Eastbrook Healthcare Center
Inspection history, citations, penalties and survey trends for this long-term care facility in Cleveland, Ohio.
- Location
- 17322 Euclid Ave, Cleveland, Ohio 44112
- CMS Provider Number
- 365129
- Inspections on file
- 40
- Latest survey
- January 15, 2026
- Citations (last 12 mo.)
- 18
Citation history
Health deficiencies cited at Eastbrook Healthcare Center during CMS and state inspections, most recent first.
The facility failed to maintain safe and sanitary conditions in multiple resident rooms and shared bathrooms, including a shared toilet that remained plugged and unusable for days with visible urine and feces, while residents were told to use a communal bathroom that lacked toilet paper. Surveyors observed sticky floors, heavy dust on vents and fans, stained privacy curtains and fall mats, and walls with stains and splatters that appeared to be blood or feces. Several rooms contained scattered food, trash, dirty urinals, gloves, and incontinence briefs, and a resident reported repeatedly asking staff to clean and help arrange items within reach. Common shower rooms and bathrooms had dirty floors, tissue and toilet paper on the ground, dried urine and feces-like stains on toilets, used razors and hair in sinks, dirty faucet seals, dust-laden vents, and apparent mold and build-up in shower areas, along with cracked and raised flooring at one room entry. These conditions were confirmed by the DON, Administrator, housekeeping staff, CNA, and an LPN.
Two residents experienced failures in accurate clinical documentation. A resident with morbid obesity, diabetes, CKD, and COPD had a weekly Mounjaro order for diabetes and weight management, but the MAR showed missed or blank entries on multiple occasions with no nursing notes indicating that the PCP was notified, despite a physician note to continue the medication and the resident reporting he sometimes did not receive it. Another resident with paraplegia and an indwelling catheter had care plan and Kardex directions for catheter care, but there were no physician orders specifying catheter care, no TAR or task documentation that catheter care was completed over an extended period, and the resident was dependent on staff for toileting hygiene, while the DON stated she believed care was done but not documented.
The facility failed to maintain therapy equipment, affecting a resident and potentially impacting all 91 residents. A resident with moderate cognitive impairment reported inadequate therapy equipment, leading to unsafe practices like using a sink for support. Observations confirmed that essential equipment was not maintained, and balance bars were inaccessible and unsafe. Therapy staff indicated the need for the equipment, but the facility had not serviced it since July 2024, despite being responsible for its maintenance.
A resident with multiple health issues fell during peri care due to being assisted by only one staff member instead of the required two. The care plan and Kardex indicated the need for two-person assistance, which was not followed, leading to the fall. The incident was confirmed by various staff members, and the facility's fall prevention policy was not adhered to.
The facility exceeded the acceptable medication error rate, with two errors identified during observations. One resident received the wrong form of Aspirin, while another received an incorrect dosage of Senna. Both errors were confirmed by the LPNs involved, indicating a failure to adhere to the facility's medication administration policy.
The facility failed to serve food at palatable temperatures, affecting several residents. Observations showed that meals were delivered without warming containers, resulting in food being served below the facility's temperature standards. Residents expressed dissatisfaction with the cold meals, highlighting a failure to comply with safe food handling practices.
The facility failed to ensure food items were appropriately labeled, dated, and contained, affecting 85 residents. Observations revealed unlabeled desserts, uncovered bacon and chicken, and improperly stored lettuce and cheese. A sanitizer pail was also found in the dry storage room. Cook #116 confirmed these findings, which were against the facility's food storage policy. Three residents were NPO at the time.
The facility failed to provide monthly spend-down letters for two residents approaching or over the resource limit, contrary to facility policy. The Business Office Manager only provided quarterly notifications, affecting residents with significant medical conditions.
The facility failed to accurately code comprehensive assessments for two residents, leading to deficiencies in their medical records. One resident's opioid use and discharge status were incorrectly documented, while another resident's fall was not recorded in the annual MDS assessment.
The facility failed to maintain a medication error rate below five percent, resulting in a 19.35% error rate. Errors included incorrect administration of nystatin and insulin for a resident, failure to flush a PEG tube before and after medication administration for another resident, and omission of several medications for a third resident.
Failure to Maintain Safe and Sanitary Resident Rooms and Bathrooms
Penalty
Summary
The deficiency involves the facility’s failure to maintain resident rooms and shared bathrooms in a safe and sanitary condition for multiple residents. One shared bathroom serving two rooms had a toilet that had been plugged and unusable for two days, with old urine and feces visible in the bowl. Residents using that bathroom reported being given urinals but having no place to empty them due to the broken toilet, and one resident reported that the communal bathroom they were told to use lacked toilet paper. The DON stated she was unaware of the problem and confirmed that no work order had been placed as previously reported to the resident. Additional observations showed multiple resident rooms with unclean and cluttered conditions. Several rooms had sticky floors, visible dust build-up on vents, fans, and mini refrigerators, and stained privacy curtains and fall mats. In some rooms, there were food crumbs, candy, banana pieces, foam cups, plastic food containers, dirty urinals, gloves, incontinence briefs, and other trash scattered on or under beds and on the floor. Walls near sinks, bathrooms, and beds had numerous stains and splatters that appeared to be blood or feces. Some residents reported having asked staff multiple times to clean their rooms and help arrange items so they could reach them. Common shower rooms and bathrooms on both floors were also found in unsanitary condition. Surveyors observed dirty floors with tissue paper, footprints, toilet paper rolls on the floor, dried urine splatter on toilet seats, stains that appeared to be feces on toilets, brown debris and stains around toilets, used disposable razors and hair clippings left in sinks, dirty faucet seals, and visible dust on floor and ceiling vents. One shower area had what appeared to be mold in the corner, orange build-up along tile grout, and soap build-up on the dispenser. In addition, damaged flooring was observed at the entryway of one room, where cracked and raised vinyl with a hole was present. These findings were confirmed at the time of observation by the DON, Administrator, Housekeeping Director, housekeepers, CNA, and LPN. The facility’s own policy required a safe, clean, comfortable, and orderly environment.
Failure to Accurately Document Medication Administration and Catheter Care
Penalty
Summary
The deficiency involves failures to maintain accurate and complete medical records and documentation for two residents. For a resident with morbid obesity, diabetes with neuropathy, chronic kidney disease, and COPD, the care plan identified risks related to hypoglycemia/hyperglycemia and nutritional problems, with interventions including glucose monitoring, insulin administration, medication monitoring, and weight and diet management. The resident had a standing order for weekly Mounjaro injections for diabetes and obesity management. Review of the MAR showed that on one date the dose was marked as not given because it was being reordered, and on two later dates the MAR was left blank, with no indication the medication was administered. Further review of nursing notes for the same periods revealed no documentation that the PCP was notified when the resident did not receive the ordered Mounjaro doses. The quarterly MDS showed the resident was cognitively intact, and a physician progress note confirmed ongoing diagnoses of morbid obesity, diabetes, and COPD, and recommended continuation of Mounjaro. In interviews, the resident reported he was supposed to receive Mounjaro weekly, mainly for weight loss, and stated that at times he did not receive the medication, though he could not recall specific dates. The DON confirmed the MAR entries showing the missed or undocumented doses and acknowledged there was no nursing documentation of physician notification, stating she believed the medication may have been given but not documented. For a second resident with paraplegia, hypertension, and neuromuscular bladder dysfunction, the care plan and Kardex indicated the need for catheter care per policy, keeping the catheter bag below bladder level and covered, and providing catheter care per policy and after each bowel incontinence episode, though no frequency was specified. The quarterly MDS documented that this resident had intact cognition, an indwelling catheter, and was dependent on staff for toileting hygiene. Review of the TAR for two consecutive months and the task bar over a one‑month period showed no documentation that catheter care was completed, and the physician orders listed only an indwelling catheter to continuous drainage with no catheter care order. In interview, the resident was unsure how often catheter care was provided, and the DON verified there was no physician order specifying catheter care and no documentation of its completion, stating she believed it was done every shift but not documented. The facility’s catheter care policy described the purpose of preventing catheter-associated UTIs but did not address documentation or frequency of catheter care.
Failure to Maintain Therapy Equipment
Penalty
Summary
The facility failed to maintain therapy equipment in proper working order, affecting one resident and potentially impacting all 91 residents. Resident #51, who has moderate cognitive impairment and requires assistance for mobility, reported that the therapy gym lacked necessary equipment, forcing him to use a sink for support while standing. Observations confirmed that essential therapy equipment, such as an ultrasound and TENS unit, were not maintained and thus unusable. Additionally, balance bars were inaccessible due to being surrounded by other equipment and were not secured, making them unsafe for use. Interviews with therapy staff, including a Certified Occupational Therapy Assistant and the Rehabilitation Director, revealed that the facility had not serviced the equipment since at least July 2024, despite being responsible for its maintenance according to the contract with therapy services. The Administrator acknowledged the overdue maintenance but argued that the equipment was not needed since there were no current orders for its use. However, therapy staff indicated they would utilize the equipment if it were operational. The facility's contract explicitly states that it is responsible for maintaining therapy equipment, yet this obligation was not fulfilled, leading to the deficiency.
Failure to Ensure Safe Transfer Leads to Resident Fall
Penalty
Summary
The facility failed to ensure the safe transfer of a resident, resulting in a fall. Resident #73, who had a history of systolic congestive heart failure, acute respiratory failure, acute kidney failure, and required assistance with personal care, was involved in the incident. The resident's care plan specified the need for two-person assistance for toileting and transfers. However, during peri care, the resident was assisted by only one staff member, STNA #305, who was new and did not check the Kardex for the required assistance level. This oversight led to the resident falling out of bed. The incident was reported by STNA #305 to LPN #223, who assessed the resident and, along with STNA #305, manually lifted the resident back to bed without using a mechanical lift. Interviews with various staff members, including the Nurse Practitioner, LPNs, and the Director of Nursing, confirmed that the resident required two-person assistance as per the care plan and Kardex. The facility's policy on managing falls and fall risks, revised in March 2018, emphasized implementing a resident-centered fall prevention plan, which was not adhered to in this case. The deficiency was investigated under Complaint Number OH00156029.
Medication Administration Errors Exceed Acceptable Rate
Penalty
Summary
The facility failed to maintain a medication error rate of less than 5%, resulting in a 6.9% error rate during the observation period. Two errors were identified out of 29 medication administration opportunities. The first error involved Resident #36, who was diagnosed with hemiplegia and hemiparesis following a cerebral infarction. The resident was prescribed Aspirin 81 mg chewable to be taken orally in the morning. However, during the medication administration, the LPN administered Aspirin 81 mg enteric coated instead of the chewable form. The LPN confirmed the error during an interview, acknowledging that she did not verify the specific type of Aspirin before administration. The second error involved Resident #73, who had diagnoses including systolic congestive heart failure, acute respiratory failure, and acute kidney failure. The resident was prescribed Senna 8.6 mg, 50 mg PO, one tablet, twice a day for constipation. During the medication administration, the LPN administered only Senna 8.6 mg, one tablet PO, failing to provide the correct dosage. The LPN confirmed the error during an interview, admitting that the medication given did not match the physician's order. The facility's policy on medication administration, which requires verification of the right resident, medication, dosage, time, and method, was not adhered to in these instances.
Failure to Ensure Palatable Food Temperature
Penalty
Summary
The facility failed to ensure that food served to residents was palatable, affecting four out of five residents observed for food palatability. Observations revealed that pre-prepared plates were sent from the kitchen to the second-floor dining room without warming containers, covered only in plastic wrap, and left on an open-air cart. This resulted in food being served at temperatures below the facility's policy standards for palatability, with hot dogs and French fries served at temperatures as low as 91 degrees Fahrenheit. Interviews with residents confirmed dissatisfaction with the temperature of their meals. One resident reported that their hot dog was not warm, another resident's food was cold upon returning from dialysis, and a third resident expressed a desire for warmer food. The facility's policy states that hot food should be served at temperatures between 100 and 120 degrees Fahrenheit or greater, indicating a failure to comply with safe food handling practices. This deficiency was investigated under Master Complaint Number OH00155188.
Failure to Properly Label, Date, and Contain Food Items
Penalty
Summary
The facility failed to ensure food items were appropriately labeled, dated, and contained, which had the potential to affect 85 residents receiving meals from the kitchen. During an observation of the kitchen, it was found that four desserts in styrofoam bowls lacked labels or dates, a case of bacon slices and a pan of fried chicken were uncovered in the walk-in cooler, and a bag of lettuce, a pack of sliced cheese, and a bag of shredded cheese were not labeled or dated. Additionally, a sanitizer pail was found in the dry storage room, and a bin of sugar was open to air. Cook #116 confirmed these findings and acknowledged that food items should be covered, labeled, and dated before being placed in the coolers. The facility's undated policy on food storage also required that all products be dated upon receipt, when opened, and when prepared. Three residents were noted to be NPO at the time of the observation.
Failure to Provide Monthly Spend-Down Letters
Penalty
Summary
The facility failed to provide spend-down letters for each month residents were approaching or over the resource limit, affecting two residents. Resident #11, diagnosed with paranoid schizophrenia, violent behavior, unspecified psychosis, impulse disorder, anxiety, and hypertension, had an ending balance of $1832.49 on 01/31/24, $1872.59 on 02/29/24, and $1912.69 on 03/31/24. The Business Office Manager (BOM) informed Resident #11's guardian on 03/27/24 that the resident was in jeopardy of losing Medicaid due to an abundance of funds. However, no spend-down letters were available for January and February 2024. Similarly, Resident #16, diagnosed with bipolar disorder, anxiety disorder, hypertension, dementia without behavioral disturbance, and chronic hepatitis C, had an ending balance of $1808.61 on 01/31/24, $1838.70 on 02/29/24, and $1868.79 on 03/31/24. A spend-down letter was provided on 03/29/24, but none were available for January and February 2024. The BOM confirmed that spend-down letters were only provided quarterly when residents had a balance of $1800.00 or more, contrary to the facility policy that required notification when the balance reached $200.00 less than the SSI resource limit.
Inaccurate Coding of Comprehensive Assessments
Penalty
Summary
The facility failed to accurately code comprehensive assessments for two residents, leading to deficiencies in their medical records. Resident #88, who had multiple diagnoses including surgical aftercare, diabetes, stroke, and end-stage renal disease, was admitted with an order for oxycodone for pain management. Despite receiving oxycodone for severe pain during a dressing change, the admission MDS assessment incorrectly indicated that the resident did not receive any opioids. Additionally, the discharge assessment for Resident #88 was inaccurately coded as a transfer to the hospital, whereas the resident was discharged against medical advice and arranged for a ride home. Resident #54, diagnosed with vascular dementia, adult failure to thrive, hyperlipidemia, chronic kidney disease, and hypertension, had an annual MDS assessment that failed to document a fall that occurred on 09/19/23. The assessment incorrectly indicated that no falls had occurred since the prior assessment. The MDS RN confirmed the error, acknowledging that the resident did have a fall, which was not reflected in the assessment. These inaccuracies in coding comprehensive assessments highlight deficiencies in the facility's record-keeping and assessment processes.
Medication Administration Errors
Penalty
Summary
The facility failed to ensure a medication error rate of less than five percent, resulting in a 19.35% error rate during the observation period. This affected three residents. For Resident #241, the LPN administered nystatin incorrectly by instructing the resident to spit instead of swallow, and administered insulin without priming the needle as required. The LPN confirmed these practices were her typical methods, which were not in accordance with the physician's orders or the facility's medication administration policy. For Resident #41, the LPN administered acetaminophen through a PEG tube without flushing the tube before or after the medication administration, resulting in a significant amount of medication being left in the cup and not administered to the resident. The LPN confirmed the omission of the flush and the leftover medication in the cup. This was not in accordance with the facility's policy for administering medications through an enteral tube. For Resident #58, the LPN failed to administer several medications, including a Breo Ellipta inhaler, Flonase nasal spray, and magnesium, and did not sign off on these medications in the Medication Administration Record. The LPN admitted to the omissions and the unavailability of magnesium. These actions were not in accordance with the physician's orders and the facility's medication administration policy.
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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