Gillette Nursing Home
Inspection history, citations, penalties and survey trends for this long-term care facility in Warren, Ohio.
- Location
- 3310 Elm Rd, Warren, Ohio 44483
- CMS Provider Number
- 366129
- Inspections on file
- 18
- Latest survey
- July 31, 2025
- Citations (last 12 mo.)
- 1
Citation history
Health deficiencies cited at Gillette Nursing Home during CMS and state inspections, most recent first.
A deficiency was cited due to the facility's failure to keep an area free from accident hazards and to provide adequate supervision to prevent accidents. The environment did not meet safety standards, and there was insufficient monitoring in the area.
Surveyors identified that shower rooms used by residents were not maintained at comfortable temperatures, with measured ambient temperatures significantly below the facility's policy range. Multiple residents who required assistance with bathing and had complex medical needs reported the shower rooms as cold or chilly, and prior complaints had been documented in Resident Council meetings.
The facility did not timely report suspected misappropriation of narcotic medications to the state agency as required by policy. Two residents with cognitive impairments and pain management needs had narcotics signed out as administered by an LPN, but there was no documentation in the MAR or progress notes to confirm administration. An internal investigation found the LPN tested positive for multiple narcotics, but the incident was not reported to the state health department despite policy requirements.
Two residents did not receive adequate supervision or assistance during transfers and fall prevention, resulting in one being transferred with a mechanical lift by only one staff member instead of two, and another experiencing multiple falls due to inconsistent use of required interventions and incomplete post-fall investigations. Nursing staff interviews and documentation confirmed that fall prevention protocols and root cause analyses were not consistently followed.
A resident with Parkinson's disease and dementia received nuplazid from a specialty pharmacy, and an LPN combined pills from two bottles into one, rather than keeping each bottle in its original packaging as required. The DON, RN, and the resident's daughter were aware of this practice, which was not in accordance with the facility's medication storage policy.
The facility failed to consistently provide showers for a resident with heart failure, diabetes, and other conditions requiring assistance with personal care. Despite the resident's preference for two to three showers per week, records showed only one shower was provided during certain weeks. The resident confirmed the need for assistance and the preference for more frequent showers, which was not met. The DON could not verify compliance with the resident's shower preferences, and the facility's policy on shower documentation was not followed.
A facility failed to ensure a physician visited a resident as required. The resident, with multiple diagnoses including congestive heart failure and cancer, was last seen by a physician on a specific date, with no further visits documented. The resident confirmed the lack of visits, and the DON acknowledged the absence of documentation. Facility policy required regular physician supervision, which was not followed.
A facility failed to implement proper infection control measures for residents on enhanced barrier precautions (EBP). A resident's room lacked signage indicating EBP, and a staff member did not wash her hands after leaving this room and before entering another resident's room, who was also on EBP. The deficiency was confirmed by the Director of Nursing and affected two residents directly, with the potential to impact others.
The facility failed to maintain a homelike environment for residents on the 600 hall, with numerous instances of wall disrepair such as black scrape marks, gouges, and unpainted patches. Observations and resident interviews revealed dissatisfaction with the state of their rooms, and the Maintenance Supervisor confirmed the ongoing challenge of keeping up with repairs. The facility's policy requires maintaining a comfortable interior, but the current conditions do not meet these expectations.
The facility failed to provide nutritionally equivalent food substitutions for five residents during a lunch meal. When the facility ran out of baked beans, the Dietary Manager instructed staff to substitute cottage cheese, which was not nutritionally equivalent as confirmed by the Dietitian.
A resident with severe cognitive impairment was fed by an STNA who stood while feeding, contrary to facility policy requiring staff to sit. The resident, dependent on staff for eating, was seated in a Geri chair, and the STNA initially claimed she couldn't reach the resident's mouth while sitting. The facility's policy emphasized feeding with attention to safety, comfort, and dignity.
A resident's medical record was left visible on an unattended computer monitor in a hallway, compromising confidentiality. Staff confirmed the screen should have been locked, and a nurse aide admitted to leaving it open. The resident had a complex medical history requiring various assistance levels.
The facility failed to implement care plan interventions for a resident with Alzheimer's and contractures, as staff were unaware of brace orders and the splint was removed from the room. Additionally, two residents lacked comprehensive care plans addressing denture management and sensory needs, leading to inadequate care and staff confusion.
A facility failed to hold a timely care plan meeting for a resident with multiple medical conditions, including intracranial hemorrhage and heart disease. Despite requiring significant assistance, no care conference was held since admission. The oversight was confirmed by the resident's family and a social worker, who cited scheduling issues due to her absence.
The facility failed to ensure staff were aware of trauma-informed care needs for three residents with PTSD. Despite care plans outlining interventions for managing triggers, staff interviews revealed a lack of awareness about these plans. This deficiency affected residents with histories of trauma, including one with Alzheimer's and another with schizophrenia, highlighting a gap in implementing the facility's trauma-informed care policy.
A resident with a history of dysphagia was served intact chicken tenders instead of a mechanical soft diet, as required by their dietary needs. The error was identified during a meal service when a surveyor intervened, and the LPN confirmed the mistake. The SLP and RD later verified that the food served did not meet the mechanical soft diet requirements.
Failure to Maintain Accident-Free Environment and Adequate Supervision
Penalty
Summary
A deficiency was identified in the facility's failure to ensure that an area was free from accident hazards and that adequate supervision was provided to prevent accidents. The report notes that the environment did not meet safety standards, which could contribute to the occurrence of accidents. Specific actions or inactions leading to this deficiency include the lack of proper hazard identification and insufficient monitoring or supervision in the affected area. No additional details about specific residents, their medical history, or their condition at the time of the deficiency are provided in the report.
Shower Rooms Not Maintained at Comfortable Temperatures
Penalty
Summary
Surveyors found that the facility failed to maintain comfortable temperatures in all resident shower rooms, as required by facility policy, which states that temperatures should be kept between 71 and 81 degrees Fahrenheit. During a facility tour, the Maintenance Director measured the ambient temperature in two shower rooms used by residents and found them to be 64.8°F and 55.9°F, both below the required range. Resident Council meeting minutes from previous months documented complaints about the shower rooms being too cold, and these complaints were confirmed by the Assistant Director of Nursing. Interviews with four cognitively intact residents who required assistance with bathing revealed that they experienced the shower rooms as cold, chilly, or ice cold. These residents had various medical conditions, including COPD, cerebral infarction, metabolic encephalopathy, obesity, muscle wasting, polyneuropathy, and chronic lymphocytic leukemia, and all required substantial to maximal assistance with bathing. The deficiency was identified as affecting these four residents and had the potential to affect all residents who did not have personal showers in their rooms.
Failure to Timely Report Suspected Misappropriation of Narcotics
Penalty
Summary
The facility failed to timely report an allegation of misappropriation of narcotic medications to the appropriate state agency, as required by policy. For one resident with a history of liver disease and moderate cognitive impairment, records showed a narcotic was signed out as administered by an LPN, but there was no corresponding documentation in the Medication Administration Record (MAR) or progress notes to confirm the medication was given. Similarly, for another resident with severe cognitive impairment and chronic pain conditions, a narcotic was signed out as administered, but again, there was no documentation in the MAR or progress notes to support that the medication was actually given. A facility investigation into narcotic diversion revealed that the LPN in question tested positive for multiple narcotics and was subsequently suspended and reported to the Board of Nursing. Despite these findings and the facility's own policy requiring immediate reporting of such allegations to the state health department, no self-reported incident (SRI) was filed with the Ohio Department of Health regarding the suspected misappropriation of narcotics. Interviews with the Administrator and Director of Nursing confirmed that they were aware of the suspicions and investigation but did not report the incident to the state agency, as they believed they could not prove misappropriation since residents did receive pain medications. The facility's policy clearly defined misappropriation and required reporting within 24 hours of an allegation, but this protocol was not followed in these cases.
Failure to Provide Adequate Supervision and Fall Prevention Measures
Penalty
Summary
The facility failed to ensure adequate supervision and assistance for two residents, resulting in deficiencies related to accident hazards and fall prevention. One resident, who had multiple diagnoses including a recent hip fracture, required transfers with a mechanical lift and two staff members as per physician orders and care plan. However, during a transfer, only one CNA was present, and the resident's feet were not properly positioned on the sit-to-stand lift, causing the resident to be lowered to the floor. This incident was confirmed through interviews and documentation, which verified that the required two-person assistance was not provided during the transfer. Another resident, with a history of Parkinson's disease, repeated falls, and severe cognitive impairment, experienced multiple falls over a period of several months. The care plan and physician orders included interventions such as nonskid socks, a body pillow, and a floor mat to reduce fall risk. Despite these interventions, documentation revealed that fall interventions were not consistently in place, and several falls occurred when required equipment was either not ordered or not documented as being used. Additionally, post-fall investigations were incomplete, lacking thorough root cause analyses as required by facility policy. Many investigation forms were missing critical information about the circumstances of the falls, interventions in place at the time, and environmental factors. Interviews with nursing staff and review of facility records confirmed that fall investigations for this resident were not fully completed and that interventions were not always implemented or documented as required. The facility's own fall protocol policy mandates timely identification of causes and implementation of interventions, but this was not consistently followed. The lack of adequate supervision, incomplete documentation, and failure to ensure fall prevention measures were in place contributed to repeated falls and the identified deficiencies.
Improper Medication Storage: Combining Bottles of Nuplazid
Penalty
Summary
Facility staff failed to ensure that medications were kept in their original packaging as required by policy and professional standards. Specifically, a resident with diagnoses including Parkinson's disease, repeated falls, and dementia with mild psychotic disturbance was prescribed nuplazid, which was obtained from a specialty pharmacy by the resident's daughter. The nuplazid was brought into the facility in bottles containing 30 capsules each. Instead of maintaining each bottle separately, an LPN combined pills from an opened bottle into a new bottle, resulting in the medications being stored together in a single bottle rather than in their original packaging. Interviews with the Director of Nursing, the resident's daughter, an RN, and the LPN confirmed that the practice of combining medication bottles occurred and was known to both staff and the resident's family. The facility's medication storage policy, dated October 2013, required that medications be kept in the original packaging dispensed by the pharmacy. This practice was not followed in this instance, leading to non-compliance with medication storage requirements.
Inconsistent Shower Provision for a Resident
Penalty
Summary
The facility failed to consistently provide showers for Resident #51, who was admitted with diagnoses including heart failure, diabetes, kidney disease, unsteadiness on feet, and required assistance with personal care. The comprehensive Minimum Data Set (MDS) 3.0 assessment indicated that Resident #51 was cognitively intact, independent in eating, but required substantial assistance for toileting, partial assistance for showering, and supervision for personal hygiene. The care plan noted a self-care performance deficit due to functional mobility and lower extremity weakness, with a preference for bathing two to three times per week. However, a review of the shower sheets revealed that Resident #51 only received one shower during the weeks of 12/01/24 and 12/21/24. An interview with Resident #51 confirmed the need for assistance with showering and a preference for at least two showers per week, which was not consistently met. The Director of Nursing (DON) could not provide additional information to verify that showers were provided according to the resident's preference. The facility's policy required documentation of the name, date, and time of showers, as well as any refusals, which was not adhered to in this case.
Physician Visit Noncompliance for a Resident
Penalty
Summary
The facility failed to ensure that a physician visited Resident #36 as required. Resident #36, who was admitted with diagnoses including congestive heart failure, diabetes, anxiety, hypertension, and cancer of the head, neck, and face, was cognitively intact and required varying levels of assistance for daily activities. The medical record indicated that the resident was last seen by the physician on 11/06/24, and an interview with the resident confirmed that he had not been seen by the physician since admission, except for the one documented visit. The Director of Nursing confirmed the lack of documented evidence of any additional physician visits. The facility's policy stated that physicians should actively supervise resident care and visit as required, which was not adhered to in this case.
Infection Control Deficiency Due to Lack of Signage and Hand Hygiene
Penalty
Summary
The facility failed to ensure appropriate infection prevention and control measures for residents on enhanced barrier precautions (EBP). Specifically, there was no signage at the entrance of Resident #45's room to indicate the need for EBP, despite a physician's order for such precautions due to extended-spectrum beta-lactamase (ESBL) in her urine. Additionally, a staff member, identified as [NAME] #204, did not wash her hands after leaving Resident #45's room and before entering Resident #23's room, who was also on EBP for a wound. This oversight was confirmed during an interview with the Director of Nursing, who acknowledged the absence of the required signage and the failure of staff to adhere to hand hygiene protocols. Resident #45, who was moderately cognitively impaired, had a history of multi-drug resistant organisms and required EBP as per her care plan. Similarly, Resident #23, who was severely cognitively impaired, required EBP due to a wound. The facility's policy on transmission-based precautions mandates that signs be placed at the entrance of rooms to indicate necessary precautions and that staff wash their hands upon entering and exiting rooms of residents on EBP. The deficiency was identified during a complaint investigation and affected two residents directly, with the potential to impact 23 others identified by the facility as being on EBP.
Facility Fails to Maintain Homelike Environment Due to Wall Disrepair
Penalty
Summary
The facility failed to maintain a homelike environment for residents on the 600 hall, as evidenced by numerous instances of wall disrepair in residents' rooms. Observations revealed various issues such as black scrape marks, gouges, punctures, and unpainted patches on the walls behind recliners and other furniture. These conditions were noted in the rooms of 20 residents, affecting nearly half of the residents on the 600 hall. Interviews with residents indicated dissatisfaction with the state of their rooms, with some expressing that the damage was present upon their admission and that it would have been repaired if they were at home. The maintenance issues were confirmed during an environmental tour with the Maintenance Supervisor, who acknowledged the ongoing challenge of keeping up with painting and patching tasks. The supervisor mentioned that while efforts to repair the walls were initiated, they were often interrupted by other duties. This lack of timely maintenance was also reflected in the Resident Council Meeting minutes, where residents had previously voiced concerns about the delay in addressing repairs. The facility's policy on Housekeeping & Maintenance, dated 09/30/12, outlines the responsibility to provide necessary maintenance services to ensure a sanitary, orderly, and comfortable interior. However, the observations and resident feedback indicate a failure to adhere to this policy, resulting in an environment that does not meet the residents' expectations for a homelike setting.
Inadequate Food Substitution for Residents
Penalty
Summary
The facility failed to provide nutritionally equivalent food substitutions for five residents during a lunch meal. On the specified day, the menu included a chili dog, baked beans, country potatoes, and watermelon. However, during the meal service, the facility ran out of baked beans. The Dietary Manager instructed the staff to substitute cottage cheese for the baked beans for five residents. This substitution was not nutritionally equivalent, as confirmed by the Dietitian, who stated that baked beans were intended to be the starchy vegetable for the meal and should have been replaced with another vegetable instead of cottage cheese.
Failure to Feed Resident with Dignity
Penalty
Summary
The facility failed to ensure that a resident was fed in a dignified manner, as observed during a survey. The resident, who was severely cognitively impaired and dependent on staff for eating, was fed by a State tested Nursing Assistant (STNA) who was standing while feeding the resident. This was observed in the main dining room where the resident was seated in a Geri chair. Despite a chair being available behind the STNA, she initially chose to stand, stating she couldn't reach the resident's mouth while sitting. The resident's medical record indicated a history of Alzheimer's disease, Bell's Palsy, unspecified dementia, and other conditions requiring assistance with personal care. The care plan noted the resident's dependency on staff for eating due to severe cognitive and communication deficits. The facility's policy on the serving of food emphasized feeding residents with attention to safety, comfort, and dignity. An interview with the Speech Language Pathologist confirmed that staff should be sitting while feeding residents, highlighting the deviation from the facility's policy in this instance.
Confidentiality Breach of Resident Records
Penalty
Summary
The facility failed to maintain the confidentiality of resident records, specifically affecting one resident. During an observation, a computer monitor in the 500 hall was found displaying the medical record of a resident, including their name, medical record, and plan of care tasks, while unattended. This occurred in a public area where another resident was present, and staff members were observed passing by without securing the information. The resident in question had a complex medical history, including type two diabetes mellitus, schizophrenia, and recurrent depressive disorder, and required various levels of assistance for daily activities. Interviews with staff confirmed that the screen should have been locked to protect the resident's information. A Licensed Practical Nurse acknowledged the issue and mentioned that she had encountered similar situations before, where she would lock the screen and re-educate staff on HIPAA regulations. A State Tested Nurse Aide admitted to leaving the computer open when responding to a call-light, acknowledging the mistake. The facility's policy on confidentiality, dated 2013, mandates that all resident information be treated confidentially and safeguarded to protect privacy.
Deficiencies in Care Plan Implementation and Development
Penalty
Summary
The facility failed to implement care plan interventions as directed for Resident #5, who was admitted with Alzheimer's Disease, systolic congestive heart failure, and required assistance with personal care. The care plan required the resident to wear a left arm and wrist splint and a left ankle-foot orthotic (AFO) when out of bed to prevent worsening contractures. However, observations revealed that the resident was not wearing the hand/wrist splint as required, and staff were unaware of the brace orders. Interviews with staff confirmed a lack of knowledge and documentation regarding the splint, and the splint was improperly removed from the resident's room. For Resident #51, the facility failed to develop a comprehensive care plan addressing her denture management needs. Despite having upper dentures and being on a minced moist diet due to chewing difficulties, the care plan did not include specific interventions for denture care. Observations showed the resident's dentures frequently fell out, causing embarrassment and discomfort. Interviews with staff revealed a lack of awareness and documentation regarding the resident's denture care needs, and the facility's interdisciplinary team did not consistently include denture care in care plans. Resident #67's care plan lacked interventions related to her impaired hearing and vision, despite her need for corrective lenses and hearing aids. Observations indicated the resident was not consistently wearing her hearing aids, and staff were unsure of the care plan details regarding hearing aid use. Interviews with staff confirmed the absence of documented care plan tasks for hearing aid assistance, and the interdisciplinary team did not adequately address the resident's sensory needs in the care plan.
Failure to Conduct Timely Care Plan Meeting
Penalty
Summary
The facility failed to hold an initial care plan meeting in a timely manner for a resident, affecting one out of 22 residents reviewed for care plans. The resident was admitted to the facility and later discharged to the hospital, returning a few days later. The resident's medical conditions included sequelae of nontraumatic intracranial hemorrhage, essential hypertension, atherosclerotic heart disease, obstructive sleep apnea, chronic heart failure, dysphagia, hemiplegia, and hemiparesis. The resident required various levels of assistance for daily activities and was dependent on staff for certain tasks. Despite these needs, there was no indication that a care conference had been held since the resident's admission. Interviews with the resident's family and the facility's social worker confirmed that a care conference had not been conducted. The social worker acknowledged the oversight, attributing it to her absence from work and being the sole person responsible for scheduling care conferences. The facility's policy stated that residents and their families should be encouraged to participate in care plan development and revisions, but this was not adhered to in this case.
Failure to Implement Trauma-Informed Care
Penalty
Summary
The facility failed to ensure that direct care staff were knowledgeable about and understood the trauma-informed care needs of three residents identified with PTSD. Resident #83, who was admitted with diagnoses including depression and a history of trauma, had a care plan that required staff to identify and manage triggering situations. However, interviews revealed that both an STNA and an LPN were unaware of Resident #83's PTSD triggers and the care plan interventions designed to prevent re-traumatization. Resident #81, with a history of trauma related to abuse and diagnoses including schizophrenia and schizoaffective disorder, had a care plan that included identifying triggers and managing them. Despite this, an RN and a CNA were unaware of any PTSD triggers or care plan interventions for Resident #81. The resident's pre-admission review and trauma checklist indicated discomfort with bathing due to past trauma, yet this information was not communicated to the care staff. Resident #62, diagnosed with Alzheimer's and anxiety, had a care plan addressing trauma from past assaults. The plan included providing a calm environment and encouraging the resident to express feelings. However, interviews with the social worker and LPN revealed a lack of awareness of the resident's PTSD triggers and care plan interventions. The Director of Nursing also admitted to not being aware of the PTSD triggers and interventions for these residents, despite reviewing care plans. The facility's policy on trauma-informed care was not effectively implemented, as evidenced by the staff's lack of knowledge and understanding of the residents' trauma-related needs.
Failure to Provide Appropriate Mechanical Soft Diet
Penalty
Summary
The facility failed to provide food at the appropriate consistency for a mechanical soft diet to Resident #39, who was one of four residents reviewed for food and nutrition. Resident #39 had a medical history that included Alzheimer's disease, unspecified dementia, chronic diastolic heart failure, type two diabetes, and oropharyngeal phase dysphagia, which required a mechanical soft diet with thin liquids. Despite these dietary requirements, during a lunch meal service, Resident #39 was served intact, breaded chicken tenders, which did not meet the mechanical soft diet specifications. The incident occurred when the Dietary Manager served the resident the incorrect meal, and the error was observed by a surveyor. The Licensed Practical Nurse present confirmed the dietary mistake and removed the inappropriate food from the resident. The Speech Language Pathologist and Registered Dietitian later confirmed that the intact chicken tenders were not suitable for a mechanical soft diet and should have been cut up before serving. The facility's document on Mechanical Soft Diet Allowances also indicated that soft tenders were allowed only if cut up.
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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