Walnut Hills Nursing Home
Inspection history, citations, penalties and survey trends for this long-term care facility in Walnut Creek, Ohio.
- Location
- 4748 Olde Pump Street, Walnut Creek, Ohio 44687
- CMS Provider Number
- 366268
- Inspections on file
- 23
- Latest survey
- March 11, 2025
- Citations (last 12 mo.)
- 0
Citation history
Health deficiencies cited at Walnut Hills Nursing Home during CMS and state inspections, most recent first.
Two residents were affected by the misappropriation of their narcotic medications by an LPN. One resident, unable to verify receipt due to their condition, had discrepancies in their medication records, while another resident with intact cognition reported not receiving their as-needed medication at night. The facility's investigation confirmed the LPN did not administer the medications as recorded, leading to the misappropriation.
The facility inaccurately reported staff hours in the PBJ report, affecting all residents. Despite having licensed nurses on duty, the report showed gaps in coverage due to issues with obtaining agency staff invoices, as confirmed by the DON.
The facility failed to ensure proper hand hygiene during meal service, affecting two residents and potentially impacting others. CNAs were observed serving lunch trays without washing or sanitizing their hands between handling trays and assisting residents, contrary to the facility's Infection Prevention and Control policy.
An LPN failed to perform hand hygiene during medication administration for two residents, despite facility policy requiring it between resident contacts. The LPN administered medications, handled cups, and documented without washing or sanitizing hands, affecting residents with specific medical orders for pain and diuretic medications.
A facility failed to follow physician-ordered oxygen settings for a resident with respiratory needs. The resident, with a history of respiratory disorder, dementia, and breast cancer, had an order for continuous oxygen at 1 to 2 LPM. However, the oxygen concentrator was set at 0.5 LPM, as confirmed by the DON. This was against the facility's policy requiring adherence to physician orders.
A facility failed to update its antibiotic stewardship policy, leading to inappropriate antibiotic use for a resident. The resident, with heart failure and chronic kidney disease, was given Augmentin despite a urine culture showing mixed microbiota and no infection criteria met. The facility's policy still referenced outdated criteria, causing a discrepancy in practice.
The facility failed to prevent and manage pressure ulcers for three residents, leading to the development and worsening of ulcers. A resident at high risk developed multiple facility-acquired pressure ulcers due to missed treatments and lack of necessary equipment. Another resident's wound declined due to inconsistent care and delayed implementation of physician orders. A third resident developed an unstageable pressure ulcer, with treatments and interventions not consistently provided. The facility did not adhere to its pressure injury prevention policy.
Two residents reported that their mail was opened by staff without permission, violating their rights to confidentiality. One resident's package was returned to sender without notification. Staff admitted to opening mail due to concerns about package contents but failed to obtain resident consent.
A facility failed to provide the correct ostomy supplies for a resident with a colostomy, as ordered by the physician. The resident was using an incorrect size ostomy bag due to the facility's lack of the ordered supplies. The resident's care plan also lacked details regarding the colostomy care and supplies, leading to non-compliance with physician orders.
A facility failed to obtain daily weights for a resident with severe malnutrition as ordered by the physician. Despite the resident's significant weight loss and the dietitian's expectation for daily monitoring, weights were only recorded on a few occasions over a month. This non-compliance was identified during a complaint investigation.
A resident with serious medical conditions did not receive timely intravenous antibiotics due to the facility's pharmacy services failing to deliver medications and supplies as needed. The resident missed several doses of Ceftriaxone and Ampicillin, and the facility lacked a pharmacy policy, contributing to the deficiency.
The facility failed to maintain accurate medical records for three residents, leading to medication administration discrepancies and inadequate care. A resident received conflicting Torsemide dosages, another had undocumented Ceftriaxone administration, and a third lacked a prescribed specialty mattress, resulting in pressure ulcers. The DON confirmed these inaccuracies.
The facility failed to maintain infection control practices for two residents. An LPN did not change gloves during wound care for a resident with pressure ulcers, and an STNA did not change gloves during incontinence care for a resident with dementia. Both actions violated facility policies.
The facility failed to ensure that state survey results were readily accessible, affecting all 45 residents. Observations revealed that the most recent health inspection was completed on a past date, and complaint inspections were completed on various dates. However, the facility did not post the survey results for the complaint investigations completed on these dates. The facility's posting corkboard did not include the plan of correction for the most recent health inspection survey results, and no survey results were available for review after a certain date.
The facility did not post daily nurse staffing information in a visible area, affecting all 45 residents. Observations on multiple days showed the data was not readily accessible, with the Scheduling Coordinator unaware of the visibility requirement. On several occasions, the staffing data was outdated or not posted at all, as confirmed by staff interviews.
A medication assistant at the facility performed duties outside her scope of practice, including documenting pain levels, assessing residents, and notifying physicians, affecting four residents with various medical conditions. The Director of Nursing confirmed the medication assistant had been educated on her scope of practice, but the facility's job description did not support the tasks performed.
The facility failed to maintain a medication error rate of less than five percent, resulting in an 11.0% error rate. Two residents were affected: one received the wrong dosage of lactulose and expired eye drops, while the other was not instructed to rinse her mouth after using an asthma inhaler.
Misappropriation of Resident Medications by LPN
Penalty
Summary
The facility failed to protect residents from the misappropriation of their medications, specifically affecting two residents. One resident, who was unable to be interviewed and dependent on staff for activities of daily living, had discrepancies in the administration of their prescribed Oxycodone. The medication administration records did not show that the as-needed Oxycodone was administered, and the resident, who typically slept through the night, was unable to verify receipt of the medication. Similarly, another resident with intact cognition and also dependent on staff for daily activities, reported not receiving the as-needed Oxycodone during the night, despite it being signed out by an LPN. This resident confirmed receiving their routine medication at scheduled times by a different LPN. The facility's investigation revealed that the LPN responsible for signing out the medications did not administer them as recorded, leading to the misappropriation of narcotic medications. The discrepancies were discovered when another LPN noticed inconsistencies in the narcotic sheets, prompting an investigation. The facility substantiated the self-reported incident and took steps to report the LPN to relevant authorities, including the Ohio Board of Nursing, Ohio Board of Pharmacy, and the local police department.
Inaccurate PBJ Staffing Report Due to Invoice Issues
Penalty
Summary
The facility failed to completely and accurately report staff hours worked for the Payroll Based Journal (PBJ) report, which had the potential to affect all 41 residents residing in the facility. Specifically, the PBJ report indicated that the facility did not have licensed nursing coverage 24 hours per day on several dates in June 2024. However, a review of the staffing schedules for those dates revealed that there was indeed a licensed nurse present in the facility. An interview with the Director of Nursing (DON) confirmed that the corporate office experienced difficulties obtaining invoices for agency staff, which resulted in the inaccurate submission of staffing data for the specified dates.
Failure to Perform Hand Hygiene During Meal Service
Penalty
Summary
The facility failed to adhere to proper hand hygiene protocols during meal service, affecting two residents directly and potentially impacting all 13 residents on the skilled unit. On the specified date, a Certified Nursing Assistant (CNA) was observed serving lunch trays to residents in the dining room without washing or sanitizing his hands between handling the trays and assisting residents with their meals. This included actions such as removing lids and cutting up meat for the residents. The CNA acknowledged during an interview that he did not perform hand hygiene during the meal service, which was contrary to the facility's Infection Prevention and Control policy. Another CNA was observed retrieving and serving lunch trays to residents in their rooms without performing hand hygiene between serving different residents. This CNA also confirmed during an interview that she did not wash or sanitize her hands between serving the trays to two different residents. The facility's policy, dated March 2020, clearly states that all staff must wash their hands between resident contacts and after handling contaminated objects, which was not followed in these instances.
Failure in Hand Hygiene During Medication Administration
Penalty
Summary
The facility failed to perform proper hand hygiene during medication administration, affecting two residents. An LPN was observed administering medications to residents without washing or sanitizing their hands before, during, or after the process. Specifically, the LPN sanitized their hands before preparing a narcotic medication for one resident and then proceeded to administer the medication without further hand hygiene. After administering the medication, the LPN handled the medication and water cups, disposed of them, and documented the administration without washing or sanitizing their hands. The deficiency was confirmed through an interview with the LPN, who acknowledged the failure to perform hand hygiene as required. The facility's policy on infection prevention and control mandates that staff wash their hands between resident contacts and after handling contaminated objects, among other situations. The residents involved had specific medical orders for pain and diuretic medications, which were administered by the LPN without adherence to the hand hygiene protocol.
Failure to Follow Physician-Ordered Oxygen Settings
Penalty
Summary
The facility failed to adhere to physician-ordered oxygen settings for a resident requiring respiratory care. Resident #15, who was admitted with diagnoses including a respiratory disorder, dementia, and breast cancer, had a physician's order for continuous oxygen administration at 1 to 2 liters per minute (LPM) via nasal cannula to maintain oxygen saturation levels above 90%. However, during an observation, the oxygen concentrator in the resident's room was set at 0.5 LPM, contrary to the prescribed order. The discrepancy was confirmed during an interview with the Director of Nursing (DON), who acknowledged that the oxygen concentrator setting did not align with the physician's order. The facility's policy on oxygen administration, which mandates adherence to physician orders except in emergencies, was not followed in this instance. This oversight affected the resident's prescribed respiratory care, as documented in the Medication Administration Record, which showed oxygen saturation levels ranging from 90% to 97% during the period in question.
Failure to Update Antibiotic Stewardship Policy
Penalty
Summary
The facility failed to update and implement their antibiotic stewardship program policy, which led to inappropriate antibiotic use for a resident. Resident #30, who was admitted with diagnoses including heart failure and chronic kidney disease, reported bladder discomfort and an inability to void. A urine culture indicated mixed microbiota, suggesting possible contamination, and no antibiotic sensitivity was identified. Despite this, the resident was started on Augmentin for seven days based on a progress note dated 08/16/24, even though the McGeer Criteria for Infection Surveillance Checklist indicated that the criteria for a urinary tract infection were not met. The Director of Nursing confirmed that the facility used the McGeer Criteria instead of the Loeb Criteria to determine the necessity of antibiotics, yet the facility's Antibiotic Stewardship Policy had not been updated to reflect this change. The policy still referenced the Loeb Minimum Criteria, leading to a discrepancy between the policy and practice. This oversight resulted in the administration of antibiotics without appropriate culture results to identify the infection's susceptibility, highlighting a failure in the facility's antibiotic stewardship program.
Failure to Prevent and Manage Pressure Ulcers
Penalty
Summary
The facility failed to provide adequate care and services to prevent the development and decline of pressure ulcers for three residents. Resident #87, who was at high risk for pressure ulcers, developed multiple facility-acquired pressure ulcers. The facility did not complete the required Braden Risk assessments and failed to provide the ordered treatments, including the use of a low air loss mattress. Observations revealed that the resident was not provided with the necessary equipment and treatments, leading to the worsening of the pressure ulcers. Resident #37 was admitted with multiple diagnoses and was at risk for pressure ulcers. The facility did not complete the required risk assessments after the initial one and failed to provide consistent wound care as ordered. The resident's wound showed a decline, with an increase in necrotic tissue, due to missed treatments and delays in implementing new physician orders. The care plan for the resident's wound was not followed, contributing to the deterioration of the wound. Resident #91, who was at risk for pressure ulcers, developed an unstageable pressure ulcer on the left heel. The facility did not complete additional risk assessments after the initial one and failed to provide the necessary treatments and interventions consistently. There was no evidence of nutritional support ordered for the resident's pressure ulcer, and the facility's documentation indicated that treatments were not completed as required. The facility's policy on pressure injury prevention and management was not adhered to, resulting in the development and worsening of pressure ulcers for the residents.
Failure to Ensure Confidentiality of Resident Mail
Penalty
Summary
The facility failed to ensure the confidentiality of residents' mail, affecting two residents out of a sample of five. Resident #79 reported that her mail, including a retail store package and a wireless service provider bill, was opened by staff without her permission. Despite having severe arthritis, Resident #79 stated she could open her own mail or would have preferred to be asked for assistance. Charge Nurse #108 admitted to opening the mail and package, claiming she was instructed to do so because the package sounded like it contained a bottle of pills. However, she did not disclose who gave the instruction and acknowledged that she should have obtained permission from the resident. Resident #91 also reported receiving opened mail without giving permission. Additionally, she was waiting for a package ordered by her daughter, which she had not received. The Life Enrichment Director (LED) #126 explained that the package was returned to the sender because it was addressed to the daughter, not the resident, and the facility had not informed Resident #91 or her daughter about this. The LED confirmed that residents have the right to receive unopened mail and that mail should only be opened with permission. The Business Office Manager stated she does not open resident mail or packages, indicating a lack of consistent policy enforcement across the facility.
Failure to Provide Ordered Ostomy Supplies
Penalty
Summary
The facility failed to ensure that the appropriate ostomy supplies were available for a resident with a colostomy, leading to non-compliance with physician orders. Resident #9, who was admitted with diagnoses including a hip fracture, weakness, atrial fibrillation, constipation, and a colostomy, was ordered to use specific ostomy supplies: [NAME] Wafer #11402 and [NAME] Bag #18182, to be changed every three days and as needed. However, during an observation, it was found that the resident was using an ostomy bag #18373, which was not the size ordered by the physician. The resident confirmed that these were the only supplies available for use. Further investigation revealed that the facility did not have the physician-ordered size ostomy bag available. The charge nurse confirmed that the resident had been discharged and readmitted on the same day without bringing back her ostomy supplies, leading to the use of the incorrect size since readmission. Additionally, the resident's care plan did not include any mention of the colostomy or interventions related to the supplies or care frequency, indicating a lack of comprehensive care planning for the resident's condition.
Failure to Obtain Daily Weights as Ordered
Penalty
Summary
The facility failed to obtain daily weights for a resident as ordered by the physician, which is a deficiency in following medical orders. The resident, who was admitted with multiple serious health conditions including severe protein calorie malnutrition, was supposed to have their weight monitored daily due to a significant weight loss prior to admission. However, the facility did not complete daily weight checks as required, with weights only recorded on a few specific dates over a month-long period. The resident's medical record indicated that daily weights were ordered, and this was confirmed by the dietitian, who expected the orders to be followed and documented in the electronic record. Despite this, the facility's records showed that daily weights were not consistently obtained, which represents non-compliance with the physician's orders. This deficiency was identified during an investigation under a specific complaint number.
Failure to Administer IV Medications Timely
Penalty
Summary
The facility failed to ensure timely administration of intravenous medications for a resident, leading to missed doses of critical antibiotics. Resident #45, who was admitted with diagnoses including cerebral infarction, bacteremia, and sepsis, had physician orders for Ceftriaxone and Ampicillin to be administered intravenously. However, the Medication Administration Record indicated that several doses of these antibiotics were not administered as ordered on multiple occasions in June 2024. The certified nurse practitioner was notified of the missed doses, and the order was extended to compensate for the missed doses. The deficiency was attributed to the facility's pharmacy services, which failed to deliver the necessary medications and supplies in a timely manner. The Director of Nursing reported difficulties in contacting the pharmacy over a weekend, resulting in missed doses due to the lack of medication or IV tubing. Pharmacy records showed discrepancies in delivery and dispensing, with some supplies running out prematurely. Additionally, the facility lacked a policy for pharmacy services, as confirmed by the Administrator. This deficiency was investigated under Complaint Number OH00154465.
Inaccurate Medical Records and Medication Administration
Penalty
Summary
The facility failed to maintain accurate medical records for three residents, leading to discrepancies in medication administration and care. For Resident #99, there was a conflict between the hospital discharge instructions and the electronic Physician's Orders regarding the dosage of Torsemide, a diuretic. The discharge instructions prescribed 40 mg once a day, while the electronic orders indicated two tablets of 20 mg daily, leading to confusion over whether the resident was receiving 20 mg or 40 mg. This inconsistency was confirmed by the Director of Nursing during an interview. Resident #45's medical records showed a failure to document the administration of Ceftriaxone, an antibiotic, on a specific date, despite interdisciplinary notes indicating it was administered. The Director of Nursing verified this omission. Additionally, Resident #87's records inaccurately reflected the use of a specialty pressure-relieving mattress. Although a low-air loss mattress was recommended and ordered, the resident was observed on a standard mattress, which contributed to the development of pressure ulcers. The Director of Nursing was unaware of the discrepancy until it was pointed out during an observation.
Infection Control Deficiencies in Wound and Incontinence Care
Penalty
Summary
The facility failed to maintain adequate infection control practices, affecting two residents. Resident #87, who was admitted with diagnoses including post-polio syndrome and hip fracture, developed two facility-acquired pressure ulcers. During an observation of wound care, an LPN did not change gloves after cleansing the wound or during the dressing change, contrary to the facility's policy. The LPN acknowledged the oversight, attributing it to the resident having just had a bath. Resident #25, admitted with dementia and other conditions, was observed receiving incontinence care. The STNA assisting the resident did not change gloves during the process, despite handling soiled materials. This was in violation of the facility's perineal care policy, which requires changing gloves if they become soiled. The STNA confirmed the failure to change gloves during an interview.
Failure to Post Recent Survey Results
Penalty
Summary
The facility failed to ensure that state survey results were readily accessible for review, including the most recent survey of the facility. This deficiency had the potential to affect all 45 residents residing in the facility. Observations and reviews revealed that the most recent health inspection was completed on 09/23/22, and complaint inspections were completed on various dates, including 03/13/23, 05/04/23, 02/06/24, and 04/04/24. However, the facility did not post the survey results for the complaint investigations completed on 03/13/23, 02/06/24, or 04/04/24. During an observation on 06/25/24, it was noted that the facility's posting corkboard did not include the facility's plan of correction for the most recent posted health inspection survey results dated 09/23/22. Additionally, other survey results posted were dated from 12/05/19 through 05/04/23, with no other survey results available for review after the survey completed on 05/04/23. Further observations on 06/26/24 revealed that the most recent survey results available in the receptionist area were dated 09/23/22, and the Business Office Manager confirmed the lack of posted survey results for the more recent complaint investigations.
Failure to Post Nurse Staffing Information Visibly
Penalty
Summary
The facility failed to post daily nurse staffing information in a location that was readily visible, potentially affecting all 45 residents. On multiple occasions, observations revealed that the nurse staffing data was not posted in a visible area. On June 25, 2024, and June 26, 2024, the data was not visible, and it was found on a clipboard wedged between bookends and a binder, not easily accessible to residents, visitors, or staff. The Scheduling Coordinator confirmed the data was not visible and was unaware of the requirement for it to be visible at all times. On June 27, 2024, the staffing data for the previous day was still posted, and the current day's data had not been updated. Similarly, on July 2, 2024, the data posted was from the previous day, and the current day's data was not available. These findings were part of an investigation under Complaint Number OH00154465.
Medication Assistant Exceeded Scope of Practice
Penalty
Summary
The facility failed to ensure that a medication assistant did not perform duties outside her scope of practice, affecting four residents. Resident #25, who had multiple diagnoses including low back pain, diabetes, and hypertension, had her pain levels documented by the medication assistant (MA-C #101) on multiple occasions in February and March 2024. Additionally, MA-C #101 documented details about Resident #25's fall and injury without follow-up documentation from a licensed nurse. The medication assistant also cleaned and bandaged the resident's knee and notified the Nurse Practitioner (NP) of the fall, actions that should have been performed by a licensed nurse. Resident #32, who had diagnoses including diabetes and bipolar disorder, also had her pain levels documented by MA-C #101 in February and March 2024. The medication assistant documented the resident's behaviors and medication refusals, actions that were outside her scope of practice. MA-C #101 stated she was told by the Director of Nursing that she could document these behaviors. Similarly, Resident #38, who had diagnoses including cerebral infarction and dementia, had her pain levels documented by MA-C #101 in February and March 2024. The medication assistant also documented a diet change for Resident #38 without an official order or verification from a licensed nurse. Resident #35, who had multiple diagnoses including malignant neoplasm of the colon and heart failure, had her pain levels documented by MA-C #101 in February and March 2024. The medication assistant revealed she had been completing resident assessments instead of a nurse to administer as-needed medications. The Director of Nursing confirmed that the medication assistant had been educated on her scope of practice but expressed that the role of medication assistants was limited if they could only administer medications. The facility's job description for a medication aide did not include the tasks performed by MA-C #101, indicating a clear violation of scope of practice regulations.
Medication Error Rate Exceeds Acceptable Threshold
Penalty
Summary
The facility failed to maintain a medication error rate of less than five percent, resulting in an error rate of 11.0%. This deficiency affected two residents. For Resident #45, the medication assistant (MA-C) administered only 15 milliliters of lactulose syrup instead of the prescribed 30 milliliters and used expired Refresh tears eye drops. The MA-C verified these errors when stopped by the surveyor. Resident #45 had multiple diagnoses, including cerebral infarction, hemiplegia, dysphagia, and congestive heart failure, and had moderately impaired cognition according to the quarterly MDS assessment. For Resident #49, the MA-C failed to instruct the resident to rinse her mouth after administering Fluticasone propionate diskus, an asthma medication. Despite the resident asking if she needed to rinse her mouth, the MA-C incorrectly informed her that it was unnecessary. The manufacturer's instructions for the medication clearly state that rinsing the mouth is required to reduce the risk of oropharyngeal candidiasis. Resident #49 had intact cognition and multiple diagnoses, including dementia, asthma, and chronic respiratory failure.
Latest citations in Ohio
A resident with intact cognition receiving Medicare Part A skilled services for metabolic encephalopathy had services discontinued while benefit days remained, but the facility did not issue the required Skilled Nursing Facility Advance Beneficiary Notice (SNF ABN). The Social Services Director later confirmed that no SNF ABN was provided and reported she believed only a Notice of Medicare Non-Coverage (NOMNC) was needed when all skilled services were stopped. This practice conflicted with the facility’s written policy, which required SNF ABNs to be issued when extended care items or services were initiated, reduced, or terminated due to expected non-coverage by Medicare.
Surveyors identified that the facility exceeded the acceptable medication error rate when two residents with type 2 DM received insulin doses that were not administered according to orders or manufacturer instructions. In two separate observations, an LPN administered Novolog and another LPN administered insulin glargine and insulin lispro without priming the insulin pens, and the insulin lispro and Novolog were given after the residents had already consumed a significant portion of their breakfast meals, despite orders for administration before meals. Manufacturer information for both insulin products required priming before each injection to ensure accurate dosing, and facility policy required medications, including insulin, to be administered safely, timely, and in accordance with prescriber orders and specified time frames.
Surveyors found that the facility failed to document tray line food temperatures for multiple meals served from two dining room kitchenettes, despite having a “Trayline Taste & Temperature Log” and a policy requiring food to be stored, prepared, distributed, and served according to professional food safety standards. Review of logs showed repeated missing entries for breakfast, lunch, and dinner services in both the Harrison and McClellan dining areas, and the Senior Director of Culinary Services confirmed that temperatures had not been recorded for those meals, potentially affecting all residents receiving meals from those kitchenettes.
The facility failed to conduct and document required periodic care conferences for two residents, despite multiple comprehensive, quarterly, and significant change MDS assessments and a policy requiring periodic care conferences with resident and/or family participation. One resident with Parkinson’s disease, post-stroke hemiplegia, TIA, DMII, and depression had only two documented care conferences over a year, while another resident with aphasia, cerebrovascular disease, DMII, gait difficulty, coagulation defect, depression, and muscle weakness had no documented care conferences in the past year, aside from a declined invitation to the representative. The UCC confirmed that care conferences were expected to occur quarterly and that no additional documentation existed for either resident.
A resident with Alzheimer's disease and type II DM, who required extensive assistance with ADLs and was receiving scheduled Lantus and sliding-scale Humalog, experienced a severely elevated blood glucose level. The on-call provider was notified and ordered an additional dose of lispro insulin with a directive to recheck the blood glucose after administration. Nursing staff administered the extra insulin but did not document any follow-up blood glucose check, and the DON confirmed that this reevaluation was required by the facility's abnormal blood glucose policy and was not completed or documented.
A resident with Parkinson’s disease, dementia, and hypothyroidism was prescribed levothyroxine once daily along with other medications. A consultant pharmacist’s monthly drug regimen review recommended that levothyroxine be given in the morning on an empty stomach, 30–60 minutes before food, per manufacturer instructions. The medical record contained no documented physician response to this recommendation, and the MAR showed the drug scheduled for morning administration while the resident was observed eating breakfast and receiving the medication at the same time. An LPN confirmed administering levothyroxine during the meal, and the DON verified there was no documentation explaining whether or why the pharmacist’s recommendation was or was not followed, resulting in a failure to act on and document the identified irregularity.
A resident with severe cognitive impairment, multiple comorbidities, documented gait and balance abnormalities, and a high fall risk was care planned and assessed by therapy to require contact guard assistance and use of a gait belt for transfers and ambulation. While being assisted by a CNA from a recliner to the bathroom with a walker, the CNA did not apply a gait belt, even though the resident had a known tendency to lean backward when standing. As the CNA reached to open the bathroom door, the resident lost balance and fell backward, striking the back of the head, and was later found by an LPN without a gait belt in place, contrary to the facility’s gait belt policy and the resident’s assessed needs.
A resident with CKD stage five requiring peritoneal dialysis (PD) was admitted with pre-admission physician orders for three daily PD exchanges and monitoring for peritonitis (fever, abdominal pain, cloudy effluent), but these monitoring orders were not entered into the facility’s physician orders. The care plan referenced PD and general monitoring but did not specifically address peritonitis monitoring. Paper PD flowsheets showed incomplete and inconsistent documentation of exchanges and resident condition, including missing condition/comments for individual treatments and no record of one ordered PD exchange. The PD cycler flowsheet lacked effluent descriptions on multiple days. The PD nurse reported facility staff were expected to monitor effluent and symptoms, and the DON confirmed the absence of specific peritonitis monitoring orders, lack of an order for the PD cycler, and documentation gaps, despite a facility policy requiring ongoing assessment and monitoring for complications before, during, and after dialysis treatments.
A nurse was observed preparing multiple oral medications for a resident with depression, traumatic brain injury, anxiety, and impaired cognition by pushing tablets and capsules from unit-dose cards directly into her ungloved hand and then using her fingers to place them into a medication cup. In a follow-up interview, the RN confirmed this practice and acknowledged that the correct procedure is to dispense medications directly from the card into the cup, contrary to the facility’s medication administration policy requiring adherence to good nursing principles and practices.
A resident with Alzheimer’s disease, diabetes, anxiety, significant ADL dependence, and behavioral symptoms was observed seated in a chair positioned against the nursing station with a locked wheelchair placed directly in front, also against the nursing station, effectively restricting movement. An LPN confirmed both wheelchair wheels were locked and that it should not have been placed there, while a CNA stated she had positioned the wheelchair to prepare for lunch, was unable to complete the transfer, and left it in place, acknowledging this was wrong. This arrangement conflicted with the facility’s restraint policy, which prohibits physical restraints except when alternatives are ineffective for treating a medical symptom and defines restraints as devices adjacent to the body that cannot be easily removed and that restrict freedom of movement or access to the body.
Failure to Issue Required SNF ABN When Discontinuing Medicare Part A Services
Penalty
Summary
The deficiency involves the facility’s failure to issue a Skilled Nursing Facility Advance Beneficiary Notice (SNF ABN) when Medicare Part A services were discontinued for a resident who still had available benefit days. The resident was admitted with a diagnosis of metabolic encephalopathy and had intact cognition per the Minimum Data Set assessment. The facility’s own SNF Beneficiary Notification Review documented that Medicare Part A skilled services began on 02/11/26 and the last covered day was 03/11/26, and that the facility initiated discharge from Medicare Part A services before the resident’s benefit days were exhausted. Despite this, no SNF ABN was provided to the resident or the resident’s representative. During interviews, the Social Services Director stated that the SNF ABN was issued hours prior to the last covered day but, upon reviewing her files, confirmed that no SNF ABN had actually been issued for this resident. She further explained that she believed an SNF ABN was only required if one skilled service remained and that if all skilled services were being discontinued, only the Notice of Medicare Non-Coverage (NOMNC) needed to be issued. The Administrator, however, stated that a resident should always receive both a SNF ABN and a NOMNC when Medicare Part A services are discontinued and benefit days remain. Review of the facility’s written policy dated 03/28/23 showed that the facility was required to issue SNF ABNs for initiation, reduction, or termination of extended care items or services when Medicare payment was not expected, which did not occur in this case.
Plan Of Correction
This Plan of Correction is submitted as required under State and Federal law. This Plan of Correction does not constitute an admission on the part of the Facility that the findings cited are accurate, that the findings constitute a deficiency or that the scope and severity regarding the deficiency cited are correctly applied. Any changes to the Facility's policies and procedures should be inadmissible in any proceeding on that basis. Without admitting or denying the validity or the existence of the alleged noncompliance, the Facility submits this Plan of Correction with the intention that it be inadmissible by any third party in any civil or other action against the facility or any employee, agent, officer, director or shareholder of the Facility. The Facility is utilizing this Plan of Correction as its allegation of substantial compliance as of 05/29/2026 F-0582 Corrective action for resident/s: On 5/14/26 Resident #34 was informed of rights and responsibilities related to Advanced Beneficiary Notice and voiced understanding of information for future reference by administrator. Identification of other residents who may be affected: Any resident receiving skilled services from nursing or therapy services. The Administrator audited all residents who were discharged from skilled services in the past 30 days to ensure they were issued a Notice of Non-Coverage and Advanced Beneficiary Notice on 5/29/26. No non-compliance was noted. Measures for systemic change: On 5/14/2026 Business Office Manager, Director of Rehab, Minimum Data Set nurse, Director of Nursing and Social Services Director were educated on proper procedure of issuing of Notice Of Medicare Non Coverage and Advanced Beneficiary Notice by administrator. All upcoming discharges from skilled services will be reviewed weekly at Utilization Review meeting to ensure notices will be delivered timely. How Corrective Action will be monitored: Administrator or designee to complete audits of all residents being discharged from skilled services to ensure they were issued a Notice of Non-Coverage and Advanced Beneficiary. This audit will be completed weekly x 4 weeks, then monthly x 2 months. Corrective action will be initiated for any noted non-compliance. Audit findings will be reviewed as part of the monthly quality assurance process to determine the need for further monitoring. Date of Compliance 5/29/26
Insulin Administration Errors and Failure to Prime Insulin Pens
Penalty
Summary
The deficiency involves the facility’s failure to maintain a medication error rate below 5%, with surveyors identifying 3 errors out of 28 medication administration opportunities, resulting in a 10.71% error rate. For one resident with type 2 diabetes mellitus and moderate cognitive impairment, the physician’s order directed Novolog insulin 10 units via subcutaneous pen-injector to be given before meals. During an observed medication pass, the LPN administered 10 units of Novolog insulin without priming the pen and did so after the resident had already consumed approximately 50% of the breakfast meal. The LPN later confirmed she did not prime the pen and acknowledged that the insulin was ordered to be administered prior to meals. Manufacturer instructions for the Novolog FlexPen specified that an air shot (priming) must be performed before each injection to ensure proper dosing. Another resident, also diagnosed with type 2 diabetes mellitus and with intact cognition, had orders for insulin glargine 35 units subcutaneously twice daily and insulin lispro 20 units subcutaneously before meals, plus 12 units subcutaneously if blood glucose was between 251 mg/dL and 300 mg/dL. During an observed medication administration, an LPN administered 35 units of insulin glargine and 32 units of insulin lispro without priming the insulin pens and after the resident had consumed approximately 90% of the breakfast meal, despite orders for insulin lispro to be given before meals. The LPN later stated she could not remember if she had primed the pen and acknowledged that the insulin was ordered to be administered prior to meals. Manufacturer information for insulin lispro stated that the pen must be primed before each injection to confirm insulin delivery and remove air, and that failure to prime could result in too much or too little insulin. The DON confirmed the expectation that insulin be administered as ordered, including priming each pen with two units before dialing the prescribed dose, and facility policy required medications, including insulin, to be administered safely, timely, and in accordance with prescriber orders and required time frames.
Plan Of Correction
This Plan of Correction is submitted as required under State and Federal law. This Plan of Correction does not constitute an admission on the part of the Facility that the findings cited are accurate, that the findings constitute a deficiency or that the scope and severity regarding the deficiency cited are correctly applied. Any changes to the Facility's policies and procedures should be inadmissible in any proceeding on that basis. Without admitting or denying the validity or the existence of the alleged noncompliance, the Facility submits this Plan of Correction with the intention that it be inadmissible by any third party in any civil or other action against the facility or any employee, agent, officer, director or shareholder of the Facility. The Facility is utilizing this Plan of Correction as an allegation of substantial compliance as of 5/29/2026. F-0759 Corrective action for resident/s: Residents #21 and #22 were assessed and evaluated by nurse and Director of Nursing 5/14/26. Resident #21 and #22 both denied any adverse effects and none were noted upon assessment by the Director of Nursing on 5/14/2026. Notification made to physician on 5/14/2026. LPN # 2 competency Eval on insulin administration with the Director of Nursing completed 5/14/2026. Identification of other residents who may be affected: Diabetic residents on assignment of LPN #2/station 2 have the potential to be affected and were assessed by the DON/Designee on 5/14/26 and found to be within normal limits. Measures for systemic change: All Nurses were educated by the Director of Nursing on the steps for Insulin administration per competency, diabetes clinical protocol policy, Medication and treatment orders policy, administering medications policy, and Obtaining fingerstick Glucose Level policy On 5/14/2026. How Corrective Action will be monitored: Director of Nursing and Assistant Director of Nursing will complete insulin administration audits on 5 nurses. This audit will be completed weekly x 4 weeks, then monthly x 2 months. Corrective action will be initiated for any noted non-compliance. Audit findings will be reviewed as part of the monthly quality assurance process to determine the need for further monitoring. Date of Compliance: 5/29/2026
Failure to Document Tray Line Food Temperatures in Dining Room Kitchenettes
Penalty
Summary
The deficiency involves the facility’s failure to document tray line food temperatures for meals served from the Harrison and McClellan Dining Room kitchenettes, as required by professional standards for food service safety and the facility’s own policy. Review of the “Trayline Taste & Temperature Log” (revised September 2018) showed missing temperature documentation for multiple meals from the Harrison Dining Room kitchenette, including dinner on 03/30/26 and 03/31/26, lunch and dinner on 04/01/26 and 04/02/26, dinner on 04/07/26, and lunch and dinner on 04/08/26 and 04/10/26. The Senior Director of Culinary Services confirmed during interview that tray line food temperatures were not documented on the log for these meals. Similarly, review of the same log for the McClellan Dining Room kitchenette revealed that tray line food temperatures were not documented for dinner on 04/01/26, breakfast and lunch on 04/02/26, and lunch and dinner on 04/07/26. The Senior Director of Culinary Services also verified these omissions during interview. The facility census at the time was 27 residents, and the governing “Food and Nutrition” policy, approved on 09/07/21, stated that the facility must store, prepare, distribute, and serve food in accordance with professional standards for food service safety.
Plan Of Correction
F812 The facility will continue to ensure food temperatures are completed before meals are served for all residents. To ensure compliance with this standard the following measures have been taken: 1. Immediately 4/15/26 culinary supervisor #224 was re-educated by Dietary Manager to this standard and policy "Food and Nutrition" which includes documentation of food temperatures. 2. All dietary staff have been re-educated to the standard and policy "Food and Nutrition" during the month of April 2026. 3. Audits of food temperature documentation to be completed by Dietary Manager 4 x per week for 4 weeks then weekly for 4 weeks. 4. Administrator to validate audits/compliance and provide additional training as needed. Administrator will present to QAPI committee for ongoing monitoring and further direction.
Failure to Conduct and Document Required Care Conferences
Penalty
Summary
The deficiency involves the facility’s failure to complete and document comprehensive care conferences at required intervals in accordance with care plan regulations and facility policy. For one resident with Parkinson’s disease with dyskinesia, cognitive communication deficit, hemiplegia and hemiparesis following cerebral infarction, transient cerebral ischemic attack, type II diabetes mellitus, and major depressive disorder, the record showed multiple MDS assessments over a one-year period, including annual, quarterly, and significant change assessments. However, only two care conferences were documented during the last 12 months, despite the expectation that care conferences be conducted quarterly with the resident and family when possible. The Unit Care Coordinator confirmed that no additional care conference documentation existed for this resident beyond the notes dated 04/21/25 and 01/02/26. A second resident, with diagnoses including aphasia following cerebrovascular disease, cerebral infarction, type II diabetes mellitus, unsteadiness on feet, difficulty in walking, coagulation defect, depression, and muscle weakness, also had multiple MDS assessments completed over the review period, including quarterly and annual assessments. The record contained a note that a care conference was offered to the resident’s representative, who declined to attend, but there was no documentation of any care conferences for the most recent 12 months. The Unit Care Coordinator confirmed that no other care conference documentation was available for this resident. Facility policy stated that periodic care conferences involving the resident, family, and the interdisciplinary team are part of the care planning process, but the required periodic care conferences and corresponding documentation were not completed for these two residents.
Plan Of Correction
THIS PLAN OF CORRECTION SERVES AS BERKELEY SQUARE'S CREDIBLE ALLEGATION OF SUBSTANTIAL COMPLIANCE AS OF June 1, 2026. Without admitting or denying the validity or existence of the alleged deficiencies, Berkeley Square provides the following Plan of Correction: F657 The facility will continue to document completion of care conferences at the required intervals for all residents, including residents #04 & #15. To ensure compliance with this standard the following measures have be taken: 1. The social service designee and the inter- disciplinary team were re-educated by the administrator to the facility policy "Care Conference" on 4/29/26 and verbalized understanding. 2. Care conferences for resident #04 and resident #15 were conducted on or before 4/29/2026 by the interdisciplinary team. 3. Review of all other residents was conducted by the social service designee to validate and ensure that care conference schedule is up to date with timely care conferences scheduled for them on 4/15/2026. Audits of care conferences to be completed weekly for four weeks and then monthly after that by the social service designee. Documentation of the care conference including any identified concerns in the medical record. Administrator to validate audits/compliance and provide additional training as needed. Administrator will present results of these audits to QAPI committee for ongoing monitoring and further direction.
Failure to Reevaluate Blood Glucose After Treatment for Hyperglycemia
Penalty
Summary
The facility failed to ensure that a resident with diabetes received treatment in accordance with professional standards of practice when nursing staff did not reevaluate the resident's blood glucose after treatment for severe hyperglycemia. The resident, admitted with diagnoses including Alzheimer's disease, type II diabetes mellitus, and depression, had physician orders for Humalog insulin on a sliding scale before meals, Lantus insulin 25 units daily, and lisinopril 5 mg daily. The resident required extensive assistance with activities of daily living, including transfers, toileting hygiene, eating, and bathing. On the evening in question, the resident's blood glucose was documented as 532 mg/dL, and the on-call provider was notified. The provider gave a new order to administer an additional 8 units of lispro (Humalog) and to recheck the blood glucose in 30 minutes. The electronic medication administration record showed that the blood glucose of 532 mg/dL was obtained at 9:00 p.m. and that the additional 8 units of lispro were administered at 9:21 p.m. However, there was no documentation in the resident's chart that the blood glucose was rechecked after the additional insulin was given. In an interview, the DON confirmed there was no evidence of reevaluation and verified that, according to the facility's "Abnormal Blood Glucose Procedure" policy, the resident should have been reevaluated and that the evaluation step should have been included in the progress note documentation.
Plan Of Correction
F684 The facility will continue to ensure all residents, including #03, receive treatment in accordance with professional standards of practice and reevaluated for hyperglycemia. To ensure compliance with this standard the following measures have been taken: 1. The director of nursing assessed resident #03, reviewed documentation and orders and found no ill effects immediately 4/16/26. 2. All licensed nurses were re-educated to facility policy "Blood Glucose Monitoring" by the Director of Nursing/designee in April 2026. 3. Audits of like-residents that require blood sugar checks to be completed by the director of nursing/designee two times a week for 4 weeks and then monthly after that to validate correct follow through when there is abnormally high blood glucose result. The Administrator will bring results of these audits to the QAPI committee for ongoing monitoring and further direction.
Failure to Act on Pharmacist Drug Regimen Recommendation for Thyroid Medication
Penalty
Summary
The deficiency involves the facility’s failure to ensure that pharmacy recommendations from the monthly drug regimen review were acted upon and documented for a resident. The resident was admitted with diagnoses including Parkinson’s disease, dementia, and hypothyroidism, and had current physician orders for levothyroxine 150 mcg once daily, buspirone 50 mg twice daily, and losartan 100 mg once daily. A medication regimen review dated 11/25/2025 included a consultant pharmacist recommendation that levothyroxine be administered consistently in the morning on an empty stomach, at least 30–60 minutes before food, per manufacturer instructions. There was no specific physician response in the medical record to this recommendation, and the facility’s policy stated that consulting pharmacist reviews are sent to nursing and addressed with the primary care provider or consulting specialist for review and follow-up. Review of the resident’s medication administration record for April 2026 showed levothyroxine scheduled for 9:00 a.m. On observation, the resident was seen eating breakfast in the dining area at 8:03 a.m., and an LPN reported administering the levothyroxine 150 mcg to the resident while the resident was in the dining area eating breakfast. The DON confirmed there was no evidence in the resident’s medical record explaining why the consultant pharmacist’s recommendation from 11/25/2025 was or was not acted upon. This lack of documented physician review and action on the pharmacist’s identified irregularity constituted noncompliance with the drug regimen review requirements.
Plan Of Correction
F756 The facility will continue to ensure the pharmacy recommendations from the monthly drug regimen review by a licensed pharmacist are acted upon for all residents, including #08. To ensure compliance with this standard the following measures have been taken: 1. Resident #08 was assessed by the registered nurse and med review completed by 4/28/26. After review of resident's drug regime's, it was discovered that resident #8 had 2 separate medication recommendations on the same form, to be reviewed by two separate practitioners, pharmacy has been instructed and agreed to separate meds on individual forms. 2. Licensed nurses re-educated to facility policy "Drug Regimen Review" by Director of nursing/designee in April 2026 and no later than 5/8/26. Licensed nurses are responsible for ensuring the reviews and recommendations are given to the physician for timely review. 3. Review of all other current residents Drug Regimen orders completed by Director of nursing/designee on 4/16/26 to ensure recommendations were followed up on/reviewed by the physician and address concerns if needed. 4. Audit of drug regime recommendations, pharmacy recommendations, and physician follow up to be completed weekly for four weeks by the Director of nursing/designee. Administrator will present results of these audits to the QAPI committee for ongoing monitoring and further direction.
Failure to Use Required Gait Belt During Ambulation Resulting in Resident Fall
Penalty
Summary
The deficiency involves the facility’s failure to ensure that a required gait belt was used while assisting a high fall‑risk resident with ambulation, resulting in a fall with head injury. The resident had multiple diagnoses including metabolic encephalopathy, hypertension, osteoarthritis, muscle weakness, gait and mobility abnormalities, major depressive disorder, anxiety, and visual hallucinations. Admission and subsequent MDS and fall risk assessments documented that the resident was severely cognitively impaired, required moderate to maximal assistance with transfers and ambulation, could not independently come to a standing position, exhibited loss of balance while standing, used an assistive device, and had decreased muscle coordination. The resident had a history of falls prior to admission and was assessed as being at high, later moderate, risk for falls. The resident’s fall care plan identified her as at risk for falls and included interventions such as providing maximum to moderate assistance with transfers and walking short distances, use of a walker and wheelchair, and following the facility’s fall protocol. Therapy notes and care conference documentation indicated that the resident leaned backwards when standing, required contact guard to minimal assistance for bed mobility and transfers, and needed constant verbal cueing for safe sequencing during toilet transfers. The physical therapist confirmed that the resident was to use a gait belt with staff when ambulating, and the DON verified that therapy had assessed the resident as requiring contact guard assistance and a gait belt for ambulation and transfers. On the day of the incident, a CNA was assisting the resident from her recliner to the bathroom using a walker. The CNA walked beside the resident, providing guidance and support, and reported having a hand on the resident while assisting her. As they approached the bathroom door, the CNA reached for the doorknob to open it, and at that moment the resident began to lose her balance and fell backwards to the floor, striking the back of her head. The nurse who responded found the resident on her back at the foot of the bed with her feet near the bathroom, noted a red raised area on the back of the head, and documented that the resident was not wearing a gait belt and that the gait belt was on the dresser. In the facility’s investigative summary and in interviews, the CNA acknowledged that she did not have a gait belt on the resident while ambulating her, despite the resident’s assessed need for hands‑on assistance and gait belt use per facility policy and the resident’s care and therapy plans.
Failure to Implement PD Orders and Monitor Resident Receiving Peritoneal Dialysis
Penalty
Summary
The deficiency involves the facility’s failure to implement pre-admission physician orders for peritoneal dialysis (PD) and to provide ongoing monitoring for a resident with chronic kidney disease (CKD) stage five who required PD. Pre-admission orders dated 11/14/25 specified three daily PD exchanges at 6:00 A.M., 2:00 P.M., and 10:00 P.M., and directed staff to monitor for signs and symptoms of peritonitis, including fever, abdominal pain, and cloudy effluent. These monitoring orders were not entered into the facility’s physician orders. The resident’s care plan noted the need for PD and included general monitoring interventions (labs, signs of bleeding, bacteremia, septic shock, and significant vital sign changes), but did not specifically address the ordered monitoring for peritonitis. Review of PD documentation showed incomplete and inconsistent charting of treatments and resident condition. The paper peritoneal flowsheet had columns for time of PD and condition/comments, including instructions to call the nurse immediately for cloudy fluid, abdominal pain, or fever. However, the first entry on 11/15/26 at 2:00 P.M. only noted that the PD nurse completed the exchange, and the 10:00 P.M. entry that day had no condition/comment documentation. Subsequent days (11/16/25, 11/17/25, and 11/18/25) contained only one condition/comment entry per day rather than for each exchange, and there was no documentation that the 6:00 A.M. PD on 11/18/25 was completed. The PD cycler flowsheet starting 11/19/25 lacked any description of the effluent on multiple days. The PD nurse from the dialysis company stated facility staff were expected to monitor effluent for cloudiness and assess for abdominal pain and fever, and the DON confirmed there was no electronic physician order for peritonitis monitoring or for use of the PD cycler, that the paper charting did not allow for effluent description or symptom documentation for each treatment, and that PD was not documented at one ordered time. The facility’s dialysis policy required ongoing assessment and monitoring for complications before, during, and after treatments, which was not reflected in the documentation for this resident.
Improper Infection Control During Medication Administration
Penalty
Summary
Surveyors identified a deficiency in infection prevention and control related to medication administration for Resident #29. The resident was admitted on 02/28/14 with diagnoses including depression, traumatic brain injury, and anxiety, and had impaired cognition per a quarterly MDS assessment. During an observation on 03/25/26 at 6:58 A.M., RN #281 prepared the resident’s medications by removing an Amoxicillin-Pot Clavulanate tablet from the medication card and pushing it directly into her ungloved hand, then using her fingers to place the pill into a medication cup. The same process was observed for multiple other medications, including Escitalopram Oxalate, Furosemide, Sennosides, Lyrica, and Vitamin D, each being pushed from the card into the RN’s ungloved hand and then transferred by her fingers into the medication cup before administration to Resident #29. In a subsequent interview at 7:27 A.M. the same day, RN #281 confirmed she had placed each medication into her ungloved hands prior to administration and acknowledged that the proper procedure was to push the pills directly from the card into the medication cup. Review of the facility’s “Medication Administration – General guidelines” policy, revised 10/08/25, stated that medications are to be administered in accordance with good nursing principles and practices. This practice failure was cited as a deficiency under Complaint Number 2681777.
Improper Use of Wheelchair as a Physical Restraint
Penalty
Summary
Surveyors identified a deficiency related to the facility’s failure to ensure a resident was free from physical restraints. Resident #7, admitted with diagnoses including Alzheimer’s disease, diabetes mellitus, and anxiety disorder, was documented on a recent MDS as rarely understood and dependent for ADLs except eating. The resident ambulated independently on the unit without an assistive device and had documented verbal and other behaviors occurring one to three days during the look-back period. The care plan noted the resident had potential to be physically aggressive, chase staff, throw objects, and be combative with care, with interventions such as offering choices, administering medications as ordered, and intervening early when agitation occurred. During an observation and interview, Resident #7 was found sitting in a chair with the right arm of the chair positioned against the nursing station and a wheelchair placed directly in front of him. The left arm of the wheelchair was also against the nursing station, and both wheelchair wheels were locked, creating a barrier that appeared to restrain the resident, who was sleeping with his knees touching the locked wheelchair. An LPN confirmed both wheelchair wheels were locked and that the wheelchair should not have been placed in front of the resident. A CNA reported she had placed the wheelchair there in preparation to get the resident up for lunch, was unable to transfer him, and left the wheelchair in that position, acknowledging it was wrong to keep it there. The facility’s physical restraint policy stated that physical restraints are not used except when alternatives are not appropriate or effective for treating a medical symptom and defined physical restraints as any device attached or adjacent to the body that the individual cannot easily remove and that restricts freedom of movement or access to the body.
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