Delhi Post-acute
Inspection history, citations, penalties and survey trends for this long-term care facility in Cincinnati, Ohio.
- Location
- 5999 Bender Road, Cincinnati, Ohio 45233
- CMS Provider Number
- 365530
- Inspections on file
- 34
- Latest survey
- February 19, 2026
- Citations (last 12 mo.)
- 5
Citation history
Health deficiencies cited at Delhi Post-acute during CMS and state inspections, most recent first.
A cognitively intact resident with COPD, vascular dementia, and major depressive disorder reported that an LPN sent explicit photos of her exposed breasts, allowed the resident to have sexual contact with her breasts, and touched the resident’s genitals. The resident stated that the LPN recorded a video of this sexual contact using the resident’s personal phone, and facility leadership and surveyors later viewed video evidence clearly showing the LPN’s face and exposed breasts during the encounter. Law enforcement was notified and reported that the LPN confessed to sexual contact with the resident, despite a facility policy stating residents must be free from abuse, including sexual abuse.
The facility failed to report an allegation of staff-to-resident sexual abuse to the state agency within required federal timeframes. A resident with COPD, vascular dementia with behavioral disturbance, and major depressive disorder, who had intact cognition and required staff assistance for bathing, was the subject of the allegation. The facility became aware of the alleged abuse but did not submit the Self-Reported Investigation to the state agency until more than 24 hours after discovery, despite a written abuse policy requiring allegations to be reported within federally mandated timeframes.
A resident with COPD, anxiety disorder, and osteoporosis, who had intact cognition but was dependent on staff for all ADLs, used a power wheelchair with a seatbelt for mobility. However, the resident’s care plan did not address the use of the power wheelchair or seatbelt, and the medical record contained no assessment of the appropriateness of the seatbelt. The DON and DOR confirmed both the resident’s use of the device and the absence of any related assessment or care plan, resulting in a deficiency in comprehensive care planning for device use.
Surveyors observed two ceiling vents with brown, fuzzy buildup in the kitchen, including one directly above the meal prep area. The Dietary Director confirmed the vents were dirty and could blow debris onto food, creating a risk of contamination for all residents.
Two residents with complex medical conditions had incomplete and inaccurate documentation of PRN pain medication administration, with multiple instances where medications were signed out but not properly recorded on the MAR, contrary to facility policy.
A facility failed to obtain and implement hospital recommendations for BiPAP use for a resident with COPD and heart failure, resulting in the resident using the device without physician orders. The resident had a BiPAP machine in her room, which was initially unused due to staff unfamiliarity. The DON confirmed the resident used the machine without orders, and an LPN was observed adjusting the device without knowing the correct settings. Facility policy required checking medical records and physician orders before using such devices, which was not adhered to.
A resident with chronic pain conditions did not receive nine doses of Lyrica as ordered due to the medication being unavailable in the facility and emergency supply. The facility's policy required timely administration of medications, which was not adhered to, leading to a deficiency finding.
The facility's Dietary Director, in position since January 2024, lacked the required food service manager certification, potentially affecting 94 of 95 residents receiving meals. Despite working towards certification, the DD had not scheduled the exam, as confirmed by interviews with the DD, Administrator, and RD. The job description required completion of an approved dietary manager's course.
The facility did not follow the approved menu, affecting 94 residents. The planned lunch included Polish sausage, sauerkraut, mashed potatoes, green beans, and cake, but the served trays lacked green beans and cake. Instead, an orange was provided, which was not an appropriate substitute. The Dietary Director cited staffing issues, and the RD confirmed the menu should be followed.
The facility failed to maintain cleanliness in the kitchen, affecting 94 residents. Observations showed a dirty ice machine, a dusty fan blowing towards clean dishes, and a dusty dish rack. Interviews confirmed the lack of cleaning logs and inadequate cleaning schedules. Facility documents lacked guidelines for cleaning, and the existing schedule did not meet manufacturer's recommendations.
A resident with an anxiety disorder missed four doses of Ativan due to the facility's failure to reorder the medication in a timely manner. Despite having a physician's order for Ativan every six hours, the medication supply was exhausted, and the resident confirmed the lack of medication. Interviews with nursing staff revealed that the normal process for reordering was not followed, and the facility's policy on ensuring a sufficient supply of medications was not adhered to.
A resident with an anxiety disorder missed four doses of Ativan due to the facility's failure to reorder the medication in a timely manner. Despite the facility's policy to reorder medications at least two days before the last dose, the staff did not follow this procedure, leading to a significant medication error. Interviews confirmed the oversight and the resulting missed doses.
A resident with an anxiety disorder did not receive prescribed doses of Ativan due to an exhausted supply, yet the medication was inaccurately documented as administered by an RN. The error was confirmed by the RN and acknowledged by the DON, highlighting a documentation deficiency in the facility.
Failure to Protect Resident From Sexual Abuse by LPN
Penalty
Summary
The facility failed to protect a resident from sexual abuse by a staff member. A cognitively intact resident with COPD, vascular dementia, and major depressive disorder, who required setup or cleanup assistance for mobility and transfers, reported that an LPN sent him pictures of her exposed breasts and allowed him to have sexual contact with her breasts. The resident stated that the LPN also touched his genitals on at least one occasion, though he could not recall the date. The resident reported that the LPN videotaped him sucking on her breasts using his personal cell phone, and he later showed a portion of this video to surveyors, which clearly depicted the LPN’s face and exposed breasts. The DON and Administrator viewed a video on the resident’s phone showing approximately 45 seconds of sexual contact between the resident and the LPN, with both clearly visible. The facility’s self-reported incident documentation and subsequent investigation concluded that the allegation of sexual abuse by the LPN toward the resident was substantiated. Law enforcement became involved, and detectives confirmed that the LPN confessed to having sexual contact with the resident and that they were pursuing a sexual battery charge. These events occurred despite a facility policy stating that residents have the right to be free from abuse, including sexual abuse.
Failure to Timely Report Alleged Staff-to-Resident Sexual Abuse
Penalty
Summary
The facility failed to timely report an allegation of staff-to-resident sexual abuse to the Ohio Department of Health (ODH) within required federal timeframes. A resident admitted with COPD, vascular dementia with behavioral disturbance, and major depressive disorder, who had intact cognition per a recent MDS and was dependent on staff for bathing, was the subject of the allegation. The facility’s Self-Reported Investigation (SRI) for this resident showed the allegation was discovered on 02/01/26, but the SRI was not created until 02/02/26 at 12:06 p.m. The DON confirmed that the facility received notification of the alleged staff-to-resident sexual abuse on 02/01/26 at 11:00 a.m. and did not report the incident to the state agency until more than 24 hours later, despite a facility policy requiring allegations to be reported within federal timeframes. This deficiency was identified through medical record review, review of the facility’s SRI, staff interview with the DON, and review of the facility’s Abuse, Neglect, Exploitation, and Misappropriation Prevention Program policy dated April 2021, which states that any allegations must be reported within timeframes required by federal requirements.
Failure to Care Plan and Assess Seatbelt Use with Power Wheelchair
Penalty
Summary
The facility failed to develop a comprehensive care plan addressing the use of a power wheelchair with a seatbelt for one resident. The resident was admitted with diagnoses including chronic obstructive pulmonary disease, anxiety disorder, and osteoporosis, and had intact cognition but was dependent on staff for all ADLs. Review of the resident’s care plan dated 12/12/25 showed no inclusion of the power wheelchair or seatbelt use, and the medical record lacked any assessment of the appropriateness of the seatbelt in the power wheelchair. During interviews, the DON and DOR confirmed that the resident used a power wheelchair with a seatbelt for mobility, that no assessment regarding seatbelt use had been conducted, and that the resident’s plan of care should have reflected the use of the seatbelt. These findings demonstrate that the facility did not develop and implement a complete, measurable care plan that addressed all of the resident’s needs related to the use of the power wheelchair and seatbelt, nor did it perform an assessment to determine the appropriateness of the device, resulting in a deficiency in comprehensive care planning for device use.
Unclean Kitchen Vents Observed Over Food Prep Area
Penalty
Summary
During an initial tour of the facility kitchen, surveyors observed two ceiling vents with a brown, fuzzy buildup, with one vent located directly above the meal preparation area. The Dietary Director confirmed that the vents were dirty and acknowledged the potential for debris to be blown onto the food preparation area, which could contaminate food. This deficiency was identified during the course of a complaint investigation and had the potential to affect all residents in the facility, which had a census of 102 at the time of the survey.
Incomplete Medication Administration Documentation
Penalty
Summary
The facility failed to maintain complete and accurate clinical records for two residents, specifically regarding the documentation of medication administration. For one resident with diagnoses including COPD, CKD, schizophrenia, and diabetes, there were multiple instances where oxycodone-acetaminophen was signed out for administration, but the corresponding medication administration record (MAR) either lacked documentation of administration or had discrepancies in timing. On several occasions, the medication was signed out at specific times, but there was no documentation to confirm that the medication was actually administered. Similarly, for another resident with diagnoses including above-the-knee amputation, COPD, and peripheral vascular disease, the MAR and sign-out sheets for oxycodone showed that the medication was signed out at various times, but documentation of administration was either missing or did not correspond with the sign-out times. Interviews with the DON and Administrator confirmed that the facility was unaware of these documentation lapses until the issue was identified during the survey. Facility policy requires that the date and time of medication administration be recorded in the resident's medical record, which was not consistently followed in these cases.
Failure to Implement and Document BiPAP Use
Penalty
Summary
The facility failed to timely obtain and implement hospital recommendations for the use of positive airway pressure devices for a resident, and there were no physician orders for these devices. Resident #72, who had chronic obstructive pulmonary disease (COPD) and diastolic heart failure, was admitted to the facility and later discharged to the hospital due to shortness of breath and other complications. Upon returning to the facility, the hospital discharge summary recommended the use of BiPAP while sleeping, but there were no specifications for the settings, and no follow-up was conducted to clarify these settings. The medical record for Resident #72 showed no progress notes regarding follow-up with the hospital for BiPAP settings, and there were no physician orders for its use. The resident had a BiPAP machine in her room, which was unused for several nights because the staff did not know how to apply it. An unidentified nurse eventually set up the device, and the resident used it herself at bedtime without any physician orders. The Director of Nursing (DON) confirmed that the resident used the machine without orders and was unsure how it was delivered without an order. During an observation, a Licensed Practical Nurse (LPN) was seen adjusting the BiPAP mask for the resident, who was using the machine without a physician order. The LPN was unaware of the correct settings and had to check the order, which did not exist. The facility's policy required nurses to check the medical record for baseline oxygen saturation levels and review the physician's order for settings before using positive air pressure devices, which was not followed in this case.
Medication Administration Deficiency
Penalty
Summary
The facility failed to provide medications as ordered for a resident, identified as Resident #72, who was admitted with diagnoses including chronic obstructive pulmonary disease, anxiety disorder, and major depressive disorder. The resident's care plan indicated a risk for pain due to shingles neuropathy, chronic back pain, and toe fractures, with interventions to administer medications as ordered. However, the Medication Administration Record for August 2024 showed that the resident did not receive nine doses of Lyrica 75 mg on specific dates because the medication was unavailable. The deficiency was confirmed during an interview with a registered nurse who verified the unavailability of the medication in both the facility and the emergency supply. The facility's policy on administering medications, dated April 2019, required medications to be administered in a safe and timely manner, within one hour of their prescribed time. This deficiency was investigated under Complaint Number OH00158245.
Dietary Director Lacks Required Certification
Penalty
Summary
The facility failed to ensure that the designated Director of Food and Nutrition Services met the necessary qualifications for a dietary supervisor position. The Dietary Director (DD), who had been in the role since January 2024, was in the process of completing her certified dietary manager course but had not yet obtained the required food service manager certification. Interviews with the DD, the facility's Administrator, and the Registered Dietitian (RD) confirmed that the DD was working towards certification but had not scheduled the exam. The Administrator acknowledged that the DD did not meet the qualifications for her position, as outlined in the job description, which required completion of an approved dietary manager's course. This deficiency had the potential to affect 94 of the 95 residents receiving meals from the kitchen.
Failure to Follow Approved Menu
Penalty
Summary
The facility failed to adhere to the planned menu as approved by the dietitian, which had the potential to affect 94 of 95 residents receiving meals from the kitchen. On the specified date, the planned lunch menu included Polish sausage on a bun, sauerkraut, garlic mashed potatoes, green beans, and Jello rainbow cake. However, observations revealed that the lunch trays served included Polish sausage on a bun, mashed potatoes, and sauerkraut, but lacked green beans and cake. Instead, an orange was provided for residents with a regular diet order, canned fruit for those with a mechanical soft diet order, and apple slices for residents with a renal diet order. Interviews with the Dietary Director and Registered Dietitian confirmed that the menu was not followed as planned. The Dietary Director acknowledged the absence of green beans and cake, citing a lack of staff to bake the cake. The Registered Dietitian, who had not reviewed the menus since they were approved by a previous dietitian, stated that the facility should follow the menus and that an orange was not an appropriate substitute for cake. The Director of Nursing and the Administrator also confirmed that the kitchen staff should adhere to the menus and obtain approval from the dietitian for any changes. The facility's policy, revised in October 2008, mandates that menus meet residents' nutritional needs, be prepared in advance, and be followed, with all menus reviewed and approved by the dietitian.
Deficiencies in Kitchen Sanitation and Equipment Cleaning
Penalty
Summary
The facility was found to have deficiencies in maintaining cleanliness and sanitation in the kitchen, which had the potential to affect 94 of 95 residents receiving meals. Observations revealed a black and pink substance on the interior ice shield of the ice machine, which remained uncleaned over two days. Additionally, a fan in the dish room had dust and dirt buildup, with dust visibly blowing towards clean dishes. A metal dish rack used for storing clean water pitchers also had dust buildup. Interviews with facility staff, including the Administrator, Maintenance Director (MD), Registered Dietitian (RD), and Director of Nursing (DON), confirmed the lack of cleanliness and the absence of a cleaning log for the fans. The ice machine was scheduled for cleaning every six months, but the MD suggested a quarterly schedule might be necessary. The RD noted general cleaning needs and emphasized the importance of keeping equipment clean to prevent contamination. Facility documents lacked guidelines for cleaning the ice machine, fan, and dish racks, and the existing cleaning schedule did not align with the manufacturer's recommendations for more frequent cleanings.
Medication Reordering Failure Leads to Missed Doses
Penalty
Summary
The facility failed to ensure that medications were ordered and available for administration as prescribed by the physician for a resident diagnosed with an anxiety disorder. The resident had a physician's order for Ativan, an antianxiety medication, to be administered every six hours. However, the facility ran out of the medication, resulting in the resident missing four doses over two days. The medication error report confirmed that the Ativan supply was exhausted, and the resident confirmed the lack of medication. Interviews with nursing staff revealed that the normal process for reordering medications was not followed. The staff did not reorder the Ativan in a timely manner, despite the facility's policy requiring medications to be reordered at least two days before the last available dose. The Regional Nurse Consultant and the Director of Nursing confirmed that the staff should have reordered the medication earlier, and the failure to do so led to the missed doses. The facility's policy emphasized the importance of ensuring a sufficient supply of medications and timely administration, which was not adhered to in this case.
Failure to Administer Ativan Due to Reordering Lapse
Penalty
Summary
The facility failed to ensure that Resident #40 was free from significant medication errors, specifically regarding the administration of Ativan, an antianxiety medication. Resident #40, who was cognitively intact and diagnosed with an anxiety disorder, had a physician's order for Ativan to be administered every six hours. However, the facility ran out of the medication, resulting in the resident missing four doses between May 19 and May 20, 2024. The medication error was confirmed through interviews with the resident and nursing staff, who acknowledged the lack of medication and the failure to reorder it in a timely manner. The facility's policy required that medications be reordered at least two days before the last available dose, or when there were ten doses left. Despite this, the staff did not reorder the Ativan in time, leading to the medication error. Interviews with the nursing staff and the Director of Nursing confirmed that the facility did not follow its policy, resulting in the resident missing the prescribed doses. The Director of Nursing acknowledged the significant medication error and the failure to administer the medication as ordered.
Medication Administration Documentation Error
Penalty
Summary
The facility failed to ensure accurate documentation of medication administration for a resident diagnosed with an anxiety disorder. The resident was prescribed Ativan, an antianxiety medication, to be administered every six hours. However, the Medication Administration Record (MAR) indicated that the medication was documented as administered by a registered nurse, despite the medication supply being exhausted, resulting in missed doses. The registered nurse confirmed that the medication was not administered due to the inability to access the emergency box, and the documentation was made in error. The Director of Nursing acknowledged that medication should not be documented as administered unless it has actually been given. This deficiency affected one resident out of a sample of 19, within a facility census of 95 residents.
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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