Lanfair Center For Rehab & Nsg Care Inc
Inspection history, citations, penalties and survey trends for this long-term care facility in Lancaster, Ohio.
- Location
- 1590 Chartwell Street, Lancaster, Ohio 43130
- CMS Provider Number
- 366215
- Inspections on file
- 22
- Latest survey
- June 11, 2025
- Citations (last 12 mo.)
- 0
Citation history
Health deficiencies cited at Lanfair Center For Rehab & Nsg Care Inc during CMS and state inspections, most recent first.
A resident with dementia, dysphagia, and acute kidney failure, who was at nutritional risk, did not consistently receive a physician-ordered nutritional supplement (Gelato) with meals. Observations and staff interviews confirmed the supplement was missing from meal trays, and the resident experienced a significant weight loss over three weeks.
A deficiency was identified when a nurse performed wound care for a resident with unhealed surgical wounds using only gloves and not a gown, despite facility policy and posted signage requiring both gown and glove use for Enhanced Barrier Precautions (EBP). The nurse later confirmed not following EBP, and review of policy and CMS guidance indicated EBP was required for residents with chronic wounds.
Surveyors found multiple open and undated food items in the refrigerator, pantry, and kitchen serving area, including deli sandwiches, deli meat, crackers, orange syrup, and bags of chips. The Dietary Manager confirmed these items were not labeled or dated as required by facility policy, affecting all residents except one who was NPO.
A resident with dementia and other mental health diagnoses was prescribed an antipsychotic for behaviors that were not consistently documented or monitored. Staff confirmed the medication was used for dementia, which is not an appropriate diagnosis for antipsychotic use, and that regular wandering was not properly recorded in the medical record.
The facility did not update the PASARR for two residents after significant changes in their mental health diagnoses, including the addition of schizoaffective disorder, anxiety disorder, and major depressive disorder. The most recent PASARR submissions for these residents did not reflect their current mental health status, as confirmed by the Regional Director of Social Services and Activities.
Two residents did not have comprehensive care plans addressing their specific needs: one resident's plan lacked individualized swallowing strategies recommended by ST despite a history of dysphagia and weight loss, while another resident's plan did not address c-pap use, with the device observed improperly stored and no physician orders in place. Facility staff confirmed these omissions, which were not in accordance with facility policy.
A resident with multiple medical conditions and physician orders for daily wound care did not receive wound treatments as prescribed. Observations showed that dressings remained unchanged for more than a day, despite documentation indicating otherwise. An RN confirmed that daily wound care was not performed according to orders.
Two residents experienced significant unplanned weight loss without the facility implementing or documenting individualized interventions or consistent weekly weight monitoring as required by policy. For one resident with dysphagia and multiple comorbidities, recommended swallowing strategies were not included in the care plan, and intake of nutritional supplements was not tracked. For another resident with malnutrition and diabetes, weekly weights and reweights were not consistently obtained after a marked weight loss, and supplement intake was inconsistent. Staff interviews confirmed lapses in monitoring and documentation.
Two residents did not receive appropriate respiratory care due to missing physician orders and lack of documentation. One resident received continuous oxygen therapy without proper documentation in the MAR, despite orders and observations indicating ongoing use. Another resident used a CPAP machine without a physician order or care plan, and the device was stored improperly on the floor without protection, contrary to facility policy.
Physicians did not provide clear medical reasons for declining pharmacy-recommended gradual dose reductions of psychotropic medications for two residents with dementia and psychiatric diagnoses. Instead, recommendations were declined with either no explanation or non-medical reasons, such as family requests, as confirmed by the DON.
A registered nurse failed to use required gloves and gown while performing wound care on a resident with multiple open wounds, despite facility policy and CDC guidance mandating Enhanced Barrier Precautions for such high-contact care activities. The resident had a history of fractures, falls, and skin conditions, and physician orders specified daily wound care for open wounds.
The facility failed to maintain the dish machine in safe operating condition, affecting all 74 residents. The machine had been broken for at least a month, requiring towels to prevent water backflow. The facility awaited corporate approval for repairs, using a three-sink hand washing protocol in the interim.
A CNA failed to perform proper hand hygiene during meal service, affecting four residents. The CNA wore gloves while delivering meal trays and did not change gloves or use hand sanitizer between residents, contrary to the facility's infection control policies. A Dietary Coordinator confirmed the CNA's non-compliance with the policies, which require hand hygiene between rooms and do not recommend glove use during tray service.
The facility failed to provide a dignified dining experience by serving meals on Styrofoam tableware and plastic cutlery due to a broken dish machine. Observations and interviews confirmed the use of disposable materials, affecting all residents. Residents reported difficulty eating with plastic utensils, and the facility's policy of using glassware and china was not followed.
Failure to Provide Ordered Nutritional Supplement for Resident at Risk of Weight Loss
Penalty
Summary
A deficiency was identified when a resident with a history of dementia, dysphagia, and acute kidney failure, who was at nutritional risk, was not provided with nutritional supplements as ordered. The resident had a physician's order for a pureed diet, nectar thick liquids, and four ounces of Gelato, a high-calorie nutritional supplement, to be given with each meal. The care plan specifically included the provision of Gelato at all meals to prevent significant weight change. However, during multiple observations, the resident's meal trays did not include the ordered Gelato, and this omission was confirmed by both nursing and dietary staff. Review of the resident's weight records showed a significant weight loss of 7.6 pounds, or 5 percent, over a three-week period. Staff interviews confirmed that the Gelato was not consistently provided as ordered, and dietary staff acknowledged the supplement was not placed on the resident's tray during at least one observed meal. This failure to provide the prescribed nutritional supplement contributed to the resident's continued weight loss, as documented in the medical record and observed by surveyors.
Failure to Implement Enhanced Barrier Precautions During Wound Care
Penalty
Summary
During the annual survey, it was observed that the facility failed to implement Enhanced Barrier Precautions (EBP) during wound care for a resident with a history of orthopedic surgery and a surgical wound infection. The resident had been admitted with severe sepsis secondary to a right ankle wound infection, had undergone multiple surgeries, and was receiving ongoing wound care and antibiotics. Facility policy and CMS guidance both required the use of gown and gloves for high-contact care activities, such as wound care for residents with unhealed surgical wounds. Despite signage indicating EBP requirements, a registered nurse performed a dressing change using only gloves and did not wear a gown. The nurse confirmed after the procedure that she did not wear a gown and stated that the resident was not on EBP precautions, despite the presence of unhealed surgical wounds and posted signage. Review of facility policy and the CMS QSO-24-08-NH memo confirmed that EBP, including gown and glove use, was indicated for residents with chronic or unhealed surgical wounds. This incident was identified as a deficiency and was also noted as evidence of continued non-compliance from a previous survey.
Failure to Label and Store Food Items Properly
Penalty
Summary
Surveyors observed multiple instances of improper food labeling and storage throughout the facility. In the walk-in refrigerator, there was an undated jar of minced garlic, three open and undated deli sandwiches, and an open, undated package of deli meat. In the pantry, an undated half bottle of orange concentrated syrup and a large open, undated bag of crackers were found. Additionally, in the kitchen serving area, four large bags of chips were open and undated. These findings were confirmed by the Dietary Manager during interviews. The facility's policy requires all perishable food to be stored in a manner that optimizes food safety and quality, including labeling and dating opened food items, which was not followed in these instances. All residents in the facility, except for one who was nothing by mouth, were affected by these deficiencies, as the improper storage and labeling of food items could impact the safety and quality of food served.
Inadequate Diagnosis and Monitoring for Psychotropic Medication Use
Penalty
Summary
The facility failed to ensure that a resident had an appropriate diagnosis for the use of psychotropic medications and did not adequately monitor the resident's behaviors. The resident, who had diagnoses including dementia with psychotic disturbance, anxiety disorder, and major depressive disorder, was prescribed an antipsychotic (Quetiapine) for crying and restlessness related to dementia. However, documentation showed minimal recorded behaviors, with only two instances of restlessness noted by nursing staff and no behaviors documented by nurse aides over a one-month period. Progress notes were repetitive and lacked specific details about the resident's behaviors, such as wandering or taking items, despite these being described as regular occurrences. Observations confirmed that the resident was frequently wandering the unit, but this behavior was not consistently documented in the medical record. Interviews with facility staff verified that the antipsychotic was prescribed for dementia, which was not considered an appropriate diagnosis for such medication, and that behavior monitoring was insufficient. The lack of accurate and thorough documentation, as well as the use of psychotropic medication without a proper diagnosis, contributed to the deficiency identified during the survey.
Failure to Update PASARR Following Changes in Mental Health Diagnoses
Penalty
Summary
The facility failed to notify the state of changes in mental health diagnoses for two residents, as required by the Preadmission Screening and Resident Review (PASARR) process. One resident was admitted with multiple diagnoses, including dementia, epilepsy, bipolar disorder, and later developed schizoaffective disorder, anxiety disorder, and major depressive disorder. Despite these changes, the last PASARR submission was several years prior and did not reflect the updated diagnoses. Another resident, initially admitted with dementia and other conditions, was later diagnosed with major depressive disorder and anxiety disorder, but the most recent PASARR did not indicate any mental disorders. Interviews with the Regional Director of Social Services and Activities confirmed that PASARR updates were not completed when the residents' diagnoses changed.
Failure to Develop Comprehensive Care Plans for Swallowing Strategies and C-PAP Use
Penalty
Summary
The facility failed to develop comprehensive care plans for two residents in the areas of swallowing strategies and c-pap use. For one resident with a complex medical history including cerebrovascular disease, dysphagia, and dementia, the medical record and speech therapy (ST) assessments recommended specific swallowing strategies such as a pureed diet with thickened liquids, no straws, small bites, and upright posture during meals. However, the resident's care plan did not include these individualized swallowing recommendations, despite documented weight loss and ongoing nutritional concerns. This omission was confirmed by facility staff during interviews. For another resident with multiple diagnoses including obstructive sleep apnea and a history of orthopedic aftercare, the care plan did not address the use of a c-pap machine. There were no physician orders for the c-pap, and observations revealed the c-pap mask was left on the floor under the bed without a protective bag. The absence of a care plan for c-pap use was confirmed by facility staff. Facility policy requires a comprehensive care plan to be developed within 21 days of admission and updated as the resident's condition changes. In both cases, the facility did not ensure that the care plans reflected the residents' current needs and recommendations, as evidenced by the lack of documented swallowing strategies and c-pap use in the respective care plans.
Failure to Provide Daily Wound Care as Ordered
Penalty
Summary
A resident with multiple medical conditions, including multiple pelvic fractures, pustular psoriasis, diabetes mellitus type 2, moderate protein malnutrition, hyperlipidemia, and low back pain, was admitted to the facility and had physician orders for daily wound care to the right dorsal foot and left lower extremity. The orders specified cleansing with in-house wound cleanser, application of SilvaSorb gel, and appropriate dressings to be changed daily and as needed. The resident's care plan also documented the presence of pressure injuries and pustular psoriasis, with interventions in place for wound management. Despite these orders, review of the treatment administration record indicated that wound care was signed as completed on a specific date. However, observations on subsequent days revealed that the dressings on the resident's left foot, left leg, and right foot were dated from a previous day, indicating that the daily wound care had not been performed as ordered. An RN confirmed that the dressings in place were not changed daily as required by the physician's orders, resulting in a failure to provide the prescribed wound care.
Failure to Implement and Monitor Individualized Nutrition Interventions After Significant Weight Loss
Penalty
Summary
The facility failed to develop and implement comprehensive and individualized interventions to prevent significant weight loss for two residents. For one resident with multiple complex medical conditions, including cerebrovascular disease, dysphagia, and dementia, there was a lack of documented evidence that swallowing strategies recommended by speech therapy were incorporated into the care plan. The resident experienced significant weight loss over several months, but weekly weights were not consistently obtained following these losses, and there was no documentation of individualized interventions after further weight decline. Additionally, the intake of nutritional supplements, such as Thrive Gelato, was not monitored, as the facility considered it part of fortified foods rather than a supplement, resulting in a lack of documentation regarding the resident's actual consumption. For another resident with diagnoses including moderate protein-calorie malnutrition and diabetes, there was a documented significant weight loss exceeding 11% in one month. Although the care plan called for weekly weights following significant weight changes, these were not consistently obtained. The dietitian recommended a reweight and an appetite stimulant, but the reweights were not completed, and weekly weights were not continued as required by facility policy. The resident's intake of nutritional supplements was also inconsistent, with documentation showing refusals and varied acceptance, but no further individualized interventions were implemented at the time of the deficiency. Interviews with facility staff, including the RD, DON, and nursing staff, confirmed that the required monitoring and documentation were not performed according to policy. Staff also indicated a lack of awareness or implementation of specific swallowing strategies for the resident with dysphagia, and there was confusion regarding the classification and monitoring of nutritional supplements. The facility's own policy required weekly weights and close monitoring after significant weight loss, but these procedures were not followed for the affected residents.
Failure to Ensure Physician Orders and Documentation for Respiratory Care
Penalty
Summary
The facility failed to provide safe and appropriate respiratory care for two residents by not ensuring proper physician orders and documentation for respiratory devices and oxygen therapy. For one resident with chronic obstructive pulmonary disease and other significant health conditions, there was a physician order for continuous oxygen at two liters via nasal cannula as needed, with instructions for nursing staff to check placement and record oxygen concentration every shift. However, the resident's Medication Administration Record (MAR) did not document oxygen use, despite multiple progress notes and observations indicating the resident was receiving oxygen at three liters per minute and wearing oxygen continuously. The program director confirmed the resident wore oxygen most of the time, but this was not reflected in the MAR, and the order was technically as needed, though the resident received it continuously. For another resident with a history of orthopedic aftercare, obstructive sleep apnea, and other comorbidities, there were no physician orders or care plan addressing the use of a CPAP machine. Observations revealed the CPAP mask was stored inappropriately on the floor under the bed without a protective bag. Interviews with the DON and regional nurse confirmed the lack of orders and improper storage. The facility's policy required a physician's order for CPAP/BiPAP devices, including machine settings, and monitoring of the resident's tolerance, but these standards were not met.
Failure to Provide Medical Justification for Declining Pharmacy-Recommended GDRs
Penalty
Summary
The facility failed to ensure that physicians provided clear and medically justified reasons for not implementing pharmacy-recommended gradual dose reductions (GDR) of psychotropic medications for two residents. In both cases, the pharmacist had reviewed the residents' drug regimens and recommended dose reductions based on the absence of documented behaviors and the presence of dementia diagnoses. However, the physicians either declined the recommendations without providing any reasoning or cited non-medical reasons, such as family requests, without further explanation. For one resident with multiple diagnoses including dementia, psychotic disturbance, and major depressive disorder, the pharmacist recommended reducing the dose of Quetiapine on several occasions, but the physician either gave no reason or referenced family wishes for not making changes. Another resident with severe cognitive impairment and several psychiatric diagnoses was also recommended for dose reductions of Duloxetine and Olanzapine, but the physician again declined without providing a medical rationale, sometimes citing resident or family requests. The DON confirmed that GDR recommendations were declined without appropriate medical reasoning.
Failure to Follow Enhanced Barrier Precautions During Wound Care
Penalty
Summary
A deficiency was identified when a registered nurse performed wound care on a resident with multiple open wounds, including on the right dorsal foot and left lower extremity, without following Enhanced Barrier Precautions (EBP) as required by both facility policy and CDC guidelines. The nurse acknowledged during the procedure that EBP, specifically the use of gloves and a gown during high-contact resident care activities such as wound care, was not followed. The resident involved had a medical history that included multiple pelvic fractures, repeated falls, generalized pustular psoriasis, and edema. Physician orders directed daily wound care for open wounds, which required cleansing, application of Silvasorb, and appropriate dressings. Despite these orders and the facility's policy, the required personal protective equipment was not used during the observed wound care procedure.
Dish Machine Maintenance Failure
Penalty
Summary
The facility failed to maintain the dish machine in the kitchen in safe operating condition, which had the potential to affect all 74 residents residing in the facility. During an observation, a bright red sign was noted on the dish machine instructing staff not to remove towels placed at its base to prevent water backflow. The Dietary Coordinator confirmed that the dish machine was broken and had been in this condition for at least a month. The facility was using a three-sink hand washing protocol for dishes while awaiting corporate approval for a repair bid submitted by an outside vendor. The Maintenance Coordinator stated that the dish machine had been replaced a year ago and broke down shortly after the warranty expired. The machine had been non-operational for at least four weeks. The Administrator confirmed the breakdown and the expiration of the warranty. A review of the repair bid revealed that several components of the dish machine needed replacement, including the air trap, O-ring, booster heater, booster tank, and drain pump. The proposal for repairs was valid until a specified date but had not yet been signed by the facility.
Failure in Hand Hygiene During Meal Service
Penalty
Summary
The facility failed to ensure proper hand hygiene was performed by staff during meal service, affecting four residents on the Pleasantville Unit. During an observation, a Certified Nursing Assistant (CNA) was seen wearing gloves while delivering meal trays to multiple residents without removing the gloves or performing hand hygiene between each resident. This action was confirmed by a Dietary Coordinator who was present during the meal service and observed the CNA's failure to adhere to the facility's infection control policy. The facility's policy on Room Tray Service, dated November 2017, requires nursing staff to follow infection control protocols, including using hand sanitizer between rooms and washing hands if they touch anything other than the tray. The policy does not recommend wearing gloves during tray service. Additionally, the facility's Hand Washing/Hand Hygiene policy emphasizes that gloves do not replace handwashing and that staff should use an alcohol-based hand rub after contact with inanimate objects in the resident's vicinity. The CNA's actions were not in compliance with these policies, leading to the deficiency.
Deficiency in Dignified Dining Experience Due to Use of Disposable Tableware
Penalty
Summary
The facility failed to provide residents with a dignified dining experience by serving meals on Styrofoam tableware and cups with plastic cutlery. This issue was observed in three residents during meal service and had the potential to affect all 74 residents in the facility. Observations revealed the use of Styrofoam and aluminum trays in the meal preparation area, and interviews with staff and residents confirmed the use of these materials due to a broken dish machine. The dish machine had been out of service for at least a month, and the facility was awaiting corporate approval to fix it. Residents expressed difficulty in eating meals with plastic cutlery, particularly with cutting meat, and one resident was unable to open the aluminum tray on her own. The facility's policy from November 2017 stated that meals should be served on glassware and china or dining ware, which was not being followed. The Administrator confirmed the dish machine had been broken since June 2024 and that the facility had been using disposable dinnerware since then. This deficiency was investigated under Complaint Number OH00159475.
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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