Altercare Of Navarre Ctr For Rehab & Nrsg Care
Inspection history, citations, penalties and survey trends for this long-term care facility in Navarre, Ohio.
- Location
- 517 Park Street Nw, Navarre, Ohio 44662
- CMS Provider Number
- 365482
- Inspections on file
- 31
- Latest survey
- July 15, 2025
- Citations (last 12 mo.)
- 1
Citation history
Health deficiencies cited at Altercare Of Navarre Ctr For Rehab & Nrsg Care during CMS and state inspections, most recent first.
A facility failed to notify a resident's responsible party about new medical orders and changes in the resident's condition. The resident, with severe cognitive impairment, was not reported to have tested positive for Covid, nor was the responsible party informed of a new antibiotic prescription for a UTI. Additionally, incorrect medication orders were entered for the resident, which were intended for another resident, and this error was only discovered after the resident fell. The responsible party was not notified of these new orders.
A resident with severe cognitive impairment received incorrect medications due to a transcription error, where medications intended for another resident were entered into their medical record. The error was discovered after the resident experienced a fall, leading to a review of their medications.
The facility failed to provide ordered wound care for three residents, leading to deficiencies in treatment. A resident had a wound vac set incorrectly, while another did not receive documented wound care. A third resident lacked timely wound assessments. Staff interviews revealed that an agency nurse responsible for wound care was not completing tasks, and floor nurses were inadequately managing wound care.
A resident with a history of osteomyelitis, diabetes, and partial foot amputation had a stage three pressure ulcer on the left heel. Despite physician orders for specific wound care, the facility failed to assess and document the wound properly. Interviews revealed that the wound nurse was not completing care, and floor nurses were not consistently performing wound care. Observations confirmed the resident's wound care was not completed as ordered.
The facility failed to serve proper portion sizes to residents on a carbohydrate controlled diet, affecting six residents. Observations showed that all residents received the same portion sizes, contrary to the dietary requirements. The Certified Dietary Manager confirmed the incorrect servings and noted the lack of appropriate measuring utensils.
A facility failed to monitor a resident's oxygen saturations as per physician orders. The resident, with chronic respiratory and heart conditions, had an order for continuous oxygen at two liters per minute via nasal cannula, with instructions to record oxygen saturation every shift. However, only one oxygen saturation level was recorded over an 11-day period. A nurse confirmed the lack of records and noted that the monitoring requirement was not activated in the electronic medical record.
Two residents in the facility were inaccurately assessed for pressure ulcer stages, leading to deficiencies in care. A resident with Parkinson's and Alzheimer's was misclassified with a stage three ulcer, which was actually a stage two, as confirmed by staff. Another resident with paraplegia and heart failure had a similar misclassification. These errors were confirmed by the nursing staff, indicating a failure in providing appropriate pressure ulcer care.
A facility failed to discard a resident's expired Lantus insulin, which was found during a medication cart observation. The resident, with major depressive disorder and type two diabetes, had a physician's order for daily insulin administration. The ADON confirmed the insulin was expired and should have been discarded after 28 days at room temperature.
A facility failed to maintain infection control procedures during a resident's wound care. An LPN used scissors placed on a contaminated bin without proper disinfection, breaching infection control protocols. The resident had pressure ulcers on both heels, and the facility's policy emphasized prevention and treatment of such injuries.
The facility failed to prevent the misappropriation of resident medication, affecting three residents. During audits, it was discovered that Oxycodone was missing for three residents, and the facility could not account for the medications or the pharmacy narcotic sheets. Investigations were inconclusive, and no potential wrongdoer was identified. The facility's failure to follow its policy on narcotic management and the presence of missing log pages contributed to the inability to account for the medications.
Failure to Notify Responsible Party of Resident's Condition and Medication Changes
Penalty
Summary
The facility failed to notify the responsible party of Resident #8 about new medical orders and changes in the resident's condition. Resident #8, who was admitted with multiple diagnoses including Alzheimer's disease and severe cognitive impairment, was placed in isolation for Covid precautions on 12/02/24. However, there was no documentation that the resident's representative was informed of the positive Covid test on 11/28/24. Additionally, on 12/14/24, Resident #8 was prescribed an oral antibiotic for a urinary tract infection, but again, there was no record of notification to the responsible party. Further issues arose on 01/04/25 when new medication orders were mistakenly entered for Resident #8, which were intended for another resident. This error was discovered after Resident #8 experienced a fall on 01/07/25, prompting a review of the medications by a nurse practitioner. The Regional Nurse Consultant confirmed that the responsible party was not informed of these new orders. This deficiency was investigated under Master Complaint Number OH00161501.
Medication Error Due to Incorrect Transcription
Penalty
Summary
The facility failed to prevent a significant medication error involving a resident who was admitted with multiple diagnoses, including Alzheimer's disease and severe cognitive impairment. The error occurred when new medication orders intended for another resident were mistakenly entered into the medical record of the affected resident. As a result, the resident received incorrect medications, including amlodipine, atorvastatin, and azathioprine, over a period of four days before the error was discovered. The error was identified after the resident experienced a fall, prompting a review of their medications by a nurse practitioner. It was confirmed that the medications administered were not intended for the resident in question but were meant for another resident. The facility's Medication Error Policy and Procedure acknowledges the potential for human and system errors in medication administration, emphasizing the importance of ensuring medications are administered correctly to prevent harm.
Deficient Wound Care Practices in Facility
Penalty
Summary
The facility failed to ensure that wound care was completed as ordered for three residents, leading to deficiencies in their treatment. Resident #51, who was admitted with a non-healing wound and osteomyelitis, had a wound vac set at 135 mmHg instead of the ordered 125 mmHg. Interviews with staff revealed that an agency nurse responsible for wound care had not been completing the care for several weeks, and floor nurses were not consistently performing the required wound care. Resident #43, admitted with necrotizing fasciitis and other conditions, did not receive wound care as ordered. The treatment administration records indicated that wound care was documented as completed when it was not. Observations confirmed that the dressing on the resident's foot was not changed as required, and interviews with staff highlighted that the agency nurse was pulled to other duties, leaving floor nurses to manage wound care inadequately. Resident #77, with multiple wounds and a history of hospitalizations, did not have timely wound assessments from 12/02/24 to 12/18/24. The facility lacked evidence of wound assessments, including sizing and staging, during this period. Interviews confirmed that wound care was not completed as ordered, and the facility's policy to promote wound healing was not followed. These deficiencies were investigated under a specific complaint number, indicating non-compliance with care standards.
Failure to Provide Ordered Wound Care for Resident
Penalty
Summary
The facility failed to ensure proper wound care for a resident with a pressure ulcer, as ordered by the physician. The resident, who had a history of acute osteomyelitis, diabetes, and a partial traumatic amputation, was admitted with a stage three pressure ulcer on the left heel. Despite having specific physician orders for wound care, there was no evidence that the facility assessed the resident's pressure ulcer from early December to mid-December. The resident was discharged to the hospital and returned to the facility, but the wound care orders were not consistently followed, as confirmed by interviews with nursing staff. The facility's policy on pressure injuries emphasized the importance of identifying residents at risk, implementing preventive interventions, and providing care for existing pressure injuries. However, interviews with nursing staff revealed that the designated wound nurse had not been completing wound care, and floor nurses were not consistently performing the required wound care. Observations confirmed that the resident's wound care was not completed as ordered, and there were no wound assessments, including sizing and staging, documented for a significant period. This deficiency was investigated under a specific complaint number.
Improper Portion Sizes Served to Residents on Carbohydrate Controlled Diet
Penalty
Summary
The facility failed to ensure proper portion sizes of food were served to residents on a carbohydrate controlled (CCHO)/low concentrated sweet (LCS) diet. This deficiency affected six residents on the 200 hall who had trays served. The menu and spreadsheet for lunch indicated that the carbohydrate controlled diet required a #10 scoop (3/8 cup) of au gratin potatoes and a three-ounce serving of mixed vegetables, while the regular diet included a #8 scoop (1/2 cup) of au gratin potatoes and four ounces of mixed vegetables. Observations made on the tray line revealed that all residents, regardless of their diet, were served the same portion sizes using the same utensils. The Certified Dietary Manager (CDM) confirmed that residents on the carbohydrate controlled diets were served 1/2 cup of au gratin potatoes instead of the required 3/8 cup and four ounces of mixed vegetables instead of three ounces. The CDM also noted the absence of a three-ounce spoodle to measure the correct portion of mixed vegetables. This deficiency was investigated under Complaint Number OH00156489.
Failure to Monitor Resident's Oxygen Saturations
Penalty
Summary
The facility failed to monitor a resident's oxygen saturations in accordance with physician orders. This deficiency affected a resident with chronic respiratory failure, congestive heart failure, obstructive sleep apnea, and atherosclerotic heart disease. The physician had ordered continuous oxygen at two liters per minute via nasal cannula, with instructions to check placement and record oxygen saturation every shift. However, between August 15 and August 26, only one oxygen saturation level was recorded on August 23. Observations on August 28 showed the resident's oxygen saturation at 98% with oxygen at two liters per minute. During an interview, a registered nurse confirmed the absence of additional oxygen saturation records and noted that the monitoring requirement was not activated in the electronic medical record.
Inaccurate Staging of Pressure Ulcers in Residents
Penalty
Summary
The facility failed to accurately stage pressure ulcer wounds for two residents, leading to deficiencies in their care. Resident #47, who has diagnoses including Parkinson's disease and Alzheimer's, was identified as high risk for pressure ulcers. On 07/01/24, a wound nurse practitioner evaluated a new wound on Resident #47's sacrum, initially staging it as a stage three pressure ulcer. However, subsequent observations and interviews with LPN #375 revealed that the wound was shallow with only partial thickness skin loss, indicating it should have been staged as a stage two pressure ulcer. This misclassification was confirmed by the Director of Nursing and other staff. Similarly, Resident #39, with conditions such as paraplegia and heart failure, was also at high risk for pressure ulcers. A wound on her left ischium was initially staged as a stage three pressure ulcer on 04/08/24. Despite healing and reopening, the wound was inaccurately staged as a stage three ulcer when it should have been a stage two, as confirmed by Regional RN #500. These inaccuracies in staging pressure ulcers highlight the facility's failure to provide appropriate pressure ulcer care and prevent new ulcers from developing.
Expired Insulin Not Discarded
Penalty
Summary
The facility failed to ensure that a resident's expired Lantus long-acting insulin was discarded appropriately. This deficiency was identified during an observation of the medication cart, where it was found that the Lantus Kwikpen for a resident, who was admitted with major depressive disorder and type two diabetes, was expired. The resident had a physician's order for 56 units of Lantus insulin to be administered once daily between 7:00 A.M. and 11:00 A.M. The Assistant Director of Nursing confirmed that the insulin was expired and should have been discarded, as per the prescribing information, which states that the Lantus Kwikpen should be discarded after 28 days at room temperature when in use or opened.
Infection Control Breach During Wound Care
Penalty
Summary
The facility failed to maintain appropriate infection control procedures during the wound care of Resident #193, who was admitted with cellulitis of the right lower limb and pressure ulcers on both heels. The resident's medical records indicated orders for wound care, including the application of liquid skin prep/barrier film and dressings. During an observation, the LPN Wound Care Supervisor was seen placing scissors on a contaminated red isolation bin and using them without proper disinfection during the wound care process. This included cutting old dressings and kerlix for the resident's bilateral heel pressure ulcers. The LPN confirmed in an interview that the scissors were not appropriately cleansed before use, which is a breach of infection control protocols. The facility's policy on pressure injuries emphasized the importance of preventing and treating such injuries, but the observed actions did not align with these guidelines. The failure to properly disinfect the scissors before use in wound care represents a significant lapse in infection prevention and control practices.
Failure to Prevent Misappropriation of Resident Medication
Penalty
Summary
The facility failed to prevent the misappropriation of resident medication, affecting three residents. Resident #10 was admitted with diagnoses including status post triple aortic repair and acute respiratory failure. The resident had an order for Oxycodone 5 mg for pain management. During an audit, it was discovered that Resident #10's Oxycodone was missing from the medication cart, and the facility could not account for the medication or the pharmacy narcotic sheet. The investigation was inconclusive, and the facility could not determine if misappropriation occurred or identify a potential wrongdoer. Additionally, there were missing pages from the Control Sheet Record log, indicating a failure to follow the facility's policy on narcotic management. Resident #11, who had a diagnosis of secondary malignant neoplasm of the large intestine and rectum, also had an order for Oxycodone 5 mg. During a medication audit, it was found that the sheet for Resident #11's Oxycodone was missing. The facility could not determine when the medication was removed, who removed it, or how much was missing due to missing narcotic log sheets and inaccurate completion of the Control Sheet Records. The investigation was again inconclusive, and no potential wrongdoer was identified. Resident #12, admitted with a fracture of the second lumbar vertebra and chronic kidney disease, had an order for Oxycodone 5 mg. During an audit, it was discovered that two medication sheets for Resident #12's Oxycodone were missing. The facility was unable to provide evidence of when the medication was added or removed from the medication cart due to inaccurate narcotic count logs and missing pages. The investigation could not determine when the medication was removed, who removed it, or how much was missing. The facility's failure to follow its policy on narcotic management and the presence of missing log pages contributed to the inability to account for the medications.
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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