Gardens Of Belden Village
Inspection history, citations, penalties and survey trends for this long-term care facility in Canton, Ohio.
- Location
- 5005 Higbee Avenue Nw, Canton, Ohio 44718
- CMS Provider Number
- 365324
- Inspections on file
- 43
- Latest survey
- March 2, 2026
- Citations (last 12 mo.)
- 3
Citation history
Health deficiencies cited at Gardens Of Belden Village during CMS and state inspections, most recent first.
A cognitively impaired resident with dementia and severe communication deficits was inappropriately touched on the breast by another ambulatory, cognitively intact resident, as directly witnessed by a CNA at the nurses’ station. The witnessing CNA immediately intervened and reported the incident to an LPN, but the facility’s subsequent investigation concluded that no abuse occurred, relying on an assumption that the cognitively impaired resident had lifted her own shirt and that there were no witnesses. The administrator reported being unaware of the CNA’s written witness statement describing the breast touching, and the resident’s husband stated the incident was downplayed and that he was not informed his wife’s breast had been touched. The facility’s actions did not align with its abuse policy requiring thorough investigation and witness interviews, resulting in a failure to ensure the resident was free from sexual abuse.
A cognitively impaired resident with dementia was allegedly sexually abused when another ambulatory, cognitively intact resident lifted her shirt and touched her breast at the nurses’ station, as witnessed by a CNA who immediately intervened and reported the incident to an LPN and the DON. The facility’s investigation concluded no abuse occurred, but it did not include interviewing all staff who were present and aware of the allegation, including an LPN who heard the CNA’s report and was never asked for a statement. The Administrator was unaware of the CNA’s written statement describing breast touching and told the resident’s husband a different version of events that he felt downplayed what happened, despite facility policy requiring that all witnesses be interviewed in abuse investigations.
Two residents experienced significant weight loss without appropriate individualized nutrition care planning or required weight monitoring. One resident with dementia and other psychiatric diagnoses had documented weight decline and a dietician‑ordered change in Med Pass supplements, but weekly weights were not obtained as required, the new supplement order was not entered for many days, and the care plan was not updated to reflect the weight loss. Another resident with neurologic and psychiatric conditions had multiple documented weight changes, but admission and weekly weights were not consistently taken, and no care plan was developed to address the weight loss, despite a dietician note identifying a significant one‑month weight change and ordering changes to tube feeding and continued monitoring.
A resident with a history of fractures and anxiety disorder experienced symptoms of Norovirus, including nausea and vomiting, which were not documented or addressed by the facility. Despite staff awareness and family concerns, the facility failed to notify the physician or obtain medication orders, violating their policy for change of condition.
Two residents in an LTC facility suffered injuries due to deficiencies in care and equipment maintenance. One resident was not transferred with a gait belt as required, resulting in a hip fracture, while another fell due to a malfunctioning bed side rail, leading to a fibula fracture. The facility lacked proper equipment and maintenance protocols, contributing to these incidents.
The facility failed to maintain sanitary conditions in the kitchen, affecting all 87 residents receiving meals. Observations revealed soiled equipment, undated and unlabeled food items, and non-functional dishwashing facilities. Staff interviews confirmed ongoing issues with the dish machine and sink, which were not promptly addressed. Additionally, unit refrigerators contained spoiled or expired food, and facility policies on sanitization and food labeling were not followed.
The facility failed to ensure proper PPE use for staff interacting with COVID-19 positive residents. A housekeeping staff member did not wear the required N95 mask and eye protection, and a nurse improperly donned and doffed PPE, contrary to facility policy and CDC guidelines.
A resident with end-stage renal disease did not receive proper pre and post-dialysis evaluations as required by physician orders. The facility failed to document vital signs before dialysis and did not assess the dialysis shunt for bruit or thrill. The facility's policy lacked a requirement for pre-dialysis evaluations, contributing to the deficiency.
The facility failed to complete timely repairs for environmental concerns affecting three residents. A resident's room had stained and broken ceiling tiles, and another resident's bathroom sink was plugged with standing dirty water. Despite contractor repairs, the facility did not replace ceiling tiles or address flooring issues. The maintenance policy lacked specifics on repair timeframes, contributing to delays.
A resident with Alzheimer's, depression, and anxiety did not receive proper perineal care after an incontinence episode. Two LPNs failed to follow the facility's policy, which required washing the perineal area from front to back. Instead, they only cleaned from the back to the front, leading to a deficiency.
Failure to Protect Cognitively Impaired Resident From Sexual Abuse by Another Resident
Penalty
Summary
The facility failed to protect a cognitively impaired resident from sexual abuse by another resident. One resident was admitted with dementia with psychotic disturbance, cognitive communication deficit, and type 2 diabetes, and was care planned for impaired cognitive function requiring supervision, reorientation, and monitoring. A 5-Day MDS documented severe cognitive impairment, and the resident’s husband reported she was confused and unable to make her needs known. There were no progress notes documenting physical or sexual abuse involving this resident on the date of the incident. Another resident, admitted with cerebral infarction, schizophrenia, and psychoactive substance abuse, had intact cognition and was ambulatory per the admission MDS. This resident’s care plan did not include any information related to sexual history or sexual behaviors. On the evening in question, a CNA witnessed this cognitively intact resident lift the cognitively impaired resident’s shirt and rub her left breast at the nurses’ station. The CNA immediately intervened, separated the residents, questioned the resident who did the touching, and reported the incident to an LPN. The resident who committed the touching denied the behavior and made a comment that the other resident should wear a bra. The facility’s self-reported incident described the CNA’s account, but the facility’s investigation ultimately concluded that no abuse had occurred, based on a belief that the cognitively impaired resident had lifted her own shirt and that there were no witnesses. The administrator later stated he was unaware of the CNA’s written witness statement describing the breast touching. The resident’s husband reported that the administrator downplayed what had happened and that he was not informed that his wife’s breast had been touched inappropriately. Review of facility policy on abuse, neglect, exploitation, and misappropriation of resident property showed that all alleged violations of abuse were to be investigated and all witnesses interviewed, but the investigation did not fully incorporate the CNA’s eyewitness account, leading to a failure to ensure the resident was free from sexual abuse.
Failure to Thoroughly Investigate Sexual Abuse Allegation
Penalty
Summary
The deficiency involves the facility’s failure to thoroughly investigate an allegation of sexual abuse involving Resident #77. Resident #77 was admitted with dementia with psychotic disturbance, cognitive communication deficit, and type 2 diabetes, and had a care plan identifying impaired cognitive function and the need for supervision, reorientation, and monitoring for changes. A 5-Day MDS assessment documented severe cognitive impairment, and an attempted interview during the survey showed the resident could only state her name and was unable to answer questions. Despite these documented cognitive limitations, there were no progress notes in the medical record addressing the alleged physical or sexual abuse on the date of the incident. The alleged perpetrator, Resident #43, had diagnoses including cerebral infarction, schizophrenia, and psychoactive substance abuse, and was documented as cognitively intact and ambulatory on the admission MDS. The care plan for Resident #43 did not include any information related to sexual history or sexual behaviors. According to the facility’s self-reported incident (SRI), a CNA witnessed Resident #43 lift Resident #77’s shirt and touch her left breast at approximately 10:30 P.M., then immediately separated the residents and reported the incident to an LPN, who notified the DON. The SRI indicated an investigation was started, including monitoring both residents, and the facility ultimately concluded that no abuse had occurred. However, the investigation did not include interviewing all relevant witnesses as required by the facility’s abuse policy. LPN #267, who was working and orienting with the reporting LPN at the time of the incident and who heard the CNA’s report that Resident #43 went into Resident #77’s shirt and rubbed her breast, was never interviewed or asked to provide a statement. The Administrator acknowledged he did not interview LPN #267 and was unaware of the CNA’s written witness statement describing breast touching, and he stated the allegation was found unsubstantiated because it was reported that the resident lifted her own shirt and there were no witnesses. Additionally, Resident #77’s husband reported that the incident was downplayed to him by the Administrator and that he was not informed that his wife’s breast had been touched inappropriately. The facility’s policy required interviewing all witnesses, but this was not done, resulting in an incomplete investigation of the sexual abuse allegation.
Failure to Implement Individualized Nutrition Care Plans and Required Weight Monitoring
Penalty
Summary
The deficiency involves the facility’s failure to implement and maintain individualized, comprehensive nutrition plans and appropriate weight monitoring for two residents, in accordance with its own weight assessment policy. For one resident with Alzheimer’s disease, dementia, and intermittent explosive disorder, the admission orders included a regular diet with Med Pass supplement and the care plan identified risk for malnutrition due to diagnoses, depression, and supplement use. However, the care plan was not revised or individualized to address subsequent weight loss. Weight records showed a decline from 121.2 lbs on admission to 110 lbs over several weeks, and weekly weights were not obtained as required during the first four weeks after admission. The registered dietician documented a significant 8% one‑month weight loss and ordered a change in the Med Pass supplement regimen and continued weight monitoring per physician order. Despite this, the original Med Pass order was not discontinued until 11 days later, and the new Med Pass order was not entered into the system or reflected on the MAR until that same later date. Interviews with the RD, the regional director of operations, and the DON confirmed that weights were not taken on admission and weekly for four weeks as required, that weights were not monitored weekly after the significant weight change, that the supplement order change from 01/19/26 was not entered until 01/30/26, and that the nutrition care plan was not updated to reflect the resident’s weight loss. For another resident with cerebral infarction, schizophrenia, and psychoactive substance abuse, the care plan did not include any plan for weight loss. Weight records showed an admission weight of 164 lbs, followed by weights of 166 lbs, 156 lbs, and 154 lbs, and the resident’s weight was not taken at admission or weekly for four weeks as required by policy. The RD later documented a significant 7% one‑month weight change and ordered changes to tube feeding (Jevity 1.5) and continued nutrition monitoring with weights per physician order. However, interviews confirmed that required admission and weekly weights were not obtained, that weekly weights were not taken after the significant weight loss, and that there was no care plan addressing the resident’s weight loss, contrary to the facility’s policy requiring multidisciplinary, individualized care plans for weight loss or impaired nutrition.
Failure to Address Resident's Change of Condition
Penalty
Summary
The facility failed to provide timely care and services to a resident who experienced a change of condition. The resident, who had a history of multiple fractures and anxiety disorder, was admitted following a motor vehicle accident. During her stay, she experienced symptoms consistent with Norovirus, including nausea, vomiting, and diarrhea, which were not documented in her nursing progress notes. Despite her complaints and visible symptoms, there was no evidence of physician notification or medication orders to address her condition. Interviews with staff and family members revealed that the resident was visibly ill around Christmas, with severe symptoms that limited her participation in therapy sessions. The therapy director and certified nursing assistants recalled the resident's condition and confirmed that the nursing staff was aware of her symptoms. However, the registered nurse on duty could not recall if the resident had requested medication for nausea, and the facility's policy for change of condition was not followed. The facility's policy required prompt notification of the physician and obtaining medication orders when a resident experienced a significant change in condition. The regional director of nursing confirmed that the facility did not adhere to this procedure for the resident, resulting in a deficiency. The family member also reported concerns to the facility administrator, who acknowledged receiving the complaint and passing it on to nurse managers, but no action was taken to alleviate the resident's symptoms.
Deficiencies in Resident Transfer and Equipment Maintenance Lead to Injuries
Penalty
Summary
The facility failed to ensure effective measures were in place to prevent resident falls with injury, affecting two residents. Resident #38 was not transferred appropriately using a gait belt, as care planned, resulting in a fall and a fractured hip. The incident occurred when a CNA attempted to transfer the resident from a bedside commode to a wheelchair without the use of a gait belt, which was a required intervention in the resident's care plan. The CNA admitted to not using a gait belt, citing the facility's lack of availability of such equipment. The resident, who had intact cognition, sustained a closed intertrochanteric fracture of the left hip, requiring surgical repair and resulting in chronic pain. Resident #48 experienced a fall due to a malfunctioning bed U-bar side rail, which was not maintained in good repair. During incontinence care, the resident used the side rail to assist in rolling over, but the rail detached, causing the resident to fall out of bed and sustain a fracture to the left fibula. The facility's policy lacked specific information on the frequency of maintenance checks for bed rails, contributing to the incident. The resident, who was cognitively intact and required assistance for bed mobility, was admitted to the hospital following the fall. Both incidents highlight deficiencies in the facility's adherence to care plans and equipment maintenance protocols. The lack of proper equipment and maintenance checks directly contributed to the harm experienced by the residents. Interviews with staff and review of facility policies confirmed these lapses, indicating a need for improved safety measures and adherence to care protocols to prevent future occurrences.
Sanitation and Food Storage Deficiencies in Facility Kitchen
Penalty
Summary
The facility failed to maintain the kitchen in a sanitary manner, affecting all 87 residents receiving meals. During an inspection, it was observed that the reach-in refrigerator had visible caked-on soiling, undated and unlabeled food items, and multiple spills with food particles. The steam table was also visibly soiled, and the three-compartment sink was non-functional due to a plugged drain. The high-temperature dish machine did not reach the required temperature for proper sanitation. Interviews with staff revealed that the issues with the dish machine and sink had been ongoing, with the maintenance director aware of the problems but unable to resolve them promptly. Additionally, the facility's unit refrigerators for resident use contained undated and unlabeled food items, some of which were spoiled or expired. The facility's policy on sanitization was not followed, as manual washing and sanitizing were not conducted according to the three-step process outlined. The facility's policy on food brought in by visitors also lacked specific dating timeframes, contributing to the improper labeling and storage of perishable food items. These deficiencies indicate a failure to adhere to professional standards for food storage, preparation, and sanitation, impacting the quality of care provided to the residents.
Improper Use of PPE for COVID-19 Positive Residents
Penalty
Summary
The facility failed to ensure the appropriate use of personal protective equipment (PPE) for staff interacting with COVID-19 positive residents, affecting multiple residents on the second floor. In one instance, a housekeeping staff member was observed exiting a COVID-19 positive resident's room wearing a blue surgical gown, gloves, and a blue surgical mask, but not the required N95 mask and eye protection, despite signage indicating the need for such precautions. This staff member confirmed the oversight and acknowledged cleaning both resident rooms and common areas on the second floor. In another instance, a registered nurse was observed improperly donning PPE before entering a COVID-19 positive resident's room. The nurse initially entered the room without eye protection, believing her glasses sufficed, and only applied goggles after being prompted. After completing her tasks, the nurse failed to doff her N95 mask and eye protection before interacting with other residents and staff, contrary to the facility's COVID-19 policy and CDC guidelines. These actions were inconsistent with the facility's established procedures for PPE use during droplet precautions.
Failure to Monitor Dialysis Care for a Resident
Penalty
Summary
The facility failed to ensure proper monitoring of a resident requiring dialysis care, specifically Resident #13, who was affected by this deficiency. Resident #13 had multiple diagnoses, including end-stage renal disease and dependence on renal dialysis, and was scheduled for dialysis treatments at an off-site center three times a week. Despite having physician orders to check the dialysis site for signs of infection every shift, the facility did not complete pre-dialysis evaluations from January 2024 through October 2024 and post-dialysis evaluations from December 2023 through October 2024. Additionally, there was no documentation of vital signs being monitored before dialysis, and only post-dialysis vitals were recorded from June to October 2024. The facility's nursing progress notes and the Medication and Treatment Administration Records did not show any documentation of the assessment of the bruit or thrill of the resident's dialysis shunt. The care plan for Resident #13 included interventions such as checking the arteriovenous fistula every shift and coordinating care with dialysis, but these were not followed. An interview with RN #885 revealed that pre and post-dialysis vitals were checked at the dialysis center, and the paper documenting these vitals was discarded after being reviewed and entered into the electronic medical record. The facility's policy on Hemodialysis Access Care, revised in September 2010, did not include a requirement for pre-dialysis evaluations, contributing to the deficiency.
Delayed Repairs and Environmental Concerns in Resident Rooms
Penalty
Summary
The facility failed to ensure timely repairs following identified environmental concerns, affecting three residents. Observations revealed that Resident #59's room had multiple ceiling tiles with dried water stains, a hole in the bathroom drywall exposing a pipe, rust stains on the floor, and broken ceiling tiles. Resident #48's room had missing and stained ceiling tiles. Interviews confirmed these findings, and it was noted that the original water leak stemmed from issues with the toilet flange, causing damage to multiple rooms. Although repairs were completed by a contractor, the facility had not replaced the ceiling tiles or addressed the flooring issues in Resident #59's room. Additionally, Resident #69 and her daughters reported a plugged bathroom sink that was often full of dirty water, which had not been addressed by maintenance. An observation confirmed the sink was half full of standing dirty water. The facility's maintenance policy lacked specifics on the timeframe for completing repairs, contributing to the delay in addressing these issues. The deficiency was investigated under Complaint Number OH00158304.
Inadequate Perineal Care for Incontinent Resident
Penalty
Summary
The facility failed to ensure proper perineal care for a resident with incontinence of bowel and bladder, leading to a deficiency. The resident, who had been diagnosed with Alzheimer's disease, depression, and anxiety, was observed during incontinence care by two LPNs. The care plan for the resident included checking for incontinence and ensuring the skin was clean and dry if wet or soiled. However, during the observation, the LPNs did not perform perineal care appropriately after an episode of urinary and bowel incontinence. During the care, the LPNs unfastened the resident's brief, cleaned the rectal area and buttocks, and then attempted to refasten the brief without adequately cleaning the perineal area. When questioned, one of the LPNs admitted to not cleaning the resident appropriately, as she had only reached from the back to the front without following the facility's policy for perineal care. The facility's policy required washing the perineal area from front to back, separating the labia, and cleaning with downward strokes, which was not followed in this instance.
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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