Northcrest Rehab And Nursing Center
Inspection history, citations, penalties and survey trends for this long-term care facility in Napoleon, Ohio.
- Location
- 240 Northcrest Drive, Napoleon, Ohio 43545
- CMS Provider Number
- 365163
- Inspections on file
- 37
- Latest survey
- January 23, 2025
- Citations (last 12 mo.)
- 0
Citation history
Health deficiencies cited at Northcrest Rehab And Nursing Center during CMS and state inspections, most recent first.
The facility failed to implement proper infection control practices for residents in droplet and contact isolation. A CNA did not use gloves or change an N95 mask when moving between residents, and another CNA did not wear a gown for a resident in contact isolation. These actions were inconsistent with the facility's infection control policies.
A facility failed to maintain clean and trimmed fingernails for a resident with a CVA and left-sided hemiplegia, who was dependent on staff for personal hygiene. Despite the care plan and facility policy requiring regular nail care, observations revealed the resident's nails were long and dirty, with debris under the nails. Documentation showed inconsistency in trimming the nails, and a CNA confirmed the deficiency.
A resident with severe cognitive impairment and multiple medical conditions did not receive prescribed care, including the application of a PRAFO brace and use of washcloths for hand positioning, as per physician orders. Observations revealed the absence of these interventions, and staff interviews confirmed a lack of awareness of the specific care requirements, despite documentation indicating completion.
The facility failed to implement fall interventions for two residents, leading to deficiencies in their care. One resident, who was moderately cognitively impaired, was observed with her bed not in the lowest position and missing nonskid strips. Another resident, with a history of falls and dementia, had a regular call light instead of a touch pad and lacked nonskid strips. Staff confirmed these discrepancies, noting room changes as a potential factor.
The facility failed to ensure proper medication storage and administration for two residents. One resident, unable to self-administer, had aspirin on her bedside cabinet, intending to use it for acne. Another resident was found with unattended medication on her overbed table, as she did not want to take all the pills at once. These incidents indicate non-compliance with the facility's medication policies.
A resident with multiple health issues, including urinary retention, experienced inadequate catheter care in an LTC facility. The resident's indwelling urinary catheter frequently leaked, leading to soiled bedding and refusal of care. Despite staff attempts to address the issue, there was a lack of documentation and communication with the urologist, contributing to the deficiency.
The facility failed to administer medications as ordered by the physician, resulting in a medication error rate of 6.9%, exceeding the acceptable threshold of 5%. Two residents received their medications outside the prescribed times, as confirmed by the MAR and an LPN interview. The facility's policy requires medications to be administered within one hour of their prescribed time.
A facility failed to obtain a resident's blood glucose level at the scheduled time, as required by a physician's order for Novolog insulin administration via sliding scale. An LPN admitted to not checking the blood glucose level at 7:00 A.M. because the resident could not be located. The level was later checked, and insulin was administered based on the reading. The oversight was confirmed during a staff interview.
The facility failed to maintain sanitary conditions in the common showers used by residents on the 100 and 200 halls. Observations revealed black and orange substances in the 200-A and 200-B shower rooms, which the Environmental Services Director was unaware of. Non-operable exhaust fans may have contributed to the issue, as confirmed by interviews with staff.
A facility failed to follow physician orders for a resident's stage IV pressure ulcer treatment, resulting in a saturated dressing and soiled bed linen. The resident, with multiple health issues, had a care plan requiring specific wound care interventions. Observations showed the dressing lacked a foam border and was not changed as needed, contrary to facility policy.
A facility failed to administer and monitor nutritional supplements for a resident as per physician orders. The resident, with severe malnutrition and a stage 4 pressure ulcer, was supposed to receive Boost Breeze three times daily, but it was not provided during meals, and the amount consumed was not documented. Staff interviews confirmed the oversight, and the resident's preference for chocolate-flavored supplements was not honored.
Infection Control Deficiencies in PPE Usage
Penalty
Summary
The facility failed to implement proper infection control practices related to COVID-19 droplet isolation and contact isolation, affecting several residents. Resident #37, who was in droplet isolation for COVID-19, was observed to have improper PPE usage by CNA #771. The CNA entered the resident's room without gloves, did not perform hand hygiene upon exiting, and failed to change the N95 mask before attending to another resident, Resident #28, who was not in isolation. This indicates a lack of adherence to the facility's infection control policies. Resident #56, also in droplet isolation for COVID-19, was similarly affected by improper PPE practices. CNA #771 entered the room without donning the required PPE, including a gown and gloves, and was preparing to assist the resident with eating. This was observed by LPN #664, who intervened and instructed the CNA to wear the appropriate PPE. This further highlights the inconsistency in following infection control protocols. Resident #12, who was on contact isolation for MRSA, was also subject to improper infection control practices. CNA #604 entered the resident's room without wearing a disposable gown, despite the requirement to do so for any care provided to the resident. The Unit Manager confirmed the necessity of wearing a gown and gloves for residents in contact isolation. The facility's policies clearly state the need for PPE and hand hygiene, yet these were not consistently followed, leading to the deficiencies noted in the report.
Failure to Maintain Clean and Trimmed Fingernails for a Dependent Resident
Penalty
Summary
The facility failed to ensure that a dependent resident's fingernails were kept clean and trimmed, as required by their policy. The resident, who was admitted with a diagnosis of cerebral vascular accident (CVA) resulting in left-sided hemiplegia and hemiparesis, was noted to have moderate cognitive impairment and was dependent on staff for personal hygiene. Despite the care plan indicating the need for assistance with personal hygiene due to self-care deficits, observations on two consecutive days revealed that the resident's fingernails were long and dirty, with black and yellow debris caked under the nails, particularly under the right thumbnail. The facility's policy on nail care, dated October 2010, outlines the necessity of cleaning the nail bed, keeping nails trimmed, and preventing infections. However, documentation from the resident's shower sheets indicated that while the resident's fingernails were cleaned, they were not consistently trimmed. Interviews with a Certified Nurse Aide confirmed the observations of the resident's long and dirty fingernails, indicating a lapse in the facility's adherence to its own nail care policy.
Failure to Apply Brace/Splint Per Physician Order
Penalty
Summary
The facility failed to apply a brace/splint per physician order for a resident with severe cognitive impairment and multiple medical conditions, including traumatic subdural hemorrhage and a displaced fracture of the second cervical vertebra. The resident was dependent on staff for activities of daily living and had specific physician orders for a left lower extremity PRAFO brace to be worn in the morning and removed at bedtime, along with passive range of motion exercises and the use of rolled-up washcloths in both hands to be removed every six hours to check skin integrity. However, observations on multiple occasions revealed that the resident did not have the prescribed splints or washcloths in place, and the PRAFO boot was not consistently applied as ordered. Interviews with facility staff, including a Certified Nursing Assistant (CNA), confirmed the absence of the required splints and washcloths, and the CNA was unaware of the specific orders for the resident's care. The facility's policy on Rehabilitative/Functional Maintenance Nursing Care emphasized the importance of assisting residents with their prosthetic devices and following physician prescriptions, yet these protocols were not adhered to in the case of this resident. This deficiency in care was documented despite the Treatment Administration Record indicating that the interventions were completed, highlighting a discrepancy between recorded care and actual practice.
Failure to Implement Fall Interventions for Residents
Penalty
Summary
The facility failed to implement fall interventions for two residents, leading to deficiencies in their care. Resident #15, who was moderately cognitively impaired and dependent on staff for various activities, was observed on multiple occasions with her bed not in the lowest position, contrary to her care plan. Additionally, nonskid strips were missing from the designated areas around her recliner. Staff interviews confirmed these observations, and it was noted that the room had been rearranged, which may have contributed to the oversight. Similarly, Resident #48, who had a history of falls and dementia, was found to have a regular push button call light instead of the touch pad call light specified in her care plan. Furthermore, nonskid strips were absent from the designated areas around her bed. Staff interviews verified these discrepancies, and it was mentioned that Resident #48 had recently changed rooms, which might have led to the failure in implementing the prescribed interventions.
Medication Storage and Administration Deficiency
Penalty
Summary
The facility failed to ensure proper storage of medications, affecting two residents. Resident #22, diagnosed with chronic obstructive pulmonary disease and dementia, was observed with a bottle of aspirin on her bedside cabinet, despite being unable to self-administer medications. The Unit Manager confirmed the presence of the aspirin and removed it, noting that Resident #22 intended to use it as a skin treatment for acne. The aspirin was later stored in the medication room, but the Unit Manager had not yet consulted with the physician regarding the resident's request. Resident #16, with a history of ovarian and breast cancer and mild cognitive impairment, was found with a medication cup containing four unidentified pills on her overbed table. The Registered Nurse verified that the medication cup was left unattended, as Resident #16 did not want to take all the medications at once. The nurse stated she would return to ensure the resident took the medication. Both incidents highlight a failure to adhere to the facility's policy on safe medication storage and administration.
Failure to Maintain Effective Catheter Care
Penalty
Summary
The facility failed to maintain effective and sanitary care for a resident with an indwelling urinary catheter. The resident, who was admitted with multiple diagnoses including type II diabetes mellitus, neurofunction dysfunction of the bladder, and urinary retention, was dependent on staff for activities of daily living and utilized an indwelling urinary catheter. The care plan required catheter care every shift and monthly changes by the Director of Nursing (DON). However, there was no documentation indicating that the urologist was informed of the catheter's function, and the medical record lacked evidence of the catheter being changed as ordered in September 2024. Observations and interviews revealed ongoing issues with the resident's catheter care. The resident experienced frequent leaking of the catheter, resulting in soiled bedding, and refused care on multiple occasions. Despite attempts by staff to change the linens and provide catheter care, the resident's refusal persisted. The DON confirmed that the catheter was changed on October 1, 2024, but it continued to leak, and no additional interventions were implemented to address the issue. Furthermore, there was no documentation of the catheter change in the medical record, and the urologist had not been contacted since the resident's admission. The deficiency was further highlighted by the lack of communication and documentation regarding the resident's catheter care. Interviews with staff, including the DON and LPNs, confirmed the ongoing concerns with the leaking catheter and the resident's refusal of care. The facility's failure to document catheter changes and notify the urologist contributed to the deficiency, as did the absence of interventions to address the leaking catheter. This deficiency was investigated under Complaint Number OH00157794.
Medication Administration Errors Exceed Acceptable Rate
Penalty
Summary
The facility failed to ensure medications were administered as ordered by the physician and within prescribed time frames, resulting in a medication error rate above five percent. This deficiency was observed during a medication administration process involving two residents. One resident was administered Cymbalta, an antidepressant, at 10:22 A.M., which was outside the prescribed administration time of 7:00 A.M. as per the physician's order. The medication administration record (MAR) confirmed the prescribed times, and the error was verified through an interview with the LPN responsible for the administration. Another resident was administered budesonide-formoterol fumarate inhalation aerosol at 10:36 A.M., which was also outside the prescribed administration time of 8:00 A.M. as documented in the MAR. The LPN confirmed the deviation from the prescribed schedule during an interview. The facility's policy, revised in April 2019, mandates that medications be administered within one hour of their prescribed time unless otherwise specified. The observed errors resulted in a medication administration error rate of 6.9%, exceeding the acceptable threshold of five percent.
Failure to Obtain Blood Glucose Levels as Ordered
Penalty
Summary
The facility failed to obtain blood glucose levels as ordered for a resident, which was discovered during a complaint investigation. On the morning of October 1, 2024, an LPN was observed administering medications, including Novolog insulin, to a resident based on sliding scale blood glucose levels. However, the LPN admitted to not obtaining the resident's blood glucose level at the scheduled 7:00 A.M. time because the resident could not be located. The blood glucose level was eventually checked later in the morning, revealing a reading of 204 mg/dL, and the LPN administered four units of insulin accordingly. The resident's medical record indicated a physician's order for Novolog insulin administration via sliding scale, with specific units to be given based on blood glucose levels at designated times throughout the day. The order specified administration times at 7:00 A.M., 11:00 A.M., 4:30 P.M., and 8:00 P.M. However, the medication administration record for October 2024 showed no documentation of the blood glucose level being obtained at the 7:00 A.M. scheduled time on October 1, 2024. This oversight was confirmed during an interview with the LPN, who acknowledged the failure to obtain the blood glucose level as ordered.
Unsanitary Conditions in Common Showers
Penalty
Summary
The facility failed to maintain the resident common showers in a sanitary manner, affecting all 27 residents residing on the 100 and 200 halls. During an observation with the Environmental Services Director (ESD), a black substance was found clinging to the ceiling and corner of the wall above the shower stall in the 200-A common shower room, along with a black and orange residue on the shower stall baseboard. Similarly, an orange and black substance was observed clinging to the baseboard of the 200-B common shower stall. The ESD was unaware of these substances prior to the observation. Interviews with State tested Nurse Aides (STNAs) confirmed that residents from the 100 and 200 halls used these common showers. A follow-up interview with the ESD revealed that the exhaust fans in the shower rooms were not operable, potentially contributing to increased moisture and the presence of the substances.
Failure to Adhere to Pressure Ulcer Treatment Orders
Penalty
Summary
The facility failed to ensure pressure ulcer treatments were completed in accordance with physician orders for a resident with multiple medical conditions, including a stage IV pressure ulcer. The resident was admitted with a stage IV pressure ulcer to the right flank area, and the care plan included specific interventions for wound care. However, observations revealed that the dressing on the resident's wound was saturated with drainage, which had penetrated the dressing and soiled the bed linen. The dressing did not include a foam border as required by the physician's orders, and no attempts were made to change the saturated dressing before it caused further soiling. The resident's medical record indicated a history of chronic obstructive pulmonary disease, intellectual disabilities, and other significant health issues. The wound specialist certified nurse practitioner had assessed the wound as stable, but the facility's staff failed to adhere to the prescribed treatment regimen. The facility's policy required wound care procedures to be completed per physician orders, including the application of dressings with initials, time, and date. The deficiency was identified during an investigation under a master complaint number.
Failure to Administer and Monitor Nutritional Supplements
Penalty
Summary
The facility failed to administer and monitor nutritional supplements for a resident in accordance with physician orders. The resident, who was moderately cognitively impaired and dependent on staff for activities of daily living, had multiple health issues including severe protein-calorie malnutrition and a stage 4 pressure ulcer. The physician had ordered Boost Breeze to be given three times a day, with the amount consumed to be recorded. However, the medication administration records showed that while the supplement was marked as administered, the amount consumed was not documented. Observations revealed that the resident did not receive the Boost Breeze supplement during meals, and instead, a different supplement, Thrive, was provided but not consumed. Interviews with staff confirmed that the Boost Breeze was not listed on the resident's diet card, and there was no documentation of the amount consumed. The dietary manager and nursing staff acknowledged the oversight, and it was noted that the resident preferred chocolate-flavored supplements, which were not provided. This deficiency was identified during an investigation under a specific complaint number.
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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