Arbors At Fairlawn The
Inspection history, citations, penalties and survey trends for this long-term care facility in Fairlawn, Ohio.
- Location
- 575 S Cleveland Massillon Road, Fairlawn, Ohio 44333
- CMS Provider Number
- 365689
- Inspections on file
- 27
- Latest survey
- May 12, 2025
- Citations (last 12 mo.)
- 0
Citation history
Health deficiencies cited at Arbors At Fairlawn The during CMS and state inspections, most recent first.
A resident with multiple chronic conditions experienced several significant events, including hospital transfers, refusals of treatment, and not returning from a leave of absence, without required notifications being made to the physician or the resident's daughter. Documentation did not show that the physician or family were informed, and staff interviews confirmed inconsistencies in the notification process.
A resident with multiple chronic conditions, who was permitted unsupervised community outings, did not return from an LOA as expected. Staff failed to follow facility policy by not promptly contacting the resident, his emergency contacts, or local hospitals when he was overdue. The lack of timely action and communication resulted in a delay in discovering that the resident had passed away at a hospital.
A facility failed to provide sufficient staffing, resulting in inadequate care for residents, including missed showers, delayed incontinence care, and neglect of personal hygiene. Residents reported not receiving scheduled showers and being left in soiled conditions due to staff shortages. Observations confirmed that residents were not checked or changed as required, highlighting significant staffing issues.
The facility failed to provide scheduled showers for residents dependent on staff for ADLs, affecting four residents. Due to staffing shortages, residents were often given bed baths instead of showers, leading to inadequate personal hygiene. Interviews with residents and CNAs confirmed the issue, and observations noted poor hygiene in some residents.
A facility failed to implement fall interventions for a resident with a history of falls and cognitive impairment. The resident's care plan included wearing hipsters, having a call light within reach, and removing the wheelchair from the room while in bed. However, observations revealed these interventions were not followed, as the wheelchair was left next to the bed, the call light was not accessible, and the resident was not wearing hipsters. The resident had a history of multiple falls, some with injuries, and the Director of Nursing confirmed the interventions were not being implemented as required.
The facility failed to provide timely incontinence care for three residents, leading to a deficiency. A resident with an indwelling catheter was found with a bowel movement and not changed since the start of the CNA's shift. Another resident was found with a saturated brief and red skin due to lying on wrinkled bedding. A third resident was found in a urine-saturated gown and bedding, having waited all day to be changed. The DON stated residents should be checked and changed by 8:30 A.M., but this was not followed.
A resident with psychiatric conditions was emergently discharged to a hospital without proper notification to their legal guardian or mother. The facility placed the discharge notice in the resident's belongings, which were not accessible to the resident or their representatives. Interviews revealed that the discharge notice was not sent by certified mail, leading to confusion and a lack of proper discharge planning.
A facility failed to collaborate with a hospital to assess a resident's condition before refusing their return after hospitalization. The resident, with a history of mental health issues, was deemed stable by the hospital, but the facility did not perform an onsite visit or communicate effectively. An immediate discharge notice was improperly handled, and the facility did not evaluate the resident's condition as required by policy.
A resident with severe cognitive impairment and mobility issues sustained a significant leg injury during a manual transfer by two STNAs, contrary to her care plan which required a mechanical lift. The incident highlighted a lack of communication and training regarding transfer procedures, as confirmed by the DON. The facility's policy on accident prevention was not followed, leading to the resident's hospitalization for treatment.
A facility failed to administer treatments as ordered for a resident with multiple diagnoses, including skin cancer and dementia. The resident's treatment for biopsy sites was not completed on several occasions, as confirmed by nursing staff and other residents. This deficiency was part of a complaint investigation affecting one of four residents reviewed.
The facility did not secure resident medical records, affecting multiple residents. Sensitive information, including medication details, therapy information, and bowel movement records, was found in an easily accessible file holder near the main entrance. The administrator confirmed the records were unsecure and accessible to the public.
A resident with an indwelling urinary catheter did not have appropriate physician's orders or monitoring in place, leading to inadequate catheter care. The resident reported that staff did not clean the catheter entry site, and the collection bag and tubing had not been changed since admission. Staff confirmed the lack of specific orders for catheter care, contrary to facility policies requiring such interventions.
The facility failed to date and monitor the replacement of oxygen tubing for three residents, despite having policies requiring weekly changes. A resident with chronic respiratory conditions and another with COPD were found with undated tubing, confirmed by an LPN and an RN. Additionally, a third resident's records showed no documented tubing changes for over a month, contrary to facility policy.
A facility failed to monitor a resident's use of anticoagulant and psychotropic medications, resulting in a deficiency. The resident, with a complex medical history, was prescribed Eliquis and Sertraline but lacked monitoring for side effects. Staff interviews revealed that point-of-care charting did not include side effect monitoring, and necessary orders were missing. The DON confirmed the expected monitoring was not completed, contrary to facility policies.
A facility failed to post adequate signage for a resident on enhanced-barrier precautions (EBP) due to an indwelling catheter. Observations revealed a PPE hanger on the resident's door without any sign indicating the required precautions. Staff relied on verbal communication and the Kardex for information on transmission-based precautions. The facility's policy lacked guidance on signage, contributing to the deficiency, as confirmed by the DON.
Failure to Notify Physician and Family of Resident Status Changes
Penalty
Summary
The facility failed to notify a resident's physician and daughter of significant changes in the resident's status, as required. The resident, who had diagnoses including chronic obstructive pulmonary disorder, diabetes, and congestive heart failure, was cognitively intact and listed as his own responsible party, with his daughter as the secondary contact. On multiple occasions, including when the resident was sent to the emergency room, refused treatments or medications, and did not return from a leave of absence, there was no evidence in the medical record that the physician or the resident's daughter were notified of these events. Progress notes documented the resident's refusals and hospital transfers, but lacked documentation of required notifications to the physician and family member. Additionally, the resident's daughter ultimately contacted the facility to report the resident's death, further indicating a lack of timely communication from the facility regarding the resident's status. Interviews with staff, including the Director of Nursing, confirmed inconsistencies in the notification process for significant changes, hospitalizations, refusals of treatment, and absences from the facility.
Failure to Ensure Resident Safety After Missed Return from LOA
Penalty
Summary
The facility failed to ensure the safety of a resident who did not return in a timely manner after a leave of absence (LOA). The resident, who had diagnoses including chronic obstructive pulmonary disorder, diabetes, and congestive heart failure, was cognitively intact and independent in transfers. His care plan allowed for unsupervised outings in his powerchair, and he routinely took public transportation to visit a nearby city, always returning before midnight. On the day in question, the resident signed out at 11:55 A.M. but did not return by midnight as expected. Staff actions were inconsistent with facility policy and expectations. The LPN on duty noted the resident's absence late at night, attempted to call his cell phone without success, and texted the DON, who instructed her to call local hospitals. However, the LPN did not follow through with these instructions, citing being too busy and assuming the day shift would handle it. There was no evidence that the resident's emergency contacts or local hospitals were called during the night. The DON was not updated until the following morning, at which point it was discovered that the resident had passed away at a hospital after being brought in from a grocery store. Interviews with staff revealed uncertainty about the care plan and the appropriate steps to take when a resident did not return from an LOA. The facility's policy required documentation of the resident's departure, destination, and expected return time, as well as staff knowledge of the resident's whereabouts. Despite these requirements, the lack of timely follow-up and communication contributed to the failure to ensure the resident's safety after he did not return as anticipated.
Inadequate Staffing Leads to Neglect in Resident Care
Penalty
Summary
The facility failed to provide sufficient staffing to meet the needs of its residents, resulting in inadequate assistance with showers, bathing, incontinence care, dressing, personal hygiene, and changing of soiled sheets. This deficiency affected six residents and had the potential to impact all 73 residents in the facility. Observations and interviews revealed that residents did not receive scheduled showers or were forced to accept bed baths due to staffing shortages. For instance, Resident #46 did not receive scheduled showers on multiple occasions, and Resident #38 reported feeling forced to accept bed baths instead of showers. Resident #9 experienced significant neglect in personal hygiene and incontinence care. On one occasion, Resident #9 was found with oily hair, strong body odor, and dirty fingernails, indicating a lack of proper bathing. Additionally, Resident #9 was left in soiled bedding for an extended period after spilling coffee and having a bowel movement, as the assigned CNA was too busy to provide timely care. Similar issues were observed with Resident #49, who was found with saturated briefs and red, creased skin due to prolonged exposure to urine and bowel movements. The facility's staffing issues were further highlighted by the experiences of Residents #49 and #56, who were left in soiled conditions for extended periods. Resident #49's brief was saturated with urine and bowel movement, and the resident's skin showed signs of neglect. CNA #241 admitted to being unable to provide timely care due to being busy with other residents. Resident #56 also reported being saturated with urine and waiting all day for assistance. The Director of Nursing confirmed that residents should be checked and changed every two hours, but this standard was not met due to insufficient staffing.
Failure to Provide Scheduled Showers Due to Staffing Issues
Penalty
Summary
The facility failed to provide adequate assistance with activities of daily living (ADLs), specifically bathing and showers, for residents who were dependent on staff. This deficiency affected four residents who were reviewed for ADLs. The facility's census was 73, and the issue was identified through observations, resident and staff interviews, and record reviews. The facility's policy required that residents unable to perform ADLs receive necessary services to maintain good grooming and hygiene. Resident #46, who was cognitively intact and required supervision or touch assistance with bathing, did not receive scheduled showers on two occasions due to staff shortages. Interviews with the resident and a CNA confirmed the lack of showers as per the resident's preference. Similarly, Resident #38, who was dependent on staff for bathing, did not receive scheduled showers and was instead given bed baths, which the resident felt were inadequate. The CNA attributed this to insufficient staffing, which led to a preference for bed baths over showers due to time constraints. Resident #9, who required substantial assistance with bathing, was observed with poor hygiene, including oily hair and a strong body odor, indicating missed showers. The resident confirmed not receiving baths as scheduled. Resident #13, who required assistance with personal care, also missed several scheduled showers due to staff shortages, as confirmed by the Director of Nursing. The facility's failure to provide scheduled showers and maintain personal hygiene for these residents was documented as a deficiency under a complaint investigation.
Failure to Implement Fall Interventions for At-Risk Resident
Penalty
Summary
The facility failed to ensure that fall interventions were in place for a resident with a history of falls and who was at risk for falls. The resident, who was moderately cognitively impaired and used a wheelchair for mobility, had a care plan that included interventions such as wearing hipsters, having a call light within reach, a 'call before fall' sign in the room, and removing the wheelchair from the room while in bed. However, during observations, it was noted that the resident's wheelchair was next to the bed, the call light was not within reach, and there was no 'call before fall' sign in the room. Additionally, the resident was not wearing hipsters, and the CNA confirmed that the resident had not worn hipsters since moving to a different hall. The resident had a documented history of multiple falls, some resulting in injuries, over a period of several months. Despite this history, the interventions outlined in the care plan were not consistently implemented. The Medication Technician and CNA both failed to ensure the resident's environment was free from fall hazards, as they left the wheelchair and walker within reach and did not assist the resident in wearing hipsters. The Director of Nursing confirmed that the resident was at high risk for falls and that the interventions were still in place, yet they were not being followed, leading to noncompliance with the facility's policy on accidents and supervision.
Failure to Provide Timely Incontinence Care
Penalty
Summary
The facility failed to provide timely incontinence care for three residents, leading to a deficiency in care. Resident #9, who was cognitively intact and had an indwelling catheter, was found lying in bed with an odor of stool. Despite confirming a bowel movement, the resident had not been changed since the start of the CNA's shift at 6:00 A.M. It was only after the surveyor's request that the CNA attended to the resident, revealing a large bowel movement. Resident #49, who was moderately cognitively impaired and always incontinent of bowel and bladder, was found with a saturated brief and red, creased skin due to lying on wrinkled bedding. The CNA admitted this was the first time she had checked on the resident for incontinence needs during her shift, as she was occupied with other residents. Resident #56, who was cognitively intact and frequently incontinent, was found sitting in a urine-saturated gown and bedding. The resident reported waiting all day to be changed, and the CNA confirmed this was the first time she had attended to the resident for incontinence care that day. The Director of Nursing stated that residents should be checked and changed by 8:30 A.M., but this was not adhered to, as evidenced by the observations.
Failure to Properly Notify Resident and Representatives of Emergency Discharge
Penalty
Summary
The facility failed to properly notify Resident #74 and their representatives of an emergency discharge. Resident #74, who had a legal guardian, was transferred to a hospital for an acute psychiatric stay and did not return to the facility. The facility did not provide written notification of the discharge to the resident's guardian or mother, nor did they ensure the resident received the discharge notice. The discharge notice was placed in the resident's belongings, which were not accessible to the resident or their representatives. Resident #74 had a history of schizoaffective disorder, mood disorder, and other psychiatric conditions. The resident exhibited behaviors such as verbal aggression, refusal of care, and wandering. On 12/09/24, the resident's condition worsened, leading to an emergency psychiatric admission. The facility determined that the resident's behaviors posed a risk to others and initiated an emergency discharge without proper notification to the resident's guardian or mother. Interviews with facility staff and the resident's representatives revealed that the discharge notice was not sent by certified mail, and there was no evidence that the guardian or mother received it. The facility's failure to communicate the discharge and appeal rights to the resident's representatives resulted in confusion and a lack of proper discharge planning. The resident's mother was unaware of the discharge and expected the resident to return to the facility.
Failure to Collaborate with Hospital for Resident's Return
Penalty
Summary
The facility failed to collaborate with the hospital to ascertain the accurate status of a resident's condition before refusing to allow the resident to return to the facility after hospitalization. The resident, who had a history of schizoaffective disorder, anxiety, and other mental health issues, was transferred to the hospital for an acute psychiatric stay due to worsening psychotic behaviors. Despite the hospital's assessment that the resident was stable and ready for discharge back to the facility, the facility did not perform an onsite visit or communicate effectively with the hospital to evaluate the resident's condition. The facility issued an immediate discharge notice to the resident, citing safety concerns, but failed to properly notify the resident's legal guardian and mother. The discharge notice was placed in the resident's belongings and not directly communicated to the resident or their family. Interviews with facility staff revealed that there was no attempt to collaborate with the hospital to assess the resident's mental health status or determine if the resident was stable for discharge back to the facility. The facility's actions were based on their assessment of the resident's behavior prior to hospitalization, without considering the hospital's findings. The facility's policy required them to evaluate the resident's condition to ensure their needs were within the facility's scope of care, which they failed to do. The lack of communication and collaboration with the hospital and the improper handling of the discharge notice contributed to the deficiency. The resident's legal guardian and mother expressed a desire for the resident to return to the facility, but the facility did not take the necessary steps to facilitate this process.
Failure to Ensure Safe Transfer Results in Resident Injury
Penalty
Summary
The facility failed to ensure a safe transfer for a resident, resulting in a significant injury. The resident, who was severely cognitively impaired and dependent on two staff members for transfers, sustained a 10-centimeter laceration to her right calf during a staff-assisted transfer. This injury required emergency medical attention and resulted in the resident being transferred to a local hospital for treatment, which included 21 sutures. The resident's care plan, initiated prior to the incident, indicated a need for one-person assistance for certain activities and two-person assistance with a mechanical lift for transfers. However, there were no specific physician orders detailing the transfer method. On the night of the incident, two State Tested Nursing Assistants (STNAs) manually transferred the resident without using the mechanical lift, which was contrary to the care plan. During the transfer, the resident sustained the laceration, and the staff were unable to explain how the injury occurred. Interviews with staff revealed a lack of communication and training regarding the resident's transfer status. The Director of Nursing (DON) confirmed that the resident required a mechanical lift for transfers, but this was not communicated effectively to the staff. Additionally, staff members reported not receiving recent training on transfer techniques or the use of assistive devices. The facility's policy on accidents and supervision emphasized the need for individualized care plans and adequate supervision to prevent accidents, which was not adhered to in this case.
Failure to Administer Treatments as Ordered
Penalty
Summary
The facility failed to ensure that all treatments were completed according to physician orders for Resident #39. This resident, who was admitted with diagnoses including malignant neoplasm of the skin, hypothyroidism, dementia, Alzheimer's disease, and hypertension, required various levels of assistance for daily activities due to impaired cognition. The physician orders specified that biopsy sites should be cleansed with soap and water, followed by the application of Mupirocin 2% cream, and covered with a bandage daily for 10 to 14 days post-procedure. However, the Treatment Administration Record (TAR) for August and September 2024 showed that these treatments were not completed on several specified dates. Interviews with nursing staff, including RNs and LPNs, confirmed that there were instances when Resident #39 did not receive the prescribed treatment for her biopsy sites. Additionally, interviews with other residents revealed that they also experienced times when their treatments were not completed as ordered. This deficiency was investigated under Complaint Number OH00157498, affecting one resident of the four reviewed for treatment administration, within a facility census of 69.
Breach of Resident Medical Record Confidentiality
Penalty
Summary
The facility failed to ensure the security and confidentiality of resident medical records, affecting thirteen out of thirty-six sampled residents. During an observation, it was noted that a plastic file holder on the wall near the main entrance contained unsecured files. These files included sensitive information such as specific medications taken by several residents, skilled therapy information for one resident, and details concerning bowel movements for two residents. The administrator confirmed in an interview that these records were unsecure and easily accessible to the general public.
Inadequate Urinary Catheter Care for Resident
Penalty
Summary
The facility failed to ensure appropriate orders and monitoring were in place for a resident with a urinary catheter. Resident #112, who was moderately cognitively intact, had an indwelling catheter but lacked physician's orders for changing the catheter bag monthly or as needed, monitoring urine, or changing the catheter prior to a specified date. Interviews with the Director of Nursing and staff revealed that the resident was on enhanced barrier precautions due to the catheter, but there were no specific orders regarding catheter care in the medical record before the deficiency was identified. Observations and interviews indicated that the resident's catheter care was inadequate. The resident reported that staff did not clean the catheter where it entered her body, and the collection bag and tubing had not been changed since her admission. Staff interviews confirmed that the resident had the catheter since admission, and there were no orders for changing the tubing or collection bag. The facility's policies on catheterization and catheter irrigation required interventions to prevent complications and specific orders for catheter care, which were not followed in this case.
Failure to Date and Replace Oxygen Tubing
Penalty
Summary
The facility failed to ensure that respiratory equipment, specifically oxygen tubing, was dated and monitored for routine replacement, affecting three residents. Resident #35, who was cognitively intact and had a history of chronic respiratory conditions, was observed with undated oxygen tubing despite a physician's order for continuous oxygen use. An LPN confirmed that the tubing should have been dated and changed weekly, but no such documentation was present. Similarly, Resident #113, who had multiple diagnoses including COPD and acute respiratory failure, was found with undated oxygen tubing. Although the resident had an order for oxygen use as needed, there were no orders for routine tubing replacement. An RN confirmed the absence of a date on the tubing. Resident #19, with a history of COPD and other health issues, also had undated oxygen tubing, and records showed no documented tubing changes for over a month. The facility's policy required weekly changes of oxygen tubing, which was not adhered to in these cases.
Failure to Monitor Anticoagulant and Psychotropic Medications
Penalty
Summary
The facility failed to adequately monitor a resident's use of anticoagulant and psychotropic medications, leading to a deficiency in medication management. Resident #113, who was cognitively intact, had a complex medical history including type two diabetes, chronic obstructive pulmonary disease, acute respiratory failure with hypoxia, chronic congestive heart failure, depression, insomnia, and hyperlipidemia. Despite being prescribed medications such as Eliquis (an anticoagulant) and Sertraline hydrochloride (an antidepressant), there was no evidence of monitoring for side effects in the resident's medical records, medication administration records, or treatment administration records. Interviews with staff revealed that the facility's point-of-care charting did not include monitoring for medication side effects, and there were no orders on the MAR or TAR for such monitoring. The Director of Nursing confirmed that the expected monitoring for signs and symptoms of bleeding and side effects was not completed, as the necessary ancillary orders had not been entered. The facility's policies on medication monitoring and adverse drug events emphasized the importance of ongoing evaluation and documentation, which were not adhered to in this case.
Inadequate Signage for Enhanced Barrier Precautions
Penalty
Summary
The facility failed to ensure adequate signage was posted to instruct staff and visitors of proper precautions for a resident on enhanced-barrier precautions (EBP). This deficiency was identified during an observation where Resident #112's door had a yellow personal protective equipment (PPE) hanger with various PPE items, but no sign was present to communicate the reason for the PPE or the specific precautions required. The Director of Nursing (DON) confirmed that signage should have been present, as Resident #112 was on EBP due to an indwelling catheter. Interviews with staff, including State tested Nursing Assistants (STNAs) and a Licensed Practical Nurse (LPN), revealed that information about transmission-based precautions was typically communicated verbally or through the Kardex, rather than through signage. The facility's policy on Enhanced Barrier Precautions, revised in March 2024, did not provide guidance on the use of signage, which was a contributing factor to the deficiency. The CDC guidance on EBP emphasizes the importance of signage to inform individuals entering a resident's room about the necessary precautions and recommended PPE. The lack of signage for Resident #112, who had been on EBP since admission, indicates a gap in the facility's infection prevention and control program, as confirmed by the DON during a follow-up interview.
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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