Unger Park Post Acute
Inspection history, citations, penalties and survey trends for this long-term care facility in Bucyrus, Ohio.
- Location
- 1170 W Mansfield Street, Bucyrus, Ohio 44820
- CMS Provider Number
- 365619
- Inspections on file
- 22
- Latest survey
- July 17, 2025
- Citations (last 12 mo.)
- 1
Citation history
Health deficiencies cited at Unger Park Post Acute during CMS and state inspections, most recent first.
A dietary aide was hired and began working without a completed BCI background check, as confirmed by review of employee files, the BCI log, and staff interview. Facility policy requires background checks to be completed before employment for all direct access staff, but this process was not followed, potentially affecting all residents.
The facility failed to prevent and respond to an increased pattern of UTIs, affecting two residents with multiple infections identified as E. coli. Despite the infection control logs showing at least 58 residents with UTIs not present upon admission, no specific in-services for UTI prevention were conducted. The infection preventionist admitted the facility did not recognize or address the increase in UTIs, contrary to their policy requiring ongoing surveillance and preventative interventions.
The facility failed to conduct timely care conferences for several residents, affecting six out of 19 reviewed. Residents with various medical conditions, including hemiplegia, PTSD, and dementia, missed scheduled care conferences in specific months. Interviews with staff confirmed the absence of these conferences, and the facility's policy encouraged resident and family participation in care planning, but there was no documentation of attempts or explanations for the missed conferences.
The facility failed to provide adequate activities for residents in the memory care unit, affecting all 13 residents. Observations showed a lack of engaging activities and an absence of an activity calendar. Interviews revealed that residents were often unaware of activities, and staff struggled to conduct activities due to understaffing and limited involvement from the activity director.
The facility failed to ensure required physician visits for several residents, as mandated by policy. Despite frequent visits by NPs, some residents did not receive physician visits for extended periods, affecting those with conditions like Alzheimer's and chronic obstructive pulmonary disease. Interviews confirmed the lack of adherence to the policy, which requires physician visits every 30 days for the first 90 days and every 60 days thereafter.
The facility failed to provide palatable and appetizing meals to residents, as observed through resident and staff interviews. Issues included cold food, dry chicken, and mushy Brussel sprouts, affecting residents with various medical conditions. The Dietary Manager confirmed the food quality issues, which did not align with the facility's policy on food preparation and serving.
The facility failed to maintain a clean and sanitary kitchen, affecting all residents except one. Observations revealed splattered food debris and chipping walls near the dishwasher, and paint strips hanging from the ventilation hood. The Dietary Manager and District Manager confirmed these findings, which violated the facility's Environment policy requiring cleanliness in food preparation and service areas.
The facility failed to maintain the kitchen's walk-in and reach-in coolers at safe temperatures, with readings consistently above the required 41 degrees Fahrenheit. This affected all residents except one who did not receive meals from the kitchen. Various food items were stored at unsafe temperatures, violating the facility's food storage policy.
A facility failed to ensure a resident's code status was consistent across records, with a DNRCCA documented in the paper chart and a full code order in the EMR. The resident, who was cognitively intact, had a documented DNRCCA status, but the EMR was not updated, as confirmed by an RN. The facility's policy requires annual review and updates of advance directives, which was not adhered to, leading to this discrepancy.
A resident reported that their bathroom was not cleaned regularly, and observations confirmed the presence of dried feces, a towel, and a paper towel in the bathroom. A CNA verified these conditions, acknowledging that the bathrooms were supposed to be cleaned daily, indicating a failure to maintain a clean and safe environment.
A facility failed to administer tube feedings according to physician orders for a resident with severe malnutrition and other medical conditions. The resident's tube feeding was observed running outside the prescribed hours, and the MAR showed missed feedings on several days. Staff interviews revealed confusion about the feeding schedule, leading to improper administration.
A resident with type two diabetes did not receive insulin dose adjustments as ordered by the physician, leading to significant medication errors. The facility's medication administration record showed fixed doses were given without adjustments based on blood sugar levels, as confirmed by the DON and the physician.
The facility did not complete reference checks for four new employees, including an RN, a SW/AA, a MT, and a CNA. This was confirmed through personnel records and an interview with the HRD, potentially impacting all 74 residents.
A resident with cognitive impairments was found inappropriately touching another resident who was unable to consent, due to a failure in monitoring and care planning. The incident was reported to the police as a sexual assault, but the facility marked it as unsubstantiated physical abuse. The care plan for the resident with behavioral issues lacked new interventions post-incident.
A facility failed to ensure medications were fully ingested, affecting a resident with Alzheimer's and potentially impacting others. A resident was found with partially dissolved pills left at the bedside, contrary to facility policy. Staff interviews revealed inconsistencies, with an LPN initially denying but later confirming the oversight.
Failure to Complete Employee Background Checks Prior to Employment
Penalty
Summary
The facility failed to ensure that employee background checks were completed prior to employment, as required by facility policy. Specifically, review of an employee file for a dietary aide revealed that the individual began employment without evidence of a completed Bureau of Criminal Investigation (BCI) background check. The BCI log did not show that a background check was performed for this employee, and the Human Resource Director confirmed that the check had not been completed. Facility policy mandates that background and criminal checks, including fingerprinting, must be initiated within two days of an employment offer and completed before the employee starts work. This lapse had the potential to affect all 56 residents in the facility.
Failure to Prevent and Respond to Increased UTIs
Penalty
Summary
The facility failed to prevent and respond to an increased pattern of urinary tract infections (UTIs) among its residents, specifically affecting two residents who were reviewed for UTIs. Resident #16, who was cognitively intact and frequently incontinent of urine, experienced multiple UTIs over a period of several months, with urine cultures consistently identifying Escherichia coli (E. coli). Similarly, Resident #60, who was always continent of bladder and bowel, also had multiple UTIs with E. coli identified in the urine cultures. The infection control logs indicated that at least 58 residents were diagnosed with UTIs that were not present upon admission. The facility's infection prevention and control program was found lacking, as there were no in-services conducted specifically for the prevention of UTIs during the review period. Although a handwashing in-service was conducted, it was related to another infection control concern and not the increase in UTIs or E. coli. The facility's infection preventionist acknowledged the lack of recognition and response to the increase in UTIs, which was contrary to the facility's policy that required ongoing surveillance and preventative interventions for significant infections.
Failure to Conduct Timely Care Conferences
Penalty
Summary
The facility failed to ensure timely completion of care conferences for several residents, affecting six out of the 19 residents reviewed. These residents had various medical conditions, including hemiplegia, PTSD, bipolar disorder, schizophrenia, anxiety, dementia, COPD, diabetes, and depression. The review of medical records and progress notes revealed that care conferences were not held as required in specific months for each resident. For instance, Resident #07 did not have care conferences in May and August 2024, while Resident #08 missed a conference in July 2024. Similarly, other residents also missed their scheduled care conferences in different months. Interviews with facility staff, including the Social Worker/Administrative Assistant and the Director of Nursing, confirmed the absence of these care conferences. The facility's policy on care planning indicated that the interdisciplinary team was responsible for developing care plans and encouraged resident and family participation. However, there was no documented evidence of care conferences being held or attempted for the affected residents, nor was there documentation explaining why participation was not practicable.
Inadequate Activity Program in Memory Care Unit
Penalty
Summary
The facility failed to ensure that activities on the memory care unit met the needs and preferences of all 13 residents. Observations revealed that there was no activity calendar posted in the memory care unit, and residents were often left without engaging activities. For instance, during several observations, residents were found in common areas with a television playing, but none were actively watching or participating in any structured activities. Interviews with residents and staff indicated a lack of awareness and participation in activities, with one resident expressing boredom and another unaware of scheduled activities. The care plans for residents, such as Resident #04 and Resident #175, highlighted the need for structured activities to prevent social isolation and engage residents with cognitive impairments. However, the facility's activity program did not adequately address these needs. The activity director admitted to limited presence in the memory care unit and a lack of specialized training for memory care activities. The activity calendar, when eventually posted, included basic daily routines but lacked engaging and varied activities tailored to the residents' needs. Staff interviews revealed that the memory care unit was often understaffed, with only two CNAs available, making it challenging to conduct activities, especially when managing residents' behaviors. The activity director's limited involvement and the absence of a consistent and engaging activity schedule contributed to the deficiency in meeting the residents' needs for meaningful engagement and social interaction.
Failure to Ensure Required Physician Visits
Penalty
Summary
The facility failed to ensure that physician visits were completed as required for five out of nine residents reviewed. The policy mandates that attending physicians must visit residents at least once every 30 days for the first 90 days following admission, and then every 60 days thereafter. However, the review of medical records and interviews with staff revealed that several residents did not receive the required physician visits. For instance, one resident was seen by a nurse practitioner monthly but had no documented physician visit for nearly ten months. Another resident, with severe cognitive impairment, was seen by a physician only three times over several months, despite frequent visits by a nurse practitioner. The deficiency affected residents with various medical conditions, including fibromyalgia, Alzheimer's, chronic obstructive pulmonary disease, and major depressive disorder. Interviews with the facility's administrator and assistant director of nursing confirmed the lack of physician visits as per the policy. The facility's policy allows for alternating visits by a physician assistant or nurse practitioner after the initial 90 days, but the schedule must not exceed every 60 days. The absence of documented physician visits for the affected residents indicates a failure to adhere to this policy, leading to the deficiency noted in the report.
Deficiency in Food Quality and Palatability
Penalty
Summary
The facility failed to ensure that residents received food that was palatable and appetizing, which met their nutritional recommendations. This deficiency was identified through observations, resident interviews, and staff interviews. Four residents were affected, all of whom reported issues with the food served during lunch. The issues included food being served cold, chicken being too dry to chew, and Brussel sprouts being mushy or lacking taste. The Dietary Manager confirmed these observations, noting that the chicken was dry and the food temperatures were not consistently maintained at the desired levels. The medical records of the affected residents revealed various diagnoses, including type 2 diabetes mellitus, paranoid schizophrenia, chronic obstructive pulmonary disease, and dementia. Despite these conditions, the residents were cognitively intact and able to articulate their dissatisfaction with the meals. The facility's Food Quality and Palatability policy stated that food should be prepared to conserve nutritive value, flavor, and appearance, and served at a safe and appetizing temperature. However, the observations and interviews indicated that the facility did not adhere to this policy, resulting in the identified deficiency.
Kitchen Sanitation Deficiency
Penalty
Summary
The facility failed to maintain the kitchen in a clean and sanitary condition, affecting all residents except one who did not receive meals from the kitchen. During an observation of the kitchen, it was found that the wall across from the dishwasher had splattered food debris and parts of the wall were chipping. The Dietary Manager confirmed these findings. Additionally, the ventilation hood above the clean pan rack and stove top had paint strips hanging down, which the Dietary Manager attributed to excessive cleaning. A follow-up observation with the District Manager confirmed that the white paint strips were chipping from the ventilation hood. The facility's Environment policy required all food preparation and service areas to be maintained in a clean and sanitary condition, which was not adhered to in this instance.
Failure to Maintain Safe Cooler Temperatures
Penalty
Summary
The facility failed to ensure that the kitchen's walk-in cooler and reach-in cooler were functioning in a safe and operable condition, which had the potential to affect all residents except one who did not receive meals from the kitchen. During an observation on December 16, 2024, the reach-in cooler was found to have an ambient internal temperature of 44 degrees Fahrenheit, and the walk-in cooler had a temperature of 47 degrees Fahrenheit. These temperatures were verified by the Dietary Manager (DM) #333. Further inspection revealed that various food items stored in the walk-in cooler, such as cottage cheese, cream cheese, whole milk, pre-sliced cheese, sliced ham, homemade coleslaw, and buffet ham log, were also above the required temperature of 41 degrees Fahrenheit. The temperature logs for the walk-in cooler showed consistent readings above the required 41 degrees Fahrenheit over several days in December 2024, with temperatures ranging from 42 to 47 degrees Fahrenheit. The facility's policy on food storage mandates that all perishable foods be maintained at a temperature of 41 degrees Fahrenheit or below, except during necessary periods of preparation and service. The Equipment policy also requires that all food service equipment be clean, sanitary, and in proper working order. Despite these policies, the facility did not maintain the coolers at the appropriate temperatures, leading to the deficiency.
Discrepancy in Resident Code Status Documentation
Penalty
Summary
The facility failed to ensure that the code status of a resident matched across different records, leading to a discrepancy in the medical documentation. Resident #12, who was cognitively intact, had a documented code status of Do Not Resuscitate Comfort Care Arrest (DNRCCA) in the hard/paper chart dated 10/23/24. However, the electronic medical record (EMR) contained a physician's order dated 12/16/24 indicating the resident was a full code. This inconsistency was confirmed during an interview with Registered Nurse (RN) #230, who acknowledged the discrepancy and stated that the order in the EMR had not been updated to reflect the resident's DNRCCA status. The facility's policy on advance directives requires the interdisciplinary team to review and update the resident's advance directives annually during the assessment process, ensuring that the directives align with the resident's current wishes. However, in this case, the policy was not followed, resulting in conflicting information between the paper chart and the EMR. This oversight affected the accuracy of the resident's medical records and could potentially impact the care provided to the resident.
Failure to Maintain Clean and Safe Environment
Penalty
Summary
The facility failed to provide a safe, clean, comfortable, and homelike environment for a resident, as required. A resident, who was cognitively intact and always continent of bladder and bowel, reported that their bathroom was not cleaned regularly. During an observation, dried feces were found on the lower left side of the toilet, along with a towel on the floor and a brown paper towel behind the toilet. A follow-up observation confirmed that these conditions remained unchanged, and a small puddle was also noted in front of the toilet. A CNA verified these conditions and acknowledged that the bathrooms were supposed to be cleaned daily, indicating a lapse in maintaining the cleanliness of the resident's environment.
Failure to Administer Tube Feedings Per Physician Orders
Penalty
Summary
The facility failed to administer tube feedings in accordance with physician orders for a resident with multiple medical conditions, including cerebral infarction and severe protein-calorie malnutrition. The resident was prescribed Osmolite 1.2 Cal via nasogastric tube at 80 mL per hour from 6:00 P.M. to 6:00 A.M. daily. However, on the morning of December 16, 2024, the tube feeding was observed to be running at 10:25 A.M., contrary to the physician's order. Interviews revealed that the tube feeding was mistakenly connected by a staff member who believed it was supposed to be administered during the day. Additionally, the medication administration record (MAR) indicated that the resident did not receive their tube feeding as ordered on December 11, 12, and 13, 2024. The Director of Nursing confirmed the discrepancies in the MAR and acknowledged the failure to administer the tube feeding per the physician's order on those dates. This oversight in following the prescribed feeding schedule potentially impacted the resident's nutritional intake and appetite during mealtimes.
Failure to Adjust Insulin Doses as Ordered
Penalty
Summary
The facility failed to administer medications as ordered by the physician, resulting in significant medication errors for a resident with multiple diagnoses, including type two diabetes. The resident was cognitively intact and had an active physician order for Humulin 70/30 insulin, which required dose adjustments based on blood sugar levels. However, the medication administration record for December 2024 showed that the nurses consistently signed off on administering fixed doses of insulin without adjusting them according to the physician's orders and the resident's blood sugar readings. The Director of Nursing (DON) confirmed that the insulin order was not updated after the physician made changes, and acknowledged that the order was confusing. The DON verified that the insulin doses should have been adjusted on specific dates in December, but the facility could not provide evidence that these adjustments were made. An interview with the physician further confirmed that the insulin should have been adjusted according to the active orders, indicating a failure to follow the prescribed medication regimen for the resident.
Failure to Complete Reference Checks for New Employees
Penalty
Summary
The facility failed to ensure that reference checks were completed for four new employees, which included a Registered Nurse, a Social Worker/Administrative Assistant, a Medication Technician, and a Certified Nursing Assistant. This deficiency was identified through a review of employee personnel records, background check logs, and staff interviews. The absence of documented evidence of reference checks for these employees was confirmed during an interview with the Human Resource Director. This oversight had the potential to affect all 74 residents residing in the facility.
Failure to Prevent Resident-to-Resident Sexual Altercation
Penalty
Summary
The facility failed to prevent an inappropriate resident-to-resident altercation that was sexual in nature, affecting one resident. Resident #105, who was admitted for a short-term respite stay, was involved in an incident where another resident, Resident #82, was found in her room with his hand up her dress on her breast area. Resident #105 had a history of hemiplegia, cerebrovascular disease, and was on psychotropic medications for depression. She required substantial assistance for mobility and was unable to provide a statement or recall the incident due to her cognitive state. Resident #82, who had diagnoses of paranoid schizophrenia and bipolar II disorder, was found to have impaired cognition and socially inappropriate behaviors. On the day of the incident, Resident #82 was observed by LPN #63 to be pacing the hallways, entering and exiting rooms, and eventually lying in bed with Resident #105. Despite being redirected earlier, Resident #82 was found groping Resident #105, which led to immediate intervention by LPN #63. The facility's investigation revealed that Resident #82 had a recent change in cognition and was experiencing a decline in mental health, which was not adequately addressed in his care plan. The facility's response included notifying the police, who documented the incident as a sexual assault due to Resident #105's inability to consent. The facility's investigation and documentation, however, marked the incident as physical abuse and unsubstantiated. The care plan for Resident #82 did not include new interventions for sexual behaviors after the incident, and the facility's policy on abuse and neglect was not effectively implemented to prevent the incident. The deficiency highlights a failure in monitoring and care planning for residents with known behavioral issues.
Medication Administration Deficiency
Penalty
Summary
The facility failed to ensure that medications were fully ingested and not left at the bedside, affecting one resident and potentially impacting eight others who were independently mobile and cognitively impaired. Resident #21, who was admitted with Alzheimer's and dementia with behavioral disturbance, was observed with a plastic medication cup containing four partially dissolved pills on her overbed table. This observation was made despite the facility's policy requiring that residents be observed to ensure complete ingestion of medications. Interviews with staff revealed inconsistencies in medication administration practices. A State Tested Nursing Assistant confirmed the presence of the pills, noting that such occurrences were not uncommon. An LPN initially denied leaving medications at the bedside but later acknowledged that the medications were from her administration, as the handwriting on the cup was hers. The LPN had relied on the resident's non-verbal indication that she had taken the pills, which was not in compliance with the facility's medication administration guidelines.
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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