Sanctuary At Wilmington Place
Inspection history, citations, penalties and survey trends for this long-term care facility in Dayton, Ohio.
- Location
- 264 Wilmington Avenue, Dayton, Ohio 45420
- CMS Provider Number
- 365789
- Inspections on file
- 30
- Latest survey
- January 27, 2026
- Citations (last 12 mo.)
- 1
Citation history
Health deficiencies cited at Sanctuary At Wilmington Place during CMS and state inspections, most recent first.
A resident with COPD, dementia, and other comorbidities, who required supervision and assistance with a pureed diet and thin liquids, was left sitting in a chair with a covered breakfast tray in front of him for a period of time without feeding assistance. Staff practice was to place trays in rooms for residents needing help and then continue delivering other trays before returning to assist, resulting in a delay in feeding this dependent resident. Dietary leadership and the dietician confirmed that trays for residents needing assistance should not be delivered until staff are ready to provide direct supervision and help with eating.
A resident with dementia was later diagnosed with schizoaffective disorder bipolar type, but the facility did not complete an updated PASARR as required after the new diagnosis. The only PASARR on file was from admission, despite facility policy mandating prompt referral for Level II review when a new serious mental disorder is identified.
A resident with chronic respiratory failure and COPD did not have their oxygen tubing changed weekly as ordered by the physician. Observation and staff interview confirmed the tubing was not replaced according to the schedule, despite facility policy requiring weekly changes and infection control measures.
A nurse prepared medications for a resident with COPD, stroke, and dementia, but another LPN administered the medications, contrary to facility policy requiring the same nurse to both prepare and administer medications. Both staff confirmed this practice, which was observed during a medication pass and had the potential to affect all residents on the hall.
A resident with dementia, COPD, and stroke did not have physician-approved pharmacy recommendations implemented, including changes to pain and anticoagulant medications. Staff interviews and medical record review confirmed the orders were not carried out, and hospice was not notified to coordinate care.
A resident with COPD, stroke, and dementia did not receive multiple doses of Rivaroxaban as ordered because the medication was out of stock or unavailable, despite notifications to the pharmacy and reorders. The facility's policy requiring administration of medications as ordered was not followed.
A medication cart was found to contain an open, undated bottle of Rhopressa 0.02% Ophthalmic Solution for a resident with glaucoma and other chronic conditions. An LPN confirmed the medication should have been dated upon opening, in accordance with facility policy and manufacturer guidelines.
The facility did not implement or document required water management protocols to reduce Legionella risk, including missing system diagrams and unperformed chlorine testing. During a pressure ulcer dressing change for a resident with multiple health conditions, two LPNs failed to follow Enhanced Barrier Precautions, did not use gowns, and used improper wound cleaning technique. These failures in infection prevention and control had the potential to affect all residents.
A resident with multiple diagnoses and severely impaired cognition experienced two significant changes in condition—one involving low oxygen saturation and another involving unresponsiveness after medication. In both instances, although the physician was notified and care was provided, there was no documentation that the resident's POA was informed, contrary to facility policy.
A resident with multiple complex medical conditions was admitted and identified as being at risk for falls, but the facility did not timely develop or implement fall interventions. The resident experienced a fall resulting in a skin tear before any specific fall prevention measures were added to the care plan, despite facility policy requiring such interventions at admission.
A resident with multiple health conditions did not receive their prescribed guaifenesin medication on time, resulting in missed doses. The medication was ordered to be administered twice daily, but the first dose was delayed, as confirmed by the ADON. This incident highlights a failure to adhere to the facility's medication administration policy.
A resident with multiple health conditions did not receive medications as ordered, resulting in significant medication errors. The facility failed to administer furosemide and Medrol according to physician orders, despite having the medications in stock. The resident reported missing doses, and the ADON confirmed the errors, which were also evident in the MAR and a photograph of the Medrol pack.
The facility failed to provide appropriately sized briefs for two residents, leading to improper fit and discomfort. One resident, with conditions including cerebrovascular attack and morbid obesity, was given a two XL brief instead of the required three XL, leaving skin exposed. Another resident, with peripheral vascular disease and renal insufficiency, experienced skin irritation due to the lack of three XL briefs. Staff confirmed the absence of the correct size in supply rooms, violating the facility's policy on accommodating resident needs.
A resident with a surgical incision experienced bleeding on multiple occasions, as noted in PT and OT records, but the physician was not notified, contrary to the facility's policy. The Wound NP confirmed she was unaware of the bleeding, highlighting a failure in communication and adherence to the Notification of Changes policy.
A resident, dependent on staff for toileting and incontinent of bowel and bladder, did not receive appropriate incontinence care. During an observation, CNAs used a single towel for cleaning without turning it over for different areas and failed to clean urine from the resident's legs. Interviews confirmed the inadequate care, with one CNA citing a lack of supplies. The facility's perineal care policy, which requires using separate sections of a washcloth or new wipes for each stroke, was not followed.
A resident, who was cognitively intact and had significant medical conditions, requested the COVID-19 vaccine and completed a consent form. Despite this, the facility failed to administer the vaccine as requested, as confirmed by both the resident and the ADON. The facility's policy to educate and offer vaccines was not adhered to in this instance.
The facility failed to assist a resident with arranging transportation to physician appointments, resulting in missed orthopedic and cardiologist appointments due to transportation-related issues and a change in payor source that was not identified in time. This deficiency was confirmed by interviews with the resident and the DON.
Failure to Provide Timely Feeding Assistance to Dependent Resident
Penalty
Summary
The deficiency involves the facility’s failure to provide timely assistance with eating to a dependent resident who required supervision and assistance during meals. The resident had diagnoses including COPD, unspecified dementia, anxiety disorder, hypertension, overactive bladder, and spinal stenosis. The most recent MDS showed moderately impaired cognition and a need for supervision at meals, and the care plan documented that the resident required assistance with meals as needed. Physician orders specified a pureed diet with thin/regular liquids, upright positioning during meals, and total supervision during meals because the resident needed assistance with feeding. A quarterly nutrition assessment further documented that the resident required supervision at meals and was fully dependent at times. On the morning of the survey observation, the resident was observed sitting in a chair with eyes closed and a breakfast tray in front of him with the lid still on at 8:35 A.M., and again at 8:42 A.M. with the tray still unopened. At 8:51 A.M., a CNA entered the room to feed the resident and reported that another CNA had delivered the tray earlier. At 8:54 A.M., the second CNA confirmed she had placed the tray in the room around 8:35 A.M. and explained that staff typically place trays in rooms for residents needing assistance, then continue delivering other trays before returning to assist with eating. The Dietary Supervisor and Corporate Compliance staff confirmed that CNAs or other staff should not deliver trays to residents who need assistance with eating until they are ready to assist, and the Dietician confirmed the resident needed assistance and supervision at all times when eating. This sequence of actions resulted in a delay in feeding assistance for the dependent resident.
Failure to Update PASARR After New Mental Health Diagnosis
Penalty
Summary
The facility failed to ensure an updated Pre-admission Screening and Resident Review (PASARR) was completed for a resident with a newly identified serious mental illness. Medical record review showed that the resident was admitted with diagnoses including dementia and later received a diagnosis of schizoaffective disorder bipolar type. The initial PASARR, completed at admission, indicated no serious mental illness, but after the new diagnosis was added, there was no documentation of an updated PASARR. Staff interview confirmed that only the original PASARR was on file, and facility policy requires prompt referral for a Level II review when a new serious mental disorder is identified.
Failure to Change Oxygen Tubing as Ordered
Penalty
Summary
The facility failed to ensure that oxygen tubing was changed as ordered for a resident requiring continuous oxygen therapy. Medical record review showed that the resident, admitted with chronic respiratory failure with hypoxia, COPD, and a history of pulmonary embolism, had a physician's order for continuous oxygen at bedtime and for the oxygen tubing to be changed weekly on Sundays. During an observation, the oxygen tubing in the resident's room was found to be dated more than two weeks prior, indicating it had not been changed according to the order. Staff confirmed the date on the tubing, and facility policy required weekly changes of oxygen tubing and mask/cannula, as well as adherence to infection control measures.
Medications Not Administered by Preparing Nurse
Penalty
Summary
A deficiency occurred when a nurse prepared medications for a resident but did not administer them herself, instead handing them to another nurse to administer. Specifically, one LPN pulled and prepared medications from the medication cart for a resident with chronic obstructive pulmonary disease, cerebral infarction, and dementia, who was dependent on staff for medication administration. The prepared medications were then given to a second LPN, who administered them to the resident. Both nurses confirmed this sequence of events during interviews. Facility policy requires that medications be administered by licensed nurses in accordance with standards of practice, and that the nurse who prepares the medications should be the one to administer them. This practice was not followed, as observed during the medication pass. The incident was identified during a review of medication administration for one resident, but it had the potential to affect all residents on the same hall.
Failure to Implement Physician-Approved Pharmacy Recommendations
Penalty
Summary
The facility failed to implement pharmacy recommendations that were approved by the facility physician for a resident with diagnoses including dementia, COPD, and cerebral infarction. The contracted pharmacy conducted a new admission review and recommended changes to the resident's medication regimen, including adjusting the Lidocaine patch order, discontinuing Oxybutynin, and switching from Xarelto to Eliquis. The physician reviewed and approved these recommendations, ordering the changes as suggested by the pharmacy. Despite the physician's approval, the facility did not implement the medication changes for the resident. Medical record review confirmed that the approved pharmacy recommendations were not carried out, and interviews with staff, including the MDS nurse and DON, verified there was no documentation of the orders being implemented. Additionally, the hospice RN reported that hospice was not contacted regarding the approved medication changes, and if they had been informed, they would have coordinated with the hospice physician and approval department.
Failure to Administer Physician-Ordered Medication Due to Unavailability
Penalty
Summary
The facility failed to administer medications as ordered by the physician for one resident with diagnoses including COPD, stroke, and dementia, who had moderate cognitive impairment. Medical record review showed that the resident did not receive prescribed doses of Rivaroxaban 20 mg on four separate occasions in May 2025 due to the medication being out of stock or unavailable. Documentation indicated that the pharmacy was notified and reorders were sent, but there was no evidence the resident received the missed doses. The facility's policy requires medications to be administered as ordered and in accordance with standards of practice, but this was not followed in these instances.
Failure to Date Opened Ophthalmic Medication
Penalty
Summary
A deficiency was identified when a medication cart on the 400-hall was observed to contain an open container of Rhopressa 0.02% Ophthalmic Solution prescribed for a resident with diagnoses including open angle glaucoma, hypertension, Parkinson's Disease, and chronic kidney disease. The medication bottle, which was ordered to be administered as one drop in both eyes daily, was found to be opened but not dated. During the observation, an LPN confirmed that the bottle was indeed opened and undated, and acknowledged that it should have been dated at the time of opening. Review of the facility's medication storage policy indicated that all medications are to be stored according to manufacturer recommendations, which for Rhopressa includes a specific timeframe for use after opening.
Failure to Implement Water Management and Infection Control Protocols
Penalty
Summary
The facility failed to implement and document an effective Water Management Program (WMP) to reduce the risk of Legionella in the water system. Review of the facility's Legionella Environmental Assessment Form revealed it lacked a description or diagram of the water system, and there was no documentation of required monthly chlorine testing or visual inspections for biofilm. The Maintenance Supervisor confirmed that these assessments and tests had not been completed, despite the facility's policy stating that such control measures and documentation were required. Additionally, the facility did not ensure proper infection prevention and control practices during a pressure ulcer dressing change for a resident with multiple comorbidities, including diabetes, hypertension, heart failure, and anemia. The resident had a pressure ulcer on the sacrum and buttocks, and physician orders required twice-daily wound care. During an observed dressing change, there was no Enhanced Barrier Precautions (EBP) signage or PPE cart outside the room, and the LPNs involved did not wear gowns as required by EBP guidelines for residents with wounds. The wound was also cleansed from the outside toward the center, contrary to recommended technique. Staff interviews confirmed that the required EBP protocols were not followed, including the use of gowns and the correct wound cleaning technique. The failure to follow these infection control measures and to maintain a comprehensive WMP had the potential to affect all residents in the facility, as confirmed by the census of 59 residents.
Failure to Notify POA of Resident Health Changes
Penalty
Summary
The facility failed to notify a resident's responsible party or power of attorney (POA) of significant health changes, as required by facility policy. Medical record review for a resident with diagnoses including Parkinson's disease, anxiety, hypertension, and glaucoma, and with severely impaired cognition, showed two separate incidents where the resident experienced notable changes in condition: one involving low oxygen saturation and wheezing, and another where the resident was lethargic and unresponsive after medication administration. In both cases, while the physician was notified and interventions were initiated, there was no documented evidence that the resident's POA was informed of these changes. Staff interviews confirmed that no notification was made to the POA during these events, despite facility policy mandating such communication.
Failure to Timely Implement Fall Interventions for At-Risk Resident
Penalty
Summary
A deficiency was identified when the facility failed to timely develop and implement fall interventions for a resident who was at risk for falls. The resident, who had multiple diagnoses including encephalopathy, altered mental status, diabetes, depression, acute respiratory failure, chronic kidney disease, anemia, peripheral vascular disease, visual hallucinations, congestive heart failure, chronic atrial fibrillation, and obstructive sleep apnea, was admitted and assessed as being at risk for falls. The admission assessment indicated the need to follow the facility's fall protocol and to anticipate the resident's needs. However, no specific fall interventions were care planned until several days after admission. An incident occurred in which the resident was found on the floor with a skin tear, requiring treatment and assistance back to bed. Review of the care plan showed that fall interventions were not added until after this incident. Staff interviews confirmed that fall interventions were not care planned until after the fall, and facility policy required that fall interventions be initiated on the resident's baseline care plan. This lapse affected the resident's safety and represented a failure to provide adequate supervision and accident hazard prevention as required.
Medication Administration Deficiency
Penalty
Summary
The facility failed to ensure that medications were available and administered as ordered for a resident. The resident, who had been admitted with diagnoses including chronic obstructive pulmonary disease, asthma, diabetes mellitus type II, atrial fibrillation, and bipolar disorder, was discharged from the hospital with a medication order for guaifenesin 600 mg to be taken every 12 hours. A subsequent physician order on 12/17/24 specified guaifenesin extended release 600 mg twice daily for seven days. However, the resident did not receive the first dose until 12/18/24 at 9:00 A.M., resulting in missed doses. This was confirmed by an interview with the Assistant Director of Nursing, who verified the delay in medication administration. The facility's policy on medication administration requires that medications be administered by licensed nurses as ordered by the physician, which was not adhered to in this case.
Medication Administration Errors
Penalty
Summary
The facility failed to ensure that medications were administered as ordered, leading to significant medication errors for a resident. The resident, who had a medical history including chronic obstructive pulmonary disease, asthma, diabetes mellitus type II, atrial fibrillation, and bipolar disorder, was admitted with specific medication orders. These included a diuretic, furosemide 20 mg daily, and a steroid, Medrol dose pack, with detailed instructions. However, the facility did not administer these medications according to the physician's orders. The resident reported not receiving medications for several days post-admission, and the Assistant Director of Nursing confirmed the missed doses and incorrect administration of Medrol. The review of the medication administration record (MAR) showed discrepancies in the administration of Medrol and furosemide. The Medrol was not given according to the dose pack instructions, and the furosemide was not administered on the scheduled days despite being available in the facility's contingency medication supply. A photograph of the Medrol pack revealed that several tablets were not administered as per the instructions. The facility's policy on medication administration, which mandates that medications be given as ordered by the physician, was not followed, leading to this deficiency.
Failure to Provide Properly Sized Briefs for Residents
Penalty
Summary
The facility failed to provide appropriately sized briefs for residents who required and preferred a specific size, affecting two residents. Resident #7, who was admitted with diagnoses including cerebrovascular attack, coronary artery disease, and morbid obesity, was cognitively intact and dependent on staff for toileting. Despite her requests for a three XL brief, the facility only provided a two XL brief, which did not fit properly, leaving her skin exposed. Multiple staff members confirmed the lack of three XL briefs in the facility, and observations in the supply rooms verified their absence. Similarly, Resident #16, who was admitted with diagnoses including peripheral vascular disease, respiratory failure, and renal insufficiency, was frequently incontinent and also required a three XL brief. She reported that the facility often ran out of her size, resulting in her wearing a two XL brief that caused skin irritation. Observations confirmed the absence of three XL briefs in the supply rooms. The facility's policy on resident rights states that residents have the right to reasonable accommodation of their needs and preferences, which was not upheld in these cases.
Failure to Notify Physician of Change in Resident's Condition
Penalty
Summary
The facility failed to ensure that a change in condition was reported to the physician for a resident who was cognitively intact and had been admitted with multiple diagnoses, including aftercare for a displaced supracondylar fracture with intercondylar extension of the lower end of the right femur. The resident experienced bleeding from her surgical incision site on multiple occasions as documented in the Physical Therapy and Occupational Therapy notes. However, there was no evidence that the physician was notified of this bleeding, as required by the facility's policy on Notification of Changes. The deficiency was further confirmed through an interview with the Wound Nurse Practitioner, who verified that she was not informed about the bleeding from the resident's incision site. The facility's policy mandates prompt notification of the resident's physician and representative when there is a change requiring notification, which was not adhered to in this case. This oversight was identified during an investigation under Complaint Number OH00159578.
Inadequate Incontinence Care for Resident
Penalty
Summary
The facility failed to provide appropriate and thorough incontinence care for Resident #7, who was dependent on staff for toileting and was incontinent of bowel and bladder. During an observation of incontinence care, it was noted that the CNAs used a bath towel to clean the resident, but did not turn the towel over to use a clean section for washing different areas. Additionally, when the resident urinated during the care, the CNAs did not adequately clean the urine from the resident's legs, as one CNA only used a clean cloth to wash down the front of the resident without wiping her legs. Interviews with the CNAs confirmed the inadequate care provided. CNA #186 admitted to using the same towel for cleaning due to a lack of available supplies, while CNA #188 acknowledged seeing urine running down the resident's legs and confirmed that she did not wash the resident's legs afterward. The facility's policy on perineal care, which emphasizes cleanliness and the prevention of infection and skin breakdown, was not followed, as the CNAs did not use separate sections of the washcloth or new disposable wipes for each cleaning stroke as required.
Failure to Administer COVID-19 Vaccine to Resident
Penalty
Summary
The facility failed to administer the COVID-19 vaccine to a resident who had requested it. Resident #7, who was cognitively intact and had diagnoses including cerebrovascular attack, coronary artery disease, and morbid obesity, was admitted to the facility and had expressed a desire to receive the COVID-19 vaccine. The resident had completed a vaccine consent form on 11/05/24, indicating a request for two COVID-19 vaccines. However, a review of the progress notes and the Medication Administration Record (MAR) from 11/05/24 through 11/25/24 showed no evidence that the vaccines were administered. An interview with the resident on 11/21/24 confirmed that she had been requesting the vaccines since September 2024 but had not received them. The Assistant Director of Nursing (ADON) confirmed on 11/25/24 that the resident did not receive the vaccines. The facility's policy aimed to minimize COVID-19 risks by educating and offering vaccines to residents and staff, but this was not followed in this case.
Failure to Assist with Transportation to Physician Appointments
Penalty
Summary
The facility failed to ensure that residents were assisted with arranging transportation to physician appointments, affecting one resident out of three reviewed for appointments. Resident #52, who was admitted on 12/27/23, had diagnoses including type two diabetes mellitus, chronic obstructive pulmonary disease, chronic viral hepatitis, hypertension, and osteoarthritis of the hip. Despite being cognitively intact with a BIMS score of 14 out of 15, Resident #52 missed multiple orthopedic and cardiologist appointments due to transportation-related issues. The orthopedic appointments were scheduled but missed on 02/28/24, 03/11/24, 03/14/24, and 04/01/24, while the cardiologist appointment was missed on 04/16/24. There was no documented reason for the missed appointments on 02/28/24 and 04/16/24. Interviews with Resident #52 and the Director of Nursing (DON) confirmed the delays and issues in scheduling and attending these appointments. The DON acknowledged that the missed appointments on 04/01/24 and 04/16/24 were due to a change in payor source that was not identified in time. Facility staff were responsible for contacting transportation companies and providing the correct payor source information, which was not done, leading to the missed appointments. This deficiency was investigated under Complaint Number OH00152779.
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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