Birchaven Retirement Village
Inspection history, citations, penalties and survey trends for this long-term care facility in Findlay, Ohio.
- Location
- 15100 Birchaven Lane, Findlay, Ohio 45840
- CMS Provider Number
- 365973
- Inspections on file
- 18
- Latest survey
- January 9, 2025
- Citations (last 12 mo.)
- 0
Citation history
Health deficiencies cited at Birchaven Retirement Village during CMS and state inspections, most recent first.
The facility did not serve food according to the menu and dietary spreadsheet, affecting 29 residents. During a meal service, broccoli cheddar soup was served using a four-ounce ladle instead of the specified six-ounce portion. Chef confirmed the error.
The facility failed to properly label, date, and dispose of food items in unit refrigerators, affecting residents on the Birch, Cedar, and Dogwood units. Observations revealed unlabeled and undated food items, including sandwiches, containers with unknown substances, and leaking containers. Staff confirmed these items should have been disposed of, impacting 45 residents in a facility with a census of 90.
The facility failed to implement proper infection control practices for COVID-19 and EBP, affecting six residents. Observations revealed that residents who tested positive for COVID-19 were not properly isolated, and staff did not consistently wear or dispose of PPE as required. Additionally, hand hygiene practices were not followed, and residents on EBP did not receive care with the necessary precautions.
The facility failed to ensure residents received education and provided consent for COVID-19 vaccinations prior to administration or refusal, affecting five residents. Medical records lacked documentation of vaccine information, consent, or refusal. An interview with the DON revealed the absence of a form and policy for COVID-19 vaccine consent, contributing to the deficiency.
The facility failed to treat residents with dignity and respect. A resident experienced a significant delay in receiving their meal, while two other residents had their lunch interrupted for physical examinations by a CNP. The facility lacks a specific policy on dignity, relying instead on general residents' rights.
A CNP discussed a resident's medical condition and treatment in the dining room with other residents present, violating the facility's privacy policy and HIPAA. The resident was being treated for pain with tramadol and was cognitively intact. The CNP did not adjust her rounds based on residents' schedules, leading to the breach of confidentiality.
A resident with severe cognitive impairment had bruising on their forearm that was noticed by a CNA but not reported to facility management until the resident's family informed the ADON. This delay in reporting led to a deficiency in addressing potential abuse or neglect.
The facility failed to conduct thorough investigations for injuries of unknown origin for two residents. One resident with Alzheimer's was found with bruising, and another with dementia had redness and swelling on her hand. In both cases, the facility did not perform skin checks on other residents on the same hall who could not be interviewed, contrary to their policy. This was confirmed by the Administrator and DON.
A facility failed to provide a translator phone for a Spanish-speaking resident, as ordered by a physician. Despite attempts to use personal phone applications, staff were unable to communicate effectively with the resident. The resident's daughter and staff confirmed the absence of a translator phone, and the ADON was unsure of the effectiveness of a tablet application intended for communication.
A facility failed to monitor and implement constipation interventions for a resident at high risk due to health conditions and opioid use. The care plan required monitoring bowel movements and administering medications, but records showed gaps in documentation and medication administration. The DON confirmed these lapses, acknowledging the protocol was not followed.
A facility failed to ensure proper interventions to prevent aspiration for a resident receiving enteral nutrition. The resident, who was severely cognitively impaired and dependent on staff, required the head of their bed to be elevated to 45 degrees during tube feeding. Observations revealed the bed was barely elevated, and staff interviews confirmed the deficiency, with an LPN mistakenly believing the required elevation was 30 degrees.
A resident with pneumonia required oxygen therapy at two liters per minute as per the physician's order. However, observations showed the oxygen was set at four liters per minute, contrary to the order. This discrepancy was confirmed by an RN, indicating a failure to follow the facility's policy on verifying physician orders for oxygen administration.
The facility failed to administer the influenza vaccine to a resident who consented and did not offer another resident the necessary information or consent options for influenza and pneumococcal vaccines. One resident, with multiple health conditions, consented to the influenza vaccine, but there was no record of administration. Another resident, cognitively impaired, had no documentation of vaccine consent or refusal, and the facility did not obtain verbal consent from the Power of Attorney.
Improper Portioning of Broccoli Cheddar Soup
Penalty
Summary
The facility failed to ensure that food was served according to the facility menu and dietary spreadsheet, which had the potential to affect 29 residents on the Cedar and Dogwood units. During a meal service observation, it was noted that the broccoli cheddar soup was being served using a four-ounce ladle instead of the six-ounce portion specified in the menu spreadsheet. This discrepancy was confirmed in an interview with Chef #441, who acknowledged that the soup should have been served using a six-ounce ladle.
Improper Food Storage Practices in Facility Refrigerators
Penalty
Summary
The facility failed to ensure proper labeling and dating of food items stored in unit refrigerators, as well as the removal of expired food items. During an observation on the Birch-hall unit refrigerator, an unlabeled pack of two small sandwiches was found, which should have been disposed of according to Certified Nursing Assistant (CNA) #579. Additionally, the refrigerator near the dining area for the Birch-hall contained three unlabeled and undated disposable plastic containers with unknown substances, an unlabeled and undated glass jar with an unknown red substance, and a grocery bag with three unlabeled and undated disposable containers, one of which was leaking. These findings were verified by Hospitality Aide #497. Further observations on the Cedar-hall unit refrigerator revealed an unlabeled and undated bag with an unknown frozen substance and another bag with an unknown brown substance, which Activities Staff Member #501 confirmed should have been disposed of. Additionally, the refrigerator near the dining area for the Cedar and Dogwood halls contained an unlabeled and undated clear-plastic bag with an unknown food item. These deficiencies in food storage practices had the potential to affect 45 residents residing on the Birch, Cedar, and Dogwood units, with a facility census of 90.
Inadequate Infection Control Practices in LTC Facility
Penalty
Summary
The facility failed to implement proper infection control practices related to COVID-19 and Enhanced Barrier Precautions (EBP), affecting six residents. Observations revealed that residents who tested positive for COVID-19 were not properly isolated, as their room doors were left open, and there was a lack of appropriate signage and personal protective equipment (PPE) available. Staff members were observed entering rooms without wearing the required PPE, such as N95 masks, gowns, gloves, and face shields, and there were instances where PPE was not properly disposed of or disinfected after use. Resident #25, who tested positive for COVID-19, was observed without proper isolation measures in place, as there was no PPE cart or signage outside the room. Staff members were seen assisting the resident without wearing the necessary PPE. Similarly, Resident #28's room lacked proper signage and PPE, and staff were observed not disinfecting shared face shields after use. Resident #14 also tested positive for COVID-19, and similar deficiencies in PPE usage and signage were noted. For residents on EBP, such as Resident #72 and Resident #49, staff failed to wear the required gowns and gloves during high-contact care activities. Additionally, hand hygiene practices were not consistently followed, as staff did not wash or sanitize their hands after doffing PPE. Resident #82, who required EBP due to a tracheostomy and gastrostomy, reported that staff did not wear gowns or masks during care. These observations indicate a systemic failure in adhering to infection control protocols, as outlined in the facility's policy and CDC guidelines.
Failure to Document COVID-19 Vaccine Education and Consent
Penalty
Summary
The facility failed to ensure that residents received education and provided consent for COVID-19 vaccinations prior to administration or refusal. This deficiency affected five residents who were reviewed for COVID-19 vaccination. The medical records of these residents did not contain any forms indicating that they were given information about the COVID-19 vaccine, nor did they contain any documentation of consent or refusal of the vaccine. The residents involved had various medical conditions, including rhabdomyolysis, type II diabetes mellitus, obesity, cerebral infarction, chronic obstructive pulmonary disease, spinal stenosis, anemia, hyperlipidemia, hypertension, metabolic encephalopathy, cystitis, atherosclerotic heart disease, chronic congestive heart failure, long-term use of anticoagulation therapy, hypothyroidism, and chronic kidney disease. An interview with the Director of Nursing revealed that the facility did not have a form for refusal or acceptance of the COVID-19 vaccine and lacked a policy for offering the COVID-19 vaccine. While the influenza vaccine is offered from October through March, and the pneumococcal and COVID-19 vaccines are offered at any time, the absence of a formal process for documenting education and consent for the COVID-19 vaccine led to this deficiency. The facility census at the time was 90 residents.
Failure to Ensure Resident Dignity and Respect
Penalty
Summary
The facility failed to ensure residents were treated with dignity and respect, affecting three residents. Resident #23, who was cognitively impaired and required assistance with eating, was observed in the dining room waiting for their meal while other residents had already been served and finished eating. Despite being seated at 11:30 A.M., Resident #23 did not receive their meal until 12:32 P.M., causing them to motion as if they were eating due to the delay. This was confirmed by Hospitality Aide #497, who acknowledged that Resident #23 had to wait longer than others to be served. Additionally, the facility did not respect the dignity of Residents #64 and #57, who were both cognitively intact, during their lunch. Clinical Nurse Practitioner (CNP) #399 interrupted their meals to conduct physical examinations in the dining room, which was confirmed by CNP #399 and noted in the progress notes. The Director of Nursing stated that the facility does not have a specific policy on dignity but follows residents' rights. The Residents Rights handbook emphasizes treating each resident with respect and dignity, promoting their quality of life and individuality.
Breach of Resident Privacy in Dining Area
Penalty
Summary
The facility failed to maintain the privacy and confidentiality of a resident's medical information, as required by their policy and the Health Insurance Portability and Accountability Act (HIPAA). During an observation, a Clinical Nurse Practitioner (CNP) was seen discussing a resident's medical condition, treatment, and vital signs in the dining room where other residents were present. This discussion involved a resident who was cognitively intact and being treated for pain with tramadol, as per the physician's orders. The CNP confirmed in an interview that she discussed the resident's medical details in the presence of other residents and stated that she does not adjust her rounds based on the residents' schedules unless they are out of the building. The facility's policy clearly states that health information should be kept confidential and that precautions should be taken to prevent the incidental disclosure of Protected Health Information (PHI) to unauthorized individuals. This incident affected one resident out of the 90 in the facility census.
Failure to Report Injury of Unknown Origin
Penalty
Summary
The facility failed to ensure timely reporting of an injury of unknown origin and potential physical abuse involving a resident. The incident involved a resident who was severely cognitively impaired and required assistance for all activities of daily living. The resident's family member reported bruising on the resident's lower right forearm to the Assisted Director of Nursing (ADON) in the afternoon, which was the first time the facility management became aware of the issue. Prior to this, a Certified Nursing Assistant (CNA) had noticed the bruising during their shift but did not report it to the nurse on duty or any other staff. The facility's investigation revealed that the CNA observed the bruising before 6:00 A.M. but failed to report it, resulting in a delay in initiating a Self-Reported Incident (SRI). The Director of Nursing (DON) and the Administrator confirmed that the CNA did not report the bruising until after the family brought it to the facility's attention. This lack of timely reporting and communication within the facility led to a deficiency in addressing potential abuse or neglect, as the facility's management was not informed until the family intervened.
Failure to Conduct Thorough Investigations for Injuries of Unknown Origin
Penalty
Summary
The facility failed to conduct thorough investigations for injuries of unknown origin for two residents. Resident #98, who had Alzheimer's disease and was dependent on staff for daily activities, was found with bruising on her legs. Although staff and other residents were interviewed, and a skin assessment was completed for Resident #98, there was no evidence that skin assessments were conducted on other residents residing on the same hall who could not be interviewed. This lack of comprehensive investigation was confirmed by the Administrator and Director of Nursing (DON). Similarly, Resident #68, who had major depressive disorder and dementia, was found with new redness and swelling on her right hand. Despite being interviewed and having a skin assessment, the facility did not perform skin checks on other residents on the same hall who were unable to be interviewed. The facility's policy on investigating injuries of unknown origin was not followed, as confirmed by the Administrator and DON, who acknowledged that skin checks were not completed on any residents other than the affected ones.
Failure to Provide Communication Tools for Non-English Speaking Resident
Penalty
Summary
The facility failed to provide alternative methods of communication for a resident who was admitted with a primary language of Spanish and required an interpreter to communicate with healthcare staff. Despite a physician's order for a translator phone, the facility did not provide this device, and staff were unable to effectively communicate with the resident. The resident's daughter confirmed that while some common phrases were posted in the resident's room, they were insufficient for day-to-day communication, and she was unaware of any translator phone or interpreter being available. Staff interviews revealed that attempts were made to use personal phone applications to communicate with the resident, but these were ineffective as they did not recognize the resident's voice. The Assistant Director of Nursing confirmed the absence of a translator phone and mentioned the use of a tablet with an application, though its effectiveness was uncertain. This lack of proper communication tools hindered the facility's ability to meet the resident's communication needs as per the physician's orders.
Failure to Monitor and Administer Constipation Interventions
Penalty
Summary
The facility failed to adequately monitor and implement interventions for constipation for Resident #42, who was at high risk due to multiple health conditions and opioid medication use. The resident's care plan required monitoring and documenting bowel movements every shift, and administering stool softeners or laxatives as ordered. However, the medical records showed gaps in documentation of bowel movements and the absence of color descriptions, as required by the care plan. Additionally, the administration records indicated that the prescribed medications, Miralax and Colace, were not administered during the specified period, despite the resident not having documented bowel movements for several days. The Director of Nursing confirmed these lapses in documentation and medication administration, acknowledging that the facility's protocol to offer interventions after three days without a bowel movement was not followed for Resident #42.
Failure to Elevate Bed During Tube Feeding
Penalty
Summary
The facility failed to implement necessary interventions to prevent aspiration for a resident receiving enteral nutrition. Resident #49, who was severely cognitively impaired and dependent on staff for all activities of daily living, required tube feeding due to dysphagia. The resident's care plan specified that the head of their bed should be elevated to 45 degrees during and for thirty minutes after tube feeding. However, during an observation, it was noted that the resident was lying on their back with the head of the bed barely elevated while the tube feeding was running. Interviews with staff confirmed the deficiency. A CNA verified that the head of the bed should have been elevated more, and an LPN acknowledged that the bed was not elevated to the required degree. The LPN mistakenly believed the head of the bed should be at 30 degrees and admitted there was no way to determine the exact elevation. This oversight in following the care plan for Resident #49's tube feeding regimen led to the deficiency noted in the report.
Failure to Administer Oxygen Per Physician's Order
Penalty
Summary
The facility failed to ensure that oxygen was administered to a resident according to the physician's order. A resident, who was admitted with a diagnosis of pneumonia and was cognitively intact, required oxygen therapy as per the admission Minimum Data Set. The physician's order specified that the resident should receive oxygen at two liters per minute via nasal cannula. However, observations on multiple occasions revealed that the resident's oxygen was set at four liters per minute, which was confirmed by a registered nurse. The facility's policy on oxygen administration requires verification of the physician's order, which was not adhered to in this case.
Failure to Administer and Offer Vaccinations
Penalty
Summary
The facility failed to ensure that one resident received the influenza vaccination after consenting and failed to offer another resident the information, consent, or refusal of the influenza or pneumococcal vaccine. Resident #82, who had diagnoses including metabolic encephalopathy, type II diabetes mellitus, and chronic obstructive pulmonary disease, consented to the influenza vaccine on 11/29/24, but there was no evidence in the medical record that the vaccine was administered. Resident #149, with diagnoses such as cystitis, atherosclerotic heart disease, and chronic obstructive pulmonary disease, had a blank form for the influenza and pneumococcal vaccines. The Director of Nursing admitted that the resident was cognitively impaired and unable to consent, and the Power of Attorney had not signed any documents. The facility did not obtain verbal phone consent, which was an option. The influenza vaccine is offered from October through March, and the pneumococcal vaccine is offered upon admission and yearly.
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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