Springfield Nursing & Independent Living
Inspection history, citations, penalties and survey trends for this long-term care facility in Springfield, Ohio.
- Location
- 404 E Mccreight Ave, Springfield, Ohio 45503
- CMS Provider Number
- 366099
- Inspections on file
- 29
- Latest survey
- January 29, 2026
- Citations (last 12 mo.)
- 4
Citation history
Health deficiencies cited at Springfield Nursing & Independent Living during CMS and state inspections, most recent first.
The facility did not ensure a safe and clean environment, as evidenced by a shower room with damaged flooring, a hole in the drywall, debris, and stained ceiling tiles, as well as an employee entrance door that could not be secured. Staff confirmed these issues had persisted for months to over a year, affecting all residents who used the shower room and allowing potential unauthorized access through the unsecured entrance.
A resident with severe cognitive impairment and multiple medical conditions was moved to a different room without receiving written notification prior to the change. Staff interviews confirmed that neither the resident nor their representative was shown the new room or given written notice, and the facility did not follow its own policy requiring notification for room changes.
The facility did not conduct timely or thorough investigations into two separate allegations of abuse and neglect involving residents with severe cognitive impairment and dementia. In both cases, staff failed to document or conduct interviews with involved personnel or witnesses, and investigations were not initiated promptly, contrary to facility policy.
A resident experienced a major decline in cognitive and functional status after a stroke, becoming nonverbal, unable to make needs known, and fully dependent on staff for all ADLs, with all nutrition provided via tube feeding. Despite these significant changes, the facility did not complete a required significant change MDS assessment, as confirmed by staff interviews and medical record review.
A resident with multiple medical conditions, including diabetes, was not monitored for blood sugar levels according to the physician's order for twice-daily Accu-Chek testing. Instead, documentation showed that blood sugar checks were only completed once daily, a fact confirmed by the DON.
A resident with multiple medical conditions was readmitted from the hospital with a pressure ulcer and DTI, but the facility did not promptly assess, document, or initiate treatment for these wounds. Weekly wound evaluations were not completed, and physician orders for wound care were delayed. The DON confirmed the lack of timely documentation and treatment, and wound care was only provided after a significant delay, contrary to facility policy.
A resident with a history of stroke and dysphagia was readmitted on tube feedings and showed cognitive improvement, making them a candidate for SLP services to restore eating skills. However, the facility did not provide these services due to the absence of a speech therapist, resulting in a lack of care to help the resident regain oral intake abilities.
Two residents did not receive their prescribed medications as ordered, resulting in a medication error rate of 7.4%. A nurse administered the incorrect dosage of Verapamil to one resident and an insufficient dose of Metformin to another, contrary to physician orders and facility policy.
A resident with a history of stroke, dysphagia, and tube feeding was not offered or provided SLP services after readmission, despite hospital recommendations for ongoing evaluation and subsequent cognitive improvement. The facility lacked a Speech Therapist and did not document any SLP follow-up or treatment.
A resident with an unstageable sacral pressure ulcer did not receive proper infection control during wound care, as an LPN failed to don a gown and did not wash hands between glove changes. Enhanced Barrier Precautions (EBP) were not implemented as required, with no EBP signage posted and no physician order documented, despite facility policy mandating these measures for high-contact care activities.
The facility did not update or post current daily nurse staffing information at the front desk, as required, with staff and DON confirming that the information displayed was several days out of date. This issue was identified during a complaint investigation and had the potential to affect all residents.
A resident with a history of schizophrenia and bipolar disorder was re-admitted to the facility without the continuation of prescribed psychiatric medications, leading to increased verbal outbursts, manic behaviors, and hospitalization. The facility failed to follow its policy for medication reconciliation, resulting in actual harm to the resident.
The facility failed to follow the planned menu and did not inform residents of changes. On one occasion, residents were served a different meal than what was on the menu, and the Dietary Manager admitted to not notifying them. The Resident Council President also reported frequent menu deviations without prior notice, affecting all 61 residents.
The facility failed to store food properly and maintain a sanitary kitchen, affecting all 61 residents. Issues included undated and improperly stored food, a malfunctioning refrigerator, and unsanitary conditions confirmed by dietary staff and the maintenance director.
The facility failed to have the required members, including the medical director, at QAPI meetings, potentially affecting all 61 residents. Documentation for 2023 lacked sign-in sheets, and the medical director did not attend meetings in March and April 2024. The Administrator confirmed these deficiencies.
The facility failed to have a developed water management plan, potentially affecting all 61 residents. The Administrator confirmed the absence of such a plan, and the Maintenance Director revealed that only hot water temperatures were checked. The facility's policy indicated that Legionella surveillance is part of the water management plan, but no plan was in place.
The facility failed to provide a homelike environment, with multiple observations of unclean and poorly maintained areas in the behavioral unit and residents' rooms. Issues included sticky and dusty window ledges, black substances on window sills, broken blinds, rust spots in showers, and stagnant water around a toilet. Interviews confirmed that these areas should have been cleaned better.
The facility failed to conduct quarterly care conferences for four residents, including those with chronic obstructive pulmonary disease and Parkinson's disease. Residents and their representatives were not adequately informed or involved in the care planning process, contrary to the facility's policy.
The facility failed to ensure timely administration of medications for four residents, with delays ranging from over two to four hours past the scheduled times. Interviews confirmed that the LPN declined assistance, and the DON verified the late administration of medications.
The facility failed to ensure that residents and staff were offered and/or administered the COVID-19 vaccine, as required by their policy. Medical record reviews for four residents and three staff members revealed no evidence of education, consent, or administration of the COVID-19 vaccine, and interviews confirmed the lack of vaccine offers.
A facility failed to ensure a resident with severe cognitive impairment and multiple diagnoses was treated with dignity and respect. An STNA was observed interacting with the resident in a loud and abrasive tone, which was confirmed by other staff members as unprofessional behavior. The facility's policy on resident dignity was not followed.
The facility failed to develop a comprehensive care plan for a resident with multiple diagnoses, omitting plans for smoking and activities. Despite the resident's severe cognitive impairment and smoking habit, the care plan lacked necessary measures, which was confirmed by the DON.
The facility failed to complete discharge summaries for two residents, leading to a deficiency in the communication of necessary information at the time of planned discharge. Both residents had multiple diagnoses and required various levels of assistance for daily activities. Despite being discharged, the assessments titled 'Discharge Instructions' and 'Discharge Summary' were not completed for either resident.
The facility failed to provide necessary ADL care, including bathing, beard trimming, and nail trimming, for a resident who was unable to perform these tasks independently. The resident, who was cognitively intact and required supervision for all ADLs, received inconsistent care, with only one shower given out of 12 opportunities. Staff interviews confirmed the lack of available shavers and incomplete shower and nail care.
The facility failed to assess enabler bars for entrapment risk, affecting a resident with severe cognitive impairment. Despite the resident denying issues, no safety assessments were conducted, and the facility's policy on bed rail use was not followed.
The facility failed to assess the use of side rails/enabler bars for two residents with cognitive impairments and multiple diagnoses. Interviews revealed that enabler bars were not assessed for proper fit or need upon admission or routinely thereafter, despite the facility's policy requiring such assessments.
The facility failed to ensure the activity department was overseen by a qualified professional. The Activity Director, hired and promoted within the facility, lacked certification and relevant employment experience. Both the Activity Director and the Administrator confirmed the absence of necessary qualifications, potentially affecting all 61 residents.
Failure to Maintain Safe and Clean Environment in Resident and Staff Areas
Penalty
Summary
The facility failed to maintain a safe, clean, and homelike environment for its residents, staff, and the public. Observations revealed that the shower room on the [NAME] Hall had significant maintenance issues, including peeled flooring along the walls, a hole in the drywall near the baseboard, protruding drywall, and drywall debris on the floor. Additionally, two ceiling tiles in the shower room were stained with large, brownish marks. Staff interviews confirmed that these issues had persisted for several months, and all residents on the [NAME] Hall used this shower room. Further observations and interviews identified that the employee entrance door in the basement did not fit the doorframe and could not be closed, leaving the entrance open at all times. Maintenance staff confirmed that this issue had existed for quite some time and that residents could access the basement via the elevator. It was also confirmed that individuals from the community could enter the facility through this unsecured door. The facility had sought an estimate for repairs to the shower room but had not yet received a quote. These deficiencies were investigated under multiple complaint numbers and had the potential to affect all 63 residents in the facility.
Failure to Provide Written Notice Prior to Resident Room Change
Penalty
Summary
A deficiency occurred when a resident with severe cognitive impairment and multiple complex medical diagnoses, including cerebral infarction with left hemiplegia, aphasia, ischemic cardiomyopathy, obesity, congestive heart failure, and chronic kidney disease, was moved to a different room without receiving written notification prior to the change. The resident, who was dependent on staff for all activities of daily living and received nutrition via tube feeding, was moved in April 2025 as part of a facility effort to consolidate beds. The medical record review confirmed there was no evidence of written notification provided to the resident or their representative before the room change. Interviews with staff revealed that the resident was unhappy with the new room assignment, particularly because the new bed placement did not allow the resident to look out the window as before. Admissions staff confirmed that neither the resident nor their representative was shown the new room or given written notice prior to the move, and acknowledged that the facility did not provide written notice for room changes. Review of the facility's policy indicated that notification is required for changes such as room or roommate changes, but this procedure was not followed in this instance.
Failure to Timely and Thoroughly Investigate Allegations of Abuse and Neglect
Penalty
Summary
The facility failed to thoroughly and timely investigate allegations of abuse and neglect for two residents. In the first case, a resident with severe cognitive impairment, hemiplegia, and dependent on staff for all activities of daily living experienced a change in condition, including shaking and lack of eye contact, which was reported by a CNA to an LPN. The LPN assessed the resident and found no immediate concerns, but the resident was later sent to the hospital for stroke symptoms. The facility's self-reported incident (SRI) investigation was not initiated until ten days after the event, and there was no documentation of staff or resident interviews related to the neglect allegation. Both CNAs involved confirmed they were not interviewed or asked to provide witness statements regarding the incident. In the second case, a resident with dementia and delusions reported to a CNA that she had been raped by a man who entered her room. The nurse was notified, an assessment was completed, and the DON was informed. The resident was sent to the hospital for examination, which yielded negative results. The SRI investigation documented that resident interviews were conducted, but there was no evidence that staff interviews or witness statements were obtained. The nurse on duty confirmed she was not interviewed about the allegation, and the administrator acknowledged the lack of documentation for staff interviews in both cases. The facility's policy requires immediate and thorough investigation of abuse, neglect, or exploitation allegations, including identifying and interviewing all relevant persons and providing complete documentation. However, in both incidents, the facility did not follow its policy, as there was a lack of timely initiation of investigations and insufficient documentation of interviews with staff and witnesses.
Failure to Complete Significant Change MDS Assessment After Major Resident Decline
Penalty
Summary
The facility failed to complete a significant change in status assessment (SCSA) as required for a resident who experienced a major decline in condition. The resident, admitted with multiple diagnoses including cerebral infarction with left hemiplegia, aphasia, ischemic cardiomyopathy, obesity, congestive heart failure, and chronic kidney disease, was discharged to the hospital and later readmitted following a stroke. Prior to the stroke, the resident was cognitively intact, able to communicate, and required only set-up assistance for eating, consuming a regular diet by mouth. After the stroke, the resident became nonverbal, unable to make needs known, developed severe cognitive impairment, and became fully dependent on staff for all activities of daily living, receiving all nutrition via gastrostomy tube feedings. Despite these significant changes in the resident's cognitive and functional status, the facility did not complete a significant change MDS assessment within the required timeframe. Staff interviews confirmed the resident's marked decline in cognition, communication, and nutritional intake following the stroke. The facility's MDS coordinator stated she did not believe the criteria for a significant change assessment were met, despite clear evidence of major declines in multiple areas of the resident's health status. This failure was identified through medical record review, staff interviews, and review of facility policy and the RAI manual.
Failure to Monitor Blood Sugar Levels as Ordered
Penalty
Summary
The facility failed to monitor a resident's blood sugar levels as ordered by the physician. The resident, who had diagnoses including atrial fibrillation, hypertension, diabetes mellitus, and congestive heart failure, was admitted with an order for Accu-Chek (fingerstick blood sugar monitoring) to be performed two times daily. Documentation in the medical record showed that Accu-Chek was only completed once daily, rather than the twice-daily frequency specified in the physician's order. This was confirmed by the Director of Nursing during an interview, who acknowledged that the monitoring was not performed as ordered.
Failure to Timely Assess and Treat Pressure Ulcers
Penalty
Summary
The facility failed to properly assess, document, and initiate timely treatment for pressure ulcers in a resident with multiple medical conditions, including failure to thrive, dementia, right hemiplegia, and paranoid schizophrenia. Upon readmission from the hospital, the resident was documented to have a pressure ulcer on the right buttock and a deep tissue injury (DTI) to the coccyx, as well as a surgical incision on the right knee. Initial assessments by facility staff noted these wounds, but there was no evidence that appropriate treatments were ordered or initiated for the DTI to the coccyx or the open area to the right gluteal fold at that time. Further review of the medical record revealed a lack of weekly wound evaluations for the DTI to the coccyx and the right gluteal fold area between the initial assessment and a later evaluation, which did not occur until several weeks after the wounds were first identified. Physician orders for wound care to the sacrum were not placed until weeks after the wounds were observed, and there was no documentation of Enhanced Barrier Precautions or other interventions for the pressure ulcers during this period. Treatment records confirmed that only the surgical site on the right knee received timely care as ordered, while the pressure ulcers did not receive documented treatment until much later. Interviews with the DON confirmed that the facility did not have documentation to support timely initiation of treatments or completion of weekly wound measurements for the pressure ulcers. Observations of wound care performed by an LPN showed that wound care was eventually provided as ordered, but this occurred after a significant delay. Review of facility policy indicated that prompt assessment and treatment of pressure ulcers was required, but this was not followed in the case of this resident.
Failure to Provide Rehabilitative Services for Eating Skills Restoration
Penalty
Summary
The facility failed to provide appropriate rehabilitative services to restore eating skills for a resident who had recently experienced a stroke and was readmitted to the facility with new orders for NPO status and tube feedings due to dysphagia. Prior to the stroke, the resident was cognitively intact, able to make needs known, and required only set-up assistance with eating. Upon readmission, the resident's cognition was initially impaired, but improved after the first week, making the resident a candidate for speech/language pathology (SLP) services to address swallowing and eating skills. However, the facility did not provide SLP services because there had been no speech therapist on staff since October 2024. Medical record review showed that the resident had a history of cerebral infarction with left hemiplegia, aphasia, and other significant comorbidities. Hospital documentation recommended ongoing SLP evaluation and treatment, but there was no evidence of such services being provided after the resident's return to the facility. The Director of Rehab confirmed that although the resident could have benefited from SLP services after cognitive improvement, these services were not offered due to the absence of a speech therapist. This resulted in a lack of care and services aimed at restoring the resident's eating skills.
Medication Administration Errors Exceed Acceptable Rate
Penalty
Summary
The facility failed to administer medications as ordered, resulting in a medication error rate of 7.4%, which exceeds the acceptable threshold of 5%. Specifically, two medication errors were identified out of 27 medication opportunities during observation of medication administration. One resident with a history of hypertension and transient cerebral ischemic attack was ordered to receive Verapamil HCL Extended Release 240 mg, but instead was given Verapamil HCL 120 mg two tablets. Another resident with type two diabetes and hypertension was ordered Metformin HCL 1,000 mg twice daily, but only received Metformin HCL 500 mg once during the observed medication pass. The errors were confirmed through medical record review, direct observation, and staff interview. The nurse responsible for medication administration acknowledged the errors, stating she was unaware of the new Verapamil 240 mg ER order and confirmed the incorrect dosage of Metformin was given. Facility policy required medications to be administered as ordered, ensuring all rights of medication administration were followed, but these protocols were not adhered to in these instances.
Failure to Provide Required Speech/Language Pathology Services
Penalty
Summary
The facility failed to provide or offer Speech/Language Pathology (SLP) services as required for a resident with significant medical needs. A resident with a history of cerebral infarction with left hemiplegia, aphasia, ischemic cardiomyopathy, obesity, congestive heart failure, and chronic kidney disease was readmitted to the facility after a hospital stay for a stroke. Upon readmission, the resident had orders for NPO status and continuous tube feedings due to dysphagia, and had previously received SLP services in the hospital, including recommendations for ongoing SLP evaluation. Despite these recommendations and the resident's subsequent improvement in cognition, the facility did not provide SLP services because they had not had a Speech Therapist on staff since October 2024. The Director of Rehab confirmed that although the resident would have benefited from SLP services after cognitive improvement, no such services were offered or provided. The facility's practice in cases of swallowing concerns was to obtain a modified barium swallow evaluation and follow dietary recommendations, but no ongoing SLP evaluation or treatment was documented for this resident.
Failure to Follow Infection Control Procedures During Wound Care
Penalty
Summary
A deficiency was identified when a resident with multiple medical diagnoses, including adult failure to thrive, dementia, right hemiplegia, and paranoid schizophrenia, was not provided appropriate infection control measures during wound care. The resident had an unstageable pressure ulcer to the sacrum, as documented in weekly wound evaluations. During an observed dressing change, the LPN performed the procedure without donning a gown and failed to wash hands between glove changes, both of which are required infection control practices according to facility policy for Enhanced Barrier Precautions (EBP). Additionally, the resident did not have an EBP sign posted in the room or on the door, and there was no physician order for EBP documented in the medical record. The LPN confirmed during interview that the resident should have been under EBP and acknowledged not following the required procedures. Facility policy specifies that EBP, including the use of gown and gloves during high-contact care activities such as wound care, is necessary to prevent the transmission of multidrug-resistant organisms (MDRO), but these protocols were not followed in this instance.
Failure to Post Daily Nurse Staffing Information
Penalty
Summary
The facility failed to ensure that daily nursing staffing information was posted as required, potentially affecting all 63 residents in the facility. Multiple observations on different days revealed that the staffing information displayed at the front receptionist desk was outdated, consistently showing the date 05/12/25 instead of the current date. Staff interviews with both the receptionist and the Director of Nursing confirmed that the posted staffing information had not been updated. This deficiency was identified during the course of a complaint investigation.
Failure to Reconcile Medications Post-Hospital Re-admission
Penalty
Summary
The facility failed to reconcile medications for Resident #210 following a re-admission from a psychiatric hospital. Resident #210, who had a history of schizophrenia, bipolar disorder, and other significant medical conditions, was readmitted to the facility without the continuation of prescribed psychiatric medications. This oversight led to an increase in verbal outbursts, religious ideations, manic behaviors, and ultimately, the resident's hospitalization. The medical record review revealed that the discharge medication list from the psychiatric hospital included several critical medications for managing the resident's mental health conditions, which were not entered into the electronic health record upon re-admission to the facility. The Director of Nursing confirmed that the medications were not reconciled and continued upon re-admission, leading to a deterioration in the resident's condition. The progress notes indicated that Resident #210 exhibited significant behavioral changes, including verbal outbursts and self-harm, after the failure to administer the necessary medications. Despite attempts to manage the behaviors through redirection and other interventions, the resident's condition worsened, necessitating transfer to the emergency room and subsequent admission to a psychiatric hospital. The facility's policy required the attending physician to authenticate orders and the nurse to verify and transcribe these orders, which was not followed in this case. This lapse in medication reconciliation directly contributed to the resident's adverse change in condition and subsequent hospitalization.
Failure to Follow Menu and Notify Residents of Changes
Penalty
Summary
The facility failed to ensure the menu was followed and did not inform residents of menu changes. On 05/19/24, the planned menu included apple pork chop, onion roasted potatoes, dilled carrots, roll, and pumpkin crisp. However, during the lunch meal observation on the same day, residents were served apple pork chop, mashed potatoes and gravy, dilled carrots, roll, and a brownie. The Dietary Manager confirmed the menu change and admitted to not informing the residents due to a lack of awareness about the requirement to notify them. Additionally, the substitution list did not reflect any changes for that date. An interview with the Resident Council President revealed that the dietary department frequently did not follow the menu and failed to notify residents of changes. The Resident Council President mentioned an instance two nights prior when she expected the meal on the menu but received cheeseburgers instead. The facility's policy on meal substitutions, dated 01/01/24, stated that menu changes should only occur in emergency situations and that residents should be notified in advance when possible. However, this policy was not adhered to, affecting all 61 residents in the facility.
Improper Food Storage and Sanitation in Kitchen
Penalty
Summary
The facility failed to store food properly and maintain a sanitary kitchen, which had the potential to affect all 61 residents. Observations revealed multiple issues, including undated and improperly stored food items such as cereal, hamburger patties, and bacon. Additionally, the ice machine had various stains, and a bucket in the dry storage area was collecting water from the boiler system. These observations were confirmed by dietary staff and the maintenance director, who acknowledged the issues but had not yet resolved them. Further observations showed that the walk-in refrigerator was not maintaining the required temperature of 41 degrees Fahrenheit, with items such as milk, cheese, condiments, and vegetables being stored at 45 degrees Fahrenheit. Dust was also found on the light fixture above the tray line area and on the wall near the plate warmer. The facility's policies on date marking and sanitation were not being followed, as confirmed by the dietary manager and staff. These deficiencies were observed over multiple days and confirmed by various staff members.
Failure to Include Required Members in QAPI Meetings
Penalty
Summary
The facility failed to have the required members at the Quality Assurance and Performance Improvement (QAPI) meetings, which had the potential to affect all 61 residents residing in the facility. Review of QAPI documentation for January, March, June, July, and October 2023 revealed no sign-in sheets for the meetings. Sign-in sheets were only found for March and April 2024, but there was no documentation of the medical director attending the meetings in those months. An interview with the Administrator confirmed the absence of sign-in sheets for 2023 and the medical director's absence in March and April 2024. The facility's QAPI committee, as per policy, should include the medical director, who is responsible for ensuring compliance with federal and state requirements and continuous improvement in quality of care and resident satisfaction.
Lack of Water Management Plan
Penalty
Summary
The facility failed to have a developed water management plan in place, which had the potential to affect all 61 residents residing in the facility. During a review of the facility's water management binder, it was found that there was no water management plan, including a description and diagram of the water system or control measures to prevent Legionella. The Administrator confirmed the absence of a water management plan. Additionally, the Maintenance Director revealed that they only checked hot water temperatures and had no water management plan to follow. The facility's policy titled 'Legionella Surveillance' indicated that Legionella surveillance is a component of the water management plans for reducing the risk of Legionella and other opportunistic pathogens in the facility's water system, but no such plan was in place.
Failure to Maintain a Homelike Environment
Penalty
Summary
The facility failed to provide a homelike environment for its residents, as evidenced by multiple observations of unclean and poorly maintained areas. In the behavioral unit's activity room, window ledges were found to be sticky and dusty, with window sills covered in a black substance and blinds coated with a sticky yellow substance. The floor under the heaters and the baseboards also had a thick black substance. Additionally, several lights in the west hall had missing coverings and burned-out bulbs, and ceiling tiles were missing at the end of the hall. The shower room in the behavioral unit had a windowsill with a black substance and dead bugs, and the blind was covered with a sticky yellow substance. Resident #21's room had similar issues, with a broken blind, sticky window ledge, and a windowsill with black substance and bugs. The shower in this room also had rust spots. Resident #18's room had a sticky window ledge with a built-up yellow substance, a windowsill full of black substance and bugs, and a blind with a sticky yellow substance. Interviews with the maintenance man and housekeeping supervisor confirmed these findings and acknowledged that the areas should have been cleaned better during deep cleaning. Resident #31's bathroom had stagnant water around the base of the toilet, which the resident reported had been leaking for days without being fixed. Observations over several days confirmed the presence of stagnant water, which was later identified by the maintenance director as urine rather than water. The maintenance director stated that the area had not been cleaned properly and that the wax seal on the toilet was changed as a precaution. Subsequent observations confirmed that the issue was resolved after cleaning and changing the wax seal. The facility's policy on providing a safe and homelike environment was reviewed, revealing that the facility failed to adhere to its own standards in maintaining cleanliness and safety for the residents.
Failure to Conduct Quarterly Care Conferences
Penalty
Summary
The facility failed to ensure care conferences were provided quarterly for four residents. Resident #39, diagnosed with chronic obstructive pulmonary disease, was cognitively intact and required minimal assistance for daily activities. However, he only had one care conference since his admission, and he was unaware of what a care conference was. Similarly, Resident #21, diagnosed with Parkinson's disease and requiring substantial assistance for daily activities, had care conferences that were not held quarterly as required. He also reported not having any care conferences, which was confirmed by the Social Services Designee (SSD). Resident #32, also diagnosed with chronic obstructive pulmonary disease and cognitively intact, had only one care conference since admission, and the SSD confirmed this. Resident #33, with severe cognitive impairment and multiple diagnoses, had care conferences that did not include his son, who was the emergency contact, despite the facility's policy requiring notification and participation of the resident's representative. The facility's policy, revised on 01/01/24, mandates that care conferences be held regularly and involve the resident and/or their representative. However, the facility did not adhere to this policy, resulting in missed quarterly care conferences for the residents reviewed. Interviews with the residents and their representatives revealed a lack of awareness and participation in care conferences, highlighting the facility's failure to ensure proper communication and involvement in the care planning process. The Administrator acknowledged the oversight, particularly in notifying Resident #33's son, who lives out of state, and confirmed that care conferences were not held as frequently as required.
Failure to Administer Medications Timely
Penalty
Summary
The facility failed to ensure medications were administered in a timely manner and according to physician instructions, affecting four residents. Resident #13, who had severe cognitive impairment and multiple diagnoses including epilepsy and bipolar disorder, did not receive their 8:00 A.M. medications until 12:00 P.M. on one occasion and 10:44 A.M. on another. Resident #30, who was cognitively intact but required assistance for ADLs, received their 8:00 A.M. medications at 11:12 A.M. on one occasion and confirmed receiving medications late on multiple occasions. Resident #31, with diagnoses including schizoaffective disorder and type two diabetes, received their 8:00 A.M. medications at 11:20 A.M. and their 2:00 P.M. medication at 5:28 P.M. on the same day, and confirmed receiving medications late in the mornings recently. Resident #33, with severe cognitive impairment and multiple diagnoses including major depressive disorder and type two diabetes, received their 8:00 A.M. medications at 11:09 A.M. on one occasion. Interviews with the Director of Nursing (DON) and Assistant Director of Nursing (ADON) revealed that they offered assistance to the LPN responsible for the medication pass, who declined the help. The DON confirmed the late administration of medications and verified that the nursing staff have a one-hour window before and after the scheduled time to administer medications. The facility's policy on medication administration, revised on 01/01/24, states that medications should be administered within 60 minutes prior to or after the scheduled time unless otherwise ordered by a physician.
Failure to Offer and Document COVID-19 Vaccinations
Penalty
Summary
The facility failed to ensure that residents and staff were offered and/or administered the COVID-19 vaccine, as required by their policy. Medical record reviews for four residents revealed no evidence of education, consent, or administration of the COVID-19 vaccine from 07/01/23 through 05/19/24. These residents included individuals with chronic obstructive pulmonary disease, schizoaffective disorder, human immunodeficiency virus (HIV), and respiratory failure. Interviews with the residents confirmed that they had not been offered the COVID-19 vaccination in a long time, and the Director of Nursing (DON) confirmed the lack of documentation regarding the vaccine offer and administration for these residents. Additionally, the facility failed to document the offering of the COVID-19 vaccine to staff members, including an Activity Aide and two Registered Nurses. The facility's policy, dated 01/01/24, mandates the education and offering of the COVID-19 vaccine to minimize the risk of acquiring, transmitting, or experiencing complications from COVID-19. However, the review of staff records showed no documentation of the vaccine being offered, indicating a failure to adhere to the established policy.
Failure to Treat Resident with Dignity and Respect
Penalty
Summary
The facility failed to ensure all residents were treated with dignity and respect, specifically affecting one resident with severe cognitive impairment and multiple diagnoses including unspecified psychosis, bipolar disorder, schizoaffective disorder, and dementia. The resident required maximal assistance for various activities of daily living and was non-verbal. During an observation, a staff member was noted to interact with the resident in a loud and abrasive tone, instructing the resident to sit down in an unprofessional manner. This interaction was overheard by housekeeping staff who confirmed the unprofessional behavior. The facility's policy on promoting and maintaining resident dignity, dated 01/01/24, was reviewed and it was found that the staff member's actions were not in alignment with the policy. The staff member, identified as a State tested Nursing Assistant (STNA), claimed to be hard of hearing and denied any unprofessional interaction. However, the observations and interviews with other staff members confirmed the deficiency in treating the resident with dignity and respect.
Failure to Develop Comprehensive Care Plan
Penalty
Summary
The facility failed to develop a comprehensive care plan for a resident, specifically omitting plans for smoking and activities. The resident, who had multiple diagnoses including unspecified dementia, anxiety disorder, heart failure, and major depressive disorder, was admitted on an unspecified date. Despite being assessed as a smoker and having severely impaired cognition, the care plan did not include any measures related to smoking. Additionally, the care plan for activities was incomplete, with no specified preferred activities listed, even though the resident was dependent on staff for meeting emotional, intellectual, physical, and social needs due to cognitive deficits. The deficiency was confirmed during an interview with the Director of Nursing, who acknowledged the absence of a smoking care plan and the incomplete activities care plan. The facility's policies required that all safe smoking measures be documented in the care plan and that a comprehensive person-centered care plan be developed and implemented for each resident. However, these policies were not followed for this resident, leading to the identified deficiencies.
Failure to Complete Discharge Summaries for Residents
Penalty
Summary
The facility failed to complete discharge summaries for two residents, leading to a deficiency in the communication of necessary information at the time of planned discharge. Resident #57, who had multiple diagnoses including malignant neoplasm, COPD, anxiety disorder, PTSD, major depressive disorder, dementia, and hypokalemia, was discharged home without a completed discharge summary or discharge instructions. The resident had moderately impaired cognition and required various levels of assistance for daily activities. Despite being discharged on 05/09/24, the assessments titled 'Discharge Instructions' and 'Discharge Summary' dated 05/06/24 were not completed for this resident. Similarly, Resident #59, who had diagnoses including COPD, epilepsy, chronic kidney disease, type two diabetes mellitus, emphysema, hyperlipidemia, and major depressive disorder, was discharged to an assisted living facility without a completed discharge summary or discharge instructions. This resident had intact cognition and required setup assistance for several daily activities. The assessments titled 'Discharge Instructions' and 'Discharge Summary' were not completed for this resident either, despite the discharge occurring on 03/06/24. Social Services Staff confirmed the lack of completed discharge summaries for both residents, which was in violation of the facility's policy on transfer and discharge reviewed on 01/01/24.
Failure to Provide Necessary ADL Care
Penalty
Summary
The facility failed to ensure that a resident who could not perform Activities of Daily Living (ADL) independently was provided with necessary care such as bathing, beard trimming, and nail trimming. This deficiency affected one resident who was cognitively intact and required supervision for all ADLs but occasionally needed hands-on assistance. The resident used a powered wheelchair and had a history of refusing showers at times. However, out of 12 opportunities for showers, the resident only received one and refused two, indicating a lack of consistent care. Observations revealed that the resident's beard was long and unkempt, and his fingernails were long, which he stated were not trimmed unless he specifically asked for it. He also mentioned that he had requested a beard trim on the day of the observation, but it had not been done yet. Interviews with staff confirmed the lack of available shavers and incomplete shower and nail care for the resident. The Director of Nursing (DON) acknowledged that the shavers for residents had become old and were discarded, resulting in residents not getting shaved. The DON also admitted that the showers and nail care for the resident were not completed and described the situation as a work in progress. The facility's policy on Activities of Daily Living, dated January 1, 2024, stated that care and services would be provided for bathing, dressing, grooming, and oral care, and that residents unable to carry out ADLs would receive the necessary services to maintain grooming and personal care. Despite this policy, the facility failed to meet the grooming and personal care needs of the resident in question.
Failure to Assess Enabler Bars for Entrapment Risk
Penalty
Summary
The facility failed to assess side rails and/or enabler bars for entrapment risk, affecting one resident. Resident #33, who had severe cognitive impairment and required extensive assistance for activities of daily living, was observed with an enabler bar on their bed that had a gap of approximately three and a half to four inches between the bar and the mattress. Despite the resident denying any issues with the enabler bar, no assessments were completed to ensure the safety and proper fit of the enabler bar for the bed. Interviews with the Maintenance Director, Assistant Director of Nursing (ADON), and Director of Nursing (DON) confirmed that no assessments were conducted for Resident #33 or other residents using enabler bars. The facility's policy on the proper use of bed rails, which mandates correct installation, use, and maintenance, was not followed. The DON acknowledged that the assessments were on the list of things that needed to be addressed throughout the facility.
Failure to Assess Side Rails/Enabler Bars
Penalty
Summary
The facility failed to assess the use of side rails/enabler bars for two residents, leading to a deficiency. Resident #33, who had severe cognitive impairment and required extensive assistance for activities of daily living, was admitted with multiple diagnoses including dementia with behavioral disturbance. The care plan for Resident #33 included a mobility bar to assist with mobility, but no assessments for side rails or enabler bars were completed. Similarly, Resident #58, who had moderate cognitive impairment and was dependent on staff for activities of daily living, had a care plan that included a mobility bar, but no assessments were conducted for side rails or enabler bars. Interviews with the Maintenance Director and Assistant Director of Nursing revealed that enabler bars were not assessed for proper fit or need upon admission or routinely thereafter. The Director of Nursing confirmed that no assessments had been completed for any residents with enabler bars or side rails, despite the facility's policy requiring such assessments at least quarterly or upon significant changes in status. The lack of assessments for side rails and enabler bars was acknowledged as an issue that needed to be addressed throughout the facility.
Unqualified Activity Director
Penalty
Summary
The facility failed to ensure the activity department was overseen by a qualified activity professional. The personnel file for the Activity Director, who was hired on 03/15/23 and promoted on 06/12/23, revealed no certification or employment experience qualifying them for the role. During an interview, the Activity Director confirmed they were currently enrolled in a course to become certified. The Administrator also confirmed that the Activity Director was not certified and lacked the necessary previous employment experience to oversee the activity department. This deficiency had the potential to affect all 61 residents residing 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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