Harvard Gardens Rehabilitation & Care Center
Inspection history, citations, penalties and survey trends for this long-term care facility in Cleveland, Ohio.
- Location
- 18810 Harvard Ave, Cleveland, Ohio 44122
- CMS Provider Number
- 365828
- Inspections on file
- 43
- Latest survey
- March 3, 2026
- Citations (last 12 mo.)
- 5
Citation history
Health deficiencies cited at Harvard Gardens Rehabilitation & Care Center during CMS and state inspections, most recent first.
The facility failed to provide required RN coverage for at least eight consecutive hours per day, seven days a week, as shown by staffing schedules and timecard punches indicating no RN on duty on two days during a reviewed period, while 97 residents were present on each of those days. The DON confirmed in an interview that there was no RN coverage on those dates and that she was the only RN in the building, and the overall census was 107 residents. This deficiency was investigated under two complaint numbers.
The facility failed to consistently serve hot foods at adequate and palatable temperatures, as evidenced by resident reports that meals were always cold or never hot and by a test tray observation with the Dietary Manager showing entrée and vegetables at 122°F and rice at 141°F, with items described as warm but not hot when eaten. The facility also identified that two residents received no food from the kitchen, and this issue had the potential to affect 105 residents receiving meals, based on a total census of 107.
Surveyors found that the facility failed to maintain a clean, sanitary, and homelike environment for many residents, including missing bathroom and closet doors, cracked and broken room fixtures, stained privacy curtains, rusted air vents, stained and soiled flooring and toilets, a cracked sink, and a torn, soiled fall mat. Additional observations included thick dust on ceilings, a feeding pole with dried supplement residue, a windowsill with a large brown stain, and AC units containing a bird nest with birds audible inside. These conditions were confirmed during an environmental tour with the housekeeping director and affected a substantial number of residents.
Two residents’ needs and preferences were not accommodated when one bariatric resident was repeatedly observed lying directly on a bare bariatric mattress without a fitted sheet due to a lack of bariatric linens on the units, and another resident who was cognitively intact with significant mobility impairments, and who had clearly documented preference for showers, received only bed baths for several months because the only shower bed was broken and missing key parts, as confirmed by staff and direct observation.
A resident with chronic back and joint pain, receiving multiple scheduled and PRN pain medications including oxycodone ER, Lyrica, lidocaine patches, and muscle relaxants, did not consistently receive these medications at the ordered times. Audit reports and MARs showed numerous late or missed doses, medications documented as not available, and administration outside the facility’s defined time windows for "upon rising," dinner, and bedtime, without documented reasons in nursing notes. The resident reported that pain medications were not always given on time, experienced pain scores up to 10/10, and stated that pain at moderate levels was not tolerable without intervention. The DON confirmed the late administration times and acknowledged being previously unaware of the pattern of late pain medication administration.
A resident with a history of neurological and oncological conditions experienced right-sided numbness and weakness, requested hospital transfer, and reported a recent fall. Nursing staff did not thoroughly assess the neurological symptoms, delayed physician notification, and arranged non-emergency transportation, resulting in a delay of over three hours before hospital transfer. The resident was later diagnosed with a stroke and suffered a decline in mobility, requiring a wheelchair.
A resident with a complex medical history experienced right-sided numbness and weakness, requested to go to the hospital, and was transferred via stretcher after staff consultation. Despite facility policy requiring notification, there was no documentation that the responsible party was informed of the change in condition or hospital transfer, and physician notification was not clearly documented.
A CNA verbally abused a resident with dementia and behavioral issues by threatening physical harm and using profane language after an altercation. Multiple staff witnessed or heard the incident, but it was not documented in the resident's record or self-reported as required by policy. The facility failed to prevent, document, and report the verbal abuse, resulting in non-compliance with abuse prevention regulations.
A resident with dementia and behavioral issues was involved in an altercation with a CNA, who verbally threatened the resident after being physically confronted. Despite witness statements and staff interviews confirming the incident, the facility did not document the event in the medical record, failed to submit a required Self-Reported Incident, and did not notify the nurse aide registry, in violation of its abuse prevention policy.
A resident with dementia and behavioral issues was verbally threatened by a CNA, who admitted to making the threat after being provoked. Multiple staff witnessed or heard about the incident, but the DON did not report the allegation to authorities or document it as required by facility policy. The incident was not entered into the medical record or reported through the state's SRI system.
A facility failed to thoroughly investigate an allegation of staff-to-resident verbal abuse involving a resident with dementia and behavioral issues. Despite witness statements and staff interviews confirming threats and inappropriate language by a CNA, the facility did not document the incident in the medical record, submit a self-reported incident, or complete required investigative steps such as obtaining statements from all involved parties.
A resident requiring substantial assistance for incontinence care was not changed for an extended period, resulting in saturated linens and soiled bedding. A CNA was observed using a blanket as a draw sheet, placing soiled linens on the floor, and failing to apply barrier cream as required by the care plan. The DON confirmed these actions did not follow facility policy.
Expired medications, including promethazone, bisocodyl, Trulicity, humulog insulin, and others, were found stored with medications for resident use in various storage areas and medication carts. LPNs confirmed the presence of these expired drugs, which were not removed as per the facility's policy.
The facility failed to maintain proper infection control practices when using a glucometer, affecting multiple residents. An LPN did not clean the glucometer or perform hand hygiene as required. Additionally, the facility lacked a complete water management plan, posing a risk to all residents.
The facility failed to address resident concerns about call light response times, as documented in Resident Council Meeting Minutes. The Director of Nursing allegedly instructed the alteration of these minutes to remove repeated complaints, affecting multiple residents. Despite awareness of the issues, no effective action was taken, leading to ongoing dissatisfaction among residents.
The facility failed to provide required notices of potential financial obligation to two residents before discontinuing skilled services under Medicare Part A. Notices were not given 48 hours prior, and the necessary SNFABNs were not provided, resulting in a lack of proper notification about financial responsibilities.
A facility failed to conduct a quarterly care plan meeting for a resident with hemiplegia, diabetes, and muscle weakness. Despite being cognitively intact and using a wheelchair, the resident's medical records showed no documentation of care plan meetings for over a year. Interviews revealed the resident was only invited to annual meetings, and the LSW confirmed the absence of meetings in 2024, contrary to facility policy requiring quarterly reviews.
A resident with a left hand contracture did not receive necessary range of motion exercises or a palm guard after therapy services, as required by their care plan. The resident reported that ROM was only performed during therapy, and staff interviews confirmed the absence of these interventions. The facility lacked a restorative program, and no orders were written for ROM or orthotic use, leading to the resident not receiving appropriate care.
A resident with a PEG tube was not receiving the prescribed water flushes due to incorrect pump settings, delivering only 30 ml instead of 120 ml every four hours. The LPN failed to verify the pump settings and inaccurately documented compliance on the MAR. The DON dismissed the issue, claiming the resident received enough water with medications, despite no documentation of water flushes during medication administration.
A facility failed to address pharmacy recommendations for a resident prescribed quetiapine for vascular dementia. The pharmacist requested clarification of the diagnosis to justify the medication use, but the Director of Nursing did not realize the diagnosis was incorrect. The facility lacked a policy for addressing pharmacy recommendations.
The facility failed to ensure call lights were accessible and functional for five residents, affecting their ability to request assistance. A resident's call light was non-functional, confirmed by a CNA, while another's was placed out of reach, verified by the MDS Coordinator. An LPN confirmed a third resident's call light was inaccessible. A fourth resident reported inconsistent call light functionality, confirmed by the DON, and a fifth resident's call light did not illuminate, affecting timely assistance. These issues were investigated under a specific complaint number.
The facility failed to maintain kitchen cleanliness, as observed with two dusty fans running near the tray line and dishwasher, potentially affecting all 96 residents. The Dietary Manager confirmed the dust accumulation, despite the facility's policy outlining regular cleaning tasks.
The facility failed to maintain a safe and comfortable environment, with water temperatures in several residents' rooms below the required level, missing molding around an air conditioner, and a lack of hygiene supplies in another room. These issues were confirmed by the Maintenance Director, Administrator, and DON.
The facility failed to serve meals at an appropriate temperature, affecting 11 residents. Interviews revealed complaints about cold food, and observations showed food temperatures below the required 135 degrees F. A test tray confirmed the food was lukewarm and bland, indicating non-compliance with food service standards.
A facility failed to ensure a resident was seen by a physician at required intervals after admission. Despite being admitted with multiple diagnoses, the resident only had one documented physician visit during an eight-month stay. Interviews confirmed the lack of visits, and the facility's policy requiring regular physician visits was not followed, leading to non-compliance.
Failure to Provide Required Daily RN Coverage
Penalty
Summary
The facility failed to ensure that a registered nurse (RN) was on duty for at least eight consecutive hours a day, seven days a week, as required, potentially affecting all 107 residents. Review of staffing schedules and staff timecard punches for the period 12/25/25 through 12/31/25 showed that no RN worked in the facility on 12/25/25 and 12/31/25, despite census data indicating that 97 residents were in the facility on each of those days. During an interview on 02/24/26 at 3:18 P.M., the DON confirmed there was no RN coverage on those two dates and stated she was the only RN in the building on those days. This deficiency was investigated under Complaint Numbers 2671148 and 2603969. The deficiency centers on the absence of required RN coverage on specific days, as evidenced by staffing records, timecard punches, and census data, and confirmed by the DON’s interview, in the context of a facility census of 107 residents overall and 97 residents present on the days without RN coverage.
Failure to Serve Hot Foods at Adequate and Palatable Temperatures
Penalty
Summary
The facility failed to ensure that all hot foods were served at adequate and palatable temperatures for residents receiving meals. Resident interviews documented that one resident stated the food was cold all the time and another resident reported the food was never hot. During observation of a test meal tray with the Dietary Manager, the tray contained a chicken breast filet, rice, peas and carrots, and a grape drink. Food temperatures taken at that time showed the chicken breast at 122°F, peas and carrots at 122°F, and rice at 141°F, with the chicken and vegetables described as warm but not hot when consumed. The Dietary Manager verified these findings. The facility identified that two residents received no food from the kitchen, and the issue had the potential to affect 105 residents who received meals, with a total facility census of 107. This deficiency was investigated under Complaint Number 2671148 and was based on observations, resident interviews, and staff interviews indicating that hot foods were not consistently served at appropriate temperatures.
Failure to Maintain Clean, Sanitary, and Homelike Resident Environment
Penalty
Summary
The deficiency involves the facility’s failure to maintain a safe, clean, sanitary, and homelike physical environment for multiple residents. Surveyors observed that one resident’s room lacked a bathroom door, and another resident’s bed light had a visible crack, while a different resident’s headboard was broken off and resting beside the bed. Additional observations included a heavily rusted air vent in one resident’s room, a cracked sink in another resident’s living area, a torn, worn, and soiled fall mat for another resident, and a dresser missing drawers and a toilet with brown staining in another room. One resident’s room had a windowsill with a large brown stain, and another resident’s room had a supplemental feeding administration pole with a large amount of dried supplement residue. During an environmental tour with the Housekeeping Director, surveyors also noted visibly stained privacy curtains in several residents’ rooms, tile flooring in some rooms with unidentified substances and visible staining, and thick dust accumulation on the ceilings of two residents’ rooms. Air conditioning units in two residents’ rooms contained a bird nest, with birds heard chirping from within the units. Closet doors were missing in numerous residents’ rooms. The Housekeeping Director confirmed these environmental issues at the time they were observed. These findings affected 28 of the 107 residents in the facility and were investigated under two complaint numbers.
Failure to Provide Appropriate Linens and Maintain Shower Equipment to Honor Resident Preferences
Penalty
Summary
The deficiency involves the facility’s failure to reasonably accommodate residents’ needs and preferences regarding bed linens. One resident with morbid obesity, knee dislocation, and impaired lower extremity function was observed twice on the same day lying directly on a bariatric mattress without a fitted sheet. The resident reported that the facility frequently ran out of fitted sheets, gowns, and towels, and stated she did not refuse linens but that they were not available. An LPN confirmed the resident was lying on a bare mattress. Inspection of the south hall linen area, the north linen closet, and the second floor revealed no bariatric fitted sheets available for staff use. In the laundry area, only two bariatric fitted sheets were eventually located after searching, and the DON confirmed there were no bariatric fitted sheets in the residential areas. The deficiency also includes failure to honor another resident’s stated bathing preference due to lack of functioning equipment. This resident, who had cerebral infarction, cellulitis, type 2 diabetes, morbid obesity, and significant upper and lower extremity impairments, was cognitively intact and care planned to have ADL assistance with honoring choices and preferences whenever possible. Facility documentation showed it was very important to this resident to choose between types of bathing, and he specifically preferred showers. However, shower records over a nearly three‑month period showed he received only bed baths. The resident reported he had not received a shower for two and a half to three months and was told by staff that the shower bed he required was broken. Observation confirmed the shower bed was missing pins that held the frame together, and staff, including an LPN and a CNA, stated the shower bed had been nonfunctional for weeks to a couple of months and was the only shower bed available, preventing the resident from receiving showers.
Failure to Administer Pain Medications as Ordered
Penalty
Summary
The deficiency involves the facility’s failure to administer ordered pain medications in a safe and timely manner to effectively manage a resident’s pain. The resident was cognitively intact, had chronic pain conditions including left hip pain, osteoarthritis of the left knee, lumbar disc degeneration, lumbar back pain, and right foot pain, and was care planned as being at risk for back pain, fatigue, anxiety, and bone pain with an intervention to administer medications as prescribed. Physician orders included scheduled oxycodone ER twice daily (upon rising and at 7:00 P.M.), PRN oxycodone doses, a daily lidocaine 4% patch upon rising, Lyrica 75 mg three times daily, and later Baclofen and methocarbamol as muscle relaxants. The facility’s policy required medications to be administered in a safe and timely manner and in accordance with ordered time frames. Review of the medication administration audit reports and MARs for January and February showed numerous instances where the resident’s scheduled pain medications and related therapies were given late, given at times outside the defined administration windows, or not available and therefore not administered. Examples included Lyrica doses scheduled for 2:00 P.M. and 10:00 P.M. being given hours late or the following morning, lidocaine patches ordered for “upon rising” being applied in the early afternoon or evening, and oxycodone ER doses ordered for “upon rising” or 7:00 P.M. being administered late at night or the next morning. There were also documented instances where Lyrica doses at multiple times in a day were not available, and methocarbamol and oxycodone ER doses were not administered as ordered. On several dates, multiple scheduled medications (Lyrica, oxycodone ER, lidocaine patch, Baclofen) were consistently administered outside the facility’s defined time ranges for “upon rising,” “dinner,” and “bedtime.” Nursing progress notes for January and February did not document reasons for the late administration of medications, except for the not-available notations for Lyrica on specific dates. Pain ratings documented on the MAR showed the resident reporting pain levels of six out of 10 and 10 out of 10 on multiple occasions during this period. The resident reported that pain medications were not always given on time, that she had chronic back pain, and that she needed her pain to be tolerable to participate in therapy with a goal of returning home, stating that pain at a level of five or six out of 10 was not tolerable without intervention. The DON confirmed the late administration times identified in the audit reports, stated she had never seen a medication administration audit report before, was not aware that medications were being administered late, and did not know why the resident’s pain medications were administered late.
Failure to Provide Timely Medical Intervention for Acute Change in Condition
Penalty
Summary
The facility failed to provide timely medical intervention for a resident who experienced an acute change in condition, resulting in actual harm. The resident, who had a history of malignant neoplasm of the pancreas, drug-induced polyneuropathy, and previous cerebral infarction with right-sided hemiplegia and hemiparesis, reported numbness and weakness on the right side of the body and requested to be sent to the hospital. Despite these symptoms, which began several days prior and included a fall due to right leg weakness, the resident was not transferred to the hospital until over three hours after the initial complaint. During this time, the resident's symptoms were not thoroughly evaluated, and there was no evidence that the physician was promptly notified or that a physician order for hospital transfer was obtained. Documentation and interviews revealed that nursing staff did not conduct a comprehensive assessment of the resident's neurological status following the complaint of numbness and weakness. The resident's vital signs were taken and found to be within normal limits, but the underlying neurological symptoms were not adequately addressed. The decision to use non-emergency transportation further delayed the resident's transfer, and there was no documentation of timely physician notification or input regarding the resident's acute change in condition. Additionally, the resident's responsible party was not notified of the transfer to the hospital as required by facility policy. Upon arrival at the hospital, the resident was diagnosed with a cerebrovascular accident due to intracerebral hemorrhage and ischemic stroke. The hospital determined that the resident was outside the window for significant intervention, and a stroke alert was not called. Following hospitalization, the resident's mobility declined, necessitating the use of a wheelchair. The facility's failure to promptly recognize and respond to the resident's acute neurological symptoms, notify the physician, and arrange for immediate transfer resulted in a delay of care and actual harm to the resident.
Failure to Notify Responsible Party of Resident's Change in Condition and Hospital Transfer
Penalty
Summary
The facility failed to notify a resident's responsible party of a significant change in condition and subsequent transfer to the hospital. The resident, who had a history of malignant neoplasm of the pancreas, drug-induced polyneuropathy, and hemiplegia/hemiparesis following a cerebral infarction, experienced new symptoms of right-sided numbness and weakness. Despite these symptoms and the resident's request to go to the hospital, there was no documentation that the responsible party was informed of the change in condition or the hospital transfer. Medical record review showed that the resident complained of numbness and weakness, and eventually left the facility via stretcher to the emergency department. The resident was later diagnosed with a cerebrovascular accident due to intracerebral hemorrhage and ischemic stroke. Interviews with staff revealed that the LPN on duty was new and in orientation, and after consulting with the unit manager, called a physician and arranged for non-emergency transportation. However, there was no evidence in the medical record that the physician was contacted in a timely manner or that the responsible party was notified at any point during the incident. The facility's policy required prompt notification of the resident, physician, and representative in the event of a significant change in condition. Despite this, the documentation and interviews confirmed that the responsible party was not notified when the resident was sent to the hospital, and the physician's involvement was not clearly documented. This deficiency was identified during a complaint investigation and affected one resident reviewed for change in condition.
Failure to Prevent and Report Staff-to-Resident Verbal Abuse
Penalty
Summary
A deficiency occurred when a certified nursing assistant (CNA) verbally abused a resident with a history of dementia, agitation, and violent behavior. The resident, who had moderately impaired cognitive skills and exhibited physical and verbal behaviors, was involved in an incident where the CNA told him she would punch him in the face after he allegedly grabbed her hair and kicked her. Witness statements from other staff members confirmed that the CNA used threatening and profane language directed at or within earshot of the resident. The incident was not documented in the resident's progress notes, nor was it self-reported as required by facility procedures. The facility's policy prohibits all forms of abuse, including verbal abuse and intimidation, but the staff failed to prevent this incident. Interviews with staff and the resident indicated that aides sometimes had an attitude with him, and multiple staff members heard or witnessed the CNA's inappropriate conduct. The CNA was subsequently terminated, but the initial failure to prevent the verbal abuse and to document or report the incident constituted non-compliance with regulations protecting residents from abuse.
Failure to Report and Investigate Alleged Abuse Incident
Penalty
Summary
The facility failed to effectively implement its abuse prevention policy regarding the timely reporting and thorough investigation of an allegation of abuse involving a resident with multiple cognitive and behavioral diagnoses. The resident, who had a history of dementia, agitation, and non-compliance with care, was involved in an incident with a CNA, during which the CNA verbally threatened the resident after an altercation. Witness statements and interviews confirmed that the CNA used threatening language toward the resident, and that the incident was witnessed by other staff members. Despite the facility's policy requiring immediate reporting of abuse allegations to the Administrator and the state health department, as well as prompt removal of the accused staff member and thorough documentation, the incident was not documented in the resident's medical record, and no Self-Reported Incident (SRI) was submitted to the state. The personnel file for the CNA showed termination for the incident, but there was no evidence that the required notifications or documentation were completed. The Director of Nursing acknowledged the incident but stated that conflicting accounts prevented a determination of what occurred, and confirmed that no SRI was submitted and the nurse aide registry was not notified. The facility did not provide additional documentation or information regarding the incident, and interviews with staff revealed inconsistencies in their accounts. The facility's failure to follow its own abuse policy resulted in a lack of timely reporting, incomplete investigation, and insufficient documentation of the incident involving the resident and the CNA.
Failure to Report Staff-to-Resident Verbal Abuse Allegation
Penalty
Summary
The facility failed to report an allegation of staff-to-resident verbal abuse to the proper authorities as required by policy and regulation. The incident involved a resident with a history of dementia, agitation, and behavioral issues, who was alleged to have been verbally threatened by a CNA. Multiple witness statements and interviews indicated that the CNA told the resident she would physically harm him, and this was corroborated by both written and verbal accounts from other staff members. Despite these accounts, there was no documentation of the incident in the resident's medical record, nor was there a Self-Reported Incident (SRI) submitted to the state authorities. The personnel file for the CNA involved showed she was terminated for her actions, and witness statements described her using threatening and profane language toward the resident. Interviews with staff confirmed the occurrence of the incident, with one CNA reporting hearing the threats and another RN stating she heard the resident yelling about being threatened. The CNA herself admitted to making the threatening statement, citing provocation by the resident. However, the Director of Nursing (DON) insisted there were conflicting stories and did not report the incident to the nurse aide registry or submit an SRI. The facility's own policy required immediate reporting of all abuse allegations to the Administrator and to the Ohio Department of Health, with a formal investigation and submission of results within five working days. None of these steps were taken in response to the incident. The lack of reporting and documentation represented a failure to follow both internal policy and regulatory requirements for abuse reporting.
Failure to Investigate Alleged Verbal Abuse Incident
Penalty
Summary
The facility failed to conduct a thorough investigation into an allegation of staff-to-resident verbal abuse involving a resident with multiple diagnoses, including dementia with agitation and violent behavior. The resident's care plans documented ongoing behavioral challenges and interventions, and the Minimum Data Set assessment indicated moderately impaired cognitive skills and recent physical and verbal behaviors toward others. On the date of the incident, there was no documentation in the resident's medical record regarding the alleged event between the resident and a CNA, nor was there a self-reported incident (SRI) submitted for this occurrence. Personnel records showed that the CNA involved was terminated for threatening to physically harm the resident, with witness statements from other staff members corroborating the use of threatening and profane language. However, the facility's investigation lacked critical components: there was no evidence of an interview or written statement from the alleged perpetrator, no statement from another CNA present during the incident, and a missing additional statement from a witness. Interviews with staff and the resident confirmed the occurrence of yelling, cursing, and threats, but the facility did not provide further documentation or evidence of a comprehensive investigation. The facility's policy required immediate reporting of abuse allegations, assessment of the resident, notification of the physician and resident representative, removal of the accused staff member, and documentation in the medical record. Despite these requirements, the facility did not follow through with the necessary investigative steps or documentation, resulting in a failure to appropriately respond to and investigate the alleged abuse incident.
Failure to Provide Timely Incontinence Care and Maintain Proper Infection Control
Penalty
Summary
A resident with Alzheimer's disease, anxiety disorder, and type 2 diabetes mellitus was identified as being incontinent of bowel and bladder, requiring substantial to maximal assistance for toileting hygiene and other activities of daily living. The resident's care plan specified that incontinence care should be provided every two hours and as needed, including the application of barrier cream after each episode. On the day in question, there was no documentation in the progress notes or aide charting indicating that the resident's incontinence brief had been changed from 7:00 A.M. through 2:26 P.M., nor was there evidence that the resident refused care during this period. At 2:26 P.M., a CNA was observed providing incontinence care to the resident, whose brief was found to be saturated with urine and contained a moderate-sized, formed bowel movement. The resident's draw sheet and underlying sheet were also saturated with urine, with dried yellow urine visible. The CNA acknowledged that the resident appeared not to have been changed for a significant amount of time and confirmed that a blanket had been improperly used as a draw sheet. During care, the CNA placed soiled linens on the floor instead of directly into a plastic bag and failed to apply barrier cream before putting on a new brief. The DON later confirmed that these actions were not in accordance with facility policy and that incontinence care should have been provided in a timely manner.
Expired Medications Found in Storage Areas
Penalty
Summary
The facility failed to ensure that expired medications were removed from the medication storage areas, which had the potential to affect all 96 residents residing at the facility. During an observation in the South Medication Storage Room, a Licensed Practical Nurse (LPN) identified several expired medications, including promethazone hydrochloride tablets, bisocodyl suppositories, a Trulicity pen, a humulog insulin pen, deep sea nasal spray, and omeprazole tablets. These expired medications were confirmed by the LPN to be stored alongside medications intended for resident use. Further observations in the second-floor Medication Storage Room and on medication carts revealed additional expired medications, such as omeprazole tablets, aspirin, vitamin D3, vitamin B12, and clear eyes eye drops. These expired medications were also verified by another LPN to be stored with medications used for residents. The facility's policy on the storage of medications, revised in April 2019, states that discontinued, outdated, or deteriorated drugs or biologicals should be returned to the dispensing pharmacy or destroyed, indicating a failure to adhere to this policy.
Infection Control and Water Management Deficiencies
Penalty
Summary
The facility failed to maintain appropriate infection control practices when obtaining blood glucose levels via a glucometer. Observations revealed that an LPN did not clean the glucometer before or after use and did not perform hand hygiene before leaving a resident's room. The glucometer was used for multiple residents without proper disinfection, and the cleaning process did not adhere to the manufacturer's instructions or the facility's policy, which required maintaining visible wetness for a specified time. This affected three residents directly observed and had the potential to affect an additional 19 residents who required blood sugar checks. Additionally, the facility lacked a complete water management plan, which is crucial for preventing waterborne infections. The facility's water management plan was incomplete, lacking specific information about the facility, and there was no water flow diagram available. Despite testing for Legionella with negative results, the facility did not have a comprehensive plan in place, as confirmed by interviews with the Regional Maintenance staff and the Administrator. The deficiencies in infection control practices and the absence of a comprehensive water management plan posed a risk to the health and safety of all residents in the facility. The facility's policies on glucometer disinfection and hand hygiene were not followed, and the water management program did not meet the required standards, as it lacked detailed descriptions and diagrams of the water system.
Alteration of Resident Council Minutes and Unaddressed Call Light Concerns
Penalty
Summary
The facility failed to ensure that resident concerns documented in the Resident Council Meeting Minutes for November and December 2024 were not altered or removed, and failed to ensure concerns from the group meetings were acted upon. This affected multiple residents who attended the meetings and expressed concerns related to call light response times. The report highlights that the concerns were documented but subsequently altered using white-out, effectively erasing the issues from the official records. Interviews and record reviews revealed that the Resident Council meetings were held monthly, and concerns about call light response times were consistently raised by residents. Despite these concerns being documented, the Director of Nursing (DON) allegedly instructed the Former Activity Director (FAD) to alter the minutes by using white-out to remove repeated complaints about call lights. This alteration was done in the presence of Human Resources, and the original unaltered documents were taken home by the FAD. Further interviews with residents confirmed ongoing issues with call light response times, with some residents reporting waits of up to an hour or longer. The DON and Administrator were both aware of the issues, but the DON denied any involvement in altering the minutes. The Administrator acknowledged a heated argument between the DON and FAD over departmental issues, but there was no resolution to the residents' concerns. The deficiency represents non-compliance investigated under a specific complaint number.
Failure to Provide Required Notices of Non-Coverage
Penalty
Summary
The facility failed to provide all required notices of potential financial obligation to residents prior to the discontinuation of skilled services under Medicare Part A benefits. This deficiency affected two residents who were discharged from skilled therapy services but remained in the facility. For Resident #62, the Notice of Medicare Non-coverage (NOMNC) was signed by the resident representative a week after the discontinuation of services, and the required Skilled Nursing Facility Advanced Beneficiary Notice of Non-coverage (SNFABN) was not provided at all. Similarly, for Resident #107, the NOMNC was signed a day before the discontinuation of services, and the SNFABN was also not provided. Interviews with Social Worker #328 revealed that the facility initiated the end of skilled services for both residents and determined the last covered dates. However, the NOMNCs were not given 48 hours prior to the end of services as required, and the SNFABNs were not provided to either resident. This oversight in providing timely and complete notices resulted in a failure to inform the residents of their potential financial obligations, as mandated by Medicare regulations.
Failure to Conduct Quarterly Care Plan Meeting
Penalty
Summary
The facility failed to conduct a quarterly care plan meeting for a resident, identified as Resident #2, who was part of a group of three residents reviewed for care plan meetings. Resident #2 was admitted with diagnoses including hemiplegia affecting the left nondominant side, type two diabetes mellitus, and muscle weakness. The quarterly Minimum Data Set (MDS) assessment indicated that Resident #2 was cognitively intact, had no impairment of the upper extremities, and used a wheelchair for mobility. However, a review of Resident #2's medical records from January 1, 2024, through February 10, 2025, showed no documentation of care plan meetings being scheduled or held. Interviews conducted with Resident #2 and Licensed Social Worker (LSW) #328 revealed that Resident #2 was only invited to care plan meetings once a year, and LSW #328 confirmed the absence of care plan meetings in 2024. The facility's policy required the Interdisciplinary Team (IDT) to develop and implement a comprehensive, person-centered care plan for each resident, which should be reviewed and updated quarterly in conjunction with the required quarterly MDS assessment. The failure to adhere to this policy resulted in the deficiency noted in the report.
Failure to Provide ROM and Orthotic Care for Resident with Contracture
Penalty
Summary
The facility failed to provide appropriate care for a resident with a left hand contracture, as evidenced by the lack of range of motion (ROM) exercises and the absence of a palm guard or carrot orthosis after therapy services. The resident, who was cognitively intact and had a diagnosis of hemiplegia affecting the left nondominant side, was observed with contracted fingers pressing into the palm. Despite the care plan indicating the need for a left hand carrot orthosis and ROM exercises, the resident reported not receiving these interventions since the splint was lost four months prior. The resident also mentioned that ROM was only performed during therapy sessions, not by the nursing staff. Interviews with facility staff, including the resident's primary care nurse and CNA, confirmed the lack of ROM exercises and the absence of a palm guard. The Director of Therapy noted that no orders were written for the splint or ROM because the facility lacked a restorative program, and it was assumed that staff would perform ROM automatically. The Director of Nursing confirmed that without specific orders, staff would not perform routine ROM exercises. This oversight resulted in the resident not receiving necessary interventions to maintain or improve their range of motion.
Failure to Administer Prescribed Water Flushes via PEG Tube
Penalty
Summary
The facility failed to meet the hydration needs of a resident, identified as Resident #156, who was receiving nutrition via a percutaneous endoscopic gastrostomy (PEG) tube. The resident, diagnosed with malignant neoplasm of the oropharynx, was ordered to receive enteral feeding with a water flush of 120 milliliters every four hours. However, observations revealed that the feeding pump was incorrectly set to deliver only 30 milliliters of water every four hours. This discrepancy was confirmed by the Licensed Practical Nurse Unit Manager, who verified that the pump settings did not align with the physician's orders. Further investigation revealed that the primary care nurse, an LPN, had not checked the pump settings throughout her shift and had signed the Medication Administration Record (MAR) indicating compliance with the prescribed water flushes without verifying the actual delivery. The Director of Nursing was informed of the issue but dismissed the concern, stating that the resident received enough water with medications, despite the lack of documentation of water flushes during medication administration. The MAR showed that medications were not administered every four hours as required, further indicating a failure to adhere to the prescribed hydration regimen.
Failure to Address Pharmacy Recommendations for Antipsychotic Medication
Penalty
Summary
The facility failed to ensure that pharmacy recommendations were addressed for a resident, leading to a deficiency in medication management. Resident #86, who was admitted on 03/16/24, had a diagnosis of vascular dementia, unspecified severity, without behavioral disturbance, psychotic disturbance, mood disturbance, and anxiety, depression, and major depressive disorder, recurrent and moderate. The resident had active physician orders for quetiapine fumarate, an antipsychotic medication, to be administered twice daily. However, the pharmacist's recommendations to clarify and document the approved diagnosis for the use of quetiapine were not properly addressed by the facility. The pharmacist's recommendations, dated 04/04/24 and 01/15/25, requested clarification and documentation of the diagnosis to justify the use of quetiapine, listing 12 possible diagnoses. The prescriber agreed with the recommendations, but the Director of Nursing (DON) did not realize that the diagnosis for quetiapine was incorrect. The DON assumed the diagnosis was correct upon receiving the second recommendation. The facility was unable to provide a policy related to addressing pharmacy recommendations, indicating a lapse in following established procedures for medication management.
Call Light Accessibility and Functionality Deficiency
Penalty
Summary
The facility failed to ensure that call lights were easily accessible and consistently in good working order, affecting five residents. Resident #6, who had intact cognition and required assistance with transfers, reported that his call light was not functioning, and this was confirmed by a Certified Nurse Aide (CNA) who observed that the light did not illuminate when pressed. Resident #7, who was cognitively intact and required assistance with toilet hygiene, was unable to reach her call light as it was placed on the floor behind her nightstand. This was confirmed by the MDS Coordinator. Resident #154, who was alert and oriented, also had her call light on the floor behind her, making it inaccessible, as confirmed by an LPN. Resident #156, who required assistance for transfers and activities of daily living, reported that her call light had not worked consistently since her admission, and she had to wait for staff to enter her room to receive assistance. This was confirmed during an interview and observation with the Director of Nursing (DON). Resident #155, who was a fall risk and required assistance with activities of daily living, also reported that staff did not answer her call light timely, and observation revealed that her call light did not illuminate when pressed. These deficiencies were investigated under Complaint Number OH00161616.
Failure to Maintain Kitchen Cleanliness
Penalty
Summary
The facility failed to serve food in a manner that protected it from contamination, potentially affecting all 96 residents. During an observation of the tray line, two fans were running on high speed, one facing the dishwasher and the other facing the tray line. Both fans were covered with a layer of brownish/black dust. The Dietary Manager confirmed the accumulation of dirt and dust on the fans. The facility's undated policy on kitchen cleanliness outlined daily, weekly, and monthly cleaning tasks, including cleaning and sanitizing surfaces, washing dishes and equipment, and deep cleaning kitchen areas. However, the presence of dust on the fans indicated a lapse in maintaining these cleanliness standards.
Environmental Deficiencies in Resident Rooms
Penalty
Summary
The facility failed to maintain a safe, clean, and comfortable environment for its residents, as evidenced by several deficiencies observed during a survey. Water temperatures in the rooms of several residents were found to be below the required 112 degrees Fahrenheit, with measurements ranging from 84 to 103 degrees Fahrenheit. Additionally, the bottom molding surrounding the air conditioner in one resident's room was missing, creating a gap that exposed the outside environment. This resident's bed was positioned close to this gap, potentially affecting their comfort and safety. Further observations revealed that another resident's room lacked basic hygiene supplies such as hand soap and paper towels, and the cold water was shut off. The toilet in this room was also dirty and non-functional, and the resident reported having informed the staff about these issues a month prior. These deficiencies were confirmed by the Maintenance Director, Administrator, and Director of Nursing, indicating a failure to address environmental concerns in a timely manner.
Failure to Serve Meals at Appropriate Temperature
Penalty
Summary
The facility failed to serve palatable meals at an appropriate temperature, affecting 11 residents. Interviews with several residents revealed consistent complaints about the food being cold, with one resident describing it as horrible. Observations during a meal service noted that the temperatures of the food items were below the facility's minimum holding temperature of 135 degrees Fahrenheit, with the puree ravioli and renal ravioli being particularly low at 123 degrees F and 111 degrees F, respectively. A test tray was conducted to assess the meal service process. The tray, which included regular and pureed ravioli and mixed vegetables, was delivered to the unit and distributed to residents. However, the process was delayed due to a shortage of juice, causing a pause in tray distribution. The test tray, completed shortly after the last meal tray was delivered, showed that the regular ravioli was only 82 degrees F and was described as lukewarm and bland by the Unit Manager. This deficiency was investigated under a specific complaint number, indicating non-compliance with food service standards.
Failure to Ensure Regular Physician Visits for a Resident
Penalty
Summary
The facility failed to ensure that Resident #51 was seen by a physician at the required intervals following admission. Resident #51, who was admitted with multiple diagnoses including vascular dementia, depression, epilepsy, atrial fibrillation, anxiety, hypertension, heart failure, and hemiplegia, was supposed to have face-to-face visits with a physician at least once every 30 days for the first 90 days after admission, and at least once every 60 days thereafter. However, the medical records revealed that after an initial virtual visit on 02/07/24, no further visits by a general practitioner were documented until 05/08/24, and no visits were recorded after that date. Interviews conducted during the investigation confirmed the lack of physician visits. Resident #51, who was cognitively intact, stated that he had only seen the physician once during his eight-month stay at the facility. The Assistant Director of Nursing also confirmed the absence of physician notes for visits after May 2024. The facility's policy required these visits, but the policy was not adhered to, resulting in non-compliance as investigated under Master Complaint Number OH00158474.
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.
Trusted data from CMS and state health departments
Every citation, penalty and Plan of Correction is sourced from public CMS records (latest release May 27, 2026) and official state health department websites — never guesswork.
Trusted by long-term care providers and associations.
