Delaware Court Health Care Center
Inspection history, citations, penalties and survey trends for this long-term care facility in Delaware, Ohio.
- Location
- 4 New Market Dr, Delaware, Ohio 43015
- CMS Provider Number
- 365676
- Inspections on file
- 19
- Latest survey
- February 9, 2026
- Citations (last 12 mo.)
- 5
Citation history
Health deficiencies cited at Delaware Court Health Care Center during CMS and state inspections, most recent first.
The facility failed to adequately address repeated resident council concerns about limited snack variety and consistently cold food. Over many months, residents with various medical conditions, including dementia, CKD, pulmonary disease, and dysphagia, repeatedly reported that snacks lacked variety and that meals were often served cold in both rooms and the dining area. Concern forms generated from council meetings were incomplete or failed to address all issues raised, and residents stated they were not offered additional snack options or information on available items. The Activity Director confirmed that these concerns were ongoing and frequently reported, while also acknowledging a lack of knowledge about any effective actions taken to resolve the problems, despite a policy requiring written administrative responses to council concerns.
Surveyors found that multiple PTAC units in resident rooms and a private dining room were improperly sealed, leaving visible gaps to the outside that allowed cold air and, in at least one room, water intrusion. Staff and residents confirmed feeling cold air, observing peeling wallpaper with a dark substance behind it, and using towels to absorb incoming water. One resident reported having complained several times without resolution, and another linked the gaps to bugs in the room. The maintenance supervisor acknowledged prior notice of at least one room’s PTAC problem and stated that proper correction would require removing and reinstalling the unit, while the administrator confirmed there were no documented maintenance work orders despite a policy requiring such documentation.
Staff did not consistently monitor or maintain proper holding temperatures for hot foods during a lunch meal service. A dietary staff member reported that only cooking temperatures, not holding temperatures, were taken, and surveyor checks found items on the steam table either excessively hot or below the facility’s hot-holding standard. A test tray assembled by the kitchen manager showed substandard temperatures before leaving the kitchen and further cooling after being transported on a non-insulated cart to a hallway without a warming cart, resulting in food that tasted cold. These practices did not follow the facility’s policy requiring temperature checks throughout meal service and maintenance of hot foods at or above 135°F using appropriate equipment.
The facility failed to ensure puree food was prepared to the correct smooth, pudding-like consistency for several residents with dysphagia, malnutrition, neurologic conditions, and dementia who had orders for puree diets. A dietary staff member was observed pureeing breaded salmon patties with broth in a mixer, wiping the sides with a gloved hand, scraping food from the glove back into the mixer, and then using the same glove to handle a broth container. The puree remained with visible chunks of salmon and breading and did not meet the facility’s stated standard of mashed potato or pudding-like consistency, despite the staff member acknowledging the presence of distinct pieces and proceeding with the product as the final puree.
Surveyors found that the facility failed to store and label food safely, with multiple uncovered, unlabeled, and undated items in dry and cold storage, and thawed products that were labeled to be kept frozen. Dietary staff did not follow proper hand hygiene or glove-use practices while preparing pureed foods, checking food temperatures, and serving on the tray line, including using gloved hands to scrape mixers, handle containers and equipment, and place thermometers and fingers into multiple food items without changing gloves or washing hands. Overhead vents above food preparation and service areas were heavily dust-laden, and dust was reported to be blowing over food preparation areas, affecting all residents who consumed food from the kitchen.
The facility failed to maintain clean and sanitary shower rooms, affecting all residents. Observations showed black-spotted substances along grout lines and tiles in all four shower rooms, with additional issues like deteriorating fabric on a shower chair. An interview with a housekeeper revealed uncertainty about the cleaning schedule, and the facility could not provide documentation to confirm weekly cleaning as required by policy.
Failure to Address Repeated Resident Council Concerns About Snacks and Food Temperature
Penalty
Summary
The deficiency involves the facility’s failure to adequately address and respond to recurring concerns raised in resident council meetings regarding snack variety and food temperatures, affecting four cognitively intact or impaired residents with multiple medical conditions, including atrial fibrillation, pulmonary disease, dementia, chronic kidney disease, vascular disease, and dysphagia. Resident council minutes over approximately a one‑year period documented repeated complaints about limited snack options and cold food at meals. Despite these concerns being voiced at multiple meetings, the corresponding concern forms were incomplete or failed to address all issues raised. For example, some forms did not mention food temperature concerns at all, others only partially addressed snack variety, and some did not address either the lack of snack variety or cold food. Residents reported that they had asked for more variety in chips and fruit and had not been offered choices or a list of items available from the supplier, and they stated that the facility gave excuses for the continued reliance on peanut butter sandwiches. Residents also reported that food was consistently served cold both in their rooms and in the dining room. The Activity Director confirmed that resident concerns were documented in council minutes and that concern forms were written and given to department heads, but acknowledged that residents had consistent, repeated concerns about snack variety and cold food over the majority of the months reviewed. The Activity Director denied knowledge that the requested variety of snacks was ever offered, denied knowledge of what the facility was doing to improve food temperatures, and was unaware of any test trays being completed or results shared with residents. The facility’s own policy stated that administration shall respond in writing to concerns and recommendations raised by the resident council, yet the repeated, unresolved complaints and incomplete concern forms demonstrated that resident council concerns were not consistently or effectively addressed.
Unsealed PTAC Units Allow Cold Air and Moisture Into Resident Rooms
Penalty
Summary
The deficiency involves the facility’s failure to provide a safe, clean, comfortable, and homelike environment by not maintaining properly sealed Packaged Terminal Air Conditioner (PTAC) units in multiple resident rooms and a private dining room during very cold weather. A tour showed that each resident room and the private dining room had a PTAC unit installed under the window, and in several locations there was approximately a 1/4 inch gap between the unit and the wall, open to the outside, allowing cold air to enter. This condition was observed in the resident private dining room and in the rooms of six residents, where the units did not span the wall opening completely. In one room shared by two residents, the PTAC unit was not sealed around the entire unit, and staff confirmed that cold air was coming through the gap. On the right side of that unit, wallpaper was peeling from the wall from the top of the unit to the baseboard, exposing a dark substance on the wall and the back of the wallpaper. A white bath towel was rolled up under the PTAC unit. One of the residents in that room stated she could feel the cold air and explained that the towel was used to soak up water coming in from outside elements. She reported having notified administration several times about the problem without results. In another resident room, the exposed wood around the PTAC unit appeared wet and black, as if damaged, and staff verified these observations. Additional observations in other resident rooms showed similar 1/4 inch openings between the PTAC units and the walls, with cold air entering and wallpaper beginning to peel near the baseboard. One resident associated the gap with having bugs in the room. The Maintenance Supervisor stated he was responsible for checking PTAC units and sealing areas where cold air entered with silicone, but he reported being unaware of cold air coming through the units until the survey. He acknowledged that the problem with one room’s PTAC unit had been reported to him in the fall of 2025 and that correcting the issue would require removing and reinstalling the unit from the wall and outside. The Administrator confirmed there were no Maintenance Work Order Request Forms for the PTAC units or for wallpaper separating from the walls, despite the facility’s policy requiring all maintenance requests to be documented on a work order form for tracking and timely resolution.
Failure to Maintain Safe and Palatable Food Temperatures During Meal Service
Penalty
Summary
Facility staff failed to ensure that food was served at safe and palatable temperatures during a lunch meal service. During observation in the dining room, about half of the residents had already been served when a dietary staff member reported that they took cooking temperatures but not holding temperatures. Surveyor temperature checks of items on the steam table showed green beans at 184°F, mashed potatoes at 178°F, burger patties at 120°F, salmon patties at 74°F, and potatoes at 146°F. After surveyor intervention, the burger and salmon patties were returned to the oven. The dietary staff member stated that if the puree food had not taken so long, the food would not have been outside the required temperatures. The kitchen manager later stated the goal temperature for food held on the steam table was 150°F. Further observation of a test tray revealed that holding temperatures in the kitchen before plating were already below the facility’s hot-holding standard of 135°F, with the salmon patty at 119.5°F, potatoes at 106°F, and green beans at 139°F. The tray was then placed on a non-insulated cart and transported to a resident hallway that did not have a warming cart, only a metal rack, despite the facility having plate warmers and three insulated carts used elsewhere. After tray delivery, the test tray food temperatures dropped further, with the salmon patty at 106°F, potatoes at 96°F, and green beans at 109°F, and the food was described as tasting cold. The kitchen manager declined to taste the food and confirmed it would be cold. Review of the facility’s “Holding Food Temperatures and Guidelines” policy showed that it required serving line temperatures to be taken at the beginning, middle, and end of meal service, and that hot foods should be held at 135°F or higher using methods such as a proper steam table and heated plates, which was not followed in this instance.
Improper Preparation and Consistency of Puree Diets
Penalty
Summary
The deficiency involves the facility’s failure to provide puree food in the correct consistency for multiple residents with physician orders for puree diets. Six residents with diagnoses including cerebral infarction, respiratory failure, protein malnutrition, dysphagia, Parkinson’s disease, hemiplegia, hemiparesis, Alzheimer’s disease, dementia, malnutrition, heart disease, failure to thrive, pulmonary disease, and vascular disease were ordered puree texture food. Their cognitive status ranged from intact to impaired, as reflected by BIMS scores from 0 to 15. Facility policy for puree diets, dated 2022, specified that this diet is for residents who cannot chew or have difficulty swallowing and that the sides of the blender shall be scraped and processed until the food is smooth like pudding. During an observation and interview with a dietary staff member, the surveyor observed the preparation of puree food for residents on puree diets. The staff member placed three breaded salmon patties into a roboku mixer and added chicken broth one spoonful at a time, for a total of eight spoonfuls, then added additional unmeasured broth. On three occasions, the staff member wiped the sides of the mixer with a gloved hand, scraped the food from the glove onto the edge of the mixer, and then, with the same gloved hand, grabbed a jar of broth to add more liquid. Several chunks of salmon and breading remained visible on the sides of the mixer and were not fully mixed back in. The completed puree, when taste tested, was found to contain small chunks and distinct pieces rather than the intended mashed potato or pudding-like consistency. The dietary staff member acknowledged that the mixture contained chunks and distinct pieces and stated it was the best consistency they were going to achieve, despite the facility policy requiring a smooth, pudding-like texture.
Food Storage, Hand Hygiene, and Kitchen Sanitation Deficiencies
Penalty
Summary
Surveyors identified that the facility failed to store and label food in a safe and sanitary manner and did not follow its own food storage policies. During a morning observation, multiple food items in the kitchen were found uncovered, unlabeled, and undated, including a bowl of cookies in envelopes, a tray of uncovered cookies on a prep table, three foil-wrapped sandwiches in the refrigerator, a large metal bowl of fajita mix, an open bag of vanilla wafers, thawed chocolate magic cups labeled to be kept frozen, six cups of yogurt, a red bowl with an unknown substance, an open bottle of water, and several cups of pre-poured juices and milk. The kitchen manager confirmed that these items should have been covered, labeled, and dated, and facility policies required dry and cold storage areas to be maintained to keep food safe and free from contamination, with opened packages stored in sealed containers and all items labeled and dated. Surveyors also observed multiple failures in hand hygiene and glove use during food preparation, temperature checking, and tray line service, as well as unsanitary kitchen conditions. One dietary staff member preparing pureed salmon patties repeatedly reached a gloved hand into a mixer to scrape the sides, then used the same gloved hand to handle a broth jar and blender controls without performing hand hygiene or changing gloves, and reported staff had been instructed to use their hands rather than utensils for scraping. Another dietary staff member taking food temperatures stuck gloved fingers into baked beans, used those fingers to wipe the thermometer, then used a sanitizer wipe and, without changing gloves or performing hand hygiene, placed the thermometer into salmon patties and potatoes, confirming that his gloves became soiled and were not changed. During tray line service, a dietary staff member handled a roll and then, without changing gloves, used his hands to grab other food items for trays. Additionally, overhead vents above food preparation and service areas were observed to have a thick layer of dust, and the kitchen manager confirmed the vents were dirty and dust was blowing above food preparation areas. These issues affected all residents who consumed food from the kitchen, except one resident who did not eat food from the kitchen.
Facility Fails to Maintain Clean Shower Rooms
Penalty
Summary
The facility failed to maintain its shower rooms in a clean and sanitary condition, impacting all residents who used them. Observations revealed that all four shower rooms contained black-spotted substances along the grout lines and tiles, particularly at the bottom of the walls beneath the shower heads and in the corners. Additionally, the shower chair in the 100's shower room had deteriorating fabric with black-spotted substances and hair. These conditions were observed multiple times throughout the day, indicating that the shower rooms had not been cleaned as required. An interview with Housekeeper #114 confirmed that the shower areas should be cleaned weekly and as needed, but the housekeeper was unsure if they had been cleaned that week. The facility was unable to provide documentation to confirm that the cleaning had been completed weekly, as per their policy. This deficiency was investigated under Complaint Number OH00158584.
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.
Trusted data from CMS and state health departments
Every citation, penalty and Plan of Correction is sourced from public CMS records (latest release May 27, 2026) and official state health department websites — never guesswork.
Trusted by long-term care providers and associations.
