Carecore At Lima
Inspection history, citations, penalties and survey trends for this long-term care facility in Lima, Ohio.
- Location
- 599 South Shawnee Street, Lima, Ohio 45804
- CMS Provider Number
- 365202
- Inspections on file
- 30
- Latest survey
- March 20, 2026
- Citations (last 12 mo.)
- 2
Citation history
Health deficiencies cited at Carecore At Lima during CMS and state inspections, most recent first.
A cognitively intact resident with multiple chronic conditions reported that his medications, specifically pain medications, were being taken while he was being transported to the hospital. The facility’s self-reported incident stated that a thorough investigation was completed and the allegation was unsubstantiated, but the investigation file contained no staff interview statements and no documented interview with the resident to clarify which medications were involved or when they were taken. The DON and a UM confirmed that no formal statement was obtained from the resident before or during his hospital stay, and no staff interviews were documented, contrary to facility policy requiring comprehensive investigative interviews and documentation for alleged misappropriation.
A resident with multiple chronic conditions and moderate cognitive impairment was discharged home without the facility involving her POA in the discharge planning process, despite documentation that the POA had previously provided input favoring long-term placement and a care plan intervention for social services to meet with both resident and family to determine the discharge plan. The resident met with a PA, signed a discharge packet with medication and home health orders, and was picked up by family on the day of discharge, but there was no documented consultation or prior notification to the POA. The DON acknowledged that the family was not included in the discharge discussion, which conflicted with the facility’s discharge planning policy requiring collaborative planning and documentation of resident and representative notification.
A resident with a pressure ulcer on the coccyx was not properly assessed or treated upon admission, leading to the ulcer becoming unstageable with necrosis. The facility failed to notify the physician or implement treatment orders, resulting in the need for surgical intervention. The resident's condition, including spinal stenosis and protein-calorie malnutrition, increased their risk for skin breakdown, yet the facility did not adhere to its documentation and treatment protocols.
The facility failed to prevent falls and ensure a safe environment, resulting in harm to a resident who tripped over an improperly stored mechanical lift, causing a facial laceration and elbow fracture. Additionally, the facility did not conduct neurological checks after falls for another resident and failed to investigate fall incidents thoroughly. A third resident fell out of a wheelchair due to deteriorated concrete, highlighting the facility's failure to address environmental hazards.
The facility failed to complete comprehensive care plans for several residents, leading to deficiencies in addressing their specific medical needs. A resident with an indwelling catheter lacked a care plan for its management, while another with hemiplegia and a catheter had no care plan for bowel/bladder care. A resident on hospice with respiratory needs did not have a respiratory care plan, and another with cerebral infarction lacked a plan for activities of daily living. Additionally, a resident with a cutaneous abscess had no care plan for the actual skin impairment.
The facility failed to provide adequate protein portions to residents on a mechanical soft diet, affecting 14 residents. A staff member used an unlabeled scoop believed to be 3 ounces, but it was found to hold less than 2 and 2/3 ounces. The Dietary Manager and Regional Registered Dietitian could not verify the portion size, while the menu indicated a 3-ounce portion was required.
The facility failed to ensure proper hand hygiene during meal preparation and did not maintain the dishwashing machine at the required temperature. Staff were observed using gloves inappropriately, and the dishwasher's temperature was below the recommended level, potentially affecting resident safety.
The facility failed to maintain a pest-free environment, with multiple observations and interviews confirming the presence of moths in the secured unit. Residents and staff reported discomfort due to the moths, which were attributed to bird food stored inside the building. Despite routine exterminator visits, the issue persisted, affecting 35 residents.
The facility failed to maintain a safe environment, with a significant gap in the wheelchair ramp and broken tiles in the shower area. A resident experienced difficulty navigating the ramp, and another resident with a history of falls slipped in the shower due to the broken tiles. Staff confirmed these issues, and the facility's policy on safety was not followed.
The facility failed to serve palatable meals, affecting two residents. A test tray review revealed that while the meal presentation was pleasing and the temperature was appropriate, the mashed potatoes, gravy, and broccoli were bland and lacked seasoning. These findings were confirmed by an RN and echoed by two residents who found the mashed potatoes and gravy to be flavorless.
The facility failed to conduct thorough weekly skin assessments for a resident with multiple diagnoses, leaving a skin review form blank. Additionally, two residents did not receive treatments as ordered: one had unwrapped legs despite orders for compression stockings, and another had stitches that were not removed as required. The DON confirmed the assessment omission, and a nurse was unaware of the stitch removal order.
A resident with an indwelling catheter did not have appropriate treatments and services documented. The catheter was noted in the baseline care plan but not in the comprehensive care plans, and there were no physician orders for its care or removal. Staff performed catheter care but could not document it due to the absence of orders. The facility's policy required documentation and assessment of catheter care, which was not adhered to.
A resident with multiple health issues experienced severe dental pain and was not provided with prescribed Hydrocodone-Acetaminophen due to a lack of communication and medication administration failures. Despite high pain levels, the resident did not receive the necessary medication after returning from the hospital, leading to frustration and inadequate pain management.
Failure to Thoroughly Investigate Allegation of Medication Misappropriation
Penalty
Summary
The facility failed to complete a thorough investigation of an allegation of misappropriation involving one resident. The cognitively intact resident, who had multiple medical diagnoses including muscle wasting and atrophy, COPD, hypotension, severe sepsis, atherosclerotic heart disease, hypothyroidism, hyperlipidemia, CHF, anxiety disorder, atrial fibrillation, obstructive and reflux uropathy, and major depressive disorder, reported that his medications were being taken while he was being transported to the hospital. The facility submitted a Self-Reported Incident indicating that a thorough investigation had been completed and the allegation was unsubstantiated. However, review of the facility’s investigation packet revealed there were no staff interview statements and no documented interview with the resident to determine which medications were allegedly taken, when they were taken, or to obtain other specific information about the allegation. The DON and a Unit Manager confirmed that no staff interview statements were documented and that no formal statement was obtained from the resident before he left for the hospital, nor was he contacted or interviewed at the hospital. These omissions were inconsistent with the facility’s own policy, which requires thorough documentation and investigation steps including interviews with the resident, reporter, staff on all shifts, and others, as well as complete documentation of findings.
Failure to Involve POA in Discharge Planning
Penalty
Summary
The facility failed to include a resident’s family/Power of Attorney (POA) in the discharge planning process, contrary to the resident’s care plan and facility policy. The resident had multiple complex medical diagnoses, including encephalopathy, peripheral vascular disease, malnutrition, acute and chronic respiratory failure, emphysema, congestive heart failure, chronic kidney disease, and other chronic conditions, and had a BIMS score of 10 indicating moderate cognitive impairment. A care conference document showed the current discharge plan was for the resident to remain in the facility for long-term placement, with the resident present but her family not in attendance. The resident’s care plan documented that she wished to return to the community, but also reflected that, per the POA, she was considered a possible long-term placement. The care plan included an intervention that social services would meet with the resident and family on admission to determine the discharge plan. Progress notes showed that the resident met with a physician assistant to discuss an upcoming discharge home and that both the resident and the physician assistant signed the discharge packet, which included medication orders and home health orders. However, review of progress notes for the days leading up to the discharge revealed no evidence that the facility consulted with or notified the resident’s family or POA about the discharge prior to the day it occurred, when the family member received a call from the resident to pick her up. The family member, who confirmed she was the POA and wanted to be kept up to date on all care and changes, reported that she had not been consulted about this discharge and that prior notifications had been inconsistent. The DON confirmed that the discharge process had not been discussed with the family before it occurred, despite the care plan and the facility’s discharge planning policy requiring collaborative planning with the resident and representative and documentation of resident and representative notification.
Failure to Timely Assess and Treat Pressure Ulcer
Penalty
Summary
The facility failed to provide timely and appropriate care for a resident admitted with a pressure ulcer on the coccyx. Upon admission, the resident was noted to have a non-blanchable purple wound on the coccyx, but the staff did not accurately assess the wound, including taking measurements or providing a description. Furthermore, the staff failed to notify the physician to obtain and implement treatment orders. This lack of action resulted in the pressure ulcer becoming unstageable with necrosis, requiring surgical intervention. The resident, who had diagnoses including spinal stenosis, cord compression, malignant neoplasm of bone, and protein-calorie malnutrition, was dependent on two-assist for activities of daily living. Despite being at risk for skin breakdown, the facility did not conduct proper wound assessments or document the condition of the pressure ulcer from the time of admission until it was evaluated by a wound physician. The wound was not treated or monitored adequately, leading to its deterioration. The facility's documentation and treatment protocols were not followed, as evidenced by the lack of wound assessments and physician notifications. The wound was only properly assessed and treated after it had significantly worsened, necessitating excisional debridement surgeries. The facility's policies required accurate documentation and timely interventions, which were not adhered to in this case, resulting in actual harm to the resident.
Plan Of Correction
Immediate Actions Taken: On 3-11-25, the treatment nurse conducted a skin assessment on Resident #43. At this time, the wound was measured, staged, documentation completed, and wound doctor notified. Treatment continued per order. CP was reviewed to ensure all appropriate interventions were in place. Identification of like residents having the potential to be affected: Skin assessments were completed for all residents by 03-12-25 by the nursing management team. No new wounds were identified. Actions taken/systems put into place to reduce the risk of future occurrences included: The treatment nurse was provided education on or before 3-12-25 by the DON related to the expectation to conduct a 2nd skin check on all new admissions within 48 hours of admission and to ensure all skin checks are completed weekly. All direct care staff was educated on or before 3-24-25 by DON/Designee regarding Pressure Injury Prevention, completing a full skin assessment on admission and ongoing weekly, timely reporting of newly discovered skin alterations, and ensuring interventions/treatments are in place. 100% compliance was achieved, as evidenced by a signed attestation. Ongoing Monitoring: The treatment nurse will audit all admission skin assessments and ongoing weekly skin assessments, interventions/treatments, and notifications as required for completeness weekly x 4 weeks and monthly x 3 months and as needed thereafter. The DON/designee will also complete audits to ensure the treatment nurse is completing 2nd skin assessments within 48 hours of a newly admitted resident by auditing one admission weekly x 4 weeks, monthly x 3 months, and prn thereafter. The DON/designee will audit 3 random residents' weekly skin assessments for completeness and accuracy weekly x 4 weeks, monthly x 3 months, and prn thereafter. Findings will be reviewed by the QAPI Committee until such a time consistent substantial compliance has been achieved as determined by the committee.
Failure to Prevent Falls and Ensure Safe Environment
Penalty
Summary
The facility failed to ensure a safe environment to prevent falls, resulting in actual harm to Resident #23, who tripped over the legs of an improperly stored mechanical lift. This incident led to a facial laceration requiring stitches and a fractured left olecranon. The resident, who had impaired cognition and required supervision for transfers and walking, was walking with aides when the fall occurred. The mechanical lift was improperly stored in the hallway, reducing the usable width of the walkway, which contributed to the fall. Additionally, the facility failed to conduct neurological checks after falls for Resident #22 and did not thoroughly investigate fall incidents for Residents #22 and #63. Resident #22, who had impaired cognition and was at risk for falls, experienced multiple falls without proper interventions being implemented. The facility did not ensure that fall prevention measures, such as a fall mat, were in place, and there was no evidence of neurological checks being completed after unwitnessed falls. The facility also failed to provide a safe environment for Resident #52, who fell out of a wheelchair due to deteriorated concrete outside the facility. The resident, who was dependent on a wheelchair for ambulation, attempted to propel himself outside and fell into a hole in the concrete. The facility's investigation noted the fall was witnessed, but no injuries were reported. The facility did not address the environmental hazard that contributed to the fall, as the broken concrete and raised edges remained unrepaired.
Deficiencies in Comprehensive Care Planning
Penalty
Summary
The facility failed to ensure comprehensive care plans were completed for all care areas for several residents, leading to deficiencies in their care. Resident #130, who was admitted with an indwelling catheter due to obstructive uropathy, did not have a comprehensive care plan addressing the catheter. Despite receiving regular catheter care, there were no physician orders or documentation in the medical records regarding the catheter's care or continuation. Interviews with staff confirmed the lack of documentation and care planning for the catheter. Resident #22, admitted with hemiplegia, hemiparesis, and an indwelling catheter, also lacked a comprehensive care plan addressing bowel/bladder or catheter care. Observations confirmed the presence of the catheter, and interviews with staff verified the absence of a care plan for these areas. Similarly, Resident #41, who required respiratory support and was on hospice, did not have a respiratory care plan, despite being dependent on staff for activities of daily living and having a tracheostomy. Resident #57, with diagnoses including cerebral infarction and congestive heart failure, lacked a care plan for activities of daily living, despite being dependent on staff for mobility and transfers. Additionally, Resident #71, who had a cutaneous abscess on the buttock, did not have a care plan addressing the actual skin impairment, although there was a plan for the risk of skin impairment. Interviews with the Director of Nursing confirmed the absence of appropriate care plans for these residents, highlighting a systemic issue in the facility's care planning process.
Inadequate Protein Portions for Mechanical Soft Diet
Penalty
Summary
The facility failed to provide adequate protein portions to residents on a mechanical soft diet, affecting 14 residents out of a census of 80. During meal service, it was observed that a staff member was using a green handled scoop to plate mechanical soft pork loin, which was believed to be a 3-ounce scoop. However, upon further investigation, it was found that the scoop had no measurements, and another similar scoop measured 2 and 2/3 ounces. The Dietary Manager confirmed the scoop had no measurements, and a comparison with a labeled scoop showed the unlabeled scoop held less than 2 and 2/3 ounces. The Regional Registered Dietitian could not verify the portion size provided to residents, and the menu spreadsheet indicated the portion should be 3 ounces.
Deficiencies in Hand Hygiene and Dishwashing Practices
Penalty
Summary
The facility failed to ensure proper hand hygiene practices were followed by staff during meal preparation, as observed on two separate occasions. During the first observation, a staff member was seen wearing disposable gloves while plating roast beef sandwiches and cubed potatoes. The staff member used her hands to handle various food items and changed gloves without washing her hands, which is against the facility's policy. The Dietary Manager confirmed the inappropriate hand hygiene practices and acknowledged that touching bags of bread or rolls was considered a contaminated surface. In a second observation, another staff member was seen using the same pair of gloves to handle bread and scoop meat, confirming she should have changed gloves before touching ready-to-eat food. Additionally, the facility failed to maintain the dishwashing machine at the proper temperature, as required by the manufacturer's guidelines. The dishwasher's wash temperature was observed to be below the minimum recommended temperature of 120 degrees Fahrenheit, with readings of 91 degrees and 108 degrees Fahrenheit during multiple cycles. The Dietary Manager confirmed that the wash temperature did not meet the minimum requirements, which could potentially affect the cleanliness and safety of the dishes used by residents.
Failure to Maintain Pest-Free Environment
Penalty
Summary
The facility failed to maintain a pest-free environment, as evidenced by multiple observations and interviews revealing the presence of moths in the secured unit. On several occasions, moths were observed flying around the dining room and residents' rooms, causing discomfort to the residents. Interviews with residents and staff confirmed the presence of moths, with some residents expressing their annoyance. A Licensed Practical Nurse (LPN) mentioned that the exterminators attributed the moth problem to bird food stored inside the building for outdoor bird feeders. Despite the routine visits from the exterminator company, the issue persisted, and the receipts from the exterminator did not specifically mention moths. The Maintenance Director, who had been with the facility for two months, was unaware of the moth issue, although the exterminator company was noted to be responsive to facility concerns. The facility's policy on maintaining a clean, sanitary, and orderly environment was not effectively implemented, as evidenced by the ongoing moth problem. The LPN did not report the moth issue, assuming it was evident to maintenance and other staff. The facility's failure to address the moth infestation potentially affected 35 residents in the secured unit, highlighting a deficiency in maintaining a pest-free environment.
Deficiencies in Wheelchair Ramp and Shower Safety
Penalty
Summary
The facility failed to maintain a safe environment concerning the wheelchair ramp at the front of the building, which posed a risk to all residents using wheelchairs. Observations revealed a five-inch gap with exposed stone and grass at the top of the ramp, causing difficulty for residents and staff. An incident was noted where a State Tested Nursing Assistant (STNA) struggled to push a resident's wheelchair over the gap, requiring multiple attempts. Interviews with residents and staff confirmed the challenges posed by the gap, and the facility's policy on providing a safe environment was not adhered to. Additionally, the facility did not ensure the shower floor in the secured unit was free of broken tiles, affecting a resident with a history of falls and impaired cognition. The resident experienced multiple falls in the shower, reportedly due to the slippery and broken tiles, which were confirmed by staff observations. The Maintenance Director, unaware of the broken tiles, confirmed their presence upon inspection. The Director of Nursing was aware of the falls but not of the specific cause related to the broken tiles. This deficiency was investigated under a complaint.
Facility Fails to Serve Palatable Meals
Penalty
Summary
The facility failed to serve palatable meals, affecting two residents. During a test tray review, a meal consisting of roast pork loin, mashed potatoes, and broccoli was evaluated. The plate presentation was pleasing, and the food temperature was warm. However, the mashed potatoes and gravy were found to be bland with minimal flavor, and the broccoli, although cooked to an appropriate texture, was also bland and unseasoned. These observations were confirmed by Registered Nurse #178. Interviews with two residents revealed similar concerns, as they both described the mashed potatoes and gravy as lacking flavor.
Deficiencies in Skin Assessments and Treatment Adherence
Penalty
Summary
The facility failed to ensure thorough weekly skin assessments for a resident with multiple diagnoses, including type two diabetes and cutaneous abscesses. The medical record for this resident showed a blank skin review form, lacking necessary details such as wound description, measurements, and treatment orders. The Director of Nursing confirmed the omission, acknowledging that the assessments should have been completed thoroughly. Additionally, the facility did not adhere to treatment orders for two other residents. One resident, with conditions like myoneural disorder and congestive heart failure, was observed with unwrapped legs despite orders for compression stockings and wraps. The resident reported inconsistent care, and a nurse claimed the resident refused treatment, which the resident denied. Another resident, with cerebral infarction and dementia, had stitches that were not removed as ordered. The nurse on duty was unaware of the removal requirement, as no hospital paperwork was received upon the resident's return.
Failure to Document and Plan Catheter Care
Penalty
Summary
The facility failed to provide appropriate treatments and services for a resident with an indwelling catheter. The resident was admitted with a catheter due to obstructive uropathy, but there were no physician orders or comprehensive care plans addressing the catheter's care or removal. Despite the catheter being noted in the baseline care plan, it was not included in the comprehensive care plans, and there was no documentation of catheter care in the medical records. Interviews with staff revealed that catheter care was performed, but there was no place to document it due to the absence of orders. The resident expressed uncertainty about the plan for the catheter and reported that nurses informed him it would be removed when no longer needed. The Director of Nursing and a Regional Registered Nurse confirmed the lack of documentation and orders for the catheter. The facility's policy required staff to assess the ongoing need for catheters and document all care, which was not followed in this case.
Failure to Provide Prescribed Pain Management
Penalty
Summary
The facility failed to provide appropriate pain management for a resident, identified as Resident #33, who was prescribed Hydrocodone-Acetaminophen for dental pain. The resident was admitted with multiple diagnoses, including hemiplegia and heart disease, and had a care plan that included administering medications per physician orders. Despite being prescribed pain medication following hospital visits for dental pain and infection, the facility did not administer the medication as ordered. The resident's pain levels were documented as high, reaching eight out of ten on several occasions. The resident experienced severe dental pain and requested narcotic pain medication, which was not available due to a lack of a written script in the records. This led the resident to sign out of the facility to seek treatment at a hospital, where they received prescriptions for pain medication and antibiotics. Upon returning to the facility, the resident continued to experience pain and was not provided with the prescribed medication due to a pharmacy issue that was not communicated to the facility. The resident reported that the pain was mostly at night, causing loss of sleep, and refused Tylenol due to adverse effects. Interviews with the resident, social worker, RN, and DON revealed that the resident's pain management was inadequate due to a failure in communication and medication administration. The resident expressed frustration over not receiving the necessary medication and the delay in dental procedures. The DON confirmed that the pharmacy did not supply the medication and that the resident had not received any pain medication after reporting pain, highlighting a significant lapse in the facility's pain management protocol.
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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