The Laurels Of Middletown
Inspection history, citations, penalties and survey trends for this long-term care facility in Middletown, Ohio.
- Location
- 751 Kensington Street, Middletown, Ohio 45044
- CMS Provider Number
- 365457
- Inspections on file
- 23
- Latest survey
- September 26, 2025
- Citations (last 12 mo.)
- 2
Citation history
Health deficiencies cited at The Laurels Of Middletown during CMS and state inspections, most recent first.
A resident with impaired cognition and significant physical disabilities, who was care planned for two-person assistance during mobility and hygiene care, was being assisted by only one CNA during perineal care. As a result, the resident slid off the bed, hit his head on a chair, and complained of neck pain. The DON confirmed that the required two-person assistance was not provided at the time of the incident.
A significant medication error occurred when an LPN administered oxycodone to a resident with severe cognitive impairment and multiple diagnoses, despite the absence of an active physician order. The medication was recorded on the controlled drug log but not on the medication administration record, in violation of facility policy.
The facility failed to store, prepare, and distribute food in a sanitary manner, affecting all 97 residents. Observations revealed soiled areas, expired food, improper use of food thermometers, and mold in the ice machine. Staff interviews and policy reviews confirmed these deficiencies.
The facility failed to provide a clean, comfortable, and sanitary environment for its residents, affecting four individuals. Issues included broken and uncomfortable beds, visible drywall substances, and unpainted plaster on walls. Staff confirmed the residents' complaints and acknowledged the importance of addressing these issues, which had persisted for several months.
The facility failed to accurately code MDS assessments for six residents, leading to deficiencies in their comprehensive assessments. For example, one resident with severe cognitive impairment had an MDS assessment lacking functional status documentation, while another resident's dental issues were not accurately documented. The facility did not have a specific MDS completion policy but claimed to follow the RAI manual guidelines.
The facility failed to complete a PASRR upon admission for a resident with multiple mental health diagnoses, including anoxic brain injury, depression, bipolar disorder, schizoaffective disorder, functional quadriplegia, and convulsions. Despite a Review Results letter indicating a Pre-Admission Screen determination was not applicable and a level of care determination as Intermediate, there was no documentation of a PASRR in the resident's medical record. The Administrator confirmed the absence of PASRR documentation and was unable to verify its completion upon admission.
The facility failed to develop comprehensive dental care plans for two residents with significant dental issues, despite their expressed concerns and observed dental caries and broken teeth. This was confirmed by staff interviews and observations.
The facility failed to conduct regular care conferences for three residents, despite their medical conditions and cognitive status. The administrator confirmed the deficiency, citing the absence of a Social Service designee as the reason.
The facility failed to ensure proper hand hygiene and the application of a prescribed hand splint for a resident with functional quadriplegia. Despite physician orders and care plan interventions, the resident reported that the splint had not been applied for months, and his contracted hand had not been cleaned. Observations and interviews confirmed these deficiencies.
A resident with functional quadriplegia did not have his hand splint applied as ordered by the physician. Despite records indicating compliance, the resident reported and observations confirmed that the splint had not been applied for months, and his contracted hand was not cleaned, emitting a foul odor. Interviews revealed inconsistencies in care and failure to follow the facility's policy on braces and splints.
A resident with impaired cognition was found in possession of eight pills without an order or assessment permitting self-administration. The RN was unsure of the pills' origin despite having observed the resident take medication earlier. The facility's policy requires staff to observe residents swallow their medication, which was not followed.
The facility failed to ensure staff followed proper infection control procedures during IV medication administration. An LPN was observed dropping a PICC line on a resident's arm and preparing to administer a saline flush without recleaning the tip, contrary to the facility's aseptic technique policy.
The facility failed to provide timely care for a resident with a urinary tract infection, delaying the collection of a urine specimen and failing to document attempts or notify the physician of the delay. The resident had multiple medical diagnoses and required maximum staff assistance.
The facility failed to ensure timely completion of physician-ordered lab work for two residents. One resident had multiple lab tests ordered but not drawn despite recommendations, and another resident's urinalysis was delayed without proper documentation or physician notification.
The facility failed to complete weekly wound evaluations for a resident with a surgical wound following a left below the knee amputation (BKA). The resident's wound was not properly documented or measured for nearly a month, during which time the wound deteriorated. This deficiency was confirmed by an LPN and represents non-compliance with the facility's policy on Skin Management.
Failure to Provide Required Two-Person Assistance During Care Resulting in Resident Fall
Penalty
Summary
A resident with a history of nontraumatic intracerebral hemorrhage, traumatic compartment syndrome, paraplegia, and dysphagia was admitted to the facility and assessed as having impaired cognition with a BIMS score of six. The resident's care plan and comprehensive evaluation indicated a requirement for two-person assistance during self-care and mobility, specifically for toileting and hygiene care, due to the risk of falls and impaired ADL performance. Interventions included placing the bed against the wall and ensuring two staff members were present during care. On the date of the incident, the resident was receiving perineal care from a single CNA, despite the documented need for two-person assistance. While being turned to the left side, the resident slid off the bed, struck his head on a nearby chair, and landed on his back. The resident was alert and responsive but reported right-sided neck pain. The DON confirmed that only one staff member was present during the incident, which was not in accordance with the resident's care plan and facility expectations.
Medication Administered Without Active Physician Order
Penalty
Summary
A significant medication error occurred when a Licensed Practical Nurse (LPN) administered 5 mg of oxycodone to a resident who did not have an active physician order for the medication. The resident, who had diagnoses including encephalopathy, epilepsy, asthma, anxiety, dysphagia, and muscle weakness, was noted to have severely impaired cognition and required assistance with self-care. The administration of oxycodone was prompted by the resident exhibiting signs of agitation. The medication was documented on the Controlled Drug Record log but was not recorded on the medication administration record due to the absence of an active order. Review of facility policy confirmed that medications are to be administered only in accordance with written physician orders and all administrations should be recorded in the medication administration record. The incident was verified by the facility administrator, who confirmed the LPN's actions as described in the incident report.
Sanitation Deficiencies in Food Storage and Preparation
Penalty
Summary
The facility failed to store, prepare, and distribute food in a sanitary manner, potentially affecting all 97 residents. During an initial tour of the kitchen, a trash can under the hand washing sink was found soiled with splatter, and dirty dishtowels with live gnats were observed. The kitchen floor had debris, and the dishwasher had food debris. The walk-in refrigerator contained expired food items, and a large box was stored directly on the floor. The dietary manager confirmed that the facility received outdated frozen bread and allowed it to thaw on a rolling rack, following guidance from the corporate dietician based on a Google search. Pest control records could not confirm treatment for gnats despite the presence of pests in the kitchen area. During a lunch tray line observation, a dietary cook used a food thermometer without sanitizing it between uses, despite being advised not to use alcohol wipes. The dietary manager provided a dry paper towel for wiping the thermometer, which was used to check multiple food items. Additionally, the facility's ice machine had a brown substance on the front and an unknown black spotted substance inside, which was identified as mold by a dietary aide. The ice machine had not been cleaned since December 2023, contrary to the facility's policy of regular cleaning and disinfection. Further observations revealed that a dietary cook used gloved hands instead of tongs to place brats into buns during the lunch tray line. The dietary manager confirmed that tongs were available and should have been used. These deficiencies in food storage, preparation, and distribution practices were confirmed by staff interviews and policy reviews, indicating a failure to maintain sanitary conditions in the facility's kitchen, potentially impacting all residents receiving meals from the kitchen.
Failure to Maintain a Clean and Comfortable Environment
Penalty
Summary
The facility failed to provide a clean, comfortable, and sanitary environment for its residents, affecting four residents. Resident #46 reported that his bed was uncomfortable and appeared broken, with the mattress not lying correctly on the bed frame and a large white drywall substance on the wall beside his bed for several months. Resident #51 complained about feeling the bed rails through his mattress and pointed out uneven paint behind his bed. Both residents indicated that they had reported these issues to the staff, but no corrective actions had been taken. Observations confirmed the residents' complaints, with visible issues in the physical environment of their rooms. Further observations revealed that Resident #25's room had multiple black scratches on the walls, lightly covered with plaster but not painted. Resident #36's room had similar issues, with several areas of plaster but no paint. Interviews with staff, including a State Tested Nurse Aide (STNA) and the Housekeeping Manager, confirmed the residents' complaints and the poor condition of the rooms. The STNA and Housekeeping Manager acknowledged the importance of addressing these issues but noted that the problems had persisted for several months without resolution.
Inaccurate MDS Coding for Multiple Residents
Penalty
Summary
The facility failed to accurately code Minimum Data Set (MDS) assessments for six residents, leading to deficiencies in their comprehensive assessments. For instance, Resident #01, with severe cognitive impairment and multiple medical diagnoses, had an annual MDS assessment that lacked documentation to support the assessment of functional status, with section GG left blank. Similarly, Resident #24, who was cognitively intact, had a quarterly MDS assessment that also lacked documentation of functional status, with section GG left blank. The facility did not have a specific MDS completion policy but claimed to follow the RAI manual guidelines. Further deficiencies were noted for other residents. Resident #41, with multiple medical conditions including cognitive impairment, had an MDS assessment that failed to provide an assessment related to the level of care required. Resident #74, dependent on staff for medication administration, had an MDS assessment that did not assess his functioning level. Residents #92 and #82 had MDS assessments that inaccurately documented their dental status, despite observations and interviews confirming dental issues. The Regional MDS Nurse and RN confirmed the inaccuracies in the MDS assessments for these residents, indicating a failure to follow the RAI manual guidelines.
Failure to Complete PASRR Upon Admission
Penalty
Summary
The facility failed to ensure a Pre-Admission Screening and Resident Review (PASRR) was completed upon admission for a resident with multiple mental health diagnoses, including anoxic brain injury, depression, bipolar disorder, schizoaffective disorder, functional quadriplegia, and convulsions. The medical record review revealed that the resident was admitted with these conditions and was cognitively intact but dependent on assistance for toilet hygiene, bed mobility, and transfers. Despite a Review Results letter indicating a Pre-Admission Screen determination was not applicable and a level of care determination as Intermediate, there was no documentation of a PASRR in the resident's medical record. The facility's policy required all individuals with serious mental illness or intellectual/developmental disabilities to be evaluated for appropriate placement in a nursing facility, starting with a Level 1 screening. The Administrator confirmed the absence of PASRR documentation and was unable to verify its completion upon admission.
Failure to Develop Comprehensive Dental Care Plans
Penalty
Summary
The facility failed to develop a comprehensive care plan to address the dental needs of two residents. Resident #92, who was admitted with diagnoses including osteomyelitis, anxiety, COPD, CHF, and psychoactive substance abuse, had a BIMS score of 15 indicating intact cognition and required supervision for activities of daily living. Despite these needs, there was no dental care plan in place. During an interview, Resident #92 expressed concerns about her broken lower teeth, which were observed to have several dental caries and broken teeth. This was confirmed by RN #245 and Clinical Coordinator RN #324, who verified the absence of a specific dental care plan for Resident #92's dental issues. Similarly, Resident #82, admitted with diagnoses including local skin infection, cellulitis, sepsis, and bipolar disorder, also had a BIMS score of 15 indicating intact cognition and required extensive assistance for bed mobility, transfers, toileting, and eating. Despite these needs, there was no dental care plan in place. Resident #82 expressed concerns about dental caries, and observations revealed multiple blackened and fragmented teeth. This was confirmed by RN #245 and the DON, who verified the absence of a specific dental care plan for Resident #82's dental issues.
Failure to Conduct Regular Care Conferences
Penalty
Summary
The facility failed to conduct resident care conferences as required, affecting three residents out of the five reviewed. Resident #24, who has medical diagnoses including atrial fibrillation and congestive heart failure, had only one care conference documented in the past 12 months despite being cognitively intact. Resident #54, with conditions such as chronic obstructive pulmonary disease and end-stage renal disease, also had only one care conference documented in the past year, despite requiring maximum staff assistance for various activities. Resident #79, who suffers from chronic respiratory failure and diabetes mellitus, had not attended a care conference for a very long time, with only one documented care conference in the past 12 months. Interviews with the residents confirmed the lack of regular care conferences, and the facility administrator acknowledged the deficiency, attributing it to the absence of a Social Service designee. The facility's policy mandates that care conferences be held within 72 hours of admission and quarterly thereafter, but this was not adhered to. The administrator confirmed that the medical records did not contain documentation to support that care conferences were conducted or offered as per the facility's policy.
Failure to Provide Hand Hygiene and Apply Hand Splint
Penalty
Summary
The facility failed to ensure that a resident was provided with proper hand hygiene and the application of a prescribed hand splint. Resident #49, who has a diagnosis of functional quadriplegia and other related conditions, was found to be dependent on staff for most activities of daily living. Despite physician orders and care plan interventions specifying the application of a hand splint twice a week and the necessity of hand hygiene, the resident reported that the splint had not been applied for months, and his contracted hand had not been cleaned. Observations confirmed that the hand splint was not applied on multiple occasions, and a sour odor was noted in the resident's room, which the resident attributed to his unclean hand. Interviews with the resident and staff further revealed inconsistencies in the care provided. The resident stated that staff had not placed the splint or cleaned his hand in months. A registered nurse claimed to have applied a washcloth to the resident's hand but was unable to demonstrate the task when asked. The facility's policy on braces and splints required a scheduled program for applying and removing the appliance and inspecting the skin for any issues, but this was not adhered to, leading to the deficiency in care for Resident #49.
Failure to Apply Hand Splint as Ordered
Penalty
Summary
The facility failed to ensure that a resident's hand splint was applied as ordered by the physician. Resident #49, who has a diagnosis of functional quadriplegia and other related conditions, was supposed to have a hand splint applied to his right hand twice a week. Despite the Treatment Administration Record indicating that the splint was applied, the resident reported that staff had not placed the splint on his hand for months. Observations over two days confirmed that the hand splint was not applied, and the resident's contracted hand emitted a foul odor due to lack of hygiene care. Interviews with the resident and a registered nurse revealed inconsistencies in the application and care of the hand splint. The resident stated that staff had not cleaned his contracted hand or applied the splint for months. The registered nurse was unable to demonstrate how she applied a washcloth to the resident's hand, despite claiming to have done so. The facility's policy on braces and splints requires a scheduled program for applying and removing the appliance, as well as regular skin inspections, which were not adhered to in this case.
Failure to Observe Medication Administration
Penalty
Summary
The facility failed to ensure that a resident was observed taking their medications at the time of administration. This deficiency was identified during a review of the medical record, observations, and interviews with both the resident and staff. Resident #74, who has diagnoses including alcohol dependence, epilepsy, dementia, anxiety, and metabolic encephalopathy, was found to have a Brief Interview Mental Status (BIMS) score of 10, indicating impaired cognition. Despite this, the resident was in possession of a medicine cup containing eight pills, which included Depakote, Keppra, Vitamin B, Vitamin D, and aspirin, without any order or assessment permitting self-administration of medications. During an observation and interview, the resident presented the medicine cup and stated it contained the pills he needed to take. A Registered Nurse (RN) verified the resident had eight pills in the cup and admitted to being unsure where the pills had come from, despite having observed the resident take the pills he administered that morning. The facility's policy on Medication Administration, last revised on 10/17/23, requires staff to observe residents swallow their medication, which was not adhered to in this instance.
Failure to Follow Infection Control Procedures During IV Medication Administration
Penalty
Summary
The facility failed to ensure staff followed proper infection control procedures during the administration of intravenous medication. Specifically, an LPN was observed administering medication via a PICC line to a resident with diagnoses including osteomyelitis, anxiety, and heart failure. The LPN cleansed the tip of the needleless connector with an alcohol swab but then intentionally dropped the line, causing it to land on the resident's arm. The LPN was prepared to administer the saline flush without recleaning the potentially contaminated tip until the surveyor intervened. The facility's policy on medication administration, last revised on 10/17/23, requires injections to be prepared using aseptic technique in a clean area.
Failure to Provide Timely Care for Urinary Tract Infection
Penalty
Summary
The facility failed to provide timely care and services to treat a urinary tract infection for a resident with multiple medical diagnoses, including neuromuscular dysfunction of the bladder. The resident, who had moderate cognitive impairment and required maximum staff assistance, was admitted with a physician order for a 16 French indwelling catheter and a subsequent order for a urinalysis with culture due to dysuria. Despite the resident's complaints of pain, dark-colored urine, and burning with urination, the facility delayed obtaining the urine specimen and failed to document attempts to collect it or notify the physician of the delay. The medical record revealed that the urine specimen was eventually obtained and placed in the refrigerator for lab pick-up, but there was no documentation of attempts to collect the specimen on the specified dates or any record of the resident refusing the collection. The Director of Nursing confirmed the lack of documentation and the failure to notify the physician about the delay. This deficiency was identified during an investigation under Complaint Number OH00153951.
Failure to Complete Physician-Ordered Lab Work in a Timely Manner
Penalty
Summary
The facility failed to ensure physician-ordered laboratory work was completed in a timely manner for two residents. Resident #52, who was admitted with multiple diagnoses including blindness, urine retention, and diabetes, had physician orders for various lab tests to be drawn every three months. Despite pharmacy recommendations on three separate occasions, the lab work had not been drawn as of the survey date. The Director of Nursing confirmed the oversight during an interview. Resident #298, admitted with diagnoses such as pneumonia and chronic obstructive pulmonary disease, had a physician order for a repeat urinalysis with culture due to dysuria. The medical record indicated that the resident complained of pain and dark-colored urine, and an order for a urinalysis was given. However, there was no documentation to support that the facility attempted to collect the urine specimen on the specified dates or that the resident refused the collection. Additionally, there was no documentation that the physician was notified of the delay. The Director of Nursing confirmed these findings during an interview.
Failure to Complete Weekly Wound Evaluations
Penalty
Summary
The facility failed to complete weekly wound evaluations for a resident with a surgical wound following a left below the knee amputation (BKA). The resident, who was admitted with multiple medical diagnoses including diabetes mellitus with neuropathy and depression, had a surgical wound with 20 staples that was not properly documented or measured from 02/20/24 until 03/19/24. The only wound evaluation during this period was on 03/19/24, which revealed the wound had deteriorated and measured 0.57 cm in length, 1.97 cm in width, and 1.6 cm in depth. The resident had injured the left BKA stump the day before, causing the incision to open, drain, and increase in pain, as noted by a Certified Nurse Practitioner (CNP) on 03/19/24. An interview with an LPN confirmed the lack of documentation for weekly wound evaluations for the resident's left BKA surgical site. The facility's policy on Skin Management, revised on 07/14/21, required weekly documentation of wound location, measurements, and characteristics until resolved. This deficiency was investigated under Complaint Number OH00152531 and represents non-compliance with the facility's own policy and standard care practices.
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.
Trusted data from CMS and state health departments
Every citation, penalty and Plan of Correction is sourced from public CMS records (latest release May 27, 2026) and official state health department websites — never guesswork.
Trusted by long-term care providers and associations.
