Garden Park Health Care Center
Inspection history, citations, penalties and survey trends for this long-term care facility in Cincinnati, Ohio.
- Location
- 3536 Washington Ave, Cincinnati, Ohio 45229
- CMS Provider Number
- 365529
- Inspections on file
- 36
- Latest survey
- December 18, 2025
- Citations (last 12 mo.)
- 27
Citation history
Health deficiencies cited at Garden Park Health Care Center during CMS and state inspections, most recent first.
Several residents did not receive their prescribed medications, including Potassium, Buprenorphine, Zoloft, and Levetiracetam, because the medications were not available during the scheduled administration. An LPN confirmed the omissions during medication pass, and facility policy requires medications to be reordered in advance to prevent such occurrences.
Staff failed to promptly report multiple incidents of resident-to-resident sexual abuse to the state agency, including situations involving cognitively impaired residents and public sexual activity. Although staff separated the involved residents and documented the events, the required notifications and investigations were delayed, contrary to facility policy and regulatory requirements.
The facility did not promptly or thoroughly investigate multiple incidents of resident-to-resident sexual abuse, including one involving a cognitively impaired resident and another involving two residents engaging in sexual activity in a public area. Staff failed to immediately report the incidents, did not conduct timely interviews or obtain witness statements, and did not assess the residents' capacity to consent, resulting in delayed and incomplete investigations.
A resident with impaired cognition and multiple medical conditions did not receive appropriate hand and nail hygiene, resulting in excessively long and dirty fingernails that interfered with the use of a communication device. Staff interviews confirmed that nail care was only performed during scheduled showers and was not consistently documented or offered outside of those times, contrary to facility policy.
A resident with a history of falls and multiple medical conditions was identified as needing a fall mat beside the bed per care plan and physician order. Despite this, repeated observations and staff interviews confirmed the fall mat was not in place while the resident was in bed, contrary to facility policy and documented interventions.
A facility failed to maintain a clean and safe environment, affecting 36 residents. Observations revealed a resident's room with dirty linen, damaged walls, and a sticky floor. The main corridor had exposed light fixtures and missing handrail endcaps. The resident, with multiple diagnoses, expressed dissatisfaction with her room's condition. The facility's policy on providing a homelike environment was not followed.
The facility's dishwasher was not maintained properly, affecting all 46 residents who received food from the kitchen. The dishwasher's wash and rinse temperature was 120°F, and it lacked the necessary chemical sanitizer, registering at zero ppm. The Dietary Manager confirmed the deficiency, which was investigated under a complaint.
The facility failed to notify the state mental health authority of significant changes in the mental health conditions of two residents, as required by PASARR. One resident was diagnosed with adjustment disorder and another with depression, but the facility did not complete the necessary PASARR updates or notifications. This non-compliance was confirmed during an interview with the Social Services Director.
The facility failed to develop comprehensive care plans for two residents, one lacking a dental care plan despite being edentulous, and another without plans for a prosthetic limb and activities. Both residents were cognitively intact, and the deficiencies were confirmed by the MDS Coordinator.
A resident with a below-the-knee amputation experienced prolonged issues with a poorly fitting prosthesis, which the facility failed to address in a timely manner. Despite receiving a prosthesis, the resident reported discomfort and pain, leading to an inability to use it effectively. The facility did not follow up on the prosthesis issues for several months, and the resident's insurance was not billed for the original prosthesis. The Director of Rehabilitation later discovered these issues and initiated steps to resolve them.
A resident with intact cognition reported a theft of two hundred dollars from their room to an LPN, who documented the incident and informed the administration. However, the facility failed to report this allegation to the Ohio Department of Health as required by their policy, which mandates timely investigation and reporting of such incidents.
The facility failed to maintain medication error rates below five percent, with an observed error rate of 11.1%. Three residents were affected due to unavailable medications and improper administration techniques. An LPN confirmed the errors, which included not administering loratadine, amiodarone, and Claritin due to unavailability, and not priming a Lantus insulin pen before use.
The facility failed to maintain a safe and clean environment for its 46 residents, with issues such as inadequate lighting, broken and discolored ceiling tiles, cobwebs, dust, debris, and dead bugs in common areas. Residents' rooms had water-damaged windows, requiring towels to soak up rainwater, and the 200-hall lacked handrails. The kitchen and dining areas had missing ceiling tiles and dead bugs in light fixtures, while the 300-hall had broken tiles and mold-like discoloration. Interviews with staff and residents confirmed these persistent issues.
The facility failed to maintain food safety and sanitation standards, affecting all 46 residents. Observations revealed unsanitary conditions in the kitchen, including food debris on trash cans and mold-like substance on wall tiles. Additionally, a dietary staff member did not sanitize the food thermometer between uses on different food items, contrary to the facility's sanitation policy.
The facility failed to maintain essential equipment, affecting two residents and potentially all 46 residents due to a malfunctioning dishwasher. A resident's bed was broken, causing discomfort and safety issues, while another's bed had a spliced electrical cord, preventing necessary movement for care. The dishwasher failed to reach required sanitization temperatures, with no effective maintenance or documentation of repairs.
The facility failed to provide secured handrails in the hallway of the 200 unit, potentially affecting 15 independently mobile residents. During a tour, it was observed that no handrails were affixed to the walls. The Administrator confirmed this absence, stating that the unit was being remodeled and handrails needed to be ordered. This issue was investigated under multiple complaint numbers.
Medication Administration Errors Due to Unavailable Medications
Penalty
Summary
The facility failed to administer medications as ordered by physicians, resulting in four medication errors out of 41 opportunities, which equates to a 9.75% medication error rate. This deficiency affected three residents who were observed during medication administration. Specifically, one resident with diagnoses including left ventricular failure and cognitive communication deficit did not receive prescribed Potassium and Buprenorphine due to the medications not being available. Another resident with epilepsy, COPD, and anxiety disorder did not receive their ordered Zoloft, and a third resident with atherosclerotic heart disease, diabetes, and convulsions did not receive their prescribed Levetiracetam, both omissions also due to the medications not being available at the time of administration. Observations and staff interviews confirmed that the medications were omitted during the morning medication pass because they were not on hand. Review of facility policy indicated that medications should be reordered from the pharmacy at least three days before the last dose is administered to ensure availability. The failure to have these medications available and administered as ordered led directly to the cited deficiency.
Failure to Timely Report Resident-to-Resident Sexual Abuse Allegations
Penalty
Summary
The facility failed to report allegations of resident-to-resident sexual abuse to the state agency within the required 24-hour timeframe. This deficiency was identified through medical record reviews, facility self-reported incidents (SRIs), incident investigations, and interviews with residents and staff. In one instance, a resident with severe cognitive impairment and another resident with moderate cognitive impairment were observed in a sexually inappropriate situation. Staff separated the residents and documented the event, but the incident was not reported to administration or the state agency until several days later. The Director of Nursing (DON) confirmed that the staff did not immediately report the incident, and the SRI was filed four days after the event occurred. In another case, two residents were observed engaging in sexual activity in a public area of the facility, specifically the smoking porch, in the presence of other residents. Both residents were physically exposed, and other residents complained about the incident. Staff addressed the behavior with the involved residents, but the incident was not reported to the administration or the state agency as required. The DON later confirmed that the incident was not investigated promptly to determine if sexual abuse had occurred, and the facility did not immediately file an SRI. The facility's policy required all allegations of abuse to be reported within the required timeframes, but this was not followed. Interviews with staff, including an LPN and a CNA, confirmed that the incidents were observed and reported internally but not escalated to the appropriate administrative or regulatory authorities in a timely manner. The DON and Administrator acknowledged the delay in reporting and the lack of immediate investigation. The failure to report these incidents as required affected four residents reviewed for abuse, all of whom had varying degrees of cognitive and behavioral impairments.
Failure to Timely and Thoroughly Investigate Resident-to-Resident Sexual Abuse Allegations
Penalty
Summary
The facility failed to thoroughly and timely investigate multiple allegations of resident-to-resident sexual abuse, affecting four residents. In one incident, a resident with severe cognitive impairment and a history of sexually inappropriate behavior was observed sitting on another resident's lap and kissing him. Staff separated the residents and provided education on personal boundaries, but the incident was not immediately reported to administration. The Director of Nursing (DON) only became aware of the event two days later during a routine review, and the state-required Self-Reported Incident (SRI) was not filed until four days after the incident. The facility's investigation did not include timely interviews or witness statements from staff involved, and the residents involved did not recall the incident when later interviewed. In another event, two residents were observed engaging in sexual activity in a public area, specifically the smoking porch, in view of other residents. Staff intervened and explained the inappropriateness of the behavior, but the residents dismissed the staff's concerns. Despite the incident being reported to the DON the following day, no investigation was initiated until several weeks later. The facility did not immediately assess the residents' capacity to consent or report the incident to the state agency as required. The DON later confirmed that the decision not to file an SRI was based on an assumption of consent, without proper investigation. The facility's policy required immediate investigation and thorough documentation of all abuse allegations, including identification of responsible staff, interviews with all involved parties, and a focus on determining the occurrence and extent of abuse. However, in both incidents, the facility failed to follow these procedures, resulting in delayed and incomplete investigations. The lack of timely reporting, failure to obtain staff and witness statements, and inadequate assessment of resident capacity to consent contributed to the deficiency.
Failure to Provide Hand and Nail Hygiene for Dependent Resident
Penalty
Summary
The facility failed to provide appropriate hand and nail hygiene for a dependent resident who required staff assistance with personal care. Medical record review showed the resident had moderately impaired cognition and required help with bathing and personal hygiene. During observation, the resident was found to have fingernails that were too long and had debris underneath, which interfered with his ability to use his communication device. The resident confirmed that staff had not offered to cut his nails, and the length of his nails made it difficult for him to use his iPad for communication. Interviews with facility staff, including the DON, ADON, and an LPN, confirmed that nail care was expected to be performed during scheduled showers, which were offered at least twice weekly, but there was no set schedule for hand or nail care outside of these times. The facility policy required daily cleaning and regular trimming of nails, but this was not consistently implemented. Staff also confirmed that documentation of nail care or refusals was expected but not always completed. This resulted in the resident not receiving necessary nail care as required by facility policy.
Failure to Implement Physician-Ordered Fall Prevention Intervention
Penalty
Summary
A deficiency occurred when the facility failed to implement fall prevention interventions as ordered by the physician and outlined in the resident's care plan. A resident with diagnoses including type two diabetes mellitus, chronic kidney disease, depression, and spastic hemiplegia was identified as being at risk for falls, with a history of one to two falls in the past three months. The care plan and physician's order specified that a fall mat should be placed on the right side of the resident's bed at all times when the resident was in bed, following a recent fall where the resident rolled out of bed while attempting to reposition himself. Despite these documented interventions, multiple observations on consecutive days revealed that the fall mat was not in place while the resident was in bed. Staff interviews with CNAs and an LPN confirmed that the fall mat was not present, even though they were aware of the care plan and physician's order. Review of the facility's policy on managing falls indicated that staff were expected to implement interventions to prevent falls and minimize complications, but this was not followed in this instance.
Facility Fails to Maintain Clean and Safe Environment
Penalty
Summary
The facility failed to maintain a clean and safe environment, affecting 36 residents out of a census of 45. During an initial tour, it was observed that a resident's room had dirty linen spread across the floor, walls with large areas needing repair, a stained and sticky floor tile, a wall shelf removed and leaning in a corner, and a small closet lacking cove base. Additionally, the main corridor had five light fixtures without covers, exposing the bulb and wiring, and the handrails lacked endcaps. These conditions were verified by the Administrator and Maintenance Director. The resident involved, who had diagnoses of thoracic spinal fracture with paraplegia, protein-calorie malnutrition, and schizophrenia, expressed dissatisfaction with the state of her room, particularly the walls, floor, and closet. The facility's policy on providing a safe, clean, comfortable, and homelike environment was not adhered to, as evidenced by the observations and interviews conducted. This deficiency was investigated under Complaint Number OH00162166.
Dishwasher Maintenance Deficiency
Penalty
Summary
The facility failed to maintain its dishwasher in a manner that prevents foodborne illness, affecting all 46 residents who received food from the kitchen. During an observation of the facility's kitchen, it was noted that the dishwasher had a wash and rinse temperature of 120 degrees Fahrenheit. The Dietary Manager (DM) tested the chemical sanitizer in the dishwasher, which registered at zero parts per million (ppm). The DM confirmed that the dishwasher was a low-temperature model requiring chemical sanitization, and verified that it was operating without the necessary chemical sanitizer. This deficiency was investigated under Complaint Number OH00161042.
Failure to Notify State Mental Health Authority of Significant Changes
Penalty
Summary
The facility failed to notify the state mental health authority of significant changes in the mental health conditions of two residents, as required by the Pre-Admission Screening and Resident Review (PASARR) process. Resident #19, who was admitted with various medical conditions including opioid dependence, received a new diagnosis of adjustment disorder on September 19, 2023. However, the facility did not complete a significant change PASARR or notify the state mental health authority of this new diagnosis. This oversight was confirmed during an interview with the Social Services Director on January 9, 2025. Similarly, Resident #46, admitted with multiple diagnoses including alcohol abuse with withdrawal, was diagnosed with depression on June 2, 2023. The facility again failed to complete a significant change PASARR or notify the state mental health authority of this new diagnosis. This was also confirmed during the same interview with the Social Services Director. The facility's PASRR policy, dated April 1, 2023, mandates compliance with the Ohio Department of Medicaid regulations, which the facility did not adhere to in these cases.
Failure to Develop Comprehensive Care Plans for Residents
Penalty
Summary
The facility failed to develop comprehensive care plans for two residents, addressing their specific medical and personal needs. Resident #28, who was admitted with multiple diagnoses including necrotizing fasciitis and type two diabetes mellitus, did not have a care plan to address his dental needs despite being edentulous and scheduled for dental impressions for dentures. The MDS Coordinator confirmed the absence of a dental care plan for Resident #28, despite the resident's cognitive intactness and the facility's awareness of his dental status. Similarly, Resident #19, who had a below-the-knee amputation and was cognitively intact, lacked a care plan for his prosthetic limb and activities. Despite having received a prosthetic limb and being involved in therapy, there was no care plan to address his amputation or prosthetic use. The resident reported participating in therapy and occasional facility activities but preferred staying in his room. The MDS Coordinator verified the absence of care plans for Resident #19's prosthetic limb and activities, indicating a failure to meet the facility's care planning policy.
Failure to Address Prosthetic Limb Issues Timely
Penalty
Summary
The facility failed to address a resident's issues with a prosthetic limb in a timely manner, affecting one of two residents with prostheses. The resident, who had a below-the-knee amputation, was admitted with multiple diagnoses including severe protein calorie malnutrition, type two diabetes mellitus, and opioid dependence. The resident received a prosthesis on April 25, 2024, but experienced discomfort and fitting issues, which were not promptly resolved. The resident's physical therapy notes indicated ongoing problems with the prosthesis, including discomfort and pain, leading to the resident's inability to tolerate wearing it. Despite being instructed to contact the prosthetic company for adjustments, the resident continued to experience issues. The resident was discharged from physical therapy on May 30, 2024, due to meeting the highest practical level of achievement, yet still could not use the prosthesis effectively. Occupational therapy also noted non-compliance with the treatment plan, further complicating the situation. The Director of Rehabilitation, who started in September 2024, discovered that the resident's insurance had not been billed for the original prosthesis, and the prosthesis was returned due to its poor fit. The resident had a lump on the limb that was not accommodated by the prosthesis, and the straps caused skin irritation. The facility's failure to follow up on the prosthesis from May 30, 2024, to September 10, 2024, contributed to the deficiency, as the resident remained without a properly fitting prosthesis for an extended period.
Failure to Report Misappropriation of Resident Funds
Penalty
Summary
The facility failed to report an allegation of misappropriation of resident funds to the Ohio Department of Health (ODH), affecting one resident out of three reviewed for such issues. The resident involved, identified as Resident #33, had intact cognition and required supervision with activities of daily living. On a specific date, the resident reported to a Licensed Practical Nurse (LPN) that two hundred dollars had been stolen from his room. The LPN documented the allegation and indicated it would be reported to the administration. Despite the report made by the LPN, the facility did not complete a Self-Reported Incident (SRI) regarding the allegation. Interviews with the Director of Nursing (DON) and the Administrator confirmed that the allegation was known to the staff but was not reported to the ODH as required. The facility's policy on abuse, neglect, exploitation, and misappropriation prevention mandates that such allegations be investigated and reported within the timeframes required by federal regulations. This deficiency was investigated under a specific complaint number.
Medication Error Rate Exceeds Acceptable Threshold
Penalty
Summary
The facility failed to maintain medication error rates below five percent, resulting in an observed error rate of 11.1% based on 36 medication opportunities and four observed errors. This deficiency affected three residents. Resident #21, diagnosed with bipolar disorder, congestive heart failure, and type two diabetes mellitus, did not receive loratadine due to its unavailability and was administered Lantus insulin without priming the pen, contrary to the manufacturer's instructions. LPN #20 confirmed these errors during an interview. Resident #26, with diagnoses including type two diabetes mellitus and chronic kidney disease, did not receive amiodarone as it was unavailable. Similarly, Resident #27, diagnosed with emphysema and generalized anxiety disorder, did not receive Claritin due to its unavailability. The facility's policy mandates that medications be administered safely, timely, and as prescribed, which was not adhered to in these instances. This deficiency was investigated under Complaint Number OH00157751.
Facility Fails to Maintain Safe and Clean Environment
Penalty
Summary
The facility failed to ensure a clean, safe, and comfortable environment for all 46 residents, as evidenced by multiple observations and interviews. The lower level, which is frequently used by residents for therapy and activities, was found to be inadequately lit, with broken and discolored ceiling tiles, cobwebs, dust, debris, and dead bugs throughout the area. A ceiling light cover was hanging down with exposed wires, and the exit enclosure was cluttered with cobwebs, dirt, and broken windows. Additionally, there was an unsecured storage area with broken fixtures and exposed pipes, and a broken electric steam table was left in the open. The 200-hall, where several residents' rooms are located, had dead bugs in light fixtures, missing light covers, and lacked handrails. The shower/bathroom in this hall had broken tiles, standing water, mold-like discoloration, rusted grab bars, and broken mirrors. Residents' windows were heavily damaged from water leaks, requiring towels to soak up rainwater. Interviews with residents confirmed the persistent water leakage and damage, with some residents having to move their beds away from the walls to avoid water damage. The 100-hall and dining room also exhibited multiple deficiencies, including mismatched paint, holes in walls, discolored and missing ceiling tiles, and dusty air vents. The kitchen area had missing ceiling tiles and dead bugs in light fixtures above food preparation areas. The 300-hall, a secured behavior unit, had similar issues with broken tiles, mold-like discoloration, and non-functional hot water in the handwashing area. Interviews with staff and residents corroborated these findings, highlighting the facility's ongoing issues with maintenance and cleanliness.
Food Safety and Sanitation Deficiencies
Penalty
Summary
The facility failed to adhere to professional standards for food service safety, which had the potential to affect all 46 residents. During an observation of the kitchen, it was noted that the trash cans had a build-up of food debris and splatter on the sides and lacked lids. Additionally, the wall tiles near the three-compartment sink were covered with an unknown black substance resembling mold. These findings were confirmed by the Dietary Manager present during the observation. Further observation of the tray service line revealed that a dietary staff member did not sanitize the food thermometer before or between taking temperatures of different food items. The thermometer was used consecutively on broccoli, pork stir fry, hamburger patty, and rice without any sanitization. The facility's policy on sanitation, dated June 2016, requires dietary staff to maintain sanitation through a comprehensive cleaning schedule, which was not followed in this instance.
Equipment Maintenance Failures in LTC Facility
Penalty
Summary
The facility failed to maintain essential equipment in safe operating condition, affecting two residents and potentially all 46 residents due to a malfunctioning dishwasher. Resident #24's bed was broken, with the bottom frame twisted and the mattress not properly aligned, causing discomfort and potential safety issues. Despite attempts by a State Tested Nurse Aide (STNA) to fix the bed, the problem persisted, indicating a lack of timely maintenance and repair. Resident #27's bed had a spliced electrical cord, joined with wire nuts and electrical tape, and was plugged into a damaged outlet. This makeshift repair was done by the Maintenance Supervisor, who claimed it was a temporary fix until a new cord could be ordered. The bed's malfunction prevented it from moving up and down, which was necessary for providing personal care. The resident was unaware of the unsafe condition of the bed's electrical cord. The facility's dishwasher was also not maintained properly, with a non-functional thermostat gauge and failure to reach the required sanitization temperature of 120 degrees Fahrenheit. The Dietary Manager used a food thermometer to check temperatures, which consistently fell short. Additionally, the sanitizer was not being dispensed due to worn-out parts, and temporary fixes were not effective. The facility lacked documentation of ordered parts or routine maintenance records, and the local Health Department had previously noted issues with sanitizer concentration monitoring.
Lack of Secured Handrails in 200 Unit Hallway
Penalty
Summary
The facility failed to ensure that there were secured handrails throughout the hallway on the 200 unit, which had the potential to affect 15 independently mobile residents residing in that unit. During an initial tour of the 200-hall, it was observed that there were no handrails affixed to the walls. This observation was confirmed in an interview with the Administrator, who acknowledged the absence of handrails and mentioned that the unit was undergoing remodeling, and he would need to order them. This deficiency was investigated under Master Complaint Numbers OH00156054, OH00155202, and OH00155184.
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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