North Royalton Post Acute
Inspection history, citations, penalties and survey trends for this long-term care facility in Parma, Ohio.
- Location
- 9055 West Sprague Road, Parma, Ohio 44133
- CMS Provider Number
- 366343
- Inspections on file
- 23
- Latest survey
- November 25, 2025
- Citations (last 12 mo.)
- 6
Citation history
Health deficiencies cited at North Royalton Post Acute during CMS and state inspections, most recent first.
Two residents experienced unmet needs when staff failed to provide timely assistance with mobility and incontinence care for one, and failed to supply wheelchair foot pedals for another, resulting in one resident remaining in bed for hours and another being transported backwards in a wheelchair with his feet dragging, despite repeated requests and staff awareness of the issues.
A resident with diabetes, neuropathy, and Alzheimer's disease missed multiple scheduled medications, including insulin, on two occasions. Nursing staff did not promptly notify the physician or monitor the resident for adverse effects as required by facility policy. The DON confirmed that monitoring and notification were not completed after the errors.
A resident with physical and cognitive impairments who required extensive assistance for toileting was left waiting for nearly an hour after requesting to use the bathroom. Despite repeated requests and interactions with multiple staff members, the resident was not assisted in a timely manner, resulting in partial incontinence and discomfort. Staff interviews confirmed that timely assistance was not provided, particularly during busy periods, and that the resident was usually continent when helped promptly.
A resident with severe cognitive impairment and a PEG tube did not receive the prescribed amount of enteral nutrition when the tube feeding pump repeatedly indicated a clog and was not infusing. The LPN on duty had not yet checked on the resident and was unaware of the issue, resulting in the resident missing the ordered nutrition.
Two residents with diabetes received insulin injections from LPNs who failed to prime the insulin pens as required by manufacturer instructions and facility policy. This resulted in a medication error rate of 6.45%, exceeding the acceptable threshold. The DON confirmed that insulin pens must be primed after attaching a new needle and before administering the prescribed dose.
A resident requiring Enhanced Barrier Precautions due to a gastrostomy and impaired skin integrity did not receive proper infection control during incontinence and wound care. Two CNAs provided high-contact care without wearing required gowns, and an LPN failed to perform hand hygiene and glove changes while treating a PEG tube site, contrary to facility policy and physician orders.
A CNA was found asleep while on duty, leading to potential neglect of a resident. The resident, who had a history of multiple medical conditions, reported hearing noises and later discovered the CNA asleep in the adjacent bed. This incident violated the facility's policy on resident protection from neglect.
A facility failed to develop a comprehensive discharge care plan for a resident with multiple diagnoses, including a femur fracture and Parkinson's disease. The resident required extensive assistance for mobility and toileting, yet the care plan lacked discharge planning. An LSW confirmed the absence of the plan, violating the facility's policy requiring care plans within seven days of assessment.
The facility failed to properly assess, monitor, and document skin impairments for three residents, leading to deficiencies in care. A resident with a surgical incision had no initial dressing order, and weekly skin checks for all three residents lacked necessary descriptions and measurements. Staff interviews revealed inconsistencies in understanding the facility's skin management policy.
Failure to Timely Assist Residents and Provide Wheelchair Foot Pedals
Penalty
Summary
The facility failed to timely assist a resident with mobility and incontinence care, as well as failed to provide necessary wheelchair foot pedals for another resident, resulting in unmet needs for both individuals. One resident, who was moderately cognitively impaired and dependent on staff for transfers and mobility, requested to be changed and to get out of bed. Despite asking his assigned CNA for assistance, he remained in bed for several hours, with staff citing the unavailability of a Broda chair and competing priorities as reasons for the delay. The resident continued to wait for assistance, expressing his needs to both staff and the surveyor, and was not assisted out of bed until much later in the day. Another resident, also moderately cognitively impaired and with significant lower extremity impairment, returned from a doctor appointment in a manual wheelchair without foot pedals. His elderly brother had to pull the wheelchair backwards through the facility, causing the resident distress and fear, as his feet dragged on the floor. The resident reported having repeatedly requested foot pedals for several days without receiving them. Staff interviews confirmed that foot pedals were not readily available or installed, and that the resident was typically pushed backwards in the wheelchair due to the lack of footrests. Staff interviews further revealed a lack of clear procedures for ensuring wheelchair foot pedals were available and installed, as well as inconsistent understanding of when residents required such equipment. The maintenance director indicated that foot pedals were stored in various locations, making them difficult to locate, while the DON acknowledged that residents should not be pulled backwards in wheelchairs. These failures resulted in the residents' needs and requests not being accommodated in a timely and appropriate manner.
Failure to Notify Physician and Monitor Resident After Medication Errors
Penalty
Summary
The facility failed to notify the physician in a timely manner and did not monitor a resident for adverse effects after medication errors occurred. Specifically, a resident with diagnoses including type 2 diabetes mellitus, diabetic neuropathy, and Alzheimer's disease missed scheduled doses of insulin and other medications on two separate occasions. On both occasions, the medication errors were not promptly identified by nursing staff, and the resident's physician was not notified as required. Additionally, there was no evidence in the medical record that the resident was monitored for adverse effects following the missed doses, despite facility policy requiring monitoring for 24 to 72 hours after a medication error. The resident involved was cognitively impaired, unable to complete mental status interviews, and dependent on staff for medication administration. The errors included missed doses of insulin, allergy medication, neuropathy medication, blood pressure medication, pain medication, and others, as well as missed blood glucose monitoring. The Director of Nursing confirmed that the required monitoring and physician notification did not occur after the medication errors, which was inconsistent with the facility's own policy on managing medication errors.
Failure to Provide Timely Toileting Assistance Resulting in Incontinence
Penalty
Summary
A deficiency was identified when a resident with Parkinson's disease and muscle wasting, who was moderately cognitively impaired and frequently incontinent of bowel and bladder, did not receive timely assistance to maintain continence. The resident required extensive assistance for toileting, as documented in the care plan. On the day of the incident, the resident requested to use the bathroom while being transported from the Activities room by two Activities Aides. Instead of assisting or notifying appropriate staff, the aides left the resident across from the nurses' station without informing anyone of her need to urinate. For over 35 minutes, the resident remained unattended and was not assisted to the bathroom, despite her repeated requests. Multiple staff, including the Activities Director and CNAs, interacted with the resident but did not provide or arrange for toileting assistance. The resident was eventually assisted to the bathroom nearly an hour after her initial request, at which point her brief was found to be wet with urine, though she was able to urinate in the toilet as well. Interviews with staff confirmed that the resident was usually continent if assisted in a timely manner, but delays often occurred, especially during busy periods such as mealtimes. The facility's policy on Activities of Daily Living emphasized the importance of preserving function, promoting independence, and maintaining dignity. However, observations and interviews revealed that staff failed to follow this policy, resulting in the resident experiencing discomfort and partial incontinence due to delayed toileting assistance. The deficiency was substantiated through direct observation, staff interviews, and review of facility records and policies.
Failure to Provide Ordered Tube Feeding Due to Unresolved Pump Clog
Penalty
Summary
A deficiency occurred when a resident with severe cognitive impairment, dysphagia following cerebral infarction, hemiplegia, hemiparesis, and aphasia did not receive the ordered amount of tube feeding. The resident was dependent for all activities of daily living and had a physician order for continuous enteral nutrition at 75 cc per hour, with specific instructions for formula type and flushes. Observations revealed that the resident's tube feeding pump was repeatedly beeping and displaying a 'clog in line downstream' error, with 370 ml remaining in a 1000 ml container that had been initiated earlier that day. The tube feeding was not infusing as ordered. Further review and interviews confirmed that the tube feeding should have been completed by early afternoon, but the resident had not received the full prescribed amount. The LPN on duty at the time had not yet checked on the resident and was unaware that the tube feeding had not been infusing. This resulted in the resident not receiving the ordered nutrition, as confirmed by both observation and staff interview.
Failure to Prime Insulin Pens Results in Medication Error Rate Above 5%
Penalty
Summary
The facility failed to maintain a medication error rate below 5%, as required, with a calculated error rate of 6.45% based on 31 observed medication administrations and two identified errors. Both errors involved the administration of insulin using pen injectors for two residents with diabetes and chronic kidney disease. In both cases, the LPNs administering the insulin did not prime the insulin pens prior to dialing the prescribed dose and administering the medication, contrary to manufacturer instructions and facility policy. The LPNs confirmed during interviews that they did not prime the pens, with one stating she only primes if air bubbles are visible and the other stating she did not believe priming was necessary. The residents involved were cognitively intact and had care plans and physician orders specifying insulin administration for diabetes management. The facility's policy and the insulin pen manufacturer’s instructions both require priming the pen after attaching a new needle and before setting the prescribed dose. The DON confirmed that the correct procedure was not followed in these instances. The deficiency was identified during a complaint investigation and was substantiated by direct observation, record review, and staff interviews.
Failure to Follow Enhanced Barrier Precautions and Infection Control During Resident Care
Penalty
Summary
Surveyors identified a failure to maintain infection control practices during incontinence and wound care for one resident. The resident, who had diagnoses including dysphagia, polyneuropathy, and a gastrostomy, required substantial assistance for mobility and personal hygiene. The care plan indicated the resident was at risk for complications related to a PEG site infection and required Enhanced Barrier Precautions (EBP), including the use of gowns and gloves during high-contact care activities such as dressing, hygiene, and wound care. During observation of incontinence care, two CNAs provided care without donning isolation gowns, despite the resident's care plan and facility policy requiring gown and glove use for high-contact activities under EBP. One CNA stated gowns were only necessary for residents with a Foley catheter, while the other was unaware of the requirement. This demonstrated a lack of adherence to established infection control protocols for residents requiring EBP. Additionally, an LPN performed wound care on the resident's PEG tube site without following proper hand hygiene or glove-changing procedures. The LPN used the same gloves to clean the soiled wound and to apply a sterile dressing, without washing hands or using hand sanitizer between steps. The DON confirmed that sterile technique was not used as ordered and that clean technique, including hand hygiene and glove changes, should have been followed. Facility policies reviewed by surveyors outlined the correct procedures, which were not adhered to during the observed care.
CNA Found Asleep on Duty, Leading to Potential Neglect
Penalty
Summary
The facility failed to ensure residents were free from potential neglect when a Certified Nurse Aide (CNA) was found asleep while on duty. This incident involved Resident #97, who reported that CNA #403 was asleep in the bed adjacent to her in her room. The resident initially heard noises but could not see who it was due to a curtain blocking her view. Upon inquiry, CNA #403 revealed herself and asked the resident not to be upset. This incident was reported to the Assistant Director of Nursing (ADON) and led to the suspension of CNA #403. Resident #97, who was affected by this incident, had a medical history that included cellulitis of the left lower limb, chronic obstructive pulmonary disease, anxiety disorder, polyneuropathy, neurogenic bowel, depression, and essential hypertension. The facility's policy on abuse, mistreatment, neglect, exploitation, and misappropriation of resident property emphasizes the residents' right to be free from such issues. However, the actions of CNA #403, as reported, were in violation of this policy, leading to a deficiency being noted under Master Complaint Number OH00159766.
Failure to Develop Comprehensive Discharge Care Plan
Penalty
Summary
The facility failed to ensure a comprehensive discharge care plan was in place for a resident, identified as Resident #99, who was reviewed for comprehensive care plans. The resident had a range of diagnoses, including a displaced intertrochanteric fracture of the left femur, Parkinson's disease, and a history of falling, among others. The resident's Admission Minimum Data Set (MDS) assessment indicated intact cognition and required extensive assistance for bed mobility and substantial assistance for toileting hygiene. Despite these needs, the comprehensive care plan dated 07/19/24 did not include a discharge care plan for the resident. An interview with Licensed Social Worker (LSW) #167 confirmed the absence of a comprehensive discharge care plan for the resident. The facility's policy, revised on 11/13/19, mandates the development of an individualized comprehensive care plan within seven days of completing the resident assessment, which was not adhered to in this case.
Inadequate Skin Impairment Documentation and Treatment
Penalty
Summary
The facility failed to ensure timely and thorough assessment, monitoring, and treatment of skin impairments for three residents. Resident #99 was admitted with a surgical incision on the left thigh, but there was no detailed documentation or physician order for the dressing change upon admission. The weekly skin checks lacked descriptions and measurements of the skin impairments, despite the facility's policy requiring such documentation. Interviews with staff revealed inconsistencies in understanding and executing the skin assessment procedures. Resident #71 also experienced inadequate documentation of a surgical incision on the lower back. The weekly skin checks for this resident similarly lacked detailed descriptions and measurements, contrary to the facility's policy. Interviews with nursing staff indicated a misunderstanding of the requirements for documenting skin assessments, with some staff believing that only circling the affected area was necessary. Resident #93's records showed a lack of initial documentation for skin assessments upon admission. Subsequent weekly skin checks identified bruising on the elbows, but again, there was no detailed description or measurement of these areas. The facility's policy clearly stated the need for comprehensive documentation of skin breakdowns, yet the staff interviews highlighted a gap in adherence to these procedures.
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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