Cedarview Care Center
Inspection history, citations, penalties and survey trends for this long-term care facility in Lebanon, Ohio.
- Location
- 115 Oregonia Road, Lebanon, Ohio 45036
- CMS Provider Number
- 365690
- Inspections on file
- 27
- Latest survey
- August 13, 2024
- Citations (last 12 mo.)
- 0
Citation history
Health deficiencies cited at Cedarview Care Center during CMS and state inspections, most recent first.
A facility failed to administer medications as ordered, resulting in a 10.26% error rate. Three residents were affected: one did not receive eye drops, another missed hepatitis C medication due to a pharmacy issue, and a third did not receive Zyprexa and Biotene mouthwash. The errors were confirmed by an RN, who noted issues with medication availability and documentation.
The facility failed to assist dependent residents with repositioning, leading to prolonged periods without movement for three residents with significant medical conditions. Staff interviews confirmed the lack of repositioning, contrary to the facility's policy aimed at preventing skin breakdown and promoting circulation.
The facility failed to accurately document a skin assessment for a resident with complex medical conditions. An LPN did not report new skin impairments, but later observations revealed excoriation and dry, scaly skin that were not documented.
The facility failed to ensure foods were stored properly, with 10 unlabeled containers and an unsealed, unlabeled sandwich found in a refrigerator without a thermometer or temperature log. An RN confirmed the deficiencies, which violated the facility's food storage policy.
A resident with multiple serious health conditions experienced a 21-pound weight increase in one day. Despite a physician order to report any weight change of three pounds or more, the facility failed to notify the physician, as confirmed by the DON and a review of the resident's medical record.
The facility failed to complete the MDS discharge assessment for a resident with multiple diagnoses within the required 14-day timeframe, as confirmed by medical record review and an interview with the MDS Coordinator.
The facility failed to transmit MDS assessments within the required 14-day timeframe for three residents, despite policy and manual guidelines. The deficiency was confirmed through medical record reviews and staff interviews.
The facility failed to notify the state mental health authority of a significant change in condition for two residents with mental disorders who began receiving hospice services. The required Pre-Admission Screening and Resident Review (PASARR) was not completed within 14 days of the change.
The facility failed to ensure a resident's fluid restriction order was properly implemented and communicated, leading to the resident consuming fluids beyond the prescribed limit. Staff were unaware of the fluid restriction due to lack of documentation and communication in the plan of care.
The facility failed to follow physician orders for assistive devices to prevent further contracture in a resident with limited range of motion. The resident, who had multiple diagnoses and was dependent on staff for all activities of daily living, was observed without the prescribed wash cloths in her hands on multiple occasions. A registered nurse confirmed the non-compliance, admitting to being unaware that the aides had not placed the wash cloths as ordered.
The facility failed to address a significant weight loss in a timely manner for a resident with Huntington's disease and other conditions. Additionally, the facility did not complete weights per physician's orders for two other residents with chronic conditions, leading to multiple undocumented weights. The facility's policies on weight monitoring and documentation were not followed.
The facility failed to ensure that oxygen tubing for two residents was changed and dated as ordered by the physician. Both residents were observed with undated oxygen tubing, and this was confirmed by an LPN and an STNA. The DON verified that the contract company responsible for this task may have forgotten to date the tubing.
The facility failed to provide full visual privacy for two residents, as observed during a survey. One resident had no privacy curtain around their bed, and another had a privacy curtain track that was coming loose from the ceiling, with no curtain in place. This was confirmed by staff and the Housekeeping Director.
The facility failed to post nurse staffing information that included the total number of RNs, LPNs, and STNAs working daily. This deficiency was observed over a period from 03/01/24 to 04/17/24 and confirmed by the Administrator. The issue had the potential to affect all 72 residents in the facility.
Medication Administration Errors in LTC Facility
Penalty
Summary
The facility failed to administer medications as ordered, resulting in a medication error rate of 10.26 percent, which is above the acceptable threshold of 5 percent. This affected three residents who were reviewed for medication administration. Resident #19, who has multiple sclerosis and other conditions, did not receive the prescribed Refresh Liquigel Ophthalmic Gel for dry eyes. Resident #26, with diagnoses including acute kidney failure and heart failure, did not receive the prescribed hepatitis C medication, sofosbuvir and velpatasvir. Resident #27, diagnosed with epilepsy and other conditions, did not receive the prescribed Zyprexa and Biotene mouthwash. The errors were observed during a medication administration session with RN #304, who confirmed the omissions. The nurse acknowledged that Resident #27 did not receive Zyprexa due to a mix-up with the medication dosage in the cart and that Biotene was not administered because it had not been delivered by the pharmacy. Similarly, Resident #19's eye drops were not available in the medication cart, and Resident #26's medication was on back order due to a lack of proper diagnosis documentation. The Director of Nursing admitted to not clarifying the medication order for Resident #26, which contributed to the pharmacy's inability to provide the medication.
Failure to Reposition Dependent Residents
Penalty
Summary
The facility failed to ensure that dependent residents were assisted with repositioning to prevent skin impairment. This deficiency affected three residents who were observed to have remained in the same position for extended periods. Resident #46, who had multiple diagnoses including respiratory failure and was ventilator-dependent, was observed lying on his back in bed without repositioning at various times throughout the day. Similarly, Resident #53, who had diagnoses including hypoxic ischemic encephalopathy and was also ventilator-dependent, was observed sitting upright in a geriatric chair without repositioning. Resident #72, with diagnoses including respiratory failure and diabetes, was observed lying on her back in bed without repositioning during the same observation periods. Interviews with staff revealed that the State tested Nurse Aide (STNA) #75 acknowledged not having had the chance to turn and reposition the three residents on the day of observation. The facility's policy on repositioning, which aims to prevent skin breakdown and promote circulation, was not followed. The policy mandates frequent repositioning for bed- or chair-bound residents to provide pressure relief and promote skin integrity. This deficiency was investigated under Complaint Number OH00153613.
Failure to Accurately Document Skin Assessment
Penalty
Summary
The facility failed to complete an accurate skin assessment for Resident #72, who had multiple complex medical conditions including respiratory failure, obstructive uropathy, pneumonia, diabetes, and seizure disorder. The resident was dependent on toileting, bed mobility, and had an indwelling catheter, tracheostomy, and ventilator. A skin assessment documented by an LPN on the morning of the incident did not report any new areas of skin impairment. However, later observations revealed bright red excoriation under the resident's left armpit and dry, scaly skin on the resident's feet, which were not documented in the skin assessment or progress notes. During an interview, the LPN acknowledged knowing about the excoriation under the resident's left armpit but admitted to not documenting it. The LPN also stated she was unaware of the condition of the resident's feet. This discrepancy between the documented skin assessment and the actual condition of the resident's skin indicates a failure to accurately assess and document the resident's skin condition, leading to a deficiency in the care provided.
Failure to Properly Store and Label Food in Refrigerator
Penalty
Summary
The facility failed to ensure foods were stored in a manner to protect against the potential spread of food-borne illness. During an observation, it was found that the refrigerator on the facility's C-hall contained 10 unlabeled containers with unidentified substances. Additionally, there was a sandwich loosely wrapped in a plastic sandwich bag that was unsealed, unlabeled, and undated. The refrigerator also lacked a thermometer and any type of temperature log. Registered Nurse (RN) #375 confirmed that the containers were unlabeled and undated, and that the sandwich was not sealed, labeled, or dated. RN #375 also verified that the refrigerator did not have a thermometer and that refrigerator temperatures should be checked and recorded on each shift. The facility's policy titled 'Food Receiving and Storage,' dated October 2017, was reviewed and it revealed that all foods stored in the refrigerator should be covered, labeled, and dated with a use-by date. The policy also stated that refrigerators must have working thermometers and be monitored for temperature according to state-specific guidelines. This deficiency had the potential to affect all 59 residents who received food from the kitchen, although 13 residents were identified as NPO and did not receive food from the kitchen. The facility census was 72.
Failure to Notify Physician of Significant Weight Change
Penalty
Summary
The facility failed to ensure the physician was notified of a significant change in a resident's condition. Resident #22, who had multiple serious diagnoses including end-stage renal disease and chronic heart failure, experienced a 21-pound weight increase over a single day. Despite an existing physician order to report any weight change of three pounds or more, there was no documentation in the resident's medical record indicating that the physician was notified of this significant weight change. The Director of Nursing confirmed the lack of documentation regarding the weight change or physician notification. The resident's medical record showed that they were admitted and readmitted to the facility with several critical health conditions. The comprehensive Minimum Data Set (MDS) assessment indicated that the resident had moderately impaired cognition and required varying levels of assistance for daily activities. Despite these vulnerabilities, the facility did not follow its own policy, which mandates notifying the attending physician of any changes in the resident's condition. This oversight was confirmed through staff interviews and a review of the facility's policy on changes in a resident's condition or status.
Failure to Complete MDS Discharge Assessment Within Required Timeframe
Penalty
Summary
The facility failed to ensure that the Minimum Data Set (MDS) discharge assessment for a resident was completed within the required 14-day timeframe. The resident, who had diagnoses including schizoaffective disorder, anxiety disorder, polysubstance abuse, and nicotine addiction, was discharged on a specified date. However, the MDS discharge assessment was not completed until 04/17/24, which exceeded the 14-day requirement. This deficiency was confirmed through medical record review, the Resident Assessment Instrument (RAI) User Manual, the facility's policy and procedure on MDS completion and submission timeframes, and an interview with the MDS Coordinator.
Failure to Transmit MDS Assessments Timely
Penalty
Summary
The facility failed to ensure that Minimum Data Set (MDS) assessments were transmitted within 14 days of completion, affecting three residents. Resident #25, diagnosed with Alzheimer's disease, bipolar disorder, schizoaffective disorder, anxiety disorder, and alcohol abuse, had an MDS quarterly assessment completed on 03/28/24 but transmitted on 04/14/24. Resident #50, with diagnoses including cerebrovascular accident with right-sided hemiplegia, alcohol abuse, chronic pain syndrome, seizure disorder, coronary artery disease, chronic obstructive pulmonary disease, and diabetes mellitus type II with neuropathy, had an MDS quarterly assessment completed on 03/26/24 but transmitted on 04/14/24. Resident #59, diagnosed with Wernicke's encephalopathy, depression, PTSD, anxiety disorder, and alcohol abuse, had an MDS quarterly assessment completed on 01/26/24 but transmitted on 02/12/24. The facility's policy, as well as the Long-Term Care Facility Resident Assessment Instrument (RAI) User's Manual, requires that MDS quarterly assessments be transmitted within 14 days after completion. Interviews with the Administrator and MDS Coordinator confirmed the late transmissions for all three residents, acknowledging that the transmission dates exceeded the 14-day timeline. This deficiency was identified through a review of medical records, the RAI User Manual, the facility's MDS Completion and Submission Timeframe policy, and staff interviews.
Failure to Notify State Mental Health Authority of Significant Change in Condition
Penalty
Summary
The facility failed to notify the state mental health authority of a significant change in condition for residents with mental disorders. This deficiency affected two residents who were reviewed for the Pre-Admission Screening and Resident Review (PASARR) admission process. Resident #49, who had diagnoses including dementia, encephalopathy, major depressive disorder, and anxiety disorder, was admitted to the facility and later had orders for hospice services. However, there was no PASARR completed within 14 days of this significant change in condition. Similarly, Resident #9, with diagnoses including dementia, major depressive disorder, bipolar disorder, and schizoaffective disorder, also had orders for hospice services on two separate occasions, but no PASARR was completed within 14 days of these changes in condition. Interviews with the Business Office Manager and Social Service Designee confirmed that both residents had significant changes in condition when they began receiving hospice services. The staff acknowledged that the facility should have completed a revised PASARR and reported the significant change to the state mental health board within the required 14-day period. This oversight indicates a failure in the facility's process for managing and reporting significant changes in the condition of residents with mental disorders.
Failure to Implement and Communicate Fluid Restriction Order
Penalty
Summary
The facility failed to ensure that the plan of care for a resident with a fluid restriction order was properly implemented and communicated to all relevant staff. The resident, who had diagnoses including acute respiratory failure with hypoxia, dementia, chronic gastric ulcer, malnutrition, dependence on oxygen, and heart failure, was ordered a fluid restriction of 2000 cc per day by the physician. However, the plan of care did not initially reflect this fluid restriction, and the division of fluids between departments was not documented. Observations revealed that the resident's meal tickets did not indicate any fluid restriction, and large containers of fluid were present at the resident's bedside, exceeding the prescribed limits. Interviews with staff members, including State Tested Nurse Assistants (STNAs) and the Dietary Manager, confirmed that they were unaware of the fluid restriction order due to the lack of communication and documentation in the plan of care. The MDS Coordinator acknowledged that the fluid restriction and its division should have been included in the plan of care and communicated to the dietary department. The deficiency was further highlighted when the night shift STNA verified that the fluid restriction intervention was only added to the plan of care after the issue was identified. The facility's policy on encouraging and restricting fluids, which required removing fluids from the room and reviewing the care plan for special needs, was not followed. This oversight led to the resident consuming fluids beyond the prescribed limit, as staff were not informed of the fluid restriction order.
Failure to Follow Physician Orders for Assistive Devices
Penalty
Summary
The facility failed to ensure physician orders were followed for assistive devices to prevent further contracture in a resident with limited range of motion. Resident #52, who had diagnoses including encephalopathy, anxiety, hypothyroidism, depression, chronic obstructive pulmonary disease, and muscle weakness, was observed without the prescribed wash cloths in her hands on multiple occasions. The resident, who had moderately impaired cognition and was dependent on staff for all activities of daily living, confirmed that staff were not consistently placing the wash cloths in her hands as ordered by the physician. The physician's order dated 04/02/24 specified that bilateral towel rolls should be applied in the resident's palms for seven hours daily, from 11:00 A.M. to 6:00 P.M. However, observations on 04/16/24 at 1:20 P.M. and 3:50 P.M. revealed that the resident did not have the wash cloths in her hands. A registered nurse verified that the wash cloths were not in place and admitted to being unaware of the non-compliance, assuming that the aides had put them in. This failure to follow physician orders was confirmed through both staff interviews and direct observations.
Failure to Address Significant Weight Loss and Complete Weights Per Physician's Orders
Penalty
Summary
The facility failed to address a significant weight loss in a timely and accurate manner for Resident #42, who had diagnoses including Huntington's disease, mood disorder, and schizophrenia. Despite the resident's weight dropping from 160.2 pounds to 144.2 pounds over six months, the weight loss was not addressed promptly. The Diet Technician Registered (DTR) acknowledged that the weight loss trend warranted attention but had not reviewed the weights obtained 18 days prior to the interview. The facility's policy required weights to be reviewed and addressed within seven days, which was not adhered to in this case. Additionally, the resident's care plan inaccurately described the weight as stable despite the ongoing weight loss, and no new dietary recommendations were made after the significant weight loss was noted. The DTR confirmed that the resident had been on the same diet and supplement order since November 2023, with no adjustments made despite the weight loss. The Director of Nursing (DON) also confirmed that the expectation was for weights to be reviewed within seven days, which did not occur in this instance. The facility's policy on nutrition and unplanned weight loss required close monitoring and reporting of significant weight loss, which was not followed in this case. The facility also failed to complete weights per the physician's order for Resident #22, who had diagnoses including end-stage renal disease, chronic heart failure, and diabetes. The resident had orders for daily and weekly weights, but multiple weights were not documented, and there was no record of refusals or attempts to weigh the resident on several dates. The Registered Dietitian (RD) verified that the weights were not documented as required. Similarly, Resident #9, who had diagnoses including dementia, edema, and heart failure, had a physician order for daily weights, but multiple weights were missing from the record. The RD confirmed that the daily weights were not documented and that she had not been informed of any refusals to be weighed. The facility's policy required weights to be obtained and recorded at established intervals, which was not followed in this case.
Failure to Change and Date Oxygen Tubing as Ordered
Penalty
Summary
The facility failed to ensure that oxygen tubing for two residents was changed and dated as ordered by the physician. Resident #19, who has diagnoses including dementia, Down syndrome, chronic respiratory failure, and pseudobulbar affect, was observed on 04/15/24 with undated oxygen tubing. The resident's medical record indicated a physician's order to change and date the oxygen tubing every Wednesday. This was confirmed by an LPN and an STNA during an interview on the same day. Similarly, Resident #61, who has diagnoses including acute respiratory failure with hypoxia, dementia, chronic gastric ulcer, malnutrition, dependence on oxygen, and heart failure, was also observed on 04/15/24 with undated oxygen tubing. The resident's medical record indicated a physician's order to change the oxygen tubing every Tuesday. This was also confirmed by the same LPN and STNA. The Director of Nursing verified that the contract company responsible for changing and dating the oxygen tubing may have forgotten to date the tubing for both residents.
Failure to Provide Full Visual Privacy for Residents
Penalty
Summary
The facility failed to provide full visual privacy for two residents, which was observed during a survey. Resident #48, who has diagnoses including acute respiratory failure, schizoaffective disorder, bipolar disorder, anxiety disorder, and depressive disorder, was found to have no privacy curtain around their bed, preventing full privacy. This was confirmed by an LPN and an STNA during an observation. Resident #48 had a roommate, further necessitating the need for a privacy curtain. Similarly, Resident #61, who has diagnoses including acute respiratory failure with hypoxia, dementia, chronic gastric ulcer, malnutrition, dependence on oxygen, and heart failure, was also found to lack full visual privacy. The privacy curtain track in Resident #61's room was coming loose from the ceiling, and there was no privacy curtain in place. This deficiency was also confirmed by an LPN and an STNA. The Housekeeping Director later verified that both double-occupied rooms lacked privacy curtains, which compromised the residents' privacy during care.
Failure to Post Nurse Staffing Information
Penalty
Summary
The facility failed to post nurse staffing information that included the total number of Registered Nurses (RN), Licensed Practical Nurses (LPN), and State tested Nurse Aides (STNA) working daily. This deficiency was observed on 04/17/24, when the nursing staffing posting did not include the required information. A review of the daily staffing postings from 03/01/24 to 04/17/24 revealed that all postings were missing the number of RNs, LPNs, and STNAs that worked. The Administrator confirmed on 04/18/24 that the staffing postings did not show the number of working RNs, LPNs, or STNAs. This issue had the potential to affect all 72 residents in the facility, which had a census of 72 at the time of the survey.
Latest citations in Ohio
A resident with intact cognition receiving Medicare Part A skilled services for metabolic encephalopathy had services discontinued while benefit days remained, but the facility did not issue the required Skilled Nursing Facility Advance Beneficiary Notice (SNF ABN). The Social Services Director later confirmed that no SNF ABN was provided and reported she believed only a Notice of Medicare Non-Coverage (NOMNC) was needed when all skilled services were stopped. This practice conflicted with the facility’s written policy, which required SNF ABNs to be issued when extended care items or services were initiated, reduced, or terminated due to expected non-coverage by Medicare.
Surveyors identified that the facility exceeded the acceptable medication error rate when two residents with type 2 DM received insulin doses that were not administered according to orders or manufacturer instructions. In two separate observations, an LPN administered Novolog and another LPN administered insulin glargine and insulin lispro without priming the insulin pens, and the insulin lispro and Novolog were given after the residents had already consumed a significant portion of their breakfast meals, despite orders for administration before meals. Manufacturer information for both insulin products required priming before each injection to ensure accurate dosing, and facility policy required medications, including insulin, to be administered safely, timely, and in accordance with prescriber orders and specified time frames.
Surveyors found that the facility failed to document tray line food temperatures for multiple meals served from two dining room kitchenettes, despite having a “Trayline Taste & Temperature Log” and a policy requiring food to be stored, prepared, distributed, and served according to professional food safety standards. Review of logs showed repeated missing entries for breakfast, lunch, and dinner services in both the Harrison and McClellan dining areas, and the Senior Director of Culinary Services confirmed that temperatures had not been recorded for those meals, potentially affecting all residents receiving meals from those kitchenettes.
The facility failed to conduct and document required periodic care conferences for two residents, despite multiple comprehensive, quarterly, and significant change MDS assessments and a policy requiring periodic care conferences with resident and/or family participation. One resident with Parkinson’s disease, post-stroke hemiplegia, TIA, DMII, and depression had only two documented care conferences over a year, while another resident with aphasia, cerebrovascular disease, DMII, gait difficulty, coagulation defect, depression, and muscle weakness had no documented care conferences in the past year, aside from a declined invitation to the representative. The UCC confirmed that care conferences were expected to occur quarterly and that no additional documentation existed for either resident.
A resident with Alzheimer's disease and type II DM, who required extensive assistance with ADLs and was receiving scheduled Lantus and sliding-scale Humalog, experienced a severely elevated blood glucose level. The on-call provider was notified and ordered an additional dose of lispro insulin with a directive to recheck the blood glucose after administration. Nursing staff administered the extra insulin but did not document any follow-up blood glucose check, and the DON confirmed that this reevaluation was required by the facility's abnormal blood glucose policy and was not completed or documented.
A resident with Parkinson’s disease, dementia, and hypothyroidism was prescribed levothyroxine once daily along with other medications. A consultant pharmacist’s monthly drug regimen review recommended that levothyroxine be given in the morning on an empty stomach, 30–60 minutes before food, per manufacturer instructions. The medical record contained no documented physician response to this recommendation, and the MAR showed the drug scheduled for morning administration while the resident was observed eating breakfast and receiving the medication at the same time. An LPN confirmed administering levothyroxine during the meal, and the DON verified there was no documentation explaining whether or why the pharmacist’s recommendation was or was not followed, resulting in a failure to act on and document the identified irregularity.
A resident with severe cognitive impairment, multiple comorbidities, documented gait and balance abnormalities, and a high fall risk was care planned and assessed by therapy to require contact guard assistance and use of a gait belt for transfers and ambulation. While being assisted by a CNA from a recliner to the bathroom with a walker, the CNA did not apply a gait belt, even though the resident had a known tendency to lean backward when standing. As the CNA reached to open the bathroom door, the resident lost balance and fell backward, striking the back of the head, and was later found by an LPN without a gait belt in place, contrary to the facility’s gait belt policy and the resident’s assessed needs.
A resident with CKD stage five requiring peritoneal dialysis (PD) was admitted with pre-admission physician orders for three daily PD exchanges and monitoring for peritonitis (fever, abdominal pain, cloudy effluent), but these monitoring orders were not entered into the facility’s physician orders. The care plan referenced PD and general monitoring but did not specifically address peritonitis monitoring. Paper PD flowsheets showed incomplete and inconsistent documentation of exchanges and resident condition, including missing condition/comments for individual treatments and no record of one ordered PD exchange. The PD cycler flowsheet lacked effluent descriptions on multiple days. The PD nurse reported facility staff were expected to monitor effluent and symptoms, and the DON confirmed the absence of specific peritonitis monitoring orders, lack of an order for the PD cycler, and documentation gaps, despite a facility policy requiring ongoing assessment and monitoring for complications before, during, and after dialysis treatments.
A nurse was observed preparing multiple oral medications for a resident with depression, traumatic brain injury, anxiety, and impaired cognition by pushing tablets and capsules from unit-dose cards directly into her ungloved hand and then using her fingers to place them into a medication cup. In a follow-up interview, the RN confirmed this practice and acknowledged that the correct procedure is to dispense medications directly from the card into the cup, contrary to the facility’s medication administration policy requiring adherence to good nursing principles and practices.
A resident with Alzheimer’s disease, diabetes, anxiety, significant ADL dependence, and behavioral symptoms was observed seated in a chair positioned against the nursing station with a locked wheelchair placed directly in front, also against the nursing station, effectively restricting movement. An LPN confirmed both wheelchair wheels were locked and that it should not have been placed there, while a CNA stated she had positioned the wheelchair to prepare for lunch, was unable to complete the transfer, and left it in place, acknowledging this was wrong. This arrangement conflicted with the facility’s restraint policy, which prohibits physical restraints except when alternatives are ineffective for treating a medical symptom and defines restraints as devices adjacent to the body that cannot be easily removed and that restrict freedom of movement or access to the body.
Failure to Issue Required SNF ABN When Discontinuing Medicare Part A Services
Penalty
Summary
The deficiency involves the facility’s failure to issue a Skilled Nursing Facility Advance Beneficiary Notice (SNF ABN) when Medicare Part A services were discontinued for a resident who still had available benefit days. The resident was admitted with a diagnosis of metabolic encephalopathy and had intact cognition per the Minimum Data Set assessment. The facility’s own SNF Beneficiary Notification Review documented that Medicare Part A skilled services began on 02/11/26 and the last covered day was 03/11/26, and that the facility initiated discharge from Medicare Part A services before the resident’s benefit days were exhausted. Despite this, no SNF ABN was provided to the resident or the resident’s representative. During interviews, the Social Services Director stated that the SNF ABN was issued hours prior to the last covered day but, upon reviewing her files, confirmed that no SNF ABN had actually been issued for this resident. She further explained that she believed an SNF ABN was only required if one skilled service remained and that if all skilled services were being discontinued, only the Notice of Medicare Non-Coverage (NOMNC) needed to be issued. The Administrator, however, stated that a resident should always receive both a SNF ABN and a NOMNC when Medicare Part A services are discontinued and benefit days remain. Review of the facility’s written policy dated 03/28/23 showed that the facility was required to issue SNF ABNs for initiation, reduction, or termination of extended care items or services when Medicare payment was not expected, which did not occur in this case.
Plan Of Correction
This Plan of Correction is submitted as required under State and Federal law. This Plan of Correction does not constitute an admission on the part of the Facility that the findings cited are accurate, that the findings constitute a deficiency or that the scope and severity regarding the deficiency cited are correctly applied. Any changes to the Facility's policies and procedures should be inadmissible in any proceeding on that basis. Without admitting or denying the validity or the existence of the alleged noncompliance, the Facility submits this Plan of Correction with the intention that it be inadmissible by any third party in any civil or other action against the facility or any employee, agent, officer, director or shareholder of the Facility. The Facility is utilizing this Plan of Correction as its allegation of substantial compliance as of 05/29/2026 F-0582 Corrective action for resident/s: On 5/14/26 Resident #34 was informed of rights and responsibilities related to Advanced Beneficiary Notice and voiced understanding of information for future reference by administrator. Identification of other residents who may be affected: Any resident receiving skilled services from nursing or therapy services. The Administrator audited all residents who were discharged from skilled services in the past 30 days to ensure they were issued a Notice of Non-Coverage and Advanced Beneficiary Notice on 5/29/26. No non-compliance was noted. Measures for systemic change: On 5/14/2026 Business Office Manager, Director of Rehab, Minimum Data Set nurse, Director of Nursing and Social Services Director were educated on proper procedure of issuing of Notice Of Medicare Non Coverage and Advanced Beneficiary Notice by administrator. All upcoming discharges from skilled services will be reviewed weekly at Utilization Review meeting to ensure notices will be delivered timely. How Corrective Action will be monitored: Administrator or designee to complete audits of all residents being discharged from skilled services to ensure they were issued a Notice of Non-Coverage and Advanced Beneficiary. This audit will be completed weekly x 4 weeks, then monthly x 2 months. Corrective action will be initiated for any noted non-compliance. Audit findings will be reviewed as part of the monthly quality assurance process to determine the need for further monitoring. Date of Compliance 5/29/26
Insulin Administration Errors and Failure to Prime Insulin Pens
Penalty
Summary
The deficiency involves the facility’s failure to maintain a medication error rate below 5%, with surveyors identifying 3 errors out of 28 medication administration opportunities, resulting in a 10.71% error rate. For one resident with type 2 diabetes mellitus and moderate cognitive impairment, the physician’s order directed Novolog insulin 10 units via subcutaneous pen-injector to be given before meals. During an observed medication pass, the LPN administered 10 units of Novolog insulin without priming the pen and did so after the resident had already consumed approximately 50% of the breakfast meal. The LPN later confirmed she did not prime the pen and acknowledged that the insulin was ordered to be administered prior to meals. Manufacturer instructions for the Novolog FlexPen specified that an air shot (priming) must be performed before each injection to ensure proper dosing. Another resident, also diagnosed with type 2 diabetes mellitus and with intact cognition, had orders for insulin glargine 35 units subcutaneously twice daily and insulin lispro 20 units subcutaneously before meals, plus 12 units subcutaneously if blood glucose was between 251 mg/dL and 300 mg/dL. During an observed medication administration, an LPN administered 35 units of insulin glargine and 32 units of insulin lispro without priming the insulin pens and after the resident had consumed approximately 90% of the breakfast meal, despite orders for insulin lispro to be given before meals. The LPN later stated she could not remember if she had primed the pen and acknowledged that the insulin was ordered to be administered prior to meals. Manufacturer information for insulin lispro stated that the pen must be primed before each injection to confirm insulin delivery and remove air, and that failure to prime could result in too much or too little insulin. The DON confirmed the expectation that insulin be administered as ordered, including priming each pen with two units before dialing the prescribed dose, and facility policy required medications, including insulin, to be administered safely, timely, and in accordance with prescriber orders and required time frames.
Plan Of Correction
This Plan of Correction is submitted as required under State and Federal law. This Plan of Correction does not constitute an admission on the part of the Facility that the findings cited are accurate, that the findings constitute a deficiency or that the scope and severity regarding the deficiency cited are correctly applied. Any changes to the Facility's policies and procedures should be inadmissible in any proceeding on that basis. Without admitting or denying the validity or the existence of the alleged noncompliance, the Facility submits this Plan of Correction with the intention that it be inadmissible by any third party in any civil or other action against the facility or any employee, agent, officer, director or shareholder of the Facility. The Facility is utilizing this Plan of Correction as an allegation of substantial compliance as of 5/29/2026. F-0759 Corrective action for resident/s: Residents #21 and #22 were assessed and evaluated by nurse and Director of Nursing 5/14/26. Resident #21 and #22 both denied any adverse effects and none were noted upon assessment by the Director of Nursing on 5/14/2026. Notification made to physician on 5/14/2026. LPN # 2 competency Eval on insulin administration with the Director of Nursing completed 5/14/2026. Identification of other residents who may be affected: Diabetic residents on assignment of LPN #2/station 2 have the potential to be affected and were assessed by the DON/Designee on 5/14/26 and found to be within normal limits. Measures for systemic change: All Nurses were educated by the Director of Nursing on the steps for Insulin administration per competency, diabetes clinical protocol policy, Medication and treatment orders policy, administering medications policy, and Obtaining fingerstick Glucose Level policy On 5/14/2026. How Corrective Action will be monitored: Director of Nursing and Assistant Director of Nursing will complete insulin administration audits on 5 nurses. This audit will be completed weekly x 4 weeks, then monthly x 2 months. Corrective action will be initiated for any noted non-compliance. Audit findings will be reviewed as part of the monthly quality assurance process to determine the need for further monitoring. Date of Compliance: 5/29/2026
Failure to Document Tray Line Food Temperatures in Dining Room Kitchenettes
Penalty
Summary
The deficiency involves the facility’s failure to document tray line food temperatures for meals served from the Harrison and McClellan Dining Room kitchenettes, as required by professional standards for food service safety and the facility’s own policy. Review of the “Trayline Taste & Temperature Log” (revised September 2018) showed missing temperature documentation for multiple meals from the Harrison Dining Room kitchenette, including dinner on 03/30/26 and 03/31/26, lunch and dinner on 04/01/26 and 04/02/26, dinner on 04/07/26, and lunch and dinner on 04/08/26 and 04/10/26. The Senior Director of Culinary Services confirmed during interview that tray line food temperatures were not documented on the log for these meals. Similarly, review of the same log for the McClellan Dining Room kitchenette revealed that tray line food temperatures were not documented for dinner on 04/01/26, breakfast and lunch on 04/02/26, and lunch and dinner on 04/07/26. The Senior Director of Culinary Services also verified these omissions during interview. The facility census at the time was 27 residents, and the governing “Food and Nutrition” policy, approved on 09/07/21, stated that the facility must store, prepare, distribute, and serve food in accordance with professional standards for food service safety.
Plan Of Correction
F812 The facility will continue to ensure food temperatures are completed before meals are served for all residents. To ensure compliance with this standard the following measures have been taken: 1. Immediately 4/15/26 culinary supervisor #224 was re-educated by Dietary Manager to this standard and policy "Food and Nutrition" which includes documentation of food temperatures. 2. All dietary staff have been re-educated to the standard and policy "Food and Nutrition" during the month of April 2026. 3. Audits of food temperature documentation to be completed by Dietary Manager 4 x per week for 4 weeks then weekly for 4 weeks. 4. Administrator to validate audits/compliance and provide additional training as needed. Administrator will present to QAPI committee for ongoing monitoring and further direction.
Failure to Conduct and Document Required Care Conferences
Penalty
Summary
The deficiency involves the facility’s failure to complete and document comprehensive care conferences at required intervals in accordance with care plan regulations and facility policy. For one resident with Parkinson’s disease with dyskinesia, cognitive communication deficit, hemiplegia and hemiparesis following cerebral infarction, transient cerebral ischemic attack, type II diabetes mellitus, and major depressive disorder, the record showed multiple MDS assessments over a one-year period, including annual, quarterly, and significant change assessments. However, only two care conferences were documented during the last 12 months, despite the expectation that care conferences be conducted quarterly with the resident and family when possible. The Unit Care Coordinator confirmed that no additional care conference documentation existed for this resident beyond the notes dated 04/21/25 and 01/02/26. A second resident, with diagnoses including aphasia following cerebrovascular disease, cerebral infarction, type II diabetes mellitus, unsteadiness on feet, difficulty in walking, coagulation defect, depression, and muscle weakness, also had multiple MDS assessments completed over the review period, including quarterly and annual assessments. The record contained a note that a care conference was offered to the resident’s representative, who declined to attend, but there was no documentation of any care conferences for the most recent 12 months. The Unit Care Coordinator confirmed that no other care conference documentation was available for this resident. Facility policy stated that periodic care conferences involving the resident, family, and the interdisciplinary team are part of the care planning process, but the required periodic care conferences and corresponding documentation were not completed for these two residents.
Plan Of Correction
THIS PLAN OF CORRECTION SERVES AS BERKELEY SQUARE'S CREDIBLE ALLEGATION OF SUBSTANTIAL COMPLIANCE AS OF June 1, 2026. Without admitting or denying the validity or existence of the alleged deficiencies, Berkeley Square provides the following Plan of Correction: F657 The facility will continue to document completion of care conferences at the required intervals for all residents, including residents #04 & #15. To ensure compliance with this standard the following measures have be taken: 1. The social service designee and the inter- disciplinary team were re-educated by the administrator to the facility policy "Care Conference" on 4/29/26 and verbalized understanding. 2. Care conferences for resident #04 and resident #15 were conducted on or before 4/29/2026 by the interdisciplinary team. 3. Review of all other residents was conducted by the social service designee to validate and ensure that care conference schedule is up to date with timely care conferences scheduled for them on 4/15/2026. Audits of care conferences to be completed weekly for four weeks and then monthly after that by the social service designee. Documentation of the care conference including any identified concerns in the medical record. Administrator to validate audits/compliance and provide additional training as needed. Administrator will present results of these audits to QAPI committee for ongoing monitoring and further direction.
Failure to Reevaluate Blood Glucose After Treatment for Hyperglycemia
Penalty
Summary
The facility failed to ensure that a resident with diabetes received treatment in accordance with professional standards of practice when nursing staff did not reevaluate the resident's blood glucose after treatment for severe hyperglycemia. The resident, admitted with diagnoses including Alzheimer's disease, type II diabetes mellitus, and depression, had physician orders for Humalog insulin on a sliding scale before meals, Lantus insulin 25 units daily, and lisinopril 5 mg daily. The resident required extensive assistance with activities of daily living, including transfers, toileting hygiene, eating, and bathing. On the evening in question, the resident's blood glucose was documented as 532 mg/dL, and the on-call provider was notified. The provider gave a new order to administer an additional 8 units of lispro (Humalog) and to recheck the blood glucose in 30 minutes. The electronic medication administration record showed that the blood glucose of 532 mg/dL was obtained at 9:00 p.m. and that the additional 8 units of lispro were administered at 9:21 p.m. However, there was no documentation in the resident's chart that the blood glucose was rechecked after the additional insulin was given. In an interview, the DON confirmed there was no evidence of reevaluation and verified that, according to the facility's "Abnormal Blood Glucose Procedure" policy, the resident should have been reevaluated and that the evaluation step should have been included in the progress note documentation.
Plan Of Correction
F684 The facility will continue to ensure all residents, including #03, receive treatment in accordance with professional standards of practice and reevaluated for hyperglycemia. To ensure compliance with this standard the following measures have been taken: 1. The director of nursing assessed resident #03, reviewed documentation and orders and found no ill effects immediately 4/16/26. 2. All licensed nurses were re-educated to facility policy "Blood Glucose Monitoring" by the Director of Nursing/designee in April 2026. 3. Audits of like-residents that require blood sugar checks to be completed by the director of nursing/designee two times a week for 4 weeks and then monthly after that to validate correct follow through when there is abnormally high blood glucose result. The Administrator will bring results of these audits to the QAPI committee for ongoing monitoring and further direction.
Failure to Act on Pharmacist Drug Regimen Recommendation for Thyroid Medication
Penalty
Summary
The deficiency involves the facility’s failure to ensure that pharmacy recommendations from the monthly drug regimen review were acted upon and documented for a resident. The resident was admitted with diagnoses including Parkinson’s disease, dementia, and hypothyroidism, and had current physician orders for levothyroxine 150 mcg once daily, buspirone 50 mg twice daily, and losartan 100 mg once daily. A medication regimen review dated 11/25/2025 included a consultant pharmacist recommendation that levothyroxine be administered consistently in the morning on an empty stomach, at least 30–60 minutes before food, per manufacturer instructions. There was no specific physician response in the medical record to this recommendation, and the facility’s policy stated that consulting pharmacist reviews are sent to nursing and addressed with the primary care provider or consulting specialist for review and follow-up. Review of the resident’s medication administration record for April 2026 showed levothyroxine scheduled for 9:00 a.m. On observation, the resident was seen eating breakfast in the dining area at 8:03 a.m., and an LPN reported administering the levothyroxine 150 mcg to the resident while the resident was in the dining area eating breakfast. The DON confirmed there was no evidence in the resident’s medical record explaining why the consultant pharmacist’s recommendation from 11/25/2025 was or was not acted upon. This lack of documented physician review and action on the pharmacist’s identified irregularity constituted noncompliance with the drug regimen review requirements.
Plan Of Correction
F756 The facility will continue to ensure the pharmacy recommendations from the monthly drug regimen review by a licensed pharmacist are acted upon for all residents, including #08. To ensure compliance with this standard the following measures have been taken: 1. Resident #08 was assessed by the registered nurse and med review completed by 4/28/26. After review of resident's drug regime's, it was discovered that resident #8 had 2 separate medication recommendations on the same form, to be reviewed by two separate practitioners, pharmacy has been instructed and agreed to separate meds on individual forms. 2. Licensed nurses re-educated to facility policy "Drug Regimen Review" by Director of nursing/designee in April 2026 and no later than 5/8/26. Licensed nurses are responsible for ensuring the reviews and recommendations are given to the physician for timely review. 3. Review of all other current residents Drug Regimen orders completed by Director of nursing/designee on 4/16/26 to ensure recommendations were followed up on/reviewed by the physician and address concerns if needed. 4. Audit of drug regime recommendations, pharmacy recommendations, and physician follow up to be completed weekly for four weeks by the Director of nursing/designee. Administrator will present results of these audits to the QAPI committee for ongoing monitoring and further direction.
Failure to Use Required Gait Belt During Ambulation Resulting in Resident Fall
Penalty
Summary
The deficiency involves the facility’s failure to ensure that a required gait belt was used while assisting a high fall‑risk resident with ambulation, resulting in a fall with head injury. The resident had multiple diagnoses including metabolic encephalopathy, hypertension, osteoarthritis, muscle weakness, gait and mobility abnormalities, major depressive disorder, anxiety, and visual hallucinations. Admission and subsequent MDS and fall risk assessments documented that the resident was severely cognitively impaired, required moderate to maximal assistance with transfers and ambulation, could not independently come to a standing position, exhibited loss of balance while standing, used an assistive device, and had decreased muscle coordination. The resident had a history of falls prior to admission and was assessed as being at high, later moderate, risk for falls. The resident’s fall care plan identified her as at risk for falls and included interventions such as providing maximum to moderate assistance with transfers and walking short distances, use of a walker and wheelchair, and following the facility’s fall protocol. Therapy notes and care conference documentation indicated that the resident leaned backwards when standing, required contact guard to minimal assistance for bed mobility and transfers, and needed constant verbal cueing for safe sequencing during toilet transfers. The physical therapist confirmed that the resident was to use a gait belt with staff when ambulating, and the DON verified that therapy had assessed the resident as requiring contact guard assistance and a gait belt for ambulation and transfers. On the day of the incident, a CNA was assisting the resident from her recliner to the bathroom using a walker. The CNA walked beside the resident, providing guidance and support, and reported having a hand on the resident while assisting her. As they approached the bathroom door, the CNA reached for the doorknob to open it, and at that moment the resident began to lose her balance and fell backwards to the floor, striking the back of her head. The nurse who responded found the resident on her back at the foot of the bed with her feet near the bathroom, noted a red raised area on the back of the head, and documented that the resident was not wearing a gait belt and that the gait belt was on the dresser. In the facility’s investigative summary and in interviews, the CNA acknowledged that she did not have a gait belt on the resident while ambulating her, despite the resident’s assessed need for hands‑on assistance and gait belt use per facility policy and the resident’s care and therapy plans.
Failure to Implement PD Orders and Monitor Resident Receiving Peritoneal Dialysis
Penalty
Summary
The deficiency involves the facility’s failure to implement pre-admission physician orders for peritoneal dialysis (PD) and to provide ongoing monitoring for a resident with chronic kidney disease (CKD) stage five who required PD. Pre-admission orders dated 11/14/25 specified three daily PD exchanges at 6:00 A.M., 2:00 P.M., and 10:00 P.M., and directed staff to monitor for signs and symptoms of peritonitis, including fever, abdominal pain, and cloudy effluent. These monitoring orders were not entered into the facility’s physician orders. The resident’s care plan noted the need for PD and included general monitoring interventions (labs, signs of bleeding, bacteremia, septic shock, and significant vital sign changes), but did not specifically address the ordered monitoring for peritonitis. Review of PD documentation showed incomplete and inconsistent charting of treatments and resident condition. The paper peritoneal flowsheet had columns for time of PD and condition/comments, including instructions to call the nurse immediately for cloudy fluid, abdominal pain, or fever. However, the first entry on 11/15/26 at 2:00 P.M. only noted that the PD nurse completed the exchange, and the 10:00 P.M. entry that day had no condition/comment documentation. Subsequent days (11/16/25, 11/17/25, and 11/18/25) contained only one condition/comment entry per day rather than for each exchange, and there was no documentation that the 6:00 A.M. PD on 11/18/25 was completed. The PD cycler flowsheet starting 11/19/25 lacked any description of the effluent on multiple days. The PD nurse from the dialysis company stated facility staff were expected to monitor effluent for cloudiness and assess for abdominal pain and fever, and the DON confirmed there was no electronic physician order for peritonitis monitoring or for use of the PD cycler, that the paper charting did not allow for effluent description or symptom documentation for each treatment, and that PD was not documented at one ordered time. The facility’s dialysis policy required ongoing assessment and monitoring for complications before, during, and after treatments, which was not reflected in the documentation for this resident.
Improper Infection Control During Medication Administration
Penalty
Summary
Surveyors identified a deficiency in infection prevention and control related to medication administration for Resident #29. The resident was admitted on 02/28/14 with diagnoses including depression, traumatic brain injury, and anxiety, and had impaired cognition per a quarterly MDS assessment. During an observation on 03/25/26 at 6:58 A.M., RN #281 prepared the resident’s medications by removing an Amoxicillin-Pot Clavulanate tablet from the medication card and pushing it directly into her ungloved hand, then using her fingers to place the pill into a medication cup. The same process was observed for multiple other medications, including Escitalopram Oxalate, Furosemide, Sennosides, Lyrica, and Vitamin D, each being pushed from the card into the RN’s ungloved hand and then transferred by her fingers into the medication cup before administration to Resident #29. In a subsequent interview at 7:27 A.M. the same day, RN #281 confirmed she had placed each medication into her ungloved hands prior to administration and acknowledged that the proper procedure was to push the pills directly from the card into the medication cup. Review of the facility’s “Medication Administration – General guidelines” policy, revised 10/08/25, stated that medications are to be administered in accordance with good nursing principles and practices. This practice failure was cited as a deficiency under Complaint Number 2681777.
Improper Use of Wheelchair as a Physical Restraint
Penalty
Summary
Surveyors identified a deficiency related to the facility’s failure to ensure a resident was free from physical restraints. Resident #7, admitted with diagnoses including Alzheimer’s disease, diabetes mellitus, and anxiety disorder, was documented on a recent MDS as rarely understood and dependent for ADLs except eating. The resident ambulated independently on the unit without an assistive device and had documented verbal and other behaviors occurring one to three days during the look-back period. The care plan noted the resident had potential to be physically aggressive, chase staff, throw objects, and be combative with care, with interventions such as offering choices, administering medications as ordered, and intervening early when agitation occurred. During an observation and interview, Resident #7 was found sitting in a chair with the right arm of the chair positioned against the nursing station and a wheelchair placed directly in front of him. The left arm of the wheelchair was also against the nursing station, and both wheelchair wheels were locked, creating a barrier that appeared to restrain the resident, who was sleeping with his knees touching the locked wheelchair. An LPN confirmed both wheelchair wheels were locked and that the wheelchair should not have been placed in front of the resident. A CNA reported she had placed the wheelchair there in preparation to get the resident up for lunch, was unable to transfer him, and left the wheelchair in that position, acknowledging it was wrong to keep it there. The facility’s physical restraint policy stated that physical restraints are not used except when alternatives are not appropriate or effective for treating a medical symptom and defined physical restraints as any device attached or adjacent to the body that the individual cannot easily remove and that restricts freedom of movement or access to the body.
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