O'neill Healthcare North Olmsted
Inspection history, citations, penalties and survey trends for this long-term care facility in North Olmsted, Ohio.
- Location
- 4800 Clague Road, North Olmsted, Ohio 44070
- CMS Provider Number
- 366272
- Inspections on file
- 22
- Latest survey
- April 9, 2025
- Citations (last 12 mo.)
- 0
Citation history
Health deficiencies cited at O'neill Healthcare North Olmsted during CMS and state inspections, most recent first.
The facility did not consistently update individualized care plans or implement new fall prevention interventions after multiple residents experienced falls, including incidents with injuries. Post-fall investigations were incomplete, lacking root cause analysis and witness statements, and immediate interventions were not always documented or added to care plans. Staff interviews confirmed inconsistent investigation practices and delays in updating care plans for residents at high risk for falls.
Several residents and their representatives were not given the federally required 30-day period to rescind binding arbitration agreements, instead being limited to 21 days as stated in the facility's documentation. This was confirmed through record review and staff interviews, affecting multiple residents who signed these agreements.
A resident with severe cognitive and physical impairments, dependent on staff for all ADLs and transfers, was not assisted out of bed as required by their care plan. Despite having a care plan specifying use of a mechanical lift and two staff for transfers to a wheelchair, the resident remained in bed for several days, with staff interviews confirming no medical reason for this inaction.
A resident with multiple medical conditions did not receive a timely referral or appointment for cataract surgery as recommended by an ophthalmologist. Despite documentation of the need for follow-up, the facility did not schedule the necessary appointment, and staff confirmed the delay during interviews.
A resident with limited mobility and multiple medical conditions did not receive pressure ulcer dressings as ordered on several occasions. Despite physician orders for specific wound care interventions, documentation and staff interviews confirmed that treatments were missed, and the resident developed a deep tissue injury in addition to an existing wound. Facility protocols for wound care and monitoring were not followed.
A resident with multiple chronic conditions was evaluated by a consultant dentist for mouth pain, who recommended a referral to an Oral Maxillofacial Surgeon. Despite this, staff did not schedule the necessary follow-up dental appointment in a timely manner after being made aware of the need.
Surveyors found that three residents requiring enhanced barrier precautions (EBP) due to intravenous access, Foley catheter, or wounds did not have appropriate PPE or signage in place as ordered. The DON confirmed EBP was not implemented at the time of observation, and EBP for one resident was only started after the survey began, despite facility policy and CDC guidance requiring these precautions.
Three residents with complex medical conditions were not assessed for or offered influenza and/or pneumococcal vaccines, and their records lacked required documentation of vaccine assessment, consent, or refusal, despite facility policy mandating these actions.
Three residents with complex medical conditions were not timely offered the COVID-19 vaccine, as required by facility policy. Documentation was incomplete or missing, with unsigned or absent consent forms and no evidence in the medical records that the vaccine was offered. These deficiencies were confirmed by a unit manager during interviews.
A resident with a history of falls and a right leg fracture was admitted to the facility. Despite being instructed on the use of the call light, the resident was not fully oriented and was frequently incontinent. Observations revealed the call light was out of reach, and there was no bedside table, compromising her safety. The resident was found attempting to get out of bed, unaware of the call light's location. A staff member confirmed these observations and provided a call pendant, acknowledging the need for a bedside tray table.
Failure to Update Care Plans and Conduct Thorough Fall Investigations
Penalty
Summary
The facility failed to ensure individualized care plan interventions were developed, updated, and implemented following falls for multiple residents, and did not conduct thorough post-fall investigations with root cause analysis. For one resident with a history of falls and moderate cognitive impairment, repeated falls occurred, including incidents resulting in wrist fractures, without evidence of new fall prevention interventions being added to the care plan or thorough investigations being completed. Staff interviews confirmed that witness statements were not consistently obtained, and care plans were not updated after each fall, despite the resident being identified as high risk for falls and requiring assistance with ambulation and toileting. Another resident with hemiplegia, diabetes, and mild cognitive impairment experienced multiple falls over the course of a year. The care plan and fall interventions were not consistently updated to reflect new interventions identified after each fall, and some interventions were delayed in being added to the care plan. Fall investigations lacked witness statements, and immediate interventions were not always documented or incorporated into the resident's care plan in a timely manner. Staff interviews confirmed that fall investigations were often verbal and not thoroughly documented. A third resident with severe cognitive impairment and multiple comorbidities experienced an unwitnessed fall resulting in a head injury. The post-fall assessment did not identify a root cause, and there were no witness statements or comprehensive investigation documented. The facility's policy required individualized interventions and thorough investigation after each fall, but these procedures were not consistently followed for the residents reviewed.
Failure to Provide Required 30-Day Rescission Period for Arbitration Agreements
Penalty
Summary
The facility failed to ensure that residents or their representatives were informed of their right to rescind a binding arbitration agreement within the federally required 30 calendar days after signing. Instead, the arbitration agreements provided to residents specified only a 21-day period for rescission. This deficiency was identified through a review of the arbitration agreements for four residents, all of whom had signed agreements that did not comply with the 30-day rescission requirement. The facility had a total of 33 residents who had agreed to binding arbitration upon admission, and the census at the time was 57. Interviews with the Admissions Director confirmed that the arbitration agreement in use was last revised in 2021 and that the agreements for the affected residents all stated a 21-day rescission period. Upon review of the relevant regulation, the Admissions Director acknowledged that the agreements should have allowed for a 30-day rescission period, as required. The deficiency was based on direct review of resident records and facility documentation, as well as staff interviews.
Failure to Assist Dependent Resident with Out-of-Bed Transfers
Penalty
Summary
Staff failed to provide necessary assistance to a resident with severe physical and cognitive impairments, resulting in the resident not being assisted out of bed as required by their care plan. The resident, who had a history of cerebral infarction with hemiplegia/hemiparesis, diabetes, intracardiac thrombosis, peripheral vascular disease, hypertensive heart disease, chronic atrial fibrillation, vitreous degeneration, and aphasia, was assessed as being dependent on staff for all activities of daily living, including transfers and mobility. The care plan specified that the resident should be encouraged to be out of bed using a mechanical lift and with the assistance of two staff members for transfers to a tilt-in-space wheelchair. Despite these documented needs and interventions, multiple observations over several days revealed that the resident remained in bed and was not assisted into their wheelchair. Interviews with nursing and therapy staff confirmed that the resident had not been assisted out of bed since discharge from skilled therapy services, and there was no medical reason preventing the resident from being mobilized. The facility's policy required staff to provide assistance with activities of daily living, including transfers, for residents unable to perform these tasks independently, but this was not followed in the resident's case.
Failure to Schedule Cataract Surgery Referral for Resident
Penalty
Summary
The facility failed to ensure that a resident received timely follow-up for vision care as recommended by a specialist. The resident, who had multiple diagnoses including acute kidney injury, type 2 diabetes mellitus, major depressive disorder, anxiety, insomnia, muscle weakness, and cervicalgia, was seen by an ophthalmologist who recommended a cataract evaluation and possible surgery. Documentation in the medical record showed an order for referral to an ophthalmologist for cataract surgery, but there was no evidence that the referral was sent or an appointment scheduled. Interviews with the resident and the unit manager confirmed that the surgery had not been scheduled, despite the facility being aware of the need for follow-up since February.
Failure to Complete Pressure Ulcer Dressings as Ordered
Penalty
Summary
The facility failed to ensure that pressure ulcer dressings were completed as ordered for a resident with multiple medical conditions, including limited mobility, obesity, and a history of falls and transient ischemic attacks. The resident was assessed as having moderately impaired cognition and was at low risk for pressure ulcer development according to the Braden scale, but required frequent repositioning and maximum assistance due to spending most of each shift in bed or a chair. Physician orders were in place for wound care, including cleansing and application of triad ointment to wounds on the buttocks and sacral area, with specific instructions for frequency and additional interventions such as use of a low-air loss mattress and regular turning. Despite these orders, review of the Treatment Administration Record (TAR) revealed that wound care treatments were not documented as completed on three separate night shifts. Staff interviews confirmed that the treatments were not applied as ordered on those dates. Observations and medical record reviews further indicated that the resident developed a deep tissue injury (DTI) on the left buttock, classified as a pressure ulcer, in addition to a moisture-associated skin damage (MASD) wound. Facility policy required adherence to physician orders and regular monitoring of wound care, but these protocols were not followed, resulting in a deficiency related to pressure ulcer care.
Failure to Schedule Follow-Up Dental Appointment
Penalty
Summary
The facility failed to ensure that a follow-up dental appointment was scheduled for a resident who required further evaluation. The resident, who had multiple diagnoses including heart failure, morbid obesity, hemiplegia, neuropathy, and other chronic conditions, was seen by a consultant dentist for mouth pain. The dentist recommended a referral to an Oral Maxillofacial Surgeon. Despite this recommendation, the follow-up appointment was not scheduled in a timely manner. The resident reported needing the appointment since January, and staff confirmed that they were aware of the need for the appointment but had not scheduled it promptly.
Failure to Implement Enhanced Barrier Precautions for Residents with Indwelling Devices and Wounds
Penalty
Summary
The facility failed to implement enhanced barrier precautions (EBP) for three residents who were identified as requiring them, as observed during a survey. For one resident with an intravenous midline for antibiotic administration, there was no evidence of EBP, such as signage or personal protective equipment (PPE), at the bedside despite a physician's order for EBP related to intravenous access. The DON confirmed that EBP was not in place at the time of observation and stated that PPE was kept in resident bathrooms and signs were posted on name cards by the doorway, but these measures were not observed in practice. Another resident with a Foley catheter, ordered to have EBP due to the indwelling device, was also observed without appropriate signage or PPE in place. The DON confirmed the absence of EBP for this resident as well. A third resident with wounds, including a deep tissue injury and moisture-associated skin damage, had a care plan and physician order for EBP due to increased risk of multidrug-resistant organism (MDRO) acquisition, but EBP was not initiated until after the survey process began. Facility policy and CDC guidance require EBP for residents with wounds or indwelling devices, but these were not consistently implemented as required.
Failure to Assess and Offer Influenza and Pneumococcal Vaccines
Penalty
Summary
The facility failed to ensure that residents were properly assessed for their vaccination status and were offered influenza and pneumococcal vaccines as required. Specifically, three residents with multiple chronic conditions and complex medical histories did not have documentation in their medical records indicating that they were assessed for or offered the influenza and/or pneumococcal vaccines. For one resident, there was no evidence of an influenza vaccination assessment or consent form, nor any documentation that the influenza vaccine was offered for the current season. Another resident's record lacked a completed pneumococcal vaccination assessment and consent form, with no documentation that the vaccine was offered. A third resident's record was missing both pneumococcal and influenza vaccination assessment and consent forms, as well as any documentation that these vaccines were offered. Interviews with the unit manager confirmed the absence of required documentation and the failure to offer the vaccines. Review of facility policies indicated that it is the facility's protocol to offer these vaccines to all residents, provide educational materials, and document consent or refusal in the resident's chart. However, these procedures were not followed for the affected residents, resulting in the identified deficiency.
Failure to Timely Offer and Document COVID-19 Vaccination to Residents
Penalty
Summary
The facility failed to ensure that the COVID-19 vaccine was timely offered to three residents, as required by policy and regulatory guidance. For one resident, the medical record showed that the COVID-19 vaccine consent form was left unsigned, undated, and incomplete, with no evidence that the vaccine was offered. For a second resident, there was no documentation in the medical record that the COVID-19 vaccination assessment or consent form was completed, nor any indication that the vaccine was offered. For a third resident, both the physical and electronic medical records lacked any COVID-19 vaccination assessment, consent form, or documentation that the vaccine was offered. These findings were confirmed through interviews with a unit manager, who acknowledged the absence of required documentation and the failure to offer the vaccine as per facility policy. The residents involved had complex medical histories, including conditions such as diabetes, heart failure, kidney disease, stroke, dementia, and other chronic illnesses. The facility's infection control policy referenced adherence to CDC and APIC guidelines but was not followed in these cases.
Failure to Accommodate Resident Needs and Ensure Safety
Penalty
Summary
The facility failed to provide appropriate and reasonable accommodations for Resident #63, which compromised her safety. Resident #63 was admitted with a history of falling, a nondisplaced fracture of the right leg, polyarthritis, and COPD. Upon admission, she was oriented to her room and instructed on the use of the call light. However, she was not fully oriented to her surroundings and was frequently incontinent. She was also instructed not to bear weight on her right leg. Despite these conditions, the resident's call light was found on the floor behind her bed, out of her reach, and there was no bedside table available in her room. Additionally, a pitcher of water was also on the floor, further indicating a lack of proper accommodations. During an observation, Resident #63 was seen attempting to get out of bed with her left foot on the floor, while her right leg, which was in a brace, remained in bed. She expressed that she needed help but was unaware of the call light's location. A staffing coordinator confirmed these observations and subsequently placed a call pendant around the resident's neck, acknowledging that the resident was a new admission and needed a bedside tray table. This situation highlights the facility's failure to ensure the resident's needs were reasonably accommodated, as evidenced by the lack of accessible call light and necessary bedside equipment.
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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