Brookview Healthcare Center
Inspection history, citations, penalties and survey trends for this long-term care facility in Defiance, Ohio.
- Location
- 214 Harding Street, Defiance, Ohio 43512
- CMS Provider Number
- 365447
- Inspections on file
- 30
- Latest survey
- February 25, 2026
- Citations (last 12 mo.)
- 3
Citation history
Health deficiencies cited at Brookview Healthcare Center during CMS and state inspections, most recent first.
A resident with multiple comorbidities and intact cognition sustained an unwitnessed fall in a dark room, was found on the floor with facial bleeding, a large forehead hematoma, periorbital bruising, and a lip laceration, and received Tylenol and wound cleansing from an LPN, but the physician was not contacted and EMS was not called until about two hours after the fall despite significant visible injuries and reported severe pain. In a separate incident, another cognitively intact resident with leg skin issues developed right knee skin tears after a fall, and although a physician ordered daily cleansing and dressing with non-adherent wrap, observation and resident report showed the knee dressing had not been changed the previous day, indicating the daily wound care order was not followed.
A resident with severe cognitive impairment and multiple chronic conditions, including Alzheimer’s disease, diabetes with polyneuropathy, psychotic disorder, hypertension, and severe protein-calorie malnutrition, had physician orders for Preservision AREDS, Protonix, and Refresh Tears. During a medication pass, an LPN did not administer these medications because they were unavailable, which was confirmed by MAR review showing they were not given as ordered. With 28 opportunities for medication administration and three omissions, the facility’s medication error rate was 10.7%, exceeding the 5% threshold, contrary to the facility’s medication administration policy.
The facility failed to prevent significant medication errors for two residents. A resident with documented allergies to Trazodone and Meloxicam, clearly noted in her pre-admission history and care plan, was nonetheless prescribed and administered Trazodone for insomnia and anxiety on multiple occasions before the allergy was recognized and the drug discontinued. Another resident with dementia and multiple comorbidities, ordered to receive a daily Rivastigmine 24-hour transdermal patch with instructions to remove the old patch before applying a new one, was observed with two patches in place from consecutive days, and an LPN reported having already removed an additional patch earlier, indicating three patches had been on simultaneously. These events occurred despite manufacturer instructions and facility policy requiring adherence to ordered dosages and proper patch removal.
A resident in an LTC facility experienced harm due to the facility's failure to provide timely treatment for constipation. Despite having physician orders for various constipation treatments, the resident did not receive any as-needed interventions for seven days, resulting in hospitalization for abdominal pain and stool impaction. The facility's bowel elimination policy was not followed, leading to the resident's condition worsening.
Two residents in the facility experienced significant weight loss without receiving adequate nutritional interventions. One resident, with dehydration and malnutrition, did not consistently receive prescribed supplements with meals. Another resident with dementia and dysphagia experienced weight loss without timely dietary adjustments, and double portions were not provided as ordered. The facility's policy for reweighing residents with significant weight changes was not consistently followed.
The facility failed to adequately monitor and document dialysis care for two residents requiring hemodialysis. One resident had multiple missed pre and post-dialysis evaluations, and another had no proper documentation or orders for a newly created fistula. Despite facility policies requiring regular assessments and documentation, these were not consistently followed, leading to deficiencies in care.
Two residents in an LTC facility did not receive prescribed medications due to pharmacy delivery issues and lack of communication. One resident missed doses of Lactulose for hyperammonemia, while another did not receive Tenapanor for irritable bowel syndrome. Both residents were aware of the missed medications, highlighting a failure in the facility's pharmaceutical services.
The facility failed to ensure timely responses to pharmacy recommendations for psychotropic medications, affecting three residents. A resident's medication evaluations were not addressed by a physician, and two residents experienced delays in implementing pharmacy recommendations for lab tests and dose reductions. The DON confirmed these failures.
A resident with type 2 diabetes did not receive insulin as ordered, leading to significant medication errors. Scheduled Humalog doses were administered late, and Tresiba doses were not given after the initial administration due to a pharmacy error. The LPN and DON confirmed these discrepancies.
An LPN failed to wear gloves while administering insulin to three residents and did not disinfect a glucometer between uses on two residents. Additionally, the DON did not follow contact precautions or perform hand hygiene when entering a resident's room with an infection, and subsequently entered another resident's room without proper hygiene measures.
Delayed Post-Fall Medical Response and Missed Wound Dressing Change
Penalty
Summary
The deficiency involves the facility’s failure to provide timely medical follow-up after a fall with injury and to complete wound care as ordered. One resident with multiple diagnoses including ovarian and abdominal lining cancer, dementia, gait difficulty, and osteoarthritis experienced an unwitnessed fall in her room in the early morning hours. A CNA discovered the resident on the floor around 4:45 A.M. in a dark room, with blood on her face and two pools of blood on the floor, after tripping over the resident’s wheelchair. An LPN cleaned the resident’s facial wounds, assessed her, and administered 650 mg of Tylenol for facial pain at 4:51 A.M., with the effectiveness documented as unknown. Despite the resident having a large hematoma on her forehead, bruising under both eyes, and a laceration to her upper lip exposing her teeth, the physician was not contacted until approximately 6:45 A.M., about two hours after the fall. The physician then ordered transfer to the emergency room, and EMS was called around 7:00 A.M., with the resident arriving at the emergency room at 7:23 A.M. EMS documentation noted that facility staff reported the fall had occurred approximately two hours before the 911 call, and the resident reported a pain score of nine out of ten upon arrival at the destination. The delay in notifying the physician and arranging emergency transport occurred even though the resident had significant visible injuries and ongoing pain. A second deficiency involved failure to follow physician orders for wound dressing changes. Another resident, cognitively intact and requiring partial/moderate assistance for personal hygiene, had scattered scabbing on both legs and developed two skin tears on the right knee after a fall. The physician ordered the right knee skin tears to be cleansed with normal saline, patted dry, covered with a non-adherent dressing, and wrapped daily and as needed until healed. On observation of wound care several days later, the dressing on the right knee was dated two days prior, and the wound nurse practitioner and the resident both confirmed that the dressing had not been changed the previous day. Review of the Treatment Administration Record showed documentation consistent with the earlier dressing date, indicating the daily dressing change order had not been carried out as written.
Medication Omission Leads to Elevated Medication Error Rate
Penalty
Summary
The deficiency involves the facility’s failure to ensure that all physician-ordered medications were administered to a resident, resulting in a medication error rate above 5 percent. Resident #70, admitted on 04/08/16, had multiple diagnoses including Alzheimer’s disease, diabetes mellitus with diabetic polyneuropathy, psychotic disorder with delusions, hypertension, severe protein calorie malnutrition, and muscle weakness. A quarterly MDS dated 01/29/26 documented severely impaired cognition with a BIMS score of 03. The resident’s care plan, dated 02/17/26, identified risk for alteration in mood related to anxiety, dementia, and depression, with an intervention to administer medications as ordered. Physician orders included Preservision AREDS 2 mg daily for macular degeneration, Protonix 40 mg daily for GERD, and Refresh Tears eye drops four times daily for dry eyes. On 02/23/26 at 9:05 A.M., an observation of LPN #362 preparing medications for Resident #70 showed that the LPN did not administer Preservision AREDS, Protonix, or Refresh Tears because the medications were unavailable. Concurrent interview with the LPN confirmed these medications would not be given at that time due to unavailability. Review of the February MAR showed these three medications were not administered on 02/23/26 for that reason. Based on 28 opportunities for medication administration and three omissions, the medication error rate was calculated at 10.7%. Review of the facility’s “Administering Medications” policy, last reviewed 04/28/25, stated that medications must be administered in accordance with orders, including required time frames. This deficiency was investigated under Complaint Numbers 2629125 and 1266301.
Medication Allergy and Transdermal Patch Administration Errors
Penalty
Summary
The deficiency involves the facility’s failure to prevent significant medication errors, including administering a medication to a resident with a documented allergy and not properly managing transdermal patch therapy. One resident with multiple diagnoses, including ovarian cancer, dementia, anxiety, depression, diabetes, and dysphagia, was admitted with documented allergies to Trazodone and Meloxicam, with noted reactions such as increased depression, aggression, abdominal pain, and nausea. Her care plan and pre-admission history and physical both identified these allergies. Despite this, after a pharmacy recommendation suggested Trazodone as an alternative to Hydroxyzine for insomnia and anxiety, the physician agreed and ordered Trazodone 50 mg daily, which was started and administered on multiple occasions. Review of the resident’s Medication Administration Record showed that she received Trazodone, a medication to which she was allergic, on five separate dates before the allergy was recognized and the medication discontinued. A progress note later documented by an RN indicated awareness that the resident had an allergy to Trazodone, and the physician was notified and changed the order to Melatonin, discontinuing Trazodone. The DON confirmed that the resident had previously had an order for and was administered Trazodone despite the documented allergy. A second deficiency involved another resident with diagnoses including type 2 diabetes mellitus, ataxia, hyperlipidemia, facial weakness following cerebrovascular disease, anxiety, dysphagia, and cognitive communication deficit, who had intact cognition but was dependent for all mobility and hygiene needs. This resident had an order for a Rivastigmine 24-hour transdermal patch for dementia, with explicit instructions to change the patch daily, place it on different areas of the body, and remove the old patch before applying a new one. During observation of incontinence care and a bed bath, the resident was found to have two Rivastigmine patches on the left shoulder/chest area, one dated for the current day and one for the previous day. An LPN verified the presence of both patches and stated she had removed a patch earlier that morning when applying the new one, indicating the resident must have had three patches on at the same time. Manufacturer instructions and facility policy required removal of the previous day’s patch and administration of medications in accordance with orders, which was not followed in this case.
Failure to Provide Timely Constipation Treatment
Penalty
Summary
The facility failed to provide timely treatment for constipation, resulting in actual harm to a resident who was admitted to the hospital with abdominal pain and stool impaction. The resident, who had intact cognition and was occasionally incontinent of bowel, was at risk for constipation as noted in their care plan. Despite having physician orders for various constipation treatments, including sennosides-docusate sodium, Dulcolax suppository, Milk of Magnesia, and polyethylene glycol, the resident did not receive any as-needed interventions for constipation between January 29 and February 4, 2025, during which no bowel movements were documented. The facility's bowel elimination policy required interventions if a resident had been without a bowel movement for 48 hours, escalating to more aggressive treatments if no results were achieved. However, the resident did not receive any as-needed medications until February 5, 2025, after seven days without a bowel movement. The resident was eventually given an enema and Milk of Magnesia, but continued to experience severe abdominal pain and was admitted to the hospital, where a manual disimpaction was performed. Interviews with the resident and the Director of Nursing confirmed the lack of timely interventions, which contributed to the resident's hospitalization.
Failure to Provide Adequate Nutritional Interventions for Residents
Penalty
Summary
The facility failed to provide adequate nutritional interventions for two residents experiencing significant weight loss. Resident #31, who was admitted with dehydration and moderate protein-calorie malnutrition, experienced a 13.5% weight loss over a short period. Despite a physician's order for a sugar-free healthshake with meals, observations revealed that the supplement was not consistently provided with Resident #31's meals. Interviews with staff confirmed the absence of the supplement on meal trays, and the dietary manager indicated that supplements were typically given between meals, contrary to the physician's order. Resident #60, diagnosed with dementia and dysphagia, also experienced significant weight loss, with a recorded 8.1% loss over 30 days and 12% over 180 days. Despite the weight loss, the resident's dietary interventions were not adjusted in a timely manner. The registered dietitian did not recommend new interventions after the initial weight loss and only suggested double portions months later. Observations showed that Resident #60 did not receive double portions as ordered, and the dietary staff had to adjust the meal portions after realizing the oversight. The facility's policy required reweighing residents with a weight change of 5% or more, but this was not consistently followed. The registered dietitian acknowledged the failure to document and assess the significant weight changes promptly. The lack of timely and appropriate nutritional interventions for both residents highlights deficiencies in the facility's weight management and dietary practices.
Deficiency in Dialysis Care Monitoring and Documentation
Penalty
Summary
The facility failed to provide adequate monitoring and documentation of dialysis care for two residents, both of whom required hemodialysis. Resident #21, who was cognitively intact and dependent on renal dialysis, had multiple instances where pre and post-dialysis evaluations were not completed. The facility had an order to monitor the resident's arteriovenous (AV) fistula for bruit and thrill every shift, but this was not consistently documented or scheduled, leading to missed evaluations. Interviews revealed that the resident himself had to remove the Band-Aid after dialysis, indicating a lack of staff involvement in post-dialysis care. Similarly, Resident #24, who also had end-stage renal disease and was on dialysis, did not have proper documentation or orders for monitoring a newly created fistula. The resident had a history of a clogged fistula and was using a port for dialysis, but a new fistula was created on the left upper arm. Despite the standard practice of checking the thrill and bruit of a fistula, there was no system in place for documenting these checks, and no orders were found for monitoring the new fistula site. Interviews confirmed that while checks were performed by some staff, there was no consistent documentation or directive for others to follow. The facility's policy on dialysis care required that the bruit and thrill of the fistula be assessed every shift and recorded on the Medication Administration Record. Additionally, assessments were to be completed before and after each dialysis session. However, these protocols were not followed, leading to a lack of communication and documentation regarding the residents' dialysis care. The failure to adhere to these policies resulted in deficiencies in the monitoring and documentation of dialysis care for both residents.
Medication Administration Failures in LTC Facility
Penalty
Summary
The facility failed to ensure that residents received medications as ordered, affecting two residents. Resident #123, who was admitted with metabolic encephalopathy and type 2 diabetes mellitus, did not receive her prescribed doses of Lactulose Oral Solution on multiple occasions due to the medication being on order or in transit from the pharmacy. This resulted in missed doses on 03/11/25, 03/24/25, and 03/25/25, as documented in the Medication Administration Record (MAR) and progress notes. Interviews with the resident and staff confirmed the lack of medication availability and administration. Resident #21, admitted with a diagnosis of dysfunctional dyspepsia, did not receive the prescribed Tenapanor for irritable bowel syndrome. The medication was not available from the pharmacy, and there was a lack of communication with the physician regarding this issue. The Director of Nursing (DON) noted the absence of the medication in a progress note, but no further action was taken until the surveyor's inquiry. The medication was not administered, and the pharmacy later indicated that the medication had fallen off their list and needed to be reordered. The deficiencies highlight a failure in the facility's pharmaceutical services, specifically in ensuring timely medication delivery and communication with healthcare providers. Both residents were cognitively intact and aware of the missed medications, which were critical for managing their respective health conditions. The facility's inability to provide these medications as ordered resulted in a lapse in care for the affected residents.
Delayed Response to Pharmacy Recommendations for Psychotropic Medications
Penalty
Summary
The facility failed to ensure timely responses to pharmacy recommendations for residents on psychotropic medications, affecting three out of five residents reviewed. For Resident #11, the facility did not ensure that a physician addressed the pharmacist's recommendations for medication evaluations and reviews, as none of the Physician Recommendation Forms were signed by a physician. This included evaluations for medications such as hydroxyzine, Trazadone, Quetiapine, Buspirone, and Duloxetine over several months. The Director of Nursing confirmed that these forms had not been signed or addressed by a physician. For Resident #60, there was a delay in responding to a pharmacy recommendation for laboratory tests to be drawn every six months. Although the physician agreed to the recommendation, the order for the tests was not noted until over a month later, and the tests were conducted shortly thereafter. Resident #62 experienced a delay in the implementation of a pharmacy recommendation for a gradual dose reduction of olanzapine. The recommendation was made in November, but the dose reduction was not ordered until February. The Director of Nursing confirmed the facility's failure to respond timely to the pharmacy recommendations for these residents.
Failure to Administer Insulin as Ordered
Penalty
Summary
The facility failed to ensure that a resident received insulin as ordered by the physician, resulting in significant medication errors. A resident with a diagnosis of type 2 diabetes mellitus did not receive her morning insulin doses on time. The resident was scheduled to receive Humalog insulin injections at specific times, but the doses were administered late. An LPN, who was working infrequently at the facility, confirmed that the insulin doses were overdue. The Regional Clinical Support Nurse also confirmed that the morning doses were given late. Additionally, the resident was supposed to receive Tresiba insulin daily, as per hospital discharge orders. However, the resident only received one dose on the day of admission, and subsequent doses were not administered. The Director of Nursing confirmed that the pharmacy canceled the order for Tresiba with the intention of replacing it with a generic version, but the order for the generic version was never confirmed. As a result, the resident did not receive the prescribed Tresiba doses after the initial administration.
Infection Control Deficiencies in Insulin Administration and Contact Precautions
Penalty
Summary
The facility failed to ensure proper infection prevention and control practices during the administration of insulin injections and the use of glucometers. An LPN administered insulin to three residents without wearing gloves, which was confirmed through observation and staff interview. Additionally, the LPN did not disinfect a glucometer between uses on two residents, contrary to the facility's policy on cleaning and disinfection of resident-care items and equipment. Furthermore, the Director of Nursing (DON) did not adhere to contact precautions when entering a resident's room who was on contact precautions due to an infection. The DON entered the room without wearing a gown or gloves, handled the resident's personal items, and failed to perform hand hygiene before entering another resident's room to provide assistance. These actions were observed and confirmed through an interview with the DON, who acknowledged the failure to follow proper infection control protocols.
Latest citations in Ohio
A resident with intact cognition receiving Medicare Part A skilled services for metabolic encephalopathy had services discontinued while benefit days remained, but the facility did not issue the required Skilled Nursing Facility Advance Beneficiary Notice (SNF ABN). The Social Services Director later confirmed that no SNF ABN was provided and reported she believed only a Notice of Medicare Non-Coverage (NOMNC) was needed when all skilled services were stopped. This practice conflicted with the facility’s written policy, which required SNF ABNs to be issued when extended care items or services were initiated, reduced, or terminated due to expected non-coverage by Medicare.
Surveyors identified that the facility exceeded the acceptable medication error rate when two residents with type 2 DM received insulin doses that were not administered according to orders or manufacturer instructions. In two separate observations, an LPN administered Novolog and another LPN administered insulin glargine and insulin lispro without priming the insulin pens, and the insulin lispro and Novolog were given after the residents had already consumed a significant portion of their breakfast meals, despite orders for administration before meals. Manufacturer information for both insulin products required priming before each injection to ensure accurate dosing, and facility policy required medications, including insulin, to be administered safely, timely, and in accordance with prescriber orders and specified time frames.
Surveyors found that the facility failed to document tray line food temperatures for multiple meals served from two dining room kitchenettes, despite having a “Trayline Taste & Temperature Log” and a policy requiring food to be stored, prepared, distributed, and served according to professional food safety standards. Review of logs showed repeated missing entries for breakfast, lunch, and dinner services in both the Harrison and McClellan dining areas, and the Senior Director of Culinary Services confirmed that temperatures had not been recorded for those meals, potentially affecting all residents receiving meals from those kitchenettes.
The facility failed to conduct and document required periodic care conferences for two residents, despite multiple comprehensive, quarterly, and significant change MDS assessments and a policy requiring periodic care conferences with resident and/or family participation. One resident with Parkinson’s disease, post-stroke hemiplegia, TIA, DMII, and depression had only two documented care conferences over a year, while another resident with aphasia, cerebrovascular disease, DMII, gait difficulty, coagulation defect, depression, and muscle weakness had no documented care conferences in the past year, aside from a declined invitation to the representative. The UCC confirmed that care conferences were expected to occur quarterly and that no additional documentation existed for either resident.
A resident with Alzheimer's disease and type II DM, who required extensive assistance with ADLs and was receiving scheduled Lantus and sliding-scale Humalog, experienced a severely elevated blood glucose level. The on-call provider was notified and ordered an additional dose of lispro insulin with a directive to recheck the blood glucose after administration. Nursing staff administered the extra insulin but did not document any follow-up blood glucose check, and the DON confirmed that this reevaluation was required by the facility's abnormal blood glucose policy and was not completed or documented.
A resident with Parkinson’s disease, dementia, and hypothyroidism was prescribed levothyroxine once daily along with other medications. A consultant pharmacist’s monthly drug regimen review recommended that levothyroxine be given in the morning on an empty stomach, 30–60 minutes before food, per manufacturer instructions. The medical record contained no documented physician response to this recommendation, and the MAR showed the drug scheduled for morning administration while the resident was observed eating breakfast and receiving the medication at the same time. An LPN confirmed administering levothyroxine during the meal, and the DON verified there was no documentation explaining whether or why the pharmacist’s recommendation was or was not followed, resulting in a failure to act on and document the identified irregularity.
A resident with severe cognitive impairment, multiple comorbidities, documented gait and balance abnormalities, and a high fall risk was care planned and assessed by therapy to require contact guard assistance and use of a gait belt for transfers and ambulation. While being assisted by a CNA from a recliner to the bathroom with a walker, the CNA did not apply a gait belt, even though the resident had a known tendency to lean backward when standing. As the CNA reached to open the bathroom door, the resident lost balance and fell backward, striking the back of the head, and was later found by an LPN without a gait belt in place, contrary to the facility’s gait belt policy and the resident’s assessed needs.
A resident with metabolic encephalopathy, muscle weakness, and a history of CVA experienced a fall in his room that was not documented in the medical record until the following morning as a late entry. Two RNs acknowledged that the fall was not recorded at the time it occurred and stated that fall incidents should be documented as soon as possible after the event, resulting in a deficiency for failure to maintain timely, professionally standard medical records.
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.
A resident with cirrhosis, ascites, mood disorder, and alcohol-induced major neurocognitive disorder, and with moderately impaired cognition, was observed sitting on a shower chair in a gown with buttocks exposed and visible from the hallway through an open room door. A CNA left the room quickly after hearing another resident yell and forgot to close the door or pull the privacy curtain, and an RN confirmed the exposure, demonstrating a failure to maintain the resident’s dignity and privacy.
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.
Untimely Documentation of Resident Fall Incident in Medical Record
Penalty
Summary
The deficiency involves the facility’s failure to document a resident’s fall incident in the medical record in a timely manner, in accordance with accepted professional standards. The resident was admitted with diagnoses including metabolic encephalopathy, muscle weakness, and cerebrovascular accident. According to the medical record, a progress note was entered as a late entry on 02/20/26 at 8:21 A.M., stating that the resident had suffered a fall in his room on 02/19/26 at 8:00 P.M. There was no evidence of any documentation of the fall incident entered in the medical record at the time of, or shortly after, the fall on 02/19/26 at 8:00 P.M. During an interview on 03/30/26 at 12:05 P.M., two RNs confirmed that the fall incident was not documented until the following morning and stated that fall incidents should be entered in the medical record as soon as possible following the event. This lack of timely documentation of the fall incident constituted non-compliance with requirements to safeguard resident-identifiable information and maintain medical records in accordance with professional standards.
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.
Resident Left Exposed and Visible From Hallway Due to Failure to Maintain Privacy
Penalty
Summary
The facility failed to ensure resident dignity and privacy when a cognitively impaired resident was left exposed and visible from the hallway. The resident, who had diagnoses including cirrhosis with ascites, mood disorder, and alcohol-induced major neurocognitive disorder, had a BIMS score of eight, indicating moderately impaired cognition. During an observation, the resident was seen sitting on a shower chair in a gown with buttocks exposed, and this exposure was visible from the open room door in the hallway. A Certified Resident Care Associate and a Registered Nurse confirmed that the resident’s buttocks were visible from the hallway. The Certified Resident Care Associate reported that she had left the resident’s room quickly after hearing a resident in an adjacent room yell and, in her haste, forgot to close the door or pull the privacy curtain, resulting in the resident’s exposed state being visible to others. This incident involved one resident out of three reviewed for dignity, in a facility with a census of 52 residents, and was identified through record review, observation, and staff interviews.
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