Arbors At Sylvania
Inspection history, citations, penalties and survey trends for this long-term care facility in Toledo, Ohio.
- Location
- 7120 Port Sylvania Drive, Toledo, Ohio 43617
- CMS Provider Number
- 366060
- Inspections on file
- 24
- Latest survey
- December 18, 2025
- Citations (last 12 mo.)
- 1
Citation history
Health deficiencies cited at Arbors At Sylvania during CMS and state inspections, most recent first.
A resident with depression and a severe leg fracture was administered Seroquel 100 mg in error due to a transcription mistake during the admission process. The intended order was for sertraline 100 mg, but Seroquel was incorrectly entered and given. The error was discovered the following day during a medication review by an RN.
A resident with multiple medical conditions experienced significant, unaddressed weight loss, dropping nearly 20% of body weight over several months. Despite this, no interventions or assessments by the dietician or nursing staff were documented, and key staff were unaware of the issue. The resident reported insufficient food intake and dissatisfaction with meals, and facility policy requiring nutritional monitoring was not followed.
A resident with myasthenia gravis and multiple comorbidities did not receive nine doses of a physician-ordered medication, Pyridostigmine Bromide, due to the facility's failure to obtain and administer the drug after admission and following a hospital stay. The medication omission was not discovered until the resident was hospitalized, and both the physician and DON were unaware of the missed order until after the fact. Facility policy requiring timely administration and reporting of discrepancies was not followed.
A CNA was observed reusing face shields between resident rooms without disinfecting them and failing to perform hand hygiene before and after resident contact, including when entering a COVID isolation room. These actions were not in accordance with posted signage and facility policy, potentially affecting multiple residents.
A resident with severe cognitive impairment and a history of localized edema was repeatedly observed with dependent positioning of the arms and visible swelling, yet no interventions or care plans were documented or implemented to address the edema. Nursing staff confirmed the presence of pitting edema and the lack of any related interventions in the medical record.
A resident with severe contractures and impaired cognition did not receive physician-ordered interventions, including the placement of washcloths in both hands to prevent further contracture. Multiple observations and staff interviews confirmed that the washcloths were not in place as required, and the care plan was not consistently followed.
A resident with severe cognitive impairment and a history of falls did not have required fall prevention interventions, such as hipsters, consistently implemented. Despite care plan updates and staff awareness, observation confirmed the resident was not wearing hipsters as indicated, reflecting a failure to follow individualized fall management strategies.
A resident with heart failure and end stage renal disease, who was ordered to receive continuous oxygen at two liters per minute, was observed receiving oxygen at three liters per minute. An LPN confirmed the discrepancy between the physician's order and the actual oxygen flow rate, in violation of facility policy.
A resident with dementia, who was fully dependent for care, was found to have a privacy curtain in their room with several unidentifiable brown stains along the bottom. Observation and staff interview confirmed the stains, and facility policy required visibly dirty curtains to be cleaned or changed, which was not done.
A resident with significant medical needs and a history of pressure ulcers was not provided with a comfortable mattress despite repeated requests and a physician order for a low air loss mattress. The air mattress in use was partially inflated, causing discomfort, and staff did not attempt to obtain a replacement, even though they were aware of the resident's concerns.
Two residents who were always incontinent and dependent on staff did not receive timely incontinence care or repositioning, as required by their care plans and facility policy. Staff failed to check or change these residents at regular intervals, resulting in prolonged periods of soiling and the development of skin excoriation and rashes. Staff interviews and observations confirmed lapses in care and a lack of awareness regarding the timing of previous incontinence checks.
A resident with chronic pain and recent back surgery did not receive ordered non-pharmacological pain interventions, specifically ice packs, as part of their pain management plan. Despite physician orders and the resident's requests, ice packs were not routinely provided or documented, and the care plan lacked specific details about these interventions. Staff confirmed that non-pharmacological measures were only given upon request, and the DON acknowledged the absence of documentation and care plan inclusion.
Medication Transcription Error on Admission
Penalty
Summary
A deficiency occurred when a resident was admitted with diagnoses including depression and a severe left leg fracture. Upon admission, the community referral form did not include a physician order for the antipsychotic medication Seroquel 100 mg, but did include an order for the antidepressant sertraline 100 mg daily. However, a physician order for Seroquel 100 mg was incorrectly entered upon admission, and the medication administration record showed that Seroquel 100 mg was administered to the resident the morning after admission. The error was traced to a transcription mistake during the admission process, resulting in the resident receiving Seroquel 100 mg instead of the intended sertraline 100 mg. The incident was identified when a registered nurse reviewed the resident's medications the day after admission and discovered the error, by which time the incorrect medication had already been administered. The facility's policy required medications to be administered as ordered by the physician, but this was not followed due to the transcription error.
Failure to Address Significant Weight Loss in Resident
Penalty
Summary
A resident with multiple complex medical conditions, including myasthenia gravis, dementia, gastroparesis, and paraplegia, experienced significant weight loss over several months following admission. The resident's weight dropped from 165 lbs at admission to 133 lbs, representing a 19.39% decrease. Despite this notable weight loss, the medical record showed no evidence of interventions being implemented to address the issue, nor were there any progress notes or assessments by the dietician or nursing staff regarding the weight loss. Interviews with facility staff revealed a lack of awareness and communication regarding the resident's weight loss. The DON was not aware of the situation, and the dietician, who is responsible for monitoring weights, did not know why interventions were not initiated. Although a therapy referral slip was completed by an LPN noting the weight loss, it is unclear if this information reached the dietician. The resident reported not receiving enough food and expressed dissatisfaction with the meals. The facility's policy requires maintaining residents' nutritional status, but this was not followed in the resident's case.
Failure to Administer Ordered Medication Due to Missed Order Entry and Oversight
Penalty
Summary
A deficiency occurred when the facility failed to obtain and administer a physician-ordered medication, Pyridostigmine Bromide, for a resident diagnosed with myasthenia gravis and other complex conditions. Upon admission, the resident had an active order for Pyridostigmine Bromide 30 mg three times daily, but the medication was not administered for a period spanning several days due to unavailability. The omission was not identified until the resident was admitted to the hospital, and upon return, the medication was reordered. Review of the Medication Administration Record showed that nine doses were missed between 05/30/25 and 06/02/25. Pharmacy documentation indicated the medication was delivered but returned due to the resident's hospital admission, and a subsequent delivery occurred days later. Interviews revealed that the physician was unaware of the medication order until after the resident's hospital stay, and the DON stated that nurses are responsible for entering medication orders upon a resident's return from the hospital, with unit managers conducting chart audits. The DON was not aware of the missed medication and believed the order was overlooked. Facility policy requires medications to be administered as ordered and discrepancies to be reported to the nurse manager, but this process was not followed in this instance.
Failure to Follow Infection Control Practices for PPE and Hand Hygiene
Penalty
Summary
The facility failed to ensure proper infection prevention and control practices were followed, as evidenced by multiple observations of a CNA reusing face shields between resident rooms without disinfecting them. The CNA donned and doffed PPE, including a face shield, when entering and exiting rooms on droplet isolation, but placed the used face shield back into the over-the-door organizer without cleaning it. The CNA also reused the same face shield for subsequent room entries without disinfecting it, despite bleach wipes being available for this purpose. Facility signage and policy required that reusable PPE such as face shields be disinfected or placed in a designated receptacle for reprocessing, but this was not followed. Additionally, the same CNA was observed failing to perform hand hygiene before and after entering resident rooms, including a COVID isolation room, and after removing PPE. The CNA delivered breakfast trays to residents without washing hands or using alcohol-based hand sanitizer, contrary to posted signage and facility policy, which required hand hygiene after PPE removal and between resident contacts. These lapses in infection control practices had the potential to affect 38 residents residing on the 100 and 200 hallways.
Failure to Initiate Edema Interventions for Dependent Resident
Penalty
Summary
The facility failed to implement interventions to address edema for a resident with a history of localized edema and multiple complex medical conditions, including anoxic brain damage, contractures, and chronic pain. The resident, who was dependent on staff for all activities of daily living and had severely impaired cognition, was observed multiple times with dependent positioning of the arms and hands, including visible edema and a closed fist in the left hand. Despite repeated observations and assessments by nursing staff confirming the presence of pitting edema in the left hand and forearm, there were no documented interventions in the medical record to address or monitor the edema. Staff interviews confirmed the absence of any care plan or interventions related to the resident's edema.
Failure to Implement Contracture Prevention Interventions
Penalty
Summary
The facility failed to implement physician-ordered interventions to prevent the deterioration of contractures for a resident with significant musculoskeletal impairments. The resident, who had diagnoses including anoxic brain damage, contractures in both hands, elbows, and shoulders, and chronic pain, was dependent on staff for all activities of daily living and had severely impaired cognition. The care plan included placing washcloths in both hands every shift to prevent fingers from clenching, cleansing and drying hands before application, and providing range of motion (ROM) as indicated. Despite these orders, multiple observations over several days revealed that the washcloths were not in place and the resident's hands remained closed-fisted. Staff interviews confirmed that the washcloths had not been applied as ordered, and the care plan interventions were not consistently followed. The resident was also noted to be unable to tolerate passive ROM due to distress, with care plans adjusted to clean hands as tolerated and monitor for skin breakdown. However, the primary intervention to prevent further contracture—placement of washcloths—was not implemented, as verified by both direct observation and staff acknowledgment.
Failure to Implement Fall Prevention Interventions as Indicated
Penalty
Summary
The facility failed to implement fall prevention interventions as indicated for a resident with multiple medical conditions, including severe cognitive impairment, mobility limitations, and a history of falls. Despite documented care plans and assessments identifying the need for specific interventions such as the use of hipsters, toileting and repositioning every two hours, and keeping the call light within reach, these measures were not consistently followed. Observation revealed that the resident was not wearing hipsters as required, and this was confirmed by an LPN at the time of observation. The resident had experienced multiple falls while attempting to ambulate to the restroom, and each incident resulted in updates to the care plan with new interventions. However, the lack of adherence to these interventions, specifically the failure to apply hipsters, demonstrated a lapse in the facility's responsibility to provide adequate supervision and implement individualized fall prevention strategies as outlined in their own policy.
Failure to Administer Oxygen at Prescribed Rate
Penalty
Summary
A deficiency occurred when a resident with diagnoses of heart failure and end stage renal disease, who was care planned and ordered to receive continuous oxygen therapy at two liters per minute via nasal cannula, was observed receiving oxygen at a rate of three liters per minute from a portable tank. The resident was cognitively intact at the time of the incident. This discrepancy was confirmed by an LPN, who verified that the oxygen was running at a higher rate than prescribed and acknowledged the physician's order for two liters per minute. Facility policy requires oxygen to be administered only as ordered by a physician.
Failure to Maintain Clean Privacy Curtain in Resident Room
Penalty
Summary
The facility failed to maintain a clean environment in a resident's room by not ensuring the privacy curtain was free of visible stains. Observation revealed that the privacy curtain in the room of a resident with dementia, who was cognitively impaired and dependent for all care, had several unidentifiable brown stains along the bottom, extending approximately two feet in length. A CNA confirmed the presence of these stains. Review of the facility's policy indicated that privacy curtains should be changed or cleaned when visibly dirty, but this was not done in this instance.
Failure to Provide Requested Mattress Accommodation
Penalty
Summary
A deficiency was identified when a resident with multiple complex medical conditions, including cervical disc disorder with myelopathy, chronic venous hypertension with ulcers, COPD, diabetes, spinal stenosis, and a history of pressure ulcers, was not provided with a comfortable mattress despite repeated requests. The resident, who was dependent on staff for all activities of daily living and at moderate risk for skin breakdown, had a physician order for a low air loss mattress. Observations revealed that the air mattress in use was only partially inflated, causing the resident's buttock to rest against the bed frame. The resident reported having requested a new mattress several months prior, but no replacement had been provided. Staff interviews confirmed awareness of the resident's complaints regarding mattress comfort. Nursing staff were responsible for checking the mattress settings each shift and had determined the settings were appropriate. However, no attempts were made to obtain a replacement mattress, and the resident continued to experience discomfort. At the time of the survey, the resident had no current skin breakdown but did have scarring from previously healed wounds. The failure to provide a comfortable mattress following the resident's request constituted non-compliance with the requirement to reasonably accommodate resident needs and preferences.
Failure to Provide Timely Incontinence Care and Repositioning
Penalty
Summary
The facility failed to provide timely and appropriate care for residents with bowel and bladder incontinence, as evidenced by observations, interviews, and medical record reviews. One resident, who was always incontinent and dependent on staff for all activities of daily living, was not checked or repositioned for extended periods. Despite care plans indicating the need for regular incontinence checks and repositioning, there was no documentation of specific intervals for these checks. Staff interviews revealed a lack of awareness regarding the timing of previous incontinence care, and direct observation found the resident heavily soiled with urine, with soiling extending to linens and wound dressings. Another resident, also always incontinent and dependent on staff, was observed to have developed excoriation and a rash due to inadequate incontinence care. The resident reported that staff were not providing the required two-hour checks and repositioning, which was corroborated by staff interviews and observations. The resident was found with excoriated skin, a large amount of urine, and a small bowel movement present, as well as two soiled incontinence briefs. Staff admitted to not having checked or changed the resident since assuming care and were unaware of the last time incontinence care was provided. Facility policy required that incontinent residents receive appropriate treatment and services, including regular checks and care to prevent infections and restore continence as much as possible. However, the lack of adherence to these policies, as demonstrated by the failure to provide timely incontinence care and repositioning, resulted in residents remaining soiled for prolonged periods and developing skin issues.
Failure to Provide and Document Non-Pharmacological Pain Interventions
Penalty
Summary
The facility failed to implement and document non-pharmacological pain management interventions as ordered for a resident with a complex medical history, including cauda equina syndrome, spinal stenosis, chronic pain, and recent back surgery. Physician orders specified the use of ice packs to the surgical incision for pain relief multiple times daily, but the care plan did not detail these interventions, and administration records lacked documentation of their use. The resident, who was cognitively intact and able to express needs, reported not receiving non-pharmacological interventions such as ice packs between scheduled pain medications, despite repeated requests and physician instructions. Observations and interviews confirmed that the resident experienced significant pain and that ice packs were not provided as ordered, with staff indicating that the resident had to request them rather than receiving them routinely. The DON verified that the medical record did not reflect the provision of ice packs and that the care plan did not include this intervention. The facility's pain management policy required incorporation of pain interventions into the care plan and revision if pain was not adequately controlled, but these steps were not followed for this resident.
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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