Amberwood Manor
Inspection history, citations, penalties and survey trends for this long-term care facility in New Philadelphia, Ohio.
- Location
- 245 South Broadway, New Philadelphia, Ohio 44663
- CMS Provider Number
- 366253
- Inspections on file
- 23
- Latest survey
- January 23, 2025
- Citations (last 12 mo.)
- 0
Citation history
Health deficiencies cited at Amberwood Manor during CMS and state inspections, most recent first.
The facility failed to maintain a comfortable and clean environment for residents on the South unit, affecting 22 residents. Outdated and malfunctioning P-TAC units led to cold room temperatures, with space heaters used as a temporary solution. Additionally, dirty floors and bathtubs were observed, with the Housekeeping Supervisor citing a lack of staff as the reason for unclean conditions. Dust accumulation and debris in heating units were also reported, contributing to unsanitary conditions.
A facility failed to obtain proper witness signatures for handling a resident's funds, affecting a resident with Alzheimer's and vascular dementia. The resident's family was unaware of the facility-managed funds account, and the authorization form lacked the resident's signature, instead having an infinity sign and two witness signatures. The facility was chosen as the representative payee by the Social Security Administration, but failed to inform the resident's responsible party, as statements were sent to the facility's address.
Two residents in an LTC facility did not receive medications as ordered, leading to deficiencies in care. One resident with diabetes did not receive prescribed insulin on two occasions due to unjustified nursing judgment, despite high blood glucose levels. Another resident did not receive evening medications because they were asleep, and the nurse did not attempt to administer them again. Both incidents were confirmed by facility staff.
A resident with a stage 4 pressure ulcer did not receive a weekly wound assessment as required by the facility's care plan. Despite being in and out of the hospital, there was no documentation of the resident refusing the assessment or any attempts to conduct it later. Interviews revealed the resident was particular about care timing, and the LPN did not document the refusal or attempt a later assessment.
Two residents experienced falls due to inadequate interventions and supervision. One resident, with Alzheimer's and moderate cognitive impairment, fell multiple times due to a non-functioning motion sensor and lack of a toileting program. Another resident, with traumatic brain injury and vascular dementia, fell when their locked wheelchair tipped forward. The facility failed to ensure proper safety measures and documentation.
A resident with multiple health conditions, including congestive heart failure and chronic kidney disease, was not provided with adequate fluids to meet her daily requirements. Observations revealed the absence of water in her room, and staff interviews confirmed delays in water delivery. The resident's fluid intake was significantly below her needs, and her lab results indicated potential dehydration.
The facility failed to address pharmacy recommendations for two residents, leading to unclarified medication orders and unaddressed irregularities. A resident had pain management orders that were not clarified, and another had antianxiety medications without specified parameters. The facility's policy requires physician response to pharmacy recommendations, which was not ensured in these cases.
A facility failed to limit the use of as-needed psychotropic medication to 14 days for a resident with multiple diagnoses, including anxiety and depression. The resident was prescribed Ativan without a documented rationale for extending the order beyond 14 days, as required by pharmacy recommendations. The physician did not sign or provide a rationale for the extended use, and the Director of Clinical Services confirmed the oversight.
A resident with multiple health conditions was found with a bottle of fluticasone propionate nasal spray on their over-the-bed table, despite not having an order to self-administer or keep medications at the bedside. A nurse confirmed that the resident should not have had any medication at the bedside.
A registered nurse failed to perform hand hygiene before administering medications to a resident with multiple health conditions, including traumatic brain injury and hypertension. The nurse touched various surfaces without cleaning her hands, contrary to the facility's infection control policy, which emphasizes hand hygiene as crucial for preventing infection spread.
An LTC facility failed to protect residents from the misappropriation of controlled medications by an agency RN. The issue was discovered when an LPN noticed discrepancies in narcotic records, revealing unrecognized signatures and missing documentation for medications like Oxycodone and Clonazepam. The affected residents had various medical conditions requiring pain management. The facility's policies on controlled substances and staff vetting were not adequately followed, leading to the misappropriation.
Facility Fails to Maintain Comfortable and Clean Environment
Penalty
Summary
The facility failed to maintain a safe, clean, and comfortable environment for residents on the South unit, affecting all 22 residents residing there. The primary issue was the failure to maintain air temperatures at a comfortable level due to outdated and malfunctioning packaged terminal air conditioner (P-TAC) units. Despite being informed by the Heating and Cooling company that the units needed replacement, the facility delayed action due to financial constraints and logistical challenges. As a result, residents were subjected to cold room temperatures, with some rooms as low as 62 degrees Fahrenheit, and space heaters were used as a temporary solution. Additionally, the facility failed to ensure cleanliness in the South unit, as observed in the dirty floors and bathtubs. The October 2024 Resident Council Minutes revealed complaints about housekeeping and dirty rooms. Observations confirmed the presence of dirt and ice melt salt buildup in hallways, dining rooms, and resident rooms. The Housekeeping and Laundry Supervisor acknowledged the issue, citing a lack of staff as the reason for the unclean conditions. Despite hiring new housekeepers, the floors in several rooms remained dirty. Further deficiencies were noted in the maintenance of resident rooms, with reports of dust accumulation and debris in heating units. Resident #9, who was allergic to dust, reported a thick layer of dust on her fan and debris in the heater unit. The bathtub in her room also had a brown, rusty appearance, with water backing up in the drain area. Housekeeper #372 confirmed the presence of standing water and discoloration in the tub, stating that attempts to clean it were unsuccessful. These issues were not addressed promptly, contributing to the overall unsanitary conditions in the facility.
Failure to Obtain Proper Authorization for Resident's Funds
Penalty
Summary
The facility failed to obtain appropriate witness signatures on the authorization for handling a resident's funds, affecting a resident who was a Medicaid recipient. The resident's granddaughter stated that the family had not been asked to sign any authorization for the facility to manage the resident's funds, and to their knowledge, the resident did not have a personal funds account with the facility. However, a review of the facility's records showed that the resident did have a personal funds account, with social security benefits being directly deposited and care costs automatically transferred to the facility. The authorization form had an infinity sign in place of the resident's signature, with two witness signatures, one of which was a Registered Nurse, and the Administrator signed as a representative payee. The resident's medical record indicated diagnoses of Alzheimer's disease and vascular dementia, with an assessment showing the resident was rarely or never able to understand others or make herself understood. The Administrator and a revenue cycle field specialist confirmed that the facility applied to be the resident's representative payee, and the Social Security Administration had chosen the facility for this role. However, the facility failed to ensure that the resident's responsible party was informed about the personal funds account, as quarterly statements were sent to the facility's address rather than to the responsible party.
Failure to Administer Medications as Ordered
Penalty
Summary
The facility failed to administer medications as ordered for two residents, leading to deficiencies in care. Resident #238, who has diagnoses including type 2 diabetes and major depressive disorder, did not receive their prescribed Lantus insulin on two occasions. Despite having high blood glucose levels, the insulin was withheld by an agency nurse due to the concurrent administration of metformin, which was not justified by the resident's medical condition or orders. The resident, who was cognitively intact, expressed distress and reported the issue, which was confirmed by the Director of Nursing. Resident #5, with a complex medical history including chronic kidney disease and diabetes, did not receive their evening medications as per their preference due to being asleep. The medications included critical drugs such as Buspar, Colace, and Eliquis. The resident reported that the nurse did not attempt to administer the medications again, contrary to expectations. This was corroborated by the Director of Clinical Services, who confirmed that the agency nurse did not make a second attempt to administer the medications.
Failure to Conduct Weekly Wound Assessments
Penalty
Summary
The facility failed to ensure weekly wound assessments were completed for a resident with a stage 4 pressure ulcer. The resident, who had multiple diagnoses including chronic kidney disease, diabetes, and a stage 4 pressure ulcer, was admitted to the facility with a care plan that required weekly assessments by the in-house skin/wound team. Despite this, there was no documented skin measurement or wound assessment for the week of December 10, 2024. The resident had been in and out of the hospital during this period, and the Director of Clinical Services suggested this was the reason for the missed assessment. However, there was no documentation of the resident refusing the assessment or any attempts to conduct it later. Interviews with facility staff revealed that the resident was particular about the timing of his care and had refused to see the wound nurse if she was not present at the expected time. The Licensed Practical Nurse confirmed that she did not document the resident's refusal or attempt to assess the wound on a later date. The facility's policy on skin and wound care emphasized evidence-based preventative care, yet the lack of documentation and follow-up on the resident's wound assessment indicated a failure to adhere to this policy.
Inadequate Fall Interventions and Supervision
Penalty
Summary
The facility failed to ensure appropriate fall interventions for Resident #14, who had multiple diagnoses including Alzheimer's disease and moderate cognitive impairment. Despite a care plan intervention to place a motion sensor in the bathroom, there was no evidence of the sensor being in place or functioning when Resident #14 fell on 11/29/24. Additionally, the resident was frequently incontinent of urine, but a toileting program was not implemented, and the restorative nursing services for transfers and toileting hygiene were not properly documented or executed. This lack of appropriate interventions and documentation led to multiple falls for Resident #14. Resident #26, who had moderately impaired cognition and multiple diagnoses including traumatic brain injury and vascular dementia, experienced an unwitnessed fall in the dining room. The resident was found on the floor next to a locked wheelchair, which they could not lock themselves. The post-fall huddle revealed that the resident attempted to turn the wheelchair, which was locked, causing them to tip forward and fall. The Director of Clinical Services confirmed that the wheelchair should not have been locked, indicating a failure in providing adequate supervision and ensuring the resident's safety.
Failure to Provide Adequate Hydration
Penalty
Summary
The facility failed to ensure adequate hydration for Resident #137, who was readmitted with multiple diagnoses including congestive heart failure, chronic kidney disease, and protein-calorie malnutrition. The resident's nutritional assessment indicated a daily fluid requirement of 1900 ml to 2100 ml, but documentation showed that her daily intake ranged from 480 ml to 960 ml, significantly below her needs. Laboratory results revealed elevated potassium and blood urea nitrogen levels, indicating potential dehydration. Observations and interviews on January 22 revealed that Resident #137 did not have a cup of water in her room, and she complained of a dry cough and a very dry tongue. A Certified Nursing Assistant (CNA) admitted that water delivery was delayed due to staffing issues, and the resident confirmed that she had not received sufficient water throughout the day. The Registered Dietitian (RD) confirmed that the resident's fluid intake was inadequate and that her lab results had worsened. The facility's Resident Hydration Policy requires that residents be offered sufficient fluids to maintain hydration, with nursing staff primarily responsible for fluid intake monitoring. However, the policy was not followed, as evidenced by the lack of water at the resident's bedside and the failure to meet her fluid requirements. The interdisciplinary team did not adequately address the resident's hydration needs, leading to the deficiency.
Failure to Address Pharmacy Recommendations in Medication Regimen Reviews
Penalty
Summary
The facility failed to ensure that monthly drug regimen reviews identified irregularities in the medication regimens of two residents and did not respond to pharmacy recommendations in a timely manner. For Resident #17, the pharmacy requested clarification on the use of acetaminophen and hydrocodone/acetaminophen for pain management, suggesting that hydrocodone/acetaminophen be reserved for more severe pain. However, there was no evidence that the physician responded to this recommendation, and the orders were not clarified until they were discontinued months later. Additionally, an order for Ativan was written without a time limit, and the pharmacy did not address this issue as per their recommendations. For Resident #26, the pharmacy recommended adding acetaminophen for mild pain and clarifying the use of Oxycodone for severe pain, but these recommendations were not signed or acted upon by the physician. Furthermore, the pharmacy suggested discontinuing one of the two antianxiety medications or specifying parameters for their use, but the facility physician declined this recommendation without addressing the psychiatric doctor's involvement. Another recommendation to adjust antidepressant and antianxiety medications was declined by the physician without providing a rationale. The facility's Medication Regimen Review policy requires that physicians either accept and act upon pharmacy recommendations or provide an explanation for rejecting them. However, in these cases, the facility did not ensure that the physicians responded appropriately to the pharmacy's recommendations, leading to a failure in addressing potential medication irregularities for the residents involved.
Failure to Limit As-Needed Psychotropic Medication to 14 Days
Penalty
Summary
The facility failed to ensure that as-needed psychotropic medications were limited to 14 days without a documented rationale for extending the order. This deficiency affected one resident who was prescribed Ativan, an antianxiety medication, on an as-needed basis. The resident, who had a history of hepatic encephalopathy, traumatic brain injury, major depressive disorder, anxiety disorder, vascular dementia, visual hallucinations, and violent behavior, was admitted and readmitted with these diagnoses. The quarterly Minimum Data Set indicated that the resident had moderately impaired cognition and was receiving antianxiety and antidepressant medications. The pharmacy recommendation dated September 6, 2024, specified that as-needed psychotropic medications should be limited to 14 days unless the prescriber documented the specific condition being treated, the rationale for the extended period, and the duration for the as-needed order. However, the physician did not sign the pharmacy recommendation, accept or decline it, or provide a rationale for extending the Ativan order beyond 14 days. The resident continued to receive Ativan from September 6, 2024, until October 2, 2024, without the necessary documentation. The Director of Clinical Services confirmed that the pharmacy recommendation was not signed and no rationale was provided for the extended use of Ativan.
Medication Mismanagement at Bedside
Penalty
Summary
The facility failed to ensure that medications were not left at the bedside for a resident. Resident #15, who was admitted with multiple diagnoses including diabetes, hypertension, and dementia, was observed with a bottle of fluticasone propionate nasal spray on his over-the-bed table. The resident did not have an order to self-administer medications or to have them at the bedside. An interview with a registered nurse confirmed that the resident should not have had any medication at the bedside.
Failure in Hand Hygiene During Medication Administration
Penalty
Summary
The facility failed to ensure proper hand hygiene was performed by a registered nurse during the medication administration process for Resident #7. The resident, who was admitted with multiple diagnoses including traumatic brain injury, hypertension, and dysphagia, was observed receiving medications without the nurse performing hand hygiene. The nurse, identified as RN #364, did not clean her hands before obtaining and dispensing medications into a medication cup, which she handled by placing her finger inside. Furthermore, the nurse touched various surfaces, including the nurses' station and kitchen door handle, before administering the medications. The facility's hand hygiene policy, revised in February 2024, emphasizes the importance of hand hygiene in preventing infection spread and outlines specific instances when hand cleaning is required. Despite this policy, RN #364 admitted to not performing hand hygiene before administering medications to Resident #7, acknowledging the oversight. The facility's medication administration policy also mandates adherence to infection control practices, including hand hygiene before and after resident contact, which was not followed in this instance.
Misappropriation of Controlled Medications by Agency RN
Penalty
Summary
The facility failed to protect residents from the misappropriation of controlled medications, affecting six residents. The issue was discovered when an LPN noticed discrepancies in the narcotic accountability records during a routine medication count with an agency RN. The LPN observed unrecognized signatures and unusual times for medication administration, prompting an investigation by the DON. The investigation revealed that controlled medications, including Oxycodone, Clonazepam, Norco, Percocet, and Tramadol, were signed out with unrecognizable signatures and not documented as administered in the MAR. This affected residents with various medical conditions, including diabetes, Alzheimer's disease, chronic respiratory failure, and pain management needs. The discrepancies indicated that medications were potentially diverted by RN #103, who had a history of nursing board probationary actions related to theft and drug charges. The facility's policies on Inventory Control of Controlled Substances and Abuse, Neglect, and Exploitation were not adequately followed, as the agency RN was not properly vetted, and the narcotic counts were not accurately reconciled. The facility's failure to ensure proper documentation and accountability of controlled substances led to the misappropriation, impacting the residents' medication management and safety.
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.
Trusted data from CMS and state health departments
Every citation, penalty and Plan of Correction is sourced from public CMS records (latest release May 27, 2026) and official state health department websites — never guesswork.
Trusted by long-term care providers and associations.
