Tranquility Of Richmond Heights
Inspection history, citations, penalties and survey trends for this long-term care facility in Richmond Heights, Ohio.
- Location
- 562 Richmond Road, Richmond Heights, Ohio 44143
- CMS Provider Number
- 366377
- Inspections on file
- 30
- Latest survey
- July 14, 2025
- Citations (last 12 mo.)
- 2
Citation history
Health deficiencies cited at Tranquility Of Richmond Heights during CMS and state inspections, most recent first.
A resident was not properly assessed or prepared for transfer or discharge, and the facility did not ensure that the process met the resident's needs and preferences.
A resident with multiple medical conditions was not documented as having their guardian's concerns addressed after the guardian was not notified about a scheduled orthopedic follow-up appointment. The guardian only learned of the appointment after the resident was absent, voiced concerns to the Administrator and DON, but these concerns were not recorded in the medical record or concern log, contrary to facility policy.
Surveyors found the dumpster area unsanitary, with the lid and enclosure left open and significant debris such as cups, plastic wrap, gloves, and food wrappers scattered around. The Dietary Manager confirmed the findings and indicated that the maintenance director was responsible for maintaining the area.
The facility did not implement enhanced barrier precautions for multiple residents with wounds or indwelling medical devices, as required by CDC guidance, resulting in a lack of signage, PPE availability, and staff adherence during high-contact care activities. Staff interviews and observations confirmed inconsistent use of gowns and gloves, and a general lack of awareness regarding EBP. Additionally, the facility had not developed or implemented a water management program or Legionella risk assessment, despite having relevant policies and resources.
The facility did not ensure that education on the risks and benefits of flu and pneumonia vaccines was provided or documented, and failed to obtain written consent for these immunizations. Several residents with complex medical conditions were affected, with consent forms either missing, incomplete, or only indicating verbal consent or declination without specifying who made the decision or providing a signature. Staff confirmed that forms were not properly completed, following instructions from the previous DON.
The facility did not provide documented education on COVID-19 vaccine risks and benefits or obtain written consent for immunization for five residents with complex medical conditions. Consent forms were incomplete, often only noting a verbal declination without specifying who made the decision, and lacked signatures. Staff interviews confirmed that written consent and proper documentation were not obtained, contrary to facility policy.
A resident with end stage renal disease who required dialysis did not have consistent communication or documentation maintained between the facility and the dialysis center. Staff interviews confirmed that the resident refused vital sign checks and did not return communication sheets from the dialysis center, and the facility did not retain copies or reach out directly to the dialysis provider, resulting in a lack of required monitoring and documentation.
Pharmacy recommendations for medication changes, lab monitoring, and therapy evaluations were not reviewed or addressed by a physician in a timely manner for several residents with complex medical and psychiatric conditions. Delays ranged from several weeks to months, affecting the management of anticoagulants, sedating medications, and duplicate therapies, with documentation confirming the lack of prompt physician response.
The facility did not ensure routine nutritional assessments and monitoring for two residents with complex medical needs, resulting in missed weight records, significant weight changes, and delayed care planning. Both residents experienced extended periods without nutritional oversight due to a lapse in dietitian services, as confirmed by staff interviews and record reviews.
The facility failed to notify two residents about past due payments, resulting in 30-day discharge notices without proper documentation. One resident, dependent on staff for daily activities, was unaware of insurance issues leading to nonpayment. Another resident, independent in daily activities, was not informed about the option to appeal the discharge. Staff interviews revealed a lack of awareness and documentation regarding the discharge notices, violating facility policy.
A resident with multiple health issues, including cancer and dementia, did not receive necessary assistance and care at an LTC facility. The resident was found incontinent and lethargic, with staff failing to provide incontinence care or recognize her deteriorating condition. The resident's family had to intervene, and she was eventually admitted to the hospital, where her condition was found to have worsened significantly.
A resident with multiple health conditions was admitted to the hospital, but the facility failed to document this event. The DON stated that the regional nurse advised against documenting hospital admissions, and the resident's medications were incorrectly marked as given while the resident was hospitalized. The facility was aware of the admission, but there was no written record of notification.
A resident with cognitive impairments was left unattended in a facility transport van without air conditioning for 20 to 30 minutes, leading to discomfort and a late arrival at a medical appointment. The incident occurred when an employee left the resident in the van to retrieve another resident, resulting in inadequate supervision and safety measures.
The facility failed to provide scheduled activities and support residents' mental and psychosocial wellbeing. Observations revealed that residents were left in the common area watching television or sleeping without any organized activities, and a scheduled scenic ride was canceled without an alternative activity provided. Interviews confirmed that there were not enough activities offered, contrary to the facility's policy.
The facility failed to ensure a dignified eating experience for three residents. Two STNAs were observed using their cell phones and not being seated while feeding the residents, violating the facility's policy on maintaining resident dignity during meals.
Failure to Ensure Safe and Individualized Transfer/Discharge
Penalty
Summary
The facility failed to ensure that the transfer or discharge process met the resident's needs and preferences, and did not adequately prepare the resident for a safe transfer or discharge. The report identifies that the necessary steps to assess and address the resident's individual requirements and preferences during the transfer or discharge process were not followed, resulting in a deficiency related to resident care planning and transition.
Failure to Document Guardian's Concerns Regarding Resident Care
Penalty
Summary
The facility failed to document concerns raised by a resident's guardian regarding the resident's care, specifically related to notification about a scheduled follow-up appointment with an orthopedic physician. The resident, who had diagnoses including fractured pelvis and left arm, anemia, anxiety, dementia, depression, neuromuscular dysfunction of the bladder, and schizophrenia, was admitted with a scheduled orthopedic follow-up. The guardian was not informed of the appointment and only learned of it when another family member visited and found the resident absent. The guardian expressed her concerns to the Administrator and the DON, but there was no documentation of these concerns in the resident's medical record or in the facility's Concern Log. Facility policy requires that all services provided, progress toward care plan goals, and any changes in the resident's condition be documented in the medical record to facilitate communication among the interdisciplinary team. Despite this, there was no record of the guardian's expressed concerns or the facility's response. Interviews with facility leadership confirmed the lack of documentation regarding the guardian's complaints about notification of appointments or other care concerns during the resident's stay.
Unsanitary Dumpster Area and Improper Refuse Disposal
Penalty
Summary
Surveyors observed that the dumpster area was not maintained in a sanitary condition. The lid of the dumpster and the enclosure were both left open, and there was significant debris, including cups, plastic wrap, gloves, and food wrappers, scattered around the dumpster inside the enclosure. The Dietary Manager confirmed these findings during the observation and stated that the maintenance director was responsible for the upkeep of the dumpster area. This deficiency had the potential to affect all residents in the facility, which had a census of 48 at the time of the survey.
Failure to Implement Enhanced Barrier Precautions and Water Management Program
Penalty
Summary
The facility failed to implement enhanced barrier precautions (EBP) as required for residents with wounds or indwelling medical devices, affecting nine residents out of ten reviewed for transmission-based precautions and EBP. Medical record reviews revealed that several residents had conditions such as indwelling Foley catheters, suprapubic catheters, dialysis catheters, PICC lines, feeding tubes, and chronic wounds, all of which necessitate the use of gowns and gloves during high-contact care activities according to CDC guidance. Despite care plans and, in some cases, physician orders indicating the need for EBP, there was a lack of signage, PPE availability, and staff adherence to these precautions throughout the facility. Observations confirmed that only one resident room had signage and PPE indicating isolation precautions, while other rooms with residents requiring EBP had neither. During direct care activities such as wound care, tube feeding, and catheter care, staff members did not don gowns or have access to appropriate PPE, and there was no signage to alert staff to the need for EBP. Interviews with staff, including laundry personnel and CNAs, revealed a lack of awareness and inconsistent practices regarding EBP, with some staff recalling that PPE was previously provided but was no longer being used as required. Additionally, the facility failed to develop and implement a water management program and Legionella risk assessment, as confirmed by the Maintenance Director and Administrator. Despite having a policy and access to a CDC toolkit for Legionella control, no risk assessment or water management plan was in place. This omission had the potential to affect all residents in the facility, as there was no systematic approach to identifying or mitigating risks associated with Legionella in the water system.
Failure to Provide and Document Immunization Education and Consent
Penalty
Summary
The facility failed to ensure that education on the risks and benefits of influenza and pneumococcal immunizations was provided to residents or their representatives, and failed to obtain written consent for these vaccinations. In multiple cases, consent forms were either missing, incomplete, or only indicated verbal consent or declination without specifying who made the decision or providing a signature. For example, some forms did not indicate whether the resident or a representative provided consent or declination, and there was no documentation that education was given regarding the vaccines. Several residents with complex medical histories, including conditions such as hypertension, dementia, hemiplegia, Alzheimer's disease, Parkinson's disease, end stage renal disease, and dependence on renal dialysis, were affected by these documentation failures. In some instances, residents received vaccinations despite the medical record indicating a verbal declination, and in other cases, there was no consent form present at all for administered vaccines. The facility's own policies required that education be provided and documented, and that consent or declination be recorded in the medical record, but these steps were not consistently followed. Staff interviews confirmed that the immunization consent forms lacked signatures and did not specify who provided consent or declination. An LPN stated that the previous DON had instructed staff to simply write "verbal" or "verbally" on the forms, which was considered sufficient at the time. This practice resulted in incomplete documentation and a lack of evidence that residents or their representatives were properly informed or had provided written consent for immunizations.
Failure to Provide COVID-19 Vaccine Education and Obtain Written Consent
Penalty
Summary
The facility failed to provide education on the risks and benefits of COVID-19 immunization and did not obtain written consent for COVID-19 vaccinations for five residents. Medical record reviews for these residents, who had complex medical histories including hypertension, dementia, cerebrovascular disease, dysphagia, chronic kidney disease, Alzheimer's disease, Parkinson's disease, and end stage renal disease, revealed that COVID-19 vaccination consent forms were either not dated, not signed, or only indicated a verbal declination without specifying whether the decision was made by the resident or a representative. There was also no documentation confirming that education on immunization risks and benefits had been provided. Interviews with facility staff confirmed that the consent forms lacked signatures and did not indicate who provided the consent or declination. An LPN stated that the previous DON had instructed staff to simply write "verbal" or "verbally" on the forms, which was considered sufficient at the time. Review of the facility's policy indicated that resources and counseling on the importance of COVID-19 vaccination were to be offered, but this was not reflected in the documentation for the affected residents.
Failure to Maintain Communication and Monitoring for Dialysis Care
Penalty
Summary
The facility failed to ensure proper communication and monitoring between the facility and the dialysis center for a resident with end stage renal disease who was dependent on dialysis. The resident's care plan required regular communication with the dialysis center, monitoring of the vascular access site, and documentation of post-dialysis observations. However, review of the medical record showed that dialysis communication was only documented on two occasions, with no additional evidence of ongoing communication or documentation in the resident's record or the facility's dialysis communication book. Interviews with staff revealed that the resident consistently refused to have vital signs taken before and after dialysis and would not return the dialysis communication sheets from the dialysis center. The RN confirmed that no communication or documentation was provided upon the resident's return from dialysis, and the DON acknowledged that the facility did not retain copies of the communication sheets nor did they reach out directly to the dialysis center. Facility policy required documentation of dialysis-related care and communication, but this was not consistently followed for the resident in question.
Failure to Timely Address Pharmacy Recommendations by Physician
Penalty
Summary
The facility failed to ensure that pharmacy recommendations were reviewed and addressed by a physician in a timely manner for multiple residents. For one resident with multiple chronic conditions, pharmacy recommendations regarding necessary lab monitoring for anticoagulant therapy, discontinuation of a sedating muscle relaxant, and evaluation of duplicate antihypertensive therapy were not addressed by a physician for several weeks to months. Documentation showed that the recommended labs and medication changes were delayed, and the resident continued on the medications until well after the recommendations were made. Another resident with complex psychiatric and medical diagnoses was receiving multiple medications, including anticoagulants and anti-inflammatories. The pharmacist recommended discontinuing Naproxen due to bleeding risk, limiting the duration of an as-needed anxiolytic, and obtaining regular blood counts to monitor for bleeding. These recommendations were not addressed by the physician in a timely manner, with some responses delayed by over a month and others not documented at all, despite the physician being present in the facility weekly. A third resident with chronic venous insufficiency and psychiatric diagnoses had pharmacy recommendations for a gradual dose reduction of a sleep aid and re-evaluation of antihypertensive therapy. These recommendations were also not addressed by a physician until two months after they were made. Interviews with the DON confirmed the lack of timely physician response to pharmacy recommendations, and no additional evidence was found to show that the recommendations were addressed promptly.
Failure to Routinely Assess and Monitor Resident Nutrition
Penalty
Summary
The facility failed to ensure that residents were routinely assessed and monitored for nutritional status, resulting in lapses in care for two residents. One resident with multiple complex diagnoses, including hemiplegia, diabetes, heart failure, and chronic kidney disease, was admitted and placed on a regular diet with PEG tube feedings. Despite significant weight fluctuations and a 12% weight gain over five months, there were missing weight records for two months and no nutritional assessment or care plan was completed from admission until nearly seven months later. The registered dietitian supervisor confirmed the absence of prior assessments and identified the resident as high risk for nutritional issues. Another resident with end stage renal disease, diabetes, heart failure, and blindness experienced a 7.5% weight loss over one month and had not received a nutritional assessment or care plan from admission until over five months later. The nutrition note indicated significant weight loss, underweight BMI, and lack of communication with the dialysis dietitian. Both the registered dietitian supervisor and the administrator acknowledged a lapse in dietitian services for several months, and there was no evidence of nutritional oversight or monitoring for these residents during that period.
Failure to Notify Residents of Payment Issues and Discharge Rights
Penalty
Summary
The facility failed to provide timely notification to two residents regarding past due payments, resulting in the issuance of a 30-day discharge notice without proper documentation in the medical records. Resident #32, who had been residing in the facility for over a year, was not informed about the outstanding payments until receiving the discharge notice. The resident, who was cognitively intact and dependent on staff for daily activities, was unaware of the facility's failure to submit necessary documentation to the insurance company, which led to the nonpayment issue. The resident had filed an appeal against the discharge notice but had not been updated about the hearing. Similarly, Resident #7, who was cognitively intact and independent in daily activities, was also issued a 30-day discharge notice without prior notification of outstanding payments. The resident was not informed about the option to appeal the discharge notice and expressed confusion about the sudden change in her residency status. The facility's policy required documentation of discussions with residents regarding nonpayment, which was not adhered to in these cases. Interviews with facility staff revealed a lack of awareness about the insurance payment issues and a failure to document the discharge notices and reasons in the medical records. The Director of Nursing expressed skepticism about Resident #32's claims, while the Administrator acknowledged the oversight in documentation. The facility's policy on transfers and discharges was not followed, leading to non-compliance with regulatory requirements.
Failure to Provide Assistance and Recognize Change in Condition
Penalty
Summary
The facility failed to provide necessary assistance and recognize a change in condition for Resident #100, who was admitted with multiple health issues including breast cancer, dementia, and multiple sclerosis. The resident was moderately cognitively impaired and required supervision for daily activities. On a scheduled day for a medical appointment, the resident was found incontinent of a large amount of stool, which delayed her appointment. The resident's daughter had to reschedule the appointment and later found that her mother was not eating or drinking properly, a change that was not communicated by the facility. The resident's sister arrived to take her to a radiation treatment and found her in bed, incontinent, and not ready for the appointment. Despite requesting assistance from the staff, the sister was informed that the resident was self-sufficient in toileting and had to clean her up herself. The resident was lethargic and unable to stand, which was a significant change from her usual condition. The sister managed to reschedule the appointment, but upon arrival, the resident was sent to the ER due to her deteriorated state and was subsequently admitted to the hospital. The facility did not document the resident's whereabouts or condition from the time she left for her appointment until the next day when the LPN contacted the family. The Director of Nursing confirmed the lack of documentation and acknowledged the resident's drastic change in condition. The family was dissatisfied with the care provided, and the resident was eventually discharged from the hospital to her daughter's home, where she passed away.
Failure to Document Resident's Hospital Admission
Penalty
Summary
The facility failed to ensure appropriate and accurate medical record documentation for a resident who was admitted to the hospital. The resident, who had a history of breast cancer, dementia, multiple sclerosis, high blood pressure, a left mastectomy, and a psychotic disorder with delusions, was moderately cognitively impaired and required supervision for all care. On the day of the incident, the resident missed a scheduled appointment due to incontinence and was later taken to a rescheduled appointment. However, there was no documentation from the time the resident left the facility until the next morning when an LPN contacted the resident's daughter, who informed the facility that the resident had been admitted to the hospital and would not be returning. The Director of Nursing (DON) was unable to recall who notified the facility about the resident's hospital admission and stated that the regional nurse advised against documenting hospital admissions in the medical record. Despite this, the August Medication Administration Record indicated that the resident's morning medications were marked as given, even though the resident was in the hospital at that time. The DON confirmed the lack of documentation regarding the resident's whereabouts and acknowledged that the facility was aware of the hospital admission, although there was no written record of this notification.
Resident Left Unattended in Hot Transport Van
Penalty
Summary
The facility failed to ensure the safety and adequate supervision of a resident with cognitive and neurological impairments, including dementia, who was at risk for falls and poor decision-making. The resident was left unattended in a facility transport van without air conditioning for an extended period. On the day of the incident, the resident was scheduled for a medical appointment and was loaded onto the transport van by an employee. The employee left the van door open and went to retrieve another resident, who was not ready for transport. This delay resulted in the resident being left in the van for 20 to 30 minutes without air conditioning, despite the outdoor temperature being 85 degrees Fahrenheit. The resident reported feeling unwell, experiencing a headache, and sweating due to the conditions in the van. The employee confirmed that the air conditioning was not left on during this time and that the resident arrived late to her medical appointment. This incident was part of a broader investigation into the facility's compliance with safety and supervision standards, specifically regarding transportation to outside appointments.
Failure to Provide Scheduled Activities and Support Residents' Wellbeing
Penalty
Summary
The facility failed to provide scheduled activities and support the residents' mental and psychosocial wellbeing. On the specified date, the activity calendar listed room visits, exercise, brain teasers, and a scenic ride with an ice cream stop. However, observations revealed that residents were left in the common area watching television or sleeping without any organized activities. The scenic ride was canceled due to a broken bus window, and no alternative activities were provided for the residents. Staff were observed seated at the nurse's desk, and no staff were present to engage the residents in activities during multiple observations throughout the day. Interviews with residents confirmed that there were not enough activities offered, and they spent a lot of time watching television. The facility's policy stated that activities should include religious programs, exercise programs, social activities, education programs, and indoor/outdoor activities, but these were not provided as scheduled. The deficiency affected three residents directly and had the potential to affect nine others observed for participation in activities.
Failure to Ensure Dignified Eating Experience for Residents
Penalty
Summary
The facility failed to ensure residents had a dignified eating experience, affecting three residents. Resident #12, who had epilepsy, legal blindness, and cerebral infarction, required moderate assistance for eating. Resident #19, diagnosed with multiple sclerosis, quadriplegia, and muscle weakness, had intact cognition and required setup and cleanup for eating. Resident #34, with unspecified dementia and legal blindness, required supervision and touch assistance with eating. During an observation, STNA #203 was seen using her cell phone while feeding Resident #19, and STNA #204 was observed standing and using her cell phone while feeding Residents #12 and #34. Both STNAs admitted they should not have been using their cell phones and should have been seated while feeding the residents. The facility's policy on Promoting/Maintaining Resident Dignity During Meals, dated 01/01/24, stated that staff should focus on the resident, address them individually, and be seated while feeding them. The actions of STNA #203 and STNA #204 were in direct violation of this policy, leading to a failure in providing a dignified eating experience for the residents. This deficiency was investigated under Complaint Number OH00152849.
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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