Loveland Health Care Center
Inspection history, citations, penalties and survey trends for this long-term care facility in Loveland, Ohio.
- Location
- 501 North Second Street, Loveland, Ohio 45140
- CMS Provider Number
- 365427
- Inspections on file
- 18
- Latest survey
- April 17, 2025
- Citations (last 12 mo.)
- 0
Citation history
Health deficiencies cited at Loveland Health Care Center during CMS and state inspections, most recent first.
Surveyors found that food items such as croutons, rolls, chocolate cakes, and beverages were not properly dated or labeled, and unsanitary conditions were present in the kitchen, including a dirty ice scoop container and grime on steam tables. These deficiencies in food storage and equipment sanitation had the potential to affect all 73 residents receiving meals from the kitchen.
Staff did not keep garbage cans in the kitchen food prep areas covered, as required by facility policy. During observation, uncovered garbage receptacles were found near the handwashing and dishwashing sinks, and this was confirmed by the Dietary Director. This practice had the potential to affect all residents receiving food from the kitchen.
A resident with cognitive impairment and multiple health issues was not treated with dignity during feeding assistance. An LPN was observed using her cell phone while feeding the resident, contrary to the facility's policy on resident rights. The LPN admitted to being unaware of any restrictions on cell phone use during such activities.
A resident, who was cognitively intact and required substantial assistance with bathing, was not accommodated according to their bathing preferences. Despite the facility's policy allowing for self-determination and preference-based care, the resident's request for a bed bath outside the scheduled days was denied. This deficiency was identified during a complaint investigation.
A resident with multiple medical conditions, including psoriasis, was admitted to the facility without a comprehensive care plan addressing their psoriasis and related itching. Despite having orders for Triamcinolone cream and Hydroxyzine, the resident reported inadequate relief and expressed a desire to see a dermatologist. The absence of a care plan for these issues was confirmed by an LPN Unit Manager.
A resident, who was cognitively intact and required setup assistance for oral hygiene, reported inadequate oral care during their stay. The care plan required daily brushing and flossing, but there was no documentation of oral care being provided. A CNA admitted to not offering oral care unless requested, citing time constraints, and there was no system for documenting oral care activities. An LPN confirmed the lack of documentation, despite facility policy requiring daily oral care.
A resident at risk for falls did not have the required anti-rollback device on their wheelchair, as specified in their care plan. The resident's wheelchair was replaced with a smaller one lacking this safety feature, which was confirmed by the ADON. The facility's policy emphasized the need for a care plan to address fall risks, which was not followed.
A CNA failed to sanitize hands between feeding two residents, one with cognitive impairment and the other requiring setup assistance, despite being trained to use one hand per resident. This breach of the facility's infection control policy was observed during a survey.
A facility failed to implement Enhanced Barrier Precautions (EBP) for a resident with a stage two pressure ulcer and a colostomy. Despite the resident's condition, there was no physician order for EBP, and during care observations, staff did not use required PPE. Interviews revealed staff were unaware of the need for EBP, and facility policy outlined the necessity for such precautions for residents with chronic wounds or indwelling devices.
The facility failed to maintain a homelike environment and ensure regular cleaning for its residents. Observations revealed cobwebs, black marks, and other cleanliness issues in the rooms of three residents. Additionally, a resident's room was not cleaned on multiple days due to staffing shortages, despite the facility's policy requiring routine cleaning.
Failure to Properly Label, Store, and Sanitize Food and Equipment
Penalty
Summary
Surveyors observed multiple deficiencies in the facility's food storage and kitchen sanitation practices. In the kitchen, a shallow pan with croutons and a pan with rolls were found covered but not dated. Additionally, the ice machine's scoop was stored in a container with yellow sludge and stagnant water, and the container lacked drainage holes. Dietary staff confirmed the presence of undated food items and the unsanitary condition of the ice scoop container. Further inspection of the kitchen revealed 11 undated chocolate cakes, undated pitchers of iced tea and lemonade, and a stick of butter with a substance on its wrapper in the walk-in refrigerator. The steam tables were also found to have a buildup of grime and debris. The Dietary Director confirmed these findings. Review of facility policies indicated that all food should be covered, dated, and labeled, and that equipment should be washed and sanitized after every use. These failures had the potential to affect all 73 residents who received food from the kitchen.
Uncovered Kitchen Garbage Receptacles in Food Prep Areas
Penalty
Summary
Staff failed to ensure that garbage receptacles in the kitchen food preparation areas were covered, as required by facility policy. During an observation, it was noted that the garbage can by the primary handwashing sink and another by the dishwashing sink next to a prep-area counter were both uncovered. The Dietary Director confirmed that these garbage receptacles were not covered with lids. The facility's policy states that garbage cans should be covered when not in use. This deficiency had the potential to affect all 73 residents who receive food from the kitchen. No specific residents were directly involved or affected at the time of the observation, but the census indicated 73 residents could be impacted by this practice.
Failure to Maintain Resident Dignity During Feeding Assistance
Penalty
Summary
The facility failed to ensure that staff treated residents with dignity and respect during feeding assistance, specifically affecting one resident. The resident, who had moderately impaired cognition and required partial, moderate assistance with eating, was observed being fed by an LPN who was simultaneously scrolling through her cell phone. This action was in direct violation of the resident's right to a dignified existence and the facility's policy on resident rights. The resident involved had a history of cerebral infarction, chronic obstructive pulmonary disease, schizoaffective disorder-bipolar type, anxiety disorder, and protein calorie malnutrition. The care plan required one-staff extensive assistance with meals, including spoon-feeding and drinks in sippy cups. Despite this, the LPN admitted to using her cell phone while feeding the resident, claiming she was unaware of any rules against such behavior. This incident was part of a complaint investigation, highlighting a deficiency in maintaining the dignity and respect of residents during care.
Failure to Accommodate Resident Bathing Preferences
Penalty
Summary
The facility failed to accommodate the bathing preferences of a resident, identified as Resident #10, who was part of a sample of five residents. Resident #10, who was cognitively intact and required substantial assistance with bathing, had a care plan that scheduled showers twice weekly on Monday and Thursday nights. However, the resident expressed dissatisfaction with this schedule, demanding a bed bath and complaining about not receiving the care he deserved. The resident was vocal about the night staff's refusal to provide a bed bath or change his bed linens, which was confirmed by LPN #164 during an interview. The facility's policy stated that residents had the right to self-determination and that their preferences should be incorporated into their care plan. Despite this, the resident's request for a bed bath outside the scheduled days was not accommodated. The facility's policy on ADL care also indicated that assistance should be provided according to the resident's preferences, which was not adhered to in this case. The deficiency was identified during an investigation under Complaint number OH00159395.
Failure to Address Psoriasis in Resident Care Plan
Penalty
Summary
The facility failed to ensure that the care plan for a resident was comprehensive and addressed all of the resident's care needs. Specifically, the care plan did not include provisions for managing the resident's psoriasis or the discomfort related to itching. This oversight was identified during a review of the resident's medical records and care plan, which revealed that despite the resident's diagnosis of psoriasis and the presence of itching, there was no care plan in place to address these issues. The resident, who was admitted with multiple complex medical conditions including hepatic failure, diabetes, and chronic heart failure, expressed a need for help with psoriasis management and indicated that the current treatment was not fully effective. Interviews with the resident and the LPN Unit Manager confirmed the absence of a care plan for psoriasis and itching. The resident reported using Triamcinolone cream and Hydroxyzine for itching, but noted that non-medicated lotions applied by staff were less effective. The resident also expressed a desire to see a dermatologist. The facility's policy on care planning, which requires the development of an individualized comprehensive care plan for each resident, was not adhered to in this case, as verified by the LPN Unit Manager.
Failure to Provide Daily Oral Care Assistance
Penalty
Summary
The facility failed to ensure that residents received necessary assistance with daily oral care, specifically affecting one resident. This resident, who was cognitively intact and required setup assistance for oral hygiene, reported having brushed his teeth only once during his stay. The care plan indicated a need for daily brushing and flossing, yet there was no documentation of oral care being provided or refused. Interviews revealed that oral care was not routinely offered unless requested by the resident, and there was no system in place for documenting oral care activities. The Certified Nursing Assistant (CNA) responsible for the resident's care admitted to not offering oral care unless specifically asked, citing time constraints as a reason. The CNA also noted the absence of a designated area in the medical record for documenting oral care. The Licensed Practical Nurse (LPN) Unit Supervisor confirmed the lack of documentation for oral care, despite the facility's policy requiring daily oral care services. This deficiency was identified under a specific complaint number, indicating noncompliance with the facility's policies on activities of daily living (ADL) care.
Failure to Implement Fall Prevention Interventions
Penalty
Summary
The facility failed to ensure that fall prevention interventions were in place for a resident assessed for fall risk, as outlined in the care plan. Resident #62, who was admitted with diagnoses including unspecified anxiety disorder, major depressive disorder, and unspecified malignant neoplasm, was identified as having a potential for injuries related to falls. The care plan included specific interventions such as the use of anti-rollbacks on the wheelchair, non-skid footwear, and a raised toilet seat, among others. However, during an observation, it was noted that the resident's wheelchair did not have the anti-rollback device installed, contrary to the care plan. An interview with the Assistant Director of Nursing confirmed that the wheelchair used by Resident #62 did not have the anti-rollback device, as required by the care plan. The resident mentioned that maintenance had replaced her previous wheelchair, which had the anti-rollback device, with a smaller one that lacked this safety feature. This change was made because the resident had difficulty maneuvering the wider wheelchair through a narrow bathroom doorway. The facility's Fall Prevention Policy and Procedure, dated February 2024, emphasized the importance of implementing a care plan to address fall risk factors, which was not adhered to in this case.
Failure to Sanitize Hands During Feeding Assistance
Penalty
Summary
The facility failed to ensure proper hand sanitation by staff when providing feeding assistance to residents, as observed during a survey. Certified Nursing Assistant (CNA) #156 was seen feeding two residents, Resident #65 and Resident #72, without sanitizing her hands between interactions. Resident #72, who was cognitively intact and required setup assistance for eating, was fed salad using a fork that was switched between hands without sanitation. Similarly, Resident #65, who had severely impaired cognition and was dependent on assistance for eating, was fed pureed cake and milk without the CNA sanitizing her hands between feeding the two residents. During an interview, CNA #156 acknowledged that she had been trained to use only one hand per resident when feeding multiple residents simultaneously and admitted to not sanitizing her hands between feeding the two residents. The facility's policy on General Infection Control, dated November 2023, mandates that all staff follow proper infection control measures to prevent the spread of infection, which was not adhered to in this instance.
Failure to Implement Enhanced Barrier Precautions for Resident with Open Wound
Penalty
Summary
The facility failed to implement Enhanced Barrier Precautions (EBP) for a resident with an open wound, which was identified as a stage two pressure ulcer on the coccyx. The resident, who was severely cognitively impaired and dependent on staff for various activities, was always incontinent for bladder and had a colostomy. Despite these conditions, there was no physician order for EBP from the time the wound was discovered until the survey date. During an observation of wound and incontinence care, it was noted that there was no sign on the door indicating EBP, and no cart with Personal Protective Equipment (PPE) was available. The staff involved in the care did not wear gowns, which are required under EBP guidelines. Interviews with the staff revealed a lack of awareness regarding the necessity of EBP for the resident. The LPN and STNA involved in the care admitted to not wearing gowns and confirmed the absence of EBP signage and orders. The facility's policy on EBP, which was not dated, clearly outlined the need for such precautions for residents with chronic wounds or indwelling medical devices, regardless of infection status. The Quality, Safety, and Oversight (QSO) memo further supported the requirement for EBP in such cases, emphasizing the need for precautions even if the resident was not known to be infected or colonized with a Multidrug Resistant Organism (MDRO). This deficiency was investigated under a specific complaint number.
Failure to Maintain a Homelike Environment and Regular Cleaning
Penalty
Summary
The facility failed to provide a homelike environment for its residents, as evidenced by the conditions observed in the rooms of three residents. Resident #13's room had cobwebs in the window sills, a thick black substance and scuff marks on the walls, holes with nails sticking out, and a sticky bathroom floor. The curtains were dusty and wrinkled, and there was a dried substance on the inside bathroom door. Resident #32's room had similar issues, with holes in the walls, black marks, a dusty vent, stained floors, and a dried substance on the bathroom door. Resident #75's room had black marks on the walls, dirt by the handrails in the bathroom, and molding coming off the wall. These observations were confirmed during a tour with the Housekeeping Supervisor. Additionally, the facility failed to ensure regular cleaning of Resident #75's room. The medical record review showed that Resident #75 was cognitively intact and required assistance for certain activities. The daily housekeeping documents revealed multiple days where the room was not cleaned, and the Housekeeping Aide confirmed that there was insufficient staff to clean all areas, leading to missed cleaning days. The facility's policy stated that resident areas should be cleaned routinely, but this was not adhered to, resulting in non-compliance with the expected standards of cleanliness and maintenance.
Latest citations in Ohio
A resident with intact cognition receiving Medicare Part A skilled services for metabolic encephalopathy had services discontinued while benefit days remained, but the facility did not issue the required Skilled Nursing Facility Advance Beneficiary Notice (SNF ABN). The Social Services Director later confirmed that no SNF ABN was provided and reported she believed only a Notice of Medicare Non-Coverage (NOMNC) was needed when all skilled services were stopped. This practice conflicted with the facility’s written policy, which required SNF ABNs to be issued when extended care items or services were initiated, reduced, or terminated due to expected non-coverage by Medicare.
Surveyors identified that the facility exceeded the acceptable medication error rate when two residents with type 2 DM received insulin doses that were not administered according to orders or manufacturer instructions. In two separate observations, an LPN administered Novolog and another LPN administered insulin glargine and insulin lispro without priming the insulin pens, and the insulin lispro and Novolog were given after the residents had already consumed a significant portion of their breakfast meals, despite orders for administration before meals. Manufacturer information for both insulin products required priming before each injection to ensure accurate dosing, and facility policy required medications, including insulin, to be administered safely, timely, and in accordance with prescriber orders and specified time frames.
Surveyors found that the facility failed to document tray line food temperatures for multiple meals served from two dining room kitchenettes, despite having a “Trayline Taste & Temperature Log” and a policy requiring food to be stored, prepared, distributed, and served according to professional food safety standards. Review of logs showed repeated missing entries for breakfast, lunch, and dinner services in both the Harrison and McClellan dining areas, and the Senior Director of Culinary Services confirmed that temperatures had not been recorded for those meals, potentially affecting all residents receiving meals from those kitchenettes.
The facility failed to conduct and document required periodic care conferences for two residents, despite multiple comprehensive, quarterly, and significant change MDS assessments and a policy requiring periodic care conferences with resident and/or family participation. One resident with Parkinson’s disease, post-stroke hemiplegia, TIA, DMII, and depression had only two documented care conferences over a year, while another resident with aphasia, cerebrovascular disease, DMII, gait difficulty, coagulation defect, depression, and muscle weakness had no documented care conferences in the past year, aside from a declined invitation to the representative. The UCC confirmed that care conferences were expected to occur quarterly and that no additional documentation existed for either resident.
A resident with Alzheimer's disease and type II DM, who required extensive assistance with ADLs and was receiving scheduled Lantus and sliding-scale Humalog, experienced a severely elevated blood glucose level. The on-call provider was notified and ordered an additional dose of lispro insulin with a directive to recheck the blood glucose after administration. Nursing staff administered the extra insulin but did not document any follow-up blood glucose check, and the DON confirmed that this reevaluation was required by the facility's abnormal blood glucose policy and was not completed or documented.
A resident with Parkinson’s disease, dementia, and hypothyroidism was prescribed levothyroxine once daily along with other medications. A consultant pharmacist’s monthly drug regimen review recommended that levothyroxine be given in the morning on an empty stomach, 30–60 minutes before food, per manufacturer instructions. The medical record contained no documented physician response to this recommendation, and the MAR showed the drug scheduled for morning administration while the resident was observed eating breakfast and receiving the medication at the same time. An LPN confirmed administering levothyroxine during the meal, and the DON verified there was no documentation explaining whether or why the pharmacist’s recommendation was or was not followed, resulting in a failure to act on and document the identified irregularity.
A resident with severe cognitive impairment, multiple comorbidities, documented gait and balance abnormalities, and a high fall risk was care planned and assessed by therapy to require contact guard assistance and use of a gait belt for transfers and ambulation. While being assisted by a CNA from a recliner to the bathroom with a walker, the CNA did not apply a gait belt, even though the resident had a known tendency to lean backward when standing. As the CNA reached to open the bathroom door, the resident lost balance and fell backward, striking the back of the head, and was later found by an LPN without a gait belt in place, contrary to the facility’s gait belt policy and the resident’s assessed needs.
A resident with metabolic encephalopathy, muscle weakness, and a history of CVA experienced a fall in his room that was not documented in the medical record until the following morning as a late entry. Two RNs acknowledged that the fall was not recorded at the time it occurred and stated that fall incidents should be documented as soon as possible after the event, resulting in a deficiency for failure to maintain timely, professionally standard medical records.
A resident with Alzheimer’s disease, diabetes, anxiety, significant ADL dependence, and behavioral symptoms was observed seated in a chair positioned against the nursing station with a locked wheelchair placed directly in front, also against the nursing station, effectively restricting movement. An LPN confirmed both wheelchair wheels were locked and that it should not have been placed there, while a CNA stated she had positioned the wheelchair to prepare for lunch, was unable to complete the transfer, and left it in place, acknowledging this was wrong. This arrangement conflicted with the facility’s restraint policy, which prohibits physical restraints except when alternatives are ineffective for treating a medical symptom and defines restraints as devices adjacent to the body that cannot be easily removed and that restrict freedom of movement or access to the body.
A resident with cirrhosis, ascites, mood disorder, and alcohol-induced major neurocognitive disorder, and with moderately impaired cognition, was observed sitting on a shower chair in a gown with buttocks exposed and visible from the hallway through an open room door. A CNA left the room quickly after hearing another resident yell and forgot to close the door or pull the privacy curtain, and an RN confirmed the exposure, demonstrating a failure to maintain the resident’s dignity and privacy.
Failure to Issue Required SNF ABN When Discontinuing Medicare Part A Services
Penalty
Summary
The deficiency involves the facility’s failure to issue a Skilled Nursing Facility Advance Beneficiary Notice (SNF ABN) when Medicare Part A services were discontinued for a resident who still had available benefit days. The resident was admitted with a diagnosis of metabolic encephalopathy and had intact cognition per the Minimum Data Set assessment. The facility’s own SNF Beneficiary Notification Review documented that Medicare Part A skilled services began on 02/11/26 and the last covered day was 03/11/26, and that the facility initiated discharge from Medicare Part A services before the resident’s benefit days were exhausted. Despite this, no SNF ABN was provided to the resident or the resident’s representative. During interviews, the Social Services Director stated that the SNF ABN was issued hours prior to the last covered day but, upon reviewing her files, confirmed that no SNF ABN had actually been issued for this resident. She further explained that she believed an SNF ABN was only required if one skilled service remained and that if all skilled services were being discontinued, only the Notice of Medicare Non-Coverage (NOMNC) needed to be issued. The Administrator, however, stated that a resident should always receive both a SNF ABN and a NOMNC when Medicare Part A services are discontinued and benefit days remain. Review of the facility’s written policy dated 03/28/23 showed that the facility was required to issue SNF ABNs for initiation, reduction, or termination of extended care items or services when Medicare payment was not expected, which did not occur in this case.
Plan Of Correction
This Plan of Correction is submitted as required under State and Federal law. This Plan of Correction does not constitute an admission on the part of the Facility that the findings cited are accurate, that the findings constitute a deficiency or that the scope and severity regarding the deficiency cited are correctly applied. Any changes to the Facility's policies and procedures should be inadmissible in any proceeding on that basis. Without admitting or denying the validity or the existence of the alleged noncompliance, the Facility submits this Plan of Correction with the intention that it be inadmissible by any third party in any civil or other action against the facility or any employee, agent, officer, director or shareholder of the Facility. The Facility is utilizing this Plan of Correction as its allegation of substantial compliance as of 05/29/2026 F-0582 Corrective action for resident/s: On 5/14/26 Resident #34 was informed of rights and responsibilities related to Advanced Beneficiary Notice and voiced understanding of information for future reference by administrator. Identification of other residents who may be affected: Any resident receiving skilled services from nursing or therapy services. The Administrator audited all residents who were discharged from skilled services in the past 30 days to ensure they were issued a Notice of Non-Coverage and Advanced Beneficiary Notice on 5/29/26. No non-compliance was noted. Measures for systemic change: On 5/14/2026 Business Office Manager, Director of Rehab, Minimum Data Set nurse, Director of Nursing and Social Services Director were educated on proper procedure of issuing of Notice Of Medicare Non Coverage and Advanced Beneficiary Notice by administrator. All upcoming discharges from skilled services will be reviewed weekly at Utilization Review meeting to ensure notices will be delivered timely. How Corrective Action will be monitored: Administrator or designee to complete audits of all residents being discharged from skilled services to ensure they were issued a Notice of Non-Coverage and Advanced Beneficiary. This audit will be completed weekly x 4 weeks, then monthly x 2 months. Corrective action will be initiated for any noted non-compliance. Audit findings will be reviewed as part of the monthly quality assurance process to determine the need for further monitoring. Date of Compliance 5/29/26
Insulin Administration Errors and Failure to Prime Insulin Pens
Penalty
Summary
The deficiency involves the facility’s failure to maintain a medication error rate below 5%, with surveyors identifying 3 errors out of 28 medication administration opportunities, resulting in a 10.71% error rate. For one resident with type 2 diabetes mellitus and moderate cognitive impairment, the physician’s order directed Novolog insulin 10 units via subcutaneous pen-injector to be given before meals. During an observed medication pass, the LPN administered 10 units of Novolog insulin without priming the pen and did so after the resident had already consumed approximately 50% of the breakfast meal. The LPN later confirmed she did not prime the pen and acknowledged that the insulin was ordered to be administered prior to meals. Manufacturer instructions for the Novolog FlexPen specified that an air shot (priming) must be performed before each injection to ensure proper dosing. Another resident, also diagnosed with type 2 diabetes mellitus and with intact cognition, had orders for insulin glargine 35 units subcutaneously twice daily and insulin lispro 20 units subcutaneously before meals, plus 12 units subcutaneously if blood glucose was between 251 mg/dL and 300 mg/dL. During an observed medication administration, an LPN administered 35 units of insulin glargine and 32 units of insulin lispro without priming the insulin pens and after the resident had consumed approximately 90% of the breakfast meal, despite orders for insulin lispro to be given before meals. The LPN later stated she could not remember if she had primed the pen and acknowledged that the insulin was ordered to be administered prior to meals. Manufacturer information for insulin lispro stated that the pen must be primed before each injection to confirm insulin delivery and remove air, and that failure to prime could result in too much or too little insulin. The DON confirmed the expectation that insulin be administered as ordered, including priming each pen with two units before dialing the prescribed dose, and facility policy required medications, including insulin, to be administered safely, timely, and in accordance with prescriber orders and required time frames.
Plan Of Correction
This Plan of Correction is submitted as required under State and Federal law. This Plan of Correction does not constitute an admission on the part of the Facility that the findings cited are accurate, that the findings constitute a deficiency or that the scope and severity regarding the deficiency cited are correctly applied. Any changes to the Facility's policies and procedures should be inadmissible in any proceeding on that basis. Without admitting or denying the validity or the existence of the alleged noncompliance, the Facility submits this Plan of Correction with the intention that it be inadmissible by any third party in any civil or other action against the facility or any employee, agent, officer, director or shareholder of the Facility. The Facility is utilizing this Plan of Correction as an allegation of substantial compliance as of 5/29/2026. F-0759 Corrective action for resident/s: Residents #21 and #22 were assessed and evaluated by nurse and Director of Nursing 5/14/26. Resident #21 and #22 both denied any adverse effects and none were noted upon assessment by the Director of Nursing on 5/14/2026. Notification made to physician on 5/14/2026. LPN # 2 competency Eval on insulin administration with the Director of Nursing completed 5/14/2026. Identification of other residents who may be affected: Diabetic residents on assignment of LPN #2/station 2 have the potential to be affected and were assessed by the DON/Designee on 5/14/26 and found to be within normal limits. Measures for systemic change: All Nurses were educated by the Director of Nursing on the steps for Insulin administration per competency, diabetes clinical protocol policy, Medication and treatment orders policy, administering medications policy, and Obtaining fingerstick Glucose Level policy On 5/14/2026. How Corrective Action will be monitored: Director of Nursing and Assistant Director of Nursing will complete insulin administration audits on 5 nurses. This audit will be completed weekly x 4 weeks, then monthly x 2 months. Corrective action will be initiated for any noted non-compliance. Audit findings will be reviewed as part of the monthly quality assurance process to determine the need for further monitoring. Date of Compliance: 5/29/2026
Failure to Document Tray Line Food Temperatures in Dining Room Kitchenettes
Penalty
Summary
The deficiency involves the facility’s failure to document tray line food temperatures for meals served from the Harrison and McClellan Dining Room kitchenettes, as required by professional standards for food service safety and the facility’s own policy. Review of the “Trayline Taste & Temperature Log” (revised September 2018) showed missing temperature documentation for multiple meals from the Harrison Dining Room kitchenette, including dinner on 03/30/26 and 03/31/26, lunch and dinner on 04/01/26 and 04/02/26, dinner on 04/07/26, and lunch and dinner on 04/08/26 and 04/10/26. The Senior Director of Culinary Services confirmed during interview that tray line food temperatures were not documented on the log for these meals. Similarly, review of the same log for the McClellan Dining Room kitchenette revealed that tray line food temperatures were not documented for dinner on 04/01/26, breakfast and lunch on 04/02/26, and lunch and dinner on 04/07/26. The Senior Director of Culinary Services also verified these omissions during interview. The facility census at the time was 27 residents, and the governing “Food and Nutrition” policy, approved on 09/07/21, stated that the facility must store, prepare, distribute, and serve food in accordance with professional standards for food service safety.
Plan Of Correction
F812 The facility will continue to ensure food temperatures are completed before meals are served for all residents. To ensure compliance with this standard the following measures have been taken: 1. Immediately 4/15/26 culinary supervisor #224 was re-educated by Dietary Manager to this standard and policy "Food and Nutrition" which includes documentation of food temperatures. 2. All dietary staff have been re-educated to the standard and policy "Food and Nutrition" during the month of April 2026. 3. Audits of food temperature documentation to be completed by Dietary Manager 4 x per week for 4 weeks then weekly for 4 weeks. 4. Administrator to validate audits/compliance and provide additional training as needed. Administrator will present to QAPI committee for ongoing monitoring and further direction.
Failure to Conduct and Document Required Care Conferences
Penalty
Summary
The deficiency involves the facility’s failure to complete and document comprehensive care conferences at required intervals in accordance with care plan regulations and facility policy. For one resident with Parkinson’s disease with dyskinesia, cognitive communication deficit, hemiplegia and hemiparesis following cerebral infarction, transient cerebral ischemic attack, type II diabetes mellitus, and major depressive disorder, the record showed multiple MDS assessments over a one-year period, including annual, quarterly, and significant change assessments. However, only two care conferences were documented during the last 12 months, despite the expectation that care conferences be conducted quarterly with the resident and family when possible. The Unit Care Coordinator confirmed that no additional care conference documentation existed for this resident beyond the notes dated 04/21/25 and 01/02/26. A second resident, with diagnoses including aphasia following cerebrovascular disease, cerebral infarction, type II diabetes mellitus, unsteadiness on feet, difficulty in walking, coagulation defect, depression, and muscle weakness, also had multiple MDS assessments completed over the review period, including quarterly and annual assessments. The record contained a note that a care conference was offered to the resident’s representative, who declined to attend, but there was no documentation of any care conferences for the most recent 12 months. The Unit Care Coordinator confirmed that no other care conference documentation was available for this resident. Facility policy stated that periodic care conferences involving the resident, family, and the interdisciplinary team are part of the care planning process, but the required periodic care conferences and corresponding documentation were not completed for these two residents.
Plan Of Correction
THIS PLAN OF CORRECTION SERVES AS BERKELEY SQUARE'S CREDIBLE ALLEGATION OF SUBSTANTIAL COMPLIANCE AS OF June 1, 2026. Without admitting or denying the validity or existence of the alleged deficiencies, Berkeley Square provides the following Plan of Correction: F657 The facility will continue to document completion of care conferences at the required intervals for all residents, including residents #04 & #15. To ensure compliance with this standard the following measures have be taken: 1. The social service designee and the inter- disciplinary team were re-educated by the administrator to the facility policy "Care Conference" on 4/29/26 and verbalized understanding. 2. Care conferences for resident #04 and resident #15 were conducted on or before 4/29/2026 by the interdisciplinary team. 3. Review of all other residents was conducted by the social service designee to validate and ensure that care conference schedule is up to date with timely care conferences scheduled for them on 4/15/2026. Audits of care conferences to be completed weekly for four weeks and then monthly after that by the social service designee. Documentation of the care conference including any identified concerns in the medical record. Administrator to validate audits/compliance and provide additional training as needed. Administrator will present results of these audits to QAPI committee for ongoing monitoring and further direction.
Failure to Reevaluate Blood Glucose After Treatment for Hyperglycemia
Penalty
Summary
The facility failed to ensure that a resident with diabetes received treatment in accordance with professional standards of practice when nursing staff did not reevaluate the resident's blood glucose after treatment for severe hyperglycemia. The resident, admitted with diagnoses including Alzheimer's disease, type II diabetes mellitus, and depression, had physician orders for Humalog insulin on a sliding scale before meals, Lantus insulin 25 units daily, and lisinopril 5 mg daily. The resident required extensive assistance with activities of daily living, including transfers, toileting hygiene, eating, and bathing. On the evening in question, the resident's blood glucose was documented as 532 mg/dL, and the on-call provider was notified. The provider gave a new order to administer an additional 8 units of lispro (Humalog) and to recheck the blood glucose in 30 minutes. The electronic medication administration record showed that the blood glucose of 532 mg/dL was obtained at 9:00 p.m. and that the additional 8 units of lispro were administered at 9:21 p.m. However, there was no documentation in the resident's chart that the blood glucose was rechecked after the additional insulin was given. In an interview, the DON confirmed there was no evidence of reevaluation and verified that, according to the facility's "Abnormal Blood Glucose Procedure" policy, the resident should have been reevaluated and that the evaluation step should have been included in the progress note documentation.
Plan Of Correction
F684 The facility will continue to ensure all residents, including #03, receive treatment in accordance with professional standards of practice and reevaluated for hyperglycemia. To ensure compliance with this standard the following measures have been taken: 1. The director of nursing assessed resident #03, reviewed documentation and orders and found no ill effects immediately 4/16/26. 2. All licensed nurses were re-educated to facility policy "Blood Glucose Monitoring" by the Director of Nursing/designee in April 2026. 3. Audits of like-residents that require blood sugar checks to be completed by the director of nursing/designee two times a week for 4 weeks and then monthly after that to validate correct follow through when there is abnormally high blood glucose result. The Administrator will bring results of these audits to the QAPI committee for ongoing monitoring and further direction.
Failure to Act on Pharmacist Drug Regimen Recommendation for Thyroid Medication
Penalty
Summary
The deficiency involves the facility’s failure to ensure that pharmacy recommendations from the monthly drug regimen review were acted upon and documented for a resident. The resident was admitted with diagnoses including Parkinson’s disease, dementia, and hypothyroidism, and had current physician orders for levothyroxine 150 mcg once daily, buspirone 50 mg twice daily, and losartan 100 mg once daily. A medication regimen review dated 11/25/2025 included a consultant pharmacist recommendation that levothyroxine be administered consistently in the morning on an empty stomach, at least 30–60 minutes before food, per manufacturer instructions. There was no specific physician response in the medical record to this recommendation, and the facility’s policy stated that consulting pharmacist reviews are sent to nursing and addressed with the primary care provider or consulting specialist for review and follow-up. Review of the resident’s medication administration record for April 2026 showed levothyroxine scheduled for 9:00 a.m. On observation, the resident was seen eating breakfast in the dining area at 8:03 a.m., and an LPN reported administering the levothyroxine 150 mcg to the resident while the resident was in the dining area eating breakfast. The DON confirmed there was no evidence in the resident’s medical record explaining why the consultant pharmacist’s recommendation from 11/25/2025 was or was not acted upon. This lack of documented physician review and action on the pharmacist’s identified irregularity constituted noncompliance with the drug regimen review requirements.
Plan Of Correction
F756 The facility will continue to ensure the pharmacy recommendations from the monthly drug regimen review by a licensed pharmacist are acted upon for all residents, including #08. To ensure compliance with this standard the following measures have been taken: 1. Resident #08 was assessed by the registered nurse and med review completed by 4/28/26. After review of resident's drug regime's, it was discovered that resident #8 had 2 separate medication recommendations on the same form, to be reviewed by two separate practitioners, pharmacy has been instructed and agreed to separate meds on individual forms. 2. Licensed nurses re-educated to facility policy "Drug Regimen Review" by Director of nursing/designee in April 2026 and no later than 5/8/26. Licensed nurses are responsible for ensuring the reviews and recommendations are given to the physician for timely review. 3. Review of all other current residents Drug Regimen orders completed by Director of nursing/designee on 4/16/26 to ensure recommendations were followed up on/reviewed by the physician and address concerns if needed. 4. Audit of drug regime recommendations, pharmacy recommendations, and physician follow up to be completed weekly for four weeks by the Director of nursing/designee. Administrator will present results of these audits to the QAPI committee for ongoing monitoring and further direction.
Failure to Use Required Gait Belt During Ambulation Resulting in Resident Fall
Penalty
Summary
The deficiency involves the facility’s failure to ensure that a required gait belt was used while assisting a high fall‑risk resident with ambulation, resulting in a fall with head injury. The resident had multiple diagnoses including metabolic encephalopathy, hypertension, osteoarthritis, muscle weakness, gait and mobility abnormalities, major depressive disorder, anxiety, and visual hallucinations. Admission and subsequent MDS and fall risk assessments documented that the resident was severely cognitively impaired, required moderate to maximal assistance with transfers and ambulation, could not independently come to a standing position, exhibited loss of balance while standing, used an assistive device, and had decreased muscle coordination. The resident had a history of falls prior to admission and was assessed as being at high, later moderate, risk for falls. The resident’s fall care plan identified her as at risk for falls and included interventions such as providing maximum to moderate assistance with transfers and walking short distances, use of a walker and wheelchair, and following the facility’s fall protocol. Therapy notes and care conference documentation indicated that the resident leaned backwards when standing, required contact guard to minimal assistance for bed mobility and transfers, and needed constant verbal cueing for safe sequencing during toilet transfers. The physical therapist confirmed that the resident was to use a gait belt with staff when ambulating, and the DON verified that therapy had assessed the resident as requiring contact guard assistance and a gait belt for ambulation and transfers. On the day of the incident, a CNA was assisting the resident from her recliner to the bathroom using a walker. The CNA walked beside the resident, providing guidance and support, and reported having a hand on the resident while assisting her. As they approached the bathroom door, the CNA reached for the doorknob to open it, and at that moment the resident began to lose her balance and fell backwards to the floor, striking the back of her head. The nurse who responded found the resident on her back at the foot of the bed with her feet near the bathroom, noted a red raised area on the back of the head, and documented that the resident was not wearing a gait belt and that the gait belt was on the dresser. In the facility’s investigative summary and in interviews, the CNA acknowledged that she did not have a gait belt on the resident while ambulating her, despite the resident’s assessed need for hands‑on assistance and gait belt use per facility policy and the resident’s care and therapy plans.
Untimely Documentation of Resident Fall Incident in Medical Record
Penalty
Summary
The deficiency involves the facility’s failure to document a resident’s fall incident in the medical record in a timely manner, in accordance with accepted professional standards. The resident was admitted with diagnoses including metabolic encephalopathy, muscle weakness, and cerebrovascular accident. According to the medical record, a progress note was entered as a late entry on 02/20/26 at 8:21 A.M., stating that the resident had suffered a fall in his room on 02/19/26 at 8:00 P.M. There was no evidence of any documentation of the fall incident entered in the medical record at the time of, or shortly after, the fall on 02/19/26 at 8:00 P.M. During an interview on 03/30/26 at 12:05 P.M., two RNs confirmed that the fall incident was not documented until the following morning and stated that fall incidents should be entered in the medical record as soon as possible following the event. This lack of timely documentation of the fall incident constituted non-compliance with requirements to safeguard resident-identifiable information and maintain medical records in accordance with professional standards.
Improper Use of Wheelchair as a Physical Restraint
Penalty
Summary
Surveyors identified a deficiency related to the facility’s failure to ensure a resident was free from physical restraints. Resident #7, admitted with diagnoses including Alzheimer’s disease, diabetes mellitus, and anxiety disorder, was documented on a recent MDS as rarely understood and dependent for ADLs except eating. The resident ambulated independently on the unit without an assistive device and had documented verbal and other behaviors occurring one to three days during the look-back period. The care plan noted the resident had potential to be physically aggressive, chase staff, throw objects, and be combative with care, with interventions such as offering choices, administering medications as ordered, and intervening early when agitation occurred. During an observation and interview, Resident #7 was found sitting in a chair with the right arm of the chair positioned against the nursing station and a wheelchair placed directly in front of him. The left arm of the wheelchair was also against the nursing station, and both wheelchair wheels were locked, creating a barrier that appeared to restrain the resident, who was sleeping with his knees touching the locked wheelchair. An LPN confirmed both wheelchair wheels were locked and that the wheelchair should not have been placed in front of the resident. A CNA reported she had placed the wheelchair there in preparation to get the resident up for lunch, was unable to transfer him, and left the wheelchair in that position, acknowledging it was wrong to keep it there. The facility’s physical restraint policy stated that physical restraints are not used except when alternatives are not appropriate or effective for treating a medical symptom and defined physical restraints as any device attached or adjacent to the body that the individual cannot easily remove and that restricts freedom of movement or access to the body.
Resident Left Exposed and Visible From Hallway Due to Failure to Maintain Privacy
Penalty
Summary
The facility failed to ensure resident dignity and privacy when a cognitively impaired resident was left exposed and visible from the hallway. The resident, who had diagnoses including cirrhosis with ascites, mood disorder, and alcohol-induced major neurocognitive disorder, had a BIMS score of eight, indicating moderately impaired cognition. During an observation, the resident was seen sitting on a shower chair in a gown with buttocks exposed, and this exposure was visible from the open room door in the hallway. A Certified Resident Care Associate and a Registered Nurse confirmed that the resident’s buttocks were visible from the hallway. The Certified Resident Care Associate reported that she had left the resident’s room quickly after hearing a resident in an adjacent room yell and, in her haste, forgot to close the door or pull the privacy curtain, resulting in the resident’s exposed state being visible to others. This incident involved one resident out of three reviewed for dignity, in a facility with a census of 52 residents, and was identified through record review, observation, and staff interviews.
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