Kenwood Terrace Healthcare Center
Inspection history, citations, penalties and survey trends for this long-term care facility in Cincinnati, Ohio.
- Location
- 7450 Keller Road, Cincinnati, Ohio 45243
- CMS Provider Number
- 365178
- Inspections on file
- 28
- Latest survey
- July 30, 2025
- Citations (last 12 mo.)
- 3
Citation history
Health deficiencies cited at Kenwood Terrace Healthcare Center during CMS and state inspections, most recent first.
A deficiency was identified when hot water temperatures in multiple rooms were found to be below the required range, affecting several residents and potentially impacting many more. Facility leadership confirmed ongoing issues with mixing valves and acknowledged missing water temperature monitoring logs for two months.
A resident dependent on a mechanical lift for transfers sustained a forehead injury when the lift malfunctioned due to a broken mechanical strut, causing it to tilt and the sling bar to strike the resident. Facility records and interviews confirmed that required routine inspections and maintenance of the lift had not been performed or documented, leading to the equipment failure and incident.
The facility failed to store food properly and maintain kitchen equipment in a sanitary manner, affecting all 82 residents. Observations revealed undated food items in the refrigerator, freezer, and pantry, dented cans in dry storage, and a dirty microwave. The Executive Chef confirmed these issues, which violated the facility's food storage policy.
The facility failed to complete discharge MDS assessments in a timely manner for two residents, affecting compliance with regulatory requirements. One resident with multiple diagnoses, including COPD and acute kidney failure, was discharged without a completed assessment. Another resident with conditions such as spinal fusion and cognitive communication deficit was also discharged without a timely assessment. An MDS nurse confirmed the delay in completing these assessments.
The facility failed to conduct required care conferences for two residents, impacting their involvement in care planning. One resident with multiple health issues did not have documented conferences in two quarters of 2024, and was unaware of any care discussions. Another resident with chronic conditions also lacked documented conferences in two quarters, despite policy requirements for resident involvement.
Two residents were administered antipsychotic medications without appropriate indications. One resident with intact cognition was given Seroquel despite no documented need, while another with severe cognitive impairment was prescribed olanzapine for insomnia without a suitable diagnosis. These actions were confirmed by facility staff.
A resident with multiple health conditions experienced a critically low blood sugar level, but the facility failed to promptly notify the physician of this critical lab result. The lab work was completed and results were available, but the physician was not informed until the following day, contrary to the facility's policy on critical value management.
A resident with a history of cognitive impairments was admitted to an LTC facility with both upper and lower dentures, but later reported missing the lower set. Despite the resident's difficulty chewing and the absence of a documented item inventory list, the facility failed to arrange for dental services to address the issue. Interviews confirmed the lack of documentation or action taken to resolve the missing dentures.
A resident with multiple health conditions, including vascular dementia, expressed a preference for showers twice weekly, which was not consistently honored by the facility. Despite being cognitively intact and having communicated her preference, the resident mostly received bed baths over a three-month period. Interviews confirmed the resident's dissatisfaction and a CNA acknowledged the inconsistency in providing showers.
A facility failed to include a spinal cord stimulator in a resident's care plan, despite the resident's history of back surgeries and chronic pain. The resident managed the device independently, and staff interviews revealed a lack of awareness about the device, leading to incomplete care planning.
A facility failed to store medications properly in the medication cart, affecting residents prescribed iron. An observation revealed an unlabeled cup with green tablets in the cart. An LPN confirmed these were iron pills not stored correctly. The facility's policy required proper storage of medications.
A Dietary Manager was observed touching hamburger buns with bare hands during lunch preparation, violating the facility's policy on sanitary food handling. The manager confirmed the action, which was against the requirement to use serving utensils to prevent cross-contamination. This was noted during a complaint investigation.
The facility failed to follow infection prevention procedures during medication administration, affecting two residents. An RN used bare hands to handle medications for a resident with major depressive disorder and another with chronic heart failure, contrary to the facility's policy against touching medications and discarding dropped ones.
The facility failed to notify three residents of their Medicaid account balances, which exceeded the SSI resource limit, potentially affecting their Medicaid eligibility. Despite having intact cognition, the residents did not receive required notifications when their balances were within $200 of the limit. The Business Office Manager confirmed the lack of notifications, which is against the facility's policy.
The facility failed to investigate grievances and communicate findings to residents or their representatives, affecting two residents. One resident's family member filed a grievance regarding care concerns, but the facility did not provide investigation results. Another resident's family member also filed a grievance and requested a report, but was told it only goes to the State, with no results provided. The Executive Director confirmed the facility's failure to investigate and communicate grievance resolutions.
The facility failed to securely store medications for three residents. A resident had Fluticasone Propionate unsecured in their room, another had Gabapentin and Hydroxyzine without physician orders, and a third had an unsecured bottle of Betadine. Staff confirmed these medications should not have been left in the residents' rooms.
Failure to Maintain Adequate Hot Water Temperatures
Penalty
Summary
The facility failed to maintain a comfortable hot water supply for residents, staff, and the public, as evidenced by observations, interviews, and review of facility water temperatures. On the date of observation, hot water temperatures in several resident rooms and empty rooms ranged from 95 to 102 degrees Fahrenheit, which is below the expected regulatory range of 105-120 degrees Fahrenheit. The Administrator verified these temperatures at the time of observation. Four residents were specifically reviewed for hot water temperatures, and the issue had the potential to affect 59 residents residing on multiple hallways within the facility. Interviews with the Administrator and DON confirmed ongoing problems with the facility's mixing valves, and a company had recently serviced the system. Both acknowledged that there had been resident complaints about water temperature in the past, though not recently. Additionally, the facility was unable to provide water temperature monitoring logs for the months of May and June, as the maintenance department had not completed this required monitoring. The deficiency was investigated under a specific complaint number.
Failure to Maintain and Inspect Mechanical Lifts Resulting in Resident Injury
Penalty
Summary
The facility failed to properly maintain and inspect mechanical lifts used for resident transfers, resulting in an incident involving a resident with multiple medical conditions, including cardiomegaly, congestive heart failure, morbid obesity, and cervical stenosis. The resident, who was dependent on staff for mobility and required a two-person mechanical lift for all transfers, was being moved when the lift tilted to the right and the sling bar struck the resident on the forehead, causing moderate swelling. The incident occurred while two staff members were assisting the resident, and it was later determined that a mechanical strut on the lift had broken, causing the floor legs to fold back and the lift to tilt. Review of facility records revealed that no routine inspections or maintenance had been completed or documented for the mechanical lifts in use, despite manufacturer guidelines requiring inspection of all mechanical parts at least every six months. Interviews with facility leadership confirmed the absence of inspection records. The lack of proper maintenance and inspection of the mechanical lift directly contributed to the equipment failure and subsequent resident injury.
Deficiency in Food Storage and Kitchen Sanitation
Penalty
Summary
The facility failed to ensure food was stored and kitchen equipment was maintained in a sanitary manner, potentially affecting all 82 residents. During an observation of the facility kitchen, it was found that the walk-in refrigerator contained marinara sauce and two whipped toppings without expiration dates, and the freezer had opened cauliflower also lacking an expiration date. In the pantry, open packages of raisin bran, toasted oats, marshmallows, and cornbread were found without expiration dates. Additionally, a container of oregano on the spice shelf had an expiration date of 09/28/23. In the dry storage area, severely dented cans of mandarin oranges and pumpkin were placed on the shelf for facility use. A large amount of debris with a strong odor was observed in the microwave. An interview with the Executive Chef confirmed the improper dating of food items, the presence of dented cans in dry storage, and the unclean appearance of the microwave. The Executive Chef stated that dented cans were supposed to be placed on the bottom shelf to be sent back and that the microwave was supposed to be cleaned once per shift. The facility's policy on food storage, dated 08/20/18, requires all food to be stored in sealed containers and labeled with dates.
Failure to Complete Timely Discharge MDS Assessments
Penalty
Summary
The facility failed to complete discharge Minimum Data Set (MDS) assessments in a timely manner for two residents, affecting their compliance with regulatory requirements. Resident #63, who had multiple diagnoses including chronic obstructive pulmonary disease and acute kidney failure, was discharged to home on 10/09/24 without a completed discharge MDS assessment. Similarly, Resident #82, with conditions such as spinal fusion and cognitive communication deficit, was discharged to home on 10/23/24, also without a completed discharge MDS assessment. An interview with MDS Nurse #495 confirmed that the discharge MDS assessments for both residents were not completed on time, indicating a lapse in the facility's assessment processes.
Failure to Conduct Required Care Conferences
Penalty
Summary
The facility failed to ensure that care conferences were held as required for two residents, affecting their ability to participate in their care planning. Resident #12, who was admitted with multiple diagnoses including end stage renal disease, diabetes, and congestive heart failure, did not have documented care conferences in the second and fourth quarters of 2024. Despite being offered a care conference in the third quarter, there was no evidence of engagement in the other quarters, and the resident was unaware of any discussions regarding her care. Similarly, Resident #38, with diagnoses such as chronic obstructive pulmonary disease and atrial fibrillation, did not have documented care conferences in the first and second quarters of 2024. Although care conferences were held in the third and fourth quarters, there was no documentation of engagement in the earlier quarters. The facility's policy requires that residents and their representatives be informed and involved in care planning, but this was not consistently followed, as verified by the Regional Director of Clinical Operations.
Inappropriate Use of Antipsychotic Medications
Penalty
Summary
The facility failed to ensure that antipsychotic medications were administered to residents for appropriate indications. Resident #241 was admitted with diagnoses including end-stage renal disease, gout, and anemia, but there were no documented indications for the use of antipsychotic medication in the medical record. Despite having intact cognition as per the Minimum Data Set (MDS) assessment, Resident #241 was prescribed 25 mg of Seroquel daily without adequate justification. This was confirmed by the Divisional Director of Clinical Operations during an interview. Similarly, Resident #84, who was admitted with Alzheimer's dementia, cerebrovascular accident with right-side hemiplegia/hemiparesis, and diabetes mellitus type II, was prescribed olanzapine 5 mg at bedtime for insomnia. The MDS admission assessment indicated severe cognitive impairment and frequent incontinence, yet there was no appropriate diagnosis for the use of olanzapine. The Director of Nursing verified that Resident #84 did not have a suitable indication for the antipsychotic medication, highlighting a failure in ensuring medications were used appropriately.
Failure to Promptly Notify Physician of Critical Lab Value
Penalty
Summary
The facility failed to promptly notify a physician of a critical laboratory value for a resident, which constituted a deficiency in care. The resident, who had been admitted with diagnoses including diabetes mellitus type II with diabetic polyneuropathy, chronic obstructive pulmonary disease with lower respiratory infection, and generalized muscle weakness, experienced a change in condition on 07/15/24, feeling lightheaded and dizzy. Laboratory tests were ordered, and results were available on 07/16/24, revealing a critically low blood sugar level. However, the physician was not notified of these critical results until 07/17/24, more than 18 hours after the results were reported. The facility's policy on Critical Laboratory Value Management requires that nurses promptly notify the ordering physician of critical values and document the communication. In this case, there was no documentation of such notification until the following day, as confirmed by the Director of Nursing. This delay in communication could have impacted the resident's care and treatment, as the critical laboratory value was not addressed in a timely manner.
Failure to Provide Prompt Dental Care for Missing Dentures
Penalty
Summary
The facility failed to provide prompt and appropriate dental services for a resident who was missing their lower dentures. The resident, who had a history of schizoaffective bipolar disorder, depression, and dementia, among other conditions, was admitted to the facility with both upper and lower dentures. However, there was no item inventory list upon admission to confirm the presence of the dentures. The resident reported occasional difficulty chewing due to the absence of the bottom dentures, as noted in dietary progress notes. Despite this, the facility did not arrange for dental services to address the missing dentures. Interviews and observations revealed that the resident was only wearing top dentures and could not recall when the bottom dentures went missing. The facility's Regional Director of Clinical Services confirmed that there was no documentation regarding the missing dentures or any arrangements for dental services after the issue was reported. This deficiency affected one of the six residents reviewed for personal property, highlighting a lapse in the facility's responsibility to ensure residents receive necessary dental care.
Failure to Honor Resident's Bathing Preferences
Penalty
Summary
The facility failed to honor and promote a resident's choice for bathing, affecting one resident reviewed for activities of daily living. The resident, who was admitted with multiple diagnoses including hemiplegia, chronic kidney disease, and vascular dementia, was found to be cognitively intact and had expressed that the choice of bathing options was very important. Despite this, the resident received only four showers over a three-month period, with the majority of bathing instances being bed baths, contrary to her preference for showers twice weekly. Interviews with the resident confirmed her dissatisfaction with the frequency and type of bathing provided, as she felt bed baths did not adequately clean her. A social services note indicated that the resident had been encouraged to communicate her needs to the nursing staff and management, but the issue persisted. A Certified Nurse Aide corroborated that the resident mostly received bed baths, highlighting a failure in the facility's responsibility to support resident self-determination and choice.
Failure to Include Spinal Cord Stimulator in Care Plan
Penalty
Summary
The facility failed to develop a comprehensive care plan for a resident with an implanted spinal cord stimulator, which was necessary for effective pain management. The resident, who was cognitively intact and had a history of back surgeries, including a thoracic laminectomy with a paddle lead and rechargeable battery, was admitted with conditions such as type II diabetes mellitus, chronic kidney disease, obesity, and a non-pressure chronic ulcer. Despite the resident's complaints of acute and chronic pain and the presence of an indwelling medical device, the care plan did not include instructions on managing the spinal cord stimulator. The deficiency was identified during a survey when it was observed that the resident's spinal cord adapter was visible among personal items in the room, and the resident reported recharging the device himself. Interviews with the resident and staff, including the Director of Nursing and a Licensed Practical Nurse, revealed that the care plan lacked information about the spinal cord stimulator because the LPN responsible for care planning was unaware of its existence. The facility's policy required a resident-centered care plan to address all needs, but this was not adhered to in this case.
Improper Medication Storage in Medication Cart
Penalty
Summary
The facility failed to ensure that medications were stored in appropriate containers within the medication cart, which had the potential to affect three residents prescribed iron on the 500-Hall. Specifically, the medical records indicated that three residents had physician orders for ferrous sulfate 325 mg for anemia, with varying dosages and times of administration. During an observation, it was noted that the medication cart on the 500-Hall contained an unlabeled plastic medication cup with multiple green round tablets. An LPN confirmed that these pills were iron and acknowledged that they were not labeled or stored properly in the medication cart. The facility's policy on the storage of medications, dated August 2020, required that medications and biologicals be stored safely, securely, and properly according to manufacturer recommendations. This deficiency was identified during the course of a complaint investigation.
Unsanitary Food Handling by Dietary Manager
Penalty
Summary
The facility failed to ensure that food was prepared in a sanitary manner, as observed during a lunch meal preparation. Specifically, the Dietary Manager was seen touching hamburger buns with bare hands while preparing a lunch tray for a resident. During an interview, the Dietary Manager confirmed that she had used her bare hands to handle the buns and acknowledged that this was against the facility's policy. The policy, dated September 2017, required all staff to use serving utensils appropriately to prevent cross-contamination. This incident was identified during a complaint investigation.
Infection Control Breach During Medication Administration
Penalty
Summary
The facility failed to implement appropriate infection prevention procedures during medication administration, affecting two residents. Resident #79, who had diagnoses including major depressive disorder and mixed hyperlipidemia, was observed during medication administration. The RN administering the medication used her bare hands to pop Amlodipine and Galantamine pills from the pill card and placed them into a medication cup, even after one pill had dropped onto the medication cart. The RN confirmed during an interview that she had touched the medications with her bare hands. Similarly, Resident #63, with diagnoses including chronic diastolic congestive heart failure and stage III chronic kidney disease, was also affected. The RN administering medications for this resident used her bare hands to pop Namenda and Zoloft pills from the pill card and fished out Acetaminophen and Cyanocobalamin pills from house stock bottles. The RN admitted during an interview that she had touched multiple medications with her bare hands, contrary to the facility's policy, which states that licensed medical professionals should not touch medications during administration and should discard dropped medications.
Failure to Notify Residents of Medicaid Account Balances
Penalty
Summary
The facility failed to notify residents of their Medicaid account balances, which is a requirement to ensure residents remain within the Supplemental Security Income (SSI) resource limit. This deficiency affected three residents who were reviewed for notification of Medicaid account balances. Resident #28, who was admitted with diagnoses including schizoaffective disorder and diabetes mellitus type II, had a balance of $27,554.84, far exceeding the SSI resource limit of $2,000. Resident #29, with diagnoses of congestive heart failure and dementia, had a balance of $6,942.67. Resident #61, diagnosed with schizoaffective disorder and bladder cancer, had a balance of $16,775.66. All three residents had intact cognition and reported not receiving notification letters from the facility when their balances were within $200 of the SSI limit. The Business Office Manager confirmed that the facility did not provide written or verbal notifications to the residents when their account balances approached the SSI resource limit, which could negatively impact their Medicaid eligibility. The facility's policy, revised in 2017, mandates monthly notifications to Medicaid residents with trust fund balances nearing the SSI limit. This oversight was identified during a complaint investigation, highlighting the facility's non-compliance with its own policy and federal requirements.
Failure to Investigate and Communicate Grievance Findings
Penalty
Summary
The facility failed to properly investigate grievances and provide a summary of the findings to the residents or their representatives, affecting two residents out of three reviewed for grievances. Resident #55, who had multiple diagnoses including schizoaffective disorder and diabetes, was involved in a grievance initiated by a family member regarding care concerns attributed to a State tested Nurse Aide (STNA). Despite the grievance being filed, there was no communication from the facility regarding the investigation, findings, or resolution of the concern. Similarly, Resident #8601, who had diagnoses including a right femur neck fracture and depression, was involved in a grievance initiated by a family member concerning care provided by an STNA. The family member requested a copy of the investigation report but was informed by the Administrator that these reports only go to the State, and the results of the investigation were never provided. The Executive Director confirmed the facility's failure to investigate the concerns, complete a comprehensive written decision, and inform the residents or their representatives of the resolution.
Medication Storage Deficiency
Penalty
Summary
The facility failed to ensure medications were securely stored, affecting three residents. For Resident #56, a bottle of Fluticasone Propionate was observed unsecured on the dresser in the resident's room. The resident, who has a diagnosis of schizoaffective disorder and requires supervision for daily activities, had an active physician order for the medication. An LPN confirmed that the medication should not have been left unsecured in the room. For Resident #24, three medication bottles, including Gabapentin and Hydroxyzine, were found unsecured in the resident's room. The resident, who has a history of cerebral vascular accident and other medical conditions, stated that the medications were prescribed by a psychologist and kept in the room for personal use. However, there were no physician orders for these medications in the medical record. The DON confirmed that the resident should not have prescription medications in the room. Additionally, for Resident #54, a large bottle of Betadine was found unsecured in the resident's room, despite a warning label indicating it should not be ingested. An RN verified that the bottle should not have been left in the room.
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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