Emerald Pointe Health And Rehab Ctr
Inspection history, citations, penalties and survey trends for this long-term care facility in Barnesville, Ohio.
- Location
- 100 Michelli Street, Barnesville, Ohio 43713
- CMS Provider Number
- 366352
- Inspections on file
- 26
- Latest survey
- December 9, 2025
- Citations (last 12 mo.)
- 1
Citation history
Health deficiencies cited at Emerald Pointe Health And Rehab Ctr during CMS and state inspections, most recent first.
A resident with multiple acute conditions did not receive all ordered doses of an IV antibiotic, with no documentation of administration, refusal, or unavailability for two doses. Nursing staff did not record the missed doses or notify the physician or pharmacy, contrary to facility policy.
A facility failed to notify a physician about a resident's elevated blood pressure readings, which were outside the specified parameters. Despite multiple instances of high readings, there was no evidence of physician notification, as confirmed by the DON. The resident had several health conditions, including hypertension, requiring close monitoring.
A facility failed to create comprehensive care plans for a resident with impaired vision and dental issues. The resident, who was cognitively intact, struggled to read the menu card due to small print, affecting meal choices. Staff were unaware of these challenges, and interviews confirmed the absence of individualized care plans for the resident's vision and dental needs.
A facility failed to provide a variety of activities to meet residents' interests, particularly in the evenings and on weekends. A resident, who was cognitively intact and had specific activity preferences, expressed boredom due to limited activity options. The activity calendars showed a lack of organized activities after early afternoon on weekdays and repetitive schedules on weekends. The Activity Director discontinued evening activities based on feedback from a small group, without consulting all residents or guardians.
The facility failed to provide necessary vision and hearing services to two residents. One resident with end-stage macular degeneration did not receive new glasses, affecting his ability to read menu cards. Another resident with impaired vision and cataracts had no follow-up for recommended eye exams and was not wearing effective glasses. Both residents experienced significant difficulties due to these oversights.
The facility failed to implement proper bowel management protocols for three residents, leading to lapses in bowel movement documentation and lack of interventions. Despite being at risk for constipation, the residents did not receive consistent monitoring or medication to facilitate bowel movements. The DON confirmed the absence of a bowel protocol and standing orders, resulting in deficiencies in care.
A resident with multiple health conditions, including a UTI, was prescribed Bactrim DS to be administered twice daily for 10 days. However, the resident received 21 doses instead of the ordered 20 doses, as confirmed by the DON.
A resident with multiple chronic conditions was found to have a bottle of Fluticasone Propionate Nasal Suspension in her room without an order for self-administration or bedside storage. Observations confirmed the presence of the nasal spray on two consecutive days, and an LPN verified the lack of proper authorization for the resident to have the medication at bedside.
A facility failed to notify a resident's nephrologist of abnormal lab results, despite physician orders to do so. The resident, with chronic kidney disease and other conditions, had elevated BUN and creatinine levels and a decreased GFR on two occasions. The deficiency was confirmed by the DON, who acknowledged the lack of documentation showing the nephrologist was informed.
The facility failed to maintain accurate medical records for three residents, leading to deficiencies in medication administration and documentation. A resident did not have a documented dose of Keflex, another had no record of receiving a consented vaccine, and a third had outdated care plan and dialysis schedule information. The ADON and DON confirmed these discrepancies.
The facility failed to implement proper infection control measures for two residents. A resident with a UTI received an incorrect dosage of antibiotics and was not placed on contact isolation despite having MRSA and Group B Strep. Another resident with respiratory symptoms was not adequately monitored or tested for COVID-19 or influenza, and was observed without a mask in communal areas. Staff interviews confirmed lapses in monitoring and infection control practices.
A resident with chronic infections and multiple diagnoses reported testicle pain, leading to a urinalysis that showed abnormalities. Despite the urine culture indicating mixed commensal flora, suggesting possible contamination, the resident was prescribed Cipro by a urologist without meeting the required criteria. The DON confirmed the antibiotic use did not meet the necessary criteria.
A resident with Alzheimer's and osteoporosis was neglected due to inadequate supervision, resulting in a fall. The resident, who required moderate assistance, was left unattended overnight by a CNA who failed to perform two-hour checks. The resident was found on the floor the next morning, incontinent and in pain. Staff interviews revealed the resident was last seen content in her recliner, but the facility's supervision policy was not followed.
A resident with Alzheimer's and dementia was found on the floor after being left unattended for hours, despite being at risk for falls and requiring assistance. A CNA failed to perform required checks, and the facility did not report the incident as neglect to the state agency, contrary to policy.
The facility failed to ensure competent nurse staffing for medication administration, leading to potential medication errors involving two residents. One resident experienced a significant drop in blood pressure after allegedly receiving the wrong medications, and staff did not follow proper procedures for medication administration and documentation.
Failure to Administer and Document IV Antibiotic Doses
Penalty
Summary
The facility failed to ensure that a resident received all physician-ordered doses of an intravenous (IV) antibiotic. The resident, who was admitted with multiple diagnoses including acute pyelonephritis, sepsis, bacteremia, urinary tract infection, and acute kidney injury, was prescribed Cefepime-Dextrose IV Solution to be administered every 12 hours for 10 days. Record review showed that on two occasions, there was no documented evidence that the IV antibiotic was administered, refused, or unavailable, and there was no documentation of physician notification or attempts to contact the pharmacy regarding missing medication. Interviews with nursing staff confirmed that medications should be documented as administered or refused on the Medication Administration Record (MAR), and that any unavailability should be reported and documented. However, for the missed doses, there was no documentation in the MAR, progress notes, or any indication that the physician or pharmacy was notified. The facility's policy requires documentation of administration, refusal, or unavailability, but this was not followed in the resident's case.
Failure to Notify Physician of Elevated Blood Pressure Readings
Penalty
Summary
The facility failed to ensure physician notification of a resident's blood pressure readings that were outside the specified parameters. This deficiency affected a resident who was admitted with multiple diagnoses, including breast cancer, chronic kidney disease, cardiac murmur, atrial septal defect, hypertension, diabetes mellitus, renal insufficiency, and urinary tract infection. The resident's treatment plan included monitoring blood pressure and notifying the physician if readings exceeded 130/80 mmHg. However, the medical record review revealed multiple instances where the resident's blood pressure readings were above the specified threshold, yet there was no evidence that the physician was notified as required. The deficiency was confirmed during an interview with the Director of Nursing, who verified the lack of documentation indicating physician notification for the elevated blood pressure readings. The facility's failure to adhere to the physician's orders for monitoring and reporting blood pressure deviations represents a lapse in the standard of care expected in managing the resident's health conditions. This oversight in communication could potentially impact the resident's treatment and health outcomes, although the report does not specify any direct consequences resulting from this deficiency.
Failure to Develop Individualized Care Plans for Sensory and Dental Needs
Penalty
Summary
The facility failed to develop comprehensive and individualized care plans for a resident with communication-sensory concerns. The resident, who was admitted with diagnoses including end-stage macular degeneration and cerebral infarction, was found to have highly impaired vision and dental issues. Despite being cognitively intact, the resident struggled with reading the dietary/menu card due to the small print, which affected his ability to choose meals. Interviews and observations revealed that the resident had been using the same glasses for a long time and had not received adequate dental care, as his teeth were in poor condition and causing discomfort. The deficiency was further highlighted during interactions with staff, where a CNA was unaware of the resident's inability to read the menu card. Additionally, interviews with social services and the regional director of clinical services confirmed that the resident did not have an individualized care plan addressing his vision or dental needs. This lack of a comprehensive care plan for the resident's specific sensory and dental issues contributed to the deficiency identified by the surveyors.
Lack of Varied Activities for Residents
Penalty
Summary
The facility failed to provide a variety of activities to meet the interests of residents, particularly in the evenings and on weekends. This deficiency was identified through observations, interviews, and reviews of activity calendars and resident records. A specific resident, who was cognitively intact and had a preference for activities such as listening to music, going outside, and participating in group activities, was affected by this lack of variety. The resident expressed boredom and dissatisfaction with the limited activities available, especially in the late afternoons and weekends. The activity calendars for several months revealed a lack of organized activities after early afternoon on weekdays and a repetitive schedule on weekends. The resident's participation records showed limited engagement in activities, with most of the resident's time spent on self-initiated activities like watching television and working on puzzles. The resident also had limited family visits and pet interactions, which further contributed to the resident's sense of isolation and boredom. Interviews with the Activity Director revealed that evening activities were discontinued due to low participation, based on feedback from a small group of residents. However, this decision was not communicated to all residents or their guardians. The Activity Director acknowledged the lack of variety in weekend activities and expressed willingness to try new activities that might interest the residents. Despite this, the current schedule did not adequately address the needs and preferences of the residents, leading to the identified deficiency.
Failure to Provide Vision and Hearing Services
Penalty
Summary
The facility failed to ensure that residents received proper treatment and assistive devices to maintain their vision and hearing abilities, affecting two residents. Resident #3, who was admitted with diagnoses including end-stage macular degeneration and cerebral infarction, was cognitively intact but had highly impaired vision. Despite wearing glasses, there was no evidence that Resident #3 was assessed or received new glasses to improve his visual acuity. Observations revealed that Resident #3 struggled to read the dietary/menu card due to small print, leading to frustration and an inability to make informed meal choices. Resident #18, admitted with multiple diagnoses including Parkinson's disease and impaired vision, required glasses for optimal vision. However, there was no evidence of follow-up for a dilated fundus exam or new eyeglasses as recommended. Despite a care plan intervention to ensure glasses were worn and clean, Resident #18 was observed not wearing glasses and reported that her current glasses were ineffective. Her cataract surgery had been rescheduled multiple times, and no interim measures were taken to address her vision concerns.
Failure to Implement Bowel Management Protocols
Penalty
Summary
The facility failed to ensure proper identification, assessment, and intervention for bowel function in three residents, leading to deficiencies in their care. Resident #13, who was at risk for constipation, did not have a bowel movement documented from 02/15/25 to 02/25/25, despite being administered a laxative on 02/16/25. The Director of Nursing (DON) confirmed the absence of a bowel protocol and standing orders for medications to facilitate bowel movements, and acknowledged the lack of documentation for Resident #13's bowel movements during this period. Resident #46, who was cognitively impaired and always incontinent of bowel and bladder, also experienced lapses in bowel movement documentation. From 02/15/25 to 02/18/25 and 02/23/25 to 02/27/25, there were no records of bowel movements, and the MAR for February 2025 showed no evidence of medication administration to aid bowel movements. The DON verified the absence of a bowel protocol and confirmed the lack of documentation for these periods. Resident #51, with a history of constipation and cognitive impairment, had no documented bowel movements on several occasions in February 2025. The resident's care plan included monitoring for constipation, but there was no evidence of interventions to assist with bowel movements. The DON stated that interventions should be implemented if a resident has no bowel movement for two to three days, but confirmed that Resident #51 went four days without a bowel movement, with no staff identification or intervention documented.
Resident Received Excessive Antibiotic Dose
Penalty
Summary
The facility failed to ensure a resident's drug regimen was free from unnecessary medications when a resident was administered antibiotics not at the ordered dose. Resident #27, who was admitted with multiple diagnoses including breast cancer, chronic kidney disease, and a urinary tract infection, was affected by this deficiency. A physician's order was received for Bactrim DS to be administered twice a day for 10 days, totaling 20 doses. However, the electronic Medication Administration Record indicated that the resident received 21 doses instead of the ordered 20 doses. This discrepancy was confirmed during an interview with the Director of Nursing.
Medication Storage Deficiency
Penalty
Summary
The facility failed to ensure the safe storage of medications, specifically affecting one resident. The resident, who had intact cognition, was admitted with multiple diagnoses including fractures, respiratory failure, and chronic conditions. A review of the medical record showed that the resident had a physician's order for Fluticasone Propionate Nasal Suspension, to be administered once daily, but did not have an order to self-administer or keep the nasal spray at bedside. Observations on two consecutive days revealed that the resident had a bottle of the nasal spray on top of her refrigerator in her room. An interview with an LPN confirmed the presence of the nasal spray in the resident's room and verified that there was no order for self-administration or bedside storage.
Failure to Notify Nephrologist of Abnormal Lab Results
Penalty
Summary
The facility failed to notify a resident's nephrologist of abnormal laboratory results, which was a requirement as per the physician's orders. Resident #27, who was admitted with multiple diagnoses including chronic kidney disease and renal insufficiency, had abnormal lab results on two separate occasions. The Comprehensive Metabolic Panel on 07/26/24 showed elevated BUN and creatinine levels, and a decreased estimated GFR. Similarly, the panel on 01/02/25 revealed further abnormalities, including elevated BUN, creatinine, and BUN/Crea ratio, along with low hemoglobin and hematocrit levels. Despite these findings, there was no evidence in the medical record that the nephrologist was informed of these results as ordered by Physician #279. The deficiency was confirmed during an interview with the Director of Nursing, who verified that there was no documentation indicating that the nephrologist had been notified of the abnormal lab results. This oversight affected Resident #27, who was cognitively intact and receiving a diuretic, and was one of five residents reviewed for unnecessary medications in a facility with a census of 63.
Deficiencies in Medical Record Accuracy and Medication Administration
Penalty
Summary
The facility failed to maintain accurate and thorough medical records for three residents, leading to deficiencies in medication administration and documentation. For Resident #34, there was a lack of documentation for the administration of an evening dose of Keflex on 02/04/25, despite an order for the antibiotic to be given twice daily for cellulitis. The assistant director of nursing confirmed the missing documentation and noted that there was no record of the dose being missed, refused, or any notification to a physician. Additionally, the facility's medication administration policy requires documentation of medication refusal or unavailability, which was not adhered to in this case. Resident #13's records showed a consent for the Prevnar 20 vaccine, but there was no documentation of its administration in the medication administration record. The assistant director of nursing acknowledged the absence of documentation and mentioned a potential issue with their electronic documentation system. For Resident #18, the care plan inaccurately listed the resident as receiving Coumadin, while the electronic physician orders indicated the resident was on Apixaban. Furthermore, the Kardex contained outdated information regarding the resident's dialysis schedule, which had changed due to transportation concerns. The director of nursing confirmed the inaccuracies in the care plan and Kardex.
Inadequate Infection Control and Monitoring for Residents
Penalty
Summary
The facility failed to implement appropriate infection prevention and control measures for two residents, leading to deficiencies in care. Resident #27, who was admitted with renal insufficiency, non-Alzheimer dementia, and a urinary tract infection (UTI), was prescribed Bactrim DS for a UTI based on a urinalysis from an external urology office. However, the facility administered 21 doses instead of the ordered 20 doses. Additionally, the facility did not receive or act upon the urinalysis and urine culture results, which indicated the presence of MRSA and Group B Strep, until much later. Consequently, the resident was not placed on contact isolation precautions during the antibiotic treatment period. Resident #21, with a history of chronic obstructive pulmonary disease, diabetes, and other conditions, exhibited signs of a respiratory illness but was not adequately monitored. Despite complaints of sinus congestion and cold symptoms, there was no consistent documentation of the resident's temperature or respiratory status from 02/20/25 to 02/25/25. The resident was not tested for COVID-19 or influenza, even though she exhibited symptoms that could be contagious. Observations revealed that the resident was not wearing a mask while in communal areas, increasing the risk of spreading the illness. Interviews with facility staff, including the Assistant Director of Nursing and the Director of Nursing, confirmed lapses in monitoring and infection control practices. The facility's failure to receive timely laboratory results and implement necessary precautions for Resident #27, along with inadequate monitoring and testing for Resident #21, contributed to the deficiencies identified by the surveyors. The facility's infection control policy was not effectively followed, leading to potential risks for residents and staff.
Antibiotic Ordered Without Meeting Criteria
Penalty
Summary
The facility failed to ensure antibiotics were ordered based on the required criteria for a resident with a history of chronic infections. The resident, who was admitted with multiple diagnoses including chronic kidney disease, type 2 diabetes, and paraplegia, reported testicle pain, which he associated with urinary tract infections. A urine test strip indicated abnormalities, and a urinalysis confirmed the presence of moderate leukocytes, blood, and nitrites. Despite these findings, the Loeb's minimum criteria form for initiating antibiotic therapy was not completed, and no minimum criteria were marked. The urologist ordered Cipro, an antibiotic, for the resident based on his history and symptoms, but the Director of Nursing later verified that the use of Cipro did not meet the criteria. The resident's urine culture results, which were faxed to the facility, showed mixed commensal flora, indicating a mix of bacteria that typically reside in the urinary tract without causing infection. This suggested possible contamination during sample collection rather than a true infection. Despite this, the resident was administered Cipro, starting the evening after the urologist's order. The Director of Nursing confirmed that a culture and sensitivity test was not completed due to the mixed flora results, and acknowledged that the antibiotic order did not meet the necessary criteria.
Neglect Due to Inadequate Supervision
Penalty
Summary
The facility failed to provide adequate care and supervision to prevent neglect of a resident, who was admitted with multiple diagnoses including Alzheimer's disease, dementia, and osteoporosis. The resident was identified as being at risk for falls and required moderate assistance with daily activities. Despite these needs, the resident was left unattended for an extended period, resulting in a fall. The resident was found on the floor in her room, incontinent and in pain, but unable to communicate the location of the pain. The incident occurred when a CNA failed to perform the required two-hour checks on the resident, assuming the resident would seek help if needed. The CNA did not check on the resident for the remainder of the night shift, despite being aware of the facility's standard for regular checks. The resident was discovered on the floor the following morning by another staff member, leading to an investigation. Interviews with staff revealed that the resident was last seen in her recliner, appearing content and with her call light within reach. However, the facility's policy on resident supervision was not followed, as the resident was not checked on multiple times throughout the night as required. The facility's Director of Nursing confirmed that the staff should have conducted rounds every two hours, regardless of the resident's preference for privacy.
Failure to Report Alleged Neglect
Penalty
Summary
The facility failed to report an allegation of resident neglect to the state survey agency, affecting one resident. The resident, who was admitted with diagnoses including Alzheimer's disease, dementia, and muscle weakness, was found on the floor in her room after being left unattended for an extended period. The care plan indicated the resident was at risk for falls and required assistance with toileting and showers, yet the resident was not checked on as required. The incident occurred when the resident was found on the floor in front of her recliner, incontinent of urine, and in pain. Camera footage revealed the resident had been on the floor for several hours. A CNA admitted to not checking on the resident during the night shift, assuming the resident would seek help if needed, despite being aware of the two-hour check and change standard. The facility's policy mandates reporting all allegations of neglect to the state agency, but the Administrator did not report the incident, believing it was not neglect. Interviews confirmed the resident was a fall risk and should have been checked on multiple times during the night. The facility's failure to report the incident as neglect was identified during a complaint investigation.
Medication Administration Deficiency
Penalty
Summary
The facility failed to ensure competent nurse staffing to administer medications according to professional standards, affecting two residents. Resident #44, who had diagnoses including congestive heart failure, chronic ischemic heart disease, hypertension, and atrial fibrillation, experienced a significant drop in blood pressure after allegedly receiving the wrong medications. The medication administration records indicated that RN #100 signed off on medications that were not administered by her, and there was confusion about the medications returned to the medication cart, which were not properly disposed of as per policy. Resident #41, who had similar diagnoses, was also involved in the incident. She only took part of her morning medications, and the remaining medications were mistakenly placed in Resident #44's slot in the medication cart. RN #225, who was assisting with the medication pass, administered medications without verifying them himself, which is against standard nursing practice. The facility's Director of Nursing (DON) did not verify the returned medications and relied on the nurses' statements, failing to confirm whether a medication error had occurred. Interviews with the involved staff revealed that there were lapses in following proper medication administration procedures, including signing off on medications not administered by the nurse and returning opened medications to the cart. The facility's investigation identified these concerns but did not conclusively determine if a medication error occurred. The DON acknowledged the issues and provided education to the staff, but the report highlights significant deficiencies in medication administration practices and staff competency.
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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