Beachwood Pointe Care Center
Inspection history, citations, penalties and survey trends for this long-term care facility in Beachwood, Ohio.
- Location
- 23900 Chagrin Blvd, Beachwood, Ohio 44122
- CMS Provider Number
- 365071
- Inspections on file
- 48
- Latest survey
- February 5, 2026
- Citations (last 12 mo.)
- 11
Citation history
Health deficiencies cited at Beachwood Pointe Care Center during CMS and state inspections, most recent first.
Surveyors found heavily soiled hallways and an unsanitary main shower area, including used soap on the floor, rust stains, mold, and dried stains on shower equipment. A resident with multiple chronic conditions and intact cognition reported refusing to shower due to the dirty environment, and another resident stated the only working shower was disgusting and that shower chairs were covered in feces and urine. These conditions conflicted with the facility’s policy requiring a clean, sanitary, and orderly homelike environment.
A resident with multiple diagnoses, impaired cognition, frequent incontinence, and need for substantial assistance with mobility did not receive a comprehensive, timely care plan. At admission, the facility created care plans only for malnutrition and activities, and later added plans for DM, polypharmacy, HTN, antidepressant use, and ADLs. The facility did not create care plans for mechanical lift transfers, verbal aggression toward staff and peers, or bowel and bladder incontinence, despite these being identified needs. The MDS nurse stated care plans should be created on admission, and the DON confirmed the lack of these care plans, contrary to the facility’s policy requiring an IDT-developed, person-centered care plan for each resident.
Two residents who were dependent on staff for ADLs and experienced frequent bowel and bladder incontinence did not receive incontinence care as ordered and as needed. Care plans required regular checks, toileting assistance, peri-care, and use of moisturizers/barrier creams, but incontinence records showed an average of only two changes per day. One resident reported long waits to be changed, and another reported being left in a soiled brief for hours. An LPN and a CNA stated that residents had longer wait times when staffing was short, and the DON confirmed there was no documentation showing that incontinence care was consistently provided as ordered and as needed.
A resident with insulin-dependent type 2 DM and intact cognition had expired orders for sliding-scale insulin and continuous glucose monitoring, with no new orders entered, while the care plan called for diabetes medications as ordered and monitoring for effectiveness. Over a multi-week period, staff checked the resident’s blood glucose only sporadically, with several days of no checks, and the resident reported that blood sugars were not being monitored throughout the day. An LPN acknowledged checking blood glucose without an active order and described random, unscheduled monitoring, and the DON confirmed there were no current orders for sliding-scale insulin or routine blood glucose checks. The facility’s insulin administration policy offered little guidance on the frequency of blood glucose monitoring.
Surveyors found that staff failed to monitor and safely store food brought in by families and visitors, resulting in unlabeled and moldy food items in a resident lounge refrigerator. The refrigerator was also found to be soiled and sticky, and there was confusion among staff about who was responsible for monitoring and discarding perishable foods, contrary to facility policy.
Surveyors observed that the dumpster area was not maintained in a clean and sanitary condition, with loose rubbish found around and under the stairs leading to the dumpster. The Administrator confirmed that maintenance was responsible for weekly cleaning after the dumpster was emptied, in accordance with facility policy. This lapse had the potential to impact all residents.
Surveyors found widespread unclean and non-homelike conditions, including visible dirt, overflowing garbage, broken fixtures, and dust throughout the facility. These issues were confirmed by facility staff and were not in accordance with the facility's policy for maintaining a safe, clean, and comfortable environment, potentially affecting all residents.
The facility did not follow dietitian-approved menus or maintain menu item availability during meal service, resulting in unapproved substitutions, inconsistent portion sizes, and lack of adherence to standardized recipes. Substitutions were made without consulting the RD, and menu items were depleted during service, affecting residents on various diets, including those requiring pureed or mechanical soft foods.
The facility did not ensure that meals were prepared and served according to approved menus and recipes, resulting in unapproved substitutions, missing menu items, and food served below safe temperatures. Staff did not consistently document substitutions or consult with the RD, and test trays revealed food was often unpalatable, improperly textured, and not warm enough. These deficiencies affected all residents receiving meals.
Surveyors found that the facility did not maintain a sanitary kitchen, with expired food items left in storage, incomplete cleaning logs, and missing food temperature records. These failures had the potential to affect nearly all residents receiving meals from the kitchen, in violation of facility policy and food safety standards.
Several residents did not receive their physician-ordered pureed diets, with staff substituting menu items and failing to ensure the correct texture and temperature of pureed foods. The Food Service Director made substitutions without consulting the RD, and test trays were not routinely performed to verify food quality, resulting in residents receiving meals that did not meet their prescribed dietary needs.
A facility failed to reorder medications in a timely manner, causing a resident with breast cancer to miss doses of Verzenio. The error occurred when an agency nurse stored empty boxes in the medication cart, leading to a miscount and delay in reordering. The resident missed approximately two days of doses, as confirmed by the DON.
The facility failed to provide privacy curtains in shared rooms, affecting two residents who had to use the bathroom to change clothes for privacy. The absence of curtains or hooks for hanging them was confirmed through observations and interviews with the residents and the Administrator.
The facility failed to maintain kitchen sanitation and equipment, affecting resident safety. The dishwasher's temperature gauges were non-functional, and staff were unaware of proper sanitation procedures. Additionally, the three-compartment sink lacked testing strips for sanitizer concentration, and freezer temperatures were not maintained, resulting in improperly frozen food. These issues were not recognized by the staff or administration, leading to deficiencies in compliance with facility policies.
The facility failed to maintain a clean and homelike environment, with pervasive urine odors, unsanitary conditions, and missing door thresholds affecting residents' quality of life. Observations revealed strong urine odors and soiled bedding due to inadequate incontinence care. Staff confirmed these findings, and the facility's policy on maintaining a homelike environment was not followed.
The facility failed to investigate and report allegations of verbal abuse and withholding of medication involving two residents. One resident alleged an LPN verbally abused her and withheld pain medication, while another resident's family member reported a CNA yelling at residents. The facility did not conduct investigations or file required reports, dismissing the allegations as behavioral issues or lacking evidence.
The facility failed to report and investigate allegations of abuse involving two residents. One resident alleged verbal abuse and medication withholding by an LPN, while another's family member reported a CNA yelling at residents. The facility did not conduct investigations or file required reports, dismissing the claims as behavioral issues. This non-compliance was identified under a complaint investigation.
The facility failed to investigate allegations of verbal abuse and withholding of medication involving two residents. One resident alleged an LPN verbally abused her and withheld pain medication, while another resident's family member reported a CNA yelling at residents. The facility did not conduct investigations, dismissing the allegations as behavioral issues or lacking evidence, violating their abuse prevention policy.
The facility failed to provide timely incontinence care to several residents, including those with cognitive impairments and hospice needs. A resident with spastic hemiplegia was found in a neglected state due to staffing miscommunication, while another with schizophrenia had a urine-soaked room with no care documentation. A hospice resident reported long delays in care, and another resident's care needs were misdocumented, leading to inadequate attention. These incidents highlight systemic issues in managing incontinence care.
The facility failed to maintain sufficient and competent staff, resulting in neglect of residents. A resident with spastic hemiplegia was not provided incontinence care for over 10 hours, leading to soaked bedding and a strong urine odor. Another resident with schizophrenia and dementia had a urine-soaked room, with no documented care provided. A third resident with diabetes and urinary incontinence was found with stained bedding and an inaccurate care plan. The facility's staffing policies and assessments were inadequate, leading to significant deficiencies.
The facility failed to employ a qualified dietary manager, as the current manager lacked formal training and had not passed the SERV Safe course. Additionally, the facility did not have a full-time dietitian, with the current dietitian working only seven to ten hours per week. This deficiency had the potential to affect all 94 residents receiving food from the facility kitchen.
The facility failed to maintain sanitary conditions in food storage and preparation, affecting 94 residents. Expired food items were found, and condiment packets lacked expiration dates. Cleaning schedules were not followed, with incomplete logs and unsanitary conditions in the kitchen. Temperature monitoring for dish machines and refrigerators was inadequate, violating facility policies.
The facility failed to maintain a safe, sanitary, and homelike environment for residents, with issues such as chipped paint, stained curtains, and missing furniture parts observed in several rooms. Despite weekly inspections through a program called Angel Walks, deficiencies persisted, including peeling paint, lack of supplies, and missing dresser drawers, as confirmed by staff and family interviews.
The facility failed to develop and implement comprehensive care plans for several residents, including those requiring repositioning, wound care, PTSD management, and hospice coordination. Despite staff awareness of these needs, care plans were either missing or incomplete, indicating a systemic issue in addressing resident-specific requirements.
A resident with chronic respiratory failure, hypertension, and dementia was not monitored for cholesterol levels as recommended by the pharmacy. Despite a physician's approval for a lipid panel to be conducted, a laboratory error resulted in the test being scheduled for the following year, leaving the resident without the necessary monitoring since the last test in June 2022.
The facility did not adhere to the pureed diet menu for residents requiring such diets, affecting three residents. Despite the menu specifying pureed chicken, vegetables, bread, and cookies, only the chicken and vegetables were pureed, and pureed bread was omitted. This was confirmed through observation and staff interviews, indicating a failure to follow the facility's puree food preparation policy.
A facility failed to timely complete medical record requests for a resident with significant medical conditions, despite multiple requests from the family attorney. The medical records department and social services assistant were unaware of the requests, and the administrator had forwarded the request to the facility owner, who indicated that attorneys would handle it. No evidence of the request was found in the logbook, highlighting a communication and record-keeping breakdown.
A facility failed to obtain a STAT urinalysis for a resident with an indwelling catheter, delaying UTI treatment. The test ordered by a physician was not collected until several days later, despite expectations for quicker processing. The facility's policy lacked guidance on STAT lab timeframes.
A facility failed to consistently document physician-ordered treatments for a resident, including weekly Braden assessments, catheter care, and specific wound care instructions. The Treatment Administration Record showed missing entries for these orders on several occasions, which was confirmed by the DON.
A resident's call light was found to be non-functional, as reported by the resident and confirmed by the DOM during an observation. The DOM had previously replaced the bulb, but the issue persisted due to suspected loose wiring. The facility's policy required regular checks of call lights by nursing and maintenance staff.
The facility failed to maintain a clean, safe, and sanitary environment, affecting a resident and potentially all 90 residents. Observations revealed a door hanging off in a resident's room, food splatter on window shades, a cabinet door hanging off in the dining room, and peeling paint, mold, and paper on the floor in the shower room. Housekeeping did not clean the dining room after dinner due to the absence of evening staff.
Unsanitary Hallways and Shower Area Affect Resident Bathing
Penalty
Summary
The facility failed to ensure a sanitary, clean, and homelike environment, particularly in resident care areas and the main second-floor shower. Surveyors observed that the hallway for rooms 110 through 122 was heavily soiled with salt from snow, gum, dried stains, and miscellaneous debris, a condition confirmed by a CNA. The facility’s own “Homelike Environment” policy, dated 2001, states that staff and management are to maximize a clean, sanitary, and orderly environment. The second-floor main shower was observed with two used bars of soap on the floor, three used bottles of body soap on the shelf, rust stains and mold covering the shower stall floor, and dried stains on the shower chair and shower bed frame. These conditions were verified by a unit manager. One resident with intact cognition, admitted with diagnoses including type 2 diabetes, chronic pain, anxiety disorder, muscle weakness, and bilateral age-related nuclear cataracts, reported that the shower was very dirty and that she did not want to shower there. Another resident stated she would not shower because the only working shower was on the second floor and described the shower chairs as covered in feces and urine. These findings were investigated under a complaint number and involved two of three residents observed for environment, with potential impact on all residents using the second-floor shower.
Failure to Develop Comprehensive, Timely Care Plan for Resident Needs
Penalty
Summary
The facility failed to develop and revise a comprehensive, person-centered care plan in a timely manner for a resident, as required by its policy and as stated by the MDS nurse. The resident was admitted with diagnoses including type 2 diabetes, chronic pain, anxiety disorder, muscle weakness, and bilateral age-related nuclear cataracts, and a quarterly MDS showed impaired cognition, need for substantial assistance with bed mobility and transfers, use of an electric wheelchair, and frequent bowel and bladder incontinence. On admission, the facility created care plans only for malnutrition and activities, and later, on a subsequent date, added care plans for diabetes mellitus, polypharmacy, hypertension, use of antidepressant, and activities of daily living. However, there were no care plans addressing transfers via mechanical lift, the resident’s verbal aggression toward staff and peers, or incontinence of bowel and bladder, despite these being identified needs. The DON confirmed the absence of these care plans, and the deficiency was identified incidentally during a complaint investigation. The facility’s own undated policy on comprehensive person-centered care plans required the interdisciplinary team, in conjunction with the resident and family, to develop and implement a comprehensive care plan for each resident, but this was not fully carried out for this resident, as evidenced by the missing care plan components for key clinical and behavioral issues.
Failure to Provide Ordered and As-Needed Incontinence Care
Penalty
Summary
The facility failed to ensure incontinence care was completed as ordered and as needed for residents who were dependent on staff for activities of daily living. One resident, admitted with diagnoses including spastic hemiplegia, osteoarthritis, and hypertension, had a care plan indicating episodes of incontinence related to aging, with interventions to check the resident every two hours, assist with toileting as needed, and provide peri-care after each incontinent episode. A quarterly MDS showed this resident had impaired cognition, was dependent on staff for all ADLs, used an electric wheelchair, and experienced frequent bowel and bladder incontinence. Review of incontinence sheets over nearly a month showed staff changed this resident on average twice a day, and the resident reported having to wait a long time to be changed, sometimes stating staff did not show up, though she could not provide specific times or dates. Another resident, admitted with diagnoses including type 2 diabetes, chronic pain, anxiety disorder, muscle weakness, and bilateral age-related nuclear cataracts, had a quarterly MDS indicating intact cognition, need for substantial assistance with bed mobility and transfers, use of an electric wheelchair, and frequent bowel and bladder incontinence. The care plan documented that this resident had episodes of incontinence and depended on staff for assistance, with interventions including application of skin moisturizers/barrier creams as needed and provision of toileting/incontinent care as needed. Incontinence sheets for this resident over the same time frame also showed an average of two changes per day. Staff interviews, including with an LPN and a CNA, indicated that when staffing was short, residents experienced longer wait times to be changed. This resident reported being left in a soiled brief for hours throughout the week. The DON confirmed there was a lack of documentation indicating that incontinence care was completed as ordered and as needed.
Failure to Maintain Current Diabetic Orders and Consistent Blood Glucose Monitoring
Penalty
Summary
The deficiency involves the facility’s failure to ensure that a resident’s diabetic drug regimen and related monitoring were supported by current physician orders and appropriate blood glucose checks. A resident with type 2 diabetes, chronic pain, anxiety disorder, muscle weakness, and bilateral age-related nuclear cataracts was admitted on 12/24/25 and had intact cognition, required substantial assistance with mobility, and used an electric wheelchair. The care plan dated 02/03/26 identified the resident as insulin dependent, with interventions to administer diabetes medications as ordered and monitor side effects and effectiveness. The December 2025 and January 2026 MARs showed an order for Humalog KwikPen per sliding scale from 12/27/25 through 01/17/26 and an order for a Freestyle Libre continuous blood glucose monitoring device from 12/31/25 through 01/13/26, with no new orders entered after those end dates. From 01/19/26 through 02/02/26, blood glucose monitoring for this resident was sporadic and not performed consistently throughout the day, with some days having one or two checks and several days with no checks at all. The resident reported that staff were not checking blood glucose levels throughout the day. An LPN stated she checked the resident’s blood glucose without having an order and described the situation as confusing, with staff checking blood sugars randomly rather than on a scheduled basis, and indicated she would need to contact the physician for order verification. The physician later stated he was unaware there was no order to check blood sugars before meals and that it made no sense to check when there was a plan in place. The DON confirmed there was no new order for a sliding scale or for staff to check the resident’s blood glucose three times a day. Review of the facility’s undated Insulin Administration policy showed it provided little guidance on the frequency of blood glucose monitoring.
Failure to Monitor and Safely Store Outside Food in Resident Refrigerator
Penalty
Summary
The facility failed to ensure proper monitoring and safe storage of foods brought in by family and visitors for residents. During an observation of the second-floor resident lounge refrigerator, surveyors found the exterior of the refrigerator heavily soiled with dried food, fingerprints, and a sticky handle. Inside, there was a paper plate with two cheeseburgers and an open package of microwavable chicken patties, both lacking resident names and dates. The chicken patties were visibly moldy and emitted a bad odor. Certified Nurse Aide (CNA) confirmed the presence of mold and the lack of labeling, stating that dietary staff were supposed to monitor the refrigerator. Further interviews revealed confusion regarding responsibility for monitoring the unit refrigerators, with the Dietary Director believing nursing staff were responsible. Review of the facility's policy indicated that perishable foods must be stored in resealable containers labeled with the resident's name, item, and use-by date, and that nursing staff are responsible for discarding perishable foods on or before the use-by date. The failure to follow these procedures had the potential to affect 36 residents on the second floor, with one resident identified as receiving nothing by mouth.
Improper Maintenance of Dumpster Area
Penalty
Summary
The facility failed to maintain the dumpster and refuse area in a clean and sanitary condition, as observed during a survey. On the date of observation, various loose rubbish was found around and underneath the stairs leading to the dumpster. The Administrator confirmed this finding and stated that maintenance is responsible for cleaning the area weekly after the dumpster is emptied to prevent rodent attraction. Review of the facility's policy on garbage and refuse disposal indicated that storage areas and receptacles should be kept in good repair and cleaned frequently enough to prevent buildup or attraction of pests. This deficiency had the potential to affect all 102 residents in the facility.
Failure to Maintain Clean and Homelike Environment
Penalty
Summary
Surveyors observed multiple instances of unclean and non-homelike conditions throughout the facility during building tours. Specific findings included visible dirt at door thresholds, overflowing garbage cans, caked hair and dirt under sinks, stained ceiling tiles, broken mirrors, and plastic tape hanging from overhead lights. Elevator thresholds and baseboards on all units were noted to have built-up dust and debris. Additional issues included missing baseboards exposing walls, peeling paint, dust and dead insects on windowsills, and dirty blinds. Some soap dispensers were found empty, and certain wall areas were damaged or torn away, further exposing the underlying structure. These deficiencies were verified by the Maintenance Director, Environmental Service Director, and a housekeeper at the time of observation. The facility's own policy, which emphasizes providing a safe, clean, comfortable, and homelike environment, was not followed as evidenced by the observed conditions. The findings had the potential to affect all 102 residents residing in the facility. The deficiency was investigated under multiple complaint numbers.
Failure to Follow Dietitian-Approved Menus and Maintain Menu Item Availability
Penalty
Summary
The facility failed to ensure that the registered dietitian-approved dietary menus were followed and that menu items were not depleted during meal service, potentially affecting 99 residents who received meals. Observations revealed that the lunch menu for a specific day was not followed as written: the approved menu called for Chinese pepper steak, fried rice, oriental blend vegetables, iced mandarin orange cake, and beverages, but substitutions and omissions occurred. For example, two different types of cake were served due to running out of the specified mandarin orange cake, and carrot cake was substituted for residents on certain floors. Additionally, the serving size of pepper steak was not consistent with the production sheet, as a four-ounce scoop was used instead of the required six-ounce portion. Further observations and interviews indicated that menu modifications and substitutions were made without consultation or approval from the registered dietitian. For pureed diets, seasoned cream of rice was not provided as a modification for fried rice; instead, pureed wheat bread was given, a change that had not been discussed with the dietitian. The food service director also confirmed that baked chicken was routinely substituted for beef in mechanical soft and pureed diets due to concerns about meat texture, but these substitutions were not documented on the substitution log or menu, and no standardized recipes were followed for these changes. Additionally, when the facility ran out of fried rice, white rice was served instead, and pudding was substituted for pureed dessert when the specified cake was unavailable. Interviews with dietary staff revealed that recipes were not consistently used or followed, and some staff were unaware of the required ingredients for menu items, such as eggs in fried rice. The registered dietitian confirmed that she had not been conducting test trays and had recently reminded staff that modified diets must match the menu. Facility policy required the use of standardized recipes, but this was not adhered to, as evidenced by the lack of recipe use and undocumented substitutions. One resident on a pureed diet was observed receiving a meal that did not match the approved menu, but no swallowing concerns were noted at the time.
Failure to Provide Palatable and Properly Prepared Meals at Safe Temperatures
Penalty
Summary
The facility failed to ensure that meals served to residents were palatable, attractive, and at a safe and appetizing temperature, as required by facility policy. Observations during a lunch service revealed that menu items were not prepared or served according to the approved menu and recipes. Substitutions were made without proper documentation or consultation with the Registered Dietitian, such as replacing fried rice with white rice, pepper steak with baked chicken for modified diets, and substituting desserts without ensuring appropriate texture for pureed diets. Additionally, some menu items were omitted entirely, and staff did not follow recipes for certain dishes. Temperature checks showed that food items left the kitchen at appropriate temperatures but were not maintained during transport and service, resulting in meals being served below the required hot holding temperature of 135°F. Test trays conducted after meal service revealed that several food items were not warm enough, had undesirable textures, and lacked seasoning. The pureed foods were not consistently smooth, with some containing gristle or bean strings, and the pureed bread was described as grainy and pasty. The Food Service Director acknowledged not routinely conducting test trays or tasting pureed foods prior to service. Interviews with dietary staff and the Registered Dietitian confirmed that recipes were not always followed, substitutions were not properly logged, and the menu was not consistently adhered to for modified diets. The Registered Dietitian also stated that test trays were not being performed as required. These actions and inactions resulted in the failure to provide residents with meals that were palatable, attractive, and served at safe and appetizing temperatures, potentially affecting all residents receiving meals from the facility.
Failure to Maintain Sanitary Kitchen and Food Safety Standards
Penalty
Summary
Surveyors observed that the facility failed to maintain a clean and sanitary kitchen as required by professional standards and facility policy. During a kitchen tour, multiple food items were found past their best buy or use by dates, including dinner rolls, hot dog buns, diced tomatoes, sliced onions, leftover ham, and packages of cheese. The Food Service Director confirmed these items should have been discarded but remained in storage. Additionally, the facility was unable to provide evidence of completed daily staff cleaning logs for August, and only partially completed logs for September were available. Each of the three scheduled dietary aides was supposed to complete and submit a daily cleaning sheet, but this was not consistently done. Further review revealed that tray line food temperatures for August were not available, and several days in September lacked recorded temperatures for meals. The facility's policy requires that all local, state, and federal standards be followed to ensure food safety and sanitation, including proper handling, labeling, and timely use or disposal of perishable foods. The failure to adhere to these procedures had the potential to affect 99 residents who received meals from the kitchen, with three residents identified as not receiving food by mouth.
Failure to Provide Physician-Ordered Pureed Diets and Proper Food Consistency
Penalty
Summary
The facility failed to provide four residents with the physician-ordered pureed diet as required, instead substituting menu items and not following the prescribed modifications. Medical record review for one resident with severe cognitive impairment and a pureed diet order revealed that, during meal service, the resident received pureed chicken, pureed vegetables, pureed wheat bread, and pudding, rather than the specified menu items. Observations of the tray line and test trays showed that the correct pureed alternatives were not prepared or served, such as substituting pureed wheat bread for cream of rice and using chicken instead of beef for pureed and mechanical soft diets. The Food Service Director (FSD) confirmed these substitutions were made without consulting the Registered Dietitian (RD) and that test trays were not routinely performed to check for appropriate texture or taste. Further review and interviews revealed that the pureed foods served did not consistently meet the required smooth, homogenous consistency, with items being grainy, pasty, or containing noticeable strings and gristle. Temperatures of the food items were also found to be below preferred serving temperatures. The RD confirmed that menus were to be followed and that modified diets should receive the items as written on the menu production sheets. Facility policy required that pureed foods be smooth and free of lumps or chunks, and that texture modifications be individualized and prepared as ordered by the physician and interdisciplinary team. These requirements were not met, resulting in residents not receiving food in the form designed to meet their individual needs.
Medication Reordering Failure Leads to Missed Doses
Penalty
Summary
The facility failed to timely reorder medications, resulting in missed doses for a resident. Resident #32, who has diagnoses including schizophrenia, diabetes, and breast cancer, was affected by this deficiency. The resident had a prescription for Verzenio, a medication for breast cancer, to be taken twice daily. However, the medication was not administered on the mornings of December 12th through December 14th, 2023, because it was not available at the facility. An interview with a registered nurse revealed that an agency nurse mistakenly stored empty boxes in the medication cart, leading to a miscount of the remaining doses and a delay in reordering the medication. Consequently, the resident missed approximately two days of doses. The Director of Nursing confirmed these findings.
Lack of Privacy Curtains in Shared Rooms
Penalty
Summary
The facility failed to provide privacy curtains in shared rooms, affecting two residents out of six reviewed for privacy. Resident #82 and Resident #5, who shared a room, did not have any wall or barrier between their beds, nor were there privacy curtains or hooks available for hanging them. This lack of privacy was confirmed through observation and interviews with both residents and the facility's Administrator. The residents reported that they had to use the bathroom to change clothes to maintain privacy, as their room had never been equipped with privacy curtains during their stay. This deficiency was investigated under OH00160860.
Deficiencies in Kitchen Sanitation and Equipment Maintenance
Penalty
Summary
The facility failed to maintain the kitchen in a safe and sanitary manner, which had the potential to affect all residents except two who were receiving nothing by mouth. During an observation of the dishwasher, it was noted that the temperature gauges did not move during the wash cycles, indicating that the rinse and sanitation cycles might not have reached the required temperatures for proper sanitation. Dietary staff, including a newly hired Food Service Director, were unaware of the correct temperature requirements and did not document the dishwasher temperatures. The Administrator, who was responsible for audits, also misunderstood the function of the gauges and did not recognize the issue. Additionally, the facility did not maintain proper sanitation levels in the three-compartment sink. There were no testing strips available to check the sanitizer concentration, and staff had not documented the concentration levels for the month of October. The Food Service Director confirmed the lack of documentation and testing strips, indicating a lapse in following the facility's policy for maintaining sanitation standards. The freezer temperatures were also not maintained at the required levels, with recorded temperatures ranging from eight to ten degrees Fahrenheit, while the policy required temperatures to be less than zero degrees Fahrenheit. Observations revealed that food items in the freezer were not frozen solid, with some items being semi-liquid or mushy. The Maintenance Director later identified an issue with the freezer's outside coil, which affected its ability to maintain proper temperatures. The facility's policies for refrigerator and freezer maintenance, as well as dishwashing procedures, were not adhered to, leading to these deficiencies.
Facility Fails to Maintain Clean and Homelike Environment
Penalty
Summary
The facility failed to maintain a clean, comfortable, and homelike environment for its residents, as evidenced by pervasive urine odors, unsanitary conditions, and missing door thresholds. Observations and interviews revealed that the first-floor central bathroom was not maintained in a clean manner, with a black substance along the base of the shower, which was identified as caked-on dirt. Additionally, the facility did not ensure that door thresholds were intact, affecting multiple rooms and common areas, and the hallway handrail on the second floor was broken, resulting in sharp edges. Specific incidents highlighted the facility's failure to provide timely incontinence care and maintain sanitary conditions. One resident reported not receiving incontinence care for over 24 hours, resulting in a strong urine odor and soiled bedding. Another resident's room was found with urine-soaked sheets and a strong odor, with staff unable to provide documentation of care attempts. These conditions were verified by staff, including the DON, who acknowledged the persistent urine smell and unsanitary conditions. The facility's policy on providing a homelike environment was not adhered to, as evidenced by the observations of urine odors, unsanitary conditions, and missing door thresholds. The report includes interviews with residents and staff, confirming the lack of cleanliness and maintenance, which affected the quality of life for the residents. The facility's failure to address these issues resulted in a non-compliance finding under the investigated complaint numbers.
Failure to Investigate and Report Allegations of Abuse
Penalty
Summary
The facility failed to implement its abuse policy by not investigating and reporting allegations of verbal abuse and withholding of medication. Resident #22 alleged that an LPN verbally abused her and withheld her pain medication out of retaliation. Despite the resident's report to the Administrator, no investigation was conducted, and the incident was not reported as required by the facility's abuse prevention policy. The Administrator and DON dismissed the allegations as part of the resident's behavioral pattern, which was documented in her care plan. Additionally, the facility did not investigate or report an allegation made by Resident #104's daughter-in-law, who claimed that a CNA was yelling at residents in the third-floor dining room. The daughter-in-law was upset and removed Resident #104 from the facility against medical advice. The DON acknowledged receiving the complaint but did not conduct an investigation or file a self-reported incident, as she believed there was no evidence to support the allegation. The facility's policies require that all allegations of abuse be promptly and thoroughly investigated, with findings reported to the appropriate authorities. However, in both cases, the facility did not adhere to these policies, resulting in a failure to protect residents from potential abuse and neglect. The lack of investigation and reporting represents non-compliance with federal requirements and the facility's own abuse prevention program.
Failure to Report and Investigate Abuse Allegations
Penalty
Summary
The facility failed to report and investigate allegations of abuse involving two residents. Resident #22 alleged that an LPN verbally abused her and withheld her pain medication out of retaliation. Despite the resident's intact cognition and her report to the Administrator, the facility did not conduct an investigation or file a self-reported incident (SRI) with the Ohio Department of Health. The Administrator and DON dismissed the allegations as part of the resident's behavioral pattern, as documented in her care plan, and moved the LPN to a different floor without further action. In another incident, Resident #104's daughter-in-law reported that a CNA was yelling at residents in the third-floor dining room, prompting her to remove the resident from the facility against medical advice. The facility did not investigate the allegation or file an SRI, as the DON believed there was no evidence to support the claim. The CNA was sent home immediately, and no further shifts were worked by the CNA at the facility. The facility's failure to investigate or report these allegations was contrary to their abuse prevention policy, which mandates prompt and thorough investigations of all abuse reports. The facility's policy requires that all allegations of abuse be investigated and reported within specific time frames, but this was not adhered to in these cases. The policy outlines that investigations should include interviews with the person reporting the incident, witnesses, and the resident involved, with written and signed witness reports. The results should be documented and reported to the appropriate authorities within five days. The facility's non-compliance with these procedures was identified under Complaint Number OH00158925.
Failure to Investigate Allegations of Abuse
Penalty
Summary
The facility failed to investigate allegations of verbal abuse and withholding of medication involving two residents. Resident #22 alleged that an LPN verbally abused her and withheld her pain medication out of retaliation. Despite the resident's report to the Administrator, no investigation was conducted, and the LPN was merely reassigned to a different floor. The facility's Director of Nursing (DON) and Administrator dismissed the allegations as part of the resident's behavioral pattern, as documented in her care plan, and did not follow the facility's abuse investigation policy. In another incident, Resident #104's daughter-in-law reported that a CNA was yelling at residents in the dining room, prompting her to remove the resident from the facility against medical advice. The CNA was sent home immediately, but no investigation was conducted to assess the situation or gather witness statements. The DON admitted to not investigating the incident, as she believed there was no evidence to support the allegation. The facility's failure to investigate these allegations is a violation of their abuse prevention policy, which mandates prompt and thorough investigations of all reports of abuse. The policy requires interviews with the person reporting the incident, witnesses, and the resident involved, with documentation of the findings. The facility did not adhere to these procedures, resulting in non-compliance with federal requirements.
Failure to Provide Timely Incontinence Care
Penalty
Summary
The facility failed to provide timely incontinence care to several residents, as observed in multiple instances. Resident #15, who had spastic hemiplegia and was frequently incontinent, was found in a state of neglect with a strong urine odor and soaked bedding, indicating she had not been changed since 1:00 A.M. Staffing issues contributed to this deficiency, as the CNA assigned to her was pulled to another duty without proper communication, leaving Resident #15 without care for an extended period. Resident #48, diagnosed with schizophrenia and dementia, was also neglected in terms of incontinence care. His room was found in a state of disarray with urine-soaked sheets and a strong odor, yet there was no documentation of him refusing care. Staff interviews revealed a lack of awareness and documentation regarding his care needs, further highlighting the facility's failure to provide adequate incontinence care. Resident #1, who was receiving hospice services, reported not receiving timely incontinence care, sometimes going over 12 hours without being changed. Despite her care plan indicating she should be checked every two hours, staff failed to adhere to this schedule. Similarly, Resident #7, who was occasionally incontinent, was found with urine-stained bedding, and staff were unaware of her care needs due to inaccurate documentation. These incidents collectively demonstrate a systemic issue in the facility's management of incontinence care.
Staffing Deficiencies Lead to Resident Neglect
Penalty
Summary
The facility failed to maintain sufficient and competent staff on the first floor, affecting several residents, including Resident #15, who was found in a state of neglect. Resident #15, with a history of spastic hemiplegia, hypertension, and osteoarthritis, was not provided with incontinence care from 1:00 A.M. until 11:26 A.M. on the day of the survey. The resident was found lying in bed with a strong urine odor, soaked incontinence products, and stained bedding, indicating prolonged neglect. The staff, including CNAs and LPNs, were unaware of the changes in assignments, leading to a lack of care for Resident #15. Resident #48, diagnosed with schizophrenia, dementia, diabetes, and frontotemporal neurocognitive disorder, was also affected by the staffing issues. The resident's room had a strong urine odor, and a large puddle of urine was found in the center of the room. The resident's care plan required regular incontinence care and assistance, but there was no documented evidence of care being provided or refused. The DON confirmed the lack of documentation and the presence of urine in the resident's room. Resident #7, with a history of diabetes, urinary incontinence, major depression, and hypertension, was found in a similar state of neglect. The resident's room had a strong urine odor, and the bedding was stained with urine. The resident was supposed to receive regular incontinence care, but there was no evidence of care being provided. The Kardex used by staff was inaccurate, leading to confusion about the resident's care needs. The facility's policies and staffing assessments failed to ensure adequate staffing and care for the residents, resulting in significant deficiencies.
Lack of Qualified Dietary Manager and Full-Time Dietitian
Penalty
Summary
The facility failed to employ a qualified dietary manager to oversee the food service department, which had the potential to affect all 94 residents receiving food from the facility kitchen. The dietary manager, identified as DM #574, had no formal certified dietary manager training and had not passed the SERV Safe course. DM #574 had been in the position for about four months without any additional formal training to qualify her as the dietary manager. Additionally, the facility did not employ a full-time dietitian, as Dietitian #664 only worked seven to ten hours per week. The facility census was 97, and three residents were identified as receiving nothing by mouth.
Sanitation and Food Storage Deficiencies
Penalty
Summary
The facility failed to store, prepare, and serve food under sanitary conditions, potentially affecting 94 residents. During an initial tour of the kitchen, expired and visibly spoiled food items, such as milk and yogurt, were found. Additionally, individual condiment packets were removed from their original packaging and lacked expiration dates. The kitchen cleaning schedule was not adhered to, as evidenced by the absence of daily or weekly cleaning logs and the presence of food particles in the sink. Furthermore, the chemical sanitizer was found to be empty, and the dish machine temperature logs were incomplete, indicating a lack of proper sanitation practices. Temperature monitoring logs for refrigerators on different floors were not maintained, and food temperature logs for specific dates were incomplete. Interviews with staff confirmed these deficiencies, and the facility's policies on cleaning, sanitation, and food storage were not followed. These lapses in protocol and documentation highlight significant issues in maintaining sanitary conditions in food storage and preparation areas, posing a risk of foodborne illness to the residents.
Facility Fails to Maintain Safe and Homelike Environment
Penalty
Summary
The facility failed to maintain resident rooms in a safe, sanitary, and homelike condition, affecting seven residents. During the annual survey, it was observed that several rooms had chipped wall paint, stained window shades, and privacy curtains. Specifically, rooms for three residents had chipped paint and brown stains on the window shades and curtains, while another resident's room had holes in the wall behind the bed. Additionally, one room had a large patch of bare wall, chipped paint, and stained curtains, while another room had a chipped and jagged tile floor at the bathroom entrance, posing a risk to residents using wheeled walkers. Further observations revealed that one resident's room had peeling paint on the door, missing slats in the vertical blinds, and stained ceiling tiles. Interviews with the Maintenance Director indicated that resident rooms were inspected weekly through a program called Angel Walks, where managers inspected assigned rooms and reported issues during weekly meetings. However, interviews with a resident's family and an LPN confirmed the presence of peeling paint and lack of supplies in one room, and another resident reported that a dresser drawer had been missing for a year. These deficiencies were identified during the investigation of a specific complaint.
Deficiencies in Care Plan Development and Implementation
Penalty
Summary
The facility failed to ensure that care plans were adequately developed and implemented to meet the needs of several residents. Resident #16, who required frequent repositioning due to spastic hemiplegia, did not have a care plan addressing this need, despite staff acknowledging the necessity for frequent repositioning. Similarly, Resident #60, who had a stage III pressure ulcer, lacked a care plan for wound management, even though the wound was documented and known to the nursing staff. Resident #74, diagnosed with PTSD, did not have a care plan addressing this condition, despite the resident experiencing flashbacks and receiving counseling from outside providers. Additionally, Resident #7, who was on hospice services, did not have a care plan coordinating these services, despite a physician's order for hospice admission. Lastly, Resident #197, who had a surgical wound from a traumatic amputation, did not have a wound care plan initiated until a month after admission, and even then, no interventions were listed. These deficiencies indicate a systemic issue in the facility's ability to develop and implement comprehensive care plans tailored to the individual needs of residents.
Failure to Address Pharmacy Recommendations for Lipitor Monitoring
Penalty
Summary
The facility failed to ensure that pharmacy recommendations were addressed for a resident taking Lipitor, a medication used to lower cholesterol. The resident, who had diagnoses including chronic respiratory failure, hypertension, and dementia, had not had a lipid panel completed since June 22, 2022. A pharmacy recommendation dated September 20, 2023, advised that a lipid panel be conducted immediately and annually thereafter to monitor the effects of Lipitor. Although the physician signed off on this recommendation on October 10, 2023, indicating that a lipid panel should be completed, the laboratory order created on the same day mistakenly set the collection date for October 2, 2024. An interview with the Director of Nursing confirmed that the lipid panel was not completed as per the pharmacy's recommendation, and the last lipid panel was indeed conducted on June 22, 2022.
Failure to Follow Pureed Diet Menu
Penalty
Summary
The facility failed to ensure that the pureed menu was followed for residents requiring a pureed diet, affecting three residents. Resident #38, who had diagnoses including congestive heart failure and diabetes mellitus, was on a regular pureed diet with thin liquids. Resident #71, with conditions such as hypertension and dementia, also required a regular pureed diet with thin liquids. Resident #350, diagnosed with chronic bronchitis and type II diabetes mellitus, was on a regular pureed diet with honey thick consistency liquids. The facility's lunch menu production sheet specified that residents on a pureed diet should receive pureed chicken, mashed potatoes, pureed vegetable blend, pureed bread, pureed cookie, and milk. However, during an observation, it was noted that the facility staff only pureed the chicken and mixed vegetables, omitting the pureed bread from the menu. Resident #350 was observed receiving pureed chicken, pureed mixed vegetables, mashed potatoes, a pureed cookie, and honey thick milk, but no pureed bread was served. An interview with a dietary staff member confirmed that pureed bread was listed on the menu but was not prepared or served to residents requiring a pureed diet. The facility's policy on puree food preparation stated that residents on pureed diets should receive portions equivalent to those on regular or therapeutic diets, which was not adhered to in this instance.
Failure to Timely Complete Medical Record Requests
Penalty
Summary
The facility failed to ensure timely completion of medical record requests for a resident, affecting one resident out of the 97 in the facility census. The resident in question had a history of significant medical conditions, including a complete traumatic amputation, peripheral vascular disease, hypertension, chronic obstructive pulmonary disease, cardiomyopathy, and severe protein-calorie malnutrition. The deficiency was identified through a review of the closed medical record, medical record request forms, and interviews with facility staff. The deficiency arose when the family attorney of the resident made multiple requests for the resident's medical records, initially via fax and later through email. Despite these requests, the facility's medical records department and social services assistant were unaware of any such requests. The administrator had forwarded the request to the facility owner, who indicated that the facility attorneys would handle it. However, there was no evidence in the medical record request logbook of any request for the resident's records, indicating a breakdown in communication and record-keeping within the facility.
Delayed STAT Urinalysis Leads to Treatment Delay
Penalty
Summary
The facility failed to ensure a STAT urinalysis test was obtained according to the physician's order for a resident, leading to a delay in the treatment of a urinary tract infection (UTI). The resident, who had an indwelling catheter and intact cognition, was admitted with multiple diagnoses including peripheral vascular disease and severe-protein-calorie malnutrition. A physician ordered a STAT urinalysis with culture and sensitivity on 09/26/23, but the test was not collected until 10/04/23. The results, which were abnormal, were reported on the same day, but no new orders were given until 10/06/23 when an antibiotic was prescribed. Interviews with the Director of Nursing (DON) and the Nurse Practitioner revealed that there was no documented evidence of attempts to collect the urine sample until 10/04/23, and the Nurse Practitioner expected STAT labs to be completed within three days. The facility's policy on lab results did not provide guidance on timeframes for obtaining lab samples or STAT labs. This deficiency was investigated under Complaint Number OH00155587.
Inconsistent Documentation of Physician-Ordered Treatments
Penalty
Summary
The facility failed to ensure that physician-ordered treatments were consistently documented in the medical record for a resident. This deficiency was identified during a closed record review and interview, affecting one resident out of 25 records reviewed. The resident had several physician orders, including a weekly Braden assessment, catheter care every shift, no compression to a right above knee amputation, and treatment for a right stump. However, the Treatment Administration Record (TAR) showed missing documentation for these orders on multiple dates. The Director of Nursing confirmed the absence of documentation for the specified physician orders on the missing dates.
Non-Functional Call Light for a Resident
Penalty
Summary
The facility failed to ensure that a resident had a functional call light, affecting one of the 24 residents reviewed for call lights. During an interview, the resident reported that her call light was not lighting up when she pressed the call button. An observation conducted with the facility's Director of Maintenance (DOM) confirmed that the call light above the resident's door was not working when activated. The DOM noted that he had replaced the bulb several days earlier and, upon shaking the call light, it lit up, indicating a possible issue with loose wiring attached to the bulb. The facility's policy, which was undated, stated that resident call lights were to be checked regularly by nursing and maintenance staff to ensure they were functioning properly.
Facility Fails to Maintain Clean and Safe Environment
Penalty
Summary
The facility failed to maintain a clean, safe, and sanitary environment, affecting Resident #67 and potentially all 90 residents. Observations revealed multiple deficiencies: Resident #67's room had a door hanging off the close, the third-floor dining room had window shades with food splatter and a cabinet door hanging off, and the shower room had peeling ceiling paint, mold, and paper on the floor. These observations were verified by interviews with the respective staff members present at the time. Additionally, the Housekeeping Supervisor confirmed that the dining room was not cleaned after dinner due to the absence of evening housekeeping staff. These deficiencies were investigated under Complaint Numbers OH00153302, OH00152029, and OH00151866.
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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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