Altercare Of Wadsworth
Inspection history, citations, penalties and survey trends for this long-term care facility in Wadsworth, Ohio.
- Location
- 147 Garfield St, Wadsworth, Ohio 44281
- CMS Provider Number
- 365268
- Inspections on file
- 23
- Latest survey
- July 24, 2025
- Citations (last 12 mo.)
- 5
Citation history
Health deficiencies cited at Altercare Of Wadsworth during CMS and state inspections, most recent first.
The facility failed to date insulin pens after opening, affecting three residents with diabetes. During medication administration, an LPN and the DON confirmed that insulin pens for these residents were not dated, contrary to facility policy. The LPN was unsure of the insulin pens' effective duration post-opening.
The facility failed to maintain infection control during medication administration for two residents. An LPN allowed a pill to be ingested after it fell on a comforter, and another LPN mishandled a pill that fell on a cart and failed to disinfect a surface before placing a glucometer on it. Both actions were confirmed as inappropriate by the DON.
The facility failed to have the designated infection control preventionist participate in the QAPI committee and attend required meetings. Despite completing the infection preventionist training, the RN was not listed as a committee member and did not attend meetings from December 2023 through March 2024, as confirmed by interviews and sign-in sheets.
The facility failed to invite a resident's POA to all care plan meetings. The resident, who was severely cognitively impaired and dependent for activities of daily living, had a POA who expressed a preference to attend all care conferences. However, the POA was not invited to the quarterly care plan meetings on two occasions. The LSW confirmed that notifications were mailed out, but no follow-up calls were made, and the resident's name was missing from the invitation list for one of the meetings.
The facility failed to notify two residents and their responsible parties of changes in wound treatment and skin injury. One resident developed wounds due to improper use of incontinence brief tape, and the POA was not informed. Another resident and their responsible party were not notified of new physician orders for wound treatment.
The facility failed to ensure that a resident was ambulated per physician orders to maintain functional abilities. Despite a physician's order for a restorative ambulation program, the resident was not offered or assisted with ambulation on multiple dates. Interviews confirmed that staff were not following the prescribed program, and the resident expressed a desire to maintain his walking ability.
The facility failed to follow physician orders for a resident requiring Tubigrip and arm elevation, resulting in significant swelling. Additionally, improper fitting of incontinence briefs caused skin injuries, with staff failing to take preventive measures or provide proper education.
The facility failed to follow and implement orders for a resting hand splint for a resident who was severely cognitively impaired and dependent for activities of daily living. Observations and interviews revealed that the splint was not applied as ordered due to misunderstandings and forgetfulness. Further investigation showed that a new order for a different splint was not entered into the electronic medical system, resulting in the order not being implemented.
A resident with a neuromuscular dysfunction of the bladder and a suprapubic catheter had their urinary catheter bag repeatedly placed on the bed above the bladder, contrary to physician orders and facility policy. This improper positioning was confirmed by the resident, an LPN, and the DON, highlighting a failure in adhering to proper catheter care protocols.
The facility failed to provide enteral nutrition per the physician's order for a resident with multiple diagnoses, including dysphagia and hemiplegia. Observations revealed the resident's tube feeding was not running as prescribed, and the resident exhibited signs of dehydration. The LPN responsible for the resident confirmed the discrepancy upon reviewing the physician's orders.
The facility failed to monitor oxygen saturation levels for three residents receiving continuous and as-needed oxygen therapy. Despite orders to check oxygen saturation every shift, the required monitoring was not performed, as confirmed by the DON and other staff.
The facility failed to ensure proper monitoring and communication for a resident requiring dialysis services. Post-dialysis assessments were not conducted on multiple occasions, and there was no documentation received from the dialysis center for nearly a month. The Director of Nursing confirmed that the necessary assessments were not performed, leading to a deficiency in providing safe and appropriate dialysis care.
The facility failed to ensure a physician's order for an as-needed psychotropic medication had a time-frame for usage for a resident with multiple psychiatric diagnoses. The PRN order for Ativan 0.5 mg was issued without an end date, contrary to the facility's policy requiring a 14-day limit unless extended by the prescribing practitioner with documented rationale.
The facility failed to ensure accurate documentation in the medical records for two residents, leading to discrepancies in their treatment. One resident continued to receive a treatment that should have been discontinued, and another had duplicate treatment orders for the same pressure ulcer.
Failure to Date Insulin Pens After Opening
Penalty
Summary
The facility failed to ensure that insulin pens were properly dated and labeled after opening, affecting three residents who were observed during medication administration. Resident #9, who was admitted with a diagnosis of diabetes, had a physician's order for Glargine insulin to be administered twice daily. During an observation, it was noted that the insulin pen for this resident was not dated to indicate when it was opened. Interviews with the LPN and the Director of Nursing confirmed the absence of a date on the insulin pen, and the LPN admitted to being unsure of the duration for which insulin pens remain effective after opening. Similarly, Resident #16, also diagnosed with diabetes, had an order for Basaglar Kwikpen insulin to be administered once daily. The insulin pen for this resident was also found to be undated during the medication administration observation. The same issue was observed with Resident #40, who had an order for Fiasp insulin to be administered with meals. The facility's policy on medication storage, which requires medications to be stored following manufacturers' recommendations and to be dated upon opening, was not adhered to in these cases.
Infection Control Breaches During Medication Administration
Penalty
Summary
The facility failed to maintain proper infection control procedures during medication administration, affecting two residents. For Resident #49, the incident occurred when an LPN administered medications, including Gabapentin, Metoprolol Succinate ER, and Pantoprazole. During the process, one of the pills was dropped onto the resident's comforter. Instead of discarding the contaminated pill, the LPN instructed the resident to ingest it, which was confirmed as inappropriate by both the LPN and the Director of Nursing (DON). For Resident #46, the deficiency involved an LPN who mishandled medication by allowing a Lexapro pill to fall onto the medication cart. The LPN picked up the pill with bare hands and placed it back into the medicine cup, which was then given to the resident. Additionally, the LPN failed to use a barrier or disinfect the overbed tray before placing a glucometer on it. Both actions were confirmed as breaches of infection control protocols by the LPN and the DON.
Infection Control Preventionist Not Participating in QAPI Committee
Penalty
Summary
The facility failed to have the designated infection control preventionist participate in the Quality Assurance Performance Improvement (QAPI) committee and attend meetings as required. Registered Nurse (RN) #596, who completed the infection preventionist training course on 03/01/23, was not listed as a member of the QAPI committee. Additionally, RN #596 did not attend the QAPI monthly committee meetings held from December 2023 through March 2024, despite her claim of attending every meeting to present infection control information. This deficiency was confirmed through interviews and review of meeting sign-in sheets, which showed no evidence of her attendance.
Failure to Invite POA to Care Plan Meetings
Penalty
Summary
The facility failed to invite Resident #60's Power of Attorney (POA) to all care plan meetings. Resident #60, who was admitted with diagnoses including muscle weakness, lack of coordination, hemiplegia, and hemiparesis following a cerebral infarction, was severely cognitively impaired and dependent for activities of daily living. Despite this, the POA was only invited to two care plan meetings, as revealed during an interview on 04/23/24. The POA expressed a preference to attend all care conference meetings, but records showed that the POA was not present at the quarterly care plan meetings on 12/06/24 and 03/10/24. Licensed Social Worker (LSW) #557 confirmed that notifications for care plan meetings were mailed out at the beginning of the previous month, but no follow-up calls or further notifications were made. A review of the lists provided to the receptionist for mailing invitations revealed that Resident #60's name was missing from the list for December 2023 and was the last name on the list for March 2024. LSW #557 was unsure why Resident #60's name was omitted from the December list, confirming that the POA was not properly notified for the care plan meetings on 12/06/24 and 03/10/24.
Failure to Notify Residents and Responsible Parties of Wound Treatment Changes
Penalty
Summary
The facility failed to ensure that residents and/or their responsible parties were notified of changes in wound treatment and skin injury. This deficiency affected two residents. Resident #60, who was severely cognitively impaired and dependent for activities of daily living, developed wounds on the right upper and anterior thigh due to the tape from an incontinence brief being placed directly on the skin. Despite the presence of a Power of Attorney (POA) for Health Care, the POA was not notified of the wounds. The Assistant Director of Nursing (ADON)/Wound Care Nurse confirmed that the POA had not been informed due to time constraints. Similarly, Resident #26, who had diagnoses including Alzheimer's disease, chronic kidney disease, and diabetes mellitus, was not notified of new physician orders for wound treatment to the buttocks. The resident's responsible party was also not informed. The ADON verified that staff did not notify Resident #26 or the responsible party of the new treatment orders. The Director of Nursing confirmed that notifications should be made within the same shift. The facility's policy required immediate notification of the resident and their authorized representative when there was a new form of treatment.
Failure to Follow Physician's Orders for Restorative Ambulation Program
Penalty
Summary
The facility failed to ensure that Resident #65 was ambulated per physician orders to maintain functional abilities. Resident #65, who had diagnoses including Parkinsonism, muscle weakness, and age-related physical debility, was referred for a restorative ambulation program. The physician's order specified that staff were to assist the resident to ambulate up to 326 feet with his walker for 15 minutes a day, four to seven days a week as tolerated. However, documentation revealed that the resident was not offered or assisted with ambulation on multiple dates in April 2024, and was only assisted three days in one week and two days in another week during that month. Interviews with Resident #65 and the Assistant Director of Nursing (ADON) confirmed that the resident was not receiving the prescribed ambulation assistance. Resident #65 expressed a desire to maintain his walking ability, but stated that staff were not assisting him to ambulate with his walker since he stopped receiving skilled therapy services. The ADON verified that staff were not following the physician's order for the resident's restorative program on the specified dates. The facility's policy on Restorative Nursing Care, updated in April 2024, indicated that the restorative program should be provided to maintain residents' highest level of physical functioning, but this was not adhered to in the case of Resident #65.
Failure to Follow Physician Orders and Ensure Proper Incontinence Care
Penalty
Summary
The facility failed to follow physician orders for Resident #60, who had diagnoses including muscle weakness, hemiplegia, and hemiparesis following a cerebral infarction. The orders required the application of Tubigrip to the right upper extremity and elevation of the right arm. Observations on multiple occasions revealed that the resident's right arm was not elevated, and the Tubigrip was not applied, resulting in significant swelling of the right hand. Staff members, including the ADON/Wound Care Nurse, LPN, and STNAs, confirmed the lack of compliance with the physician's orders. The LPN mentioned that the resident did not like the Tubigrip, but upon asking, the resident agreed to have the arm elevated, indicating a lack of consistent care and communication among staff members. Additionally, the facility failed to ensure that Resident #60's incontinence briefs fit appropriately, leading to skin injuries. The resident, who was severely cognitively impaired and always incontinent of bowel and bladder, had wounds on the right thigh caused by the tape on the incontinence briefs being placed directly on the skin. Observations revealed multiple scarred areas and open wounds on the resident's thigh. The ADON/Wound Care Nurse confirmed that the injuries were due to the tape on the briefs and that no measures had been taken to prevent further injury. The DON confirmed that there had been no staff education on proper brief application and that the resident was wearing the wrong size brief according to the facility's sizing chart. The deficiencies highlight a lack of adherence to physician orders and inadequate staff training and communication, resulting in preventable injuries and discomfort for Resident #60. The facility's failure to follow care plans and physician orders, along with improper incontinence care, directly contributed to the resident's deteriorating condition and skin injuries.
Failure to Implement Resting Hand Splint Orders
Penalty
Summary
The facility failed to follow and implement orders for a resting hand splint for Resident #60, who was severely cognitively impaired and dependent for activities of daily living. The resident had a physician's order dated 05/23/23 for a resting hand splint to be applied to the right hand during hours of sleep for four to six hours every shift. However, observations on 04/23/24 and 04/24/24 revealed that the splint was not applied as ordered. Interviews with staff confirmed that the splint was not applied due to misunderstandings and forgetfulness. The Assistant Director of Nursing (ADON) and a State Tested Nursing Assistant (STNA) both confirmed the resident did not have the splint on during their respective observations and interviews. Further investigation revealed that the original order for the resting hand splint was discontinued on 04/10/24, and a new order was written for a different splint. This new order required the use of a right volar inflatable resting hand splint at night for up to six hours, with specific instructions for its application and monitoring. However, the new order was not entered into the electronic medical system by the nursing staff, resulting in the order not being implemented. The Director of Nursing (DON) and the Certified Occupational Therapy Assistant (COTA) confirmed that the new order was not followed due to the failure of the nursing staff to complete the necessary documentation and implementation steps.
Improper Positioning of Urinary Catheter Bag
Penalty
Summary
The facility failed to ensure that a resident's urinary catheter bag was consistently placed below the bladder, as required to prevent complications such as urinary tract infections. The resident, who had a neuromuscular dysfunction of the bladder and a suprapubic catheter, was observed on multiple occasions with the catheter drainage bag lying on the bed above the bladder. This was contrary to the physician's orders and the facility's policy, which specified that the drainage bag should be kept below the bladder and off the floor. Interviews with the resident, an LPN, and the Director of Nursing confirmed that the drainage bag was not positioned correctly and acknowledged the potential for urine to back up into the bladder, increasing the risk of infection. The resident, who had a Foley catheter for several years and a newly created suprapubic catheter, reported that the drainage bag had always been positioned on the bed since the suprapubic catheter was placed. The LPN and the Director of Nursing both verified that the drainage bag should be hanging below the bladder to prevent complications. The facility's undated catheter care policy also supported this requirement. Despite these guidelines, the resident's catheter bag was repeatedly found in an incorrect position, indicating a failure in adhering to proper catheter care protocols.
Failure to Provide Enteral Nutrition Per Physician's Order
Penalty
Summary
The facility failed to provide enteral nutrition per the physician's order for Resident #60. Resident #60, who was admitted with diagnoses including esophagitis, gastroparesis, dysphagia, and hemiplegia following a cerebral infarction, was dependent on tube feeding for nutrition and hydration. The care plan indicated that Resident #60 was to receive enteral feeding formula Peptamen 1.5 at 65 milliliters per hour from 6:00 A.M. to 12:00 A.M., with a six-hour break from 12:00 A.M. to 6:00 A.M. However, observations on 04/25/24 at 7:30 A.M. and 9:11 A.M. revealed that the tube feeding was not running, and the resident's lips and mouth had a thick, dry, pasty film. LPN #515, who was responsible for Resident #60, initially stated that the tube feeding was only to run from 12:00 A.M. to 6:00 A.M., but upon reviewing the physician's orders, confirmed the correct schedule was from 6:00 A.M. to 12:00 A.M. The facility's undated policy on Enteral Nutrition stated that adequate nutrition support through enteral feeding would be provided to residents unable to consume adequate nutritional intake by mouth, and that enteral feeding orders would be written to ensure consistent volume infusion. The failure to adhere to the physician's order for Resident #60's enteral feeding schedule resulted in the resident not receiving the prescribed nutrition and hydration, as evidenced by the observations and interviews conducted during the survey.
Failure to Monitor Oxygen Saturation Levels
Penalty
Summary
The facility failed to monitor oxygen saturation levels for residents receiving continuous and as-needed oxygen therapy. This deficiency affected three residents. Resident #60 had an order for oxygen at two liters per nasal cannula as needed to keep SP02 greater than 92 percent, but only two oxygen saturation levels were assessed in April 2024. The Director of Nursing (DON) confirmed that oxygen saturation levels should be assessed every shift for residents with such orders. An observation revealed Resident #60's SPO2 level was 90 percent on room air, indicating inadequate monitoring. The Certified Nurse Practitioner (CNP) also confirmed that saturation levels should be checked every shift for residents with as-needed oxygen orders. Resident #31 had an order for continuous oxygen at two to four liters per nasal cannula, with instructions to check placement and record oxygen saturation every shift. However, the last documented oxygen saturation was on 04/05/24, and the Treatment Administration Record (TAR) did not include a record of oxygen saturation every shift. Interviews with the DON and a Licensed Practical Nurse (LPN) confirmed that the required monitoring was not being done. Similarly, Resident #26 had an order for oxygen one to four liters nasal cannula as needed if pulse oximeter was below 92 percent or shortness of breath, but no pulse oximeter readings were documented since 04/03/24. The DON verified that oxygen saturation should be assessed every shift for residents with such orders, but this was not being done for Resident #26.
Failure to Monitor and Communicate Dialysis Care
Penalty
Summary
The facility failed to ensure proper monitoring and communication for a resident requiring dialysis services. The resident, diagnosed with end-stage renal disease, had physician orders for dialysis on specific days. However, the medical record review revealed that post-dialysis assessments were not conducted on multiple occasions, and there was no documentation received from the dialysis center for nearly a month. Interviews with the dialysis nurse and the Director of Nursing confirmed that the facility did not consistently send or require communication from the dialysis center, and the necessary post-dialysis assessments were not performed as per the facility's policy. The Director of Nursing verified that the nursing staff were supposed to perform comprehensive assessments, including mental status, vital signs, skin assessment, dialysis access site assessment, lung sounds, edema, pain presence, and any new orders from the dialysis center. Despite this requirement, the assessments were not completed on several specified dates, and no documentation was received from the dialysis center until the day of the survey. This lack of monitoring and communication led to a deficiency in providing safe and appropriate dialysis care for the resident.
Failure to Ensure Time-Frame for PRN Psychotropic Medication
Penalty
Summary
The facility failed to ensure the physician's order for an as-needed psychotropic medication had a time-frame for usage for Resident #13. Resident #13, who was admitted with diagnoses including schizoaffective disorder, dementia with anxiety, major depressive disorder, and psychotic disorder with delusions, had a new order for Ativan 0.5 mg as needed (PRN) with no stop date. This order was identified during a review of the physician's orders for April 2024, which showed that the PRN Ativan was ordered on 03/04/24 without an end date. Interviews with the Registered Nurse (RN) and the Director of Nursing (DON) confirmed that the PRN order for Ativan did not have an end date. The RN stated that she had never administered the PRN dose of Ativan for Resident #13. The DON verified the absence of an end date and mentioned that the physician had discontinued the order on 04/24/24. The facility's Behavior Management Policy indicated that PRN orders for psychotropic medications should be limited to 14 days unless extended by the prescribing practitioner with documented rationale, which was not followed in this case.
Inaccurate Medical Record Documentation
Penalty
Summary
The facility failed to ensure accurate documentation in the medical records for two residents, leading to discrepancies in their treatment. For Resident #26, the medical record showed an order for Medihoney treatment to the left buttock, which was supposed to be discontinued one week after an assessment on 12/14/23. However, the treatment continued until 01/16/24 without any documentation explaining why. Additionally, there were no nursing assessments or progress notes from 03/21/24 to 04/22/24 to justify a new order for Medihoney treatment dated 03/23/24. Interviews with the Assistant Director of Nursing (ADON) and a Registered Nurse (RN) confirmed the discrepancies and lack of documentation in the resident's medical record, including a stage two pressure ulcer identified on 04/19/24 that was not documented in the medical record due to time constraints by the ADON. For Resident #40, the medical record revealed orders for treatments to both the left buttock and sacrum. However, an observation on 04/23/24 showed only one pressure ulcer on the sacrum, and no ulcer on the left buttock. An interview with an RN revealed that the left buttock ulcer had been renamed as a sacrum ulcer, but the treatment order for the left buttock was not discontinued. This resulted in two different orders for the same area, and staff were marking both treatments as completed. The RN confirmed that the medical record was not accurate due to the oversight in discontinuing the left buttock order.
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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