Country Court
Inspection history, citations, penalties and survey trends for this long-term care facility in Mount Vernon, Ohio.
- Location
- 1076 Coshocton Ave, Mount Vernon, Ohio 43050
- CMS Provider Number
- 365269
- Inspections on file
- 24
- Latest survey
- March 23, 2026
- Citations (last 12 mo.)
- 4
Citation history
Health deficiencies cited at Country Court during CMS and state inspections, most recent first.
A resident with severe cognitive impairment and multiple comorbidities, who depended on staff for most care, was found by a family member to have a light purple bruise on the right cheek while being assisted with lunch. The RN on duty had not previously noticed the discoloration and notified the DON, who suggested it might have resulted from contact with a bedrail during incontinence care, though staff interviews did not confirm any such contact. The incident report lacked a clear description of the event, no skin assessment or medical record entry was completed for that day, the bruise was not logged on the incident/accident log, and no self-reported incident was submitted to the State Survey Agency, despite facility policy requiring timely reporting of suspected abuse or injuries of unknown origin.
A resident with severe cognitive impairment and multiple comorbidities, who was dependent on staff for most ADLs, was found by family to have a light purple discoloration/bruise on the right cheek during care. The RN on duty had not previously noted the area and reported it to the DON, who suggested it might have been caused by contact with a bedrail but did not clearly document the nature of the incident. The facility’s investigation was incomplete: staff interviews lacked dates and times, one CNA’s phone statement omitted full identification, no abuse-related physical assessments were performed on other non-interviewable residents, the incident/accident log did not reflect the bruise, and no skin assessment or documentation of the bruise appeared in the resident’s medical record, despite policy requiring thorough abuse investigations with written statements from all involved.
The facility failed to provide and document scheduled showers for two dependent residents who required staff assistance with all ADLs, including bathing and hygiene. One resident, cognitively intact with hemiplegia and mental health diagnoses, was care planned for twice-weekly showers but reported only receiving about one per week, with records showing minimal or no documented showers since admission. Another resident with Alzheimer’s disease, malnutrition, and CKD was totally dependent for bathing and scheduled for twice-weekly showers, yet multiple scheduled shower days lacked documentation of care or refusals, and nurse notes did not show any refusals or reattempts. A family member questioned how this nonverbal resident could refuse showers, and the DON confirmed that showers were expected to be provided as care planned unless refusals were documented.
The facility failed to consistently document meal intake percentages for three residents who were care planned as being at risk for malnutrition, dehydration, and significant weight loss, and who required extensive assistance with eating and other ADLs. Despite care plan interventions directing staff to monitor and record meal percentages at each meal, record reviews showed numerous missing entries for breakfasts, lunches, and dinners over multiple months. A CNA reported documenting meal intakes after meals and not leaving before completing charting, while the DON stated that aides are expected to chart daily and that meal percentages are used to monitor nutritional status. Facility policy required nutrition documentation for all residents in accordance with regulatory and practice standards.
The facility did not maintain a clean and sanitary kitchen, potentially affecting all 53 residents. Serving pans were observed being stored wet, contrary to the facility's policy requiring dishes to be air-dried completely before storage. The Dietary Manager confirmed the requirement for complete air-drying, aligning with the facility's 2023 policy.
The facility failed to maintain a comprehensive water management plan and used ineffective disinfectants for infection control. The Water Management Plan lacked details and excluded certain areas, while water temperature checks were missed. A housekeeper used a disinfectant not effective against C. diff, and the Housekeeping Supervisor confirmed the need for retraining and appropriate supplies.
The facility failed to honor the shower preferences of six residents, who were either cognitively intact or had expressed their preferences clearly. Despite being scheduled for showers, these residents received bed baths instead, with some receiving only one shower in a month. Interviews with the residents and the DON confirmed the discrepancy between the residents' preferences and the care provided.
A high fall risk resident with Parkinson's Disease and hemiplegia was not provided with the required pad alarm in their wheelchair, as specified in their care plan and physician orders. Observations showed the absence of the alarm, and staff interviews confirmed a misunderstanding of its use, indicating a failure to adhere to the facility's fall prevention policy.
A facility failed to implement proper indwelling urinary catheter care orders for a resident with a suprapubic catheter, despite the care plan indicating the need for catheter care every shift. The resident had diagnoses including end-stage renal disease and required assistance with daily living activities. The absence of documented orders for daily catheter care and monitoring of the insertion site was confirmed by the DON, contrary to the facility's infection control policy.
A facility failed to obtain urinary testing before administering an antibiotic for a possible UTI, affecting a resident with end-stage renal disease and an indwelling catheter. Despite symptoms like flank pain and foul-smelling discharge, no assessment was completed to determine the appropriateness of antibiotic use. An LPN attempted to collect a urine sample but was unsuccessful, and only one attempt was made. The ADON confirmed the lack of assessment and testing, which was against the facility's infection control policy.
The facility failed to educate and offer the influenza vaccine to two residents, one with dementia and schizophrenia, and another with diabetes and anxiety disorder. Despite the facility's policy requiring annual vaccine offers and education, these residents were not provided with the necessary information or the opportunity to receive the vaccine in 2024 or 2025, as confirmed by the DON.
Failure to Report and Document Injury of Unknown Origin
Penalty
Summary
The deficiency involves the facility’s failure to report an allegation of an injury of unknown origin to the State Survey Agency as required by policy and regulation. A resident with Alzheimer’s disease, severe cognitive impairment (BIMS score of 00), protein calorie malnutrition, major depressive disorder, and chronic kidney disease was dependent on staff for most activities of daily living and required monitoring for skin concerns during care. On the date in question, the resident’s family member observed a light purple bruise or discoloration on the resident’s right cheek while staff were assisting with lunch and reported it to an RN, who had not previously noticed the area and then notified the DON. The DON assessed the area and suggested it could have been caused by the resident’s cheek resting on a side rail during incontinence care, but staff interviews revealed no evidence that the resident’s face had come into contact with the bed rail. Despite the family’s report and the DON’s stated intent to investigate, the incident was not fully documented or reported as required. The facility’s incident report did not specify the nature of the incident, and there was no skin assessment documented in the medical record on the date the bruise was identified. The bruise was not entered on the February incident/accident log, and review of the state’s Enhanced Information Dissemination Collection system showed no self-reported incident related to the resident’s facial discoloration for the relevant period. The DON confirmed that no self-reported incident was submitted regarding this injury of unknown origin, contrary to the facility’s abuse policy, which requires notification of the Ohio Department of Health within 24 hours and completion of an investigation within five days.
Failure to Thoroughly Investigate Injury of Unknown Origin and Document Findings
Penalty
Summary
The deficiency involves the facility’s failure to conduct a thorough investigation of an injury of unknown origin involving a resident with severe cognitive impairment and extensive care needs. The resident, admitted with diagnoses including Alzheimer’s disease, protein calorie malnutrition, major depressive disorder, and chronic kidney disease, required substantial/maximal assistance with eating and bed mobility and was dependent on staff for bathing, hygiene, and transfers. The resident’s care plan included monitoring for skin concerns during care. On the date of the incident, the resident’s daughter observed a light purple discoloration/bruise on the resident’s right cheek while staff were assisting with lunch and reported it to an RN, who had not noticed it earlier and reported it to the DON. The DON’s incident report suggested the area could have been caused by the resident’s cheek resting on a side rail during incontinence care, but the nature of the incident was not clearly documented. The facility’s investigative process was incomplete and poorly documented. Staff interviews did not reveal any evidence of the resident’s face contacting the bed rail, and the interviews with multiple CNAs lacked dates and times. One CNA’s witness statement, obtained by phone, did not include her last name or title. No physical assessments for abuse were conducted on non-interviewable residents to determine if others were affected. The incident/accident log contained no entry for the resident’s cheek bruise, and the resident’s medical record had no documentation of the bruise or a skin assessment on the date it was identified. The DON confirmed that the incident report constituted the full investigation, that no other residents were assessed for injuries, that no written staff education was completed for prevention of recurrence, and that there was no medical record documentation of the discoloration/bruise, despite facility policy requiring all abuse investigations to be thoroughly investigated with written statements from all involved parties.
Failure to Provide and Document Scheduled Showers for Dependent Residents
Penalty
Summary
The facility failed to provide scheduled showers and document bathing care for dependent residents as outlined in their care plans and facility policy. One resident with hemiplegia, tremors, anxiety disorder, and major depressive disorder was care planned and scheduled to receive showers on Mondays and Fridays and required assistance with all ADLs. Review of the shower schedule and shower sheets showed only a few showers documented over a multi-month period, and CNA Point of Care records showed no evidence of showers since admission. The resident reported she did not receive showers as scheduled, stating she was fortunate to receive one shower per week and that she was upset about not getting the two weekly showers planned. Another resident with Alzheimer’s disease, protein calorie malnutrition, major depressive disorder, and chronic kidney disease was care planned as totally or nearly dependent on staff for bathing, hygiene, and dressing, with showers scheduled twice weekly. Review of shower documentation revealed multiple missed shower dates with no evidence that showers were provided on those days. Nursing progress notes contained no documentation of shower refusals or attempts to provide showers at a later time. The resident’s daughter reported staff told her the resident refused showers, but she stated the resident does not speak and expressed confusion about how the resident could refuse. The DON confirmed the missing shower documentation for both residents and stated that showers are to be provided as care planned, requested, and as needed unless refusals are documented, as required by the facility’s ADL policy.
Failure to Consistently Document Meal Intake for Residents at Nutritional Risk
Penalty
Summary
Surveyors identified a deficiency in the facility’s failure to ensure meal intakes were consistently documented for residents identified as being at nutritional risk, which was necessary to maintain residents’ health and monitor nutritional status. For one resident with Huntington’s disease, dysphagia, abnormal weight loss, bipolar disorder, and adult failure to thrive, the care plan identified risks for altered nutrition, dehydration, and significant weight loss, with interventions that included monitoring and documenting meal percentages at each meal. Record review showed multiple missing meal intake entries across January, February, and March 2026 for this resident, including undocumented breakfasts, lunches, and dinners on numerous specific dates, despite the care plan requirement to document each meal. A second resident, admitted with Alzheimer’s disease, protein calorie malnutrition, major depressive disorder, and chronic kidney disease, was care planned as being at risk for malnutrition, altered fluid maintenance/dehydration, and significant weight loss, with interventions to monitor and document meal percentages for each meal. Review of this resident’s records revealed missing documentation of meal percentages for several breakfasts, lunches, and dinners in January, February, and March 2026. These gaps occurred even though the resident required substantial/maximal assistance with eating and was dependent on staff for several ADLs, and despite the care plan directive to document each meal consumed. A third resident with non-traumatic subdural hemorrhage, visual hallucinations, Down syndrome, chronic pain syndrome, and left foot drop was also care planned as being at risk for malnutrition, altered fluid maintenance/dehydration, and significant weight loss, with interventions to monitor and document meal percentages at each meal due to consuming less than 75% of meals and needing assistance with meals. Record review showed numerous missing meal percentage entries for this resident’s breakfasts, lunches, and dinners across January, February, and March 2026. CNA #122 stated that meal intakes are recorded after meals and that she does not leave her shift until documentation is complete, while the DON stated that aides are expected to chart daily, including meal percentages, and confirmed that meal percentages are used to monitor residents’ nutritional status. Facility policy on nutrition documentation required that nutrition documentation be completed on all residents in accordance with regulations and standards of practice.
Failure to Maintain Sanitary Kitchen Conditions
Penalty
Summary
The facility failed to maintain the kitchen in a clean and sanitary manner, which had the potential to affect all 53 residents residing in the facility. During an observation of the kitchen, it was noted that serving pans of various sizes were being stored while still wet. Specifically, six serving pans were stacked on the shelf without being completely air-dried. An interview with the Dietary Manager confirmed that after washing, dishes are required to be air-dried completely before being stacked and stored. The facility's policy on Cleaning Dishes/Dish Machine, dated 2023, states that dishes should be air-dried on dish racks and not dried with towels, and they should not be nested unless completely dry.
Deficiencies in Water Management and Infection Control
Penalty
Summary
The facility failed to maintain a comprehensive water management plan, which had the potential to affect all residents. The undated Water Management Plan was not descriptive of the facility, lacking details on limits or control measures. It excluded the basement and fixtures such as the backflow prevention device in the flow diagrams. Additionally, water temperature checks for empty rooms were not completed in January, March, and April of 2024. The Administrator acknowledged that the Water Management Plan was a template still in development and confirmed the absence of minimum water temperature indications and the exclusion of the basement floor plan in the flow diagrams. Furthermore, the facility did not utilize appropriate disinfectants to prevent the spread of communicable diseases. A housekeeper was observed cleaning a resident's room who was in isolation for Clostridium Difficile (C. diff) using Clorox Clean-Up Disinfectant with Bleach, which was not effective against C. diff. The Housekeeping Supervisor confirmed the product's ineffectiveness against C. diff and acknowledged the need for retraining staff and ordering appropriate cleaning supplies. The infection control nurse verified that there was no outbreak of C. diff at the facility but confirmed the need for retraining on effective cleaning agents.
Failure to Honor Resident Shower Preferences
Penalty
Summary
The facility failed to honor the residents' preferences for showers, affecting six residents who were reviewed for this aspect of care. Each of these residents had expressed a preference for showers over bed baths, as documented in their medical records and care plans. Despite this, the facility did not provide showers according to their preferences, as confirmed by interviews with the residents and the Director of Nursing (DON). Resident #47, who was cognitively intact and had a preference for showers, did not receive any showers from January 21 to February 18, 2025, despite being scheduled for bathing twice a week. Similarly, Resident #30, who also had intact cognition and a preference for showers, received only one shower in the same period. Resident #26, who preferred showers during the day, received only three showers in the last 30 days, all of which were at night, contrary to her preference. Other residents, including Resident #19, #21, and #43, also did not receive showers according to their preferences. Resident #19 preferred showers twice a week but only received bed baths. Resident #21, who had moderately impaired cognition, received only one shower in the reviewed period, while Resident #43, who was cognitively intact, received only one shower and one tub bath, with the rest being bed baths. The facility's policy on personal hygiene and bathing was not adhered to, as it required that residents be given the opportunity to bathe according to their preferences.
Failure to Implement Fall Prevention Measures for High-Risk Resident
Penalty
Summary
The facility failed to ensure that fall prevention measures were adequately implemented for a high fall risk resident. Resident #19, who has a history of Parkinson's Disease, hemiplegia on the left side, anxiety, depression, and a history of stroke, was identified as being at high risk for falls. Despite the resident's care plan and physician orders specifying the use of a pad alarm in both the wheelchair and bed to alert staff of unassisted transfers, observations revealed that the pad alarm was not consistently placed in the resident's wheelchair. On multiple occasions, Resident #19 was observed without a pad alarm in the wheelchair, contrary to the care plan and physician orders. Interviews with facility staff, including a CNA and the ADON, confirmed the absence of the pad alarm in the wheelchair and a misunderstanding regarding its required use. The facility's policy on fall prevention and management was not adhered to, as the necessary interventions were not consistently implemented to prevent potential accidents for this high-risk resident.
Failure to Implement Indwelling Urinary Catheter Care Orders
Penalty
Summary
The facility failed to implement proper indwelling urinary catheter care orders for a resident with a suprapubic indwelling urinary catheter. The resident, who was admitted with diagnoses including end-stage renal disease, obstructive uropathy, and high blood pressure, had a care plan indicating the need for catheter care every shift. However, there were no physician orders for daily catheter care or monitoring of the insertion site documented in the treatment administration record. The Director of Nursing confirmed the absence of these orders, which is contrary to the facility's policy on infection control for indwelling catheter care. The resident's Minimum Data Set indicated moderately impaired cognition and a need for assistance with daily living activities, including personal hygiene, which underscores the importance of adhering to catheter care protocols to prevent urinary tract infections.
Failure to Obtain Urinary Testing Before Antibiotic Use
Penalty
Summary
The facility failed to obtain urinary testing prior to administering an antibiotic medication for a possible urinary tract infection (UTI) and did not complete the necessary criteria for the use of the antibiotic. This deficiency affected Resident #21, who was admitted with diagnoses including end-stage renal disease, obstructive uropathy, and high blood pressure. The resident had moderately impaired cognition and required assistance with activities of daily living, including transfers and personal hygiene, and had an indwelling urinary catheter. Despite the presence of symptoms such as flank pain and foul-smelling discharge from the catheter, there was no assessment to determine if the use of an antibiotic was appropriate before administration. The medical record review revealed that an order for Amoxicillin was given without prior urine sample collection for laboratory testing and culture/sensitivity to accurately prescribe the appropriate antibiotic. The Licensed Practical Nurse (LPN) attempted to collect a urine sample but was unsuccessful, and only one attempt was made. The Assistant Director of Nursing (ADON) confirmed that there was no assessment completed to determine if the resident's symptoms met the criteria for a UTI and warranted antibiotic treatment. The facility's policy on infection control for indwelling catheter care was not followed, as there was no culture and sensitivity test completed to ensure the most effective antibiotic was ordered.
Failure to Educate and Offer Influenza Vaccine
Penalty
Summary
The facility failed to ensure that two residents, Resident #9 and Resident #17, received education regarding the benefits and potential side effects of the influenza vaccination. Resident #9, who was diagnosed with unspecified dementia, schizophrenia, and peripheral vascular disease, refused the influenza vaccine on 02/17/23, but there was no evidence of education provided at that time. Additionally, the resident was not offered the vaccine in 2024 or 2025. Resident #17, diagnosed with peripheral vascular disease, diabetes mellitus, and anxiety disorder, was never offered the influenza vaccine in 2024 or 2025. An interview with the facility's Director of Nursing confirmed that these residents were not educated or offered the vaccine in the specified years, despite the facility's policy requiring that all residents be offered the vaccine upon admission and annually. The facility's Influenza and Pneumococcal Vaccine policy, revised on 04/06/21, states that residents or their representatives should be educated on the benefits and side effects of the vaccines, with the influenza vaccine being offered between 10/01 and 03/31 each year. The policy also includes recommendations from the Centers for Disease Control (CDC). However, the facility did not adhere to this policy for the two residents in question.
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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