Village At The Greene
Inspection history, citations, penalties and survey trends for this long-term care facility in Dayton, Ohio.
- Location
- 4381 Tonawanda Trail, Dayton, Ohio 45430
- CMS Provider Number
- 365497
- Inspections on file
- 23
- Latest survey
- February 25, 2026
- Citations (last 12 mo.)
- 4
Citation history
Health deficiencies cited at Village At The Greene during CMS and state inspections, most recent first.
A resident with multiple chronic conditions, cognitively intact and dependent for ADLs with tube feeding, was transferred to the hospital, readmitted, and later given a 30‑day discharge notice. Social Services informed the resident’s daughter that there were no remaining bed hold days and that the resident would return as skilled, and later mailed a discharge notice stating the resident’s welfare and needs could no longer be met. The RSC later acknowledged the true basis for the discharge was concern about lack of a payer source and that the form was completed incorrectly. The RBOM confirmed the stay was still covered by managed Medicaid through a specified approval period when the notice was issued and that no bill for non‑payment had been sent, despite facility policy limiting discharge to defined causes such as inability to meet needs or failure to pay.
The facility failed to complete required discharge summaries/recapitulations of stay and to obtain physician discharge orders before discharging two residents. One resident with multiple chronic conditions, including anemia, DM, morbid obesity, bipolar disorder with psychotic features, and CHF, was dependent on staff for several ADLs and was discharged without a documented discharge summary or physician discharge order. Another resident with MS, left hemiplegia, prior CVA, DM, CKD stage IV, and receiving tube feeding was transferred, readmitted, and later discharged to another facility, again without a documented discharge summary or physician discharge order. The DON confirmed these omissions, which were inconsistent with facility policies requiring physician-written discharge orders and comprehensive discharge summaries with recapitulation of stay, final health status, medication reconciliation, and a post-discharge care plan.
A resident with COPD, sleep apnea, and other comorbidities was repeatedly provided CPAP therapy and supplemental O2 without any corresponding physician orders, despite the care plan calling for oxygen as ordered by a physician. Clinical notes documented the resident on O2 via mask, CPAP, and nasal cannula on multiple occasions, and surveyors observed the resident using a CPAP set at 6 cmH2O with 2 L O2 at night. The resident and an LPN confirmed nightly CPAP and O2 use since admission, and the DON acknowledged that no physician orders for CPAP or O2 had been obtained, even though the facility’s oxygen policy required safe use.
A resident with cancer, CHF, and COPD, who initially received PT, OT, and ST and was dependent for bed mobility and transfers, had therapy services discontinued when skilled insurance coverage ended, despite not meeting therapy goals and documented need for continued services for mobility, ADLs, transfers, cognition, communication, and dysphagia. The resident reported that therapy stopped after insurance ended, that she wanted to get strong enough to return home, and that she previously could stand and transfer with one staff but now was only transferred with a mechanical lift. Staff interviews confirmed the resident was removed from the therapy caseload due to payer changes, Part B coverage had not been verified, Medicaid was pending, nursing staff were not instructed that manual transfers were possible, and no restorative programs were in place, contrary to facility policy requiring collaboration and transition to restorative care.
A Dietary Aide failed to change gloves between handling contaminated surfaces and food, potentially affecting 12 residents. The aide used the same gloves to touch trays, silverware, cabinets, and food items, leading to possible contamination. This was confirmed during an interview with the aide.
The facility failed to provide necessary ADL assistance to residents, affecting their care and well-being. A resident with hemiplegia and diabetes had unmet nail care needs due to staff confusion. Two residents with severe cognitive impairments were left in bed without required assistance, and another resident reported missed showers. Staffing issues contributed to these deficiencies, and the facility's ADL policy was not followed.
The facility failed to complete significant change assessments within the required 14-day period for three residents receiving hospice services. A resident with dementia and breast cancer, another with severe cognitive impairment, and a third with heart disease were all affected by this deficiency. The assessments were completed beyond the mandated timeframe, as confirmed by an RN, violating the facility's policy.
The facility failed to ensure accurate MDS assessments for three residents, leading to discrepancies in recorded weights and levels of assistance required. A resident with Alzheimer's had incorrect weight and transfer assistance recorded, while another with hemiplegia had an inaccurate weight entry. A third resident with heart disease had a significant weight loss unrecorded. These errors were confirmed by a Dietetic Technician.
A facility failed to document nephrostomy tube care for a resident with end-stage renal disease and other medical conditions. Despite physician orders to change gauze dressings every other day, the Treatment Administration Record lacked documentation of these changes until a later date. An interview with the Administrator confirmed the absence of documentation and a nephrostomy tube care policy.
The facility failed to obtain timely weights for three residents, impacting their nutritional care. A resident was not weighed upon readmission, another experienced significant weight loss without timely reweighs, and a third did not receive weekly weights as ordered. The facility's policy requires weights within 24 hours of admission/readmission and reweighs for significant changes, which were not followed.
A facility failed to document tracheostomy and oral care as ordered for a resident in a persistent vegetative state with a tracheostomy. The resident's medical record showed orders for care three times daily and inner cannula changes twice daily, but documentation was missing for several dates. The Administrator confirmed the lack of documentation and the absence of a tracheostomy care policy.
A facility failed to document the completion and sending of dialysis communication forms for a resident with end-stage renal disease, who required dialysis three times a week. Despite obtaining the resident's weight and vital signs as ordered, the facility did not have documentation to support communication with the dialysis center on several occasions, as confirmed by the administrator. This was contrary to the facility's policy requiring ongoing communication and collaboration with the dialysis facility.
The facility failed to administer medications as ordered, resulting in a 10.34% medication error rate. Two residents were affected: one received incorrect doses of inhalation aerosol and nasal spray, while another received a lower dose of sertraline than prescribed. The errors were due to non-compliance with the facility's medication administration policy.
A significant medication error occurred when an LPN failed to prime an insulin pen before administering insulin to a resident. The resident, who required assistance with daily activities, had a physician order for Novolog insulin. The LPN used a Humalog insulin kwikpen as a substitute but did not prime it with two units before administering the prescribed dose. This error was confirmed during an interview with the LPN.
The facility failed to properly label and store medications and ensure safe administration practices, affecting two residents. One resident had undated insulin and Vitamin B12, and medication was left at the bedside. Another resident had a multivitamin found on their bed, despite being observed taking it earlier. Facility policies on medication administration and storage were not followed.
A facility failed to follow infection control procedures during tracheostomy care for a resident in a persistent vegetative state. The resident required tracheostomy and oral care multiple times daily, but gowns were not available for staff, and a Respiratory Therapist performed care without wearing a gown, despite the resident coughing during the procedure. The facility's policy required gowns for high-contact care activities to prevent the transmission of multidrug-resistant organisms.
A resident, who was a high fall risk and dependent on transfers, suffered a right distal femur fracture during a transfer when CNAs failed to use a mechanical lift as required by the care plan. Despite the resident's inability to bear weight, the CNAs attempted to transfer her without a lift or gait belt, resulting in a fall. The facility's policy on using assistive devices was not followed, and the care plan did not accurately reflect the need for a mechanical lift.
A resident with severe cognitive impairment was reportedly handled roughly by a CNA, but the incident was not immediately addressed by the facility's administration. The report was delayed due to the Administrator being off-duty and the DON not taking immediate action. The facility's abuse policy, which requires immediate reporting and investigation, was not followed, and the incident was not reported to the state agency.
A facility failed to implement its abuse policy when a CNA was reported for rough handling and inappropriate language towards a resident with severe cognitive impairment. The incident was not immediately addressed due to communication lapses, and the involved CNA was not suspended or reported to the state agency as required by policy.
A facility failed to implement its abuse policy when a CNA was reported for being rough and speaking inappropriately to a resident with severe cognitive impairment. The incident was not immediately addressed due to communication lapses, and the involved CNA continued working without suspension. The facility did not report the incident to the state agency as required by its policy.
The facility failed to provide regular bathing for two residents, one with severe cognitive impairment and another with vascular dementia, both requiring maximal assistance. Observations and records indicated inadequate personal hygiene and lack of documented bathing, confirmed by the facility's administrator.
A resident with severe cognitive impairment and high fall risk fell in the dining room due to inadequate supervision and lack of hands-on assistance during a transfer. The STNA did not use a gait belt, leading to the resident losing balance and sustaining a head laceration. The facility failed to conduct additional fall risk assessments and did not fully implement the care plan interventions.
Two residents in a LTC facility were affected by medication administration errors. One resident received Lisinopril without documented blood pressure checks, contrary to physician orders, and was given the medication even when their SBP was below the specified threshold. Another resident did not receive Apixaban as ordered following hospital discharge, with no documentation of administration. The facility lacked a policy for medication administration, contributing to these deficiencies.
An LPN failed to follow infection control procedures during medication administration for a resident with multiple medical conditions. The LPN handled medications with bare hands without performing hand hygiene, violating the facility's infection control policy. This incident was confirmed during a complaint investigation.
A resident with severe cognitive impairment and dependent for eating was observed without staff assistance during a meal, despite physician orders and care plans indicating the need for one-to-one feeding assistance. Staff interviews confirmed the lack of assistance, and the facility's policy on Activities of Daily Living was not followed.
Inappropriate 30‑Day Discharge Notice Issued Without Proper Cause
Penalty
Summary
The deficiency involves the facility issuing an inappropriate 30‑day discharge notice to a resident without proper cause. The resident, admitted with multiple sclerosis, left hemiplegia, cerebral infarction, diabetes mellitus, and stage IV chronic kidney disease, was cognitively intact and dependent for bed mobility, bathing, toileting, and transfers, and received tube feeding per a quarterly MDS. The resident had been transferred to the hospital and then readmitted to the facility before ultimately being discharged to another facility. On the morning of 08/28/25, Social Services documented informing the resident’s daughter that the resident had no remaining bed hold days and would be returning as skilled, and that a list of facilities would be emailed. A nursing note later that day documented the resident’s arrival back to the facility. A subsequent Social Service note dated 09/03/25 documented that a 30‑day discharge notice was mailed to the resident’s daughter, stating the discharge was because the resident’s welfare and needs could no longer be met at the facility. The written Discharge Notice, dated 09/03/25, listed the discharge date as 10/03/25 to another SNF for the same stated reason. However, the Resident Service Coordinator later confirmed that the actual reason for issuing the 30‑day discharge notice was concern about lack of a payer source, not inability to meet the resident’s needs, and acknowledged the form was filled out incorrectly. The Regional Business Office Manager confirmed that the resident’s stay was covered by a managed Medicaid product approved from 08/23/25 to 09/11/25, that the Notice of Discharge was issued on 09/04/25 while coverage was still approved, and that no bill for non‑payment had been issued to the resident or representative at the time the notice was sent. The facility’s own policy allows discharge for specific reasons, including inability to meet needs or failure to pay, and requires proper written notice, but the documentation and interviews showed the stated discharge reason did not match the actual circumstances or policy criteria.
Failure to Complete Discharge Summaries and Obtain Physician Discharge Orders
Penalty
Summary
The deficiency involves the facility’s failure to complete required discharge summaries/recapitulations of stay and to obtain physician discharge orders prior to residents leaving the facility. For one resident admitted with anemia, diabetes mellitus, morbid obesity, bipolar disease with psychotic features, and congestive heart failure, the medical record showed dependence on staff for bathing, toilet hygiene, bed mobility, transfers, and set-up assistance with eating, and documented a discharge date of 10/16/25. However, there was no documentation of a discharge summary or recapitulation of stay, and no evidence that physician discharge orders were obtained before the resident’s discharge. For another resident admitted with multiple sclerosis, left hemiplegia, cerebral infarction, diabetes mellitus, and stage IV chronic kidney disease, the record showed the resident was cognitively intact, dependent for bed mobility, bathing, toileting, and transfers, and received nutrition via tube feeding. This resident was transferred to the hospital, readmitted, and later discharged to another facility on 09/24/25. The medical record lacked documentation of a discharge summary/recapitulation of stay and did not show that physician discharge orders were obtained prior to discharge. The DON confirmed that both residents’ records were missing these required elements, despite facility policies stating that discharges must occur only upon a physician’s written order and that a discharge summary including recapitulation of stay, final health status, medication reconciliation, and a post-discharge plan of care must be completed when discharge is anticipated.
CPAP and Oxygen Administered Without Physician Orders
Penalty
Summary
The deficiency involves the facility’s failure to obtain physician orders prior to administering CPAP therapy and supplemental oxygen to a resident. The resident was admitted with diagnoses including a stress fracture of the left femur, COPD, type 2 diabetes mellitus with complications, and morbid obesity. The care plan, initiated shortly after admission, identified altered cardiovascular and respiratory status related to hypertension, iron deficiency anemia, sleep apnea, and COPD, and included interventions to provide oxygen as ordered by a physician. The admission MDS documented that the resident was cognitively intact, required varying levels of assistance with ADLs, and used oxygen therapy. However, review of the physician orders revealed no orders for CPAP use or for oxygen administration. Despite this, clinical notes documented the resident on oxygen via mask, CPAP, and nasal cannula on multiple dates, with recorded oxygen saturations ranging from 90% to 96%. Surveyor observations showed a CPAP machine, oxygen concentrator, and portable oxygen tank present in the resident’s room, and on multiple mornings the resident was observed in bed with a CPAP mask in place, oxygen at 2 liters attached through CPAP tubing, and the CPAP set at 6 cmH2O. In interviews, the resident reported using the CPAP with 2 liters of oxygen every night since admission, and an LPN confirmed nightly use of CPAP and oxygen and acknowledged there were no physician orders for the CPAP setting or oxygen flow rate. The DON also confirmed that the resident had oxygen in the room and had not had physician orders for oxygen or CPAP use since admission. The facility’s oxygen policy stated that oxygen would be used in a safe manner, but the documented and observed use of CPAP and oxygen occurred without corresponding physician orders.
Failure to Continue Therapy Services After Insurance Denial
Penalty
Summary
The deficiency involves the facility’s failure to provide ongoing specialized rehabilitative services to ensure a resident maintained the highest practicable level of physical and functional mobility. The resident was admitted with malignant neoplasm of the cerebellum and right lung, congestive heart failure, and COPD, and the admission MDS showed modified independence in decision making, substantial/maximal assistance needed for toilet hygiene, and dependence for bed mobility and transfers. The resident initially received PT, OT, and ST per physician orders, and the care plan included PT/OT evaluation and treatment. OT, PT, and ST evaluations were completed, and subsequent OT and PT discharge summaries documented that the resident had not met therapy goals and would benefit from continued therapy for functional mobility, ADLs, transfers, safety, and for ongoing cognitive/communication and dysphagia needs. However, PT and ST services were discharged due to insurance exhaustion and loss of appeal, and the resident remained in the facility without further therapy. Interviews confirmed that after skilled insurance coverage ended, the resident was removed from the therapy caseload and had not received therapy services since the discharge date, while Medicaid status was still pending and Part B coverage had not yet been verified. The resident reported that therapy had stopped a few weeks earlier when insurance ended, that she had applied for Medicaid, and that her goal was to return home once she became stronger and more independent. She stated that when she was in therapy she could stand and transfer with one staff member, but currently nursing staff only used a mechanical lift and did not assist her to stand. An STNA corroborated that when the resident was on therapy she could transfer with one staff assist, but nursing staff now used a mechanical lift for all transfers and had not been informed by therapy that manual assistance was possible. The PT and Director of Rehab acknowledged that the resident would benefit from therapy, that services had been discontinued due to insurance denial, that Part B coverage had not been verified, and that the facility did not have restorative programs, despite a facility policy stating that therapy services are to help residents reach maximum functional performance and transition to restorative nursing when appropriate.
Improper Glove Usage by Dietary Aide
Penalty
Summary
The facility failed to ensure proper glove usage by Dietary Aide (DA) #122, which led to potential contamination of food served to 12 residents. During an observation, DA #122 was seen using the same pair of gloves to touch various surfaces, including trays, silverware, and cabinets, before handling food items such as rolls and coffee cups. The DA did not change gloves between these tasks, resulting in the potential contamination of food served to residents. This was confirmed during an interview with DA #122, who acknowledged touching contaminated gloves to food items intended for residents.
Deficiency in Providing ADL Assistance
Penalty
Summary
The facility failed to provide adequate care and services for residents requiring assistance with Activities of Daily Living (ADLs), affecting five residents. Resident #22, who had hemiplegia and diabetes, was observed with long fingernails despite expressing the need for assistance in trimming them. Staff interviews revealed confusion about who was responsible for nail care, particularly for diabetic residents, leading to the resident's needs being unmet over several days. Resident #43, with severe cognitive impairment and a history of falls, was observed in bed during multiple checks, despite care plan interventions requiring her to be up and utilizing a hoyer lift for transfers. Similarly, Resident #09, with severe cognitive impairment and physical limitations, was found in bed with consumed meal trays, indicating a lack of assistance with transfers and mobility as outlined in their care plan. Resident #53, also with severe cognitive impairment, was observed in bed during checks, despite requiring assistance for transfers. CNA staffing issues were noted, with only one CNA available for a significant portion of the day. Resident #73, who was cognitively intact, reported not receiving showers as scheduled, with documentation confirming missed showers. The facility's policy on ADLs was not adhered to, resulting in unmet care needs for these residents.
Failure to Timely Complete Significant Change Assessments for Hospice Residents
Penalty
Summary
The facility failed to ensure that significant change assessments were completed in a timely manner for three residents receiving hospice services. Resident #43, who had multiple diagnoses including dementia and breast cancer, began receiving hospice services on February 6, 2024. However, the significant change Minimum Data Set (MDS) assessment was not completed until February 22, 2024, which was beyond the required 14-day period. This delay was confirmed by Registered Nurse (RN) #139, who acknowledged that the assessment should have been completed by February 19, 2024. Similarly, Resident #45, who had severe cognitive impairment and was picked up by hospice on January 2, 2025, had their significant change MDS assessment completed on January 22, 2025, instead of the required date of January 15, 2025. Resident #51, with a history of heart disease and other conditions, was also affected by this deficiency. The resident was picked up by hospice on February 6, 2025, but the significant change MDS assessment was not completed until February 22, 2025, missing the deadline of February 19, 2025. These findings were corroborated by RN #139 and were in violation of the facility's policy, which mandates that a comprehensive MDS assessment be completed within 14 days of a significant change.
Inaccurate MDS Assessments Affect Resident Care Plans
Penalty
Summary
The facility failed to ensure that Minimum Data Set (MDS) assessments were completed accurately for three residents, affecting the accuracy of their care plans. Resident #37, diagnosed with Alzheimer's disease and dementia with severe agitation, had an MDS assessment that inaccurately reflected their weight and level of assistance required for transfers. The resident's weight was incorrectly recorded as 145 pounds instead of 132 pounds, and the MDS did not accurately reflect the resident's dependence on staff for transfers, as verified by a Registered Nurse. Resident #22, with diagnoses including hemiplegia and type 2 diabetes mellitus, had an MDS assessment that inaccurately recorded their weight as 238 pounds, despite medical records showing a weight of 225 pounds. Similarly, Resident #51, diagnosed with hypertensive heart disease and psychosis, had an MDS assessment that inaccurately recorded their weight as 232 pounds, while the actual weight was 205 pounds, indicating a significant, non-prescribed weight loss. These inaccuracies were confirmed by the Dietetic Technician, who acknowledged the errors in the MDS entries.
Failure in Nephrostomy Tube Care Documentation
Penalty
Summary
The facility failed to ensure proper nephrostomy tube care for a resident with end-stage renal disease, atrial fibrillation, hypertension, anemia, and malignant neoplasm of the cervix. The resident was admitted with an indwelling catheter and required substantial assistance with daily activities. A physician's order dated 02/18/25 specified that gauze dressings for bilateral nephrostomy tubes should be changed every other day. However, the facility's Treatment Administration Record for February 2024 lacked documentation of these dressing changes until 02/18/25, despite hospital discharge orders from 02/10/25 indicating the need for such care. An interview with the Administrator confirmed the absence of documentation for nephrostomy tube care prior to 02/18/25 and revealed that the facility did not have a nephrostomy tube care policy in place.
Failure to Obtain Timely Weights for Residents
Penalty
Summary
The facility failed to obtain weights for residents in a timely manner, affecting three residents reviewed for nutrition. Resident #49 was not weighed upon readmission from the hospital on 12/28/24, despite the facility's policy requiring weights to be taken within 24 hours of admission or readmission. The resident, who had multiple diagnoses including moderate protein-calorie malnutrition and severely impaired cognition, was weighed on 12/06/24 and not again until 01/11/25. The Dietetic Technician confirmed the lapse in obtaining the weight upon readmission. Resident #51 experienced significant weight loss, with a noted 8.1% loss over 25 days and a 7.7% loss over 80 days. Despite requests for reweighs on 09/20/24 and 01/31/25, these were not conducted within the expected 48-hour timeframe. Resident #64, who had a care plan for weekly weights due to significant weight loss, had only seven weights taken out of eleven opportunities. The Registered Diet Tech confirmed the failure to adhere to the weekly weight order. The facility's policy mandates weights within 24 hours of admission/readmission and reweighs for significant weight changes, which were not followed in these cases.
Failure to Document Tracheostomy Care as Ordered
Penalty
Summary
The facility failed to provide tracheostomy and oral care as ordered for a resident in a persistent vegetative state with multiple medical conditions, including respiratory failure and a tracheostomy. The resident was dependent on staff for all activities of daily living. The medical record indicated orders for tracheostomy care and oral care three times per day and to change the inner cannula twice per day. However, the February 2024 Respiratory Administration Record lacked documentation to confirm that the care was completed on several specified dates. An interview with the Administrator confirmed the absence of documentation for the ordered care on those dates and revealed that the facility did not have a tracheostomy care policy. Additionally, the facility's Skills Documentation/Evaluation Record for tracheostomy care required staff to chart the procedure on the treatment record.
Failure to Document Dialysis Communication
Penalty
Summary
The facility failed to ensure that dialysis communication forms were completed and sent to the dialysis center for a resident who required such services. This deficiency affected a resident with end-stage renal disease, diabetes mellitus, and hypertension, who was dependent on dialysis. The resident's medical record indicated that they were cognitively intact and required substantial assistance with daily activities. Despite having physician orders to attend dialysis three times a week and to obtain weight and vital signs before and after dialysis, the facility did not document sending communication forms to the dialysis center on multiple occasions. The facility's administrator confirmed the lack of documentation for the communication forms and stated that the facility was often in contact with the dialysis center via phone, although this was not documented in the medical record. The facility's policy required ongoing communication and collaboration with the dialysis facility, as well as monitoring the resident's condition before and after dialysis treatments. However, the absence of documented communication forms indicated a failure to adhere to this policy, leading to the deficiency noted in the report.
Medication Administration Errors Exceed Acceptable Rate
Penalty
Summary
The facility failed to ensure that medications were administered as ordered, resulting in a medication error rate of 10.34%, which is above the acceptable threshold of 5%. This deficiency affected two residents. Resident #33, who has chronic kidney disease, morbid obesity, left hemiplegia, diabetes mellitus, heart failure, depression, and spina bifida, was supposed to receive two puffs of Stiolo Respimat inhalation aerosol and two sprays of Flonase in each nostril daily. However, an LPN administered only one puff of the inhalation aerosol and one spray of Flonase per nostril. Resident #62, with medical conditions including a left femur fracture, anemia, nondisplaced fracture of the greater trochanter, diabetes mellitus, atrial fibrillation, Alzheimer's disease, and depression, was ordered to receive 100 mg of sertraline daily. Instead, an LPN administered only 25 mg of sertraline. The facility's medication administration policy requires that medications be administered as prescribed and that staff verify the medication and dosage schedule against the resident's medication administration record (MAR) before administration. These errors indicate a failure to adhere to the facility's medication administration policy.
Failure to Prime Insulin Pen Leads to Medication Error
Penalty
Summary
The facility failed to prevent a significant medication error when a Licensed Practical Nurse (LPN) did not prime an insulin pen prior to administering insulin to a resident. The resident, who was cognitively intact and required substantial assistance with daily activities, had a physician order for Novolog insulin to be administered subcutaneously at breakfast. During an observation, the LPN prepared the resident's medication using a Humalog insulin kwikpen as a substitute for Novolog but did not prime the pen with two units before administering the prescribed 28 units. This oversight was confirmed during an interview with the LPN, indicating a lapse in proper medication administration protocol.
Medication Labeling and Administration Deficiencies
Penalty
Summary
The facility failed to ensure proper labeling and storage of medications, as well as safe administration practices, affecting two residents. For Resident #33, the facility did not date the Humalog insulin kwikpen or the Vitamin B12 bottle after opening. Additionally, a Licensed Practical Nurse (LPN) left Sevelamer Carbonate medication at the bedside, which the resident confirmed was a common practice. These actions were confirmed through observations and interviews with the LPNs involved. For Resident #51, the facility did not ensure that medications were ingested as required by their policy. An orange pill, identified as a multivitamin, was found on the resident's bed, despite the LPN having observed the resident taking her pills earlier. The resident's care plan noted a behavior of holding medications under her tongue and spitting them out, which required monitoring and documentation of observed behaviors and interventions. The facility's policy mandates that residents are observed to ensure medications are completely ingested, which was not adhered to in this case.
Infection Control Deficiency in Tracheostomy Care
Penalty
Summary
The facility failed to adhere to infection control procedures during tracheostomy care for Resident #13, who was in a persistent vegetative state and dependent on staff for all activities of daily living. The resident had a tracheostomy and required tracheostomy care and oral care three times per day, as well as a change of the inner cannula twice per day. Despite the presence of an Enhanced Barrier Precautions (EBP) sign in the resident's room, there was no documentation of a physician order for EBP, and gowns were not available for staff use during care. During an observation, a Respiratory Therapist (RT) was seen performing tracheal suctioning and oral care for Resident #13 while wearing only a mask and gloves, without a gown. The RT confirmed that the resident coughed during the procedure and acknowledged the absence of a sign to follow EBP and the lack of gowns in the room. The facility's policy on EBP, dated August 2022, required the use of an impervious gown during high-contact resident care activities, including tracheostomy care, to prevent the transmission of multidrug-resistant organisms.
Failure to Use Mechanical Lift Results in Resident Injury
Penalty
Summary
The facility failed to ensure a resident was properly transferred using a mechanical lift, resulting in actual harm. Resident #27, who was a high fall risk and dependent on transfers, suffered a right distal femur fracture during a transfer. The resident had multiple diagnoses, including chronic obstructive pulmonary disease, cancer, neurogenic bladder, cerebrovascular attack, non-Alzheimer's dementia, hemiplegia, or hemiparesis, and respiratory failure. The care plan indicated the need for a mechanical lift for all transfers, but this was not followed. On the day of the incident, CNAs #93 and #95 attempted to transfer Resident #27 without using a mechanical lift or gait belt, despite the resident's inability to bear weight. The CNAs lifted the resident from under the arms, and when the resident was unable to stand, they lowered her to the floor. The incident was witnessed, and the resident was later found to have a swollen knee and a right distal femur fracture. The facility's policy required the use of assistive devices to reduce accidents, but this was not adhered to in this case. Interviews with staff revealed a lack of adherence to the care plan and Kardex, which did not accurately reflect the need for a mechanical lift. The Administrator acknowledged that the mechanical lift was not consistently used for Resident #27's transfers, and there was no evidence of a family request to discontinue its use. The incident highlighted a failure in communication and adherence to established protocols, leading to the resident's injury.
Failure to Implement Abuse Policy
Penalty
Summary
The facility failed to implement its abuse policy, affecting a resident with severe cognitive impairment and multiple diagnoses, including Alzheimer's disease and dementia. The resident required assistance with daily activities and was reported to have been handled roughly by a CNA during a transfer. The incident was reported by another CNA via a messaging program used by the facility, but the report was not immediately addressed by the Administrator or the Director of Nursing (DON). The Administrator was off-duty and did not receive the message until two days later, while the DON, who received the message, did not take immediate action to suspend the involved CNA or initiate an investigation. The facility's policy requires immediate reporting and investigation of abuse allegations, but this protocol was not followed. The DON admitted to not following the abuse policy and acknowledged that the involved CNA should have been suspended pending an investigation. Additionally, the incident was not reported to the state agency as required. The failure to adhere to the established procedures for reporting and investigating abuse allegations resulted in a deficiency in the facility's compliance with its own policies and state regulations.
Failure to Implement Abuse Policy
Penalty
Summary
The facility failed to implement its abuse policy, affecting one resident who was severely cognitively impaired and required assistance with daily activities. An incident occurred where a CNA was reported to have been rough and verbally inappropriate with the resident during a transfer. The incident was initially reported by another CNA via a messaging program used by the facility, but the report was not immediately addressed by the Administrator or the Director of Nursing (DON) due to communication lapses and failure to follow protocol. The Administrator did not receive the message until returning to work two days later, and the DON, who was informed of the incident, did not take immediate action to suspend the involved CNA or report the incident to the state agency as required by the facility's policy. The facility's self-reported incidents log showed no evidence of the allegation being reported to the state agency, indicating a failure to adhere to the established procedures for handling abuse allegations.
Failure to Implement Abuse Policy
Penalty
Summary
The facility failed to implement its abuse policy, affecting a resident with severe cognitive impairment and multiple diagnoses, including Alzheimer's disease and dementia. The incident involved a Certified Nursing Assistant (CNA) being rough and speaking inappropriately to the resident during a transfer. The incident was reported by another CNA via a messaging program used by the facility, but the report was not immediately addressed by the Administrator or the Director of Nursing (DON) due to communication lapses and failure to follow the facility's abuse reporting policy. The Administrator did not receive the message until returning to work two days later, and the DON, who received the message, did not take immediate action to suspend the involved CNA or report the incident to the state agency as required. The facility's policy mandates immediate reporting and investigation of abuse allegations, but this was not followed, as evidenced by the lack of a self-reported incident to the state agency and the continued work of the involved CNA without suspension pending investigation.
Failure to Provide Regular Bathing for Residents
Penalty
Summary
The facility failed to ensure that residents received bathing at least twice a week, affecting two residents. Resident #27, who was severely cognitively impaired and required maximal assistance for bathing, was observed with oily hair, indicating inadequate personal hygiene. The medical record review showed that Resident #27 had only nine episodes of bathing out of 16 opportunities over a specified period. The resident's family expressed concern about the irregularity of bathing, confirming the deficiency in care. Resident #17, who had diagnoses including traumatic subdural hemorrhage and vascular dementia, also required maximal assistance for bathing. The review of the bathing record for Resident #17 revealed no evidence of bathing over a specified period. The facility's administrator confirmed that if showers were not documented, they were not completed. The facility's policy stated that each resident should receive necessary care to maintain their well-being, which was not adhered to in these cases.
Failure to Prevent Resident Fall Due to Inadequate Supervision
Penalty
Summary
The facility failed to provide adequate care and supervision to prevent a fall for Resident #32, who was identified as being at high risk for falls. The resident, who had severe cognitive impairment and required substantial assistance with mobility and transfers, fell in the dining room while being assisted by a State Tested Nursing Assistant (STNA). The STNA did not use a gait belt or provide hands-on assistance during the transfer to the dining room chair, which led to the resident losing balance and falling. The resident sustained a laceration to the head and was subsequently sent to the emergency room for evaluation. The medical record review revealed that the facility had not completed any additional fall risk assessments for Resident #32 since admission, despite the resident's high fall risk status. The care plan included interventions to mitigate fall risks, such as using a gait belt for transfers and ensuring staff presence during toileting, but these were not adequately implemented. The facility's policy stated that the environment should be free of accident hazards and that residents should receive adequate supervision and assistive devices to reduce accidents, which was not adhered to in this case.
Medication Administration Errors in LTC Facility
Penalty
Summary
The facility failed to ensure medications were administered as ordered, affecting two residents. Resident #18, who has medical diagnoses including paraplegia, spinal stenosis, asthma, depression, and morbid obesity, was prescribed Lisinopril with instructions to hold the medication if systolic blood pressure (SBP) was less than 120 mmHg. However, the medical record showed that staff administered Lisinopril on multiple occasions in June 2024 without documenting the resident's blood pressure. Additionally, on July 14, 2024, Lisinopril was administered despite the resident's SBP being 116 mmHg, which was below the threshold specified in the physician's order. The administrator confirmed the lack of documentation for blood pressure readings prior to medication administration. Resident #32, with medical conditions such as diabetes mellitus, vascular dementia, COPD, CKD stage IV, hypertension, and a history of transient ischemic attack, was affected by a similar issue. After being discharged from the hospital, the resident was prescribed Apixaban to be taken twice daily. However, the June 2024 Medication Administration Record did not show documentation that Apixaban was administered as ordered on June 19, 2024. The administrator confirmed the absence of documentation for the administration of Apixaban and acknowledged that the facility did not have a policy for medication administration. This deficiency was investigated under Complaint Numbers OH00155633 and OH00154410.
Infection Control Breach During Medication Administration
Penalty
Summary
The facility staff failed to adhere to infection control procedures during medication administration, as observed with Resident #18. The resident, who has medical diagnoses including paraplegia, spinal stenosis, asthma, depression, and morbid obesity, requires substantial assistance for daily activities. During a medication administration observation, an LPN was seen preparing multiple medications for the resident. The LPN placed all the medications into a medication cup and then transferred them into her bare hands to separate one specific medication, Lisinopril, before returning the remaining medications back into the cup for administration. The LPN did not perform hand hygiene or use gloves at any point during this process, which is a violation of the facility's infection control policy. The policy mandates that staff clean their hands after each direct resident contact using appropriate hand hygiene practices. This incident was confirmed through an interview with the LPN, who acknowledged handling the medications with bare hands and not performing hand hygiene. This deficiency was identified during a complaint investigation.
Failure to Provide Feeding Assistance
Penalty
Summary
The facility failed to ensure staff provided a resident assistance with feeding, affecting one of the three residents reviewed for assistance with meals. Resident #56, who had severe cognitive impairment and was dependent for eating, was observed without staff assistance during a meal. Despite physician orders and care plans indicating the need for one-to-one feeding assistance, the resident was left to feed herself, resulting in inadequate food intake and weight loss. The resident was seen playing with her food and using her fingers to eat, without any staff intervention. Interviews with staff confirmed the lack of one-to-one feeding assistance for Resident #56. Dietary Aide #103 admitted that staff were in and out of the dining room, and Dietician Technician #127 acknowledged the resident's recent weight loss and the need for feeding assistance. The facility's policy on Activities of Daily Living, which mandates necessary care and services for residents unable to perform ADLs, was not followed. This deficiency was investigated under Complaint Number OH00152620.
Latest citations in Ohio
A resident with intact cognition receiving Medicare Part A skilled services for metabolic encephalopathy had services discontinued while benefit days remained, but the facility did not issue the required Skilled Nursing Facility Advance Beneficiary Notice (SNF ABN). The Social Services Director later confirmed that no SNF ABN was provided and reported she believed only a Notice of Medicare Non-Coverage (NOMNC) was needed when all skilled services were stopped. This practice conflicted with the facility’s written policy, which required SNF ABNs to be issued when extended care items or services were initiated, reduced, or terminated due to expected non-coverage by Medicare.
Surveyors identified that the facility exceeded the acceptable medication error rate when two residents with type 2 DM received insulin doses that were not administered according to orders or manufacturer instructions. In two separate observations, an LPN administered Novolog and another LPN administered insulin glargine and insulin lispro without priming the insulin pens, and the insulin lispro and Novolog were given after the residents had already consumed a significant portion of their breakfast meals, despite orders for administration before meals. Manufacturer information for both insulin products required priming before each injection to ensure accurate dosing, and facility policy required medications, including insulin, to be administered safely, timely, and in accordance with prescriber orders and specified time frames.
Surveyors found that the facility failed to document tray line food temperatures for multiple meals served from two dining room kitchenettes, despite having a “Trayline Taste & Temperature Log” and a policy requiring food to be stored, prepared, distributed, and served according to professional food safety standards. Review of logs showed repeated missing entries for breakfast, lunch, and dinner services in both the Harrison and McClellan dining areas, and the Senior Director of Culinary Services confirmed that temperatures had not been recorded for those meals, potentially affecting all residents receiving meals from those kitchenettes.
The facility failed to conduct and document required periodic care conferences for two residents, despite multiple comprehensive, quarterly, and significant change MDS assessments and a policy requiring periodic care conferences with resident and/or family participation. One resident with Parkinson’s disease, post-stroke hemiplegia, TIA, DMII, and depression had only two documented care conferences over a year, while another resident with aphasia, cerebrovascular disease, DMII, gait difficulty, coagulation defect, depression, and muscle weakness had no documented care conferences in the past year, aside from a declined invitation to the representative. The UCC confirmed that care conferences were expected to occur quarterly and that no additional documentation existed for either resident.
A resident with Alzheimer's disease and type II DM, who required extensive assistance with ADLs and was receiving scheduled Lantus and sliding-scale Humalog, experienced a severely elevated blood glucose level. The on-call provider was notified and ordered an additional dose of lispro insulin with a directive to recheck the blood glucose after administration. Nursing staff administered the extra insulin but did not document any follow-up blood glucose check, and the DON confirmed that this reevaluation was required by the facility's abnormal blood glucose policy and was not completed or documented.
A resident with Parkinson’s disease, dementia, and hypothyroidism was prescribed levothyroxine once daily along with other medications. A consultant pharmacist’s monthly drug regimen review recommended that levothyroxine be given in the morning on an empty stomach, 30–60 minutes before food, per manufacturer instructions. The medical record contained no documented physician response to this recommendation, and the MAR showed the drug scheduled for morning administration while the resident was observed eating breakfast and receiving the medication at the same time. An LPN confirmed administering levothyroxine during the meal, and the DON verified there was no documentation explaining whether or why the pharmacist’s recommendation was or was not followed, resulting in a failure to act on and document the identified irregularity.
A resident with severe cognitive impairment, multiple comorbidities, documented gait and balance abnormalities, and a high fall risk was care planned and assessed by therapy to require contact guard assistance and use of a gait belt for transfers and ambulation. While being assisted by a CNA from a recliner to the bathroom with a walker, the CNA did not apply a gait belt, even though the resident had a known tendency to lean backward when standing. As the CNA reached to open the bathroom door, the resident lost balance and fell backward, striking the back of the head, and was later found by an LPN without a gait belt in place, contrary to the facility’s gait belt policy and the resident’s assessed needs.
A resident with CKD stage five requiring peritoneal dialysis (PD) was admitted with pre-admission physician orders for three daily PD exchanges and monitoring for peritonitis (fever, abdominal pain, cloudy effluent), but these monitoring orders were not entered into the facility’s physician orders. The care plan referenced PD and general monitoring but did not specifically address peritonitis monitoring. Paper PD flowsheets showed incomplete and inconsistent documentation of exchanges and resident condition, including missing condition/comments for individual treatments and no record of one ordered PD exchange. The PD cycler flowsheet lacked effluent descriptions on multiple days. The PD nurse reported facility staff were expected to monitor effluent and symptoms, and the DON confirmed the absence of specific peritonitis monitoring orders, lack of an order for the PD cycler, and documentation gaps, despite a facility policy requiring ongoing assessment and monitoring for complications before, during, and after dialysis treatments.
A nurse was observed preparing multiple oral medications for a resident with depression, traumatic brain injury, anxiety, and impaired cognition by pushing tablets and capsules from unit-dose cards directly into her ungloved hand and then using her fingers to place them into a medication cup. In a follow-up interview, the RN confirmed this practice and acknowledged that the correct procedure is to dispense medications directly from the card into the cup, contrary to the facility’s medication administration policy requiring adherence to good nursing principles and practices.
A resident with Alzheimer’s disease, diabetes, anxiety, significant ADL dependence, and behavioral symptoms was observed seated in a chair positioned against the nursing station with a locked wheelchair placed directly in front, also against the nursing station, effectively restricting movement. An LPN confirmed both wheelchair wheels were locked and that it should not have been placed there, while a CNA stated she had positioned the wheelchair to prepare for lunch, was unable to complete the transfer, and left it in place, acknowledging this was wrong. This arrangement conflicted with the facility’s restraint policy, which prohibits physical restraints except when alternatives are ineffective for treating a medical symptom and defines restraints as devices adjacent to the body that cannot be easily removed and that restrict freedom of movement or access to the body.
Failure to Issue Required SNF ABN When Discontinuing Medicare Part A Services
Penalty
Summary
The deficiency involves the facility’s failure to issue a Skilled Nursing Facility Advance Beneficiary Notice (SNF ABN) when Medicare Part A services were discontinued for a resident who still had available benefit days. The resident was admitted with a diagnosis of metabolic encephalopathy and had intact cognition per the Minimum Data Set assessment. The facility’s own SNF Beneficiary Notification Review documented that Medicare Part A skilled services began on 02/11/26 and the last covered day was 03/11/26, and that the facility initiated discharge from Medicare Part A services before the resident’s benefit days were exhausted. Despite this, no SNF ABN was provided to the resident or the resident’s representative. During interviews, the Social Services Director stated that the SNF ABN was issued hours prior to the last covered day but, upon reviewing her files, confirmed that no SNF ABN had actually been issued for this resident. She further explained that she believed an SNF ABN was only required if one skilled service remained and that if all skilled services were being discontinued, only the Notice of Medicare Non-Coverage (NOMNC) needed to be issued. The Administrator, however, stated that a resident should always receive both a SNF ABN and a NOMNC when Medicare Part A services are discontinued and benefit days remain. Review of the facility’s written policy dated 03/28/23 showed that the facility was required to issue SNF ABNs for initiation, reduction, or termination of extended care items or services when Medicare payment was not expected, which did not occur in this case.
Plan Of Correction
This Plan of Correction is submitted as required under State and Federal law. This Plan of Correction does not constitute an admission on the part of the Facility that the findings cited are accurate, that the findings constitute a deficiency or that the scope and severity regarding the deficiency cited are correctly applied. Any changes to the Facility's policies and procedures should be inadmissible in any proceeding on that basis. Without admitting or denying the validity or the existence of the alleged noncompliance, the Facility submits this Plan of Correction with the intention that it be inadmissible by any third party in any civil or other action against the facility or any employee, agent, officer, director or shareholder of the Facility. The Facility is utilizing this Plan of Correction as its allegation of substantial compliance as of 05/29/2026 F-0582 Corrective action for resident/s: On 5/14/26 Resident #34 was informed of rights and responsibilities related to Advanced Beneficiary Notice and voiced understanding of information for future reference by administrator. Identification of other residents who may be affected: Any resident receiving skilled services from nursing or therapy services. The Administrator audited all residents who were discharged from skilled services in the past 30 days to ensure they were issued a Notice of Non-Coverage and Advanced Beneficiary Notice on 5/29/26. No non-compliance was noted. Measures for systemic change: On 5/14/2026 Business Office Manager, Director of Rehab, Minimum Data Set nurse, Director of Nursing and Social Services Director were educated on proper procedure of issuing of Notice Of Medicare Non Coverage and Advanced Beneficiary Notice by administrator. All upcoming discharges from skilled services will be reviewed weekly at Utilization Review meeting to ensure notices will be delivered timely. How Corrective Action will be monitored: Administrator or designee to complete audits of all residents being discharged from skilled services to ensure they were issued a Notice of Non-Coverage and Advanced Beneficiary. This audit will be completed weekly x 4 weeks, then monthly x 2 months. Corrective action will be initiated for any noted non-compliance. Audit findings will be reviewed as part of the monthly quality assurance process to determine the need for further monitoring. Date of Compliance 5/29/26
Insulin Administration Errors and Failure to Prime Insulin Pens
Penalty
Summary
The deficiency involves the facility’s failure to maintain a medication error rate below 5%, with surveyors identifying 3 errors out of 28 medication administration opportunities, resulting in a 10.71% error rate. For one resident with type 2 diabetes mellitus and moderate cognitive impairment, the physician’s order directed Novolog insulin 10 units via subcutaneous pen-injector to be given before meals. During an observed medication pass, the LPN administered 10 units of Novolog insulin without priming the pen and did so after the resident had already consumed approximately 50% of the breakfast meal. The LPN later confirmed she did not prime the pen and acknowledged that the insulin was ordered to be administered prior to meals. Manufacturer instructions for the Novolog FlexPen specified that an air shot (priming) must be performed before each injection to ensure proper dosing. Another resident, also diagnosed with type 2 diabetes mellitus and with intact cognition, had orders for insulin glargine 35 units subcutaneously twice daily and insulin lispro 20 units subcutaneously before meals, plus 12 units subcutaneously if blood glucose was between 251 mg/dL and 300 mg/dL. During an observed medication administration, an LPN administered 35 units of insulin glargine and 32 units of insulin lispro without priming the insulin pens and after the resident had consumed approximately 90% of the breakfast meal, despite orders for insulin lispro to be given before meals. The LPN later stated she could not remember if she had primed the pen and acknowledged that the insulin was ordered to be administered prior to meals. Manufacturer information for insulin lispro stated that the pen must be primed before each injection to confirm insulin delivery and remove air, and that failure to prime could result in too much or too little insulin. The DON confirmed the expectation that insulin be administered as ordered, including priming each pen with two units before dialing the prescribed dose, and facility policy required medications, including insulin, to be administered safely, timely, and in accordance with prescriber orders and required time frames.
Plan Of Correction
This Plan of Correction is submitted as required under State and Federal law. This Plan of Correction does not constitute an admission on the part of the Facility that the findings cited are accurate, that the findings constitute a deficiency or that the scope and severity regarding the deficiency cited are correctly applied. Any changes to the Facility's policies and procedures should be inadmissible in any proceeding on that basis. Without admitting or denying the validity or the existence of the alleged noncompliance, the Facility submits this Plan of Correction with the intention that it be inadmissible by any third party in any civil or other action against the facility or any employee, agent, officer, director or shareholder of the Facility. The Facility is utilizing this Plan of Correction as an allegation of substantial compliance as of 5/29/2026. F-0759 Corrective action for resident/s: Residents #21 and #22 were assessed and evaluated by nurse and Director of Nursing 5/14/26. Resident #21 and #22 both denied any adverse effects and none were noted upon assessment by the Director of Nursing on 5/14/2026. Notification made to physician on 5/14/2026. LPN # 2 competency Eval on insulin administration with the Director of Nursing completed 5/14/2026. Identification of other residents who may be affected: Diabetic residents on assignment of LPN #2/station 2 have the potential to be affected and were assessed by the DON/Designee on 5/14/26 and found to be within normal limits. Measures for systemic change: All Nurses were educated by the Director of Nursing on the steps for Insulin administration per competency, diabetes clinical protocol policy, Medication and treatment orders policy, administering medications policy, and Obtaining fingerstick Glucose Level policy On 5/14/2026. How Corrective Action will be monitored: Director of Nursing and Assistant Director of Nursing will complete insulin administration audits on 5 nurses. This audit will be completed weekly x 4 weeks, then monthly x 2 months. Corrective action will be initiated for any noted non-compliance. Audit findings will be reviewed as part of the monthly quality assurance process to determine the need for further monitoring. Date of Compliance: 5/29/2026
Failure to Document Tray Line Food Temperatures in Dining Room Kitchenettes
Penalty
Summary
The deficiency involves the facility’s failure to document tray line food temperatures for meals served from the Harrison and McClellan Dining Room kitchenettes, as required by professional standards for food service safety and the facility’s own policy. Review of the “Trayline Taste & Temperature Log” (revised September 2018) showed missing temperature documentation for multiple meals from the Harrison Dining Room kitchenette, including dinner on 03/30/26 and 03/31/26, lunch and dinner on 04/01/26 and 04/02/26, dinner on 04/07/26, and lunch and dinner on 04/08/26 and 04/10/26. The Senior Director of Culinary Services confirmed during interview that tray line food temperatures were not documented on the log for these meals. Similarly, review of the same log for the McClellan Dining Room kitchenette revealed that tray line food temperatures were not documented for dinner on 04/01/26, breakfast and lunch on 04/02/26, and lunch and dinner on 04/07/26. The Senior Director of Culinary Services also verified these omissions during interview. The facility census at the time was 27 residents, and the governing “Food and Nutrition” policy, approved on 09/07/21, stated that the facility must store, prepare, distribute, and serve food in accordance with professional standards for food service safety.
Plan Of Correction
F812 The facility will continue to ensure food temperatures are completed before meals are served for all residents. To ensure compliance with this standard the following measures have been taken: 1. Immediately 4/15/26 culinary supervisor #224 was re-educated by Dietary Manager to this standard and policy "Food and Nutrition" which includes documentation of food temperatures. 2. All dietary staff have been re-educated to the standard and policy "Food and Nutrition" during the month of April 2026. 3. Audits of food temperature documentation to be completed by Dietary Manager 4 x per week for 4 weeks then weekly for 4 weeks. 4. Administrator to validate audits/compliance and provide additional training as needed. Administrator will present to QAPI committee for ongoing monitoring and further direction.
Failure to Conduct and Document Required Care Conferences
Penalty
Summary
The deficiency involves the facility’s failure to complete and document comprehensive care conferences at required intervals in accordance with care plan regulations and facility policy. For one resident with Parkinson’s disease with dyskinesia, cognitive communication deficit, hemiplegia and hemiparesis following cerebral infarction, transient cerebral ischemic attack, type II diabetes mellitus, and major depressive disorder, the record showed multiple MDS assessments over a one-year period, including annual, quarterly, and significant change assessments. However, only two care conferences were documented during the last 12 months, despite the expectation that care conferences be conducted quarterly with the resident and family when possible. The Unit Care Coordinator confirmed that no additional care conference documentation existed for this resident beyond the notes dated 04/21/25 and 01/02/26. A second resident, with diagnoses including aphasia following cerebrovascular disease, cerebral infarction, type II diabetes mellitus, unsteadiness on feet, difficulty in walking, coagulation defect, depression, and muscle weakness, also had multiple MDS assessments completed over the review period, including quarterly and annual assessments. The record contained a note that a care conference was offered to the resident’s representative, who declined to attend, but there was no documentation of any care conferences for the most recent 12 months. The Unit Care Coordinator confirmed that no other care conference documentation was available for this resident. Facility policy stated that periodic care conferences involving the resident, family, and the interdisciplinary team are part of the care planning process, but the required periodic care conferences and corresponding documentation were not completed for these two residents.
Plan Of Correction
THIS PLAN OF CORRECTION SERVES AS BERKELEY SQUARE'S CREDIBLE ALLEGATION OF SUBSTANTIAL COMPLIANCE AS OF June 1, 2026. Without admitting or denying the validity or existence of the alleged deficiencies, Berkeley Square provides the following Plan of Correction: F657 The facility will continue to document completion of care conferences at the required intervals for all residents, including residents #04 & #15. To ensure compliance with this standard the following measures have be taken: 1. The social service designee and the inter- disciplinary team were re-educated by the administrator to the facility policy "Care Conference" on 4/29/26 and verbalized understanding. 2. Care conferences for resident #04 and resident #15 were conducted on or before 4/29/2026 by the interdisciplinary team. 3. Review of all other residents was conducted by the social service designee to validate and ensure that care conference schedule is up to date with timely care conferences scheduled for them on 4/15/2026. Audits of care conferences to be completed weekly for four weeks and then monthly after that by the social service designee. Documentation of the care conference including any identified concerns in the medical record. Administrator to validate audits/compliance and provide additional training as needed. Administrator will present results of these audits to QAPI committee for ongoing monitoring and further direction.
Failure to Reevaluate Blood Glucose After Treatment for Hyperglycemia
Penalty
Summary
The facility failed to ensure that a resident with diabetes received treatment in accordance with professional standards of practice when nursing staff did not reevaluate the resident's blood glucose after treatment for severe hyperglycemia. The resident, admitted with diagnoses including Alzheimer's disease, type II diabetes mellitus, and depression, had physician orders for Humalog insulin on a sliding scale before meals, Lantus insulin 25 units daily, and lisinopril 5 mg daily. The resident required extensive assistance with activities of daily living, including transfers, toileting hygiene, eating, and bathing. On the evening in question, the resident's blood glucose was documented as 532 mg/dL, and the on-call provider was notified. The provider gave a new order to administer an additional 8 units of lispro (Humalog) and to recheck the blood glucose in 30 minutes. The electronic medication administration record showed that the blood glucose of 532 mg/dL was obtained at 9:00 p.m. and that the additional 8 units of lispro were administered at 9:21 p.m. However, there was no documentation in the resident's chart that the blood glucose was rechecked after the additional insulin was given. In an interview, the DON confirmed there was no evidence of reevaluation and verified that, according to the facility's "Abnormal Blood Glucose Procedure" policy, the resident should have been reevaluated and that the evaluation step should have been included in the progress note documentation.
Plan Of Correction
F684 The facility will continue to ensure all residents, including #03, receive treatment in accordance with professional standards of practice and reevaluated for hyperglycemia. To ensure compliance with this standard the following measures have been taken: 1. The director of nursing assessed resident #03, reviewed documentation and orders and found no ill effects immediately 4/16/26. 2. All licensed nurses were re-educated to facility policy "Blood Glucose Monitoring" by the Director of Nursing/designee in April 2026. 3. Audits of like-residents that require blood sugar checks to be completed by the director of nursing/designee two times a week for 4 weeks and then monthly after that to validate correct follow through when there is abnormally high blood glucose result. The Administrator will bring results of these audits to the QAPI committee for ongoing monitoring and further direction.
Failure to Act on Pharmacist Drug Regimen Recommendation for Thyroid Medication
Penalty
Summary
The deficiency involves the facility’s failure to ensure that pharmacy recommendations from the monthly drug regimen review were acted upon and documented for a resident. The resident was admitted with diagnoses including Parkinson’s disease, dementia, and hypothyroidism, and had current physician orders for levothyroxine 150 mcg once daily, buspirone 50 mg twice daily, and losartan 100 mg once daily. A medication regimen review dated 11/25/2025 included a consultant pharmacist recommendation that levothyroxine be administered consistently in the morning on an empty stomach, at least 30–60 minutes before food, per manufacturer instructions. There was no specific physician response in the medical record to this recommendation, and the facility’s policy stated that consulting pharmacist reviews are sent to nursing and addressed with the primary care provider or consulting specialist for review and follow-up. Review of the resident’s medication administration record for April 2026 showed levothyroxine scheduled for 9:00 a.m. On observation, the resident was seen eating breakfast in the dining area at 8:03 a.m., and an LPN reported administering the levothyroxine 150 mcg to the resident while the resident was in the dining area eating breakfast. The DON confirmed there was no evidence in the resident’s medical record explaining why the consultant pharmacist’s recommendation from 11/25/2025 was or was not acted upon. This lack of documented physician review and action on the pharmacist’s identified irregularity constituted noncompliance with the drug regimen review requirements.
Plan Of Correction
F756 The facility will continue to ensure the pharmacy recommendations from the monthly drug regimen review by a licensed pharmacist are acted upon for all residents, including #08. To ensure compliance with this standard the following measures have been taken: 1. Resident #08 was assessed by the registered nurse and med review completed by 4/28/26. After review of resident's drug regime's, it was discovered that resident #8 had 2 separate medication recommendations on the same form, to be reviewed by two separate practitioners, pharmacy has been instructed and agreed to separate meds on individual forms. 2. Licensed nurses re-educated to facility policy "Drug Regimen Review" by Director of nursing/designee in April 2026 and no later than 5/8/26. Licensed nurses are responsible for ensuring the reviews and recommendations are given to the physician for timely review. 3. Review of all other current residents Drug Regimen orders completed by Director of nursing/designee on 4/16/26 to ensure recommendations were followed up on/reviewed by the physician and address concerns if needed. 4. Audit of drug regime recommendations, pharmacy recommendations, and physician follow up to be completed weekly for four weeks by the Director of nursing/designee. Administrator will present results of these audits to the QAPI committee for ongoing monitoring and further direction.
Failure to Use Required Gait Belt During Ambulation Resulting in Resident Fall
Penalty
Summary
The deficiency involves the facility’s failure to ensure that a required gait belt was used while assisting a high fall‑risk resident with ambulation, resulting in a fall with head injury. The resident had multiple diagnoses including metabolic encephalopathy, hypertension, osteoarthritis, muscle weakness, gait and mobility abnormalities, major depressive disorder, anxiety, and visual hallucinations. Admission and subsequent MDS and fall risk assessments documented that the resident was severely cognitively impaired, required moderate to maximal assistance with transfers and ambulation, could not independently come to a standing position, exhibited loss of balance while standing, used an assistive device, and had decreased muscle coordination. The resident had a history of falls prior to admission and was assessed as being at high, later moderate, risk for falls. The resident’s fall care plan identified her as at risk for falls and included interventions such as providing maximum to moderate assistance with transfers and walking short distances, use of a walker and wheelchair, and following the facility’s fall protocol. Therapy notes and care conference documentation indicated that the resident leaned backwards when standing, required contact guard to minimal assistance for bed mobility and transfers, and needed constant verbal cueing for safe sequencing during toilet transfers. The physical therapist confirmed that the resident was to use a gait belt with staff when ambulating, and the DON verified that therapy had assessed the resident as requiring contact guard assistance and a gait belt for ambulation and transfers. On the day of the incident, a CNA was assisting the resident from her recliner to the bathroom using a walker. The CNA walked beside the resident, providing guidance and support, and reported having a hand on the resident while assisting her. As they approached the bathroom door, the CNA reached for the doorknob to open it, and at that moment the resident began to lose her balance and fell backwards to the floor, striking the back of her head. The nurse who responded found the resident on her back at the foot of the bed with her feet near the bathroom, noted a red raised area on the back of the head, and documented that the resident was not wearing a gait belt and that the gait belt was on the dresser. In the facility’s investigative summary and in interviews, the CNA acknowledged that she did not have a gait belt on the resident while ambulating her, despite the resident’s assessed need for hands‑on assistance and gait belt use per facility policy and the resident’s care and therapy plans.
Failure to Implement PD Orders and Monitor Resident Receiving Peritoneal Dialysis
Penalty
Summary
The deficiency involves the facility’s failure to implement pre-admission physician orders for peritoneal dialysis (PD) and to provide ongoing monitoring for a resident with chronic kidney disease (CKD) stage five who required PD. Pre-admission orders dated 11/14/25 specified three daily PD exchanges at 6:00 A.M., 2:00 P.M., and 10:00 P.M., and directed staff to monitor for signs and symptoms of peritonitis, including fever, abdominal pain, and cloudy effluent. These monitoring orders were not entered into the facility’s physician orders. The resident’s care plan noted the need for PD and included general monitoring interventions (labs, signs of bleeding, bacteremia, septic shock, and significant vital sign changes), but did not specifically address the ordered monitoring for peritonitis. Review of PD documentation showed incomplete and inconsistent charting of treatments and resident condition. The paper peritoneal flowsheet had columns for time of PD and condition/comments, including instructions to call the nurse immediately for cloudy fluid, abdominal pain, or fever. However, the first entry on 11/15/26 at 2:00 P.M. only noted that the PD nurse completed the exchange, and the 10:00 P.M. entry that day had no condition/comment documentation. Subsequent days (11/16/25, 11/17/25, and 11/18/25) contained only one condition/comment entry per day rather than for each exchange, and there was no documentation that the 6:00 A.M. PD on 11/18/25 was completed. The PD cycler flowsheet starting 11/19/25 lacked any description of the effluent on multiple days. The PD nurse from the dialysis company stated facility staff were expected to monitor effluent for cloudiness and assess for abdominal pain and fever, and the DON confirmed there was no electronic physician order for peritonitis monitoring or for use of the PD cycler, that the paper charting did not allow for effluent description or symptom documentation for each treatment, and that PD was not documented at one ordered time. The facility’s dialysis policy required ongoing assessment and monitoring for complications before, during, and after treatments, which was not reflected in the documentation for this resident.
Improper Infection Control During Medication Administration
Penalty
Summary
Surveyors identified a deficiency in infection prevention and control related to medication administration for Resident #29. The resident was admitted on 02/28/14 with diagnoses including depression, traumatic brain injury, and anxiety, and had impaired cognition per a quarterly MDS assessment. During an observation on 03/25/26 at 6:58 A.M., RN #281 prepared the resident’s medications by removing an Amoxicillin-Pot Clavulanate tablet from the medication card and pushing it directly into her ungloved hand, then using her fingers to place the pill into a medication cup. The same process was observed for multiple other medications, including Escitalopram Oxalate, Furosemide, Sennosides, Lyrica, and Vitamin D, each being pushed from the card into the RN’s ungloved hand and then transferred by her fingers into the medication cup before administration to Resident #29. In a subsequent interview at 7:27 A.M. the same day, RN #281 confirmed she had placed each medication into her ungloved hands prior to administration and acknowledged that the proper procedure was to push the pills directly from the card into the medication cup. Review of the facility’s “Medication Administration – General guidelines” policy, revised 10/08/25, stated that medications are to be administered in accordance with good nursing principles and practices. This practice failure was cited as a deficiency under Complaint Number 2681777.
Improper Use of Wheelchair as a Physical Restraint
Penalty
Summary
Surveyors identified a deficiency related to the facility’s failure to ensure a resident was free from physical restraints. Resident #7, admitted with diagnoses including Alzheimer’s disease, diabetes mellitus, and anxiety disorder, was documented on a recent MDS as rarely understood and dependent for ADLs except eating. The resident ambulated independently on the unit without an assistive device and had documented verbal and other behaviors occurring one to three days during the look-back period. The care plan noted the resident had potential to be physically aggressive, chase staff, throw objects, and be combative with care, with interventions such as offering choices, administering medications as ordered, and intervening early when agitation occurred. During an observation and interview, Resident #7 was found sitting in a chair with the right arm of the chair positioned against the nursing station and a wheelchair placed directly in front of him. The left arm of the wheelchair was also against the nursing station, and both wheelchair wheels were locked, creating a barrier that appeared to restrain the resident, who was sleeping with his knees touching the locked wheelchair. An LPN confirmed both wheelchair wheels were locked and that the wheelchair should not have been placed in front of the resident. A CNA reported she had placed the wheelchair there in preparation to get the resident up for lunch, was unable to transfer him, and left the wheelchair in that position, acknowledging it was wrong to keep it there. The facility’s physical restraint policy stated that physical restraints are not used except when alternatives are not appropriate or effective for treating a medical symptom and defined physical restraints as any device attached or adjacent to the body that the individual cannot easily remove and that restricts freedom of movement or access to the body.
Trusted data from CMS and state health departments
Every citation, penalty and Plan of Correction is sourced from public CMS records (latest release May 27, 2026) and official state health department websites — never guesswork.
Trusted by long-term care providers and associations.
