Brookhaven Nursing & Rehabilitation Center
Inspection history, citations, penalties and survey trends for this long-term care facility in Brookville, Ohio.
- Location
- One Country Lane, Brookville, Ohio 45309
- CMS Provider Number
- 365422
- Inspections on file
- 22
- Latest survey
- March 9, 2026
- Citations (last 12 mo.)
- 7
Citation history
Health deficiencies cited at Brookhaven Nursing & Rehabilitation Center during CMS and state inspections, most recent first.
The facility failed to conduct and complete quarterly interdisciplinary care conferences for multiple residents with complex medical conditions, including cardiovascular disease, COPD, dementia, and psychotic disorders. Although required MDS assessments and care plans addressing issues such as skin integrity, nutritional risk, and psychotropic medication monitoring were in place, the electronic records showed only sporadic care conferences, many of which were marked in error status or left incomplete with missing signatures and sections. Residents and families reported not participating in quarterly care conferences, and a corporate RN confirmed that the conferences were not held as required and that the facility’s policy calling for resident/family involvement and IDT participation in care planning was not followed.
The facility failed to provide and document evening activities for several cognitively impaired residents whose care plans identified specific activity interests and needs for assistance and verbal prompts. Activity records over a month showed no participation documented after 4:30 p.m., even though the activity calendar listed afternoon and evening programs such as nail care, snacks/hydration, sensory boxes, and movie and snack sessions in the memory care unit. Observations revealed that scheduled activities were not occurring at the designated times, and staff acknowledged that activities were not completed as planned and that documentation after 4:30 p.m. was not monitored, despite policy assigning responsibility for maintaining individual participation records to the activity coordinator.
A resident with multiple comorbidities, cognitive impairment, and dependence for toileting had care plan needs related to constipation and hydration, along with PRN orders for laxatives and a bowel protocol requiring shift-by-shift bowel documentation and action after several days without a bowel movement. Over a multi-day period, the MAR showed no constipation treatments given, CNA documentation and progress notes contained no bowel movement entries, and the NP visit note did not address bowel movement status. An RN and the Administrator confirmed that staff did not document bowel movements daily, did not follow the bowel protocol after several days without a bowel movement, did not administer PRN laxatives, and did not notify the physician or NP of the absence of bowel movements, contrary to facility policy.
A diabetic resident with impaired cognition and vascular dementia, who required assistance with mobility and toileting, did not receive routine foot and nail care despite a care plan directing staff to monitor skin and provide ordered treatments. Physician orders for the month lacked any nail care directives, and there was no documentation that nail care had been performed. Although podiatry services were eventually authorized by the resident’s durable power of attorney, observations later showed the resident complaining of foot pain, with overgrown, curling toenails causing reddened indentations on adjacent toes and white tissue noted between and along the toes.
A resident with neuromuscular bladder dysfunction and an indwelling urinary catheter, who depended on staff for toileting and mobility, was observed receiving catheter care from a CNA. After emptying the urinary drainage bag into a urinal, the CNA reinserted the drainage tubing tip into the storage sleeve without cleaning it with an alcohol pad, contrary to facility policy and the catheter care skills checklist. In interviews, the CNA acknowledged not using an alcohol pad, and an RN confirmed that the tubing end should be wiped with alcohol before reinsertion.
Surveyors found that medications, including topical treatments and a narcotic pain medication with potassium supplement, were left unsecured at the bedside of two residents without staff present. One resident with impaired cognition had a large tub of ointment and roll-on analgesic with pharmacy labels left in the room, while another resident had a medication cup with two pills on the bedside table to self-administer with lunch. The narcotic tablet had not been documented on the controlled substance count sheet, and these practices conflicted with facility policy requiring medications to be locked or attended only by authorized staff.
A resident with multiple wounds and a urinary catheter, care-planned for infection risk and placed on enhanced barrier precautions, received catheter and hygiene care from a CNA who did not don a gown as required, placed a basin directly on a bedside table without a barrier, discarded used washcloths onto a towel on the floor, failed to disinfect the catheter drainage tubing tip before reinserting it into the storage sleeve, and allowed stained bed linens to contact the CNA’s uniform while bagging them. A CDC enhanced barrier precautions sign was posted at the room, washable gowns were available on the back of the door, and facility policy required gown use for high-contact care and device care, but the CNA believed the precautions did not apply to this resident, while an RN confirmed the resident was on enhanced barrier precautions for wounds and catheter use.
The facility failed to maintain a clean kitchen, affecting 91 residents. Observations revealed a tacky substance on hoses and a dark substance on juice box nozzles. Interviews with the Dietary Director and Corporate Dietician confirmed these findings. A review of records showed an undated document for monthly deep cleaning, indicating a lack of documented cleaning procedures.
A resident with severe cognitive impairment and a feeding tube had persistent issues with the tube being black and foul-smelling. Despite repeated notes left for the physician, the facility failed to address these concerns in a timely manner. Observations and staff interviews confirmed the lack of action by medical personnel.
A resident with specific medical conditions had a physician order for Potassium Chloride ER Oral Capsule Extended Release 20 mEq, which required crushing due to swallowing difficulties. However, the facility only had a non-crushable tablet form in stock, leading to improper medication administration throughout November. Despite a signed approval for a crushable form, the order was not initiated, violating the facility's medication administration policy.
The facility failed to implement Enhanced Barrier Precautions (EBP) for two residents with indwelling medical devices, as required by their policy. Observations revealed the absence of gowns, gloves, and signage for EBP, and interviews confirmed that these residents were not care planned for EBP. The facility's EBP list did not include these residents, despite their conditions necessitating such precautions.
A resident experienced a fall and a subsequent decline in condition, but the facility failed to notify the resident's emergency contact as required by policy. The LPN mistakenly believed a visiting family member was the emergency contact and did not verify this information, leading to a delay in notifying the actual emergency contact until the resident's condition had significantly worsened.
Failure to Conduct and Complete Quarterly Interdisciplinary Care Conferences
Penalty
Summary
The deficiency involves the facility’s failure to ensure that comprehensive care plans were prepared, reviewed, and revised by an interdisciplinary team and that care conferences were scheduled and conducted quarterly, as required by facility policy. For one resident with cerebral atherosclerosis, stage IV kidney disease, and hypertension, records showed multiple timely MDS assessments and a care plan addressing risk for skin breakdown, but only one documented interdisciplinary care conference over an extended period. No additional care conferences were recorded in the electronic health record despite ongoing quarterly and annual assessments. Another resident with atrial fibrillation, COPD, chronic pain, and nutritional risk had an admission assessment and several quarterly MDS assessments completed, along with a care plan addressing nutritional risk and monitoring needs. However, the electronic record showed only one documented care conference, and both the resident and family confirmed they had not participated in quarterly care conferences. A third resident with Alzheimer’s disease, dementia, and psychotic disturbance had multiple quarterly and annual MDS assessments and a care plan for psychotropic medication monitoring, but only four care conferences were documented over a broad time frame, with all marked in error status. One of these assessments was incomplete, with only restorative nursing and nursing sections signed, and the resident’s family confirmed that quarterly care conferences had not occurred. A fourth resident with acute and chronic heart failure and vascular dementia with behaviors had multiple quarterly and annual MDS assessments completed and required staff assistance with ADLs. The electronic record showed only two care conferences, both noted as in error status or in progress, and one was incomplete with only restorative nursing and nursing sections signed. A corporate RN verified that the care conference assessments in the system were in error status, meaning the conferences were not complete and/or lacked required information and signatures, and confirmed that quarterly care conferences for all four residents had not been conducted as required. Review of the facility’s Resident Assessment policy showed that residents were to have the opportunity to discuss their goals of care and that care plans were to be developed by an interdisciplinary team with resident and/or family participation, but this policy was not implemented as written.
Failure to Provide and Document Evening Activities for Cognitively Impaired Residents
Penalty
Summary
The deficiency involves the facility’s failure to provide and document resident activities during evening hours, particularly after 4:30 p.m., for residents with impaired cognition. Three residents with dementia or cognitive impairment had care plans and activity assessments identifying interests such as reading, watching television, being outdoors, socializing, and participating in group programs. Their plans of care included interventions like providing activity calendars, assisting and escorting to activities, offering materials for individual activities, and encouraging participation in groups. However, review of their electronic health records over a one‑month period showed no documented activity participation after 4:30 p.m. Surveyors also found that scheduled activities in the memory care unit were not consistently carried out as planned. The March activity calendar listed nail care and snacks/hydration in the afternoon, and repeated evening activities such as sensory boxes and movie and snack sessions. Observations showed that a scheduled nail care activity was not in progress at the designated time, and the snack and hydration activity was not completed as scheduled. Activity staff reported that only two activity staff worked and they left by 4:30 p.m. daily, and that floor staff on the memory care unit were assigned to complete and document evening activities. The Activity Director confirmed that activity participation documentation was silent after 4:30 p.m., that the scheduled activities were not followed on a specific date, and that she did not monitor charting to ensure staff documented resident participation, despite facility policy stating that the activity coordinator maintains individual participation records.
Failure to Monitor and Implement Bowel Protocol for Constipation
Penalty
Summary
The deficiency involves the facility’s failure to monitor and document a resident’s bowel movements and to implement its bowel movement protocol when the resident did not have a bowel movement. The resident had multiple diagnoses including type 1 diabetes, epilepsy, history of myocardial infarction, Lewy body dementia with progressive cognitive decline, constipation, kidney disease stage three, and sepsis, and was cognitively impaired and nonverbal. The resident required supervision for eating, moderate assistance for bed mobility, and was dependent for toileting and transfers. The care plan identified increased nutrition and hydration needs and included monitoring for signs and symptoms of dehydration, monitoring labs and weights, and reporting refusals to eat or swallowing difficulties. Physician orders included a consistent carbohydrate, mechanical soft diet, a PRN Dulcolax suppository for constipation, and a nutritional supplement. Additional PRN laxative and stool softener orders (MiraLax, Colace, Senna) had been discontinued. From early to mid-February, the Medication Administration Record showed no administration of constipation treatments, and CNA bowel movement documentation and progress notes were silent for any bowel movements during the specified period. The NP’s visit note documented a soft abdomen with positive bowel sounds and no acute distress, but there was no documentation of bowel movement status. The RN confirmed that the electronic health record contained no bowel movement documentation after a certain date, that staff were expected to chart bowel movements daily, and that the electronic system should have triggered an alert for assessment and PRN laxative use, which did not occur. The RN also verified that the physician was not notified of the lack of bowel movements. The Administrator confirmed that the bowel movement protocol, which requires bowel movements to be documented every shift and directs staff to consider PRN treatment or physician notification after three consecutive days without a bowel movement, was not implemented, and that daily bowel movement charting and PRN laxative administration after three days did not occur. The NP stated she was not notified that the resident was not having bowel movements.
Failure to Provide Routine Foot and Nail Care for Diabetic Resident
Penalty
Summary
The deficiency involves the facility’s failure to ensure routine foot care for a diabetic resident with impaired cognition and vascular dementia. The resident was admitted with diagnoses including acute and chronic heart failure, type 2 diabetes, and vascular dementia, and required setup assistance for eating and moderate assistance for toileting, bed mobility, and transfers. The care plan identified diabetes mellitus with insulin dependence and included interventions such as blood glucose monitoring, diet and medications as ordered, and checking the body for skin breaks. However, review of the physician’s orders for the relevant month showed no orders related to nail care, and the facility was unable to locate any documentation that nail care had been provided. The resident’s quarterly MDS showed impaired cognition without behaviors or rejection of care. The resident initially did not authorize podiatry services per a consent form, but a later podiatry services authorization form showed that the durable power of attorney consented to podiatry services. A weekly nursing skin and body review documented a head-to-toe assessment with no new skin areas noted shortly before the deficiency was identified. Subsequent observations revealed the resident attempting to self-propel in a wheelchair, bumping her foot and stating that it hurt. A focused observation of the left foot showed overgrown nails on the third and fourth toes extending past the end of the toes and curling toward adjacent toes, causing reddened indentations where they touched. The great toe had white-colored tissue at the end of the toe, between the great and second toes, and along the side of the second toe, and the resident complained of pain when questioned by staff. These findings demonstrated that routine foot and nail care had not been provided as needed for this diabetic resident.
Failure to Follow Facility Procedure for Cleaning Urinary Drainage Tubing
Penalty
Summary
The deficiency involves the facility’s failure to provide appropriate urinary catheter care in accordance with its own policy and skills checklist. A resident with neuromuscular dysfunction of the bladder, intact cognition, and dependence on staff for toileting, transfers, and bed mobility was admitted with an indwelling urinary catheter. The resident’s care plan specified catheter care every shift, changing the catheter bag as needed, and changing the catheter per physician orders. The quarterly MDS documented ongoing urinary catheter use. During an observation, a CNA performed catheter care and then proceeded to empty the resident’s urinary drainage bag into a urinal after performing hand hygiene and donning gloves. After draining the bag, the CNA reinserted the tip of the drainage tubing back into the storage sleeve on the urinary drainage bag without using an alcohol pad to clean the end of the tubing. In a subsequent interview, the CNA acknowledged not using an alcohol pad, and an RN confirmed that staff should clean the end of the drainage tubing with an alcohol pad before reinserting it into the storage sleeve. Review of the facility’s catheter care and urinary output measurement skills checklist from 2009 showed that staff were required to close the drainage outlet, wipe it with an alcohol pad, and then reinsert it into the catheter bag without contaminating it. This failure was identified as an incidental finding during a complaint investigation.
Unsecured Medications Left at Bedside and Failure to Follow Medication Storage Policy
Penalty
Summary
The deficiency involves the facility’s failure to ensure medications were properly stored and not left at the bedside unsupervised. For one resident with cerebral atherosclerosis, stage IV kidney disease, hypertension, impaired cognition, and a care plan addressing risk for skin breakdown, physician orders included triamcinolone acetonide cream applied twice daily to the lower legs for stasis dermatitis. During observation of this resident’s room, surveyors found a large tub of ointment and two bottles of roll-on Biofreeze with pharmacy labels left in the room. These medications were present without staff supervision, contrary to the facility’s policy that medications must be locked or attended by authorized personnel. For another resident with atrial fibrillation, COPD, chronic pain, and a care plan addressing pain management, physician orders included daily potassium chloride ER 20 mEq and hydrocodone-acetaminophen 7.5-325 mg every six hours for pain. During observation, this resident was alone in the room in a wheelchair with a lunch tray and a medication cup containing two oval white pills on the bedside table. The resident stated the pills were a pain pill and a potassium pill left for her to take with lunch. The hydrocodone-acetaminophen tablet, a narcotic, had not been signed out on the controlled substance count sheet at the time of observation. The facility’s own medication storage policy states that only licensed nurses or those lawfully authorized to administer medications may access them and that medications must be locked or attended by authorized persons, which was not followed in these instances.
Failure to Follow Enhanced Barrier Precautions During Catheter and Wound-Related Care
Penalty
Summary
The deficiency involves the facility’s failure to ensure staff followed its infection prevention and control program, specifically enhanced barrier precautions, for a resident with multiple wounds and a urinary catheter. The resident had osteomyelitis of the sacral vertebra, peripheral vascular disease, neuromuscular bladder dysfunction, and was dependent on staff for toileting, transfers, and bed mobility. The resident’s MDS showed intact cognition, urinary catheter use, and receipt of ointments/medications to areas other than the feet. The care plan identified the resident as at risk for infection related to wounds and included interventions such as enhanced barrier precautions. Physician orders directed daily wound care to the chest, bilateral calves, and right heel. A CDC enhanced barrier precautions sign was posted outside the room, stating that providers and staff must wear gloves and a gown for high-contact resident care activities, including device care such as urinary catheter care and wound care requiring dressings. During observation, a CNA entered the resident’s room to provide urinary catheter care without donning a gown, despite the enhanced barrier precautions signage and the resident’s status. The CNA performed hand hygiene and donned gloves but placed a basin of warm soapy water directly on the bedside table without a barrier, completed catheter care, then threw the used washcloth onto a cloth towel laid on the floor. After emptying the basin and changing gloves, the CNA emptied the urinary drainage bag into a urinal and reinserted the drainage tubing tip into the storage sleeve without cleaning it with alcohol. The CNA then picked up the towel and dirty washcloths from the floor and placed them in a plastic bag, and also placed a stained bath blanket from the bed into the same bag, allowing the linen to come into contact with the CNA’s uniform. The CNA stated they did not believe the enhanced barrier sign applied to this resident and acknowledged not using a gown. An RN confirmed the resident was on enhanced barrier precautions for wounds and a urinary catheter and that staff should be using gowns for catheter care; washable gowns were observed hanging on the back of the resident’s door. Facility policy required staff to wear an impervious gown for high-contact care, including hygiene, linen changes, toileting assistance, and device care such as urinary catheters and wound care.
Unsanitary Kitchen Conditions
Penalty
Summary
The facility failed to maintain a clean and sanitary kitchen area, which had the potential to affect 91 residents who received meals from the facility's kitchen. During observations on November 18 and November 20, 2024, a tacky substance was found on the hoses, and a dark substance was observed on the nozzles that connect to juice boxes. Interviews with the Dietary Director and Corporate Dietician confirmed the presence of these substances. A review of the facility's records, specifically a document titled 'Monthly Kitchen Deep Clean,' revealed that there was an expectation for Dietary and Maintenance staff to collaborate on a pre-scheduled evening to clean equipment. However, the document was not dated, indicating a lack of documentation regarding the execution of these cleaning procedures.
Failure to Address Feeding Tube Concerns
Penalty
Summary
The facility failed to timely address concerns with a resident's feeding tube, affecting one of two residents reviewed for feeding tubes. The resident, who had severe cognitive impairment and was receiving hospice services, had a feeding tube that was repeatedly noted to be black in color and emitting a foul odor. Despite these observations, there was no documentation of the feeding tube concerns being addressed by the facility physician, Nurse Practitioner, or Hospice staff. Nursing notes indicated that the feeding tube was clogged and later unclogged, but the discoloration and odor persisted over several days. Notes were left for the physician in the communication book on multiple occasions, yet no action was taken until the Hospice on-call physician was notified. Observations confirmed the feeding tube's condition, and interviews with staff, including an LPN and the Director of Nursing, corroborated that the concerns were not addressed by the appropriate medical personnel.
Failure to Administer Medications Per Physician Orders
Penalty
Summary
The facility failed to administer medications according to physician orders for a resident diagnosed with malignant neoplasm of the right kidney, anemia in chronic kidney disease, and unspecified atrial fibrillation. The resident, who was cognitively intact and required assistance with various activities, had a physician order for Potassium Chloride ER Oral Capsule Extended Release 20 mEq to be administered once daily. However, the facility had Potassium Chloride ER Oral Tablet Extended Release in stock, which was not suitable for the resident's needs as the medication was not crushable, contrary to the physician's order to crush medications due to a swallow evaluation result. Throughout November, the resident's medications were crushed and administered daily, except on the morning of the observation when the LPN held the medication due to its non-crushable form. Interviews with the LPN and DON confirmed that a fax form signed by the Nurse Practitioner approved the use of a crushable form of the medication, but this order was not initiated. The facility's policy stated that long-acting or enteric-coated dosage forms should not be crushed, and an alternative should be sought, highlighting a failure in following the policy and physician orders.
Failure to Implement Enhanced Barrier Precautions
Penalty
Summary
The facility failed to implement Enhanced Barrier Precautions (EBP) for two residents, affecting their infection control measures. Resident #75, who was admitted with Parkinsonism, dementia, and neuromuscular dysfunction of the bladder, had a suprapubic catheter but lacked documentation for EBP. Observations on two separate occasions revealed that there were no gowns or gloves available, and no signage was present to advise staff that the resident was under EBP. Similarly, Resident #138, admitted with acute kidney failure, end-stage renal disease, and dependence on renal dialysis, had a dialysis catheter but also lacked EBP documentation. Observations showed the absence of gowns, gloves, and signage for EBP. Interviews with the LPN Unit Manager/Infection Preventionist confirmed that residents with indwelling medical devices should be under EBP, which was not the case for Residents #75 and #138. The EBP list provided to the survey team did not include these residents, and the Director of Nursing confirmed that they were not care planned for EBP. The facility's policy on EBP, dated August 2022, indicated that gloves and gowns should be used for residents with indwelling medical devices, but this was not implemented for the two residents in question.
Failure to Notify Emergency Contact of Resident's Fall and Decline
Penalty
Summary
The facility failed to ensure a resident's emergency contact was notified of a fall and a subsequent change in condition. This deficiency affected one resident who was moderately cognitively impaired and had diagnoses including muscle weakness, vascular dementia, heart failure, and pleural effusion. The resident experienced a fall while attempting to transfer from a wheelchair to the bed, and although the resident's physician and son were notified, the son was not listed as the emergency contact. The resident's level of consciousness declined significantly the following day, but the emergency contact was not notified until later in the evening when they visited the facility and expressed concerns about the resident's condition, leading to the resident being sent to the emergency room for evaluation. Interviews with the Director of Nursing, a Registered Nurse, and the Licensed Practical Nurse (LPN) assigned to the resident revealed that the LPN mistakenly believed a visiting family member was the emergency contact and assumed that the emergency contact had been informed about the fall. The LPN did not verify this information and failed to notify the actual emergency contact about the resident's fall and subsequent decline in condition. The facility's policy requires immediate notification of the resident, attending physician, and the resident's representative or interested family member in the event of an accident or significant change in the resident's status, which was not adhered to in this case.
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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