Eastland Rehabilitation And Nursing Center
Inspection history, citations, penalties and survey trends for this long-term care facility in Columbus, Ohio.
- Location
- 2425 Kimberly Parkway East, Columbus, Ohio 43232
- CMS Provider Number
- 365572
- Inspections on file
- 33
- Latest survey
- October 14, 2025
- Citations (last 12 mo.)
- 1
Citation history
Health deficiencies cited at Eastland Rehabilitation And Nursing Center during CMS and state inspections, most recent first.
A resident with multiple chronic conditions and severe cognitive impairment experienced increased pain and swelling in the left knee, which was reported by two CNAs to a nurse. The RN assessed the knee but did not notify the physician, believing the symptoms were due to existing cellulitis. The physician and CNP were not informed until several days later, when an x-ray revealed a fracture and the resident was sent to the ER. This resulted in a failure to promptly report a significant change in condition.
Two residents experienced worsening or development of pressure ulcers due to the facility's failure to provide comprehensive assessment, monitoring, and individualized interventions. One resident's sacral ulcer progressed to Stage IV with infection and osteomyelitis due to missed treatments, inaccurate orders, and lack of preventive care, while another resident developed a Stage III ankle ulcer with missed assessments and preventive measures. Staff lacked wound care training, and documentation and communication lapses contributed to the deficiencies.
Surveyors found that insulin pens and vials on two medication carts were opened, undated, and lacked resident identifiers, as confirmed by an LPN and an RN. This failure to properly label and date insulin was not in accordance with facility policy and had the potential to affect multiple residents receiving insulin.
Surveyors found that food items were stored directly on the floor in the kitchen's dry storage area, contrary to facility policy, and observed unsanitary conditions such as dusty light fixtures, ceiling cracks, and peeling paint over food preparation and serving areas. These deficiencies had the potential to affect nearly all residents who consumed food from the kitchen.
A resident with chronic pressure ulcer wounds did not have enhanced barrier precautions implemented as required, despite the care plan indicating the need for such measures. There was no physician order for enhanced barrier precautions, and the facility could not provide a relevant policy. This issue was identified through record review and staff interviews.
Two residents who required meal assistance, both with significant cognitive and physical impairments, were observed being fed by CNAs who stood over them rather than sitting, contrary to dignified dining procedures. Staff interviews confirmed awareness of proper protocol but revealed a preference for standing, affecting the quality of care for these and potentially other residents needing dining assistance.
A resident with dysphagia and a recommendation for one-on-one meal supervision was left unsupervised in the dining room while eating, despite being on a mechanically altered diet and requiring assistance. This lack of supervision was confirmed by a CNA and had the potential to affect multiple residents with swallowing difficulties.
A resident receiving in-center dialysis did not have required pre- and post-dialysis assessments performed or documented, and communication with the dialysis center was inconsistent. Multiple communication sheets were missing or incomplete, and staff interviews confirmed that the established process for monitoring and documenting dialysis care was not consistently followed, contrary to facility policy.
A resident with chronic pain received PRN Oxycodone/Acetaminophen without clear numeric definitions for 'moderate' or 'severe' pain in the physician orders. Nursing staff and the DON confirmed that the orders lacked specific parameters, resulting in the medication being administered based on subjective judgment rather than defined criteria, contrary to facility policy.
A resident with multiple health conditions required specific wound care, but an LPN failed to follow proper infection control practices during a dressing change. The LPN did not wash hands between glove changes, violating the facility's hand hygiene policy, which led to a deficiency finding.
A resident alleged that a staff member pushed him, causing a fall and back pain. The facility failed to report this allegation to the state agency immediately, as required by policy. The DON was informed by hospital staff but did not notify the Administrator due to a lack of documentation. The Administrator only became aware of the incident through a surveyor, leading to noncompliance with state regulations.
A resident with intact cognition alleged being pushed by a staff member, leading to a fall. The facility delayed initiating an investigation and suspending the accused staff member, contrary to its policy. The Director of Nursing was aware of the allegation but did not report it to the Administrator due to lack of documentation. The facility could not substantiate the abuse claim.
The facility failed to conduct a comprehensive continence assessment for a resident with multiple diagnoses, leading to inconsistent documentation and lack of appropriate interventions. Interviews revealed conflicting information about the resident's continence status, and the facility's policy for thorough assessment was not followed.
A resident with multiple medical conditions did not receive timely lab tests and physician notifications, leading to delayed treatment. Additionally, there was an error in medication administration where both old and new dosages of thyroid supplement were given due to a failure to discontinue the previous dosage.
A resident with multiple diagnoses, including malnutrition and C-difficile colitis, did not receive timely nutritional supplements and was not weighed weekly as ordered, resulting in a significant weight loss. Staff interviews and observations confirmed the facility's failure to follow policies for weight assessment and nutritional support.
Failure to Timely Notify Physician of Change in Resident Condition
Penalty
Summary
A deficiency occurred when the facility failed to promptly notify a resident's physician of a significant change in condition. The resident, who had multiple medical diagnoses including dementia, major depressive disorder, COPD, diabetes, osteoporosis, heart failure, and hypertension, was admitted with severely impaired cognition and required assistance with activities of daily living. On two consecutive days, the resident complained to two CNAs about increased pain and swelling in her left knee, which prevented participation in daily activities. Both CNAs observed the swelling and reported it to the nurse on duty. The RN assessed the knee and administered routine pain medication but did not notify the physician, attributing the symptoms to cellulitis for which the resident was already being treated. Subsequent review and interviews revealed that the cellulitis was unrelated to the resident's knee, as it was associated with a wound on the lower leg. The physician and CNP were not informed of the increased pain and swelling until several days later, at which point an x-ray revealed distal fracture fragments and the resident was sent to the emergency room for further evaluation. The failure to timely report the change in condition to the physician was confirmed through closed medical record review and staff interviews, affecting one resident out of three reviewed for change in condition.
Failure to Implement Comprehensive Pressure Ulcer Prevention and Care
Penalty
Summary
The facility failed to develop and implement a comprehensive and individualized pressure ulcer program, resulting in the development and worsening of pressure ulcers for two residents. One resident, who was cognitively impaired, dependent on staff for activities of daily living, and at high risk for skin breakdown, was admitted with a Stage III pressure ulcer to the sacrum and a Stage IV ulcer to the left knee. There was a lack of proper assessment, monitoring, and intervention to prevent further decline. The resident's sacral ulcer deteriorated to a Stage IV with infection and osteomyelitis, with contributing factors including missed and duplicate treatment applications, missed antibiotic doses, and a lack of effective pressure-reducing interventions. Documentation revealed multiple missed wound care treatments, incomplete or inaccurate orders, and failure to consistently implement preventive measures such as turning, repositioning, and barrier cream application. Staff interviews revealed that wound care orders were not always accurately transcribed or implemented, and that key staff, including the LPN responsible for wound care and the DON, lacked formal wound care training. There were also lapses in communication between the wound care provider, nursing staff, and medical director, resulting in continued use of outdated or inappropriate wound care orders. The resident did not receive consistent monitoring of vital signs or daily skilled charting while on antibiotics, and there was a delay in transferring the resident to the hospital despite evidence of wound deterioration and infection. A second resident, also cognitively impaired and dependent on staff, was identified as being at moderate risk for skin breakdown. This resident developed a right lateral ankle wound that was not classified or consistently assessed. Weekly skin assessments were missed for multiple weeks, and preventive interventions such as heel floating and turning/repositioning were not consistently implemented or documented. Observations confirmed that the resident was not turned or had heels floated as required, and the wound was later identified as a Stage III pressure ulcer. Facility policy required weekly wound measurements and documentation, which was not followed for either resident.
Insulin Storage and Labeling Deficiency
Penalty
Summary
Surveyors observed that insulin medications, including Basaglar KwikPen, Insulin Lispro vials, Tresiba FlexTouch, Admelog, and Lantus, were stored on the 100 and 300 hall medication carts without proper labeling. Specifically, these insulin pens and vials were found to be opened, undated, and lacking resident identifiers. These observations were confirmed during interviews with both an LPN and an RN, who verified the presence of undated and unlabeled insulin on the respective medication carts. The facility's policy on medication storage requires that all drugs and biologics be stored in a safe, secure, and orderly manner, in their original packaging or dispensing systems, and that any containers with missing or incomplete labels be returned to the pharmacy for proper labeling before storage. The failure to label and date insulin pens and vials, as well as to include resident identifiers, was found to be inconsistent with this policy. This deficiency had the potential to affect six residents who received insulin on the affected halls.
Unsanitary Food Storage and Kitchen Conditions
Penalty
Summary
The facility failed to store food in a sanitary manner, as observed during multiple inspections of the kitchen's dry storage and food preparation areas. Specifically, three cans of three bean salad, a case of hot dog buns, a case of sliced pineapple rings, and two cases of snack pack puddings were found stored directly on the floor in the dry storage room. Staff interviews confirmed that these food items had been received and placed on the floor two days prior to the observation. Additionally, the facility's policy requires that food in dry storage areas be kept off the floor at least 18 inches, which was not followed. Further observations revealed unsanitary conditions in the food preparation and serving areas, including a dusty light fixture over the steam wells, a two-foot-long crack with visible paint chips in the painted ceiling, and a four-foot crack with peeling paint hanging down two inches from the ceiling directly over clean food trays and open drinking cups. Staff interviews confirmed the presence of these issues, as well as a dusty ceiling fan over the steam wells. These conditions had the potential to affect 73 of 76 residents who consumed food from the kitchen.
Failure to Implement Enhanced Barrier Precautions for Resident with Chronic Wounds
Penalty
Summary
The facility failed to implement enhanced barrier precautions for a resident with chronic pressure ulcer wounds. Record review showed that the resident was admitted with multiple diagnoses, including adult failure to thrive, Alzheimer's disease, anxiety disorder, metabolic encephalopathy, and difficulty walking. The resident's care plan indicated the need for enhanced barrier precautions due to chronic wounds, but there was no corresponding physician order for these precautions during the resident's stay. Additionally, the facility was unable to provide a policy on enhanced barrier precautions. This deficiency was confirmed through interviews and review of facility documentation.
Failure to Provide Dignified Dining Assistance
Penalty
Summary
The facility failed to provide dignified dining assistance to two residents who required help with their meals. One resident, with moderate cognitive impairment and muscle wasting, was observed being fed by a CNA who stood over him during the meal. This was confirmed by a registered nurse, who stated that there was no reason for the CNA to stand while feeding the resident, and that this was not a dignified dining procedure. The resident's medical records indicated a need for assistance with all meals, as ordered by the physician. Another resident, with severe cognitive impairment, protein-calorie malnutrition, cerebral infarction, aphasia, muscle wasting, dysphagia, vascular dementia, and poor vision, was also observed being fed by CNAs who stood over him while he was in bed. Both CNAs acknowledged during interviews that they were aware they should sit while assisting with feeding, but stated they preferred to stand. The resident's care plan and physician orders documented the need for assistance with all meals due to his medical conditions. These observations were made during dining and had the potential to affect additional residents who required assistance with meals.
Failure to Supervise Resident at Risk for Choking During Meals
Penalty
Summary
The facility failed to provide required supervision in the dining room for a resident identified as being at risk for choking. Resident #33, who had diagnoses including dysphagia, cognitive communication deficit, and vascular dementia, was assessed as needing one-on-one supervision and assistance with meals and was on a mechanically altered diet. Despite these documented needs, observation showed that Resident #33 and another resident were left unsupervised in the dining room while feeding themselves. This lack of supervision was confirmed by a CNA, who acknowledged that the resident at risk for choking was unsupervised during the meal period. The deficiency had the potential to affect 23 other residents identified as having dysphagia.
Failure to Perform and Document Pre/Post Dialysis Assessments and Communication
Penalty
Summary
The facility failed to ensure proper communication with the dialysis center and did not perform required pre- and post-dialysis assessments for a resident dependent on renal dialysis. Medical record review showed that the resident, who had multiple diagnoses including end stage renal disease and was cognitively intact, had physician orders for in-center dialysis three times weekly. However, these orders did not specify requirements for pre- or post-dialysis assessments. Documentation revealed that there were no progress notes or assessments related to pre- or post-dialysis care for the resident over a period of several weeks. Further review of dialysis communication records indicated multiple missing communication sheets and numerous instances where pre- and post-dialysis assessments were not documented. Interviews with nursing staff and the DON confirmed that the process was to send a communication sheet with the resident to the dialysis center and to document vital signs, shunt site checks, and any new orders, but this was not consistently done. The facility's own hemodialysis policy required ongoing assessment and communication, including monitoring the access site before and after dialysis, but these steps were not followed as evidenced by the missing documentation and incomplete records.
Lack of Defined Parameters for PRN Pain Medication Administration
Penalty
Summary
The facility failed to ensure that proper parameters were identified for as needed (PRN) pain medications for one resident. Review of the medical record showed that the resident had multiple diagnoses, including chronic pain, and was prescribed Oxycodone/Acetaminophen with instructions to administer one tablet every six hours as needed for severe pain. However, the order did not define what constituted 'severe' pain. The medication administration record indicated that the resident received the PRN medication daily over a two-week period, with pain levels at the time of administration ranging from zero to nine. A subsequent order for the same medication for moderate pain also lacked a definition for 'moderate' pain. Interviews with nursing staff and the Director of Nursing confirmed that the orders did not specify numeric parameters for 'moderate' or 'severe' pain, and staff relied on their own judgment or the resident's request for medication. The facility's policy required that pain management interventions reflect the severity of pain, but this was not reflected in the physician orders or the medication administration process for this resident.
Infection Control Deficiency During Dressing Change
Penalty
Summary
The facility failed to adhere to proper infection control practices during a dressing change for a resident. The resident, who was admitted with conditions including anterior cord syndrome, atrial fibrillation, chronic kidney disease, and peripheral vascular disease, required specific wound care orders for a wound on the superior sternum. The physician's orders specified cleansing the wound with normal saline, applying a hydroconductive dressing, and covering it with a super absorbent dressing, to be changed on specific days and as needed. During an observation of the dressing change, an LPN was noted to have cleaned her hands and donned gloves before removing the old dressing, which had a moderate amount of bloody drainage. However, the LPN failed to wash her hands between glove changes, instead using hand sanitizer only after the procedure was completed. This was in violation of the facility's hand hygiene policy, which requires the use of an alcohol-based hand rub or soap and water after removing gloves. The LPN confirmed during an interview that she did not wash her hands between glove changes, leading to the deficiency finding.
Failure to Report Alleged Abuse in a Timely Manner
Penalty
Summary
The facility failed to report an allegation of physical abuse involving a resident to the state agency immediately as required. The resident, who had intact cognition and required supervision with activities of daily living, alleged that a staff member pushed him during an altercation, causing him to fall and experience back pain. This incident was reported to hospital staff during the resident's admission, but the facility did not initiate a Self-Reported Incident (SRI) until several days later, after being informed by a surveyor. The facility's policy mandates that such allegations be reported to the Ohio Department of Health immediately, but this was not adhered to. Interviews with facility staff revealed a breakdown in communication and reporting procedures. The Director of Nursing (DON) was informed of the allegation by hospital staff but did not report it to the Administrator due to a lack of official documentation. The Administrator was unaware of the incident until informed by the surveyor. Despite the resident's report being documented in hospital records, which were accessible to facility staff, the allegation was not communicated to the appropriate authorities in a timely manner, resulting in noncompliance with state regulations.
Failure to Protect Resident from Potential Abuse During Investigation
Penalty
Summary
The facility failed to protect residents from potential abuse during an investigation involving a resident who alleged being pushed by a staff member, leading to a fall. The resident, who had intact cognition and required assistance with activities of daily living, reported the incident to hospital staff after being admitted with back pain. The facility's Self-Reported Incident (SRI) was initiated several days after the alleged incident, and the staff member accused of abuse was not suspended until the facility was informed by a surveyor. Interviews revealed that the Director of Nursing (DON) was aware of the allegation but did not inform the Administrator due to a lack of official documentation. The Administrator confirmed that staff should report abuse allegations immediately and that accused staff should be suspended pending investigation. Despite the facility's policy requiring immediate removal of accused staff, the Social Services Director (SSD) involved was not suspended until days later. The facility was unable to substantiate the abuse allegation.
Failure to Conduct Comprehensive Continence Assessment
Penalty
Summary
The facility failed to complete a comprehensive assessment of continence for a resident, identified as Resident #27, who was admitted with diagnoses including diabetes, bipolar disorder, and septic arthritis of the left leg. The initial nursing admission assessment documented the resident as continent, despite noting that the resident was wet during both day and night. A subsequent Minimum Data Set (MDS) assessment indicated that the resident required supervision with toileting and was frequently incontinent of bowel and bladder. However, there was no further assessment or documentation to address the incontinence identified in the MDS assessment. Interviews with the resident and a nursing assistant revealed conflicting information about the resident's continence status. The resident reported only a few bladder accidents, while the nursing assistant stated that the resident was incontinent of bowel and bladder all the time. The facility's policy required a thorough assessment to determine factors contributing to urinary incontinence, but no such comprehensive assessment was conducted. The Regional Director of Clinical Services confirmed the lack of a comprehensive assessment, noting that only the admission nursing assessment was available.
Failure to Complete Lab Tests and Notify Physician Timely
Penalty
Summary
The facility failed to ensure laboratory testing was completed as ordered, timely notification of the physician regarding the results, and proper medication administration for a resident. The resident, who had a history of C-difficile colitis, hypothyroidism, and other conditions, was admitted from the hospital and required specific lab tests and medication adjustments. On one occasion, the resident's condition changed, prompting a new order for a CBC test and urinalysis, but the CBC was not completed until five days later, and the physician was not notified of the lab results until several days after they were available. The laboratory results revealed several abnormal levels, including a very high TSH and very low Vitamin D, but these were not communicated to the medical provider in a timely manner. Additionally, there was a failure to properly document and follow up on the orders, leading to a delay in addressing the resident's medical needs. The DON confirmed that the results were not reviewed with the provider as documented and that the CBC was not obtained promptly. Furthermore, there was an error in medication administration where the resident received both the old and new dosages of thyroid supplement medication due to a failure to discontinue the previous dosage. This error was acknowledged by the ADON, who admitted to being distracted and not discontinuing the old dosage. The facility provided documentation that the nurse who administered the medication later corrected the record, but no explanation was given for why the medication was left on the MAR, potentially leading to further errors.
Failure to Maintain Resident's Nutritional Status
Penalty
Summary
The facility failed to ensure a resident maintained acceptable parameters of nutritional status, including body weight. Resident #2, who was admitted from the hospital with multiple diagnoses including C-difficile colitis, dysphagia, and malnutrition, was not provided with the recommended nutritional supplements in a timely manner. Despite a recommendation for a house shake to be added to the resident's lunch tray on 03/25/24, the order was not obtained until 04/15/24, and the resident did not receive the supplement consistently as observed on 04/22/24. Additionally, the resident's weight was not monitored weekly as ordered, with no evidence of weighing since admission on 03/20/24 until the surveyor's request on 04/23/24, revealing a 6.2-pound weight loss. The resident's medical record indicated a history of significant weight loss and malnutrition, with a physician's order for weekly weights and nutritional supplements to support calorie intake. However, the facility's failure to follow up on these recommendations and orders resulted in the resident not receiving the necessary nutritional support. Interviews with staff confirmed that the resident did not receive the prescribed supplements and that weights were not recorded as required. The resident's nutritional status was further compromised by the lack of consistent meal assistance and monitoring. Observations and interviews revealed that the facility's policies and procedures for weight assessment and intervention were not followed. The multidisciplinary team did not prevent, monitor, or intervene for the resident's undesirable weight loss, as evidenced by the lack of recorded weights and the absence of nutritional supplements on the medication administration record. The deficiency was confirmed by multiple staff members, including the Director of Nursing and the Certified Nurse Practitioner, who acknowledged the importance of regular weight monitoring and nutritional support for the resident's health and well-being.
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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