Ohio Living Westminster-thurber
Inspection history, citations, penalties and survey trends for this long-term care facility in Columbus, Ohio.
- Location
- 717 Neil Avenue, Columbus, Ohio 43215
- CMS Provider Number
- 365416
- Inspections on file
- 22
- Latest survey
- May 29, 2025
- Citations (last 12 mo.)
- 0
Citation history
Health deficiencies cited at Ohio Living Westminster-thurber during CMS and state inspections, most recent first.
A staff member failed to properly sanitize a food thermometer between checking the temperatures of various lunch items, using a dry rag instead of alcohol wipes as required by facility policy. This practice was confirmed by both the staff member and the chef, and had the potential to affect all residents receiving the meal.
A CNA did not complete the required 12 hours of annual continuing education, with only 6.25 hours documented over a 19-month period. Facility policy and training practices allowed for gaps exceeding 12 months without meeting education requirements, and the policy lacked specific details on the 12-hour mandate.
A resident with severe dementia and multiple comorbidities was prescribed Seroquel without any orders or documentation for behavioral monitoring to assess the medication's effectiveness or necessity. Staff and physician interviews confirmed the absence of recent behavioral issues, and observations showed no negative behaviors, yet the antipsychotic regimen was continued without appropriate evaluation or monitoring.
A resident, who was cognitively intact and required significant assistance for toileting, reported to surveyors that a CNA had provided rough care and, on a separate occasion, had engaged in inappropriate sexual contact during incontinence care. Although concerns about rough care were previously reported by the resident's family, the more serious allegations of abuse were not reported to the State agency within the required timeframe, as confirmed by interviews and record reviews. The DON only became aware of the abuse allegations during the survey and acknowledged the failure to report as required by facility policy.
The facility did not complete or properly document required care conferences for two residents, including one with intact cognition and another with cognitive impairment and multiple diagnoses. Care conferences were either missing, not held at required intervals, or lacked complete documentation in key areas such as code status and nursing needs, contrary to facility policy and regulatory requirements.
A resident with a severe right foot deformity and limited mobility did not receive a new orthopedic boot as recommended by the podiatrist. The resident's current boot was observed to be in poor condition, and staff confirmed the recommendation for a replacement was not followed. The resident expressed willingness to use a new boot for improved foot positioning.
A resident with multiple cardiac and neurological conditions was prescribed Aspirin for CAD. During a monthly drug regimen review, the pharmacist recommended evaluating and possibly discontinuing Aspirin based on current CVD prevention guidelines. The DON noted the medical director was notified, but the prescriber response was left blank and only the DON signed the form. Despite a follow-up from the pharmacist, the recommendation remained pending, and the physician's acknowledgment to discontinue Aspirin was undated, with the discontinuation order not finalized until several days later, contrary to facility policy requiring timely physician documentation.
A resident receiving hospice care did not have up-to-date hospice documentation maintained by the facility. Staff were unable to locate recent hospice notes, and the available records only included information up to March, with no documentation for subsequent months. The hospice provider confirmed timely transmission of records, but facility staff could not account for missing documentation, resulting in a failure to ensure proper hospice communication and recordkeeping.
An LPN was observed using an unsanitized pen from the medication cart to open single-dose blister pods for three residents, including those with chronic heart and neurological conditions. The pen, not cleaned between uses, was used to create an opening in the packaging, and the tablets were then dispensed into medication cups. This practice was confirmed by both the LPN and the DON and did not follow the facility's medication administration policy, which requires sanitary handling and avoidance of direct contact with medications.
Two residents received antibiotics without meeting the facility's established clinical criteria for appropriate use. In both cases, antibiotics were administered despite incomplete documentation and failure to meet McGeers' Criteria, as confirmed by the DON and facility records.
A facility failed to regularly assess a resident's indwelling urinary catheter as per the care plan, affecting a resident with neurogenic bladder and urinary retention. The care plan required staff to document catheter assessments every shift, including urine output details. Interviews with LPNs and the DON confirmed the lack of documentation, indicating non-compliance with the care plan.
The facility failed to maintain and dispose of rodent traps in the third-floor kitchenette, affecting 16 residents who received food from this area. A deceased mouse was found in a trap near the dishwasher, and a large hole in the drywall allowed rodent access. Despite multiple observations, staff did not identify the mouse, even during lunch service. Interviews confirmed a lack of awareness and prompt action, with the Director of Environmental Services admitting to not encountering any mice during daily rounds.
Improper Food Thermometer Sanitization During Meal Service
Penalty
Summary
A staff member checked the temperatures of multiple lunch food items, including pork, beef, German potato salad, peas, ground meats, and soup, by wiping the thermometer on a dry rag between each item instead of using alcohol wipes. The dry rag was resting on the steam table counter. The staff member confirmed that she typically used alcohol wipes but could not find them at the time. The chef also confirmed that alcohol wipes should have been used to clean the thermometer between checking each food item. Facility policy indicated that staff should be aware of sources of food-borne organisms, including contaminated equipment and cross contamination.
Failure to Ensure Required Annual Continuing Education for CNA
Penalty
Summary
The facility failed to ensure that a certified nursing assistant (CNA) completed the required 12 hours of continuing education within a 12-month period, as evidenced by a review of personnel files and training logs. The CNA in question had only completed 6.25 hours of continuing education over a 19-month period, with training sessions spread out and not meeting the annual requirement. An interview with the Human Resources staff confirmed that the facility's practice of using a rolling calendar for training could result in staff going more than 12 months without completing the necessary education. Additionally, the facility's policy on training and staff development did not specify the requirement for 12 hours of continuing education per year.
Failure to Monitor Psychotropic Medication Use and Necessity
Penalty
Summary
The facility failed to ensure adequate behavioral monitoring and evaluation of psychotropic medication necessity for a resident with multiple complex diagnoses, including severe dementia with agitation and neurocognitive disorder with Lewy bodies. Upon review, the resident had physician orders for Seroquel, an antipsychotic medication, without any accompanying instructions for behavioral monitoring. There were no orders or documentation specifying behavioral monitoring, and the Medication Administration Record did not reflect any monitoring for effectiveness or adverse consequences related to the use of Seroquel. Progress notes from the period reviewed did not document any negative behaviors, and staff interviews confirmed the absence of recent behavioral issues. Further, the physician acknowledged that the Seroquel prescription was continued from a previous care setting and not based on recent behaviors, with no recent reports of behavioral issues or attempts at gradual dose reduction. Observations of the resident showed no negative behaviors, and staff interviews corroborated a decline in the resident's condition but no current behavioral concerns. The FDA guidelines for Seroquel indicate it is not approved for elderly patients with dementia-related psychosis, and the medication carries a black box warning for this population. Despite this, the facility did not implement or document behavioral monitoring to justify the ongoing use of the antipsychotic medication.
Failure to Timely Report Alleged Sexual and Physical Abuse
Penalty
Summary
The facility failed to report an allegation of sexual and physical abuse involving a resident to the State agency within the required timeframe. The resident, who was cognitively intact and required substantial assistance for toileting, reported to surveyors that a CNA had provided rough care and, on a separate occasion, had used his finger to penetrate her in a sexual manner during incontinence care. The resident stated she asked the CNA to stop, but he did not comply immediately. The resident's sister had previously reported concerns about rough care to staff, which led to a grievance form being completed and the CNA's subsequent termination for unrelated reasons. However, the more serious allegations of sexual and physical abuse were not reported to the State agency as required. Interviews and record reviews confirmed that the DON was aware of concerns about rough care but denied knowledge of any allegations of penetration or abuse until informed by surveyors. Despite facility policy requiring immediate reporting of all abuse allegations, the incident was not reported to the State agency within the mandated 24-hour window. The DON acknowledged the failure to report after being notified by surveyors, and the incident was only reported to the State agency after this notification.
Failure to Complete and Document Required Care Conferences
Penalty
Summary
The facility failed to ensure that care conferences were completed as required for two residents. For one resident with diagnoses including major depressive disorder with psychotic symptoms and myotonia congenita, care conferences were only documented on three occasions, with a significant gap between two of the conferences. The resident, who had intact cognition, recalled only one care conference in the past year. The Director of Social Services confirmed that there was no evidence of additional care conferences during the required intervals, and facility policy required care planning discussions to be available as directed by federal and state guidelines. For another resident with multiple diagnoses including psychotic disorder, dementia, and Parkinson's disease, the medical record showed only two care conferences in the previous year, with one listed as "in process" and not completed. The most recent care conference documentation was incomplete, with several required sections left blank, including code status, nursing needs, and dietary services. The Social Services Director acknowledged the lack of completed documentation and missing care conferences for the required periods. Facility policy required that care planning discussions and documentation be completed as required by regulations.
Failure to Provide Recommended Orthopedic Boot for Resident with Limited Mobility
Penalty
Summary
The facility failed to follow podiatry recommendations for a resident with significant mobility limitations and a severe right foot deformity. The resident, who had diagnoses including right foot talipes equinovarus, hemiplegia, muscle weakness, and limited ambulation, was dependent on a manual wheelchair and had a care plan indicating the need for appropriate mobility devices and interventions. The care plan also noted the resident's risk for pressure areas and skin tears, and included a podiatry recommendation for new shoes due to worn-out footwear. Despite this, the resident's orthopedic boot was observed to be in poor condition, with a worn-down bottom, a hole in the heel, and visible dirt and wear. Interviews with staff confirmed that the resident rarely wore the orthopedic boot except for outside appointments, and the DON acknowledged that the podiatrist's recommendation for a new boot had not been followed up on. The resident expressed a desire for a new orthopedic boot to assist with foot positioning and stated he would wear it regularly if provided. The failure to obtain and provide the recommended orthopedic boot constituted a deficiency in maintaining and improving the resident's range of motion and mobility as required.
Failure to Ensure Timely Follow-Up of Pharmacy Recommendations
Penalty
Summary
The facility failed to ensure timely follow-up of pharmacy recommendations for a resident with multiple diagnoses, including Parkinson's disease, dementia, atherosclerotic heart disease, bradycardia, coronary artery disease, chronic diastolic heart failure, and hyperlipidemia. The resident was prescribed Aspirin for coronary artery disease, and during a monthly medication regimen review, the pharmacist recommended evaluating the continued use of Aspirin in light of current cardiovascular disease prevention guidelines, suggesting possible discontinuation. The DON selected to continue Aspirin and noted the medical director was notified, but the prescriber response section was left blank, and only the DON's signature was present on the form. Subsequent documentation showed that the pharmacist followed up on the recommendation, but the recommendation remained pending without a final response from the physician. The physician's acknowledgment to discontinue Aspirin was eventually documented, but the form lacked a date, and the discontinuation order was not finalized until several days after the follow-up request. The facility's policy required all medication regimen review findings and actions to be documented by the attending physician in the resident's medical record, which was not done in this case.
Failure to Maintain Hospice Documentation and Communication
Penalty
Summary
The facility failed to maintain proper communication and documentation of hospice services for one resident who was admitted to hospice care. The resident, who had multiple diagnoses including psychotic disorder, dementia, malnutrition, and Parkinson's disease, was cognitively impaired and dependent on staff for mobility and eating. Although there was an order for hospice admission, the facility's records only included hospice documentation up to March 2025, with no evidence of notes or documentation for April or May 2025. The hospice binder at the nursing station contained only calendars with visit notations and lacked details about the visits, care provided, or staff involved. Comprehensive assessments and physician orders were present, but there was no documentation from the previous year or recent months. Staff interviews revealed confusion about the location and maintenance of hospice records. The LPN was unsure if updated records were maintained, the liaison could not locate current hospice documentation in the electronic medical record, and the DON confirmed that records were missing and only in the process of being scanned. The Director of Social Services provided additional documents, but the most recent were still from March 2025. The hospice RN confirmed that hospice sent weekly bundles of notes to the facility and tracked their delivery, denying any delay on their part. Facility policy required coordination of care for hospice patients, but the necessary documentation was not maintained as required.
Unsanitary Practice During Medication Administration
Penalty
Summary
During medication administration, a Licensed Practical Nurse (LPN) was observed using the tip of a pen, retrieved from a stack of papers on the medication cart, to open single-dose blister pods containing oral medications for three residents. The pen, which had not been sanitized and was left unattended on the cart, was used to create a U-shaped opening in the blister pods, allowing the tablets to be removed and placed into medication cups. This practice was observed during the administration of medications such as Carvedilol and Protonix for a resident with chronic cardiopulmonary and gastrointestinal conditions, and Sinemet for two residents with Parkinson's disease and related diagnoses. The LPN confirmed that the pen was used for this purpose and acknowledged that it had never been sanitized. Interviews with the LPN and the Director of Nursing confirmed the use of the unsanitized pen to open medication packaging, which was not in accordance with the facility's medication administration policy. The policy required medications to be administered as prescribed, following manufacturers' specifications and good nursing practices, and specified that staff should avoid touching medications unless wearing gloves. The observed practice affected three residents out of twelve observed during medication administration, with the facility census at 29.
Failure to Follow Antibiotic Stewardship Protocol for Two Residents
Penalty
Summary
The facility failed to adhere to its antibiotic stewardship protocol by administering antibiotics to two residents without meeting the established clinical criteria outlined in its policy. For one resident with vascular dementia, dysphagia, cystitis, and benign prostatic hyperplasia, antibiotics were prescribed and administered following a hospital diagnosis of cystitis with hematuria, despite a urinalysis showing no bacteria and the absence of additional symptoms required by McGeers' Criteria. The infection tracking log noted that the resident did not meet the criteria for a urinary tract infection, but antibiotic therapy was continued based on the hospital's diagnosis and physician's decision. Another resident with multiple diagnoses, including obesity and reduced mobility, received antibiotics after a urine culture was completed in the hospital, but there was no documentation confirming the presence or identification of an organism in the urine. The infection tracking log for this resident indicated that McGeers' criteria were not met and the required documentation was incomplete. In both cases, the DON confirmed that antibiotics were administered without meeting the facility's established criteria for appropriate use, as required by the facility's antibiotic stewardship policy.
Failure to Regularly Assess Resident's Catheter
Penalty
Summary
The facility failed to regularly assess a resident's indwelling urinary catheter as per the resident's care plan. This deficiency affected one resident who was readmitted with diagnoses including neurogenic bladder and urinary retention. The care plan required the nursing staff to assess the catheter drainage every shift, documenting the amount, type, color, and odor of the urine, and to provide catheter care as needed. However, a review of the resident's medical record revealed a lack of evidence for routine and consistent assessment of the catheter, including monitoring of the urine output. Interviews with the nursing staff, including two LPNs and the Director of Nursing, confirmed that the staff were required to document catheter assessments in the progress notes every shift. Despite this requirement, the Director of Nursing acknowledged that the resident's medical record did not contain the necessary urinary assessments every shift, which should have included details such as drainage amount, type, color, and consistency. This deficiency was investigated under a specific complaint number, indicating non-compliance with the resident's care plan.
Failure to Maintain Rodent Traps in Kitchenette
Penalty
Summary
The facility failed to maintain and dispose of rodent traps in the third-floor kitchenette, which had the potential to affect all 16 residents who received food from this area. During an observation, a deceased mouse was found in a sticky trap near the dishwasher, and a large hole in the drywall beneath the sink was noted, allowing easy access for rodents. Despite multiple observations throughout the day, the mouse remained unidentified by staff, even during lunch service when CNAs were actively using the kitchenette to serve meals and collect ice. Interviews with staff, including CNAs, an LPN, and the Director of Environmental Services, confirmed the presence of the deceased mouse and highlighted a lack of awareness and prompt action to address the issue. The Director of Environmental Services admitted to not having encountered any mice during his daily rounds and lacked documentation of these checks. A local pest control technician emphasized the importance of immediate removal of identified mice and the necessity for staff to conduct daily checks in these areas.
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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