Best Care Health And Rehabilitation
Inspection history, citations, penalties and survey trends for this long-term care facility in Wheelersburg, Ohio.
- Location
- 2159 Dogwood Ridge Road, Wheelersburg, Ohio 45694
- CMS Provider Number
- 365398
- Inspections on file
- 24
- Latest survey
- February 17, 2026
- Citations (last 12 mo.)
- 4
Citation history
Health deficiencies cited at Best Care Health And Rehabilitation during CMS and state inspections, most recent first.
A resident with multiple comorbidities, impaired mobility, and a documented need for two-person substantial/maximal assist with a gait belt for transfers was assisted to the bathroom by a single CNA without a gait belt. During the toilet transfer, the resident reported knee pain, was holding a grab bar, and then fell to the floor, where an LPN later found the resident with pain and abrasions. Imaging and hospital records confirmed a left distal femur fracture and right hip fracture, with subsequent treatment for hypotension, hemorrhagic shock, and medical decline following the fractures. The facility’s fall investigation identified the fall during transfer and major injury but did not address that only one staff member assisted and that the gait belt and two-person assist requirements in the care plan were not followed; leadership later acknowledged the transfer was performed improperly and led to the resident’s injuries.
The facility did not notify the Ombudsman when three residents with complex medical conditions were discharged to the hospital. Medical records and staff interviews confirmed the lack of required notification, and facility policies related to discharge were either not followed or not available for review.
A resident with multiple chronic conditions and an indwelling Foley catheter did not have physician orders in place for the catheter at admission. Medical records, nursing notes, and the care plan lacked documentation of the catheter order, although CNA documentation confirmed care was provided and surveyors observed the catheter in use. The DON confirmed the absence of physician orders, and the facility lacked a related policy.
Several newly admitted residents did not receive prescribed medications for multiple days due to delays in pharmacy delivery, with staff documenting repeated attempts to obtain the medications and confirming that the facility's medication system did not always have the required drugs on hand. Nursing staff did not consistently notify the physician or NP when medications were missed, as required by facility policy.
The facility failed to address residents' repeated requests for information on free government phones during Resident Council meetings. Despite ongoing inquiries, there was no documented response or resolution, and staff interviews revealed a lack of communication and follow-up on these concerns.
The facility failed to secure medication carts on the front hall, leaving them unlocked and unattended, which could affect seven cognitively impaired and independently mobile residents. An LPN confirmed the carts should have been locked, as per the facility's policy on medication storage.
A resident with multiple medical conditions was issued a 30-day discharge notice for violating the facility's smoking policy, despite only one documented instance of noncompliance. Interviews revealed no further violations in the months following the incident, raising concerns about the justification for the discharge.
The facility failed to update PASARRs for two residents who had new diagnoses and were prescribed psychotropic medications. One resident was admitted with various diagnoses, including depression and anxiety, and later diagnosed with dementia and psychosis, receiving medications like Seroquel and Paxil. Another resident with bipolar disorder was prescribed medications such as Vraylar, but no new PASARR was completed. The Social Services Director confirmed the oversight and lack of a written policy for PASARR completion.
A facility failed to conduct regular care plan conferences for a resident admitted with multiple diagnoses, including Parkinson's disease and dementia. Despite being cognitively intact, the resident's medical record lacked documentation of a care conference since admission. This deficiency was confirmed by the Social Services Director.
A resident with a precancerous lesion on the forehead was not adequately monitored or treated, as observed by surveyors. The resident, who was cognitively impaired, had a soiled bandage over the lesion without any physician's orders for its application. The bandage was not consistently maintained, and the lesion had not been assessed since July, leading to a deficiency in care.
A facility failed to provide adequate oxygen therapy for a resident with COPD, as there were no physician's orders for oxygen, and vital signs were not recorded since June. The resident was observed using oxygen without a valid order, contrary to facility policy.
A resident with chronic low back pain was inadequately monitored for pain management, despite being prescribed medications like Zanaflex, gabapentin, and hydrocodone. Observations showed the resident frequently yelling in pain, with no pain assessments documented since a specific date. Interviews confirmed the ineffectiveness of the medications and the absence of nonpharmacological interventions, violating the facility's pain management policy.
A facility failed to assess and address the PTSD of a resident, who was admitted with multiple diagnoses including PTSD. The care plan did not include the cause of the PTSD, potential triggers, or interventions to prevent re-traumatization. The DON confirmed the lack of assessment and care plan strategies for managing the resident's PTSD.
Two residents experienced significant medication errors. One resident missed doses of prescribed insulin due to unavailability, while another was administered naloxone without a physician's order, despite no history of substance abuse. These errors were confirmed by interviews with staff and the DON.
The facility failed to ensure that two residents received up-to-date pneumococcal vaccinations as per CDC guidelines. One resident with hypertension and intellectual disabilities and another with chronic obstructive pulmonary disease did not receive the recommended PCV15 or PCV20 vaccines after their last Pneumovax 23 dose. The Director of Nursing confirmed the oversight, which was contrary to the facility's policy to follow CDC recommendations.
Failure to Follow Two-Person Transfer and Gait Belt Requirements Resulting in Fall With Fractures
Penalty
Summary
The deficiency involves the facility’s failure to provide adequate assistance and supervision during a transfer for a resident who was known to be at high risk for falls and required extensive help. The resident had diagnoses including congestive heart failure, polyneuropathy, difficult ambulation, muscle weakness, and COPD, and was assessed as being at risk for falls. A Lift, Transfer, Reposition Assessment documented that the resident required a two-person substantial/maximal assist for transfers with the use of a gait belt. The care plan and MDS further documented that the resident was cognitively intact but had weakness, poor balance, and was not steady, requiring substantial/maximal physical assistance for all transfers and being unable to stabilize without staff assistance for standing, walking, and surface-to-surface transfers. On the date of the incident, the resident was being assisted to the bathroom by a single CNA, contrary to the documented requirement for a two-person assist and use of a gait belt. The CNA’s witness statement indicated that the resident reported knee pain while being taken to the restroom and was holding onto the bathroom grab bar. The CNA moved the wheelchair and stood behind the resident when the resident began to fall to her side and then fell backward toward another bathroom door. The LPN who responded to the CNA’s request for help found the resident on the bathroom floor, complaining of left knee pain and with multiple abrasions, and assisted the resident back to bed. Subsequent imaging and hospital records showed that the resident sustained a left distal femur fracture and a right hip fracture. The facility’s own QAPI fall investigation documented that the resident fell during transfer to the toilet and sustained a major injury, with a possible root cause identified as the resident’s knee giving out. However, the investigation did not address that the transfer had been performed by only one staff member instead of the required two, and that a gait belt, which was part of the resident’s plan of care, had not been used. During interviews, facility leadership, including the DON, ADON, President of Clinical Operations, and Regional Resource Nurse, confirmed that the CNA had improperly transferred the resident alone and without a gait belt, and that the resident sustained fractures of the right hip and left femur as a result of this transfer. Hospital documentation further described the resident’s condition following the fall. At the first hospital, the resident was found to have a left distal femur fracture and right hip fracture, hypotension without external signs of bleeding, anemia, and acute hypotension, and was transferred to a higher-level trauma center due to suspected internal bleeding of the left thigh. At the second hospital, the resident was treated for hemorrhagic shock and acute on chronic shock, and the left femur fracture was described as pathological due to a combination of osteopenia and trauma. The death certificate and coroner’s report listed the cause of death as medical decline following a left distal femur fracture with surgical therapy as a consequence of a ground-level fall. The facility’s falls/accidents/incidents policy defined an avoidable accident as one in which the facility failed to implement interventions, including adequate supervision and assistive devices, consistent with the resident’s needs and care plan to eliminate or reduce the risk of an accident.
Failure to Notify Ombudsman of Resident Discharges
Penalty
Summary
The facility failed to notify the Ombudsman of resident discharges as required, affecting three out of four residents reviewed for discharge. Medical record reviews for these residents showed that each had been admitted, discharged to the hospital, and in some cases readmitted, with diagnoses including chronic lymphocytic leukemia, chronic kidney disease, cirrhosis of the liver, diabetes mellitus type two, fibromyalgia, mood disorder, atrial fibrillation, congestive heart failure, pleural effusion, and Clostridium difficile infection. Despite these discharges, there was no documentation in the nursing progress notes indicating that the Ombudsman had been notified of the residents' discharges to the hospital. Interviews with facility staff confirmed the lack of notification. The DON acknowledged that the facility had not been notifying the Ombudsman of discharges, and the Social Services Director, who was new to the position, was unaware of the requirement until recently. Review of the facility's Bed Hold and Return to Center policy referenced a Notice of Transfer Discharge policy, but this policy was not provided for review. The deficiency was identified during an investigation under a specific complaint number.
Lack of Physician Orders for Indwelling Foley Catheter
Penalty
Summary
The facility failed to ensure that physician orders were in place for a resident with an indwelling Foley catheter at the time of admission. The resident, who was admitted with multiple diagnoses including atrial fibrillation, congestive heart failure, liver cirrhosis, diabetes mellitus type 2, and chronic kidney disease with dialysis, was cognitively intact and required significant assistance with activities of daily living. Medical record review showed no physician orders for the Foley catheter, and there was no documentation in the nursing progress notes or plan of care regarding the catheter. Certified Nursing Assistant documentation confirmed care was provided for the catheter, and observations during the survey verified the presence of the indwelling Foley catheter. The Director of Nursing confirmed the absence of physician orders, and the facility did not have a policy related to physician orders for indwelling Foley catheters.
Delayed Medication Administration for New Admissions Due to Pharmacy Issues
Penalty
Summary
The facility failed to ensure that newly admitted residents received their prescribed medications in a timely manner due to delays in obtaining medications from the pharmacy. Multiple residents experienced missed doses of critical medications for several days after admission. For example, one resident with diagnoses including pleural effusion, chronic kidney disease, cirrhosis, atrial fibrillation, diabetes, and C. difficile did not receive Vancomycin, Sucralfate, and Gabapentin as ordered, with documentation indicating repeated notes of 'awaiting pharmacy' and no evidence that the physician or nurse practitioner was notified of the missed doses. Another resident admitted with conditions such as weakness, COPD, cirrhosis, hepatitis C, diabetes, and congestive heart failure did not receive several ordered medications, including Clopidogrel, Lantus insulin, nicotine patch, Sertraline, Trelegy inhaler, Cefazolin, and Creon, for several days. Nursing notes repeatedly documented that medications were not delivered or were on order, and the nurse practitioner was not notified of the missing doses until several days after admission. The medication Creon was eventually placed on hold until it became available. A third resident with atrial fibrillation, congestive heart failure, liver cirrhosis, diabetes, and chronic kidney disease did not receive lactulose for two days after admission, with nursing notes indicating the medication was 'awaiting from pharmacy.' Interviews with staff confirmed ongoing issues with timely pharmacy delivery, especially for new admissions, and that the facility's medication dispensing system did not always have the required medications on hand. There was also a lack of documentation that the physician or nurse practitioner was notified when medications were missed, contrary to facility policy.
Failure to Address Resident Concerns on Free Government Phones
Penalty
Summary
The facility failed to adequately address concerns raised by residents during Resident Council meetings, specifically regarding the availability of free government phones. The issue was first noted in the meeting minutes from April 15, 2024, where the social worker reported difficulty in securing free phones. Despite this, the response documented was that the social worker would meet with residents about the phones. In subsequent meetings on August 26 and September 16, 2024, residents continued to inquire about free government phones, but there was no documented response or resolution provided. The social worker's efforts were noted as unsuccessful, and no alternative solutions were offered. Interviews conducted on October 3, 2024, revealed a lack of communication and follow-up on the residents' requests. The Social Service Director, who had been with the facility since August 2024, was unaware of any requests for free phones. The Activities Director confirmed that residents had repeatedly requested assistance with obtaining government phones, but the process for addressing these concerns was unclear. The Administrator was responsible for addressing the concerns, but it was uncertain how or if they were resolved. A resident confirmed that the facility had not provided a response to their inquiries about government phones, indicating a breakdown in addressing resident concerns.
Medication Cart Security Lapse
Penalty
Summary
The facility failed to ensure that medication carts on the front hall were locked and secured, which had the potential to affect seven cognitively impaired and independently mobile residents out of the 22 residing on the front hall. During an observation, it was noted that two medication carts were left unlocked and unattended by staff. An interview with an LPN confirmed that the medication carts were indeed unlocked and unattended, and acknowledged that they should be locked when not attended by staff. The facility's policy on the storage of medications, dated November 2020, requires that drugs and biologicals be stored in locked compartments under proper conditions, and that unlocked medication carts should not be left unattended. This policy was not adhered to, leading to the deficiency observed by the surveyors.
Unjustified Resident Discharge Due to Smoking Policy Violation
Penalty
Summary
The facility failed to ensure that a resident was not discharged without a justified and documented reason, affecting one resident out of three reviewed for discharge rights. The resident, who had multiple medical diagnoses including Parkinson's disease, dementia, and depression, was admitted to the facility and had signed the facility's smoking policy upon admission. On one occasion, the resident was documented as violating the smoking policy by leaving the facility to purchase cigarettes and was observed smoking on the facility's front patio. Despite this single documented instance of noncompliance, the facility issued a 30-day discharge notice to the resident for violating the smoking policy. Interviews with the resident, the Ombudsman, and the Social Service Director revealed that the only documented violation of the smoking policy occurred several months prior to the discharge notice, with no further instances of noncompliance recorded in the subsequent months. The Ombudsman expressed concerns about the strength of the facility's case for an involuntary discharge based on the single documented incident. The resident expressed a desire to remain in the facility, and the Social Service Director confirmed the lack of additional documented violations.
Failure to Update PASARRs for Residents with New Diagnoses and Psychotropic Medications
Penalty
Summary
The facility failed to update the Preadmission Screening and Resident Reviews (PASARRs) for two residents who had new diagnoses and were prescribed psychotropic medications. Resident #39 was admitted with diagnoses including depression, anxiety, diabetes mellitus type two, hypertension, and congestive heart failure. The PASARR dated 07/21/23 did not indicate any serious mental illness or prescriptions for psychotropic medications. However, dementia and psychosis were later added to the resident's diagnoses, and the resident was prescribed several psychotropic medications, including Seroquel, Ativan, Trazodone, and Paxil. Despite these changes, a new PASARR was not completed. Similarly, Resident #52 was admitted with a diagnosis of bipolar disorder. The PASARR dated 06/07/24 did not list any antipsychotic medications. The resident's care plan included interventions for bipolar disorder, and the resident was later prescribed psychotropic medications, including Paxil, Trazodone, and Vraylar. Again, the facility did not complete a new PASARR following these changes. The Social Services Director confirmed the oversight and acknowledged the absence of a written policy regarding PASARR completion.
Failure to Conduct Regular Care Plan Conferences
Penalty
Summary
The facility failed to provide regular care plan conferences for residents and their representatives, specifically affecting one resident out of three reviewed for care conferences and care planning. The resident in question was admitted with multiple diagnoses, including cellulitis, Parkinson's disease, cerebral infarction, bipolar disorder, hypertension, and dementia. Despite being cognitively intact, as indicated by the Minimum Data Set (MDS) assessment, the resident's medical record lacked documentation of a care conference since their admission in 2020. This deficiency was confirmed through an interview with the Social Services Director, who acknowledged that no care conference had been conducted for the resident since their admission.
Inadequate Monitoring and Treatment of Skin Alteration
Penalty
Summary
The facility failed to ensure adequate monitoring and treatment of skin alterations for a resident with a precancerous lesion on the forehead. The resident, who was cognitively impaired and had diagnoses including Parkinson's disease, dysphagia, and Alzheimer's disease, was observed with a soiled white bandage over the lesion. The bandage was undated and lacked initials to indicate who applied it. Despite the lesion frequently bleeding, there were no physician's orders for bandage application, and the area had not been assessed since July. Observations revealed the bandage was not consistently maintained, as it was found soiled and eventually fell off, exposing a half-dollar sized lesion with dried blood. An LPN confirmed the absence of an order for the bandage and acknowledged the lack of assessment since July. The facility's inaction in monitoring and treating the skin alteration led to the deficiency, affecting the resident's care and treatment.
Failure to Ensure Adequate Oxygen Therapy for a Resident
Penalty
Summary
The facility failed to provide adequate care and services for a resident requiring oxygen therapy. Resident #8, who was admitted with chronic obstructive pulmonary disease (COPD), diabetes mellitus, and hypertension, had a care plan indicating altered respiratory status and difficulty breathing related to COPD. However, there were no physician's orders for oxygen therapy in the resident's medical records for October 2024, and the Minimum Data Set (MDS) assessment did not indicate that the resident received oxygen therapy during the review period. Additionally, vital signs records from June to October 2024 showed no recorded oxygen saturation levels or respiratory rates since June 8, 2024. On October 1, 2024, an observation revealed that Resident #8 was using oxygen delivered through a nasal cannula at a rate of two liters per minute, despite the absence of a physician's order. The resident confirmed using oxygen when experiencing shortness of breath. An interview with LPN #49 confirmed the lack of a physician's order and the absence of recorded oxygen saturation levels or respiratory rates. The facility's policy on oxygen administration, revised in October 2010, required a valid physician's order and monitoring of vital signs and oxygen saturation levels, which were not adhered to in this case.
Inadequate Pain Management Monitoring
Penalty
Summary
The facility failed to ensure adequate monitoring and management of pain for a resident with chronic low back pain. The resident, admitted with diagnoses including low back pain and restlessness, was prescribed medications such as Zanaflex, gabapentin, and hydrocodone for pain management. Despite these prescriptions, the resident's medical record showed no pain assessments or documentation of pain levels since a specific date. Observations over several days revealed the resident frequently yelling out in pain, grimacing, and holding her back, indicating ongoing discomfort. Interviews with the resident and staff confirmed the resident's persistent pain and the ineffectiveness of the prescribed medications. The facility's policy on pain assessment and management, which emphasizes a multidisciplinary approach and regular monitoring using standardized tools, was not adhered to. The Director of Nursing confirmed the absence of pain assessments and documentation of nonpharmacological interventions for the resident's chronic pain. This lack of monitoring and documentation contributed to the deficiency in providing safe and appropriate pain management for the resident.
Failure to Address PTSD in Resident Care Plan
Penalty
Summary
The facility failed to ensure that a resident with post-traumatic stress disorder (PTSD) was appropriately assessed to identify the cause of the PTSD and minimize triggers and/or re-traumatization. This deficiency affected one resident, who was admitted with multiple diagnoses including PTSD. The resident's Minimum Data Set (MDS) assessment confirmed the diagnosis of PTSD, yet the care plan did not address the cause of the PTSD, potential triggers, or interventions to reduce the risk of re-traumatization. The medical record for the resident lacked an assessment to identify the cause of the PTSD and potential triggers. An interview with the Director of Nursing (DON) confirmed that the facility had not completed an assessment of the cause of the PTSD or identified possible triggers that could cause re-traumatization. Additionally, the care plan did not include strategies for providing care to a resident with PTSD, highlighting a significant oversight in the resident's care management.
Medication Errors Affect Two Residents
Penalty
Summary
The facility failed to ensure that residents were free from significant medication errors, affecting two residents. Resident #228, who was newly admitted with diagnoses including end-stage renal disease, diabetes mellitus type two, and chronic obstructive pulmonary disorder, did not receive prescribed doses of Admelog insulin and Tresiba due to the medications not being available. The resident missed two doses of Admelog insulin and one dose of Tresiba on the day following admission. Interviews with the resident, a registered nurse, and the Director of Nursing confirmed the missed doses and the unavailability of the medications in the facility's emergency stock. Resident #45, who had moderately impaired cognition and was admitted with diagnoses including low back pain and seizures, was administered naloxone without a physician's order. The resident was found nonresponsive but breathing, and a nurse administered naloxone, which increased the resident's responsiveness before being sent to the hospital. The Director of Nursing confirmed that there was no order for naloxone and no documented history of substance abuse that would necessitate its administration, indicating the medication was given in error.
Failure to Administer Up-to-Date Pneumococcal Vaccinations
Penalty
Summary
The facility failed to ensure that residents were offered and received up-to-date pneumococcal vaccinations, as required by CDC guidelines. This deficiency was identified during a review of medical records and interviews with staff. Specifically, two residents, one with intact cognition and another with moderately impaired cognition, were affected. Resident #43, who had diagnoses including hypertension and intellectual disabilities, received a dose of Pneumovax 23 in 2018 but was not offered or administered any subsequent pneumococcal vaccines. Similarly, Resident #3, diagnosed with chronic obstructive pulmonary disease and muscle weakness, received a dose of Pneumovax 23 in 2014, with no further pneumococcal vaccines documented. The Director of Nursing confirmed that these residents had not been offered or received the recommended PCV15 or PCV20 vaccines, which should be administered at least one year after the last dose of Pneumovax 23. The facility's policy, revised in March 2022, stated that pneumococcal vaccines should be administered in accordance with CDC recommendations. However, the facility did not adhere to these guidelines, as evidenced by the lack of updated vaccinations for the affected residents. This oversight was identified through a combination of record reviews, staff interviews, and a review of CDC online resources.
Latest citations in Ohio
A resident with intact cognition receiving Medicare Part A skilled services for metabolic encephalopathy had services discontinued while benefit days remained, but the facility did not issue the required Skilled Nursing Facility Advance Beneficiary Notice (SNF ABN). The Social Services Director later confirmed that no SNF ABN was provided and reported she believed only a Notice of Medicare Non-Coverage (NOMNC) was needed when all skilled services were stopped. This practice conflicted with the facility’s written policy, which required SNF ABNs to be issued when extended care items or services were initiated, reduced, or terminated due to expected non-coverage by Medicare.
Surveyors identified that the facility exceeded the acceptable medication error rate when two residents with type 2 DM received insulin doses that were not administered according to orders or manufacturer instructions. In two separate observations, an LPN administered Novolog and another LPN administered insulin glargine and insulin lispro without priming the insulin pens, and the insulin lispro and Novolog were given after the residents had already consumed a significant portion of their breakfast meals, despite orders for administration before meals. Manufacturer information for both insulin products required priming before each injection to ensure accurate dosing, and facility policy required medications, including insulin, to be administered safely, timely, and in accordance with prescriber orders and specified time frames.
Surveyors found that the facility failed to document tray line food temperatures for multiple meals served from two dining room kitchenettes, despite having a “Trayline Taste & Temperature Log” and a policy requiring food to be stored, prepared, distributed, and served according to professional food safety standards. Review of logs showed repeated missing entries for breakfast, lunch, and dinner services in both the Harrison and McClellan dining areas, and the Senior Director of Culinary Services confirmed that temperatures had not been recorded for those meals, potentially affecting all residents receiving meals from those kitchenettes.
The facility failed to conduct and document required periodic care conferences for two residents, despite multiple comprehensive, quarterly, and significant change MDS assessments and a policy requiring periodic care conferences with resident and/or family participation. One resident with Parkinson’s disease, post-stroke hemiplegia, TIA, DMII, and depression had only two documented care conferences over a year, while another resident with aphasia, cerebrovascular disease, DMII, gait difficulty, coagulation defect, depression, and muscle weakness had no documented care conferences in the past year, aside from a declined invitation to the representative. The UCC confirmed that care conferences were expected to occur quarterly and that no additional documentation existed for either resident.
A resident with Alzheimer's disease and type II DM, who required extensive assistance with ADLs and was receiving scheduled Lantus and sliding-scale Humalog, experienced a severely elevated blood glucose level. The on-call provider was notified and ordered an additional dose of lispro insulin with a directive to recheck the blood glucose after administration. Nursing staff administered the extra insulin but did not document any follow-up blood glucose check, and the DON confirmed that this reevaluation was required by the facility's abnormal blood glucose policy and was not completed or documented.
A resident with Parkinson’s disease, dementia, and hypothyroidism was prescribed levothyroxine once daily along with other medications. A consultant pharmacist’s monthly drug regimen review recommended that levothyroxine be given in the morning on an empty stomach, 30–60 minutes before food, per manufacturer instructions. The medical record contained no documented physician response to this recommendation, and the MAR showed the drug scheduled for morning administration while the resident was observed eating breakfast and receiving the medication at the same time. An LPN confirmed administering levothyroxine during the meal, and the DON verified there was no documentation explaining whether or why the pharmacist’s recommendation was or was not followed, resulting in a failure to act on and document the identified irregularity.
A resident with severe cognitive impairment, multiple comorbidities, documented gait and balance abnormalities, and a high fall risk was care planned and assessed by therapy to require contact guard assistance and use of a gait belt for transfers and ambulation. While being assisted by a CNA from a recliner to the bathroom with a walker, the CNA did not apply a gait belt, even though the resident had a known tendency to lean backward when standing. As the CNA reached to open the bathroom door, the resident lost balance and fell backward, striking the back of the head, and was later found by an LPN without a gait belt in place, contrary to the facility’s gait belt policy and the resident’s assessed needs.
A resident with CKD stage five requiring peritoneal dialysis (PD) was admitted with pre-admission physician orders for three daily PD exchanges and monitoring for peritonitis (fever, abdominal pain, cloudy effluent), but these monitoring orders were not entered into the facility’s physician orders. The care plan referenced PD and general monitoring but did not specifically address peritonitis monitoring. Paper PD flowsheets showed incomplete and inconsistent documentation of exchanges and resident condition, including missing condition/comments for individual treatments and no record of one ordered PD exchange. The PD cycler flowsheet lacked effluent descriptions on multiple days. The PD nurse reported facility staff were expected to monitor effluent and symptoms, and the DON confirmed the absence of specific peritonitis monitoring orders, lack of an order for the PD cycler, and documentation gaps, despite a facility policy requiring ongoing assessment and monitoring for complications before, during, and after dialysis treatments.
A nurse was observed preparing multiple oral medications for a resident with depression, traumatic brain injury, anxiety, and impaired cognition by pushing tablets and capsules from unit-dose cards directly into her ungloved hand and then using her fingers to place them into a medication cup. In a follow-up interview, the RN confirmed this practice and acknowledged that the correct procedure is to dispense medications directly from the card into the cup, contrary to the facility’s medication administration policy requiring adherence to good nursing principles and practices.
A resident with Alzheimer’s disease, diabetes, anxiety, significant ADL dependence, and behavioral symptoms was observed seated in a chair positioned against the nursing station with a locked wheelchair placed directly in front, also against the nursing station, effectively restricting movement. An LPN confirmed both wheelchair wheels were locked and that it should not have been placed there, while a CNA stated she had positioned the wheelchair to prepare for lunch, was unable to complete the transfer, and left it in place, acknowledging this was wrong. This arrangement conflicted with the facility’s restraint policy, which prohibits physical restraints except when alternatives are ineffective for treating a medical symptom and defines restraints as devices adjacent to the body that cannot be easily removed and that restrict freedom of movement or access to the body.
Failure to Issue Required SNF ABN When Discontinuing Medicare Part A Services
Penalty
Summary
The deficiency involves the facility’s failure to issue a Skilled Nursing Facility Advance Beneficiary Notice (SNF ABN) when Medicare Part A services were discontinued for a resident who still had available benefit days. The resident was admitted with a diagnosis of metabolic encephalopathy and had intact cognition per the Minimum Data Set assessment. The facility’s own SNF Beneficiary Notification Review documented that Medicare Part A skilled services began on 02/11/26 and the last covered day was 03/11/26, and that the facility initiated discharge from Medicare Part A services before the resident’s benefit days were exhausted. Despite this, no SNF ABN was provided to the resident or the resident’s representative. During interviews, the Social Services Director stated that the SNF ABN was issued hours prior to the last covered day but, upon reviewing her files, confirmed that no SNF ABN had actually been issued for this resident. She further explained that she believed an SNF ABN was only required if one skilled service remained and that if all skilled services were being discontinued, only the Notice of Medicare Non-Coverage (NOMNC) needed to be issued. The Administrator, however, stated that a resident should always receive both a SNF ABN and a NOMNC when Medicare Part A services are discontinued and benefit days remain. Review of the facility’s written policy dated 03/28/23 showed that the facility was required to issue SNF ABNs for initiation, reduction, or termination of extended care items or services when Medicare payment was not expected, which did not occur in this case.
Plan Of Correction
This Plan of Correction is submitted as required under State and Federal law. This Plan of Correction does not constitute an admission on the part of the Facility that the findings cited are accurate, that the findings constitute a deficiency or that the scope and severity regarding the deficiency cited are correctly applied. Any changes to the Facility's policies and procedures should be inadmissible in any proceeding on that basis. Without admitting or denying the validity or the existence of the alleged noncompliance, the Facility submits this Plan of Correction with the intention that it be inadmissible by any third party in any civil or other action against the facility or any employee, agent, officer, director or shareholder of the Facility. The Facility is utilizing this Plan of Correction as its allegation of substantial compliance as of 05/29/2026 F-0582 Corrective action for resident/s: On 5/14/26 Resident #34 was informed of rights and responsibilities related to Advanced Beneficiary Notice and voiced understanding of information for future reference by administrator. Identification of other residents who may be affected: Any resident receiving skilled services from nursing or therapy services. The Administrator audited all residents who were discharged from skilled services in the past 30 days to ensure they were issued a Notice of Non-Coverage and Advanced Beneficiary Notice on 5/29/26. No non-compliance was noted. Measures for systemic change: On 5/14/2026 Business Office Manager, Director of Rehab, Minimum Data Set nurse, Director of Nursing and Social Services Director were educated on proper procedure of issuing of Notice Of Medicare Non Coverage and Advanced Beneficiary Notice by administrator. All upcoming discharges from skilled services will be reviewed weekly at Utilization Review meeting to ensure notices will be delivered timely. How Corrective Action will be monitored: Administrator or designee to complete audits of all residents being discharged from skilled services to ensure they were issued a Notice of Non-Coverage and Advanced Beneficiary. This audit will be completed weekly x 4 weeks, then monthly x 2 months. Corrective action will be initiated for any noted non-compliance. Audit findings will be reviewed as part of the monthly quality assurance process to determine the need for further monitoring. Date of Compliance 5/29/26
Insulin Administration Errors and Failure to Prime Insulin Pens
Penalty
Summary
The deficiency involves the facility’s failure to maintain a medication error rate below 5%, with surveyors identifying 3 errors out of 28 medication administration opportunities, resulting in a 10.71% error rate. For one resident with type 2 diabetes mellitus and moderate cognitive impairment, the physician’s order directed Novolog insulin 10 units via subcutaneous pen-injector to be given before meals. During an observed medication pass, the LPN administered 10 units of Novolog insulin without priming the pen and did so after the resident had already consumed approximately 50% of the breakfast meal. The LPN later confirmed she did not prime the pen and acknowledged that the insulin was ordered to be administered prior to meals. Manufacturer instructions for the Novolog FlexPen specified that an air shot (priming) must be performed before each injection to ensure proper dosing. Another resident, also diagnosed with type 2 diabetes mellitus and with intact cognition, had orders for insulin glargine 35 units subcutaneously twice daily and insulin lispro 20 units subcutaneously before meals, plus 12 units subcutaneously if blood glucose was between 251 mg/dL and 300 mg/dL. During an observed medication administration, an LPN administered 35 units of insulin glargine and 32 units of insulin lispro without priming the insulin pens and after the resident had consumed approximately 90% of the breakfast meal, despite orders for insulin lispro to be given before meals. The LPN later stated she could not remember if she had primed the pen and acknowledged that the insulin was ordered to be administered prior to meals. Manufacturer information for insulin lispro stated that the pen must be primed before each injection to confirm insulin delivery and remove air, and that failure to prime could result in too much or too little insulin. The DON confirmed the expectation that insulin be administered as ordered, including priming each pen with two units before dialing the prescribed dose, and facility policy required medications, including insulin, to be administered safely, timely, and in accordance with prescriber orders and required time frames.
Plan Of Correction
This Plan of Correction is submitted as required under State and Federal law. This Plan of Correction does not constitute an admission on the part of the Facility that the findings cited are accurate, that the findings constitute a deficiency or that the scope and severity regarding the deficiency cited are correctly applied. Any changes to the Facility's policies and procedures should be inadmissible in any proceeding on that basis. Without admitting or denying the validity or the existence of the alleged noncompliance, the Facility submits this Plan of Correction with the intention that it be inadmissible by any third party in any civil or other action against the facility or any employee, agent, officer, director or shareholder of the Facility. The Facility is utilizing this Plan of Correction as an allegation of substantial compliance as of 5/29/2026. F-0759 Corrective action for resident/s: Residents #21 and #22 were assessed and evaluated by nurse and Director of Nursing 5/14/26. Resident #21 and #22 both denied any adverse effects and none were noted upon assessment by the Director of Nursing on 5/14/2026. Notification made to physician on 5/14/2026. LPN # 2 competency Eval on insulin administration with the Director of Nursing completed 5/14/2026. Identification of other residents who may be affected: Diabetic residents on assignment of LPN #2/station 2 have the potential to be affected and were assessed by the DON/Designee on 5/14/26 and found to be within normal limits. Measures for systemic change: All Nurses were educated by the Director of Nursing on the steps for Insulin administration per competency, diabetes clinical protocol policy, Medication and treatment orders policy, administering medications policy, and Obtaining fingerstick Glucose Level policy On 5/14/2026. How Corrective Action will be monitored: Director of Nursing and Assistant Director of Nursing will complete insulin administration audits on 5 nurses. This audit will be completed weekly x 4 weeks, then monthly x 2 months. Corrective action will be initiated for any noted non-compliance. Audit findings will be reviewed as part of the monthly quality assurance process to determine the need for further monitoring. Date of Compliance: 5/29/2026
Failure to Document Tray Line Food Temperatures in Dining Room Kitchenettes
Penalty
Summary
The deficiency involves the facility’s failure to document tray line food temperatures for meals served from the Harrison and McClellan Dining Room kitchenettes, as required by professional standards for food service safety and the facility’s own policy. Review of the “Trayline Taste & Temperature Log” (revised September 2018) showed missing temperature documentation for multiple meals from the Harrison Dining Room kitchenette, including dinner on 03/30/26 and 03/31/26, lunch and dinner on 04/01/26 and 04/02/26, dinner on 04/07/26, and lunch and dinner on 04/08/26 and 04/10/26. The Senior Director of Culinary Services confirmed during interview that tray line food temperatures were not documented on the log for these meals. Similarly, review of the same log for the McClellan Dining Room kitchenette revealed that tray line food temperatures were not documented for dinner on 04/01/26, breakfast and lunch on 04/02/26, and lunch and dinner on 04/07/26. The Senior Director of Culinary Services also verified these omissions during interview. The facility census at the time was 27 residents, and the governing “Food and Nutrition” policy, approved on 09/07/21, stated that the facility must store, prepare, distribute, and serve food in accordance with professional standards for food service safety.
Plan Of Correction
F812 The facility will continue to ensure food temperatures are completed before meals are served for all residents. To ensure compliance with this standard the following measures have been taken: 1. Immediately 4/15/26 culinary supervisor #224 was re-educated by Dietary Manager to this standard and policy "Food and Nutrition" which includes documentation of food temperatures. 2. All dietary staff have been re-educated to the standard and policy "Food and Nutrition" during the month of April 2026. 3. Audits of food temperature documentation to be completed by Dietary Manager 4 x per week for 4 weeks then weekly for 4 weeks. 4. Administrator to validate audits/compliance and provide additional training as needed. Administrator will present to QAPI committee for ongoing monitoring and further direction.
Failure to Conduct and Document Required Care Conferences
Penalty
Summary
The deficiency involves the facility’s failure to complete and document comprehensive care conferences at required intervals in accordance with care plan regulations and facility policy. For one resident with Parkinson’s disease with dyskinesia, cognitive communication deficit, hemiplegia and hemiparesis following cerebral infarction, transient cerebral ischemic attack, type II diabetes mellitus, and major depressive disorder, the record showed multiple MDS assessments over a one-year period, including annual, quarterly, and significant change assessments. However, only two care conferences were documented during the last 12 months, despite the expectation that care conferences be conducted quarterly with the resident and family when possible. The Unit Care Coordinator confirmed that no additional care conference documentation existed for this resident beyond the notes dated 04/21/25 and 01/02/26. A second resident, with diagnoses including aphasia following cerebrovascular disease, cerebral infarction, type II diabetes mellitus, unsteadiness on feet, difficulty in walking, coagulation defect, depression, and muscle weakness, also had multiple MDS assessments completed over the review period, including quarterly and annual assessments. The record contained a note that a care conference was offered to the resident’s representative, who declined to attend, but there was no documentation of any care conferences for the most recent 12 months. The Unit Care Coordinator confirmed that no other care conference documentation was available for this resident. Facility policy stated that periodic care conferences involving the resident, family, and the interdisciplinary team are part of the care planning process, but the required periodic care conferences and corresponding documentation were not completed for these two residents.
Plan Of Correction
THIS PLAN OF CORRECTION SERVES AS BERKELEY SQUARE'S CREDIBLE ALLEGATION OF SUBSTANTIAL COMPLIANCE AS OF June 1, 2026. Without admitting or denying the validity or existence of the alleged deficiencies, Berkeley Square provides the following Plan of Correction: F657 The facility will continue to document completion of care conferences at the required intervals for all residents, including residents #04 & #15. To ensure compliance with this standard the following measures have be taken: 1. The social service designee and the inter- disciplinary team were re-educated by the administrator to the facility policy "Care Conference" on 4/29/26 and verbalized understanding. 2. Care conferences for resident #04 and resident #15 were conducted on or before 4/29/2026 by the interdisciplinary team. 3. Review of all other residents was conducted by the social service designee to validate and ensure that care conference schedule is up to date with timely care conferences scheduled for them on 4/15/2026. Audits of care conferences to be completed weekly for four weeks and then monthly after that by the social service designee. Documentation of the care conference including any identified concerns in the medical record. Administrator to validate audits/compliance and provide additional training as needed. Administrator will present results of these audits to QAPI committee for ongoing monitoring and further direction.
Failure to Reevaluate Blood Glucose After Treatment for Hyperglycemia
Penalty
Summary
The facility failed to ensure that a resident with diabetes received treatment in accordance with professional standards of practice when nursing staff did not reevaluate the resident's blood glucose after treatment for severe hyperglycemia. The resident, admitted with diagnoses including Alzheimer's disease, type II diabetes mellitus, and depression, had physician orders for Humalog insulin on a sliding scale before meals, Lantus insulin 25 units daily, and lisinopril 5 mg daily. The resident required extensive assistance with activities of daily living, including transfers, toileting hygiene, eating, and bathing. On the evening in question, the resident's blood glucose was documented as 532 mg/dL, and the on-call provider was notified. The provider gave a new order to administer an additional 8 units of lispro (Humalog) and to recheck the blood glucose in 30 minutes. The electronic medication administration record showed that the blood glucose of 532 mg/dL was obtained at 9:00 p.m. and that the additional 8 units of lispro were administered at 9:21 p.m. However, there was no documentation in the resident's chart that the blood glucose was rechecked after the additional insulin was given. In an interview, the DON confirmed there was no evidence of reevaluation and verified that, according to the facility's "Abnormal Blood Glucose Procedure" policy, the resident should have been reevaluated and that the evaluation step should have been included in the progress note documentation.
Plan Of Correction
F684 The facility will continue to ensure all residents, including #03, receive treatment in accordance with professional standards of practice and reevaluated for hyperglycemia. To ensure compliance with this standard the following measures have been taken: 1. The director of nursing assessed resident #03, reviewed documentation and orders and found no ill effects immediately 4/16/26. 2. All licensed nurses were re-educated to facility policy "Blood Glucose Monitoring" by the Director of Nursing/designee in April 2026. 3. Audits of like-residents that require blood sugar checks to be completed by the director of nursing/designee two times a week for 4 weeks and then monthly after that to validate correct follow through when there is abnormally high blood glucose result. The Administrator will bring results of these audits to the QAPI committee for ongoing monitoring and further direction.
Failure to Act on Pharmacist Drug Regimen Recommendation for Thyroid Medication
Penalty
Summary
The deficiency involves the facility’s failure to ensure that pharmacy recommendations from the monthly drug regimen review were acted upon and documented for a resident. The resident was admitted with diagnoses including Parkinson’s disease, dementia, and hypothyroidism, and had current physician orders for levothyroxine 150 mcg once daily, buspirone 50 mg twice daily, and losartan 100 mg once daily. A medication regimen review dated 11/25/2025 included a consultant pharmacist recommendation that levothyroxine be administered consistently in the morning on an empty stomach, at least 30–60 minutes before food, per manufacturer instructions. There was no specific physician response in the medical record to this recommendation, and the facility’s policy stated that consulting pharmacist reviews are sent to nursing and addressed with the primary care provider or consulting specialist for review and follow-up. Review of the resident’s medication administration record for April 2026 showed levothyroxine scheduled for 9:00 a.m. On observation, the resident was seen eating breakfast in the dining area at 8:03 a.m., and an LPN reported administering the levothyroxine 150 mcg to the resident while the resident was in the dining area eating breakfast. The DON confirmed there was no evidence in the resident’s medical record explaining why the consultant pharmacist’s recommendation from 11/25/2025 was or was not acted upon. This lack of documented physician review and action on the pharmacist’s identified irregularity constituted noncompliance with the drug regimen review requirements.
Plan Of Correction
F756 The facility will continue to ensure the pharmacy recommendations from the monthly drug regimen review by a licensed pharmacist are acted upon for all residents, including #08. To ensure compliance with this standard the following measures have been taken: 1. Resident #08 was assessed by the registered nurse and med review completed by 4/28/26. After review of resident's drug regime's, it was discovered that resident #8 had 2 separate medication recommendations on the same form, to be reviewed by two separate practitioners, pharmacy has been instructed and agreed to separate meds on individual forms. 2. Licensed nurses re-educated to facility policy "Drug Regimen Review" by Director of nursing/designee in April 2026 and no later than 5/8/26. Licensed nurses are responsible for ensuring the reviews and recommendations are given to the physician for timely review. 3. Review of all other current residents Drug Regimen orders completed by Director of nursing/designee on 4/16/26 to ensure recommendations were followed up on/reviewed by the physician and address concerns if needed. 4. Audit of drug regime recommendations, pharmacy recommendations, and physician follow up to be completed weekly for four weeks by the Director of nursing/designee. Administrator will present results of these audits to the QAPI committee for ongoing monitoring and further direction.
Failure to Use Required Gait Belt During Ambulation Resulting in Resident Fall
Penalty
Summary
The deficiency involves the facility’s failure to ensure that a required gait belt was used while assisting a high fall‑risk resident with ambulation, resulting in a fall with head injury. The resident had multiple diagnoses including metabolic encephalopathy, hypertension, osteoarthritis, muscle weakness, gait and mobility abnormalities, major depressive disorder, anxiety, and visual hallucinations. Admission and subsequent MDS and fall risk assessments documented that the resident was severely cognitively impaired, required moderate to maximal assistance with transfers and ambulation, could not independently come to a standing position, exhibited loss of balance while standing, used an assistive device, and had decreased muscle coordination. The resident had a history of falls prior to admission and was assessed as being at high, later moderate, risk for falls. The resident’s fall care plan identified her as at risk for falls and included interventions such as providing maximum to moderate assistance with transfers and walking short distances, use of a walker and wheelchair, and following the facility’s fall protocol. Therapy notes and care conference documentation indicated that the resident leaned backwards when standing, required contact guard to minimal assistance for bed mobility and transfers, and needed constant verbal cueing for safe sequencing during toilet transfers. The physical therapist confirmed that the resident was to use a gait belt with staff when ambulating, and the DON verified that therapy had assessed the resident as requiring contact guard assistance and a gait belt for ambulation and transfers. On the day of the incident, a CNA was assisting the resident from her recliner to the bathroom using a walker. The CNA walked beside the resident, providing guidance and support, and reported having a hand on the resident while assisting her. As they approached the bathroom door, the CNA reached for the doorknob to open it, and at that moment the resident began to lose her balance and fell backwards to the floor, striking the back of her head. The nurse who responded found the resident on her back at the foot of the bed with her feet near the bathroom, noted a red raised area on the back of the head, and documented that the resident was not wearing a gait belt and that the gait belt was on the dresser. In the facility’s investigative summary and in interviews, the CNA acknowledged that she did not have a gait belt on the resident while ambulating her, despite the resident’s assessed need for hands‑on assistance and gait belt use per facility policy and the resident’s care and therapy plans.
Failure to Implement PD Orders and Monitor Resident Receiving Peritoneal Dialysis
Penalty
Summary
The deficiency involves the facility’s failure to implement pre-admission physician orders for peritoneal dialysis (PD) and to provide ongoing monitoring for a resident with chronic kidney disease (CKD) stage five who required PD. Pre-admission orders dated 11/14/25 specified three daily PD exchanges at 6:00 A.M., 2:00 P.M., and 10:00 P.M., and directed staff to monitor for signs and symptoms of peritonitis, including fever, abdominal pain, and cloudy effluent. These monitoring orders were not entered into the facility’s physician orders. The resident’s care plan noted the need for PD and included general monitoring interventions (labs, signs of bleeding, bacteremia, septic shock, and significant vital sign changes), but did not specifically address the ordered monitoring for peritonitis. Review of PD documentation showed incomplete and inconsistent charting of treatments and resident condition. The paper peritoneal flowsheet had columns for time of PD and condition/comments, including instructions to call the nurse immediately for cloudy fluid, abdominal pain, or fever. However, the first entry on 11/15/26 at 2:00 P.M. only noted that the PD nurse completed the exchange, and the 10:00 P.M. entry that day had no condition/comment documentation. Subsequent days (11/16/25, 11/17/25, and 11/18/25) contained only one condition/comment entry per day rather than for each exchange, and there was no documentation that the 6:00 A.M. PD on 11/18/25 was completed. The PD cycler flowsheet starting 11/19/25 lacked any description of the effluent on multiple days. The PD nurse from the dialysis company stated facility staff were expected to monitor effluent for cloudiness and assess for abdominal pain and fever, and the DON confirmed there was no electronic physician order for peritonitis monitoring or for use of the PD cycler, that the paper charting did not allow for effluent description or symptom documentation for each treatment, and that PD was not documented at one ordered time. The facility’s dialysis policy required ongoing assessment and monitoring for complications before, during, and after treatments, which was not reflected in the documentation for this resident.
Improper Infection Control During Medication Administration
Penalty
Summary
Surveyors identified a deficiency in infection prevention and control related to medication administration for Resident #29. The resident was admitted on 02/28/14 with diagnoses including depression, traumatic brain injury, and anxiety, and had impaired cognition per a quarterly MDS assessment. During an observation on 03/25/26 at 6:58 A.M., RN #281 prepared the resident’s medications by removing an Amoxicillin-Pot Clavulanate tablet from the medication card and pushing it directly into her ungloved hand, then using her fingers to place the pill into a medication cup. The same process was observed for multiple other medications, including Escitalopram Oxalate, Furosemide, Sennosides, Lyrica, and Vitamin D, each being pushed from the card into the RN’s ungloved hand and then transferred by her fingers into the medication cup before administration to Resident #29. In a subsequent interview at 7:27 A.M. the same day, RN #281 confirmed she had placed each medication into her ungloved hands prior to administration and acknowledged that the proper procedure was to push the pills directly from the card into the medication cup. Review of the facility’s “Medication Administration – General guidelines” policy, revised 10/08/25, stated that medications are to be administered in accordance with good nursing principles and practices. This practice failure was cited as a deficiency under Complaint Number 2681777.
Improper Use of Wheelchair as a Physical Restraint
Penalty
Summary
Surveyors identified a deficiency related to the facility’s failure to ensure a resident was free from physical restraints. Resident #7, admitted with diagnoses including Alzheimer’s disease, diabetes mellitus, and anxiety disorder, was documented on a recent MDS as rarely understood and dependent for ADLs except eating. The resident ambulated independently on the unit without an assistive device and had documented verbal and other behaviors occurring one to three days during the look-back period. The care plan noted the resident had potential to be physically aggressive, chase staff, throw objects, and be combative with care, with interventions such as offering choices, administering medications as ordered, and intervening early when agitation occurred. During an observation and interview, Resident #7 was found sitting in a chair with the right arm of the chair positioned against the nursing station and a wheelchair placed directly in front of him. The left arm of the wheelchair was also against the nursing station, and both wheelchair wheels were locked, creating a barrier that appeared to restrain the resident, who was sleeping with his knees touching the locked wheelchair. An LPN confirmed both wheelchair wheels were locked and that the wheelchair should not have been placed in front of the resident. A CNA reported she had placed the wheelchair there in preparation to get the resident up for lunch, was unable to transfer him, and left the wheelchair in that position, acknowledging it was wrong to keep it there. The facility’s physical restraint policy stated that physical restraints are not used except when alternatives are not appropriate or effective for treating a medical symptom and defined physical restraints as any device attached or adjacent to the body that the individual cannot easily remove and that restricts freedom of movement or access to the body.
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