West Park Care Center Llc
Inspection history, citations, penalties and survey trends for this long-term care facility in Columbus, Ohio.
- Location
- 1700 Heinzerling Drive, Columbus, Ohio 43223
- CMS Provider Number
- 365799
- Inspections on file
- 18
- Latest survey
- March 6, 2025
- Citations (last 12 mo.)
- 0
Citation history
Health deficiencies cited at West Park Care Center Llc during CMS and state inspections, most recent first.
A facility failed to ensure adequate nutritional care for two residents at risk of malnutrition and dehydration. One resident experienced significant weight loss, leading to hospitalization and PEG tube placement, while another resident's weight was not monitored as required, resulting in an inability to accurately assess weight loss post-amputation. The facility's lack of timely nutritional assessments and interventions contributed to these deficiencies.
A resident with vascular dementia and anxiety disorder experienced hallucinations and behavioral issues, fearing people were entering her room to harm her. Despite recommendations to investigate these claims, the facility did not take action, and the resident's care plan lacked interventions to address her fears. The facility's investigation into her claims was unsubstantiated, and no new interventions were implemented. The resident's guardian was informed that the facility could not meet her needs, leading to her discharge.
The facility did not secure a surety bond sufficient to cover all resident funds, managing $158,125 with a bond of only $50,000. Interviews with the Administrator and DON confirmed the lack of evidence for an adequate bond increase.
The facility failed to maintain hot water temperatures below 120°F, affecting multiple residents, and did not document or investigate a fall involving a resident with cognitive impairments. The Maintenance Director confirmed the elevated temperatures, and the DON acknowledged the lack of documentation for the fall.
A resident with multiple health conditions was observed wearing a hospital gown on two occasions, despite having personal clothing available. The resident's care plan required staff to encourage participation in dressing, but this was not followed, as confirmed by a CNA. The facility's policy emphasized treating residents with dignity, which was not upheld in this instance.
A facility failed to notify a resident's PCP of a significant weight gain, which was outside the physician-ordered parameters. The resident had multiple diagnoses, including congestive heart failure and morbid obesity, and specific orders for weight monitoring. Despite a weight increase exceeding the threshold, the PCP was not informed, as confirmed by staff interviews and record reviews.
A resident with severe cognitive impairment and a stage II pressure ulcer on the right heel had their care plan inadequately revised. Despite multiple instances of care rejection, the care plan lacked necessary interventions. The resident was hospitalized due to the ulcer's decline and returned after a below-the-knee amputation. The DON confirmed the absence of required interventions, contrary to the facility's guidelines.
A resident with multiple medical conditions did not receive routine showers as per their care plan, receiving only one shower since admission. Despite being scheduled for showers twice a week, the resident had to repeatedly request assistance for personal hygiene. A CNA confirmed the resident's requests and provided a shower outside the scheduled day, highlighting a failure to adhere to the facility's shower policy.
A facility failed to implement physician orders for three residents, including daily weights for a resident with heart failure, a fluid restriction for a resident with multiple diagnoses, and lymphedema wraps for a resident. The deficiencies were confirmed by the DON and were not documented as per facility policy.
A facility failed to address a resident's leaking nephrostomy tube and did not document the resident's transfer to the ER for replacement. The resident, with multiple health issues, was found with a leaking collection bag wrapped in a towel and trash bag. The RN was unaware of the leak, and despite contacting urology, the NP ordered an ER visit. The DON confirmed the lack of documentation, violating facility policy.
A facility failed to store respiratory equipment properly, affecting a resident with multiple health conditions including emphysema. The resident's nebulizer was found in a dresser drawer without a protective bag, as confirmed by an RN.
A facility failed to administer medications as ordered, resulting in a medication error rate of 10.71%, exceeding the acceptable 5% threshold. A resident with multiple health conditions, including dementia and chronic kidney disease, received incorrect forms of medications during a medication pass. The RN administered Aspirin EC, Oyster shell calcium without vitamin D, and Senna instead of the prescribed medications. The facility's policy required accurate medication administration, which was not followed.
A resident was found with an Albuterol inhaler on their bedside stand without a physician's order or self-administration evaluation, contrary to the facility's policy requiring medications to be stored in locked compartments. This affected one of 18 residents observed for medication storage.
A facility failed to maintain hospice communication notes for a resident receiving hospice services. The resident had multiple medical conditions and was admitted with a requirement for hospice care. Despite the hospice contract stipulating communication through written records, the hospice binder lacked these notes. Staff interviews confirmed the absence of notes, which were only provided after surveyor intervention.
Failure to Monitor and Address Nutritional Needs Leads to Harm
Penalty
Summary
The facility failed to ensure adequate nutritional care for a resident identified at risk of malnutrition and dehydration, leading to significant weight loss and hospitalization. Resident #52, who had a history of cerebral infarction, protein calorie malnutrition, and other conditions, experienced a 5.1% weight loss over four weeks and a severe 13.6% weight loss over less than three months. Despite these significant changes, the facility did not conduct timely nutritional assessments or implement new interventions. The resident's meal intake records showed consistent consumption of less than 50% of meals, yet no adjustments were made to address this issue. The lack of permanent dietitian coverage in October 2024 contributed to the oversight of the resident's weight loss. Resident #52's condition deteriorated, resulting in hospitalization for failure to thrive and the placement of a PEG tube for enteral nutrition support. The hospital records indicated dehydration, with elevated serum sodium, BUN, and creatinine levels. Upon readmission to the facility, the resident was placed on continuous enteral feeding and a pureed diet with nectar thickened liquids. Despite these interventions, the resident was later admitted to hospice care with a terminal diagnosis of cerebral infarction, compounded by severe weight loss. Additionally, the facility failed to complete required weight monitoring for another resident, Resident #81, who was also at nutritional risk. The facility did not obtain weekly weights for the first four weeks after admission, nor did they document weights upon the resident's readmission following a below-the-knee amputation. This oversight resulted in an inability to accurately assess the resident's weight loss, which was significantly more than expected post-amputation. The facility's policy required weekly weights for new admissions, but this was not adhered to, placing the resident at risk for more than minimal harm.
Failure to Address Behavioral Health Needs Leads to Resident Discharge
Penalty
Summary
The facility failed to investigate and implement psychiatric recommendations for a resident with vascular dementia, anxiety disorder, and other conditions, who experienced hallucinations and behavioral issues. The resident, who had moderately impaired cognition, reported fears of people entering her room to harm her. Despite recommendations from a Nurse Practitioner to investigate these claims, the facility did not take action to clarify or address the resident's statements. The resident's care plan lacked interventions to address her fears, and there was no evidence of a root cause analysis to understand her continued allegations. The facility's investigation into the resident's claims of being attacked was deemed unsubstantiated, and no new interventions were implemented to alleviate her fears. The Director of Nursing confirmed that no further investigations were conducted, and the facility did not monitor the resident's behaviors or validate her allegations. The resident's guardian was informed that the facility could not meet her needs, leading to her discharge. The guardian confirmed that no interventions were made to address the resident's hallucinations, and she was unaware of any investigation into the validity of the resident's claims.
Inadequate Surety Bond Coverage for Resident Funds
Penalty
Summary
The facility failed to secure a surety bond that adequately covered all resident funds managed by the facility. A review of the financial records for 42 residents revealed that the total amount of funds managed by the facility was $158,125. However, the surety bond, dated 05/31/24, was only increased from $40,000 to $50,000, which was insufficient to cover the total amount of resident funds. Interviews with the Administrator and the Director of Nursing confirmed that there was no evidence of further increases to the surety bond to meet the required coverage for the resident funds.
Failure to Maintain Safe Water Temperatures and Document Resident Fall
Penalty
Summary
The facility failed to maintain hot water temperatures below the maximum allowable limit of 120 degrees Fahrenheit, as observed in multiple resident rooms. Specifically, water temperatures were recorded at 124.5, 122.4, 121.3, 123.8, and 122.4 degrees Fahrenheit in various rooms, exceeding the facility's policy range of 105 to 120 degrees Fahrenheit. This oversight had the potential to affect 37 residents residing on the specified hallway. The Maintenance Director confirmed the elevated temperatures, indicating a lapse in adherence to the facility's water temperature policy. Additionally, the facility did not document or investigate a fall incident involving a resident with multiple diagnoses, including cerebral infarction and vascular dementia. The resident, who had a BIMS score indicating moderately impaired cognition, experienced a fall on a specified date, but the clinical record lacked documentation or investigation of the event. The Director of Nursing confirmed the absence of documentation and investigation, which was contrary to the facility's Fall Management Guidelines that require a fall risk evaluation and documentation in the resident's medical record after a fall.
Failure to Maintain Resident Dignity in Dressing
Penalty
Summary
The facility failed to treat a resident in a dignified manner, as evidenced by the observations and interviews conducted. The resident, who was admitted with multiple diagnoses including atrial fibrillation, diabetes mellitus, and dementia, was observed on two separate occasions wearing a hospital gown despite having personal clothing available. The resident's care plan indicated that they required assistance with activities of daily living and that staff should encourage participation to the fullest extent possible, including dressing in preferred clothing. The facility's policy on dignity emphasized that residents should be cared for in a manner that promotes their well-being and self-esteem, including supporting their rights to dress in their preferred clothing. However, the resident remained in a hospital gown, which was confirmed by a CNA, indicating a failure to adhere to the facility's policy and the resident's care plan. This deficiency affected the resident's dignity and self-worth, as outlined in the facility's policy.
Failure to Notify Physician of Significant Weight Gain
Penalty
Summary
The facility failed to notify a resident's primary care physician of a significant weight gain, which was outside the physician-ordered parameters. The resident, who was admitted with multiple diagnoses including congestive heart failure and morbid obesity, had specific physician orders for a fluid restriction and daily weight monitoring. The orders required notifying the physician if the resident experienced a weight gain of more than two pounds per day over two days or five pounds in a week. On one occasion, the resident's weight increased by more than two pounds in a single day, but there was no documented evidence that the primary care physician was informed of this change. The deficiency was confirmed through a review of the resident's medical records, staff interviews, and facility policy review. The facility's policy on change in condition notification mandates that the nurse must inform the resident, the physician, and the resident's designated representative of any significant changes in the resident's status. However, an interview with a registered nurse confirmed that the physician was not notified of the weight gain as required by the physician's orders. This oversight affected one resident out of five reviewed for unnecessary medications, within a facility census of 84.
Failure to Revise Care Plan for Resident with Pressure Ulcer
Penalty
Summary
The facility failed to adequately revise the care plan for a resident who was admitted with multiple diagnoses, including a severe cognitive impairment and a stage II pressure ulcer on the right heel. Despite the resident's behavior logs indicating 24 instances of care rejection, including treatment for the pressure ulcer, the care plan was not updated with appropriate interventions. The resident was admitted to the hospital due to a declining condition of the pressure ulcer and later returned to the facility after a below-the-knee amputation. The care plan for changes in mood and behavior, as well as the care plan for skin integrity, were updated to include areas of concern such as refusal of treatment and non-compliance with dressing changes. However, no specific interventions were added to address these issues. The Director of Nursing confirmed that the care plans lacked necessary interventions, which should have been included according to the facility's Skin and Wound Guidelines. These guidelines emphasize the need for individualized interventions to manage pressure injuries and skin alterations.
Failure to Provide Routine Showers to Resident
Penalty
Summary
The facility failed to ensure that a resident received routine showers as per their care plan and facility policy. Resident #140, who was admitted with multiple medical conditions including amyloidosis, congestive heart failure, and diabetes, was scheduled to receive showers every Wednesday and Saturday. However, since admission, the resident had only received one shower, which was not in accordance with the scheduled routine. This lack of adherence to the shower schedule was confirmed through record reviews and interviews with the resident and staff. Observations and interviews revealed that Resident #140 had to repeatedly request a shower and clothing change from multiple staff members, including therapy, before receiving assistance. The resident was observed wearing clothing with dried food stains, indicating a lack of personal hygiene care. A Certified Nursing Assistant confirmed that the resident had been asking for a shower and that she provided one despite it not being the scheduled day. The facility's policy stated that showers should be provided per request and schedule, but this was not followed, leading to the deficiency.
Failure to Implement Physician Orders for Three Residents
Penalty
Summary
The facility failed to provide appropriate treatment and care according to physician orders and resident preferences for three residents. Resident #5, who had multiple medical diagnoses including chronic heart failure and dementia, did not have daily weights recorded as ordered from 02/11/25 to 02/13/25, with no documentation explaining the omission. The Director of Nursing confirmed the failure to obtain the weights as required by the facility's policy. Resident #140, diagnosed with conditions such as congestive heart failure and diabetes, had a physician-ordered fluid restriction of 1800 ml that was not implemented. The facility's policy required collaboration between nursing and dietary departments to manage fluid restrictions, but there was no evidence of this coordination. Additionally, Resident #48, who had lymphedema, was not wearing the prescribed Circaid Reduction Kit and tubi-grips as ordered, which was confirmed by the Director of Nursing during an observation.
Failure to Address and Document Nephrostomy Tube Leak
Penalty
Summary
The facility failed to timely address a resident's leaking nephrostomy tube and accurately document the resident's hospitalization and subsequent nephrostomy tube replacement. The resident, who was admitted with multiple diagnoses including atrial fibrillation, diabetes mellitus, and obstructive uropathy, was observed with a leaking nephrostomy collection bag wrapped in a towel and placed inside a trash bag. The registered nurse was unaware of the leak until it was pointed out, and the facility delayed contacting the urology office regarding the issue. Despite obtaining an appointment for the resident with urology, the nurse practitioner ordered the resident to be sent to the emergency room for replacement of the leaking nephrostomy collection bag. However, there was no documentation in the medical record of the resident being transferred to the ER or the nephrostomy tube being replaced. The Director of Nursing confirmed the lack of documentation, which was against the facility's policy that required timely and factual documentation of care services.
Improper Storage of Respiratory Equipment
Penalty
Summary
The facility failed to ensure that respiratory equipment was stored in a sanitary manner, affecting a resident who required respiratory care. Resident #143, who was admitted with multiple diagnoses including atrial fibrillation, diabetes mellitus, and panlobular emphysema, was observed to have their nebulizer delivery system improperly stored. The nebulizer was found lying in the top drawer of the resident's dresser without a protective bag, which was confirmed by a registered nurse during an interview. This deficiency was identified during an observation conducted on February 24, 2025.
Medication Administration Errors Exceed Acceptable Rate
Penalty
Summary
The facility failed to administer medications as ordered, resulting in a medication administration error rate of 10.71%, which is above the acceptable threshold of 5%. This error rate was determined from three errors out of 28 observed opportunities during a medication pass. The errors affected one resident, who was observed during the medication administration process. The resident had a medical history that included dementia, chronic kidney disease, diabetes mellitus, lymphedema, hypertension, obstructive sleep apnea, insomnia, hyperlipidemia, and constipation. The resident's care plan included specific interventions for managing constipation, such as administering medications like stool softeners and laxatives as ordered. During the medication pass, a registered nurse administered the wrong forms of medications to the resident. Instead of the prescribed Aspirin 81 mg chewable tablet, Oyster shell calcium with vitamin D 500-5 mg/mcg, and Sennosides-Docusate Sodium 8.6-50 mg tablet, the nurse administered Aspirin enteric coated 81 mg tablet, Oyster shell calcium 500 mg tablet, and Senna 8.6 mg tablet. The facility's policy on medication administration emphasized the importance of preparing and administering medications accurately according to physician orders and professional standards, which was not adhered to in this instance.
Medication Storage Deficiency
Penalty
Summary
The facility failed to ensure that a resident's medication was properly secured, as required by their policy. Specifically, Resident #143, who was admitted with multiple diagnoses including atrial fibrillation, diabetes mellitus, and dementia, was observed to have an Albuterol Sulfate inhaler on their bedside stand. This observation was made without a physician's order permitting the inhaler to be kept at the bedside or an evaluation to determine the resident's ability to self-administer the medication. The facility's policy mandates that all medications and biologicals be stored in locked compartments. However, during an interview, RN #250 confirmed that there was no physician's order or self-administration evaluation for Resident #143 to have the inhaler at the bedside. This oversight in medication storage affected one of the 18 residents observed for medication storage, highlighting a lapse in adherence to the facility's medication and treatment storage policy.
Lack of Hospice Communication Notes for Resident
Penalty
Summary
The facility failed to ensure that hospice communication notes were readily available for a resident receiving hospice services. The resident, who was admitted on 04/07/22, had multiple medical diagnoses including frontal lobe and executive function deficit following cerebral infarction, type two diabetes mellitus with diabetic retinopathy, hemiplegia and hemiparesis, chronic hepatitis, and syncope. The hospice contract required communication between the hospice and the facility through various means, including written communication in the resident's medical record. However, upon review, it was found that the hospice binder at the nurse's station only contained three skin grids, a hospice election of service form, and a DNR order, with no hospice communication notes present. Interviews with nursing staff confirmed the absence of hospice communication notes in the hospice binder for the resident. An Agency Registered Nurse and a Registered Nurse both acknowledged that the notes were not on-site at the facility until they were faxed over from the hospice provider following surveyor intervention. This deficiency affected the resident's care as the necessary hospice communication was not readily accessible to the facility staff.
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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