staff to monitor for signs and symptoms of peritonitis, including fever, abdominal pain, and cloudy effluent. These monitoring orders were not entered into the facility’s physician orders. The resident’s care plan noted the need for PD and included general monitoring interventions (labs, signs of bleeding, bacteremia, septic shock, and significant vital sign changes), but did not specifically address the ordered monitoring for peritonitis. Review of PD documentation showed incomplete and inconsistent charting of treatments and resident condition. The paper peritoneal flowsheet had columns for time of PD and condition/comments, including instructions to call the nurse immediately for cloudy fluid, abdominal pain, or fever. However, the first entry on 11/15/26 at 2:00 P.M. only noted that the PD nurse completed the exchange, and the 10:00 P.M. entry that day had no condition/comment documentation. Subsequent days (11/16/25, 11/17/25, and 11/18/25) contained only one condition/comment entry per day rather than for each exchange, and there was no documentation that the 6:00 A.M. PD on 11/18/25 was completed. The PD cycler flowsheet starting 11/19/25 lacked any description of the effluent on multiple days. The PD nurse from the dialysis company stated facility staff were expected to monitor effluent for cloudiness and assess for abdominal pain and fever, and the DON confirmed there was no electronic physician order for peritonitis monitoring or for use of the PD cycler, that the paper charting did not allow for effluent description or symptom documentation for each treatment, and that PD was not documented at one ordered time. The facility’s dialysis policy required ongoing assessment and monitoring for complications before, during, and after treatments, which was not reflected in the documentation for this resident.
Improper Infection Control During Medication Administration
Penalty
Summary
Surveyors identified a deficiency in infection prevention and control related to medication administration for Resident #29. The resident was admitted on 02/28/14 with diagnoses including depression, traumatic brain injury, and anxiety, and had impaired cognition per a quarterly MDS assessment. During an observation on 03/25/26 at 6:58 A.M., RN #281 prepared the resident’s medications by removing an Amoxicillin-Pot Clavulanate tablet from the medication card and pushing it directly into her ungloved hand, then using her fingers to place the pill into a medication cup. The same process was observed for multiple other medications, including Escitalopram Oxalate, Furosemide, Sennosides, Lyrica, and Vitamin D, each being pushed from the card into the RN’s ungloved hand and then transferred by her fingers into the medication cup before administration to Resident #29. In a subsequent interview at 7:27 A.M. the same day, RN #281 confirmed she had placed each medication into her ungloved hands prior to administration and acknowledged that the proper procedure was to push the pills directly from the card into the medication cup. Review of the facility’s “Medication Administration – General guidelines” policy, revised 10/08/25, stated that medications are to be administered in accordance with good nursing principles and practices. This practice failure was cited as a deficiency under Complaint Number 2681777.
Improper Use of Wheelchair as a Physical Restraint
Penalty
Summary
Surveyors identified a deficiency related to the facility’s failure to ensure a resident was free from physical restraints. Resident #7, admitted with diagnoses including Alzheimer’s disease, diabetes mellitus, and anxiety disorder, was documented on a recent MDS as rarely understood and dependent for ADLs except eating. The resident ambulated independently on the unit without an assistive device and had documented verbal and other behaviors occurring one to three days during the look-back period. The care plan noted the resident had potential to be physically aggressive, chase staff, throw objects, and be combative with care, with interventions such as offering choices, administering medications as ordered, and intervening early when agitation occurred. During an observation and interview, Resident #7 was found sitting in a chair with the right arm of the chair positioned against the nursing station and a wheelchair placed directly in front of him. The left arm of the wheelchair was also against the nursing station, and both wheelchair wheels were locked, creating a barrier that appeared to restrain the resident, who was sleeping with his knees touching the locked wheelchair. An LPN confirmed both wheelchair wheels were locked and that the wheelchair should not have been placed in front of the resident. A CNA reported she had placed the wheelchair there in preparation to get the resident up for lunch, was unable to transfer him, and left the wheelchair in that position, acknowledging it was wrong to keep it there. The facility’s physical restraint policy stated that physical restraints are not used except when alternatives are not appropriate or effective for treating a medical symptom and defined physical restraints as any device attached or adjacent to the body that the individual cannot easily remove and that restricts freedom of movement or access to the body.
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