Geneva Center For Rehabilitation And Nursing
Inspection history, citations, penalties and survey trends for this long-term care facility in Geneva, Ohio.
- Location
- 1140 South Broadway, Geneva, Ohio 44041
- CMS Provider Number
- 366326
- Inspections on file
- 24
- Latest survey
- May 15, 2025
- Citations (last 12 mo.)
- 0
Citation history
Health deficiencies cited at Geneva Center For Rehabilitation And Nursing during CMS and state inspections, most recent first.
A resident with multiple chronic conditions expressed a desire to leave the facility and live in the community, but the care plan was not updated to reflect this preference, and staff did not assist with community discharge planning or document referrals to local agencies, as required by facility policy. The resident ultimately left the facility without a formal discharge plan, and her representative reported a lack of support for her discharge goals.
A resident with impaired cognition and bowel incontinence was admitted with a coccyx pressure ulcer, but the facility failed to document or provide necessary wound care. This led to the resident being hospitalized for an extensive pressure ulcer with cellulitis. Upon readmission, wound care was again delayed, despite the resident's complex medical history. Interviews confirmed the lack of timely wound care, contrary to facility policy.
The facility failed to maintain kitchen cleanliness and did not properly monitor the dish machine for effective sanitization. Staff were unaware of the correct temperature and chemical levels for the dish machine, and incorrect test strips were used. The monthly records were inaccurately filled, and the kitchen equipment was found dirty. This affected the potential safety of 63 residents.
The facility failed to implement enhanced barrier precautions (EBP) for residents with indwelling medical devices, as required by guidelines. Observations revealed that a resident with a PICC line and another with an indwelling urinary catheter lacked EBP signage and PPE at room entrances. Staff placed PPE on the floor due to improper setup. Additionally, a resident with an enteral feeding tube and another with a PICC line had EBP signage, but staff did not wear gowns during procedures, contrary to policy.
The facility did not ensure that STNAs received annual performance evaluations, as confirmed by a review of employee files and an interview with the HR Director. This affected two STNAs hired in December 2022 and had the potential to impact all 63 residents.
The facility failed to maintain comprehensive care plans and Kardexes for residents, resulting in deficiencies in care. A resident with edema did not have a care plan for her midline IV catheter, and her embolic stockings were not applied as ordered. Another resident with hemiparesis was not wearing prescribed embolic stockings due to incomplete documentation. A third resident's oxygen use was not addressed in his care plan, and safety measures were lacking. Additionally, a resident with a hand contraction did not have a care plan for a prescribed orthotic.
The facility failed to prepare pureed green beans correctly, affecting five residents on pureed diets. A staff member added excessive cooking water to the blender, resulting in a thin mixture. To correct this, a thickener was added multiple times, diluting the taste and nutrient density. The staff member confirmed the error in preparation.
The facility failed to provide privacy for urinary catheter drainage bags for three residents, affecting their right to a dignified existence. Observations showed that the catheter bags were exposed to public view without privacy coverings, as confirmed by staff interviews. Despite care plans indicating the need for privacy, the facility did not ensure the catheter bags were covered or positioned out of public view.
Two residents in the facility did not have embolic stockings applied as ordered by their physicians, despite having edema. One resident with congestive heart failure and another with hemiparesis were observed without the stockings, and staff interviews revealed a lack of awareness of the orders due to missing information in the Kardex and care plans. The facility's policy required verification of orders and application of stockings in the morning, which was not followed.
A facility failed to obtain physician's orders and provide adequate care for a resident's indwelling urinary catheter. The resident, with conditions including pneumonia and chronic kidney disease, had no orders for catheter care upon admission, and records showed no evidence of care being provided. This deficiency was confirmed by the ADON.
A facility failed to monitor and maintain a midline IV catheter for a resident with congestive heart failure, hypertension, and COPD. The resident's care plan lacked details on the catheter, and there were no orders for its maintenance or monitoring. Staff interviews revealed a lack of awareness and documentation, and the facility's policy for catheter maintenance was not followed, affecting the resident and potentially another with IV access.
The facility failed to provide proper respiratory care for two residents, including missing oxygen orders, unsecured oxygen cylinders, and absent safety signage. One resident with cognitive impairment was observed with an unsecured oxygen cylinder and no care plan for oxygen use. Another resident with chronic respiratory issues received oxygen without physician orders or safety signage, contrary to facility policy.
The facility failed to address pharmacy recommendations in a timely manner for three residents. A resident continued to receive trazadone in half tablets despite recommendations to change the dosing regimen. Another resident was prescribed Seroquel without a proper diagnosis, and recommendations to discontinue or add a diagnosis were ignored. A third resident's PRN medication orders lacked specific usage parameters, and recommendations to clarify them were not addressed.
The facility failed to conduct reference checks for four newly hired staff members, including an LPN, two STNAs, and a Maintenance Director. This oversight was confirmed by the HR Director and had the potential to affect all 63 residents in the facility.
The facility failed to obtain signed and witnessed authorizations before managing funds for three residents. One resident had $50.00 deposited without a witness signature, another had $5.00 deposited without any authorization form, and a third had previously managed funds without documented authorization. These issues were confirmed by the HR Director.
Failure to Revise Care Plan and Assist with Community Discharge Planning
Penalty
Summary
A deficiency was identified when the facility failed to revise a resident's comprehensive care plan to reflect her expressed desire to live in the community and did not provide adequate discharge planning assistance. The resident, who had multiple diagnoses including multiple sclerosis, diabetes, anxiety disorder, bipolar disorder, schizoaffective disorder, and major depression, was admitted with an initial care plan indicating long-term placement. Although the resident initially agreed to stay at the facility, she later communicated her wish to leave and live independently in an apartment, despite previous eviction issues. Documentation showed that after the resident expressed her intent to leave, the facility offered referrals to other facilities, which she declined, but did not explore or document other community-based options. There was no evidence in the care plan or nursing notes that her request to return to the community was addressed or that interventions were implemented to support her discharge goal. The facility's own policy required documentation of the resident's preferences and referrals to local contact agencies, but this was not done. Interviews with the social service designee and the resident's mother confirmed that the resident's preference for community living was not incorporated into her care plan, and no efforts were made to assist her in finding community options. The resident ultimately left the facility without a formal discharge plan, and her mother reported that the facility did not provide support for her daughter's goal to live outside the facility.
Failure to Provide Timely Pressure Ulcer Care
Penalty
Summary
The facility failed to provide comprehensive and individualized pressure ulcer care for a resident, leading to actual harm. The resident, who had impaired cognition and bowel incontinence, was admitted with a coccyx pressure ulcer. Despite the presence of a wound, the facility did not document any wound care or treatment being initiated from the time of admission. This lack of action resulted in the resident being transferred to the emergency room, where an extensive coccyx/sacral pressure ulcer with surrounding cellulitis was identified, necessitating hospitalization for wound care intervention and intravenous antibiotic treatment. Upon the resident's readmission to the facility, there was again a failure to initiate wound care promptly. The resident was readmitted for continued wound care and treatment, but no wound care was documented until several days later. The facility's inaction persisted despite the resident's complex medical history, which included diabetes mellitus type II, chronic obstructive pulmonary disease, and protein-calorie malnutrition, all of which could complicate wound healing. Interviews with facility staff confirmed the absence of wound care or treatment during critical periods, both after the initial admission and following the resident's readmission. The facility's policy required examination and treatment of pressure ulcers upon admission, but this protocol was not followed, resulting in the resident's condition worsening and requiring hospitalization.
Kitchen Sanitation and Dish Machine Monitoring Deficiency
Penalty
Summary
The facility failed to maintain the kitchen in a clean and sanitary manner and did not ensure that the dish machine was monitored for effective sanitization. During an initial kitchen tour, it was observed that the dietary staff, including the Dietary Manager and workers, were not knowledgeable about the correct temperature and chemical levels required for the dish machine. The Dietary Manager used an incorrect test strip meant for Quaternary solutions, which did not provide any results for the dish machine's chemical level. Additionally, the dietary worker was observed using the same gloves for handling both dirty and clean dishes, and the kitchen equipment, such as utensil drawers and carts, were found to be dirty with crumbs and food debris. Further investigation revealed that the monthly records for the dish machine's temperature and chemical levels were inaccurately filled out, indicating a consistent final rinse of 50 to 100 ppm, despite the facility not having the correct test strips available. Interviews with the Dietary Manager confirmed that the dish machine sanitization levels had not been tested correctly, and the records for May 2024 were inaccurate or falsified. The Dietary Manager admitted to using the wrong test strips for an unspecified duration, which could potentially affect the 63 residents residing in the facility.
Failure to Implement Enhanced Barrier Precautions
Penalty
Summary
The facility failed to implement enhanced barrier precautions (EBP) for residents with indwelling medical devices, as required by the guidelines from the Centers for Medicare & Medicaid Services. Observations revealed that Resident #262, who had a PICC line for IV antibiotic therapy, did not have EBP posted or personal protective equipment (PPE) available at the room entrance. Similarly, Resident #264, with an indwelling urinary catheter, lacked EBP signage and PPE at the room entrance. Staff members were observed placing PPE on the floor due to the absence of proper setup. Resident #56, who required an enteral feeding tube, had EBP signage, but the registered nurse administering medications did not wear a gown as required. Additionally, Resident #313, with a PICC line for IV antibiotic administration, had EBP signage, but the Assistant Director of Nursing did not wear a gown during medication administration. The facility's policy on Disease-Specific Isolation/Precautions, initiated on 04/01/24, required the use of EBP for residents with indwelling medical devices, even if the infectious status was unknown. The failure to adhere to these guidelines was confirmed through interviews with staff members, who acknowledged the absence of EBP and the lack of gown usage during high-contact resident care activities.
Failure to Conduct Annual Performance Evaluations for STNAs
Penalty
Summary
The facility failed to ensure that state-tested nursing aides (STNAs) received their required annual performance evaluations. This deficiency was identified during a review of employee files, which revealed that two STNAs, hired in December 2022, did not have documented evidence of receiving annual performance evaluations. The absence of these evaluations was confirmed during an interview with the Human Resources Director, who acknowledged that the facility did not conduct annual evaluations for their employees. This oversight had the potential to impact all 63 residents residing in the facility.
Incomplete Care Plans and Kardexes Lead to Deficiencies in Resident Care
Penalty
Summary
The facility failed to ensure comprehensive care plans and Kardexes were complete for several residents, leading to deficiencies in care. Resident #16, who had diagnoses including congestive heart failure and hypertension, was on diuretic therapy for edema but did not have a care plan addressing her midline IV catheter. Despite having orders for embolic stockings, these were not applied, and the Kardex did not reflect this requirement. Staff interviews revealed a lack of awareness and responsibility for updating the Kardex, resulting in the resident not receiving the necessary care. Resident #50, with a history of hemiparesis and cognitive impairment, also had orders for embolic stockings due to edema, which were not documented in the care plan or Kardex. Observations confirmed the resident was not wearing the stockings, and staff were unaware of the order, relying solely on the incomplete Kardex for guidance. This oversight led to the resident not receiving the prescribed treatment for her condition. Resident #52, who was cognitively impaired and required oxygen therapy, did not have a care plan addressing his oxygen use. Observations noted the absence of safety measures, such as signage and proper storage for oxygen cylinders. Similarly, Resident #14, with a hand contraction, lacked a care plan for the use of a prescribed hand orthotic. Staff interviews indicated a lack of communication and documentation regarding the orthotic, resulting in the resident not using it as intended.
Improper Puree Preparation Affects Nutrient Density
Penalty
Summary
The facility failed to properly prepare pureed green beans in a manner that preserved their nutrient value and taste, affecting five residents who required pureed consistency foods. During an observation, a staff member added green beans and a large amount of cooking water to a blender, resulting in a mixture that was too thin. To correct the consistency, the cook added a thickener multiple times, which diluted the taste and nutrient density of the green beans. The staff member acknowledged that too much water had been used, necessitating the addition of thickener to achieve the correct consistency.
Failure to Ensure Privacy for Urinary Catheter Drainage Bags
Penalty
Summary
The facility failed to provide privacy for urinary catheter drainage bags for three residents, affecting their right to a dignified existence and privacy. Observations revealed that the urinary catheter drainage bags for Residents #25, #56, and #264 were positioned in a manner that exposed them to public view from the hallway, without any privacy covering. This was confirmed through interviews with staff members, including a State Tested Nursing Assistant (STNA) and a Registered Nurse (RN), who acknowledged the lack of privacy coverings and improper positioning of the catheter bags. Resident #25, diagnosed with neuromuscular dysfunction of the bladder, multiple sclerosis, and diabetes mellitus type II, had a suprapubic catheter, with care plans indicating the need for privacy. Similarly, Resident #56, with urinary retention and diabetes mellitus type II, had an indwelling urinary catheter, and Resident #264, recently admitted with chronic kidney disease and pneumonia, also had an indwelling catheter. Despite care plans specifying the need for privacy, the facility did not ensure the catheter bags were covered or positioned out of public view, leading to the deficiency.
Failure to Apply Embolic Stockings as Ordered
Penalty
Summary
The facility failed to ensure that embolic stockings were applied as ordered by the physician for two residents, Resident #16 and Resident #50, who were reviewed for edema. Resident #16, diagnosed with congestive heart failure, hypertension, and chronic obstructive pulmonary disease, had a physician's order for TED hose to be applied in the morning and removed at night due to bilateral lower extremity edema. However, observations on multiple occasions revealed that Resident #16 was without embolic stockings, despite having moderate edema. Interviews with staff, including a State tested Nurse Aide (STNA) and an Agency Registered Nurse (RN), confirmed that the embolic stockings were not applied as ordered, and the Kardex did not include instructions for the stockings. Similarly, Resident #50, who had difficulty walking, hypertension, hemiplegia, and hemiparesis following a cerebral infarction, also had a physician's order for embolic stockings to be applied in the morning and removed at night. Observations showed that Resident #50 was without embolic stockings and had swelling in her lower extremities. Interviews with the STNA and Agency RN revealed that they were unaware of the order for embolic stockings, as it was not documented in the Kardex or care plan. The RN admitted to signing off on the application of the stockings without verifying their use. The facility's policy on applying anti-emboli stockings, dated October 2010, required staff to verify orders for stockings and review care plans for any special needs of residents. The policy also stated that stockings should be applied in the morning before residents get out of bed. The failure to adhere to these procedures resulted in the deficiency, as the residents did not receive the prescribed care to manage their edema.
Failure to Provide Adequate Catheter Care
Penalty
Summary
The facility failed to obtain physician's orders and provide adequate care for an indwelling urinary catheter for a resident. The resident, who was recently admitted, had diagnoses including pneumonia, chronic kidney disease stage III, and diabetes mellitus. Upon admission, the baseline plan of care indicated the presence of an indwelling urinary catheter. However, there were no physician's orders to monitor, maintain, or care for the catheter from the time of admission. Additionally, the medication and treatment administration records showed no evidence of catheter care being provided during this period. This deficiency was confirmed through an interview with the Assistant Director of Nursing.
Failure to Monitor and Maintain Midline IV Catheter
Penalty
Summary
The facility failed to ensure proper monitoring and maintenance of a midline intravenous catheter for Resident #16, who was admitted with diagnoses including congestive heart failure, hypertension, and chronic obstructive pulmonary disease. The resident's comprehensive care plan did not include any information regarding the midline IV catheter, and the quarterly Minimum Data Set assessment did not reflect any IV therapy. Despite orders for IV fluids, there were no subsequent orders or documentation for maintaining or monitoring the midline catheter, such as flushing or checking for signs of infection. Interviews with facility staff revealed a lack of awareness and documentation regarding the midline catheter's maintenance. The Assistant Director of Nursing confirmed that there were no physician orders or documented evidence of monitoring the catheter per facility policy or manufacturer guidelines. The facility's policy required flushing and assessing catheter function at least every 24 hours, but this was not followed. The oversight affected Resident #16 and had the potential to affect another resident with IV access.
Deficiency in Respiratory Care and Oxygen Management
Penalty
Summary
The facility failed to ensure proper respiratory care for two residents, which included the absence of oxygen orders, unsecured oxygen cylinders, and missing oxygen safety signage. Resident #52, who was cognitively impaired and had diagnoses including congestive heart failure and hypertension, was observed receiving oxygen without a sign indicating its use. Additionally, an E-cylinder was found freestanding next to his bed, contrary to the facility's policy requiring cylinders to be secured in appropriate storage racks. The Director of Nursing confirmed these observations, and it was verified that Resident #52's care plan did not include his oxygen use. Resident #264, diagnosed with pneumonia, chronic respiratory failure with hypoxia, and chronic obstructive pulmonary disease, was observed receiving continuous oxygen at three liters per minute without any physician's orders for oxygen or monitoring of blood oxygenation saturation. A CPAP machine was present, but no oxygen safety signage was posted. An LPN confirmed the absence of oxygen-related orders and signage, which was against the facility's policy that mandates a physician's order before administering oxygen and the placement of an 'Oxygen in Use' sign.
Failure to Address Pharmacy Recommendations Timely
Penalty
Summary
The facility failed to ensure that pharmacy recommendations were addressed by the physician in a timely manner, affecting three residents. For Resident #15, the pharmacist recommended changing the dosing regimen of trazadone to avoid administering half tablets. Despite multiple recommendations made on 06/12/23 and 07/17/23, the forms remained unsigned, and no changes were made until 10/17/23. This delay was confirmed by the Regional Travel Director of Nursing during an interview. Resident #21 was prescribed Seroquel without a proper diagnosis to support its use. The consultant pharmacist repeatedly recommended discontinuing the medication or adding a supporting diagnosis on 06/12/23, 07/17/23, 08/23/23, and 09/21/23. These recommendations were not signed or addressed, and the resident continued to receive the medication from 04/06/23 to 10/17/23 without a supporting diagnosis. This oversight was verified by the Regional Travel Director of Nursing. For Resident #25, the pharmacist recommended specifying the conditions under which PRN medications acetaminophen and Norco should be used. Recommendations made on 03/25/24 and 04/28/24 were not completed, and there was no evidence that the physician was notified or addressed the recommendations. As of May 2024, no changes were made to the PRN orders to specify parameters for use, contrary to the facility's medication therapy policy.
Failure to Conduct Reference Checks for New Hires
Penalty
Summary
The facility failed to ensure that all staff members received reference checks before being hired, affecting four employees: an LPN, two STNAs, and a Maintenance Director. This deficiency was identified during a record review and interview process. The review of employee files revealed no evidence that the facility made reference checks or attempted to verify information from past or current employers for these staff members. The Human Resources Director confirmed the findings and was unable to provide documented evidence of any reference checks for the affected employees. This oversight had the potential to impact all 63 residents residing in the facility.
Failure to Obtain Proper Authorization for Managing Resident Funds
Penalty
Summary
The facility failed to ensure proper authorization was obtained before managing resident funds, affecting three out of five residents reviewed for funds management. Resident #55 had $50.00 deposited in the facility's resident trust account without a witness signature on the authorization form. Resident #39 had $5.00 deposited in the trust account, but the facility could not provide documented evidence of a signed or witnessed authorization form. Similarly, Resident #61 had previously managed funds in a trust account that was closed, but the facility lacked documented evidence of a signed or witnessed authorization form for managing his personal money. These findings were confirmed during an interview with the Human Resources Director.
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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