Louisville Gardens Care Center
Inspection history, citations, penalties and survey trends for this long-term care facility in Louisville, Ohio.
- Location
- 4466 Lynnhaven Avenue Ne, Louisville, Ohio 44641
- CMS Provider Number
- 366141
- Inspections on file
- 36
- Latest survey
- December 11, 2025
- Citations (last 12 mo.)
- 17
Citation history
Health deficiencies cited at Louisville Gardens Care Center during CMS and state inspections, most recent first.
The facility did not maintain proper infection control practices, including failing to post required isolation signage for residents with COVID-19, not separating soiled linens from infected and non-infected residents, and staff not performing hand hygiene during incontinence care. These actions were inconsistent with CDC guidelines and the facility's own policies.
A resident with a deep tissue injury and multiple chronic conditions did not receive wound care as ordered by the physician. Observation and record review revealed that the dressing on the resident's heel was not changed as required, and staff confirmed the treatment was missed.
Two residents did not receive prescribed anticonvulsant medications as ordered because the medications were not available in the facility. Nursing staff and nurse practitioners attempted to obtain the necessary prescriptions and contact the pharmacy, but delays in communication and prescription processing led to multiple missed doses. Facility policy required advance ordering and documentation of medications, but these procedures were not effectively followed, resulting in the deficiency.
A resident's admission paperwork was not completed in a timely manner and was signed by the resident instead of the designated POA, despite facility policy. Additionally, an LPN failed to accurately document and administer scheduled medications for another resident, recording medications as given before actual administration and noting a medication as unavailable. These actions resulted in incomplete and inaccurate medical records.
The facility did not maintain sufficient nursing staff, resulting in missed showers, delayed call light responses, and prolonged wait times for care and meal delivery. Staff and residents reported frequent understaffing, with some units left without an aide and only a nurse present. Observations confirmed that call lights were left unanswered for over 30 minutes, and staff struggled to complete required care tasks due to inadequate staffing.
The facility did not complete required quarterly care conferences for multiple residents and failed to maintain accurate or updated care plans, including not reflecting a resident's true continence status and not updating a care plan after a resident sustained a major injury from a fall. Interviews with residents and staff confirmed these deficiencies, and facility policy required more timely and accurate care planning.
The facility did not consistently provide scheduled showers or alternative hygiene care to several residents who required assistance with ADLs, as confirmed by documentation and interviews with residents and staff. Residents with various medical conditions and cognitive statuses missed scheduled showers, and staff acknowledged challenges in completing all assigned showers due to staffing issues. Facility policy on documenting hygiene care and refusals was not consistently followed.
Two residents did not receive prescribed care as ordered: one did not have a preventative dressing changed on schedule after a pressure ulcer, with staff documenting care in error, and another experienced repeated missed doses of a dialysis-related medication due to pharmacy delays and lack of proper medication receipt tracking. Facility policies for medication ordering and documentation were not followed, resulting in gaps in care.
The facility assigned an unqualified staff member to the Activities Director position without verifying required credentials or enrollment in a state-approved training course, as confirmed by personnel file review and staff interviews. This failure had the potential to impact all residents in the facility.
A facility failed to document and treat a pressure ulcer timely for a resident. Initially, the ulcer was incorrectly documented on the left gluteal fold, but later assessments revealed it was on the right buttock. No treatment was recorded for several days, and an order for care was delayed. The Regional Clinical Director confirmed the documentation error and treatment delay.
Failure to Maintain Infection Control Practices and Hand Hygiene
Penalty
Summary
The facility failed to maintain infection prevention and control practices to prevent the spread of COVID-19 and did not ensure staff performed proper hand hygiene during incontinence care. Sixteen residents tested positive for COVID-19 within a two-week period, and records showed that these residents had physician orders for droplet isolation precautions. However, observations revealed that required signage indicating isolation precautions was missing from the rooms of residents who tested positive, and staff confirmed that these signs should have been posted to alert staff and visitors to use personal protective equipment (PPE). Additionally, the facility did not separate soiled linens from residents with COVID-19 from those without, despite staff concerns about cross-contamination. Laundry staff and CNAs reported that all soiled laundry was mixed together and placed in the same receptacle, and biohazard bags or other methods to differentiate contaminated laundry were not used. This practice was inconsistent with CDC guidance and the facility's own policies, which require clear identification of contaminated laundry to ensure safe handling. Further, staff failed to adhere to hand hygiene protocols during resident care. During incontinence care for a resident, a CNA did not perform hand hygiene before donning gloves, after glove removal, or between tasks, and handled both the resident’s personal items and bed linens with contaminated gloves. The facility’s policy and CDC guidelines require hand hygiene before and after glove use and after contact with potentially contaminated surfaces, but these procedures were not followed during the observed care.
Failure to Administer Physician-Ordered Wound Care
Penalty
Summary
Staff failed to administer wound care treatment as ordered by the physician for a resident with multiple complex medical conditions, including morbid obesity, diabetes, congestive heart failure, and a deep tissue injury to the right lateral heel. The physician's order specified that the wound should be cleansed with normal saline, patted dry, treated with betadine, covered with an ABD pad, and wrapped with gauze daily and as needed during the night shift. Review of the Treatment Administration Record (TAR) showed documentation of the wound treatment being performed on one date, but observation revealed that the dressing had not been changed as required by the order. On observation, the dressing on the resident's right lateral heel was found to be dry and intact, with the date on the dressing indicating it had not been changed on the previous day as ordered. Certified Nursing Assistants present at the time confirmed that the wound treatment had not been performed according to the physician's instructions. This lapse in care was identified during a review of records, direct observation, and staff interviews, and was cited as a deficiency affecting one resident reviewed for wounds.
Failure to Provide Timely Medication Administration Due to Unavailable Medications
Penalty
Summary
The facility failed to ensure that prescribed medications were available and administered in a timely manner to two residents. One resident, admitted with multiple complex diagnoses including epilepsy and requiring ventilator support, had a physician order for lacosamide to control seizures. The medication was not administered on two consecutive days because the pharmacy required a prescription, and the medication was not available in the facility. Nursing staff notified the nurse practitioner, who contacted the pharmacy, but the medication was still not received before the resident was readmitted to the hospital. Another resident with diagnoses including cerebral palsy, epilepsy, and profound intellectual disability had a physician order for phenobarbital suppositories to be administered three times daily. The medication was not administered for several days because the pharmacy required an updated prescription, and multiple attempts by nursing staff to provide the prescription were unsuccessful. The resident did not receive the medication until the prescription was finally sent electronically and the pharmacy delivered the medication. Facility policy required that all medications be ordered and received in advance, with documentation maintained by the charge nurse and verification by the receiving nurse. Despite these procedures, the facility did not ensure that medications were available for administration as ordered, resulting in missed doses for both residents.
Deficiencies in Timely Admission Paperwork and Medication Administration Documentation
Penalty
Summary
The facility failed to ensure timely completion of admission paperwork for one resident and accurate medication administration documentation for another. For the first resident, the admission agreement was not completed in a timely manner, as the paperwork was signed by the resident instead of the designated Power of Attorney (POA), despite the resident having moderate dementia and a POA in place. The facility's policy requires that the admission agreement be signed by the resident or their representative at the time of admission, and a copy placed in the resident's permanent file. The interim administrator confirmed that the admission paperwork was not completed as required. For the second resident, there were discrepancies in the documentation and administration of medications. An LPN administered several prescribed medications but failed to administer the Flonase nasal spray, Artificial Tears, and Lidocaine patch at the scheduled time. Despite this, the LPN documented on the Medication Administration Record (MAR) that the Flonase and Artificial Tears had been administered, and noted the Lidocaine patch as unavailable. The LPN later acknowledged that she typically completed treatments at a later time and had documented administration before actually giving the medications, which is contrary to facility policy. The facility's policies on medication administration and documentation require that medications be administered within one hour of the prescribed time and that documentation occur immediately after administration, not before. The policies also specify that all relevant details, including reasons for withheld or unavailable medications, must be accurately recorded. The failure to follow these procedures resulted in inaccurate records for the resident's medication administration.
Failure to Provide Adequate Nursing Staff and Timely Resident Care
Penalty
Summary
The facility failed to provide adequate nursing staff to meet the needs of all residents, as evidenced by multiple observations, interviews, and record reviews. The facility assessment indicated a staffing plan that included seven nurses and ten CNAs per day, but payroll-based journal data showed a one-star staffing rating for the second quarter. Several residents did not receive scheduled showers, and both staff and residents reported frequent delays in care, including long wait times for call light responses and missed appointments. Staff interviews confirmed that there were not enough aides at times, and the removal of a dedicated shower aide further impacted the ability to provide timely care. Direct observations revealed that call lights remained unanswered for extended periods, with some residents waiting over 30 minutes for assistance. Meal trays were also delayed, and there were instances where no aide was present on a unit, leaving only a nurse to manage care and medication administration. Staff were observed being unaware of the absence of assigned aides, and the DON confirmed that call lights should not go unanswered for more than 30 minutes, yet this expectation was not met. Staff also reported difficulties in obtaining assistance for two-person tasks and noted that aides were frequently no-call, no-shows, leaving units understaffed. Resident interviews corroborated these findings, with reports of waiting up to 90 minutes for care and call lights going unanswered for significant periods. One resident reported forgetting the reason for activating the call light due to the long wait, despite having a medical concern to report. Policy reviews indicated that the facility was expected to provide timely responses to resident needs, with a goal of responding to call lights within five minutes, but this standard was not achieved. The deficiency was investigated under a specific complaint number and affected all residents in the facility.
Failure to Complete Quarterly Care Conferences and Maintain Accurate, Updated Care Plans
Penalty
Summary
The facility failed to ensure that care conferences were completed at least quarterly for several residents, and did not maintain accurate or updated care plans for others. Specifically, three residents did not have documented evidence of quarterly care conferences, despite policy requiring these to be held in conjunction with the quarterly MDS assessment. Interviews with residents and staff confirmed that these conferences either did not occur or were not documented, and in some cases, residents were not invited to participate in their own care planning process. Additionally, the facility did not ensure care plan accuracy for a resident regarding incontinence care. The care plan inaccurately identified the resident as being incontinent of bowel and bladder and having an indwelling urinary catheter, when in fact the resident was continent and had never had a catheter. Interviews with the resident, an LPN, and the DON confirmed the inaccuracies in the care plan, and there was no explanation for why the care plan did not reflect the resident's actual condition. Furthermore, the facility failed to update the care plan for another resident after a significant change in condition, specifically following a fall that resulted in a major injury and subsequent hospitalization and surgery. Although immediate post-fall interventions were documented, the care plan was not revised to reflect the new risk or interventions after the resident returned from the hospital. Facility policy required care plans to be updated after significant changes or hospitalizations, but this was not done in this case.
Failure to Provide Scheduled Showers and Hygiene Assistance
Penalty
Summary
The facility failed to ensure that residents received showers as scheduled, as evidenced by record reviews, interviews, and policy review. Seven residents who required assistance with activities of daily living (ADL) did not consistently receive showers according to their individualized care plans and the facility's shower schedule. Documentation showed missed or rescheduled showers, and in several cases, there was no evidence that alternative hygiene measures, such as bed baths, were offered or provided after a shower was refused or missed. Residents affected had a range of medical conditions, including dementia, urinary incontinence, emphysema, systemic lupus erythematosus, muscle weakness, schizoaffective disorder, diabetes, aphasia, hemiplegia, depression, multiple sclerosis, and other chronic illnesses. Many were cognitively intact and expressed the importance of choosing their bathing method. Care plans and MDS assessments indicated varying levels of assistance required, from partial to total dependence on staff for bathing. Despite these documented needs and preferences, the facility did not consistently follow through with scheduled showers or provide appropriate alternatives when showers were missed or refused. Interviews with residents, CNAs, LPNs, and the Administrator confirmed the inconsistency in providing scheduled showers. Staff reported being unable to complete all assigned showers, sometimes due to the absence of a dedicated shower aide. Facility policy required documentation of showers or baths, including refusals and interventions taken, but records often lacked evidence of follow-up or alternative hygiene care. The deficiency was identified during a complaint investigation and had the potential to affect additional residents who were dependent on staff for bathing.
Failure to Administer Prescribed Treatments and Medications as Ordered
Penalty
Summary
The facility failed to ensure that prescribed treatments and medications were administered as ordered for two residents. For one resident with a history of dementia, cognitive communication deficit, and muscle weakness, there was a physician's order to apply Skin Prep to the left sacrum and cover with a bordered dressing every Monday, Wednesday, and Friday as a preventative measure following the healing of a Stage II pressure ulcer. However, observation and interviews revealed that the dressing was not changed according to the prescribed schedule. Documentation on the treatment administration record indicated that wound care was completed on certain dates, but interviews with nursing staff confirmed that this documentation was made in error, and the dressing had not been changed as required. Another resident with end stage renal disease, multiple comorbidities, and dependence on dialysis had a physician's order for sevelamer hydrochloride to be administered before meals as a potassium binder. Review of medication administration records and progress notes showed multiple instances over several months where the medication was not given because it was unavailable. Notes indicated repeated delays in receiving the medication from the pharmacy, and staff interviews confirmed confusion regarding the ordering process and significant delays in delivery. The resident reported not receiving the medication for extended periods and experiencing symptoms such as nausea and diarrhea during these gaps. Facility policy required that medication orders and receipt records be maintained and that medications be ordered in advance based on pharmacy lead times. However, the facility did not have a process to record the receipt of medications from the specific pharmacy supplying the sevelamer, and shipping invoices were incomplete. The lack of proper documentation, ordering, and follow-up led to the residents not receiving their prescribed treatments and medications as ordered.
Unqualified Staff Assigned as Activities Director
Penalty
Summary
The facility failed to ensure that its activities program was directed by a qualified professional, as required by regulation. Review of the personnel file for the current Activities Director showed that she was originally hired as a receptionist and later transferred to the Activities Director position. The job description for the Activities Director role specifies that the individual must meet certain qualifications, such as being a qualified therapeutic recreation specialist, a licensed activities professional, having relevant experience, or having completed a state-approved training course. However, there was no evidence in her employee file to demonstrate that she met any of these qualifications. Interviews with the Human Resources Director, the Administrator, and the Activities Director herself confirmed that she did not possess the required qualifications and was not enrolled in a state-approved training course at the time of her appointment. The Activities Director also stated she was unsure how to enroll in the necessary course and had not received information about enrollment until after the deficiency was identified. This lack of a qualified professional in the Activities Director role had the potential to affect all 40 residents in the facility.
Failure to Document and Treat Pressure Ulcer Timely
Penalty
Summary
The facility failed to accurately document and implement timely treatment for a pressure ulcer in a resident. Upon admission, the resident was noted to have a pressure ulcer on the left gluteal fold, but subsequent assessments revealed the ulcer was actually on the right buttock. The initial skin assessment documented a pressure ulcer on the left gluteal fold, measuring one centimeter long, one centimeter wide, and 0.1 centimeters deep. However, a later assessment by the wound nurse practitioner identified a Stage II pressure ulcer on the right buttock, measuring four centimeters long, three centimeters wide, and 0.1 centimeters deep. The treatment administration record showed no evidence of treatment for the pressure ulcer from January 13 to January 17. An order for treatment was not received until January 16, which included cleansing the area with normal saline, applying Triad paste, and covering with a dressing daily. The Regional Clinical Director confirmed the documentation error and the delay in treatment implementation. This deficiency was investigated under Complaint Number OH00161526.
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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