Walnut Creek Nursing Center
Inspection history, citations, penalties and survey trends for this long-term care facility in Kettering, Ohio.
- Location
- 5070 Lamme Road, Kettering, Ohio 45439
- CMS Provider Number
- 365821
- Inspections on file
- 42
- Latest survey
- February 25, 2026
- Citations (last 12 mo.)
- 13
Citation history
Health deficiencies cited at Walnut Creek Nursing Center during CMS and state inspections, most recent first.
The facility failed to complete timely and thorough skin assessments and wound care for two residents at risk for or with existing pressure injuries. One resident with multiple comorbidities and impaired cognition, care planned for weekly skin checks, went without documented skin assessments for an extended period until a right heel DTI was found, and the corresponding wound treatment orders were not initiated for several days after the wound was first documented. Another resident with diabetes, CHF, and other conditions was readmitted with a left heel blister and existing pressure injuries, but no wound measurements were taken for the blister over multiple days despite an active treatment order, and wound rounding was postponed. The DON confirmed the missed weekly assessments, delayed treatment orders, and lack of wound measurements, contrary to facility policy requiring routine skin observation and preventive care planning.
A resident with Parkinson’s disease, a right femur fracture, hypertension, and impaired cognition had an active order for two Senna Plus tablets as a laxative/stool softener. During a medication pass, an LPN administered multiple medications including two Senna 8.6 mg tablets instead of the ordered Senna Plus. In a later interview, the LPN confirmed the error. Facility policy required medications to be administered in accordance with physician orders, and this failure to provide the prescribed Senna Plus constituted the deficiency.
The facility failed to maintain infection surveillance logs for multiple consecutive months and did not document infection locations or types, despite several residents being in isolation for wound infections and multiple residents testing positive for COVID-19. The ADON/Infection Preventionist confirmed the absence of infection tracking logs and surveillance/maps during a COVID-19 outbreak. The DON reported that staff, residents, and families were notified of the first COVID-19 case through various methods but could not provide documentation of these notifications. The facility lacked a specific COVID-19 policy and relied on a COVID-19 QAPI Plan that required staff education and testing of all residents and staff on specified days, but the DON confirmed that required testing intervals were not followed and there was no documented evidence of staff testing, with only a log emailed to the health department reflecting positive resident cases.
Surveyors identified that resident refrigerators on multiple halls were dirty and contained improperly stored food items. A moist, stained towel was found inside a refrigerator, along with several personal food containers and opened iced coffee bottles that were unlabeled and undated. The attached freezer contained a frozen red substance on the floor, a non-functioning thermometer lying upside down, and multiple ice cream cups and personal food containers that were also unlabeled and undated. No cleaning or temperature logs were present, and the DON confirmed that daily cleaning and temperature checks were expected but not documented, and that there was no policy for cleaning resident refrigerators.
A resident with dementia and other psychiatric diagnoses, identified as at risk for elopement and living on a secured memory care unit, repeatedly attempted to exit the unit and later was discovered missing. Staff initiated a missing resident code and the resident was ultimately found off the property and returned, though staff accounts conflicted regarding how this occurred. The DON confirmed there was no thorough investigation documented, including no record of when the resident was last seen, how the resident eloped, or what measures were identified to prevent recurrence, and also confirmed that not all staff had been educated on elopement risks despite an existing wandering and elopement policy.
Surveyors found that the facility failed to maintain comprehensive, accurate care plans addressing nutritional risk for two residents. One resident with severe protein-calorie malnutrition, acute respiratory failure, and significant recent weight loss had no nutritional care plan despite documented weight decline and assessment as being at nutritional risk. Another resident with TBI, dysphagia, and severe protein-calorie malnutrition, requiring set-up assistance for eating and on a mechanically altered diet, also lacked an active dietary care plan after the previous one was discontinued during a system changeover. Nursing staff confirmed both residents were identified as nutritional risks, and leadership reported there was no facility policy on care plans.
Two residents were affected when staff failed to follow assessment expectations. After an unwitnessed fall resulting in a forehead hematoma, a resident with cognitive impairment did not receive documented neuro checks as required by facility policy, despite the DON’s expectation that such assessments be completed after unwitnessed falls or head injuries. In a separate incident, a resident with renal insufficiency, hydronephrosis, and an indwelling catheter, whose care plan called for monitoring for UTI and mental status changes, was transferred to the hospital for a change in condition without any documented nursing assessment or clinical details of the change, even though the DON stated nurses are expected to assess and document significant changes in condition.
A resident with severe cognitive impairment and multiple comorbidities, care planned as high risk for falls and requiring substantial assistance with bed mobility and transfers, fell from bed onto a fall mat during the night. Video showed the resident remained on the floor for several hours without any staff entering the room to perform the frequent checks required by the care plan. When an RN eventually entered to give medications, the RN lifted the resident from the floor to the bed without performing an assessment, did not allow time for the resident to respond about possible injuries, and then administered medications. There was no nursing documentation of the fall, no post-fall assessment, and no evidence of timely provider notification, despite facility policy requiring neurological checks and post-fall evaluations for unwitnessed falls.
The facility failed to maintain a conducive dining environment when a cognitively impaired resident with known behavioral symptoms was allowed to yell continuously during meals in the main dining room. On multiple observed occasions, this resident yelled non-stop while eating, without appearing in distress, while nearby residents on mechanically altered diets and needing set-up assistance reported ongoing disturbance and stated they had repeatedly complained to staff and management. A CNA and an LPN confirmed that the yelling occurred at every meal, that multiple residents complained, and that the resident was kept in the dining room because there was insufficient staff to feed her in her room, affecting several diners and potentially all who used the main dining room.
Surveyors found that an LPN did not follow physician orders for three residents, resulting in multiple medication administration errors. One resident who depended on staff for medications was given Milk of Magnesia instead of the ordered Mylanta. Another resident with multiple chronic conditions did not receive the ordered lactulose and was instead given potassium. A third resident with cardiac and pulmonary diagnoses did not receive ordered cyanocobalamin and apixaban, and was given high-dose vitamin D2 without an order. These errors occurred despite a facility policy requiring medications to be administered safely, timely, and as prescribed.
A resident with severe cognitive impairment and multiple comorbidities, including dementia, COPD, and a history of failure to thrive, had an order and care plan for a mechanically altered diet with supervision. During a lunch meal, the resident was served mechanically altered meatballs along with unaltered green beans and whole grapes and was observed eating the grapes alone in the room without staff supervision. An LPN and another staff member confirmed the resident’s mechanically altered diet order and acknowledged that whole grapes are not appropriate for such a diet and should not have been served, while facility policy assigned responsibility to food and nutrition services to prepare and serve the correct food consistency as ordered.
Two residents dependent on staff for care reported being treated disrespectfully and left without proper assistance by a CNA, who was described as aggressive and unprofessional during care activities. Staff and other residents confirmed ongoing concerns about the CNA's conduct, and disciplinary actions had previously been taken against the CNA for similar issues.
Staff did not immediately report allegations of abuse to administration and failed to conduct thorough investigations, including missing witness interviews and incomplete documentation, in two cases involving residents who reported mistreatment during mechanical lift transfers by CNAs and an LPN.
Staff failed to wear hairnets or contain their hair while preparing and handling food, and food items were found improperly labeled, undated, and stored directly on the floor in the kitchen. The dietary director confirmed these lapses, which affected all residents receiving meals except for one who was NPO. Facility policies require proper food storage and employee hygiene, but these were not followed during the survey.
A resident developed an avoidable stage III pressure ulcer due to the facility's failure to conduct necessary skin assessments and follow the care plan. Despite having a care plan indicating a risk for skin integrity issues, the resident did not receive documented skin assessments or pressure ulcer risk assessments upon readmission. The facility's policy for standardized risk assessments was not followed, and prescribed wound treatments were inconsistently documented.
A resident with cognitive and mobility impairments experienced multiple falls due to the facility's failure to consistently implement fall interventions, such as anti-rollbacks on the wheelchair. Despite being at risk and having a history of falls, the resident was observed without the necessary safety device and without supervision, leading to incidents of falling and injury.
A resident with multiple health conditions did not receive Midodrine as prescribed when their blood pressure was below the specified threshold. Despite clear physician orders and facility policy, the medication was not administered on several occasions, as confirmed by MAR review and DON interview.
The facility failed to complete AIMS assessments for two residents on antipsychotic medications, despite recommendations and physician orders. One resident, severely cognitively impaired and on hospice, was prescribed Risperdal and Ativan PRN without a stop date, leading to administration beyond the intended period. Another resident with dementia had a delayed AIMS assessment despite a pharmacy recommendation. The facility's policy on monitoring psychotropic drug side effects was not followed.
The facility failed to properly store medications, with expired Insulin Aspart and Potassium Chloride found in medication carts. An LPN confirmed the insulin was not discarded after 28 days, and another LPN verified the potassium chloride was expired. The DON stated no expired medications should be in carts, aligning with facility policy.
The facility failed to timely implement Enhanced Barrier Precautions (EBP) for three residents, leading to deficiencies in infection prevention and control. A resident with a stage III pressure ulcer did not have EBP ordered until much later, and no PPE or signage was observed. Another resident tested positive for Candida Auris but was not placed in EBP promptly. A third resident with a stage II pressure ulcer was also not in EBP. The ADON and RDCO confirmed that EBP should have been implemented earlier for these residents.
A facility failed to ensure staff wore appropriate PPE while caring for a COVID-19 positive resident. A CNA was observed without a gown, face shield, goggles, or N95 respirator, only wearing a surgical mask, despite the resident being under contact and droplet precautions. This violated the facility's COVID-19 QAPI Plan and CDC guidance, which require full PPE for healthcare personnel entering the room of a patient with confirmed SARS-CoV-2 infection.
A facility failed to document glucose levels before administering Lantus insulin to a resident with diabetes, despite physician orders requiring it. The resident's records showed no glucose checks before the 9:00 P.M. dose, which was confirmed by the DON. This resulted in significant medication errors and non-compliance with medication administration protocols.
Failure to Complete Timely Skin Assessments and Wound Care for Residents with Pressure Injuries
Penalty
Summary
The deficiency involves the facility’s failure to provide timely and complete skin assessments and wound care for residents with pressure injury risk or existing wounds. One resident with Alzheimer’s disease, diabetes, atherosclerotic heart disease, hypertension, impaired cognition, and significant dependence for mobility and toileting was care planned for weekly skin checks and had a Braden score indicating risk for pressure ulcers. After the admission assessment, no skin assessments were documented for this resident until nearly two months later, when a right heel pressure area was identified. The initial skin assessment documenting this right heel pressure area did not include measurements, and although the resident was added to the wound round list with a documented unstageable DTI and specified treatment, the corresponding physician treatment orders for the right heel were not entered and initiated until eight days after the wound was first documented. The DON confirmed that weekly skin assessments were not completed as care planned and that the wound treatment orders were delayed. Another resident with diabetes mellitus type 2, gout, CHF, and depression, who was dependent for bed mobility and transfers, was readmitted with a documented stage 2 pressure injury and a DTI present on admission. The readmission skin assessment noted a left heel blister but did not include any wound measurements. A physician order was in place for daily wound care to the left heel, and the treatment was documented as completed on the TAR. However, wound rounding documentation showed a visit had to be rescheduled, and no measurements of the large left heel blister were taken from readmission through the date when the blister began to pop and seep fluid and the resident complained of pain and requested transfer to the hospital. The DON verified that no measurements were obtained for this left heel blister during that period. Facility policy required routine skin observation and implementation of preventive care plans, which was not followed in these cases.
Incorrect Laxative Administered Instead of Ordered Senna Plus
Penalty
Summary
The deficiency involves the facility’s failure to administer medications as ordered for a resident. The resident, admitted with Parkinson’s disease, a right femur fracture, and hypertension, had an order starting 01/10/26 for two Senna Plus tablets, a combination laxative/stool softener. The admission MDS showed impaired cognition with a BIMS score of seven, independence with eating, supervision needed for bed mobility, moderate assistance for transfers, and maximum assistance for toileting hygiene. During a medication pass observed on 01/24/26 at 9:34 A.M., LPN #111 administered multiple medications including aspirin, Miralax, Ropinirole, carbidopa/levodopa, Vitamin D, Amlodipine, and two Senna 8.6 mg tablets. In a subsequent interview at 10:18 A.M. on 01/10/26, LPN #111 confirmed she had given Senna tablets instead of the prescribed Senna Plus tablets. Review of the facility’s “Administering Medications” policy dated 04/28/25 documented that medications must be administered in accordance with orders. This discrepancy between the ordered Senna Plus and the administered Senna tablets constituted the failure to ensure medications were given as ordered.
Failure to Maintain Infection Surveillance and Follow COVID-19 QAPI Plan
Penalty
Summary
The deficiency involves the facility’s failure to maintain and implement an effective infection prevention and control program, including accurate monitoring and tracking of infections. Infection control tracking logs were available for June, July, and August 2025 and showed no COVID-19 or TB cases, but there were no infection control logs for September, October, November, and December 2025, or January 2026. Despite this lack of documentation, there were four residents who tested positive for COVID-19 in November 2025, and the Assistant Director of Nursing/Infection Preventionist confirmed that there were no infection control tracking logs or infection location surveillance/maps for those months. The Infection Preventionist also confirmed that there were six residents in isolation for wound infections at the time of the survey, but there was no infection control tracking log documenting the types of infections. The Director of Nursing reported that when the first COVID-19 case was detected on November 23, 2025, staff were notified via WhatsApp and Paycom, residents were notified in person, and families were notified by phone; however, there was no documentation of these notifications. The DON stated the facility did not have a specific COVID-19 policy and instead followed a COVID-19 QAPI Plan that required staff education at the time of a positive case and testing of all residents and staff on days one, three, and five, with the initial positive test date as day zero. The DON confirmed that no additional staff or residents were tested on day one as required, residents were instead tested on days two, four, and nine, and there was no documented evidence of staff testing. The DON also verified that the QAPI Plan’s provisions for expanded testing if additional positives occurred were not followed, and that the only documentation of COVID-19 positive residents was a log emailed to the local health department.
Unclean Resident Refrigerators and Lack of Food Labeling and Monitoring
Penalty
Summary
Surveyors found that the facility failed to ensure resident refrigerators were clean and free from expired or improperly stored foods, affecting 106 residents, with the exception of one resident who was NPO. During observation of the resident refrigerator on the 100-Hall, Skilled Hall, and 200-Hall with the DON, the interior was noted to be dirty, with a moist hand towel lying on the top shelf that had brown stains scattered throughout. Inside the refrigerator were four personal containers of various food items that were unlabeled and undated, as well as multiple opened bottles of iced coffee without resident names, dates, or expiration dates. The attached freezer contained a frozen red substance on the floor, a thermometer lying upside down on the floor of the freezer that was stuck and unable to move, two cups of Dairy Queen ice cream with straws sticking out of the lids that were undated and unlabeled, and two additional personal containers of food that were also undated and unlabeled. There was no temperature or cleaning log present on or around the refrigerator/freezer. In an interview conducted at the time of observation, the DON confirmed the dirty condition of the refrigerators and freezers on the 100-Hall, Skilled Hall, and 200-Hall, confirmed that the refrigerator/freezer should be cleaned and temperatures checked daily, and acknowledged that the cleaning and temperature logs were missing. The DON also stated there was no policy on cleaning the residents' refrigerators. This deficiency was investigated under Complaint Number 2677474.
Failure to Thoroughly Investigate Resident Elopement
Penalty
Summary
The deficiency involves the facility’s failure to conduct a thorough investigation after a cognitively impaired resident, identified as being at risk for elopement and residing on a secured Memory Care Unit (MCU), left the facility grounds. The resident had multiple diagnoses including dementia, schizoaffective disorder, bipolar disorder, and anxiety, and had been assessed as at risk for elopement upon admission. The care plan documented impaired cognition, poor judgment, and elopement risk, with interventions such as monitoring cognitive changes, conducting elopement assessments, and providing redirection. On the day of the incident, behavior notes documented that the resident was setting off alarms and attempting to exit the MCU, with staff redirecting the resident and securing the unit doors. Later that afternoon, staff discovered the resident was not in the facility, initiated a missing resident code, and began a search. Interviews revealed inconsistent accounts of how and by whom the resident was located and returned, including reports that the resident was found approximately 0.75 miles away on a public road and transported back by staff. The Administrator and nursing staff gave differing descriptions of the circumstances of the resident’s return. The DON confirmed there was no documented evidence of a thorough investigation into the elopement, including no documentation of when the resident was last seen, how the resident exited the secured unit, or what steps were taken to prevent recurrence. The DON also verified that the facility did not provide education to all staff members on elopement risks, despite a written wandering and elopement policy that required assessment of residents at risk and review of the situation by the DON, physician, resident, and representative after an elopement event.
Failure to Maintain Nutritional Risk Care Plans for Two Residents
Penalty
Summary
Surveyors identified a failure to develop and maintain comprehensive, accurate care plans addressing nutritional risk for two residents. One resident was admitted with diagnoses including abscess of lung without pneumonia, acute respiratory failure with hypoxia, and unspecified severe protein-calorie malnutrition. The admission MDS showed the resident was cognitively intact, independent with eating, and had experienced more than 5% weight loss in the last month and 10% in the last six months without being on a prescribed weight loss regimen, with no nutritional approaches documented. Physician orders specified a regular diet with regular texture and thin consistency. Weight records showed the resident’s weight remained at 109.4 lbs shortly after admission but decreased to 96.0 lbs by the end of the month, and a subsequent weight change progress note documented a continued downward trend. An RN confirmed the resident had been assessed as at risk for nutrition but did not have a corresponding care plan, and review of active care plans confirmed there was no documented care plan addressing nutritional risk. For the second resident, the medical record showed an admission with diagnoses including traumatic brain injury (TBI), dysphagia, and unspecified severe protein-calorie malnutrition. A quarterly MDS indicated moderate cognitive impairment, a need for set-up assistance with eating, no documented swallowing disorder or weight loss, and use of a mechanically altered diet. An RN confirmed this resident was also assessed as a nutritional risk. The RN reported that the resident’s dietary care plan had been discontinued during a system changeover and that a new dietary care plan was never implemented, despite the resident’s nutritional risk status. Review of active care plans showed there was no documented care plan for nutritional risk for this resident. The Regional Director of Clinical Operations stated the facility did not have a policy on care plans. This deficiency was investigated under Complaint Number 2708144.
Failure to Complete Neuro Checks After Unwitnessed Fall and Assess Resident Before Hospital Transfer
Penalty
Summary
The deficiency involves the facility’s failure to complete required neurological assessments after an unwitnessed fall and to document an assessment for a resident with a change in condition prior to hospital transfer. One resident with diagnoses including Diabetes Mellitus Type II, vascular dementia, and hypertension, and a BIMS score of five indicating cognitive impairment, experienced an unwitnessed fall on 08/01/25 and sustained a forehead hematoma. Review of the post-fall evaluation, nursing documentation, and post-fall monitoring records showed no documented neuro assessments following this unwitnessed fall, despite facility policy stating that neuro checks are to be initiated after any unwitnessed fall or when a resident hits their head. The DON confirmed that neuro assessments were expected in such situations and verified that none were documented for this resident after the fall. The deficiency also includes the facility’s failure to complete and document a nursing assessment when another resident with diverticulitis, hydronephrosis, hypertension, renal insufficiency, and an indwelling catheter experienced a change in condition and was transferred to the hospital. This resident’s care plan identified renal insufficiency and catheter-related risks, with interventions to monitor mental status, vital signs, and signs and symptoms of UTI, including altered mental status and behavior changes. The last documented nursing assessment showed the resident was alert and oriented with no acute complaints. On the date of transfer, a transfer form was completed, but there was no documented evidence in the medical record of a nursing assessment, recognition, or evaluation of a change in condition, and the transfer form lacked clinical data related to the change in condition. The DON confirmed that nurses are expected to complete and document an assessment for a significant change in condition and that no such documentation was available for this resident.
Failure to Supervise, Assess, and Document After Unwitnessed Fall
Penalty
Summary
The deficiency involves the facility’s failure to ensure a resident’s environment was free from accident hazards and that adequate supervision and assessment were provided to prevent and respond to accidents. The resident was admitted with diagnoses including cerebral atherosclerosis, unspecified dementia with severe cognitive impairment, encephalopathy, dysphagia, and essential hypertension, and was care planned as being at risk for falls due to weakness, incontinence, psychotropic medication use, and dementia. The care plan interventions included staff assistance with transfers, keeping the call light within reach, positioning the right side of the bed against the wall, and frequent staff checks. A fall risk evaluation also identified the resident as being at risk for falls. Video footage showed that late at night the resident fell from the left side of the bed onto her knees on a fall mat between the bed and dresser, then repositioned herself to a seated position and was heard moaning. Several hours later, the same footage showed the resident lying directly on the floor on her left side with a pillow and blankets placed behind her. No staff were observed entering the room throughout the night shift to check on the resident between the time of the fall and the early morning. When an RN eventually entered the room to administer medications, he did not verbally assess the resident before moving her, but instead positioned himself behind her, placed his hands under her armpits, lifted her from the floor, and placed her back in bed while the resident moaned. The RN briefly asked what happened and if she had injuries but did not allow time for a response before stating she had none, and proceeded to administer medications. Review of the medical record revealed no nursing documentation of the fall, no post-fall assessment, and no evidence that the physician was notified at the time of the incident. The facility’s post-fall investigation, initiated after the family reported the fall and provided video footage, confirmed that staff did not enter the resident’s room to check on her throughout the night shift, that the RN did not complete any assessment prior to transferring the resident from the floor to the bed, and that no post-fall assessment or required fall follow-up documentation was completed. The facility’s falls policy required that unwitnessed falls have neurological checks initiated and that fall follow-up documentation, fall risk evaluation, and skin and pain assessments be completed after a fall, which did not occur in this case.
Failure to Maintain a Conducive Dining Environment Due to Unaddressed Resident Yelling
Penalty
Summary
The facility failed to ensure the common dining environment was conducive for residents eating in the main dining room. Resident #84, who had severe cognitive impairment, a history of behavioral symptoms directed toward others, type 2 diabetes with chronic kidney disease, major depressive disorder, anxiety, and early-onset Alzheimer's disease, was observed yelling out non-stop during lunch on two separate days while seated in the dining room. During both observations, Resident #84 did not appear to be in distress, yet continued to yell continuously throughout the meal period while other residents were dining nearby. Residents #24 and #63, both on mechanically altered diets and requiring set-up assistance with meals, were seated near Resident #84 during these meals and reported ongoing disturbance from the yelling. Resident #63, who had moderate cognitive impairment and a history of traumatic brain injury and severe protein-calorie malnutrition, stated he was tired of coming to the dining room and having to listen to the yelling every day, and reported having voiced these concerns to staff and management multiple times. Resident #24 similarly reported that the yelling occurred at every meal and that her concerns to dining staff had not resulted in any change. A CNA and an LPN confirmed that Resident #84 yelled continuously at every meal and that multiple residents complained, but stated that management would not remove Resident #84 from the dining room because there were not enough staff to feed her in her room, with only one CNA available on the hall during meals. This situation affected two of six residents reviewed for dining and had the potential to affect all 16 residents who ate in the main dining room.
Medication Administration Errors and Failure to Follow Physician Orders
Penalty
Summary
The deficiency involves the facility’s failure to ensure medications were administered according to physician orders and to maintain a medication error rate below 5%. Surveyors reviewed records for three residents and observed medication administration by an LPN. Resident #11, admitted with cerebral palsy, gastro-esophageal reflux disease without esophagitis, and major depressive disorder, had a physician order for 30 mL of Mylanta maximum strength oral suspension twice daily. During observed medication administration, the LPN instead gave 30 mL of Milk of Magnesia 1200 mg per 15 mL. In a subsequent interview, the LPN confirmed she did not administer the ordered Mylanta because she thought Milk of Magnesia was the same medication. Resident #47, admitted with multiple diagnoses including anemia, pancreatic cyst, gastritis, vitamin D deficiency, cerebral infarction without residual deficits, essential hypertension, metabolic encephalopathy, other specified pancreatic disease, and vascular dementia, had a physician order for 30 mL of lactulose oral solution 20 gm per 30 mL. The LPN administered potassium 20 mEq instead and confirmed in interview that the ordered lactulose was not given. Resident #112, admitted with hematuria, chronic diastolic congestive heart failure, obstructive sleep apnea, chronic obstructive pulmonary disease, cardiac murmur, anxiety disorder, essential hypertension, and a single subsegmental thrombotic pulmonary embolism without acute cor pulmonale, had orders for daily cyanocobalamin 1 mg and apixaban 5 mg twice daily. Observation showed the LPN administered vitamin D2 1.25 mg (50,000 IU) without an order and did not administer the ordered cyanocobalamin or apixaban. These actions were inconsistent with the facility’s Administering Medications policy, which requires medications to be administered safely, timely, and as prescribed.
Mechanically Altered Diet Order Not Followed for Cognitively Impaired Resident
Penalty
Summary
The facility failed to ensure that food was prepared and served in a form designed to meet an individual resident’s ordered mechanically altered diet. One resident with an admission date of 05/17/22 had diagnoses including vascular dementia (moderate) with behavioral disturbance, COPD, essential hypertension, and adult failure to thrive. A physician’s order dated 01/13/25 directed that this resident receive a regular diet with mechanical soft texture and regular consistency, with regular texture food/snacks as desired and with supervision. The care plan dated 06/09/25 identified the resident as being at risk for malnutrition/alteration in nutritional status related to dementia with behaviors, history of failure to thrive, depression/anxiety, diabetes, COPD, and cerebrovascular accident, and documented that the resident was to receive a mechanically altered diet and snacks with supervision. An Annual MDS dated 12/04/25 showed the resident had severe cognitive impairment. During a meal service observation on 01/06/26 at 12:24 P.M., the resident was served mechanically altered meatballs, unaltered green beans, and whole grapes. The resident was observed eating the grapes whole while alone in the room, without staff present to provide supervision. At 12:25 P.M., an LPN confirmed the resident was ordered to receive a mechanically altered meal and verified that whole grapes are not considered mechanically altered. At 12:40 P.M., another staff member confirmed the resident’s mechanically altered diet order and stated that whole grapes should not have been served to any resident on a mechanically altered diet due to whole grapes being a choke risk. Review of the facility’s 2021 “Texture and Consistency-Modified Diets” policy indicated that a physician order is required for a modified diet and that the food and nutrition services department is responsible for preparing and serving the correct food consistency as ordered.
Failure to Ensure Resident Dignity and Respect During Care
Penalty
Summary
The facility failed to ensure residents were treated with respect and dignity, as evidenced by multiple complaints and incidents involving a certified nursing assistant (CNA). One resident with Parkinson's disease, COPD, and depression, who was cognitively intact but dependent on staff for all activities of daily living, reported that the CNA was aggressive during transfer to bed using a mechanical lift. The resident was left in bed with the mechanical lift pad still underneath and the incontinence brief open after the CNA refused to assist further, stating, 'Well I ain't helping you,' and then leaving the room without returning. The resident had to call for additional help to complete care. Interviews with other staff and residents corroborated concerns about the CNA's rude and unprofessional behavior. Multiple staff members confirmed that residents frequently complained about the CNA's conduct, and another resident requested that this CNA no longer provide care due to negative interactions. The CNA had a documented history of similar incidents and had received disciplinary actions for misconduct, lack of professionalism, and unsatisfactory work performance.
Failure to Immediately Report and Thoroughly Investigate Abuse Allegations
Penalty
Summary
The facility failed to ensure that staff immediately reported allegations of abuse to administration and did not conduct thorough investigations into reported incidents. In one case, a resident with Parkinson's disease, COPD, and depression, who was cognitively intact and dependent on staff for care, reported that a CNA was aggressive during a mechanical lift transfer, left the resident in bed with an open incontinence brief and the lift pad still underneath, and did not return to assist further. The incident was not reported to administration or a supervisor until the following day, and the subsequent investigation lacked witness statements from the resident's roommate, other staff on shift, and the coworker who assisted with the transfer. In another instance, a cognitively intact resident with multiple medical conditions, including anemia and heart failure, reported feeling rushed and mistreated during a mechanical lift transfer by a CNA and an LPN. The investigation into this allegation was incomplete, missing critical documentation such as the date, time, and identity of the person providing the statement, as well as witness statements from the involved staff, other staff on shift, and the resident's roommate. Interviews with facility leadership confirmed that in both cases, the allegations were not reported immediately as required by facility policy, and the investigations did not include all necessary witness interviews or complete documentation. The facility's policy mandates immediate reporting of abuse allegations and comprehensive investigations, including interviews with all relevant parties, which was not followed in these incidents.
Failure to Follow Food Safety and Hygiene Protocols in Kitchen
Penalty
Summary
Staff in the facility's kitchen failed to follow required food safety and hygiene protocols during food preparation and storage. Observations revealed that two dietary aides were preparing and handling food without wearing hairnets or containing their hair, as required by facility policy. The dietary director confirmed that hairnets are mandatory at all times in the kitchen and acknowledged the lapse in compliance. Additionally, the kitchen was found to have an unlabeled and undated container of apple pie filling and an open, undated package of cheese slices in the refrigerator. Several food items, including a box of hamburger patties, a bag of rolls, and a box containing a turkey, were stored directly on the floor of the freezer, contrary to facility policy and food safety standards. The dietary director confirmed that all food should be properly labeled, dated, and stored off the floor, in accordance with the facility's food storage policy. The facility census was 99, with 98 residents receiving meals from the kitchen and one resident identified as NPO (nothing by mouth) and not receiving food from the kitchen. The facility's policies require food to be stored in clean, dry areas, at appropriate temperatures, and in a manner that prevents contamination, including the use of hair restraints by all food service employees. These deficiencies were identified during a complaint investigation.
Failure to Prevent and Treat Pressure Ulcer
Penalty
Summary
The facility failed to adequately assess and monitor the skin condition of Resident #17, leading to the development of an avoidable stage III pressure ulcer. Upon readmission to the facility, the resident, who had a history of malnutrition, cerebral palsy, chronic kidney disease, and other conditions, did not receive the necessary skin assessments or pressure ulcer risk assessments. These assessments were not documented from the time of readmission until the pressure ulcer was discovered on January 31, 2025. The care plan for Resident #17, which was revised in May 2023, indicated a potential for impaired skin integrity and included interventions such as routine skin assessments and care. However, these interventions were not followed, as evidenced by the lack of documented skin assessments and the subsequent development of a stage III pressure ulcer on the resident's sacrum. The facility's policy required a standardized risk assessment upon admission and throughout the resident's stay, which was not adhered to in this case. Interviews with facility staff confirmed the oversight in completing the necessary assessments and treatments. The Regional Director of Clinical Operations acknowledged that the required skin assessments were not conducted upon the resident's readmission or weekly thereafter. Additionally, the Treatment Administration Records indicated that the prescribed wound treatments were not consistently documented as completed, further contributing to the resident's condition.
Failure to Implement Fall Interventions for At-Risk Resident
Penalty
Summary
The facility failed to ensure that fall interventions were in place for a resident at risk for falls, which resulted in multiple incidents. Resident #69, who was admitted with diagnoses including psychotic disorder, cognitive disorder with Lewy bodies, anxiety disorder, depressive disorder, and muscle weakness, was identified as being at risk for falls due to dementia, impaired balance, impaired cognition, medications, poor decision-making skills, unsteady gait, and a history of falls. An intervention of anti-rollbacks to the resident's wheelchair was implemented on 02/03/25. However, observations on 03/18/25 and 03/19/25 revealed that the resident's wheelchair did not have any anti-rollback device affixed, and the resident was seen standing up and sitting back down in the wheelchair without supervision. The resident experienced a fall on 02/01/25 when attempting to sit back down in the wheelchair, resulting in no injuries but necessitating neurological checks. Another fall occurred on 02/13/25, where the resident was found on the floor with a laceration to the forehead. Despite these incidents, the necessary intervention of anti-rollbacks was not consistently applied, as confirmed by interviews with CNAs who noted the resident might be in the wrong wheelchair. The facility's policy on falls and fall risk management, revised in August 2024, requires staff to identify and implement interventions based on evaluations and current data to prevent falls and minimize complications, which was not adhered to in this case.
Failure to Administer Medication Per Physician's Orders
Penalty
Summary
The facility failed to administer medications according to the physician's orders for a resident diagnosed with multiple conditions, including acute and chronic respiratory failure, morbid obesity, and sleep apnea. The resident had a physician's order for Midodrine to be administered when systolic blood pressure was less than 100 mm/Hg. However, on multiple occasions, the resident's blood pressure readings were below this threshold, yet the medication was not administered as required. This oversight was confirmed through a review of the Medication Administration Records (MAR) and an interview with the Director of Nursing. The resident's medical record indicated that they were cognitively intact and required assistance with meals. Despite the clear parameters set for administering Midodrine, the facility's staff did not follow the prescribed orders, leading to a failure in providing the necessary pharmaceutical services. The facility's policy on administering medications, which mandates that medications be given in a safe and timely manner as prescribed, was not adhered to in this case.
Failure to Complete AIMS Assessments and Implement PRN Stop Dates
Penalty
Summary
The facility failed to complete Abnormal Involuntary Movement Scale (AIMS) assessments as ordered for two residents receiving antipsychotic medications. Resident #69, who was severely cognitively impaired and receiving hospice services, was prescribed Risperdal, which required an AIMS assessment. Despite recommendations from a monthly medication review and a physician's order, the assessment was not completed. Additionally, Resident #69 was prescribed Ativan PRN for anxiety without a stop date, and the medication was administered beyond the intended stop date. Similarly, Resident #76, who was severely cognitively impaired and diagnosed with dementia and other disorders, was prescribed Risperdal. A pharmacy recommendation for an AIMS assessment was made, but the assessment was not completed until several months later. The facility's policy on psychotropic drug use, which includes monitoring for side effects such as tardive dyskinesia, was not adhered to, as evidenced by the delayed AIMS assessments for both residents.
Improper Storage of Medications in Facility
Penalty
Summary
The facility failed to ensure proper storage of medications, as evidenced by the presence of outdated and expired medications in the medication carts. Specifically, an observation of the 100-hall medication cart revealed that an Insulin Aspart belonging to a resident was opened on 02/06/25 and had not been discarded after 28 days as required. Additionally, an observation of the 200-hall medication cart found a container of Potassium Chloride belonging to another resident that had expired on 01/24/25. Interviews with the LPNs responsible for these carts confirmed the presence of these expired medications. The Director of Nursing acknowledged that Insulin Aspart should be discarded 28 days after opening and that no expired medications should be present in the medication carts or rooms. The facility's policy on medication storage mandates that medications be stored in a manner that maintains their integrity and ensures resident safety, in accordance with Ohio Department of Health guidelines. Furthermore, the facility's policy on insulin pen labeling and packaging requires insulin pens to be individually labeled and stored in a closable plastic bag to prevent infection spread, with specific instructions for labeling and expiration dating.
Failure to Implement Enhanced Barrier Precautions
Penalty
Summary
The facility failed to timely implement Enhanced Barrier Precautions (EBP) for three residents, leading to deficiencies in infection prevention and control. Resident #17, who was cognitively intact and receiving hospice services, developed a stage III pressure ulcer on the sacrum, identified on January 31, 2025. However, EBP was not ordered until March 17, 2025, and no personal protective equipment (PPE) or signage was observed at the resident's room entrance on March 19, 2025. The Assistant Director of Nursing (ADON) confirmed that EBP should have been ordered earlier, as wound care had been provided prior to March 17, 2025. Resident #46, who had multiple diagnoses including sepsis and was receiving nutrition via a feeding tube, tested positive for Candida Auris, a multi-drug-resistant organism, on March 12, 2025. Despite this, EBP was not ordered until March 17, 2025. Similarly, Resident #14, who was severely cognitively impaired and dependent on staff for care, had a stage II pressure ulcer with active drainage observed on March 19, 2025, but was not placed in EBP. The ADON and Regional Director of Clinical Operations confirmed that EBP should have been implemented earlier for these residents, as per CDC guidance and the facility's policy on EBP.
Failure to Use Appropriate PPE for COVID-19 Positive Resident
Penalty
Summary
The facility failed to ensure that staff wore appropriate personal protective equipment (PPE) while caring for a resident who tested positive for COVID-19. The resident, who was severely cognitively impaired and receiving hospice services, was under contact and droplet precautions as per physician orders. Despite this, a Certified Nursing Assistant (CNA) was observed in the resident's room without wearing a gown, face shield, goggles, or an N95 respirator, only wearing a surgical mask. This was in direct violation of the facility's COVID-19 Quality Assurance and Performance Improvement (QAPI) Plan and the Centers for Disease Control and Prevention (CDC) guidance, which require the use of N95 respirators, eyewear, gowns, and gloves for healthcare personnel entering the room of a patient with confirmed SARS-CoV-2 infection. The incident was confirmed through staff interviews, medical record reviews, and direct observation. The CNA acknowledged the resident's COVID-19 positive status and the required precautions but admitted to not wearing the necessary PPE while providing care. The facility's policy, revised in August 2024, mandates the use of full PPE in such situations, aligning with CDC guidelines. This deficiency was identified during a complaint investigation, affecting one out of three residents reviewed for infection control in a facility with a census of 90.
Failure to Document Glucose Levels Before Insulin Administration
Penalty
Summary
The facility failed to ensure physician orders were followed and parameters were met prior to the administration of insulin, resulting in significant medication errors for a resident. The resident, who was admitted with diagnoses including diabetes mellitus with skin complications, congestive heart failure, peripheral vascular disease, and hypertension, was also under hospice care for senile asthenia. The resident's physician orders included administering Lantus, a long-acting insulin, with specific instructions to check blood glucose levels before administration and to contact a doctor if levels were outside the specified range. However, a review of the resident's July 2024 Medication Administration Record (MAR) and electronic records revealed that there was no documentation of glucose levels being obtained prior to the 9:00 P.M. administration of Lantus. This oversight was confirmed by the Director of Nursing during an interview, who acknowledged that despite the absence of glucose level documentation, the medication was still administered. This deficiency was investigated under a specific complaint number, indicating non-compliance with the required medication administration protocols.
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 metabolic encephalopathy, muscle weakness, and a history of CVA experienced a fall in his room that was not documented in the medical record until the following morning as a late entry. Two RNs acknowledged that the fall was not recorded at the time it occurred and stated that fall incidents should be documented as soon as possible after the event, resulting in a deficiency for failure to maintain timely, professionally standard medical records.
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.
A resident with cirrhosis, ascites, mood disorder, and alcohol-induced major neurocognitive disorder, and with moderately impaired cognition, was observed sitting on a shower chair in a gown with buttocks exposed and visible from the hallway through an open room door. A CNA left the room quickly after hearing another resident yell and forgot to close the door or pull the privacy curtain, and an RN confirmed the exposure, demonstrating a failure to maintain the resident’s dignity and privacy.
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.
Untimely Documentation of Resident Fall Incident in Medical Record
Penalty
Summary
The deficiency involves the facility’s failure to document a resident’s fall incident in the medical record in a timely manner, in accordance with accepted professional standards. The resident was admitted with diagnoses including metabolic encephalopathy, muscle weakness, and cerebrovascular accident. According to the medical record, a progress note was entered as a late entry on 02/20/26 at 8:21 A.M., stating that the resident had suffered a fall in his room on 02/19/26 at 8:00 P.M. There was no evidence of any documentation of the fall incident entered in the medical record at the time of, or shortly after, the fall on 02/19/26 at 8:00 P.M. During an interview on 03/30/26 at 12:05 P.M., two RNs confirmed that the fall incident was not documented until the following morning and stated that fall incidents should be entered in the medical record as soon as possible following the event. This lack of timely documentation of the fall incident constituted non-compliance with requirements to safeguard resident-identifiable information and maintain medical records in accordance with professional standards.
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.
Resident Left Exposed and Visible From Hallway Due to Failure to Maintain Privacy
Penalty
Summary
The facility failed to ensure resident dignity and privacy when a cognitively impaired resident was left exposed and visible from the hallway. The resident, who had diagnoses including cirrhosis with ascites, mood disorder, and alcohol-induced major neurocognitive disorder, had a BIMS score of eight, indicating moderately impaired cognition. During an observation, the resident was seen sitting on a shower chair in a gown with buttocks exposed, and this exposure was visible from the open room door in the hallway. A Certified Resident Care Associate and a Registered Nurse confirmed that the resident’s buttocks were visible from the hallway. The Certified Resident Care Associate reported that she had left the resident’s room quickly after hearing a resident in an adjacent room yell and, in her haste, forgot to close the door or pull the privacy curtain, resulting in the resident’s exposed state being visible to others. This incident involved one resident out of three reviewed for dignity, in a facility with a census of 52 residents, and was identified through record review, observation, and staff interviews.
Trusted data from CMS and state health departments
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