St Luke Lutheran Community-portage Lakes
Inspection history, citations, penalties and survey trends for this long-term care facility in Akron, Ohio.
- Location
- 615 Latham Ln, Akron, Ohio 44319
- CMS Provider Number
- 366280
- Inspections on file
- 23
- Latest survey
- January 29, 2025
- Citations (last 12 mo.)
- 0
Citation history
Health deficiencies cited at St Luke Lutheran Community-portage Lakes during CMS and state inspections, most recent first.
A facility failed to develop a comprehensive care plan for a resident with a new coccyx wound. Despite a WCNP ordering specific treatments, no care plan was created. The resident had multiple diagnoses, including dementia and diabetes, and required significant assistance. The deficiency was confirmed by the DON and ADON, who acknowledged the oversight, which was against the facility's policy for baseline care plans.
A facility failed to provide timely and proper wound care for a resident with a complex medical history, including venous stasis ulcers. The resident's care plan required specific interventions, but treatments were not completed on multiple occasions. An LPN responsible for the missed treatments was terminated for insubordination after failing to perform the required care, as confirmed by the DON and ADON.
A facility failed to ensure a resident's medical record accurately reflected wound care treatment orders. Despite the nursing staff following the WCNP's orders, these were not transcribed into the EMR or TAR. Interviews confirmed the orders were never entered, highlighting a lapse in maintaining accurate medical records.
The facility failed to provide the correct QIO information in the NOMNC letters to three residents completing therapy. The deficiency was confirmed through interviews with the Administrator and Social Service Designee, revealing that the letters lacked accurate QIO details.
The facility failed to ensure that three residents, who were dependent on staff for showering, received showers as scheduled. Despite being cognitively intact or impaired, these residents did not receive the necessary assistance with activities of daily living, as confirmed by interviews and shower documentation. The Director of Nursing verified the lack of evidence for scheduled showers.
A resident with type 2 diabetes and other conditions did not receive scheduled meals due to the absence of a diet card, as confirmed by the Food Service Director and DON. The resident missed at least two meals, and a concern was logged when a dinner tray was not served timely, leading to food being sourced externally.
A resident in an LTC facility suffered significant bruising on both arms due to rough handling by an STNA. Despite reports of similar past incidents, the facility's investigation was inadequate, failing to substantiate abuse or prevent further harm. The facility's policy on preventing resident harm was not effectively followed, leading to non-compliance.
The facility's call system failed to alert staff effectively, leading to delayed responses to residents' needs. Observations showed call lights were not promptly answered, and interviews revealed residents' concerns about long wait times. Staff confirmed the lack of a functioning pager system, relying on visual checks of hallway lights. Call light response audits showed significant delays, indicating a systemic issue.
A resident with dementia and other medical conditions sustained bruises on both arms due to alleged rough handling by staff during night shifts. The facility's investigation was inadequate, lacking direct witness testimony and proper documentation. Interviews revealed inconsistencies and poor communication, leading to the placement of two agency staff on a do-not-return list.
A facility failed to update a resident's care plan to reflect changes in meal assistance needs and dietary orders. Despite physician orders for meal assistance and a regular diet, the care plan lacked necessary interventions. Staff interviews revealed inconsistencies in meal assistance and documentation, with some unaware of the need to log meal intake. The DON confirmed the care plan did not accurately reflect the resident's current needs, and there was no record of interdisciplinary meetings to address these issues.
A resident with significant medical needs was not assisted out of bed according to their preference, despite requesting to be transferred after breakfast. The staff delayed the transfer, prioritizing other tasks, which led to the resident remaining in bed for an extended period. The facility's policy on transferring non-ambulatory residents was not followed, and the deficiency was acknowledged by the DON and interim Administrator.
Failure to Develop Comprehensive Wound Care Plan
Penalty
Summary
The facility failed to develop a comprehensive care plan for a resident with a new wound on the coccyx. The resident, who had multiple diagnoses including dementia, cerebral infarction, and diabetes mellitus, was admitted with severely impaired cognition and required substantial assistance with daily activities. Despite a consultation with a Wound Care Nurse Practitioner (WCNP) who ordered specific treatments for the wound, the facility did not create a care plan to address the wound care needs. The deficiency was confirmed during an interview with the Director of Nursing and the Assistant Director of Nursing, who acknowledged that a wound care plan had not been developed for the resident. The facility's policy on baseline care plans, which mandates the development of a care plan for each resident to provide effective and person-centered care, was not followed. This oversight was identified during the investigation of a complaint, highlighting a lapse in adhering to professional standards of quality care.
Failure to Provide Timely Wound Care
Penalty
Summary
The facility failed to ensure timely and proper wound care treatments for a resident, identified as Resident #41, as per physician orders. Resident #41 had a complex medical history, including cellulitis, sepsis, diabetes, and venous stasis ulcers, which required specific wound care interventions. The care plan for Resident #41 included various interventions to prevent skin breakdown, such as the use of barrier creams, pressure reduction mattresses, and regular repositioning. However, the Treatment Administration Record (TAR) indicated that the prescribed treatments were not completed on several occasions, specifically on 12/17/24, 12/18/24, and 12/21/24. Interviews with facility staff revealed that LPN #805 was responsible for the missed treatments and had been previously educated and disciplined for similar issues. Despite these measures, LPN #805 failed to perform the required treatments, leading to their termination on 12/22/24 for insubordination. The Director of Nursing and the Assistant Director of Nursing confirmed the non-compliance with the treatment orders, which was a significant factor in the deficiency identified during the investigation of Complaint Number OH00160998.
Incomplete Medical Record for Wound Care
Penalty
Summary
The facility failed to ensure that Resident #1's medical record was complete and accurately reflected the treatment orders for wound care. Resident #1, who had multiple diagnoses including dementia and diabetes mellitus, was admitted with a new wound to the coccyx. The wound care nurse practitioner (WCNP) ordered specific treatments for the wound, which were not transcribed into the Electronic Medical Record (EMR) physician orders. Despite the nursing staff following the treatment orders as noted in progress notes, the orders were absent from the official physician orders and the Treatment Administration Record (TAR). Interviews with the Licensed Practical Nurse (LPN), Director of Nursing (DON), and Assistant Director of Nursing (ADON) confirmed that the orders were never entered into the EMR. The WCNP stated that it was the facility's responsibility to ensure her orders were entered into the EMR. The deficiency was identified during an investigation of a complaint, highlighting a lapse in the facility's process for maintaining accurate and complete medical records for wound care management.
Incorrect QIO Information in NOMNC Letters
Penalty
Summary
The facility failed to provide the correct Quality Improvement Organization (QIO) information in the Notice of Medicare Non-Coverage (NOMNC) letters to residents who were completing therapy. This deficiency affected three residents, as identified in the report. Resident #145 was readmitted to the facility, and their services ended on 09/26/24, but the NOMNC letter did not include the correct QIO information. Similarly, Resident #146, admitted to the facility, had their services ended on 08/31/24, and Resident #147, also admitted, had their services ended on 02/20/24, both without the correct QIO information in their NOMNC letters. Interviews conducted on 11/27/24 with the Administrator and Social Service Designee #240 confirmed that the letters provided to these residents did not contain the correct QIO information. This oversight in providing accurate information in the NOMNC letters was identified during the review of the residents' medical records and staff interviews.
Failure to Provide Scheduled Showers for Dependent Residents
Penalty
Summary
The facility failed to provide adequate assistance with activities of daily living, specifically in ensuring that residents received showers as scheduled. This deficiency affected three residents who were dependent on staff for showering. Resident #15, who has a complete lesion at the T-7 through T-10 level of the thoracic spinal cord and is cognitively intact, did not receive showers twice a week as scheduled. The shower documentation for Resident #15 showed that showers were only offered or given on four occasions over a 60-day period, which was confirmed by both the resident and the Director of Nursing. Similarly, Resident #25, who has Down Syndrome, difficulty walking, and anxiety disorder, and is cognitively impaired, also did not receive showers twice a week as scheduled. The shower records indicated sporadic showering dates, which were insufficient according to the schedule. Resident #29, with diagnoses including radiculopathy of the lumbar region and type 2 diabetes mellitus, also did not receive showers as scheduled, with records showing only one shower since admission. Interviews with the residents and the Director of Nursing confirmed the lack of adherence to the scheduled showering routine for these residents.
Failure to Provide Scheduled Meals to Resident
Penalty
Summary
The facility failed to ensure that Resident #29 received meals as scheduled to meet their dietary needs. Resident #29, who was admitted with diagnoses including radiculopathy of the lumbar region, type 2 diabetes mellitus, and hyperlipidemia, was on a regular diet with thin liquids and was cognitively intact. The resident reported not being served breakfast on one day and lunch on another, although he could not recall the specific dates. The Food Service Director confirmed that no diet card was created for the resident due to her absence on the day of admission, resulting in the resident missing at least two meals. The Director of Nursing also confirmed that the resident missed breakfast and dinner, though the dates were unspecified. A concern log noted that the resident had an issue on November 4, 2024, regarding a dinner tray not being served timely, which was resolved by obtaining food from an outside source.
Failure to Protect Resident from Physical Abuse
Penalty
Summary
The facility failed to protect a resident from physical abuse by a State Tested Nursing Assistant (STNA), resulting in significant bruising on both arms. The incident occurred when the resident was reportedly handled roughly during care, leading to large bruises on the upper arms. The resident, who had a history of dementia with agitation and other medical conditions, reported pain and described the STNA as being rough. Interviews with the resident and his family revealed that this was not the first instance of bruising from rough handling by staff. The facility's investigation into the incident was inadequate. Although the Director of Nursing (DON) and other staff were aware of the bruising and the resident's report of rough handling, the investigation did not substantiate abuse due to conflicting witness statements and lack of direct observation of the incident. The facility's self-reported incident (SRI) and subsequent interviews with staff and hospice nurses indicated that the resident had experienced similar bruising in the past, which was also reported to the previous DON. Despite these reports, the facility did not conduct a thorough investigation into the previous incident, and the current investigation was inconclusive. The facility's policy on abuse, neglect, and exploitation requires steps to prevent resident harm, including injury from rough handling. However, the facility did not adequately follow this policy, as evidenced by the lack of a comprehensive investigation and failure to prevent further incidents of rough handling. The report highlights the facility's non-compliance with its own policies and the need for more effective measures to protect residents from abuse.
Deficient Call System Response in LTC Facility
Penalty
Summary
The facility failed to maintain an effective resident call system, which compromised the ability to promptly respond to residents' needs. Observations revealed that call lights were activated in several rooms, but staff response times were delayed, ranging from 10 to 17 minutes during a specific observation period. Additionally, there was no audible alert system or centralized panel at the nurses' station to notify staff of activated call lights, and the pagers intended for this purpose were not in use due to missing batteries. Interviews with residents and staff highlighted concerns about the call light response times. Residents expressed frustration with the delays, with one resident reporting a wait time of up to four hours over a weekend. Staff interviews confirmed the lack of a functioning pager system, with STNAs relying solely on visual checks of hallway lights to identify activated call lights. The Director of Nursing acknowledged the expectation for staff to respond immediately or as soon as possible, but the absence of a working notification system hindered this process. A review of call light response audits further demonstrated significant delays, with multiple instances of response times exceeding 20 minutes. The facility's policy required call lights to alert staff directly or through a centralized system, but this was not effectively implemented. The deficiency was investigated under Complaint Number OH00157294, indicating a systemic issue affecting the entire facility's resident population.
Failure to Investigate Allegations of Abuse
Penalty
Summary
The facility failed to thoroughly investigate allegations of potential abuse, which affected a resident who had been admitted with multiple medical conditions, including dementia with agitation and depression. The resident, who had intact cognition, was noted to have sustained bruises on both arms on two separate occasions. The first incident was reported by a hospice nurse, and the second incident was reported by another hospice nurse, both indicating rough handling by staff during night shifts. The facility's investigation into the incidents was inadequate. The initial report to the Ohio Department of Health did not include corroboration from the resident's power of attorney regarding the separate occurrences. The investigation findings for the second incident did not substantiate abuse due to a lack of direct witness testimony, as the nurse on duty was not present during the alleged rough handling. Additionally, there was no documentation of interviews with witnesses or the alleged perpetrator, and the facility's policy on abuse and neglect was not followed thoroughly. Interviews with the resident, family members, hospice staff, and facility staff revealed inconsistencies and a lack of communication regarding the incidents. The facility's Director of Nursing placed two agency staff members on a do-not-return list due to dishonesty and uncertainty about who provided care during the incidents. The facility administrator was unaware of the actions taken and acknowledged the need for further investigation after new information was brought to light.
Failure to Update Resident Care Plan for Meal Assistance
Penalty
Summary
The facility failed to review and revise the comprehensive care plan for a resident as their needs and required interventions changed. This deficiency affected a resident with multiple diagnoses, including senile degeneration of the brain, dysphagia, hemiplegia, major depressive disorder, anxiety disorder, and neuromuscular dysfunction. The resident had severely impaired cognition and was dependent on assistance for eating, yet the care plan did not reflect the necessary interventions for meal assistance or dietary changes. The resident's care plan, initiated in early March, did not include interventions related to the level of assistance needed for eating, despite physician orders indicating the need for meal assistance and a regular diet with thin liquids. The care plan also failed to document the resident's history of meal refusals, preferences, or the requirement to log meal intake in an orange folder. Interviews with staff revealed inconsistencies in meal assistance and documentation, with some staff unaware of the need to log meal intake or the level of assistance required. The Director of Nursing (DON) confirmed that interdisciplinary team meetings were held quarterly and with changes in condition, but there was no record of these meetings or updates to the care plan. The DON acknowledged that the care plan did not accurately reflect the resident's current diet orders, assistance needs, or history of meal refusals. The facility's policy required comprehensive care plans to be developed and implemented based on assessments of each resident's needs, but this was not adhered to in this case.
Failure to Honor Resident's Transfer Preferences
Penalty
Summary
The facility failed to accommodate a resident's preference regarding their transfer out of bed, which was a violation of the resident's right to self-determination. The resident, who had a history of cerebral infarction, hemiplegia, and other medical conditions, required substantial assistance for mobility and used a mechanical lift for transfers. Despite the resident's request to be transferred out of bed in the morning after breakfast, the staff did not comply with this preference. Observations revealed that the resident remained in bed well into the morning and early afternoon, despite expressing a desire to get out of bed. Interviews with staff confirmed that the resident's request was not prioritized, as the staff member responsible for the resident's care delayed the transfer until after completing other tasks. The resident expressed dissatisfaction with this delay, indicating a lack of respect for their preferences. The facility's AM Care policy, which required non-ambulatory residents to be transferred to a wheelchair, was not followed in this instance. The Director of Nursing and interim Administrator acknowledged that the resident should have been assisted out of bed when requested, confirming the deficiency in care.
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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