Pataskala Oaks Care Center
Inspection history, citations, penalties and survey trends for this long-term care facility in Pataskala, Ohio.
- Location
- 144 East Broad Street, Pataskala, Ohio 43062
- CMS Provider Number
- 365794
- Inspections on file
- 20
- Latest survey
- August 25, 2025
- Citations (last 12 mo.)
- 19
Citation history
Health deficiencies cited at Pataskala Oaks Care Center during CMS and state inspections, most recent first.
The facility failed to date a multi-dose vial of Tubersol tuberculin solution when it was opened for use. An LPN confirmed the absence of the opened date, and the manufacturer's guidelines and facility policy require that opened vials be dated and discarded after 30 days.
The facility failed to ensure that residents on a mechanically altered diet were served food at the appropriate texture, with chicken lasagna containing pieces larger than the required 1/4 inch size. This affected five residents with conditions such as dysphagia and Alzheimer's disease.
The facility failed to use appropriate hand hygiene during meal service, affecting all residents who consumed food from the kitchen. Dietary staff were observed performing various tasks and changing gloves without washing their hands, violating the facility's hand washing policy.
The facility failed to complete a bed hold notice within 24 hours for a resident discharged to the hospital. The resident, whose primary payer was Ohio Medicaid, did not have the required notification in their medical record. The Business Office Manager confirmed the notice was not sent due to the discharge occurring on a weekend, and by the following Monday, the resident's family had informed the facility that the resident would not be returning.
A facility failed to apply and document the use of a left elbow brace for a resident with cerebral palsy, despite a physician's order and staff education on its correct placement. Observations and interviews confirmed the brace was not consistently applied, and documentation was lacking due to a task option not being activated in the POC system.
A resident with multiple diagnoses, including quadriplegia and anoxic brain damage, experienced a fall due to inadequate assistance during routine care. The care plan required two-person assistance for bed mobility, but only one aide was present, leading to the incident. The interdisciplinary team noted changes in the resident's muscle tone and significant weight gain as contributing factors.
The facility failed to change oxygen and nebulizer tubing as ordered for a resident with severe cognitive impairment and respiratory issues. Observations on two consecutive days revealed that the tubing had not been changed as per the weekly schedule, and an LPN confirmed the dates were from a week ago, indicating non-compliance with physician orders and facility policy.
The facility failed to provide non-pharmacological interventions and properly document pain location and indicators of pain for a resident with complex medical conditions. The resident received as-needed pain medication multiple times without required documentation, as confirmed by the DON.
The facility failed to document an end date for an as-needed psychotropic drug, ensure non-pharmacological interventions were attempted, and complete AIMS assessments as scheduled for three residents. This resulted in improper monitoring and documentation of psychotropic medication use.
The facility failed to ensure that puree food was served according to the menu and at an appropriate texture for a resident on a puree diet. Dietary staff prepared puree chicken lasagna and chicken breast without following a recipe, resulting in a soupy consistency with visible chunks and a mixture that separated into thin liquid. The food did not meet the required 'pudding-like' consistency as per the facility's policy.
The facility failed to change the oxygen and nebulizer tubing for a resident as required by the physician's order. Despite the order being signed off as completed, observations revealed that the tubing had not been changed. An LPN confirmed the discrepancy, and the DON emphasized the expectation for accurate documentation.
The facility failed to perform proper hand hygiene during wound care for a resident with a sacrum pressure injury. An LPN did not follow the facility's wound care policy, neglecting to change gloves or wash hands during the dressing change process, despite handling heavily saturated dressings and applying new materials.
Failure to Date Multi-Dose Vial of Tubersol Tuberculin Solution
Penalty
Summary
The facility failed to date a multi-dose vial of Tubersol tuberculin solution when it was opened for use. An observation revealed an opened multi-dose vial of Tubersol tuberculin solution in the medication refrigerator without an opened date on the vial, sticker, or storage box. The storage box had a delivery date from the pharmacy, but no indication of when the vial was first used. An LPN confirmed the absence of the opened date and stated that the solution should be used within 30 days of opening. The manufacturer's guidelines and the facility's medication storage policy both require that opened vials be dated and discarded after 30 days of use.
Failure to Provide Appropriate Food Texture for Mechanically Altered Diets
Penalty
Summary
The facility failed to ensure that five residents on a mechanically altered diet were served food at an appropriate texture. Specifically, residents with diagnoses such as Alzheimer's disease, dysphagia, cerebral infarction, and diabetes mellitus were observed receiving chicken lasagna with large chunks of chicken, which did not meet the required texture standards. The facility's policy indicated that meat should be in pieces no larger than 1/4 inch, but the lasagna served contained pieces larger than this size. The Dietary Manager confirmed that the lasagna was used without alterations based on information from a previous cook and her own assumption that the meat size was appropriate. During the lunch meal observation, it was noted that the lasagna contained chicken pieces larger than a quarter, which was not suitable for residents on a mechanically altered diet. The Speech Language Pathologist confirmed that meat for such diets should be the size of a quarter or less. The Dietary Manager acknowledged that the facility policy required meat to be 1/4 inch or less and that the lasagna used did not comply with this requirement. This deficiency affected five residents out of the 15 on a mechanically altered or soft diet, compromising their dietary needs and safety.
Failure to Use Appropriate Hand Hygiene During Meal Service
Penalty
Summary
The facility failed to use appropriate hand hygiene during meal service, which had the potential to affect all 46 residents who consumed food from the kitchen. During an observation, Dietary Staff #466 was seen performing various tasks such as preparing puree food, handling oven mitts, setting up the steam table, obtaining food temperatures, and serving food without washing her hands. Although she changed gloves multiple times, she did not wash her hands throughout the observation period. Additionally, Dietary Staff #460 entered the kitchen from the dining room, put on gloves, and began preparing grilled cheese sandwiches without washing her hands. The deficiency was confirmed through an interview with Dietary Staff #466 and the Dietary Manager #459. The facility's 'Hand Washing' policy, which was undated, required employees to wash their hands in several instances, including when entering the kitchen, after handling soiled equipment or utensils, during food preparation, before donning disposable gloves, and after removing gloves. The observed actions of the dietary staff were in direct violation of this policy, leading to the identified deficiency.
Failure to Complete Bed Hold Notice Within 24 Hours
Penalty
Summary
The facility failed to complete a bed hold notice within 24 hours of a resident's discharge to the hospital. This deficiency affected one resident out of four reviewed for hospitalization. Resident #55, who was admitted to the facility and later sent to the hospital for evaluation of altered mental status, did not have a bed hold notice in their medical record. The resident's primary payer was Ohio Medicaid, which requires notification to the resident's representative about the option to hold the resident's bed following a hospital discharge. The Business Office Manager confirmed that the bed hold notice was not sent because the discharge occurred on a weekend, and by the following Monday, the resident's family had informed the facility that the resident would not be returning, so the notice was not completed. The facility's policy requires written information to be given to residents and their representatives prior to a transfer, explaining the rights and limitations regarding bed-holds.
Failure to Apply and Document Use of Elbow Brace
Penalty
Summary
The facility failed to apply and document the use of a left elbow brace for a resident with cerebral palsy, high blood pressure, and type two diabetes mellitus, who required assistance with personal care tasks and used a wheelchair for mobility. Despite a physician's order for the resident to wear a left elbow extension brace daily to prevent contracture, there was no documentation in the Treatment Administration Record (TAR) or Point of Care (POC) task documentation indicating that the brace was applied. Observations over two days revealed the brace was not applied and was instead found on furniture in the resident's room. Interviews with the resident and staff confirmed the inconsistency in applying the brace, and it was revealed that the task option for documenting the brace application was not activated in the POC system, leading to a lack of proper documentation and follow-through on the physician's order. The resident's medical record and care plan indicated the need for the brace, and staff had been educated on its correct placement. However, the failure to document and consistently apply the brace as ordered resulted in a deficiency in maintaining the resident's range of motion and preventing contracture. The facility's policy on resident mobility and range of motion, which mandates treatment to prevent a decrease in range of motion, was not adhered to in this case.
Failure to Provide Adequate Assistance Resulting in Resident Fall
Penalty
Summary
The facility failed to ensure Resident #39 received the appropriate assistance, resulting in a fall. Resident #39, who had multiple diagnoses including quadriplegia, anoxic brain damage, and chronic respiratory failure, was dependent on staff for all activities of daily living. The resident's care plan indicated a need for two-person assistance for bed mobility and transfers. However, during routine care, a State tested Nursing Assistant (STNA) assisted the resident alone, leading to the resident being assisted to the floor when turned to the opposite side. The Director of Nursing (DON) confirmed that only one aide was providing care at the time of the fall, contrary to the care plan requirements for two-person assistance. The interdisciplinary team reviewed the incident and noted that Resident #39 had been receiving Botox injections, which changed his muscle tone, and had experienced significant weight gain over the previous six months. These factors contributed to the increased risk of falls. The team determined that a larger bed would decrease the risk of future falls by providing a safer environment for bed mobility, transfers, and positioning. Despite these observations, the deficiency occurred due to the failure to follow the care plan's directive for two-person assistance during bed mobility.
Failure to Change Oxygen and Nebulizer Tubing as Ordered
Penalty
Summary
The facility failed to change oxygen and nebulizer tubing as ordered for Resident #14, who was admitted with diagnoses including asthma, high blood pressure, dementia, and weakness. The resident had severe cognitive impairment and required staff assistance for personal hygiene, transfers, and bathing. Physician orders indicated that the oxygen tubing should be changed weekly on Sunday night shifts. However, observations on two consecutive days revealed that the oxygen and nebulizer tubing dated 04/14/24 had not been changed as per the order, despite the facility policy requiring weekly changes and the LPN confirming the dates were from a week ago. On 04/22/24, Resident #14 was observed sitting in a wheelchair receiving oxygen via nasal cannula with tubing dated 04/14/24. The nebulizer tubing was also dated 04/14/24. The following day, the same tubing was observed still in use, indicating it had not been changed. An interview with the LPN confirmed that the tubing should have been changed on the previous Sunday night, but it had not been done. This failure to follow physician orders and facility policy affected the resident's respiratory care and highlighted a lapse in adherence to scheduled medical equipment maintenance.
Failure to Document Pain Management and Non-Pharmacological Interventions
Penalty
Summary
The facility failed to provide non-pharmacological interventions and properly document pain location and indicators of pain for a resident with multiple complex medical conditions, including ALS and chronic pain syndrome. The resident's care plan included various interventions for pain management, but the review of the medical record revealed that these interventions were not followed. Specifically, the resident received as-needed pain medication (Dilaudid) multiple times without any documentation of non-pharmacological interventions or descriptions of the pain's location and characteristics. The facility's 'Pain Assessment and Management' policy required staff to ask residents about pain and identify its characteristics, but this was not adhered to in the case of the resident. The Director of Nursing confirmed that there was no indication that non-pharmacological interventions had been attempted and that descriptions of the pain should have been documented. This deficiency affected one resident out of the five reviewed for unnecessary medications, highlighting a significant lapse in the facility's pain management practices.
Failure to Document and Monitor Psychotropic Medication Use
Penalty
Summary
The facility failed to ensure an end date was documented for an as-needed psychotropic drug order, document behaviors, and ensure non-pharmacological interventions were attempted prior to the administration of as-needed psychotropic drugs for Resident #46. The resident, who had multiple diagnoses including anxiety disorder and amyotrophic lateral sclerosis (ALS), received Ativan multiple times without documentation of non-pharmacological interventions or behavior descriptions. The Director of Nursing confirmed that these steps should have been taken and documented for every as-needed administration of Ativan. For Resident #38, who had severe cognitive impairment and multiple psychiatric diagnoses, the facility failed to complete Abnormal Involuntary Movement Scale (AIMS) assessments as scheduled. The resident had only one AIMS assessment completed since the previous year, and the unit manager confirmed that the order for AIMS assessments was not carried over to the new system, leading to the oversight. The resident's psychiatric note indicated intermittent verbal aggression, but no further AIMS assessments were documented. Resident #19, diagnosed with Alzheimer's disease, depression, and dementia, was on Seroquel for dementia. The facility failed to document AIMS evaluations prior to April 24, 2024, despite the resident being on antipsychotic medication. The facility's policies did not address the frequency of AIMS evaluations, and the Resident Assessment Instrument (RAI) manual indicates that residents on antipsychotic medications should be monitored for potential adverse consequences at least quarterly. The facility's failure to follow these guidelines resulted in a lack of proper monitoring for potential adverse effects of the medication.
Failure to Serve Puree Food at Appropriate Texture
Penalty
Summary
The facility failed to ensure that puree food was served according to the menu and at an appropriate texture for a resident on a puree diet. The deficiency was observed when Dietary Staff #466 prepared puree chicken lasagna and chicken breast without following a recipe, resulting in a soupy consistency with visible chunks and a mixture that separated into thin liquid. The dietary staff added unmeasured amounts of milk, broth, and thickener, which did not achieve the required 'pudding-like' consistency as per the facility's policy. The dietary staff and manager confirmed that the food was thinner than pudding or mashed potatoes and did not meet the required texture for puree diets. The affected resident had severe cognitive impairment and was on a puree diet as per the physician's order. The lunch menu for the day included a BLT with potato cakes, green beans, and a cookie, with an alternate meal of chicken lasagna and a breadstick. However, the dietary staff's preparation did not adhere to the menu or the consistency guidelines, leading to the deficiency. The facility's policy on 'Consistency Modified Diets' stated that puree food should be homogenous, cohesive, and 'pudding-like,' which was not followed in this instance.
Failure to Change Oxygen and Nebulizer Tubing as Ordered
Penalty
Summary
The facility failed to accurately document a physician order by signing off that an order had been completed when it had not. Specifically, the facility did not change the oxygen and nebulizer tubing for a resident as required by the physician's order. This affected one resident who had severe cognitive impairment and required staff assistance for personal hygiene, transfers, and bathing. The resident had diagnoses including asthma, high blood pressure, dementia, and weakness. The physician's order required the oxygen tubing to be changed every week on Sunday night shift, but the tubing dated 04/14/24 was not changed as documented on 04/21/24. Observations on 04/22/24 and 04/23/24 revealed that the resident was using oxygen and nebulizer tubing that had not been changed since 04/14/24, despite the order being signed off as completed on 04/21/24. An interview with an LPN confirmed that the tubing had not been changed, even though the order was signed off. The Director of Nursing stated that the expectation is for nurses to accurately follow physician orders and only sign off when the task has been completed.
Failure to Perform Proper Hand Hygiene During Wound Care
Penalty
Summary
The facility failed to perform proper hand hygiene during wound care for Resident #34, who was admitted with multiple diagnoses including a pressure injury to the sacrum, bacteremia, and bilateral above-the-knee amputations. During an observation, LPN #419 did not follow the facility's wound care policy, which mandates hand washing and changing gloves at specific steps in the procedure. LPN #419 placed wound dressing supplies directly on the bed without a barrier, washed her hands only before donning gloves, and did not change gloves or wash hands during the dressing change process. This included handling the heavily saturated dressing, cleansing the wound, and applying new dressing materials without changing gloves or performing hand hygiene in between steps. An interview with LPN #419 confirmed the failure to wash hands or change gloves during the dressing change. The facility's policy on wound care, dated October 2010, clearly outlines the need for hand washing and glove changes at multiple points during the procedure. The LPN admitted to only washing hands before starting and after completing the dressing change, neglecting the necessary steps in between. This oversight directly contradicts the facility's established protocols for infection prevention and control.
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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