Samaritan Care Center And Villa
Inspection history, citations, penalties and survey trends for this long-term care facility in Medina, Ohio.
- Location
- 806 E Washington Street, Medina, Ohio 44256
- CMS Provider Number
- 365817
- Inspections on file
- 19
- Latest survey
- February 12, 2026
- Citations (last 12 mo.)
- 20
Citation history
Health deficiencies cited at Samaritan Care Center And Villa during CMS and state inspections, most recent first.
Surveyors found that kitchen staff failed to label and date multiple refrigerated food items, including cooked vegetables, soups, beverages, cheeses, meats, salads, desserts, and baked goods. During an observation with the Dietary Manager, numerous containers and packages in the refrigerator were discovered without any date markings, and the Dietary Manager acknowledged that staff from the previous shift had not labeled or dated the food. Review of the facility’s food safety policy showed that all opened or prepared foods must be clearly date-marked by the person opening or preparing them, and that the Dietary Manager or designee must perform weekly spot checks for compliance. This noncompliance affected food items that could be served to all residents.
The facility did not maintain appropriate hot water temperatures in several resident rooms, as evidenced by resident reports of cold sink water and temperature checks showing water at 101–104°F after running for several minutes. One resident stated her room water had not been hot since admission and that she had previously informed staff. Review of tap water temperature logs over multiple months showed repeated low readings in multiple rooms on the same hall, indicating an ongoing failure to ensure safe, comfortable water temperatures for residents.
The facility failed to provide safe assistance during care and transfers for two high fall-risk residents, leading to falls. One resident with severe cognitive impairment, COPD, dementia, abnormal gait, and muscle weakness, who was dependent for mobility and transfers, was left unattended on her side in an elevated bed while a CNA left the room to obtain supplies after moving the bedside floor mat away; the resident turned and fell from the bed, sustaining a forehead laceration requiring sutures. Another resident with hemiplegia, dysphagia, muscle weakness, CHF, obesity, and moderate cognitive impairment, who was dependent for chair-to-bed transfers, was transferred using a sit-to-stand lift by a single CNA instead of the required assistance, causing the resident to slide out of the device, though without injury. In both cases, facility documentation identified improper supervision and failure to follow safe transfer techniques as the root causes of the falls.
Surveyors found that the facility failed to honor documented food preferences and allergy restrictions for two residents. One resident, with multiple behavioral and medical diagnoses, was served rice despite a recorded dislike and reported frequently receiving tomato-based items that upset her stomach. Another resident, with COPD and an allergy to raw onions, was served sautéed peppers and onions even after dietary staff verbally reminded each other to avoid onions, and the resident reported repeatedly receiving onions, mayonnaise, and sour cream despite stating he did not want them.
Surveyors found that food stored in both a shared nutrition refrigerator and in personal room refrigerators was not consistently labeled, dated, or disposed of when expired. Expired and unlabeled items, including nutritional shakes, yogurts, salads, and other food products, were observed in both common and personal refrigerators. These deficiencies were confirmed by the ADON during inspection and were not in accordance with facility policy.
A resident with severe cognitive impairment and multiple medical conditions developed new skin abrasions, but the facility failed to notify the resident's responsible party of this change in condition. Despite ongoing guardianship proceedings and facility policy requiring notification, the next of kin was not informed, and communication with the family was reported as inadequate.
Two residents did not have complete care plans addressing all their assessed needs. One resident with PTSD did not have a care plan for this diagnosis despite exhibiting related behaviors, and another resident with significant physical and cognitive needs did not have an activities care plan, even though their preferences and interests were documented. Staff confirmed these omissions during interviews.
A resident with a chronic wound requiring enhanced barrier precautions did not receive proper infection prevention measures during high-contact care activities. Staff provided bed bath, dressing, and transfer assistance without consistently using gowns as required by facility policy and physician orders, resulting in a failure to maintain appropriate infection control protocols.
A resident with multiple chronic conditions received Macrobid for UTI prophylaxis on a non-standard schedule due to a misinterpreted physician order. Despite discrepancies noted by pharmacy staff and the facility's policy requiring medication review, the antibiotic was administered inappropriately over several months without clarification.
Multiple residents experienced ongoing gnat infestations in their rooms, bathrooms, and common areas, with staff and dietary personnel also reporting insect activity in food service equipment. Despite attempts by housekeeping and maintenance to address the issue with chemicals and traps, the infestation persisted, and pest control service reports did not document fly activity during inspections.
Failure to Label and Date Refrigerated Food Items
Penalty
Summary
Surveyors identified a deficiency in food labeling and dating practices in the facility’s kitchen refrigerator, which had the potential to affect all 38 residents. During an observation and interview with the Dietary Manager, multiple food items were found in the refrigerator without any labels or dates, including two containers of mushrooms, a plastic container of cooked vegetable mix, peaches, potato soup, a pitcher of tea, a pitcher of lemonade, a plastic package of cheese slices, a plastic container of cooked steak for Philly cheese steak, a plastic container of chicken salad, a plastic container of Jell-O, a container of muffins, a bag of shredded cheese, and a plastic container of chili. The Dietary Manager confirmed these items were not labeled or dated and stated she had not worked the previous night and that the night staff had failed to label or date the food. Review of the facility’s 2025 “Date Marking for Food Safety” policy showed that all opened or prepared foods must be clearly marked with the date of opening and the date by which they must be consumed or discarded, and that the individual opening or preparing the food is responsible for date marking at that time, with the Dietary Manager or designee required to spot check the refrigerator weekly for compliance and document accordingly. This failure to follow the facility’s date-marking policy for multiple refrigerated food items constituted the basis of the cited deficiency.
Failure to Maintain Appropriate Resident Tap Water Temperatures
Penalty
Summary
The facility failed to maintain resident tap water at appropriate temperatures, resulting in persistently cool water in certain resident rooms. One resident reported during interview that the water in his bathroom sink was cold, and another resident stated that the water in her room had not been hot since her admission in September 2025 and that she had previously informed staff about the issue. During an interview and observation with the Maintenance Director on February 11, 2026, water temperatures measured after running for three minutes were 101°F in an occupied room and 102°F in an unoccupied room on the same hall. Review of the facility’s Tap Water Temperature Checks from July 2025 through January 2026 showed that in August 2025 the water temperature in one room was 101°F, and in January 2026 water temperatures in three rooms on the same hall were recorded at 101°F, 103°F, and 104°F. These findings demonstrate that the facility did not ensure water temperatures were maintained at appropriate levels for residents on the 100 Hall. This deficiency represents non-compliance investigated under Complaint Number 2722647 and affected one identified resident, with the potential to affect all six residents on the 100 Hall.
Failure to Provide Safe Assistance During Transfers and Bed Care Resulting in Falls
Penalty
Summary
The deficiency involves the facility’s failure to ensure residents at high risk for falls were provided safe assistance during care, resulting in falls. One resident with COPD, emphysema, dementia, abnormal gait and posture, muscle weakness, and severe cognitive impairment was assessed as dependent for bed mobility, transfers, and mobility, and identified as high risk for falls. Her care plan included use of a bedside floor mat and placement in supervised areas during restlessness. Despite these needs and interventions, the resident experienced multiple falls, including a witnessed fall in which she was left unattended on her side in bed with the bed elevated while a CNA left the room to obtain a clean brief, after having moved the bedside floor mat away to dry. During this incident, the CNA changed the resident’s brief, placed it on the bedside floor mat, then cleaned and moved the mat aside to dry. The CNA then left the bedside to get a clean brief while the resident remained on her side in bed with the bed elevated and without the floor mat in place. The resident turned and fell out of bed, sustaining a 4 cm laceration to the right forehead that required sutures. Facility documentation of the fall investigation identified that the resident had been left unattended inappropriately and that the root cause of the fall was the CNA leaving the resident on her right side with the bed elevated. A second resident, with diagnoses including cerebral infarction with hemiplegia, dysphagia, muscle weakness, CHF, osteoarthritis, obesity, hypotension, hypertension, and moderate cognitive impairment, was also assessed as dependent for chair-to-bed transfers and at high risk for falls. Her care plan included anticipating and meeting needs, ensuring the call light was within reach, encouraging non-slip footwear, and keeping commonly used items within reach. Despite this, a CNA used a sit-to-stand lift alone to transfer the resident, contrary to the required assistance and technique, resulting in the resident sliding out of the sit-to-stand device. The fall investigation identified that the sit-to-stand lift had been operated by only one person, and this was documented as the root cause of the fall, although the resident did not sustain injuries.
Failure to Honor Resident Food Preferences and Allergy Restrictions
Penalty
Summary
The deficiency involves the facility’s failure to provide food that met documented resident preferences and allergies for two residents out of three reviewed for food preferences, in a census of 38. For one resident admitted with multiple diagnoses including post-traumatic stress disorder, alcohol use, major depressive disorder, generalized anxiety disorder, history of traumatic brain injury, convulsions, anemia, essential hypertension, vitamin D deficiency, and insomnia, the food preference and allergy sheet documented numerous dislikes, including any type of tomato products and rice. During observation of the lunch tray line, this resident was plated rice despite the tray card indicating rice as a disliked item, which was confirmed by the Dietary Manager and another staff member. In interview, the resident reported that tomatoes upset her stomach and that she often receives tomato-based soups or spaghetti sauce, which she does not eat when they are served. For a second resident admitted with diagnoses including chronic obstructive pulmonary disease, emphysema, acute chronic respiratory failure, anxiety disorder, essential hypertension, and major depressive disorder, the food preference and allergy sheet documented an allergy to raw onions and dislikes of tomatoes or tomato products and yogurt. During observation of the lunch tray line, the Dietary Manager reminded a staff member not to give this resident sautéed peppers and onions, and the resident’s tray card showed an allergy to raw onions. Despite this, the plated meal for the resident included sautéed peppers and onions, which was confirmed by the Dietary Manager and the staff member. In interview, the resident stated he keeps receiving onions despite telling staff multiple times he did not want them and also reported repeatedly receiving mayonnaise and sour cream, which he does not like. This deficiency was investigated under Complaint Number 2722647.
Failure to Properly Label, Date, and Dispose of Expired Food in Resident Refrigerators
Penalty
Summary
The facility failed to ensure that food stored in both a designated nutrition refrigerator for resident use and in personal refrigerators in residents' rooms was properly labeled, dated, and that expired items were disposed of in a timely manner. During an observation with the Assistant Director of Nursing, multiple expired, unlabeled, and undated food items were found in the shared nutrition refrigerator, including a nutritional shake past its use-by date, an unlabeled and stale breadstick with red sauce, an unidentified liquid with separated particles, a visibly wilted and moldy side salad, several yogurts past their use-by dates, and a partially eaten baked potato with mold. These findings were confirmed by the ADON at the time of observation. Further inspection of five residents' personal refrigerators revealed additional concerns, such as expired cream cheese spread, protein shake, yogurts, rice pudding, and an opened, undated jar of pickles past its use-by date. The facility's policy requires all food brought in by family or visitors to be labeled with content and date, and for prepared food to be consumed within three days or discarded. The failure to follow these procedures was confirmed during the observations, affecting three of five residents reviewed for personal refrigerators and potentially impacting all residents using facility refrigeration for personal food items.
Failure to Notify Responsible Party of Change in Resident Condition
Penalty
Summary
The facility failed to notify the responsible party of a resident's change in condition. Specifically, a resident with multiple complex medical diagnoses, including diabetes with a foot ulcer, cognitive impairment, and a history of traumatic brain injury, was found to have new skin abrasions. Although the facility's records indicated that management and the physician were updated, the documentation stated the resident was his own responsible party, despite a severely impaired cognition score (BIMS of 2) and ongoing guardianship proceedings. Interviews revealed that the resident's spouse was not always informed of changes in the resident's care, and communication from the facility was described as inadequate. Facility policy required notification of a representative in cases where the resident was not competent or was in the process of obtaining guardianship. However, in this instance, the next of kin was not notified of the change in condition, contrary to policy and regulatory requirements.
Failure to Develop Comprehensive Care Plans for Residents
Penalty
Summary
The facility failed to develop and implement comprehensive care plans that addressed all identified needs for two residents. For one resident with diagnoses including bipolar disorder, acute respiratory failure, PTSD, anxiety, and type II diabetes, the care plan addressed mood and behavior issues but did not include interventions for the resident's PTSD, despite this diagnosis being present in the medical record. Observations and staff interviews confirmed the resident exhibited behaviors such as yelling, crying, and distress related to past events, and that redirection and spending time with the resident were effective, yet no care plan for PTSD was in place. For another resident with acute respiratory failure, hemiplegia, hemiparesis, and general anxiety disorder, the care plan did not address activities, even though assessments indicated the resident's preferences for reading, music, and being around pets, as well as a tendency to prefer self-directed leisure activities. The Activities Director confirmed that an activities care plan was never developed for this resident following admission. These omissions were identified through medical record review and staff interviews, and were not in accordance with the facility's policy requiring comprehensive, person-centered care plans for all residents.
Failure to Follow Enhanced Barrier Precautions During High-Contact Care
Penalty
Summary
The facility failed to maintain infection prevention protocols for a resident who required enhanced barrier precautions due to a chronic wound. The resident, who had multiple diagnoses including diabetes with a foot ulcer, malnutrition, cognitive impairment, and an above-knee amputation, had a physician order requiring the use of gown and gloves during high-contact care activities. Observations revealed that a CNA provided bed bath and dressing care, and assisted with transferring the resident using a hoyer lift, while only wearing gloves and a mask, but not a gown as required. The CNA stated she believed gowns were only necessary if wounds were seeping, which was not the case for this resident at the time. An LPN wore a gown and gloves for wound care but removed the gown in the room after the resident refused care. Interviews with staff confirmed that gowns were not consistently used during all high-contact care activities, contrary to facility policy, which requires gowns and gloves for such activities for residents with wounds, regardless of wound drainage. The Director of Nursing acknowledged the requirement for gowns and gloves during high-contact care and indicated a need for staff re-education. Review of facility policy confirmed the expectation for PPE use during specified care activities for residents on enhanced barrier precautions.
Failure to Ensure Appropriate Antibiotic Prescribing and Administration
Penalty
Summary
The facility failed to ensure that antibiotics were appropriately prescribed and administered with the correct indication, dose, and duration for a resident. The resident, who had multiple diagnoses including chronic obstructive pulmonary disease, anxiety, type II diabetes, atrial fibrillation, and peripheral vascular disease, was admitted with a hospital discharge order for Macrobid 100 mg. The facility's physician order specified Macrobid 100 mg to be given twice daily every ten days for urinary tract infection prophylaxis. Review of the Medication Administration Record showed that this regimen was followed from November 2024 through June 2025. Interviews with clinical staff revealed discrepancies and confusion regarding the intended dosing schedule. The Certified Nurse Practitioner stated he would not have written such an order, and pharmacists noted the order did not match standard therapeutic regimens or FDA-approved dosages for UTI prophylaxis. The pharmacists also indicated that the order should have been clarified, but no such recommendation was made during monthly pharmacy reviews. The facility's policy required staff to compare the MAR to the medication and consult drug references if unfamiliar, but this was not followed, resulting in the continued administration of an inappropriate antibiotic regimen.
Failure to Maintain Effective Pest Control Program
Penalty
Summary
The facility failed to maintain an effective pest control program, resulting in a persistent gnat infestation affecting multiple residents and areas within the building. Observations revealed that several residents had tiny flying insects swarming around their faces, meals, and bathrooms, with one resident reporting the issue had persisted for weeks. Staff interviews confirmed awareness of the problem, with housekeepers and maintenance staff attempting to address the infestation using chemicals, traps, and homemade remedies. Despite these efforts, the presence of gnats continued in resident rooms, bathrooms, the shower area, and even in the dietary meal cart, as noted by both staff and residents. Documentation review showed that pest control service reports did not identify fly activity during their inspection, and maintenance requests had been made regarding fly infestations. Staff interviews indicated uncertainty about the pest control company's involvement in addressing the issue, and the problem was reported to have been ongoing since at least April. The deficiency affected at least seven residents directly and had the potential to impact all residents in the facility.
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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