Austinwoods Rehab Health Care
Inspection history, citations, penalties and survey trends for this long-term care facility in Austintown, Ohio.
- Location
- 4780 Kirk Rd, Austintown, Ohio 44515
- CMS Provider Number
- 365654
- Inspections on file
- 23
- Latest survey
- November 17, 2025
- Citations (last 12 mo.)
- 3
Citation history
Health deficiencies cited at Austinwoods Rehab Health Care during CMS and state inspections, most recent first.
A resident with a recent hip injury and surgery experienced moderate to severe pain on multiple occasions, but did not receive prescribed Tylenol as needed. During a medication pass, an LPN gave scheduled medications but omitted Tylenol, despite the resident reporting significant pain. The LPN incorrectly referenced other pain management methods that were not ordered or in use, and there was no documentation of non-pharmacological interventions, resident refusal, or provider notification. The lack of timely pain management and appropriate documentation resulted in a deficiency.
A medication pass observation revealed a 16% error rate, with two residents affected by missed doses, late administration, and inaccurate documentation. An LPN failed to administer all scheduled medications, gave some outside of prescribed timeframes, and signed for doses not actually given, resulting in noncompliance with medication administration policies.
A resident's blood glucose meter was not properly cleaned and disinfected between uses, as an LPN used only an alcohol wipe instead of following the required two-step process with EPA-registered disinfectant wipes. Additionally, another resident with an enteral feeding tube did not receive medication administration under enhanced barrier precautions, as the LPN failed to wear a gown as required by facility policy and CDC guidelines. Both deficiencies were confirmed through staff interviews and policy review.
Staff failed to perform hand hygiene during wound care and incontinence care for two residents, as observed when an LPN and CNA did not wash hands before or after glove use, handled soiled dressings and personal items, and touched various surfaces without proper hand hygiene. These actions were confirmed by staff interviews and were not in accordance with facility policy or CDC guidelines.
A resident with multiple chronic conditions, including heart disease and asthma, was observed receiving oxygen therapy without a physician's order. Review of the care plan and facility policy confirmed that oxygen administration required a physician's order, and an RN verified that no such order was present.
A resident with multiple chronic conditions was found with discontinued nasal sprays at her bedside, which she self-administered without a physician's order or care plan approval. Staff allowed this practice to promote independence, contrary to facility policy requiring secure storage and proper authorization for self-administration.
A resident with multiple medical conditions and a prosthetic infection was prescribed weekly CRP and SED Rate labs while receiving IV antibiotics. On one scheduled date, the facility failed to collect and process the required labs, as confirmed by the DON, resulting in a missed physician order.
Staff failed to perform hand hygiene during wound and incontinence care for two residents. An LPN and CNA did not wash hands before or after providing wound care to a resident with multiple pressure ulcers, handling both the resident and room items with contaminated gloves. In a separate incident, an LPN and CNA did not perform hand hygiene before or after incontinence care for another resident, touching various surfaces and supplies, including items contaminated with feces. Both staff confirmed the lapses, which were not in accordance with facility policy or CDC guidelines.
A resident with multiple medical conditions, including quadriplegia and osteoporosis, required two-person assistance for bed mobility. However, a single STNA attempted to assist the resident alone, resulting in a fractured hip. Despite the resident's complaints of severe pain, there was a delay in obtaining an x-ray and notifying the physician, contrary to facility policy. The deficiency was identified during a complaint investigation.
A resident's pressure ulcer worsened from Stage I to unstageable due to the facility's failure to implement an effective prevention program, including turning and repositioning every two hours. The wound nurse was unaware of the resident's condition until it had significantly deteriorated, and there was no communication with the dialysis center regarding necessary interventions.
A resident with a complex medical history requested to go to the hospital for a CT scan due to concerns about a possible stroke. Despite this request, the nursing staff did not immediately inform the physician or facilitate the transfer. The resident was eventually sent to the hospital later that morning, diagnosed with a urinary tract infection, and received treatment before returning to the facility.
A facility failed to obtain timely laboratory tests for a resident with multiple serious health conditions, resulting in a significant delay in identifying critical lab values. Despite a STAT order for a CBC and CMP, the lab did not receive the order, and the bloodwork was not drawn until the following day, leading to the resident's transfer to the emergency room for further evaluation and treatment.
The facility failed to ensure that NPs provided visit notes in a timely manner and dated notes consistently, affecting a resident with a complex medical history. The DON confirmed that multiple notes were undated, violating the facility's Physician Services Policy.
The facility failed to implement Enhanced Barrier Precautions and proper PPE use for two residents. One resident with an unstageable pressure ulcer did not receive appropriate gown use during wound and incontinence care, and another resident with a feeding tube had a gown reused for multiple encounters, contrary to CDC guidelines.
Failure to Timely and Appropriately Address Resident Pain
Penalty
Summary
A deficiency was identified when a resident with a history of right hip dislocation, recent surgical intervention, and multiple comorbidities was not provided timely and appropriate pain management. The resident was admitted for post-surgical care and had an order for Tylenol 650 mg every four hours as needed for pain. Despite documented pain assessments indicating moderate to severe pain, the baseline care plan did not include interventions for pain related to the hip injury or surgery, and pain assessments were inconsistently documented. On several occasions, the resident reported moderate to severe pain, including two instances of severe pain, but did not receive Tylenol as ordered. During a medication pass, an LPN administered scheduled medications but did not include Tylenol, despite the resident expressing significant pain and rating it as an eight out of ten. The LPN incorrectly informed the resident that another medication (meloxicam) was for her pain and referenced a pain patch that was not actually ordered or applied. No documentation was found to indicate that non-pharmacological interventions were offered, that the resident declined Tylenol, or that the provider was notified of the increased pain. Further review of the medical record revealed no additional pain assessments or administration of Tylenol after the resident's reports of severe pain. The facility's medication administration policy required medications to be given timely and as prescribed, based on resident need and benefit. The failure to address the resident's pain in a timely and appropriate manner, as well as the lack of documentation and follow-up, led to the cited deficiency.
Medication Error Rate Exceeds Acceptable Threshold
Penalty
Summary
The facility failed to maintain a medication error rate below five percent during a medication administration observation, resulting in a 16% error rate. This was identified through record reviews, direct observation, and staff interviews. Four errors were found out of 25 medication administration opportunities, affecting two residents. The errors included missed doses, incorrect documentation, and failure to administer medications within the prescribed timeframes or according to specific instructions. For one resident with multiple diagnoses including post-surgical needs, hypertension, and anemia, the LPN prepared and administered only nine out of thirteen scheduled morning medications. Some medications, such as Vitamin E, were not available and thus not given, while others like Culturelle were administered after the surveyor left. Additionally, niacin and cefadroxil were signed as given on the MAR, but physical counts of the medication packets indicated that not all signed doses had actually been dispensed. The LPN confirmed that some medications did not appear on the MAR at the time of administration, leading to missed doses and inaccurate documentation. Another resident with complex medical conditions, including end stage renal disease and diabetes, was scheduled to receive sevelamer before meals. However, the medication was administered more than 30 minutes after breakfast, outside the prescribed timeframe, and more than one hour after the scheduled time on the MAR. The LPN acknowledged that the medication was not given as ordered, and facility policy required medications to be administered within one hour of the prescribed time or according to specific instructions such as before meals. These actions and inactions directly contributed to the facility's failure to ensure safe and accurate medication administration.
Failure to Properly Disinfect Glucometer and Maintain Enhanced Barrier Precautions
Penalty
Summary
The facility failed to ensure proper cleaning and disinfection of a blood glucose meter (BGM) after use with a resident who had complex medical conditions, including diabetes mellitus and dependence on renal dialysis. An LPN was observed using a single alcohol wipe to briskly clean only the front of the BGM before returning it to the medication cart, rather than following the facility's policy and the manufacturer's instructions, which require a two-step process using approved EPA-registered disinfectant wipes and a specified wet contact time. The LPN also demonstrated a lack of knowledge regarding the correct cleaning procedure, and the DON confirmed that the observed method was not compliant with facility policy or manufacturer guidelines. Additionally, the facility did not maintain enhanced barrier precautions (EBP) during medication administration through an enteral feeding tube for a resident with multiple medical devices and severe cognitive impairment. An LPN administered medication via the feeding tube without wearing a gown, despite the resident being on EBP per CDC guidelines and the facility's policy, which require the use of gowns and gloves during care involving enteral feeding tubes. The LPN acknowledged awareness of the EBP requirement but did not don the appropriate personal protective equipment during the procedure. Both deficiencies were confirmed through interviews with the involved LPNs and the DON, as well as review of facility policies and manufacturer instructions. The findings were based on direct observations, record reviews, and staff interviews, and affected multiple residents who either had their blood sugar checked with the BGM or had enteral feeding tubes requiring EBP.
Failure to Perform Hand Hygiene During Resident Care
Penalty
Summary
Staff failed to perform proper hand hygiene during wound care and incontinence care for two residents, as observed and confirmed through interviews and record reviews. In the first instance, a resident with multiple complex medical conditions, including multiple sclerosis, quadriplegia, and several pressure ulcers, received wound care from an LPN and a CNA who did not perform hand hygiene before donning gloves, after removing soiled dressings, or before handling clean supplies and personal items. The LPN continued to use the same gloves to reposition the resident and handle various items in the room, and only changed gloves without performing hand hygiene before exiting the room. The CNA also failed to perform hand hygiene before and after assisting with the procedure and handling the resident's personal items. In the second instance, another resident with bowel and bladder incontinence and multiple diagnoses received incontinence care from an LPN who did not wash her hands before donning gloves or after removing them. The LPN touched various surfaces and items in the resident's room, including the call light, bed remote, and bedside drawer, and also touched the resident's bandage and bed linens without performing hand hygiene. The LPN handled a package of incontinence wipes contaminated with feces and placed it on top of the resident's clean clothing. A CNA who assisted with repositioning the resident also failed to perform hand hygiene before donning gloves. The LPN eventually performed hand hygiene only after leaving the resident's room and handling soiled items. Both incidents were verified through interviews with the involved staff, who acknowledged not performing hand hygiene as required. The facility's handwashing policy and CDC guidelines were reviewed, both of which require hand hygiene before and after resident contact, after contact with blood or body fluids, and after touching contaminated surfaces. The failure to follow these protocols resulted in a deficiency related to infection control practices.
Oxygen Therapy Administered Without Physician Order
Penalty
Summary
A resident with diagnoses including hypertensive heart disease with chronic kidney disease, dementia, type 2 diabetes mellitus, and asthma was observed using an oxygen concentrator over a period of nearly two hours. Review of the resident's medical record and physician's orders revealed there was no physician's order for oxygen therapy, despite the resident actively receiving oxygen. The resident's care plan indicated that oxygen should be administered as ordered by a physician, and the facility's policy required verification of a physician's order for oxygen use. An RN confirmed that the resident did not have a physician's order for oxygen therapy at the time of the observation.
Improper Storage and Unauthorized Self-Administration of Discontinued Medications
Penalty
Summary
Facility staff failed to ensure that drugs and biologicals were properly stored and labeled according to professional standards. Specifically, a resident with diagnoses including type two diabetes mellitus, major depressive disorder, and hypertension was found to have two nasal sprays—Flonase and ipratropium bromide—at her bedside. Both medications had been discontinued by the physician, and there was no physician order permitting the resident to self-administer these medications or to keep them at her bedside. The care plan did not address self-administration, and the facility's own policy required a physician's order and interdisciplinary team decision for self-administration, as well as secure storage of medications accessible only to authorized personnel. Interviews with the resident and a registered nurse confirmed that the resident was allowed to keep and self-administer the nasal sprays, with staff stating this was to promote independence. However, the nurse later acknowledged that there was no order for self-administration and that the medications had been discontinued. The medications were subsequently removed from the bedside and returned to secure storage, but the initial failure to follow policy and physician orders resulted in the deficiency.
Failure to Obtain Ordered Laboratory Testing for a Resident
Penalty
Summary
A deficiency occurred when the facility failed to obtain physician-ordered laboratory testing for a resident with multiple medical conditions, including infection and inflammatory reaction due to a knee prosthesis, atrial fibrillation, peripheral vascular disease, rhabdomyolysis, venous thrombosis, and cognitive deficit. The resident was receiving intravenous antibiotics for a prosthetic infection, and there was a standing physician order for weekly C-Reactive Protein (CRP) and erythrocyte sedimentation rate (SED Rate) tests every Monday, with results to be faxed to infectious disease. Record review showed that while laboratory results were available for two Mondays, there were no results for one of the scheduled dates. The Director of Nursing confirmed that no lab specimen was collected on that date, and thus no results were available. Facility policy required licensed nursing professionals to be aware of and follow all physician orders as written, but this order was not followed for the specified date.
Failure to Perform Hand Hygiene During Resident Care
Penalty
Summary
Staff failed to perform proper hand hygiene during wound care and incontinence care for two residents, as observed by surveyors. In the first instance, a resident with multiple complex medical conditions, including quadriplegia and multiple pressure ulcers, received wound care from an LPN and a CNA who did not perform hand hygiene before donning gloves, after removing soiled dressings, or after removing gloves. The staff handled various items in the resident's environment, such as the call light and bed remote, without changing gloves or performing hand hygiene, and exited the room with clean supplies without sanitizing their hands. In the second instance, another resident requiring maximum assistance with toileting due to bowel and bladder incontinence was provided incontinence care by an LPN who also failed to wash hands before donning gloves, after removing gloves, and after cleaning the resident. The LPN touched multiple surfaces and personal items in the resident's room, including the call light, bed linens, and a package of incontinence wipes contaminated with feces, without performing hand hygiene. A CNA who assisted with repositioning the resident also failed to perform hand hygiene before donning gloves. Both staff members involved in each incident confirmed during interviews that they did not perform hand hygiene as required. The facility's handwashing policy and CDC guidelines were not followed, which require hand hygiene before and after resident contact, after contact with body fluids, and after touching contaminated surfaces.
Failure to Provide Adequate Assistance Leads to Resident Injury
Penalty
Summary
The facility failed to provide adequate two-person assistance with bed mobility for a resident, resulting in an injury. The resident, who had multiple medical conditions including multiple sclerosis, quadriplegia, and osteoporosis, was assessed to require two-person assistance for bed mobility. However, on the day of the incident, a single State Tested Nursing Assistant (STNA) attempted to assist the resident alone, leading to the resident experiencing extreme pain and subsequently being diagnosed with a fractured hip. The incident occurred when the STNA attempted to move the resident's pillow from one side to the other, lifting the resident's left side without assistance. Despite the resident's expression of severe pain, the STNA did not seek immediate medical evaluation. The resident continued to experience pain over the following days, and an x-ray was not performed until two days later, which confirmed the fracture. Interviews with staff revealed that the STNA was unaware of the two-person assistance requirement, and there was a lack of communication regarding the resident's condition and pain management. The facility's policy required communication with the physician and responsible parties in the event of a significant change in condition, which was not adequately followed. The resident reported the incident and pain to multiple staff members, but there was a delay in obtaining an x-ray and notifying the physician. The deficiency was identified during a complaint investigation, highlighting a failure in adhering to the resident's care plan and ensuring proper supervision to prevent accidents.
Failure to Implement Effective Pressure Ulcer Prevention Program
Penalty
Summary
The facility failed to develop and implement an effective and individualized pressure ulcer prevention program for Resident #37, leading to the worsening of a pressure ulcer on the coccyx. Resident #37 was admitted with a Stage I pressure ulcer, which deteriorated to an unstageable pressure ulcer. The facility did not ensure adequate interventions, such as turning and repositioning every two hours, were provided to prevent the deterioration of the ulcer. Additionally, there was no documented evidence of these interventions being performed, and the wound nurse was not aware of the resident's condition until it had significantly worsened. Resident #37 had multiple diagnoses, including end-stage renal disease, atrial fibrillation, and a recent hip fracture with surgical intervention. The resident was dependent on staff for mobility and had a care plan that included turning and repositioning every two hours, a pressure-reducing mattress, and a zinc cream with foam dressing for the coccyx wound. Despite these interventions being documented, there was no evidence that they were consistently implemented. The wound nurse did not assess the resident's wound until several days after being notified of concerns, and there was no communication with the dialysis center regarding the resident's pressure ulcer and necessary interventions. Interviews with staff and the resident's family revealed that the resident was compliant with turning and repositioning, but staff were not required to document these actions. The wound nurse and other staff members failed to perform comprehensive skin assessments and did not notify physicians of the resident's condition. The facility's policy on pressure ulcer identification and treatment was not followed, resulting in actual harm to Resident #37.
Failure to Honor Resident's Right to Choose Treatment
Penalty
Summary
The facility failed to honor a resident's right to choose their plan of treatment, specifically regarding the decision to go to the hospital. Resident #88, who had a complex medical history including acute pulmonary edema, type two diabetes mellitus, end stage renal disease, and other significant conditions, expressed a desire to go to the hospital for a CT scan due to concerns about a possible stroke. Despite this request, the nursing staff did not immediately inform the physician or facilitate the transfer to the hospital, as was discussed with the nurse practitioner the previous day. The resident's request was documented in the nursing notes, but there was no indication that the physician was made aware of the request at that time. The resident continued to insist on being sent to the hospital, and it was not until later that morning that the transfer was arranged. Upon evaluation at the hospital, the resident was diagnosed with a urinary tract infection and received treatment before being transferred back to the facility. The facility's failure to promptly respond to the resident's request to go to the hospital, as outlined in the Nursing Home Resident's Bill of Rights, constituted a deficiency in honoring the resident's right to choose their plan of treatment.
Failure to Obtain Timely Laboratory Tests
Penalty
Summary
The facility failed to obtain laboratory tests in a timely manner for a resident with multiple serious health conditions, including acute pulmonary edema, type two diabetes mellitus, and end stage renal disease. On 03/01/24, a STAT order was written for a Complete Blood Count (CBC) and Comprehensive Metabolic Panel (CMP) due to the resident's complaints of pain and nausea, and concerns about low sodium levels. Despite the urgency, the lab did not receive the order, and the bloodwork was not drawn until 4:50 P.M. on 03/02/24, well beyond the expected four-hour window for STAT orders as per the facility's Laboratory Services Agreement. The delay in obtaining the lab results led to a significant delay in identifying critical lab values, including a hemoglobin value of 6.2 grams per deciliter and a hematocrit of 20.3%, which necessitated the resident's transfer to the emergency room for further evaluation and treatment. The Director of Nursing (DON) confirmed that the STAT labs ordered on 03/01/24 were not obtained in a timely manner, as they were not drawn until the following day. The facility's Laboratory Services Agreement, effective since 05/02/22, stipulated that STAT phlebotomy services should be available 24/7 and provided within four hours of the request. The failure to adhere to this agreement and the delay in obtaining the necessary lab tests resulted in a significant lapse in the resident's care, as evidenced by the delayed response to the resident's critical condition.
Failure to Ensure Timely and Dated Visit Notes by Nurse Practitioners
Penalty
Summary
The facility failed to ensure that nurse practitioners provided visit notes in a timely manner and dated notes consistently to determine when the visits were made. This deficiency affected one resident, who had a complex medical history including acute pulmonary edema, type two diabetes mellitus, end stage renal disease, and other serious conditions. During an interview, the Director of Nursing (DON) confirmed that there was only one progress note from the nurse practitioner (NP) in the medical record, despite knowing that the NP had visited the resident more frequently. The DON had to call the NP to load additional notes into the electronic health record, but several of these notes did not contain the dates of the visits. The facility's Physician Services Policy required physicians to sign and date all orders and progress notes at each visit to ensure care and services were provided according to the most recent order. However, multiple notes from the NP were found to be undated, which was verified by the DON. This deficiency was identified during the investigation of a master complaint and highlighted the facility's failure to maintain accurate and timely medical records in accordance with accepted professional standards.
Failure to Implement Enhanced Barrier Precautions and Proper PPE Use
Penalty
Summary
The facility failed to implement Enhanced Barrier Precautions while providing wound care and incontinence care for Resident #37 and failed to appropriately use Personal Protective Equipment (PPE) while caring for Resident #44. Resident #37, who had diagnoses including end-stage renal disease and dependence on renal dialysis, had an order for wound care on an unstageable pressure ulcer. During an observation, a State tested Nursing Assistant (STNA) and a Licensed Practical Nurse (LPN) did not wear gowns while providing incontinence care and changing the dressing on Resident #37's wound, despite CDC guidelines requiring gowns and gloves for such high-contact care activities. Additionally, Resident #44, who had a feeding tube and was on enhanced barrier precautions, was observed with a non-pervious gown hanging on the door for multiple uses by staff. The LPN indicated that the facility believed CDC guidance was unclear regarding the re-use of gowns. However, CDC guidelines clearly state that gowns and gloves should be removed and discarded after each resident care encounter. The facility's Administrator insisted on the re-use of gowns, leading to non-compliance with infection control protocols.
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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