Liberty Nursing Center Of Mansfield
Inspection history, citations, penalties and survey trends for this long-term care facility in Mansfield, Ohio.
- Location
- 535 Lexington Avenue, Mansfield, Ohio 44907
- CMS Provider Number
- 365475
- Inspections on file
- 18
- Latest survey
- May 13, 2025
- Citations (last 12 mo.)
- 0
Citation history
Health deficiencies cited at Liberty Nursing Center Of Mansfield during CMS and state inspections, most recent first.
The facility failed to timely implement its bowel protocol for two residents who had not had bowel movements, resulting in one resident experiencing actual harm including abdominal pain, fecal emesis, and hospitalization for dehydration and constipation, while another was placed at risk. Despite care plans and physician orders, prescribed interventions such as Milk of Magnesia, Bisacodyl suppository, and Fleet enema were not administered, and staff did not document required assessments or communicate bowel status as required by facility policy.
Surveyors found that the kitchen dishwashing area was not maintained in a clean and sanitary condition, with visible buildup of substances on a pipe, a puddle of water in a corner, and excessive dirt and debris under a rubber mat. These conditions were confirmed by a dietary staff member and had the potential to affect all residents receiving food from the kitchen.
The facility did not ensure all staff received annual education or vaccine information sheets regarding the COVID-19 vaccine, nor did it document that 54 of 79 staff were offered the vaccine as required. Staff were told to obtain the vaccine from outside providers, and only new hires were asked about the vaccine upon employment. This deficiency had the potential to affect all residents.
Several residents with conditions such as depression, dementia, and schizoaffective disorder were prescribed antidepressant medications, but nursing staff did not document monitoring for effectiveness or adverse effects as required by care plans and physician orders. Despite expectations from the DON and Medical Director, and the presence of relevant care plan interventions, there was no evidence in nurse's notes or MARs that such monitoring was performed for any of the affected residents.
A resident with intact cognition and multiple medical conditions requested to receive showers at least three times per week, but was only scheduled and provided with two showers weekly according to the facility's set schedule. Despite the resident's expressed preference and facility policy supporting resident choice in bathing frequency, staff interviews and documentation confirmed the request was not accommodated.
A resident with intact cognition and significant medical conditions reported to an LPN that a CNA had engaged in inappropriate sexual contact during incontinence care. The incident was reported internally, the CNA was suspended and later terminated, and the resident's family and physician were notified. However, the facility did not report the allegation to local law enforcement as required by policy, instead deferring to the resident's and family's wishes. This failure to notify authorities was a breach of required abuse reporting protocols.
A resident with severe cognitive impairment and multiple medical conditions received a new diagnosis of psychotic disorder with hallucinations, but the facility did not complete a required PASARR evaluation following this significant change in mental health status. Staff confirmed that no level two PASARR was conducted, contrary to facility policy.
A resident with multiple health conditions and a recent fall did not receive the recommended specialized rehabilitative services, specifically a tilt wheelchair, after therapy staff identified the need. Despite the resident's ongoing complaints and the poor condition of the current wheelchair, there was no evidence that therapy staff followed through with trialing or obtaining the appropriate equipment.
A resident with diabetes experienced multiple episodes of high blood sugar, leading to several doses of Humulin insulin being administered per provider orders. However, the LPN did not document the times of administration or blood sugar rechecks in the electronic medical record or on the MAR, and the facility's policy requiring such documentation was not followed. The DON and nurse practitioner confirmed the lack of proper documentation.
Several residents signed arbitration agreements that did not include a provision for selecting a venue convenient to both parties, as required. This omission was confirmed by the Administrator and affected multiple agreements reviewed during the survey.
Surveyors observed that staff failed to maintain proper infection control practices, including leaving urinary catheter drainage bags on the floor and not using required PPE during high-contact care and when entering rooms of residents on contact or enhanced barrier precautions. These lapses occurred despite clear facility policies and care plans, and staff acknowledged the failures during interviews.
Two residents with chronic medical conditions were not offered the recommended pneumococcal conjugate vaccines (PCV15, PCV20, or PCV21) one year after receiving PPSV23, as required by CDC guidelines. This failure was confirmed by nursing staff and was not in accordance with the facility's own policy.
Staff failed to follow safe transfer protocols for three residents requiring Hoyer lifts, including transferring a resident alone without required assistance, using mechanical lifts with uncharged batteries leading to stalled transfers, and not fully opening lift legs for stability. These actions were inconsistent with facility policy and manufacturer instructions, resulting in unsafe transfer practices.
Failure to Timely Implement Bowel Protocol Resulting in Harm
Penalty
Summary
The facility failed to implement its bowel protocol in a timely manner for residents who had not had bowel movements, resulting in actual harm to one resident and placing another at risk for harm. For one resident with Parkinson's Disease, peripheral vascular disease, and dementia, there was no recorded bowel movement for five days. Despite care plan interventions and physician orders specifying a stepwise bowel protocol to be initiated after three days without a bowel movement, there was no evidence that any of the prescribed interventions—Milk of Magnesia, Bisacodyl suppository, or Fleet enema—were administered. Documentation and staff interviews confirmed that the bowel protocol was not followed, and no assessment for constipation or bowel sounds was documented during this period. The resident subsequently experienced abdominal pain and multiple episodes of emesis with fecal odor, prompting transfer to the emergency room. Hospital records indicated the resident was admitted for dehydration and constipation, with imaging revealing a moderate to large amount of retained stool and possible fecal impaction. Interviews with staff, including the RN, CNA, ADON, DON, and NP, confirmed that the bowel protocol was not implemented as required, and communication lapses occurred regarding the resident's bowel status. The DON and ADON acknowledged that the protocol should have been initiated and that the necessary medications were available but not administered. A second resident with a diagnosis of constipation also did not receive timely intervention after three days without a bowel movement, as required by the facility's bowel protocol. The resident reported not receiving requested interventions such as prune juice or a laxative. Review of records confirmed that the bowel protocol was not implemented, and the DON verified that interventions should have been provided. The facility's policy required monitoring and prompt intervention for constipation, but this was not followed for either resident, as evidenced by the lack of documentation and administration of prescribed treatments.
Unsanitary Kitchen Conditions Observed
Penalty
Summary
Surveyors observed that the facility failed to maintain a clean and sanitary kitchen environment. During an inspection of the dishwashing area, a pipe along the lower part of the wall was found with a buildup of black, white, and grey substances. Additionally, a dark puddle of water was present in the corner where the walls met. The rubber mat in the dishwashing area, designed with circular holes for drainage, had an excessive amount of dirt, buildup, and debris visible through the holes and underneath the mat. These findings were confirmed by a dietary staff member during the observation. The unsanitary conditions in the kitchen had the potential to affect all 57 residents who received food from the kitchen, with one resident identified as receiving nothing by mouth. The facility census at the time was 58.
Failure to Provide Annual COVID-19 Vaccine Education and Documentation for Staff
Penalty
Summary
The facility failed to ensure that all staff received education and vaccine information sheets regarding the COVID-19 vaccine, as required by policy and CDC/FDA guidelines. Out of 79 staff members, there was no documentation that 54 had been offered the annual COVID-19 vaccine or received education about its risks and benefits. Only 25 new staff hired since September 1, 2024, had received some education and declined the vaccine, but there was no evidence that any staff were provided with the vaccine information sheet. Interviews with staff, including RNs, the Administrator, and the Human Resource Manager, confirmed that the facility did not provide annual education or offer the vaccine to staff, instead instructing them to obtain it from their own pharmacy or physician. Further review of the facility's COVID-19 Vaccine Policies and Procedures indicated that all staff should be offered the vaccine annually and provided with education and a vaccine information sheet, with documentation maintained for all staff. However, the Administrator and HRM acknowledged that staff were only asked about the vaccine upon hire and not annually, and that the required education and information sheets were not provided. This deficiency affected 54 of 79 staff and had the potential to impact all residents, with a facility census of 58 at the time of the survey.
Failure to Monitor Effectiveness and Adverse Effects of Psychotropic Medications
Penalty
Summary
The facility failed to ensure that residents receiving psychotropic medications, specifically antidepressants, were monitored for effectiveness and adverse consequences as required. Multiple residents with diagnoses such as depression, dementia, schizoaffective disorder, and anxiety were prescribed various antidepressant medications, including Citalopram, Trazodone, Effexor, Sertraline, Bupropion, and Duloxetine. Despite care plans and physician orders indicating the need for monitoring, there was no documentation in nurse's notes or Medication Administration Records (MARs) that such monitoring occurred for these residents over extended periods. For example, one resident with severe cognitive impairment and diagnoses of Parkinson's disease and dementia was prescribed Citalopram and Trazodone, with care plans requiring monitoring every shift. However, there was no evidence in the medical record or MARs that monitoring for effectiveness or adverse effects was performed. Similar findings were noted for other residents with major depressive disorder, schizoaffective disorder, and anxiety, all of whom had orders and care plans specifying the need for monitoring, but lacked corresponding documentation. Interviews with the DON and the Medical Director confirmed that nursing staff were expected to monitor and document the effectiveness and adverse effects of psychotropic medications, but this was not being done. Additionally, the facility did not have a specific policy for psychotropic medication use, instead relying on an antipsychotic medication policy, which did not address the broader category of psychotropic drugs. This deficiency affected all five residents reviewed for unnecessary medications, out of a total of 40 residents receiving psychotropic medications in the facility.
Failure to Honor Resident's Shower Frequency Preference
Penalty
Summary
A deficiency occurred when the facility failed to honor a resident's expressed preference for shower frequency. The resident, who had intact cognition and required supervision for showering, was scheduled for showers twice weekly on specific days and shifts, as indicated by the facility's shower schedule and documentation. Despite the resident's request, made known during a care conference and to the Social Services Designee, to receive showers at least three times per week, the facility continued to provide and schedule only two showers per week. The facility's shower schedule included a note instructing staff not to change shower days for residents, and the schedule matched what was listed in the electronic medical record. Interviews with the resident, the Social Services Designee, and a Registered Nurse confirmed that the resident's request for increased shower frequency was not accommodated. The facility's policy stated that residents have the opportunity to express their preference for bathing type, frequency, and time of day, but this policy was not followed in the resident's case. The failure to support the resident's choice regarding shower frequency was identified through medical record review, staff and resident interviews, and review of facility documentation.
Failure to Report Sexual Abuse Allegation to Law Enforcement
Penalty
Summary
The facility failed to report an allegation of sexual abuse involving a resident to local law enforcement, as required by policy and regulation. A resident with intact cognition and a history of Hodgkin's lymphoma and malnutrition reported to an LPN that a CNA had groped her breast and inserted his finger into her vaginal area during incontinence care. The LPN notified the Administrator, who then informed the DON. The resident, her family, and her physician were notified, and the resident declined to be sent to the hospital. The CNA in question was suspended and later terminated, but the incident was not reported to local law enforcement or other agencies, despite the facility's policy requiring such action when a crime is suspected. The investigation revealed that the resident was upset and requested no male caregivers following the incident. The facility's documentation showed that the resident and her family declined police involvement, citing embarrassment and a desire for privacy. However, the facility did not offer alternative arrangements for the resident to speak with law enforcement in a more private setting. Interviews with staff and other residents indicated that some residents had negative impressions of the CNA, and another resident described an uncomfortable experience with the same CNA, though she had not previously reported it. The facility's policy clearly stated that suspicions of a crime, including sexual abuse, must be reported to local police immediately, in addition to notifying the state health department and the resident's family and physician. Despite this, the facility did not notify law enforcement, relying instead on the resident's and family's wishes. The omission of this required reporting constituted a failure to follow established protocols for handling allegations of abuse, potentially affecting the safety and well-being of all residents in the facility.
Failure to Complete PASARR After New Psychiatric Diagnosis
Penalty
Summary
The facility failed to complete a required Pre-admission Screening and Resident Review (PASARR) evaluation after a resident received a new diagnosis of psychotic disorder with hallucinations due to a known psychological condition. The resident, who had previously been admitted with diagnoses including Parkinson's Disease, peripheral vascular disease, and dementia, was found to be severely cognitively impaired according to a recent Minimum Data Set (MDS) assessment. Although the initial PASARR was completed prior to admission, there was no evidence in the medical record of a subsequent PASARR evaluation following the new psychiatric diagnosis. Staff interview confirmed that no level two PASARR evaluation or determination was conducted after the significant change in the resident's mental health status, despite facility policy requiring notification of the state mental health authority after such changes.
Failure to Provide Recommended Rehabilitative Services and Equipment
Penalty
Summary
The facility failed to implement recommended specialized rehabilitative services for a resident who had a history of muscle wasting, heart disease, osteoarthritis, unsteadiness, and postural kyphosis. After the resident sustained a fall from their wheelchair, a physician ordered a physical therapy evaluation and treatment. The physical therapy evaluation identified the need for a possible tilt chair to decrease the resident's fall risk, following a noted decline and the resident's report of sliding out of the wheelchair due to a bed pad. Despite this recommendation, there was no evidence that a tilt chair was trialed or that further action was taken to address the resident's wheelchair needs. The resident, who was cognitively intact and required assistance from at least two staff for bed mobility and transfers, reported ongoing issues with the condition of their wheelchair and stated that therapy staff were supposed to be working on obtaining a new wheelchair. Observation confirmed the wheelchair was in poor condition, with missing material and tape applied by the resident. The Therapy Director verified that although therapy staff had planned to trial a different wheelchair, there was no documentation or evidence that this was ever initiated or completed.
Failure to Accurately Document Insulin Administration and Blood Glucose Monitoring
Penalty
Summary
The facility failed to ensure appropriate and accurate documentation in the electronic medical records for a resident with diabetes and atherosclerotic heart disease. The resident was admitted with orders for Lantus insulin, which was later adjusted, but did not have routine blood sugar checks ordered. On one occasion, the resident experienced critically high blood sugar readings, and a series of orders were given by a nurse practitioner to administer multiple doses of Humulin insulin and to recheck blood sugars. The progress note documenting these events did not include the times of provider notification, when orders were received, the times of insulin administration, or the times of blood sugar rechecks. Further review revealed that none of the Humulin doses administered were entered into the electronic medical record or recorded on the Medication Administration Record (MAR). Interviews with the resident, the LPN involved, the DON, and the nurse practitioner confirmed that the insulin orders and administrations were not properly documented in the electronic system, and that facility policy required blood glucose monitoring results to be recorded in the MAR. The lack of documentation affected the accuracy and completeness of the resident's medical record.
Arbitration Agreements Lacked Required Venue Selection Provision
Penalty
Summary
The facility failed to include all required components in its arbitration agreements for residents, specifically omitting provisions for the selection of a venue convenient to both parties. This deficiency was identified through a review of medical records and signed arbitration agreements for five residents, where each agreement lacked the necessary clause regarding venue selection. The issue was confirmed during an interview with the Administrator, who acknowledged that the agreements did not contain this required element. A total of 33 residents had entered into arbitration agreements, and the deficiency was found in five of the seven residents reviewed for this component. The omission was consistent across multiple agreements, regardless of the residents' admission dates. The facility census at the time was 58 residents.
Failure to Follow Infection Control Protocols for Catheter Care and PPE Use
Penalty
Summary
Surveyors identified multiple deficiencies related to infection prevention and control practices. For one resident with a history of mechanical complication of a knee prosthesis, benign prostatic hyperplasia, and neuromuscular bladder dysfunction, observations revealed that the indwelling urinary catheter drainage bag was lying on the floor, contrary to physician orders and facility policy, which require the bag to be secured below the bladder and not in contact with the floor. Staff interviews confirmed awareness of the correct procedure, but the required practice was not followed. Another resident with Parkinson's disease, peripheral vascular disease, and dementia was on contact precautions due to an active infection with a highly transmissible pathogen (ESBL). Despite care plan interventions and facility policy requiring the use of personal protective equipment (PPE) upon room entry, the Administrator was observed entering the resident's room without donning any PPE. The Administrator confirmed this lapse during an interview. A third resident with diabetes, dementia, hypertension, atrial fibrillation, and obstructive uropathy had a suprapubic catheter and required enhanced barrier precautions. Observations showed the resident's catheter drainage bag was uncovered and on the floor, and staff transferring the resident did not wear the required gown and gloves during high-contact care activities, despite signage and policy indicating the need for PPE. Staff interviews confirmed knowledge of the requirements but acknowledged non-compliance during the observed care.
Failure to Administer Pneumococcal Vaccines per CDC Guidelines
Penalty
Summary
The facility failed to ensure pneumococcal vaccines were administered according to current CDC guidelines for two residents. For one resident with diagnoses including type two diabetes mellitus, COPD, atrial fibrillation, hypertension, and anxiety, the medical record showed the last pneumococcal polysaccharide vaccine (PPSV23) was administered in early 2020. Based on CDC recommendations and the resident's age and medical history, the resident should have been offered a dose of PCV15, PCV20, or PCV21 one year after the PPSV23 immunization, but this was not done. This was confirmed by a registered nurse during an interview. Similarly, another resident with heart failure, Parkinson's disease, type two diabetes mellitus, and dementia received the PPSV23 immunization in mid-2022. According to CDC guidelines, this resident should also have been offered a dose of PCV15, PCV20, or PCV21 one year after the PPSV23 immunization, but this did not occur. The facility's policy stated that pneumococcal vaccines should be administered in accordance with current CDC recommendations, but this was not followed for these two residents.
Failure to Ensure Safe Resident Transfers Using Mechanical Lifts
Penalty
Summary
The facility failed to ensure safe transfer practices for residents requiring manual and mechanical Hoyer lifts, as evidenced by multiple incidents involving three residents. One resident with severe dementia and agitation was observed being transferred by a hospice aide using a Hoyer lift without the required assistance of a second staff member, contrary to the facility's policy mandating two staff for such transfers. The aide confirmed performing the transfer alone, and the policy review supported the need for two staff to ensure safety. Another resident with severe obesity and cognitive intactness reported being left suspended in the air during transfers due to mechanical lift or battery failures. Staff interviews revealed that mechanical lifts frequently lost power during transfers, requiring the use of emergency releases or battery changes mid-transfer. There was no established protocol for charging lift batteries, and staff confirmed that lifts often began beeping and slowed down during use. During an observed transfer, the lift's metal attachment nearly struck the resident's head after being unhooked, and staff acknowledged this was not an uncommon occurrence. A third resident, dependent on staff for transfers due to dementia and muscle weakness, was observed being transferred with the mechanical lift's legs in the closed position throughout the process, contrary to manufacturer instructions and facility policy, which require the legs to be fully open for stability except when maneuvering under a bed. Staff interviews confirmed awareness of the correct procedure but did not follow it during the observed transfer. These findings demonstrate a pattern of non-compliance with established safety protocols for resident transfers using mechanical lifts.
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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