Riverside Nursing And Rehabilitation Center
Inspection history, citations, penalties and survey trends for this long-term care facility in Dayton, Ohio.
- Location
- 1390 King Tree Drive, Dayton, Ohio 45405
- CMS Provider Number
- 365877
- Inspections on file
- 43
- Latest survey
- September 2, 2025
- Citations (last 12 mo.)
- 30 (1 serious)
Citation history
Health deficiencies cited at Riverside Nursing And Rehabilitation Center during CMS and state inspections, most recent first.
A resident with severe cognitive and physical impairments, who required a Hoyer lift with two-person assistance for transfers, was manually transferred by a CNA without the required equipment or help. This improper transfer led to a left femoral neck fracture, requiring hospital admission and surgical repair. The CNA initially denied improper care but later admitted to the manual transfer, which was against facility policy and physician orders.
A resident with cellulitis and impaired skin integrity was observed with seeping fluids from unbandaged legs, creating unsanitary conditions in the facility. Staff struggled to manage the situation, leading to trails of fluid in common areas. The facility's infection prevention policy was not effectively implemented, as confirmed by the Administrator and DON.
The facility failed to maintain a safe, clean, and homelike environment for residents, as observed in multiple rooms. A resident's oxygen cannula was found on the floor with soiled items, another resident's bed was without sheets and had a shredded mattress with exposed wiring nearby, a third resident's toilet was clogged with exposed wires on the air conditioner, and a fourth resident's bed footboard was detached. These issues were confirmed by staff and are part of ongoing non-compliance.
Two residents were not treated with dignity and respect. One resident, severely cognitively impaired, was left in a common area inadequately dressed and with soiled items. Another resident, with a history of eating non-edible items, was seen chewing on a sock without staff intervention. Staff acknowledged these issues but cited convenience for their actions.
A facility failed to notify a resident's guardian and physician of significant changes, including a new roommate and a hospital transfer following a reported assault. The resident, with multiple health issues, was not on one-on-one supervision as expected. Documentation and staff interviews confirmed the lack of required notifications.
A facility failed to maintain food service safety standards when an STNA removed her N-95 mask and used her teeth to open a dressing packet for a resident with Alzheimer's and dysphasia. The STNA then handed the packet to the resident, contrary to the facility's infection prevention policy.
The facility failed to maintain a homelike environment, affecting several residents. Observations revealed issues such as a dangling outlet, rusted heaters, peeling paint, and torn blinds. Maintenance staff were aware but had not resolved these issues, indicating a lapse in communication or oversight.
The facility failed to provide adequate refrigeration for residents to store food brought in by family or visitors, affecting six residents. Residents reported no designated refrigerator for their use, and existing refrigerators were either full or for staff use. Observations showed unlabeled and undated items in a refrigerator, and the Dietary Manager confirmed the facility did not store outside food due to content uncertainty. The facility's policy allowed food from outside but did not ensure storage space availability.
A resident's rights were violated when the facility restricted his use of a motorized wheelchair and imposed supervised leave of absence requirements. Despite being cognitively intact, the resident's wheelchair was removed after an incident involving another resident, and he was not reassessed for its return. Additionally, the facility required supervision for leaving the building, despite a physician's order allowing unsupervised leave, without clear documentation or justification.
The facility failed to treat residents with dignity and respect, affecting three residents. A resident was told to return to her room when requesting shampoo, another was denied ice water outside scheduled times, and a third was led by the wrist by an STNA. These actions were inconsistent with the facility's policy on resident rights.
A cognitively intact resident, who required assistance for daily activities, was consistently woken up early against her preference due to facility scheduling. Despite expressing her dislike for early mornings, staff followed a supervisor's directive to get her up before the first shift. This deficiency was noted during a complaint investigation.
A resident with severe cognitive impairment and incontinence was not properly cleansed by an STNA during incontinence care. The STNA failed to clean the resident's genital and buttock areas, leaving the brief wet, contrary to the facility's policy. The STNA was unaware of the proper procedure and mistakenly believed hospice would provide care the next day.
A resident with cognitive impairment and medical conditions expressed severe pain during a dressing change, but the LPN did not assess or medicate the resident before the procedure. Despite the resident's repeated complaints and a policy emphasizing pain management, the LPN proceeded without addressing the pain, leading to a deficiency finding.
A resident with hemiplegia and hemiparesis was injured during a manual transfer by two STNAs, despite having orders for a Hoyer lift transfer. The lift was not working, leading to a manual transfer that resulted in a fracture to the resident's left humerus. The facility's policy required mechanical lifts for safety, but this was not followed, causing harm to the resident.
A resident in an LTC facility experienced significant medication errors due to transcription mistakes during admission. The resident's aspirin was omitted, lisinopril was given without necessary parameters, and methocarbamol was incorrectly transcribed as an as-needed medication. These errors were confirmed by LPNs and were not communicated to the physician, violating the facility's medication administration policy.
A facility failed to accurately document the administration of a resident's narcotic medications, resulting in discrepancies between the narcotic sign-out sheets and the Medication Administration Record (MAR). Interviews with the DON and nursing staff confirmed the documentation issues, despite the facility's policy emphasizing accurate documentation and adherence to the Five Rights of medication administration.
A facility failed to ensure a resident met criteria for admission to the secure unit and was in the least restrictive environment. The resident, who was cognitively intact and cooperative, was placed in the secure unit without displaying behaviors warranting such placement and without physician documentation or consent. The facility did not follow its policy requiring a mental and physical assessment and interdisciplinary team documentation.
Improper Manual Transfer Resulting in Resident Fracture
Penalty
Summary
A deficiency occurred when a resident, who was severely cognitively impaired, legally blind, and had bilateral upper and lower extremity impairments, was transferred from bed to wheelchair without the use of a mechanical lift as required by their care plan and physician orders. The resident was fully dependent on staff for transfers and had an order specifying the use of a Hoyer lift with two-person assistance. Despite these documented requirements, a Certified Nursing Assistant (CNA) manually lifted the resident by placing his arms under the resident's legs and back, transferring the resident to a wheelchair without the mechanical lift or a second staff member present. Following this improper transfer, the resident began to display left hip pain and was subsequently assessed by a nurse practitioner. An X-ray revealed a non-displaced fracture of the left femoral neck, and the resident was admitted to the hospital for surgical repair. The CNA initially denied any concerns with care or transfers but later confessed to the improper transfer during the facility's investigation. The facility's policy clearly required the use of mechanical lifts with two staff members for such transfers, which was not followed in this incident.
Inadequate Infection Control Measures for Resident with Seeping Wounds
Penalty
Summary
The facility failed to maintain a safe and sanitary environment, as evidenced by the condition of Resident #128, who had multiple medical diagnoses including dementia, cellulitis, and impaired skin integrity. The resident was observed with seeping fluids from his legs, which were not consistently bandaged as per physician orders. This resulted in trails and puddles of fluid on the floor in the common areas and hallways, posing a potential risk to other residents. Observations on multiple occasions revealed that Resident #128's legs were leaking fluid, creating wet footprints and puddles in the facility. Staff members, including STNAs, were seen attempting to clean the fluids with inadequate methods, such as using bath blankets, which only spread the fluids further. The resident's guardian confirmed that the resident often removed his bandages, exacerbating the issue. Interviews with the facility's Administrator and Director of Nursing confirmed the ongoing issue with Resident #128's seeping legs and the challenges in keeping them bandaged. Despite attempts to use different types of wraps, the resident continued to unwrap them, leading to unsanitary conditions. The facility's infection prevention policy was not effectively implemented, as evidenced by the failure to maintain a clean environment and promptly address spills of body fluids, as recommended by CDC guidelines.
Facility Fails to Maintain Safe and Clean Environment
Penalty
Summary
The facility failed to provide a safe, clean, and homelike environment for its residents, as evidenced by several observations and interviews. Resident #10 was found with an oxygen nasal cannula lying on the floor, alongside dirty pants and a soiled incontinence brief with gnats flying around it. This was confirmed by an LPN. Resident #128's room was observed to have a bed without sheets, a dirty and shredded mattress with gnats, a gap between the mattress and headboard, and exposed wiring from a metal box on the wall. An LPN verified these conditions and noted the resident's incontinence and cellulitis infection. Resident #149's room had a clogged toilet with waste and toilet paper, and a missing thermostat control panel on the window unit air conditioner, exposing wires. The administrator attempted to fix the toilet but was unsuccessful. Resident #138's room had a footboard that had fallen off the bed and was lying on the floor, as confirmed by an LPN. These deficiencies were part of a continued non-compliance issue from a previous survey.
Failure to Maintain Resident Dignity and Safety
Penalty
Summary
The facility failed to treat residents with dignity and respect, affecting two residents. Resident #70, who was severely cognitively impaired and dependent on staff for activities of daily living, was observed in a common area wearing only a hospital gown that exposed part of his chest. His soiled wheelchair cushion was on the floor, and he had an incontinence brief and clothes hanging from his wheelchair handles, with no shoes or socks on. Staff members, including a registered nurse and a state-tested nurse aide, acknowledged the inappropriate situation but justified it as a convenience for staff to complete showers. Resident #73, who had impaired cognition and a history of eating non-edible items, was observed walking down the hallway with a non-skid sock hanging from his mouth, chewing on it. Several staff members, including a registered nurse, witnessed this behavior but did not intervene. The facility's policy on resident rights emphasizes providing care that meets the psychosocial, physical, and emotional needs of residents, yet the actions observed did not align with these principles.
Failure to Notify Guardian and Physician of Resident's Condition Change
Penalty
Summary
The facility failed to ensure timely notification of a resident's guardian and physician following a change in condition, affecting one resident out of three reviewed. The resident, who was mildly cognitively impaired and required supervision for activities of daily living, had multiple diagnoses including diabetes mellitus, hypertension, and schizoaffective disorder. The resident's guardian was not informed when the resident received a new roommate, nor when the resident was sent to the hospital after reporting a sexual assault and calling 911 due to stomach pain and a belief of pregnancy. The facility's documentation lacked evidence of notifying the guardian about the roommate change and the hospital transfer. The guardian was only informed of these events by external sources, such as the hospital emergency room. Additionally, the facility discontinued one-on-one supervision for the resident without notifying the guardian, contrary to what the staff had communicated. Interviews with staff and the Director of Nursing confirmed the absence of documented notifications, and a review of facility policies highlighted the requirement for such notifications, which were not followed in this case.
Infection Control Breach During Meal Service
Penalty
Summary
The facility failed to adhere to professional standards for food service safety, as observed in the case of a resident with multiple diagnoses including Alzheimer's disease and dysphasia, who required supervision while eating. During a meal service in the main dining room, a State tested Nursing Assistant (STNA) removed her N-95 respirator and used her teeth to open a package of ranch dressing for the resident. The STNA then handed the opened dressing packet to the resident, who applied it to her salad. This action was confirmed in an interview with the STNA immediately following the observation. The facility's policy on infection prevention emphasizes the residents' right to a safe environment that minimizes infection risk, which was not upheld in this instance.
Facility Fails to Maintain Homelike Environment for Residents
Penalty
Summary
The facility failed to provide a homelike environment for its residents, as evidenced by several deficiencies observed during a survey. Seven residents were affected by various issues in their rooms, including a dangling electrical outlet, rusted heaters, peeling paint, scuffed walls, torn window blinds, and missing light bulbs. These conditions were observed during a series of inspections, and residents reported that maintenance issues had been previously communicated but remained unresolved. Interviews with the maintenance staff confirmed awareness of the problems, but there was a lack of action to address them. The maintenance man acknowledged the issues in the residents' rooms and mentioned that he believed his assistant was working on them, indicating a possible lapse in communication or oversight. These deficiencies were investigated under specific complaint numbers, highlighting the facility's non-compliance with providing a safe and homelike environment.
Inadequate Refrigeration for Resident Food Storage
Penalty
Summary
The facility failed to provide adequate refrigeration for residents to store food brought in by family or visitors, affecting six residents. Residents reported that there was no designated refrigerator for their use, and the existing refrigerators were either full or intended for staff use. One resident mentioned being reprimanded for having homemade lemonade stored in the kitchen, which she eventually had to discard. Another resident noted that while there was a refrigerator at the nursing station, it had limited space and residents were not allowed to have personal appliances in their rooms. Observations revealed that the refrigerator on the 100 hall contained meals, soda, and condiments, none of which were labeled or dated. The Dietary Manager confirmed that the facility did not store food from outside sources due to uncertainty about its contents. The facility's policy stated that residents could bring in food as long as safe storage guidelines were followed, but it did not ensure the availability of storage space. This deficiency was investigated under Complaint Number OH00157418.
Resident Rights Violation: Restriction of Mobility and Unsupervised Leave
Penalty
Summary
The facility failed to honor a resident's right to a dignified existence and self-determination by restricting the use of his electric wheelchair and limiting his ability to leave the building unattended. Resident #173, who was cognitively intact and his own person, had his motorized wheelchair removed after an incident where he allegedly ran over another resident's foot. Despite the resident's understanding of safety education and expressing a desire to have his wheelchair returned, the facility denied his request without documented reassessment or clear justification. The report details multiple incidents involving Resident #173, including an altercation in the dining room where he allegedly pinned another resident against the wall with his wheelchair. Witness statements and progress notes indicate that the resident's behavior was perceived as aggressive, leading to the removal of his motorized wheelchair. However, there was a lack of consistent documentation of ongoing behaviors that justified the continued restriction of his mobility rights. Additionally, the facility imposed supervised leave of absence restrictions on Resident #173 after he was found outside the building without signing out. Although the resident was cognitively intact and had a physician's order allowing unsupervised leave, the facility required supervision based on past incidents involving the motorized wheelchair. This decision was made without clear documentation or reassessment, further infringing on the resident's rights.
Failure to Treat Residents with Dignity and Respect
Penalty
Summary
The facility failed to ensure residents were treated with dignity and respect, affecting three residents. Resident #153, who was cognitively intact, requested a bottle of shampoo from an LPN but was told to return to her room as there was no staff available to assist her. The resident expressed dissatisfaction with being frequently told to return to her room. The LPN admitted to telling the resident to go back to her room but could not explain why. Resident #143, who was moderately cognitively impaired, requested ice water but was informed by an LPN that ice water would only be provided at scheduled times. The resident was unable to access ice water independently due to a locked room and expressed dissatisfaction with the policy. The LPN stated that asking for ice water was considered a behavior of the resident, although this was not documented in the care plan. Resident #39, who had dementia and was rarely understood, was observed being led by the wrist by an STNA. The STNA admitted that this method of ambulation could be a dignity and respect issue.
Failure to Respect Resident's Choice in Wake-Up Time
Penalty
Summary
The facility failed to respect and facilitate the self-determination and choice of a resident, identified as Resident #27, who was cognitively intact and required assistance for daily activities. Despite her preference to not wake up early, the staff consistently got her up around 6:00 A.M. because she was on a list of residents who needed to be up before the first shift. This was confirmed through observations and interviews with both the resident and a State tested Nurse Aide (STNA) who stated that the resident disliked getting up early but was required to do so per the supervisor's instructions. The resident was observed asleep at the dining room table with her head on a pillow, indicating her discomfort with the early wake-up routine. This deficiency was identified during a complaint investigation.
Improper Incontinence Care for a Resident
Penalty
Summary
The facility failed to ensure proper incontinence care for a resident, identified as Resident #137, who was severely cognitively impaired and dependent on staff for activities of daily living, including toileting. The resident was always incontinent for bowel and bladder. During an observation, a State tested Nurse Aide (STNA) #309 was seen performing incontinence care on the resident. However, the STNA did not cleanse the resident's penis, scrotum, or buttocks, and the incontinent brief was left wet. This was contrary to the facility's policy for male perineal care, which requires thorough cleansing and drying of the perineal and rectal areas. The STNA admitted during an interview that she was unaware of the facility's policy for incontinence care and only performed a general cleansing because hospice was scheduled to shower the resident. However, a review of the medical record revealed that hospice was not scheduled to visit until the following day. This incident was identified as an incidental deficiency during a complaint investigation, affecting one of the three residents reviewed for incontinence care in a facility with a census of 170.
Failure to Provide Pain Management During Dressing Change
Penalty
Summary
The facility failed to provide appropriate pain management for a resident during a dressing change, which was identified as a deficiency. The resident, who was moderately cognitively impaired and dependent on assistance for mobility, expressed pain multiple times during the procedure. Despite the resident's repeated complaints of pain, the LPN did not assess the pain's location or intensity and did not medicate the resident before proceeding with the dressing change. The Director of Nursing was present and indicated that the resident would be medicated after the procedure, but this did not occur. The resident, who had medical diagnoses including Parkinson's disease and renal disease, rated his pain as a ten on a one to ten scale, indicating severe discomfort. The facility's policy on pain management emphasizes the importance of assessing and addressing pain based on the resident's report and clinical observations. However, this policy was not followed during the incident, as the LPN admitted to not assessing or medicating the resident due to nervousness. This oversight was discovered during a complaint investigation.
Failure to Use Hoyer Lift Results in Resident Injury
Penalty
Summary
The facility failed to provide appropriate supervision and assistance with resident transfers, resulting in actual harm to a resident. Resident #66, who had a diagnosis of hemiplegia and hemiparesis following a cerebral infarction, was ordered to be transferred using a Hoyer lift with the assistance of two staff members. However, on 06/03/24, two State Tested Nursing Assistants (STNAs) manually transferred the resident from a shower chair to her bed without using the Hoyer lift, as the lift was not working. During this manual transfer, the resident sustained a fracture to her left humerus. The incident was confirmed through interviews with the resident, the STNAs involved, and the Director of Nursing (DON). The resident reported hearing a pop in her left arm during the transfer, and subsequent medical evaluation confirmed a fracture. The facility's policy on mechanical lifts and transfers emphasized the importance of safety and required the use of two employees to perform lifts safely. Despite this policy, the manual transfer was conducted, leading to the resident's injury. The facility's failure to adhere to the prescribed transfer method and ensure the functionality of the Hoyer lift directly contributed to the incident.
Medication Administration Errors in LTC Facility
Penalty
Summary
The facility failed to ensure that residents were free from significant medication errors, specifically affecting one resident. The resident, who was admitted with chronic obstructive pulmonary disease and a pressure ulcer, had discrepancies in their medication orders upon admission. The preadmission paperwork indicated that the resident was to receive aspirin, lisinopril with specific parameters, and methocarbamol routinely. However, the admitting physician's orders omitted the aspirin, did not include the parameters for lisinopril, and incorrectly transcribed methocarbamol as an as-needed medication instead of a routine one. The Medication Administration Record showed that the resident did not receive aspirin for nearly two weeks, and lisinopril was administered without the necessary blood pressure and pulse checks until the parameters were added later. Methocarbamol was given as needed rather than routinely. Interviews with two LPNs confirmed these transcription errors and the lack of physician notification regarding the discrepancies. The facility's policy on medication administration was not followed, as medications were not administered as prescribed by the provider.
Failure to Document Narcotic Administration
Penalty
Summary
The facility failed to ensure accurate documentation of the administration of a resident's narcotic medications. Specifically, the medical record for Resident #802, who has diagnoses of paraplegia and thoracic spine pain, revealed discrepancies between the narcotic sign-out sheets and the Medication Administration Record (MAR). The narcotic sign-out sheets indicated that Oxycodone HCl Oral Capsules were administered on multiple occasions, but these administrations were not consistently documented in the MAR. This discrepancy affected the accurate tracking of 39 doses of Oxycodone for Resident #802 over a period from March to April 2024. Interviews with the Director of Nursing (DON) and nursing staff confirmed the documentation issues. The DON acknowledged being unaware of any narcotic issues and admitted that nurses were frequently reminded about the importance of documenting narcotic administration. Licensed Practical Nurse (LPN) #31 and Registered Nurses (RN) #80 and #110 described the process for administering and documenting narcotics, which includes checking the Electronic Medical Record (EMR), signing out the narcotic, administering it, and then documenting the administration and its effectiveness in the EMR. However, LPN #31 admitted to not documenting all administered doses in the EMR, although he denied any misappropriation of the medication. The facility's Medication Administration policy emphasizes the importance of accurate documentation and adherence to the Five Rights of medication administration. Despite this policy, the failure to document the administration of Oxycodone in the EMR for Resident #802 represents a significant lapse in compliance with the facility's procedures and regulatory requirements. This deficiency was identified during an investigation under Complaint Number OH00153299.
Failure to Ensure Resident Met Criteria for Secure Unit Admission
Penalty
Summary
The facility failed to ensure that a resident met the criteria for admission to the secure unit and was in the least restrictive environment available. The resident, who was cognitively intact with a BIMS score of 13 out of 15, was admitted to the secure unit despite not displaying any behaviors such as hallucinations, delusions, wandering, or exit-seeking that would warrant such placement. The resident was documented as being pleasant, cooperative, and compliant with care and medications, and there was no physician documentation indicating a benefit from residing in the secure unit. Additionally, the resident did not sign a consent to be in the secure unit, and a psychiatric consult conducted later confirmed the resident was alert, oriented, and without any acute psychosis or disturbance of perception. The facility's policy for the secure unit requires a mental and physical assessment documenting that the resident would benefit from such an environment, along with interdisciplinary team documentation that the secure unit is the least restrictive approach. However, the facility did not follow this policy, as there was no initial psychiatric consult or physician documentation supporting the resident's placement in the secure unit. The facility's failure to adhere to its policy and ensure the resident was in the least restrictive environment led to the deficiency identified in the report.
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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