Springmeade Healthcenter
Inspection history, citations, penalties and survey trends for this long-term care facility in Tipp City, Ohio.
- Location
- 4375 South County Road 25 A, Tipp City, Ohio 45371
- CMS Provider Number
- 365882
- Inspections on file
- 36
- Latest survey
- April 3, 2025
- Citations (last 12 mo.)
- 0
Citation history
Health deficiencies cited at Springmeade Healthcenter during CMS and state inspections, most recent first.
The facility did not timely transcribe or implement wound care orders for several residents admitted with or at risk for pressure ulcers, resulting in delayed treatment, incomplete wound assessments, and actual harm to a resident whose pressure ulcer worsened. Wound care interventions and physician orders were not initiated as required, and documentation was incomplete or inconsistent, as confirmed by staff and record review.
Multiple residents and a family member reported that meals, especially breakfast and dinner, were often served cold, with food temperatures observed to be below required standards. Staff confirmed that the use of insulated plates instead of metal plates contributed to the issue, and only certain halls had access to metal plates due to supply limitations. Facility policy required hot foods to be held at 135°F or higher, but sampled food items were served well below this temperature, affecting the palatability and safety of meals for all residents.
The facility did not maintain a clean kitchen environment, with visible buildup of substances on light panels, vents, and windows, and failed to ensure safe food handling practices. An ADM was observed using the same gloves to touch both food and various surfaces without changing them, leading to potential cross-contamination. These deficiencies affected all residents receiving meals from the kitchen.
Multiple deficiencies were identified in the facility's infection prevention and control program, including staff not wearing required PPE during care for residents on Enhanced Barrier Precautions, inadequate hand hygiene during wound care, incomplete infection tracking and monitoring, and lack of updated policies and procedures for Legionella prevention. Staff were often unaware of which residents required EBP due to unclear signage, and water testing revealed positive Legionella results without timely intervention or notification of health authorities.
A resident with impaired cognition and multiple health issues experienced a change in condition requiring new medications and lab tests. Although the NP and physician were notified and interventions were implemented, there was no documentation or evidence that the resident's family or representative was informed of these changes. Staff interviews confirmed that family notification did not occur, and the facility could not provide a change of condition policy when requested.
A resident with multiple complex diagnoses was found to have scattered bruising on both upper extremities during a second skin assessment, with no documentation of an investigation into the cause. The DON and Unit Manager were unaware of the injury and the resident's concerns about rough handling during mechanical lift transfers until prompted by a surveyor, despite facility policy requiring investigation of such incidents.
A resident with a suprapubic catheter and complex medical history had a clear preference for having catheter changes performed by a urologist in the physician's office, but this preference was not documented in the care plan. Facility staff continued to follow standing orders for in-facility catheter changes, and the care plan was not updated to reflect the resident's wishes, as confirmed by both the resident and the MDS RN.
A resident with significant cognitive impairment and multiple medical conditions did not receive needed assistance with oral care and denture use, as required by her care plan. Staff were unaware of her need for dentures, resulting in her being without them during meals and unable to eat most of her food.
Two residents who valued group activities reported insufficient opportunities for participation, with facility-led activities ending early in the day and limited evening options that were resident-driven and not inclusive. Staff confirmed the lack of structured activities beyond the afternoon, and care plans focused mainly on independent pursuits rather than group engagement.
Three residents with skin impairments did not receive timely assessment, clear physician orders, or appropriate documentation for their wounds. In one case, a wound was not treated for two days after discovery, in another, unclear orders led to incomplete wound care, and in a third, a skin injury was not documented or reported to nursing or medical staff as required by facility policy.
Three residents experienced falls or accidents due to the facility's failure to conduct thorough investigations, identify hazards, and implement individualized interventions. One resident with dementia had multiple unwitnessed falls without comprehensive root cause analysis or detailed documentation. Another resident was injured when a CNA transported her in a wheelchair without foot pedals. A third resident with multiple fractures had several falls, with incomplete investigations and unclear documentation. Facility leadership confirmed that required documentation and analysis were not consistently performed.
A resident with impaired cognition and incontinence exhibited symptoms of a UTI and was prescribed cefuroxime, but staff failed to initiate the antibiotic as ordered despite its availability, resulting in a two-day delay in treatment. Nursing staff and the DON confirmed the medication should have been started immediately, but the facility's medication administration policy was not followed.
A resident with multiple comorbidities was prescribed Vancomycin for C-Diff, but due to pharmacy delays and lack of order update, three initial doses were missed and the full seven-day course was not completed. The DON confirmed the incomplete administration, and the resident was later hospitalized with sepsis and pancolitis.
Surveyors found that medications, including antifungal powder and topical creams, were left unsecured in the rooms of three residents with complex medical needs. These medications were present without proper labeling, physician orders, or oversight by licensed staff, in violation of medication storage protocols.
Failure to Timely Implement and Document Pressure Ulcer Care
Penalty
Summary
The facility failed to transcribe and implement treatment orders in a timely manner for the care of pressure ulcers for multiple residents, resulting in actual harm to one resident and placing others at risk for more than minimal harm. One resident was admitted with a Stage 2 pressure ulcer to the sacrum/coccyx area and did not receive any treatment or intervention from the facility for several days, despite clear documentation from the hospital regarding the wound. The wound was not treated until several days after admission, during which time it worsened to an unstageable wound. Documentation and assessment of the wound were incomplete, with missing measurements and delayed initiation of physician-ordered treatments. Another resident was identified as high risk for skin breakdown and developed a stage three pressure ulcer that was not measured or staged at the time of discovery. The wound was only identified during a weekly skin assessment, and the appropriate wound care interventions were not implemented until after the wound had progressed. The nurse and DON confirmed that the wound should have been identified and measured sooner, and that the delay in assessment and intervention contributed to the deficiency. Additional residents were admitted with existing wounds, but the facility failed to transcribe and implement hospital discharge wound care orders upon admission. Wound assessments were incomplete, with missing measurements and inconsistent documentation regarding the type and stage of wounds. Treatments were not initiated until several days after admission, and there were delays in obtaining wound physician assessments and implementing their orders. These failures were confirmed by staff interviews and review of medical records, and were not in accordance with facility policy or national guidelines for pressure injury care.
Failure to Serve Meals at Safe and Palatable Temperatures
Penalty
Summary
The facility failed to ensure that meals were served to residents at a safe and palatable temperature, as evidenced by multiple resident and family interviews, staff interviews, direct observation, and policy review. Several residents reported that their meals, particularly breakfast and dinner, were often served cold, especially when delivered to their rooms or to the 300 hall, which was the last to receive trays. One resident's daughter expressed concern due to her father's poor appetite, which was further impacted by the cold food. Direct observation confirmed that food items such as eggs and oatmeal were served below the required temperature, and the taste was not palatable. The Assistant Dietary Manager acknowledged that the use of insulated plates instead of metal plates contributed to the issue, and that only two halls had access to metal plates due to supply limitations from the previous company. Review of the facility's policy indicated that hot foods should be held at 135 degrees or higher to ensure safety and palatability, and reheated foods should reach 165 degrees. However, sampled food temperatures were significantly below these standards, with eggs at 92.5 degrees and oatmeal at 119 degrees. The facility census was 87, and there were no residents who were NPO (nothing by mouth), indicating that all residents could potentially be affected by this deficiency.
Failure to Maintain Kitchen Cleanliness and Safe Food Handling Practices
Penalty
Summary
The facility failed to maintain a clean kitchen environment and did not ensure food was served in a safe manner, affecting all residents who received meals from the kitchen. Observations revealed multiple sanitation issues, including five ceiling light panels in the dishwasher area and three sets of five lights across the kitchen with a grey flaky substance present either inside or on the outside of the panels. A vent in the dishwasher area was noted to have a thick black substance on its exterior. Additionally, four kitchen windows had splashes of a white substance, and their screens were covered with a thick layer of grey particles. One window was open during the observation, allowing wind to blow into the kitchen. The Culinary Manager confirmed these cleanliness issues. During a tray line observation, the Assistant Dietary Manager was seen serving food after washing her hands and donning gloves. However, she used her gloved hands to touch both food items and various surfaces, such as meal tickets and aluminum foil, without changing gloves between tasks. She handled the vegetable lasagna directly with her gloved hand and then used the same gloves to pick up garlic bread and manipulate other items, failing to prevent cross-contamination. The Assistant Dietary Manager acknowledged that she should have changed gloves or used utensils as per the facility's handwashing policy, which requires handwashing and glove changes to prevent cross-contamination when handling exposed food.
Failure to Implement Effective Infection Prevention and Control Program
Penalty
Summary
The facility failed to implement and maintain an effective infection prevention and control program, as evidenced by multiple deficiencies in staff adherence to Enhanced Barrier Precautions (EBP), hand hygiene, infection tracking, and water safety protocols. Staff members did not consistently wear required personal protective equipment (PPE) such as gowns and gloves when providing care to residents under EBP, including during dressing changes and wound care. In several instances, staff were unaware of which residents required EBP due to inadequate signage and communication, and PPE was not readily available or recognized in resident rooms. For example, a registered nurse performed a dressing change for a resident on EBP using only gloves, and both the nurse and housekeeping manager confirmed the lack of clear signage and PPE availability. Another resident received wound care and incontinent care without staff donning appropriate PPE, and staff interviews revealed uncertainty about which residents were on EBP. Hand hygiene practices were also deficient. During a skin assessment and peri-care for a resident with a stage three pressure ulcer, an LPN failed to change gloves after cleaning stool and before measuring the wound, resulting in potential cross-contamination. The LPN confirmed this lapse in practice during the interview. Additionally, infection tracking and monitoring were not accurately or timely maintained. The infection preventionist tracked infections using a color-coded mapping system, but failed to complete tracing for a month in which urinary tract infections (UTIs) had doubled, missing the opportunity to identify patterns and provide staff education or interventions. The facility also failed to provide updated policies and procedures for Legionella prevention and water safety. The maintenance manager and administrator were unable to provide documentation of water temperature checks, line flushing, or inspections, and the facility continued to operate under an outdated Legionella policy. Water testing revealed positive Legionella results in two areas, but the local health department was not notified, and required interventions such as flushing and retesting were delayed. The facility's policy required scheduled monitoring and a system approach to positive results, but these were not followed, as confirmed by staff interviews and policy review.
Failure to Notify Resident Representative of Change in Condition
Penalty
Summary
The facility failed to notify the resident representative when a change in health status occurred for a resident with multiple diagnoses, including dementia, hypertension, and benign prostatic hyperplasia. The resident experienced symptoms such as altered mental status, emesis, fever, and diminished lung sounds, which led to new physician orders for laboratory tests, medications, and diagnostic imaging. Medical record review showed that while the nurse practitioner and physician were notified of the resident's condition changes and new orders were implemented, there was no documentation that the resident's family or representative was informed of these significant changes, including the addition of new medications and laboratory testing. Staff interviews confirmed that the assigned LPN did not notify the family of the new orders or the change in the resident's condition. The progress notes were silent regarding family notification during the period when the resident's health status changed and interventions were initiated. Additionally, the facility was unable to provide a change of condition policy when requested during the survey process.
Failure to Investigate Injury of Unknown Origin
Penalty
Summary
The facility failed to investigate an injury of unknown origin for a resident admitted with Parkinson's disease, traumatic subdural hemorrhage, and bipolar disorder with psychotic features. Upon admission, the initial skin assessment did not document any areas of concern. However, a second skin assessment conducted three days later identified scattered bruising on both upper extremities, which was also noted in the progress notes. The family and physician were notified of the bruising, but there was no documentation of an investigation into the cause of the injuries at that time. During interviews, the resident reported feeling that staff were rough during mechanical lift transfers, though he had not reported this to staff. The DON was unaware of both the bruising and the resident's concerns until questioned by the surveyor, and the Unit Manager confirmed observing the bruising but did not document any investigation. The facility's policy requires investigation of all alleged violations, including injuries of unknown source, but this was not followed in this case.
Care Plan Failed to Reflect Resident Preference for Catheter Management
Penalty
Summary
The facility failed to ensure that the care plan for a resident with a suprapubic urinary catheter reflected the resident's preference for having catheter changes performed by the urologist in the physician's office, rather than in the facility. The resident, who had diagnoses including paraplegia, neurogenic bowel, chronic heart failure, chronic kidney disease, and neuromuscular bladder dysfunction, had a history of hospitalizations and follow-up appointments where the urologist changed the catheter in the office. Despite this, the resident's care plan and medical record did not document this preference, and facility orders continued to direct staff to change the catheter monthly on the night shift, with some orders being discontinued or unsigned without documentation of resident refusal. Interviews with the resident confirmed dissatisfaction with the facility's handling of catheter orders, and review of the care plan by the MDS RN verified that the resident's preference for in-office catheter changes was not addressed. The facility's policy required person-centered care planning, but the interdisciplinary team did not update the care plan to reflect the resident's wishes, resulting in a lack of alignment between the resident's preferences, physician orders, and the care provided.
Failure to Assist Resident with Denture Use and Oral Care
Penalty
Summary
A deficiency was identified when a resident with significant cognitive impairment and multiple medical diagnoses, including liver cell carcinoma, congestive heart failure, and depression, did not receive necessary assistance with activities of daily living (ADLs), specifically with oral care and denture use. The resident's care plan indicated a need for staff to assist with oral care and encourage denture use due to her full upper dentures and lack of lower teeth. Despite this, observations and interviews revealed that the resident was often without her dentures, impacting her ability to eat meals. The resident's daughter reported concerns that staff were not assisting her mother with her dentures, noting that she would often find her mother without them after breakfast. Multiple observations confirmed the resident did not have her dentures in, and during one meal, she was only able to eat sherbet because her dentures were not in place. A CNA interviewed was unaware the resident had dentures and relied on residents to inform her, acknowledging that confused residents may not communicate this need. The dentures were eventually located in the bathroom, but the lack of staff awareness and assistance resulted in the resident not having her dentures during meals.
Failure to Provide Adequate Activity Program for Residents
Penalty
Summary
The facility failed to provide an activity program that met the needs and preferences of its residents, as evidenced by the experiences of two residents reviewed. Both residents were cognitively intact and expressed that participating in group activities was very important to them. However, the activity calendar showed that facility-led activities were limited, with the last scheduled activity each day occurring at 2:00 P.M. and only one evening activity per week, which was resident-led and not inclusive of all residents. Interviews with the residents revealed dissatisfaction with the lack of activities in the late afternoon and evening, and that some resident-led activities were not open to everyone, leaving some residents feeling excluded. Staff interviews confirmed that the activities coordinator worked only until 4:00 P.M. and that evening activities were not facilitated by staff, nor was participation tracked. The activity leader acknowledged that there were not enough activities being conducted to meet residents' needs and that the current program did not align with the facility's policy to provide a program responsive to residents' interests and needs. Medical record and care plan reviews further indicated that the interventions for these residents primarily involved providing materials for independent activities upon request, rather than structured group activities as preferred by the residents.
Failure to Timely Assess, Document, and Treat Skin Impairments
Penalty
Summary
The facility failed to provide timely assessment, obtain appropriate treatments, clarify, and complete physician orders for three residents with skin impairments. For one resident with a history of dementia, hip dislocation, and incontinence, a new open area was discovered on the left buttock during incontinence care. Although the area was reported and assessed, there was a delay in initiating a physician order for wound treatment, which was not started until two days after the wound was first identified. Documentation showed the wound increased in size and developed drainage before treatment began. Another resident with dementia, altered mental status, and a history of skin cancer had unclear and conflicting treatment orders for wounds on the forehead. During wound care, an LPN applied only one of the two ordered ointments, and later admitted to not following the full order due to confusion about which ointment should be used. The treatment administration record was signed as if both treatments were completed, despite only one being applied. The DON confirmed that the orders were unclear and that documentation did not accurately reflect the care provided. A third resident with a history of cancer, malnutrition, and rheumatoid arthritis was observed with an undated dressing on the left forearm covering a scabbed area. The resident reported a recent bleeding incident, but there was no documentation in the medical record regarding the skin impairment, no skin assessment, and no physician notification or treatment order. Nursing staff and management were unaware of the new skin area, and facility policy requiring measurement and documentation of all skin areas was not followed.
Failure to Prevent Accidents and Incomplete Fall Investigations
Penalty
Summary
The facility failed to ensure a safe environment free from accident hazards and did not provide adequate supervision or implement appropriate interventions to prevent accidents and falls for three residents. For one resident with dementia and a history of falls, the facility did not conduct comprehensive fall investigations or root cause analyses after multiple unwitnessed falls. Documentation lacked detailed evaluation of environmental or situational hazards, and there was no evidence of witness statements or thorough review of circumstances leading to the falls. Interventions were limited to frequent checks and keeping mobility aids within reach, without clear documentation of individualized or effective fall prevention strategies. Another resident, who was cognitively intact and had a history of CVA and mobility limitations, was injured when a CNA transported her in a wheelchair without foot pedals, resulting in the resident's foot becoming caught under the chair and causing pain to a previously injured knee. The CNA admitted to not using the foot pedals because the transfer was a short distance, and the incident was documented in the medical record. The facility provided education to staff and the resident after the incident, but the initial failure to use required equipment directly contributed to the accident. A third resident with multiple fractures and a history of falls experienced several falls during her stay, some resulting in head injuries and lacerations. Fall investigations for these incidents were incomplete, with documentation consisting of brief, unclear notes that did not allow for determination of the circumstances or contributing factors. The facility did not document root cause analyses, witness statements, or details such as the last time the resident was seen or toileted. The facility's fall management policy required comprehensive documentation, but this was not followed in practice, as confirmed by interviews with facility leadership.
Delay in Initiation of Prescribed Antibiotic for UTI
Penalty
Summary
A deficiency occurred when the facility failed to timely initiate prescribed antibiotic treatment for a resident diagnosed with a urinary tract infection (UTI). The resident, who had a history of dementia, altered mental status, benign prostatic hyperplasia with urinary symptoms, and was incontinent of bowel and bladder, exhibited changes in condition including nausea, vomiting, fever, and altered mental status. Laboratory tests and physician assessments led to an order for cefuroxime axetil 500 mg twice daily to treat the UTI. Despite the order being received and the medication being available in the on-site emergency medication dispensary, the antibiotic was not started as prescribed. Documentation shows that the order for cefuroxime was received, but administration did not begin until two days later. The delay was confirmed by review of the medication administration record, which indicated that the first dose was given two days after the order was received. Interviews with nursing staff and the DON confirmed that the medication should have been started immediately and that the system would default to the next scheduled dose if not manually adjusted. The facility's policy requires medications to be administered as prescribed, but this was not followed in this instance, resulting in a delay in treatment for the resident's UTI.
Failure to Administer Full Course of Prescribed Antibiotic for C-Diff
Penalty
Summary
A deficiency occurred when a resident with a history of liver cell carcinoma, congestive heart failure, and depression was admitted and subsequently diagnosed with Clostridioides Difficile (C-Diff). The physician ordered Vancomycin to be administered four times daily for seven days. However, the medication was not available from the pharmacy at the time the order was written, resulting in three missed doses at the start of the prescribed course. The order was not updated to reflect the actual start date of the medication, and the resident did not receive the full prescribed duration of antibiotics. Documentation shows that the resident began receiving Vancomycin only after a delay, and the missed doses were noted in the Medication Administration Record and nursing progress notes. The Director of Nursing confirmed that the resident did not receive the full course as ordered. The resident experienced a decline in condition, including increased lethargy and confusion, which led to hospitalization. Hospital records indicated a diagnosis of sepsis secondary to C-Diff and pancolitis.
Failure to Secure and Appropriately Store Medications
Penalty
Summary
Surveyors identified that the facility failed to ensure medications and biologicals were safely and appropriately stored, as required by professional standards. In three separate cases, medications were found unsecured in resident rooms, accessible to individuals without proper authorization or knowledge of their use. For one resident with multiple diagnoses including bipolar disorder, vascular dementia, and diabetes, an open, unlabeled bottle of antifungal powder was found on the bedside table, despite no physician order for its use. Nursing staff confirmed that the medication should not have been present in the room and that the resident did not have an order for it. Another resident with a history of cancer, pressure ulcers, and other complex medical conditions was found to have three containers of topical medication in their room, labeled with their name and application instructions. These medications were intended for wound care and were supposed to be administered by licensed personnel. Both the wound physician and unit managers confirmed that these medications should not have been left in the resident's room unsupervised, and the containers were subsequently removed by staff. A third resident, with diagnoses including dementia, Alzheimer's disease, and a history of hip dislocation, was also found to have an open, unlabeled bottle of antifungal powder on the bedside table. Nursing staff again verified that the medication should not have been in the room and that there was no physician order for its use. In all three cases, the facility failed to follow proper medication storage protocols, resulting in medications being accessible in resident rooms without appropriate oversight.
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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