Austintown Healthcare Center
Inspection history, citations, penalties and survey trends for this long-term care facility in Youngstown, Ohio.
- Location
- 650 S Meridian Road, Youngstown, Ohio 44509
- CMS Provider Number
- 365732
- Inspections on file
- 24
- Latest survey
- March 26, 2026
- Citations (last 12 mo.)
- 4
Citation history
Health deficiencies cited at Austintown Healthcare Center during CMS and state inspections, most recent first.
A resident with multiple chronic conditions, impaired ROM, and risk for skin breakdown was observed lying on a bare bariatric mattress without a fitted sheet. The resident reported rarely having a fitted sheet because the facility lacked appropriately sized linens for bariatric beds. The Housekeeping Director confirmed ongoing difficulty obtaining fitted sheets for these beds and reliance on flat sheets, and the ADON confirmed the resident was on a bare mattress, contrary to the facility’s resident rights policy for a safe, clean, and comfortable environment.
A cognitively intact resident with a history of vertebral compression fracture, repeated falls, and bipolar disorder alleged that an RN hurt his back while assisting him to sit up during a medication pass, becoming combative and stating he was injured. Witnesses confirmed the interaction and noted the resident’s agitation and dislike of the nurse. The DON acknowledged the resident’s ongoing issues with certain nursing staff, and the Ombudsman reported notifying the Administrator that the resident had alleged physical abuse by staff. Despite this, the Administrator did not submit a required self-reported incident to the State agency, contrary to facility policy mandating timely reporting of all abuse allegations.
A resident with Parkinson’s disease, altered mental status, and severe cognitive impairment was housed in a room that was not maintained in good repair, where surveyors observed a chair rail with approximately four feet of splintered wood along the wall next to the resident’s low-position bed. The resident’s care plan did not indicate any refusal of housekeeping or maintenance services, and the Director of Plant Maintenance acknowledged that the chair rail was in disrepair and required replacement, contrary to facility policy stating that safety of residents, visitors, and employees is a top priority.
A resident receiving hospice care experienced inconsistent wound documentation between facility and hospice staff, with the facility failing to update records to reflect the progression of a pressure ulcer. Facility nursing staff were not notified of changes, and no new wound care orders or physician notifications were documented, resulting in incomplete and inaccurate medical records.
A resident with a history of stroke, hemiplegia, and dysphagia received enteral nutrition at a rate of 50 mL/hr instead of the physician-ordered 60 mL/hr. An RN documented the feeding as administered per order, but observation and interview confirmed the incorrect rate, contrary to facility policy requiring verification of the prescribed rate and volume.
A resident with end stage renal disease and other complex conditions did not consistently receive pre and post dialysis assessments or daily weights as ordered by the physician. Facility staff and leadership confirmed that these required monitoring activities were not completed or documented according to policy, with no explanation for the omissions.
The facility did not assess or initiate physician orders for a newly admitted resident with multiple complex conditions, resulting in delayed medications and treatments. Additionally, wound care was not provided as ordered for another resident, with missed treatments and undocumented application of dressings without physician notification or orders.
A resident with multiple medical conditions was admitted without documented pressure ulcers, but later records indicated a Stage III pressure ulcer was present on admission. The initial wound assessment and treatment order were delayed, and the nurse practitioner failed to enter the treatment order promptly, resulting in a delay in care. Facility staff confirmed the lack of timely documentation and implementation of wound care as required by policy.
Two residents did not receive multiple physician-ordered medications, including IV antibiotics and treatments for chronic conditions, because the medications were not available from the pharmacy upon admission. Nursing staff and the DON confirmed that delays of up to a day and a half in receiving medications were common, especially for new admissions and medications not stocked in the automated dispensing system.
A resident with a PICC line and multiple medical conditions, including a soft tissue infection, did not receive IV antibiotics under proper Enhanced Barrier Precautions. An LPN administered the medication without wearing the required gown and gloves, despite facility policy and physician orders specifying the need for these PPE measures for residents with indwelling medical devices.
The facility failed to provide scheduled showers for four residents who required assistance, despite their medical conditions necessitating regular hygiene care. Interviews with staff and residents confirmed that showers were not consistently provided, with no reasons given for the omissions.
A resident with multiple medical conditions, including a stage four pressure ulcer, was under Enhanced Barrier Precautions (EBP) for wound care. Despite appropriate signage and PPE being available, two RNs did not wear the required PPE, including gowns, during wound care. The facility's policy mandates PPE use during high-contact care activities, but this was not followed, leading to a deficiency in infection control practices.
Failure to Provide Fitted Sheet for Bariatric Bed
Penalty
Summary
Surveyors identified a deficiency related to the resident’s right to a safe, clean, comfortable, and homelike environment when a resident was found lying on a bare mattress without a fitted sheet. Record review showed the resident was admitted with multiple complex medical diagnoses, including fluid overload, chronic kidney disease, morbid obesity, bipolar disorder, diabetes with chronic kidney disease, atrial fibrillation, epilepsy, and other chronic conditions, and required assistance with personal care. A quarterly MDS assessment documented that the resident was alert, oriented, cognitively intact, had impaired range of motion in both upper and lower extremities, and was at risk for skin breakdown. During observation, surveyors noted that there was no fitted sheet on the resident’s bariatric bed. In an interview, the resident reported that he rarely had a fitted sheet on his bed because the facility did not have fitted sheets that fit his bariatric bed. The Housekeeping Director confirmed that there was no fitted sheet on the bed and acknowledged ongoing issues obtaining fitted sheets for bariatric beds, stating that flat sheets were usually used instead. The ADON confirmed that the resident did not have a fitted sheet on his bed and was lying directly on the bare mattress. Review of the facility’s Resident Rights policy indicated the facility was to provide resident-centered care that meets residents’ psychosocial, physical, and emotional needs and concerns.
Failure to Report Resident’s Allegation of Staff Abuse to State Agency
Penalty
Summary
Failure to timely report a resident’s allegation of staff-to-resident abuse to the State agency occurred after a cognitively intact resident with a history of wedge compression fracture of the T7-T8 vertebra, repeated falls, and bipolar disorder alleged that a nurse hurt his back while assisting him to sit up in bed. On the morning in question, a CPT RN entered the resident’s room to administer medications and, according to witness statements, the resident asked for help to sit up. The nurse assisted by holding the resident’s wrists/hands while he moved to a sitting position. Witness statements documented that the resident became combative, abusive, and agitated during the interaction, and that he did not like the nurse or new staff. The nurse later reported that the resident stated she had hurt him, which she denied. The DON reported that the resident had problems with Nigerian nursing staff and specifically with the CPT RN involved. The Administrator stated that the resident did not report abuse, but rather that the nurse pulled his hands to help him up and he felt it hurt his back, and confirmed that no Self-Reported Incident (SRI) was filed with the State agency. An Ombudsman reported calling the Administrator and relaying that the resident had alleged physical abuse by nursing staff, yet an SRI was still not submitted. This inaction occurred despite the facility’s abuse, neglect, and misappropriation policy requiring that alleged violations involving abuse be reported to the State Survey Agency and other authorities within specified time frames.
Failure to Maintain Resident Room in Good Repair
Penalty
Summary
The facility failed to maintain a resident room in good repair when one resident’s room was observed to be in general disrepair, specifically with a chair rail that had splintered wood approximately four feet long along the wall next to the resident’s bed. The resident, admitted with diagnoses including Parkinson’s disease without dyskinesia and altered mental status, had a quarterly MDS showing a BIMS score of three out of 15, indicating severe cognitive impairment. Review of the resident’s care plan showed no indication that the resident refused housekeeping or maintenance services. During observations on consecutive days, surveyors noted the splintered chair rail adjacent to the bed, which was in a low position and horizontal to the wall with the damaged rail, and the Director of Plant Maintenance confirmed that the chair rail was in disrepair and needed replacement, contrary to the facility’s Resident Rights policy stating that safety of residents, visitors, and employees is a top priority of care. This deficiency was cited under the requirement to ensure the nursing home area is safe, easy to use, clean, and comfortable for residents, staff, and the public, and was investigated under Complaint Number 2655564.
Inconsistent Wound Documentation and Communication for Hospice Resident
Penalty
Summary
The facility failed to maintain accurate and consistent wound documentation for a resident who was receiving hospice services. Upon admission, the resident had a red, non-blanchable area on the right outer ankle, which was initially documented as a suspected deep tissue injury (SDTI) and later as a Stage I pressure ulcer by facility staff. However, hospice documentation later identified the same wound as an unstageable pressure ulcer with significant eschar and necrotic tissue, indicating a deterioration that was not reflected in the facility's records. There was no evidence of additional wound assessments or updates in the facility's documentation after the initial assessments, despite the change in the wound's condition noted by hospice staff. Interviews with facility nursing staff revealed that they were not notified by hospice of any changes in the wound's status or given new orders for wound care. The facility's records did not show that the physician was notified of the wound's deterioration, nor were there any new or updated wound care orders documented. The facility's wound care policy required treatment based on the wound's location, stage, and drainage, but the lack of updated assessments and communication resulted in incomplete and inaccurate medical records for the resident. Additionally, the resident's guardian reported that the resident was discharged home with additional wounds to both feet, which were not documented in the facility's discharge assessment. Hospice staff also observed that preventative measures to avoid pressure ulcer deterioration may not have been consistently followed, as the resident was found sitting on her feet due to contractures. The inconsistency between facility and hospice documentation, lack of timely wound reassessment, and failure to update medical records contributed to the deficiency identified during the complaint investigation.
Failure to Administer Enteral Feeding at Ordered Rate
Penalty
Summary
A deficiency occurred when nursing staff failed to administer enteral feedings as ordered for Resident #184, who had a history of stroke, right-sided hemiplegia, dysphagia, and cognitive communication deficit. The physician's order specified that enteral feedings should be administered every shift at a rate of 60 mL per hour for 20 hours via pump. However, observation revealed that the feeding was running at 50 mL per hour instead of the ordered rate. The registered nurse had documented in the Medication Administration Record that the feeding was given as ordered, but direct observation and subsequent verification with the nurse confirmed the rate was incorrect. Facility policy required nursing staff to verify the practitioner's order, including the volume and rate to be infused, when administering enteral feedings.
Failure to Monitor and Document Dialysis Care and Daily Weights
Penalty
Summary
The facility failed to ensure that a resident requiring dialysis received appropriate monitoring and care as ordered by the physician. Specifically, the resident, who had multiple diagnoses including end stage renal disease, congestive heart failure, and chronic kidney disease, was not consistently monitored with pre and post dialysis assessments on scheduled dialysis days. There were multiple instances where these assessments were not completed or documented, as confirmed by record review and staff interviews. Additionally, daily weights, which were ordered by the physician due to the resident's medical conditions, were not consistently obtained or recorded over a period of more than two months. Interviews with facility staff, including a registered nurse, dietician, and the regional director of clinical operations, confirmed the lack of documentation and completion of both daily weights and dialysis assessments. The facility's own policy required pre and post dialysis assessments and daily weights per physician orders, but these were not followed for the resident in question. No explanations were provided for the missing documentation, and the deficiency was acknowledged by facility leadership during the survey.
Failure to Initiate Admission Assessments and Physician Orders; Incomplete Wound Care Documentation
Penalty
Summary
The facility failed to ensure that a newly admitted resident's immediate care and service needs were assessed and that physician orders were initiated at the time of admission. The resident, who had multiple complex diagnoses including local skin infection, non-pressure ulcers on both lower legs, peripheral vascular disease, diabetes, hypertension, COPD, and major depressive disorder, was admitted without an admission note, physician notification, or verification of admission orders. Medication reconciliation and initiation of critical treatments, including antibiotics, pain management, insulin, and wound care, were delayed until one to two days after admission. Required assessments such as vital signs, height, and weight were also not completed upon admission. The report further details that the admitting nurse did not complete any of the required admission assessments or initiate any of the admitting physician orders from the hospital. This resulted in missed medications, treatments, and assessments for the resident during the initial period of their stay. The facility's policy required a systematic evaluation and prioritization of resident needs upon admission, including medication reconciliation and implementation of all hospital orders, which was not followed in this case. Additionally, the facility failed to provide wound care treatments according to physician orders for another resident. The resident had an order for daily wound care to the right lower leg, but the treatment was not performed as ordered on one occasion. Furthermore, a dressing was applied to the left lower leg without a physician's order or documentation, and the physician was not notified of the new open area. Facility policy required appropriate treatment selection, obtaining a physician's order, and documentation in the treatment administration record, which was not adhered to in this instance.
Failure to Accurately Assess and Timely Treat Pressure Ulcer
Penalty
Summary
The facility failed to ensure accurate wound assessments and timely implementation of physician-ordered treatments for a resident with significant medical conditions, including osteomyelitis, peripheral vascular disease, and cellulitis. Upon admission, the resident had no documented pressure ulcers, only surgical incisions, as confirmed by both hospital discharge records and the facility's nursing admission evaluation. However, subsequent documentation, including the Minimum Data Set (MDS) and care plan, indicated the presence of a Stage III pressure ulcer on the right buttock as present upon admission, despite no prior skin assessment or documentation supporting this finding. The first wound assessment and treatment order for the pressure ulcer were not completed until several days after admission. Further review revealed that the nurse practitioner assessed the resident and provided a treatment order for the Stage III pressure ulcer, but failed to enter the order into the computer system until nine days later. As a result, the prescribed wound care was not initiated until this delay was rectified. Interviews with facility staff confirmed the lack of timely documentation and implementation of wound care orders, as well as the absence of an initial skin assessment identifying the pressure ulcer. The facility's policy required prompt review, selection, and documentation of appropriate wound treatments, which was not followed in this case.
Failure to Timely Obtain and Administer Medications from Pharmacy
Penalty
Summary
The facility failed to ensure that medications were obtained and available from the pharmacy in a timely manner to meet the needs of residents. For one resident admitted with multiple diagnoses including cellulitis, diabetes, hypertension, and depression, a review of the Medication Administration Record showed that numerous prescribed medications, such as antihypertensives, antidepressants, diabetes medications, and IV antibiotics, were not administered on the day of admission due to unavailability from the pharmacy. The resident reported feeling unwell, experiencing nausea and pain, and was unable to participate in therapy or personal care activities as a result of not receiving her medications. Another resident, admitted with diagnoses including skin infection, peripheral vascular disease, diabetes, and COPD, did not receive several ordered medications, including an antidepressant, anticonvulsant, and IV antibiotic, because they were not available from the pharmacy. Interviews with nursing staff confirmed that it was not uncommon for new admissions to experience delays of up to a day and a half before medications arrived from the pharmacy, particularly for medications not stocked in the automated dispensing system. The Director of Nursing verified that missed doses occurred due to medication unavailability. Facility policy required the pharmacy to supply and deliver needed medications, but this was not consistently achieved.
Failure to Follow Enhanced Barrier Precautions During IV Medication Administration
Penalty
Summary
A deficiency occurred when a Licensed Practical Nurse (LPN) failed to follow Enhanced Barrier Precautions (EBP) during the administration of intravenous (IV) antibiotics to a resident. The resident had a history of local skin infection, cellulitis of the left lower extremity, a displaced bicondylar fracture of the left tibia, type II diabetes mellitus, hypertension, major depressive disorder, and acute embolism and thrombosis of the deep vein of the left lower extremity. The resident was admitted with a peripherally inserted central catheter (PICC) and was receiving IV antibiotics for a soft tissue infection. The care plan and physician orders specified that EBP, including the use of gown and gloves, were required when administering medications via the PICC line. During direct observation, the LPN administered IV antibiotics to the resident without wearing the required personal protective equipment (PPE), specifically a gown and gloves. The LPN later confirmed awareness that the resident was under EBP and acknowledged that proper PPE should have been used. Facility policy on EBP and intermittent infusion both outlined the necessity of gown and gloves for residents with indwelling medical devices such as PICC lines, but these protocols were not followed during the observed medication administration.
Failure to Provide Scheduled Showers for Residents
Penalty
Summary
The facility failed to ensure that showers were completed as scheduled and preferred for four residents who required staff assistance. Resident #7, who had medical diagnoses including hemiplegia, hemiparesis, and epilepsy, was dependent on staff for showers and did not receive them on multiple scheduled dates. Similarly, Resident #8, with conditions such as necrotizing fasciitis and a stage four pressure ulcer, also missed several scheduled showers despite being dependent on staff assistance. Resident #36, diagnosed with neuroleptic induced parkinsonism and schizoaffective disorder, required substantial assistance for showers but did not receive them on numerous scheduled days. Resident #42, who had medical issues including necrotizing fasciitis and encephalopathy, also missed scheduled showers. Interviews with nursing staff and residents confirmed that showers were not consistently provided as scheduled, with no explanation given for the missed showers. This deficiency was identified during the investigation of a complaint.
Failure to Follow Enhanced Barrier Precautions
Penalty
Summary
The facility failed to ensure Enhanced Barrier Precautions (EBP) were followed for a resident, which was identified during an investigation of a complaint. The resident, who had medical diagnoses including necrotizing fasciitis, a stage four pressure ulcer, type two diabetes mellitus, morbid obesity, hypertension, and neuromuscular dysfunction of the bladder, was under EBP due to wound and ostomy care needs. Despite the presence of appropriate signage and Personal Protective Equipment (PPE) supplied for EBP, two registered nurses did not wear the required PPE, including gowns, while performing wound care for the resident. The facility's policy on Enhanced Barrier Precautions emphasizes the use of hand hygiene and targeted gown and glove use during high-contact resident care activities, such as wound care. However, during an observation, it was noted that the registered nurses did not adhere to these precautions. The nurses acknowledged that they should have worn PPE, including gowns, during the care of the resident. This incident was documented as a deficiency in infection control practices, affecting one resident out of four reviewed for infection control, in a facility with a census of 83 residents.
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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