Lakeridge Villa Health Care Center
Inspection history, citations, penalties and survey trends for this long-term care facility in Cincinnati, Ohio.
- Location
- 7220 Pippin Rd, Cincinnati, Ohio 45239
- CMS Provider Number
- 366145
- Inspections on file
- 39
- Latest survey
- March 6, 2025
- Citations (last 12 mo.)
- 0
Citation history
Health deficiencies cited at Lakeridge Villa Health Care Center during CMS and state inspections, most recent first.
The facility failed to provide residents with private phone conversations, affecting two residents who had to use the phone at the nurses' station, where conversations could be overheard. Staff confirmed awareness of the issue and resident complaints, and observations showed the phone's location did not allow for privacy, contrary to the facility's dignity policy.
A facility failed to notify a resident's representative of a significant change in condition. The resident, with severe cognitive impairment and multiple diagnoses, remained in bed, refused food, and had minimal fluid intake over two days. Despite discussing a hospice referral, the facility did not inform the guardian, and the resident passed away. This was against the facility's policy requiring prompt notification of changes in medical condition.
A resident with end-stage renal disease, diabetes, and COPD was inaccurately assessed in the MDS as needing substantial assistance with daily activities, despite being independent. Interviews with the resident, a CNA, and an LPN confirmed the resident's independence, highlighting a failure to adhere to the facility's policy requiring accuracy in assessments.
A facility failed to update a care plan for a resident who was an independent smoker. Despite being assessed as able to handle smoking materials safely, the care plan did not reflect the facility's policy allowing independent smokers to keep supplies in their rooms. Observations and interviews confirmed the resident had smoking materials in his room, and the care plan was not updated to align with the new policy.
A resident with multiple diagnoses, including depression and anxiety, was prescribed Lexapro 15 mg daily. An LPN administered only 7.5 mg on 23 occasions, contrary to the physician's order. This error was confirmed during an interview with the LPN, who acknowledged the mistake. The facility's policy requires medications to be administered as prescribed, which was not followed.
A resident with specific dietary needs due to weight loss was not provided with the prescribed double portions of food as ordered by the physician. Despite the order for double portions, the resident reported receiving only small portions, which was confirmed by observation and staff interviews.
An LPN was observed serving meals with unsecured long hair, which fell into the meal trays of two residents. The residents had medical conditions such as dementia and chronic illnesses. The facility's policy mandates that staff secure their hair to prevent contact with food, which was not followed.
An LPN failed to document the administration of narcotic medications for three residents, leading to discrepancies in medication counts. The facility's policy requires documentation at the time of administration, which was not adhered to, affecting residents with various medical conditions.
The facility failed to ensure staff donned appropriate PPE when providing care to a resident under enhanced barrier precautions (EBP). Two CNAs were observed performing catheter care without wearing gowns, despite the facility's policy requiring gowns for residents on EBP. The resident had multiple medical conditions, including an indwelling catheter and active wounds, necessitating EBP.
The facility failed to provide adequate supervision during smoke breaks for two residents, leading to potential safety hazards. One resident, with multiple medical conditions and moderate cognitive impairment, was not assessed for smoking safety, while another resident, requiring supervision due to poor decision-making, was observed smoking unsupervised. The facility's policy on smoking safety was not consistently enforced, posing potential risks.
The facility failed to follow the menu and document substitutions, affecting all 90 residents who received meals. The Dietary Manager served different portions and items than those listed on the menu, did not document the substitution of English muffins for toast, and did not inform the dietitian of changes. The Director of Nursing confirmed these discrepancies.
The facility failed to maintain kitchen sanitation and ensure the dishwasher had appropriate chemical levels, with food debris found on the fryer and the dishwasher operating at zero ppm of chemical sanitizer while in use.
The facility failed to ensure residents were not provided plastic utensils with meals, affecting 46 out of 90 residents. The facility ran out of silverware and used plastic silverware for residents on the second floor, as confirmed by a dietary aide. The facility's policy states that single-service items should only be used in extenuating circumstances.
Lack of Privacy in Resident Phone Conversations
Penalty
Summary
The facility failed to ensure residents had reasonable access to and privacy in their use of communication methods, specifically phone conversations. This deficiency affected two residents, one with moderately impaired cognition and another who was cognitively intact. Both residents were required to use the phone at the nurses' station, which did not provide privacy, as conversations could be overheard by staff and other residents. Resident interviews confirmed discomfort and complaints about the lack of privacy, which were acknowledged by the staff. Observations revealed that the phone at the nurses' station was the only available option for residents to make calls, and it was positioned in a way that did not allow for private conversations. Staff interviews confirmed that they were aware of the privacy issues and had received complaints from multiple residents. The facility's policy on dignity, which emphasizes the protection of resident privacy, was not adhered to in this situation.
Failure to Notify Resident's Representative of Change in Condition
Penalty
Summary
The facility failed to notify the resident's representative of a change in condition for Resident #87, who was admitted with diagnoses including Parkinson's Disease, dementia without behavioral disturbance, and schizoaffective disorder. The Minimum Data Set (MDS) assessment indicated that the resident had severely impaired cognition and required staff assistance with activities of daily living. A progress note dated January 5, 2025, revealed that the resident had remained in bed for two days, refused food, and had minimal fluid intake. Despite these significant changes, there was no documentation that the resident's guardian was informed. An interview with the Director of Nursing confirmed that although a hospice referral was discussed due to the resident's decline, the guardian was not notified, and the resident subsequently passed away. The facility's policy required prompt notification of the resident's representative in such cases, which was not adhered to.
Inaccurate Resident Assessment in LTC Facility
Penalty
Summary
The facility staff failed to ensure the accuracy of comprehensive resident assessments, affecting one resident out of four reviewed for comprehensive assessments. The resident, admitted with diagnoses including end-stage renal disease, diabetes, and chronic obstructive pulmonary disease (COPD), was documented in the Minimum Data Set (MDS) assessment as requiring substantial to maximum assistance with toileting, bathing, and dressing. However, interviews with the resident, a CNA, and an LPN confirmed that the resident was independent in these activities and had been since admission. The LPN acknowledged that the MDS assessment was inaccurate regarding the resident's functional status. The facility policy requires all individuals completing any portion of the MDS to sign a form attesting to the accuracy of the information, which was not adhered to in this case.
Failure to Update Care Plan for Independent Smoker
Penalty
Summary
The facility failed to appropriately revise the care plan for a resident who was an independent smoker. The resident, admitted with diagnoses including rheumatoid arthritis, unspecified mental disorder, and cognitive communication deficit, was initially assessed as able to safely handle smoking materials. However, the care plan did not reflect the facility's updated policy allowing independent smokers to keep smoking supplies in their rooms. Despite the resident's ability to smoke independently, the care plan still included interventions such as securing cigarettes and lighters at the nurses' station and checking the resident's room for smoking materials. Observations and interviews revealed discrepancies between the care plan and the facility's practice. The resident was observed with smoking materials in his room, and both the resident and the Administrator confirmed that independent smokers were allowed to keep their supplies. The Director of Nursing acknowledged that the care plan had not been updated to align with the new policy, which permitted independent smokers to retain smoking supplies in their rooms. This oversight in updating the care plan led to a deficiency in the facility's compliance with its own policies and procedures.
Medication Administration Error
Penalty
Summary
The facility failed to ensure that residents were free from significant medication errors, specifically affecting one resident. The resident, who was admitted with diagnoses including encephalopathy, depression, anxiety, acute kidney failure, urine retention, and alcohol abuse, had a physician's order for Lexapro 15 mg to be administered once daily. However, during an observation of medication administration, an LPN administered only 7.5 mg of Lexapro to the resident. Upon interview, the LPN confirmed that she had consistently administered the incorrect dose of Lexapro on 23 occasions in January and February. The facility's policy on administering medications, dated April 2019, mandates that medications should be administered safely, timely, and as prescribed, which was not adhered to in this case.
Failure to Provide Prescribed Double Portions to Resident
Penalty
Summary
The facility failed to provide a resident with a diet in accordance with the physician's orders and the resident's preferences. Resident #192, who has diagnoses including diabetes, mild intellectual disability, and bilateral below the knee amputations, was admitted with an order to receive double portions of food due to weight loss. However, on 03/03/25, the resident reported receiving only small portions, which was confirmed by an observation of the dinner tray that did not contain double portions. Interviews with CNAs also confirmed that the resident received only single portions at dinner.
Improper Hair Restraint During Meal Service
Penalty
Summary
The facility failed to ensure proper hygiene practices during meal service, as observed with two residents. A Licensed Practical Nurse (LPN) was seen serving meal trays to residents with her long hair unsecured, which fell into the meal trays of two residents. The residents involved had significant medical histories, including dementia, congestive heart failure, chronic kidney disease, diabetes mellitus type two, osteoarthritis, and peripheral vascular disease. The facility's policy on preventing foodborne illness requires that all employees serving food must secure their hair to prevent contact with residents' food, which was not adhered to in this instance.
Failure to Document Narcotic Medication Administration
Penalty
Summary
The facility failed to ensure proper documentation of narcotic medication administration by nurses, affecting three residents. Resident #14, admitted with diagnoses including a right femur fracture and anxiety, had discrepancies in the Tramadol count. The controlled substance count sheet indicated three doses remaining, but observation revealed only two doses in the cart. LPN #30 confirmed administering a dose earlier in the day but had not documented it. Similarly, Resident #32, with diagnoses such as cerebral infarction and dementia, had a discrepancy in the Ativan count. The count sheet showed 12 doses remaining, but only 11 were found in the cart. LPN #30 admitted to administering a dose without documentation. Resident #67, diagnosed with cirrhosis and depression, also had a discrepancy in the Ativan count, with the count sheet showing 40 doses remaining, but only 39 were present. Again, LPN #30 confirmed administering a dose without documentation. The facility's policy requires documentation of medication administration at the time of administration, which was not followed in these instances.
Failure to Don Appropriate PPE for Resident on EBP
Penalty
Summary
The facility failed to ensure that staff donned appropriate personal protective equipment (PPE) when providing direct care to a resident under enhanced barrier precautions (EBP). This deficiency was observed during catheter care for a resident with multiple medical conditions, including unspecified quadriplegia, incomplete paraplegia, neuromuscular dysfunction of the bladder, and osteomyelitis. The resident was admitted on October 3, 2024, and was placed under EBP due to active wounds, an indwelling catheter, and a colostomy. The care plan for the resident included educating the resident and family on the use of EBP and proper PPE, as well as posting EBP signage on the resident's door. On March 5, 2025, two certified nursing assistants (CNAs) were observed providing catheter care to the resident without donning gowns, which is a requirement under the facility's EBP policy. The CNAs entered the resident's room wearing face masks and clean gloves but failed to wear gowns while transferring the resident, removing the resident's pants, emptying the catheter bag, performing catheter care, and placing a clean brief on the resident. This was confirmed in an interview with one of the CNAs, who acknowledged that neither she nor her colleague donned a gown prior to providing direct care to the resident. The facility's policy, dated August 2022, clearly states that employees should don gowns when providing care to a resident on EBP.
Inadequate Supervision During Resident Smoke Breaks
Penalty
Summary
The facility failed to ensure adequate supervision and safety measures during smoke breaks for two residents, leading to potential safety hazards. Resident #01, who has multiple medical conditions including end-stage renal disease and moderate cognitive impairment, was not assessed for smoking safety, and their care plan lacked interventions related to smoking. Despite using tobacco, there was no evidence of a smoking assessment or restrictions, and the resident reported smoking outside designated times without staff intervention. Resident #02, diagnosed with conditions such as encephalopathy and nicotine dependence, was identified as requiring supervision during smoking due to poor decision-making and noncompliance with the smoking policy. The resident's care plan included interventions for supervised smoking and securing smoking materials, but observations revealed the resident smoking unsupervised at the facility's front entrance. Staff interviews confirmed the resident's noncompliance and the facility's challenges in enforcing the smoking policy, with staff often redirecting the resident without consistent supervision. The facility's policy mandates that residents should not possess smoking materials and must wear a smoking apron, yet these measures were not enforced for Resident #02. Interviews with staff, including the DON and Administrator, highlighted the facility's struggle to balance policy enforcement with resident independence, resulting in unsupervised smoking activities. The lack of consistent supervision and adherence to the smoking policy for both residents posed potential safety risks, as evidenced by the presence of cigarette butts and ashes at the facility's entrance.
Failure to Follow Menu and Document Substitutions
Penalty
Summary
The facility failed to ensure the menu was followed, affecting all 90 residents who received meals from the kitchen. On the morning of 05/06/24, the breakfast menu specified that residents on a regular diet were to receive six ounces of hot or cold cereal, two ounces of cheesy scrambled eggs, and one slice of toast. However, the Dietary Manager (DM) served six ounces of oatmeal, a number ten scoop of eggs, two sausage links, and a whole English muffin instead. Similarly, residents on mechanical and pureed diets received different portions and items than those listed on the menu. The substitution of English muffins for toast was not documented in the substitution log, and the dietitian was not informed of this change. Additionally, the DM used incorrect scoop sizes due to missing equipment and made unauthorized changes to the menu by adding sausage links for additional protein variety. During the tray line, the DM also altered the portion sizes of English muffins partway through service, serving only one half or one slice to some residents due to concerns about running out of English muffins. The Director of Nursing (DON) confirmed these discrepancies and the lack of documentation for the substitutions. The facility's Substitutions policy, dated April 2007, states that the food service manager, in conjunction with the dietitian, may make food substitutions as appropriate and necessary, and all substitutions must be noted on the menu and filed according to established dietary policies. The failure to follow the menu, document substitutions, and inform the dietitian of changes led to the deficiency. This affected the nutritional intake and consistency of meals provided to the residents, as the portions and items served did not align with the planned menu or dietary requirements.
Sanitation and Dishwasher Chemical Levels Deficiency
Penalty
Summary
The facility failed to maintain the kitchen in a sanitary manner and ensure the dishwasher had the appropriate level of chemicals to prevent foodborne illness. During an observation of the kitchen, food debris was found built up in the oil and on the edges of the fryer, as well as on the fryer basket. Additionally, there was brown splatter on the side of the fryer and brown water on the floor of the kitchen near the steam table where food was served. The Dietary Manager confirmed these observations during an interview. Further observation revealed that the dishwasher's temperature was 125 degrees Fahrenheit for both the wash and rinse cycles, and the chemical levels tested at zero parts per million (ppm). Despite this, dietary staff were observed actively running dishes through the dishwasher. The Dietary Manager verified that the dishwasher required chemicals to sanitize the dishes and confirmed that it was operating with zero ppm of chemical sanitizer while in use. The facility's Food Preparation and Service policy, dated November 2022, mandates that all food service equipment and utensils be sanitized according to current guidelines and manufacturer instructions.
Use of Plastic Utensils Due to Silverware Shortage
Penalty
Summary
The facility failed to ensure residents were not provided plastic utensils with meals, affecting 46 out of 90 residents. On the morning of May 6, 2024, during an observation of the tray line, it was revealed that the facility ran out of silverware and resorted to using plastic silverware for residents on the second floor. This was confirmed by an interview with a dietary aide who verified the shortage of silverware. The facility's policy on disposable dishes and utensils, dated November 2007, states that single-service items should only be used in extenuating circumstances such as dish machine failure, individual resident needs and requests, or other documented reasons. This deficiency was investigated under Master Complaint Number OH00153346.
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 metabolic encephalopathy, muscle weakness, and a history of CVA experienced a fall in his room that was not documented in the medical record until the following morning as a late entry. Two RNs acknowledged that the fall was not recorded at the time it occurred and stated that fall incidents should be documented as soon as possible after the event, resulting in a deficiency for failure to maintain timely, professionally standard medical records.
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.
A resident with cirrhosis, ascites, mood disorder, and alcohol-induced major neurocognitive disorder, and with moderately impaired cognition, was observed sitting on a shower chair in a gown with buttocks exposed and visible from the hallway through an open room door. A CNA left the room quickly after hearing another resident yell and forgot to close the door or pull the privacy curtain, and an RN confirmed the exposure, demonstrating a failure to maintain the resident’s dignity and privacy.
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.
Untimely Documentation of Resident Fall Incident in Medical Record
Penalty
Summary
The deficiency involves the facility’s failure to document a resident’s fall incident in the medical record in a timely manner, in accordance with accepted professional standards. The resident was admitted with diagnoses including metabolic encephalopathy, muscle weakness, and cerebrovascular accident. According to the medical record, a progress note was entered as a late entry on 02/20/26 at 8:21 A.M., stating that the resident had suffered a fall in his room on 02/19/26 at 8:00 P.M. There was no evidence of any documentation of the fall incident entered in the medical record at the time of, or shortly after, the fall on 02/19/26 at 8:00 P.M. During an interview on 03/30/26 at 12:05 P.M., two RNs confirmed that the fall incident was not documented until the following morning and stated that fall incidents should be entered in the medical record as soon as possible following the event. This lack of timely documentation of the fall incident constituted non-compliance with requirements to safeguard resident-identifiable information and maintain medical records in accordance with professional standards.
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.
Resident Left Exposed and Visible From Hallway Due to Failure to Maintain Privacy
Penalty
Summary
The facility failed to ensure resident dignity and privacy when a cognitively impaired resident was left exposed and visible from the hallway. The resident, who had diagnoses including cirrhosis with ascites, mood disorder, and alcohol-induced major neurocognitive disorder, had a BIMS score of eight, indicating moderately impaired cognition. During an observation, the resident was seen sitting on a shower chair in a gown with buttocks exposed, and this exposure was visible from the open room door in the hallway. A Certified Resident Care Associate and a Registered Nurse confirmed that the resident’s buttocks were visible from the hallway. The Certified Resident Care Associate reported that she had left the resident’s room quickly after hearing a resident in an adjacent room yell and, in her haste, forgot to close the door or pull the privacy curtain, resulting in the resident’s exposed state being visible to others. This incident involved one resident out of three reviewed for dignity, in a facility with a census of 52 residents, and was identified through record review, observation, and staff interviews.
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