Willoughby Post Acute
Inspection history, citations, penalties and survey trends for this long-term care facility in Willoughby, Ohio.
- Location
- 37603 Euclid Ave, Willoughby, Ohio 44094
- CMS Provider Number
- 365305
- Inspections on file
- 31
- Latest survey
- October 22, 2025
- Citations (last 12 mo.)
- 5
Citation history
Health deficiencies cited at Willoughby Post Acute during CMS and state inspections, most recent first.
A resident admitted for respite care with hospice services suffered a fall resulting in leg fractures, but did not receive timely pain assessment or intervention. Despite exhibiting severe pain behaviors throughout the night, staff failed to document pain assessments, offer or administer pain medication, or notify hospice until the following day. The resident's injuries were only identified after a hospice nurse intervened and ordered an x-ray, leading to hospital transfer.
Surveyors found that carpeting throughout the facility's hallways was heavily stained and discolored, with multiple large black and brown stains observed in various locations. Despite routine cleaning, the Environmental Service Manager and Administrator confirmed the stains persisted due to the age of the carpeting, and no active plans or quotes for replacement were in place. This failure did not meet the facility's policy for providing a clean and comfortable environment.
The facility did not keep an area free from accident hazards and failed to provide adequate supervision, resulting in an increased risk of accidents for residents.
A resident was not protected from a significant medication error due to a failure in the medication administration process.
The facility did not establish or maintain an infection prevention and control program as required, resulting in a deficiency identified by surveyors.
The facility was found to have insufficient staffing levels, with a one-star staffing rating and low weekend staffing. Interviews with CNAs and residents revealed that due to staff call-offs, residents were not checked and changed every two hours, and some did not receive scheduled showers. Residents reported delays in staff responding to call lights and inconsistent bathing, especially on weekends.
The facility failed to properly clean and sanitize rooms before admitting new residents, as observed in a room claimed to be deep cleaned but found with personal items and dirt. The Housekeeping Supervisor acknowledged past concerns and temporary solutions, while a resident's daughter reported a dirty room upon admission. The facility's cleaning policy was not followed, leading to this deficiency.
A facility failed to collect a urinalysis for a resident as ordered by a physician. The resident, who had type two diabetes and other conditions, was noted to have worsening confusion and anxiety, prompting a stat urinalysis order. The urinalysis was delayed, and subsequent orders for a straight catheterization were not documented as completed. The DON confirmed the failure to collect the urinalysis and the lack of documentation explaining the omission.
A resident received incorrect medication due to a failure in following the facility's medication administration policy. The resident, who was cognitively intact and had a history of heart-related conditions, was mistakenly given another resident's medication, including a blood pressure pill and a multivitamin. The error was not documented, and the nurse involved initially denied the mistake. The facility's policy on the Five Rights of medication administration was not followed, leading to this deficiency.
A medication error occurred when a nurse administered a blood pressure pill and a multivitamin intended for another resident to a cognitively intact resident with multiple health conditions. The error was not documented in the resident's medical record, and there was no physician notification or new orders recorded. The resident's daughter witnessed the error, and the facility's policy on medication administration was not followed.
A resident with secondary parkinsonism did not receive their antiparkinsonian medication, Rytary, as prescribed, leading to significant medication errors. The medication was often administered late, and on one occasion, two doses were given together. The DON confirmed the issue, noting that nurses might not have been recording administration times accurately, which violated the facility's policy.
The facility failed to maintain a clean and homelike environment for two residents, as evidenced by spider webs and a black substance under the sink in a resident's room. Despite a grievance from a resident's family and photo evidence, the issues remained unaddressed, as confirmed by a survey and the Maintenance Director. This deficiency was investigated under a specific complaint number.
Failure to Provide Timely Pain Assessment and Intervention After Fall
Penalty
Summary
A deficiency occurred when a resident admitted for respite care with hospice services experienced a fall resulting in displaced fractures of the left tibia and fibula. Despite the fall, there was no evidence of a pain assessment at admission or after the incident. The resident was found on the floor by an LPN, who documented no apparent injuries and did not complete a pain assessment or notify hospice of the fall. Throughout the night following the fall, the resident exhibited significant distress, including screaming, crying, and aggression, yet there was no documentation of pain assessments, offers or refusals of pain medication, or notification to hospice regarding the resident's deteriorating condition. The resident's pain escalated, and it was not until a hospice visit the following day that swelling, bruising, and inability to bear weight on the left knee were observed. The hospice nurse notified the facility, and an x-ray was ordered, which later confirmed the fractures. The medication administration record showed no pain medication was offered, refused, or administered until nearly 24 hours after the fall, despite the resident's ongoing and escalating pain. Interviews with staff confirmed a lack of pain assessment, inadequate documentation, and failure to notify hospice in a timely manner. Facility policy required pain assessment at admission and during changes in condition, but this was not followed. The resident was eventually transferred to the hospital after the fractures were identified, but there was no documentation of the transfer, pain assessment at discharge, or communication of x-ray results to hospice. The failure to provide timely and adequate pain assessment and intervention following the fall resulted in actual harm to the resident.
Failure to Maintain Clean and Sanitary Carpeting in Facility Hallways
Penalty
Summary
The facility failed to maintain the carpeting in the hallways of all units in a clean and sanitary condition, as observed during multiple walkthroughs. Surveyors noted that the carpeting throughout the facility was discolored and contained numerous black and brown stains of varying sizes in multiple locations, including near double doors, entrances to resident rooms, lounge areas, elevator lobbies, and outside utility rooms. These findings were confirmed during an environmental tour with the Environmental Service Manager and the Administrator, who both acknowledged the presence of extensive staining and discoloration. Interviews with the Environmental Service Manager revealed that while routine cleaning was performed by a floor technician, the age and condition of the carpeting prevented effective removal of the stains. The Environmental Service Manager was aware of the issue but was unsure if any steps had been taken to obtain quotes or initiate the process for carpet replacement. The Administrator also confirmed that no quotes had been obtained and no active plans were in place to replace the carpeting. Review of the facility's policy indicated that residents were to be provided with a safe, clean, comfortable, and homelike environment, which was not met in this instance.
Failure to Maintain Safe Environment and Supervision
Penalty
Summary
The facility failed to ensure that an area was free from accident hazards and did not provide adequate supervision to prevent accidents. Surveyors observed that the environment contained hazards that could lead to resident accidents, and staff did not implement sufficient measures to monitor or protect residents from these risks. This deficiency was identified based on direct observations and findings during the survey, which indicated lapses in maintaining a safe environment and in providing necessary supervision to prevent accidents.
Significant Medication Error Occurred
Penalty
Summary
Residents were not ensured to be free from significant medication errors. The report identifies that there was at least one instance where a resident experienced a significant medication error, indicating a failure in the medication administration process. Specific details about the actions or inactions leading to the error, as well as information about the resident's medical history or condition at the time, are not provided in the report.
Failure to Implement Infection Prevention and Control Program
Penalty
Summary
The facility failed to provide and implement an infection prevention and control program. This deficiency was identified during the survey process, indicating that the required measures to prevent and control infections were not established or maintained as per regulatory standards. The report does not provide further details regarding specific actions, inactions, or events, nor does it mention any particular residents or staff involved in the deficiency.
Insufficient Staffing Levels
Penalty
Summary
The facility failed to provide sufficient nursing staff to meet the needs of all residents, as evidenced by a review of the Payroll-Based Journal (PBJ) Staffing Data Report and interviews with residents and staff. The facility, with a census of 132 residents, was found to have a one-star staffing rating and excessively low weekend staffing for the fiscal year quarter 3 of 2024. The facility's assessment indicated a certified bed capacity of 157, with an average daily census of 19.4 for short stays and 105.4 for long stays. Despite this, the staffing levels on specific dates were below the required levels, with licensed nurses at 1.05 and nurse aides at 1.4 on one day, and licensed nurses at 1.05 and nurse aides at 1.29 on another day. Interviews with Certified Nursing Assistants (CNAs) and residents revealed that due to staff call-offs, residents were not being checked and changed every two hours, and some did not receive their scheduled showers. Residents reported that it could take up to an hour for staff to respond to call lights, and showers and bathing were not consistently provided, particularly on weekends. The facility's administrator confirmed that corporate staff reviewed the actual staff punches used to submit the PBJ. This deficiency was investigated under Complaint Number OH00158759.
Failure to Properly Clean and Sanitize Rooms Before New Admissions
Penalty
Summary
The facility failed to ensure that rooms were appropriately cleaned and sanitized before admitting new residents, which had the potential to affect all new admissions. During an interview, the Housekeeping Supervisor stated that rooms are supposed to be deep cleaned within 24 hours of a resident's discharge. This deep cleaning process includes removing all trash, packing the former resident's belongings, emptying and cleaning drawers and closets, and cleaning all surfaces. However, observations revealed that a room, which was claimed to be deep cleaned and ready for a new admission, contained a white brief, oxygen tubing, a used urinal with dried urine, and a collection canister with dried urine in the nightstand. Additionally, another observation of the same room showed potato chips and crumbs in the nightstand drawer, large dust piles behind the stand, and dry drips of fluid on the stand, indicating that the cleaning process was not thoroughly completed. The Housekeeping Supervisor acknowledged that there had been previous concerns about rooms not being deep cleaned before new admissions, and attempts to rotate housekeepers to address the issue were only temporarily effective. An interview with a resident's daughter revealed that upon admission, the room appeared dirty, with unclean floors and personal items from another resident still present in the drawers and closet. The facility's policy on routine cleaning, which aligns with CDC recommendations and OSHA standards, was not adhered to, leading to this deficiency. The report indicates that this issue was investigated under a specific complaint number.
Failure to Collect Urinalysis as Ordered
Penalty
Summary
The facility failed to collect a urinalysis for a resident as per the physician's orders. The resident, who was cognitively intact, had a diagnosis of type two diabetes mellitus, hydronephrosis, weakness, and retention of urine. The resident was dependent on toileting and frequently incontinent of urine. A Certified Nurse Practitioner noted worsening confusion and anxiety in the resident and ordered a urinalysis to be sent stat. However, the urinalysis was not collected until three days later, and the results showed mixed flora, preventing a sensitivity test. Subsequently, a new physician order was issued to perform a straight catheterization for a urinalysis with culture and sensitivity, but there was no documentation that this was completed. The Director of Nursing confirmed that the urinalysis was not collected as ordered and that there was no documentation explaining why it was not done. This deficiency was identified during an investigation under a specific complaint number.
Medication Error Due to Incorrect Administration
Penalty
Summary
The facility failed to administer the correct medication to a resident, resulting in a medication error. The incident involved a resident who was cognitively intact and had a medical history including endocarditis, heart failure, hypertension, vascular dementia, and weakness. On the day of the error, the resident was mistakenly given another resident's medication, which included a blood pressure pill and a multivitamin. The error was not documented in the resident's medical record, and there was no record of physician notification or any new orders regarding the error. The Director of Nursing (DON) confirmed the lack of documentation and acknowledged that the Registered Nurse (RN) involved did not record the names of the medications administered in error. The resident's daughter witnessed the error and reported that the nurse initially denied the mistake but later admitted it after reviewing the records. The daughter noted that the incorrect medications given included sodium bicarbonate, colace, norvasc, and simethicone. The facility's policy on medication administration emphasizes the importance of the Five Rights, including the right resident and right drug, which were not adhered to in this case. The deficiency was investigated under a specific complaint number, indicating non-compliance with the facility's medication administration policy.
Failure to Document Medication Error and Notify Physician
Penalty
Summary
The facility failed to document a medication error involving a resident who was cognitively intact and had diagnoses including endocarditis, heart failure, hypertension, vascular dementia, and weakness. The error occurred when a registered nurse administered a blood pressure pill and a multivitamin intended for another resident to this resident. The incident was not documented in the resident's medical record, and there was no record of physician notification or any new orders following the error. The Director of Nursing confirmed the lack of documentation and acknowledged that the nurse involved did not record the names of the medications administered in error. The resident's daughter witnessed the error and reported that the nurse initially denied the mistake but later admitted it after reviewing the records. The daughter noted the medications given in error were sodium bicarbonate, colace, norvasc, and simethicone. Despite the error, the resident's blood pressure was monitored, and no abnormal readings were observed. The facility's policy on medication administration emphasizes the importance of the Five Rights, including verifying the right resident and medication, which was not adhered to in this case.
Failure to Administer Antiparkinsonian Medication Timely
Penalty
Summary
The facility failed to administer an antiparkinsonian medication, Rytary, as ordered by the prescriber, resulting in a significant medication error for Resident #118. The resident, who was admitted with diagnoses including hereditary spastic paraplegia and secondary parkinsonism, was prescribed Rytary to be taken four times daily. However, a review of the medication administration record from August to September 2024 revealed multiple instances where the medication was administered late. Specific instances included doses being given several hours after the scheduled time, and on one occasion, two doses were administered together instead of separately. Interviews conducted with Resident #118 and the Director of Nursing (DON) confirmed the medication administration issues. The resident expressed concerns about the late administration of his medication, which was supposed to be given four times a day. The DON acknowledged the findings and suggested that nurses might not have been signing off on medication administration at the actual time it was given, contrary to the facility's policy. The facility's policy required medications to be administered within 60 minutes of the scheduled time and recorded immediately after administration. This deficiency was investigated under Complaint Number OH00157103.
Failure to Maintain a Clean and Homelike Environment
Penalty
Summary
The facility failed to maintain a clean, comfortable, and homelike environment for two residents, as observed during a survey. Resident #134, who had diagnoses including congestive heart failure, anemia, hypertension, hyperlipidemia, and glaucoma, was noted to have intact cognition according to a Minimum Data Set 3.0 assessment. A grievance was logged by the family of Resident #134, expressing concerns about the cleanliness of the resident's room, specifically mentioning spider webs on the window sill and a black substance under the sink. Photos submitted by the family corroborated these claims, showing spider webs and an exposed sink pipe with a black substance on the wall and under the sink counter. During the survey, the room previously occupied by Resident #134 and currently occupied by Resident #109 was inspected, revealing that the spider webs and black substance were still present, confirming the family's concerns. The Maintenance Director verified these findings, acknowledging that the issues had not been addressed. The facility's policy on routine cleaning, which aligns with CDC recommendations, was reviewed, indicating a failure to adhere to these standards. This deficiency was investigated under Complaint Number OH00155736.
Latest citations in Ohio
A resident with intact cognition receiving Medicare Part A skilled services for metabolic encephalopathy had services discontinued while benefit days remained, but the facility did not issue the required Skilled Nursing Facility Advance Beneficiary Notice (SNF ABN). The Social Services Director later confirmed that no SNF ABN was provided and reported she believed only a Notice of Medicare Non-Coverage (NOMNC) was needed when all skilled services were stopped. This practice conflicted with the facility’s written policy, which required SNF ABNs to be issued when extended care items or services were initiated, reduced, or terminated due to expected non-coverage by Medicare.
Surveyors identified that the facility exceeded the acceptable medication error rate when two residents with type 2 DM received insulin doses that were not administered according to orders or manufacturer instructions. In two separate observations, an LPN administered Novolog and another LPN administered insulin glargine and insulin lispro without priming the insulin pens, and the insulin lispro and Novolog were given after the residents had already consumed a significant portion of their breakfast meals, despite orders for administration before meals. Manufacturer information for both insulin products required priming before each injection to ensure accurate dosing, and facility policy required medications, including insulin, to be administered safely, timely, and in accordance with prescriber orders and specified time frames.
Surveyors found that the facility failed to document tray line food temperatures for multiple meals served from two dining room kitchenettes, despite having a “Trayline Taste & Temperature Log” and a policy requiring food to be stored, prepared, distributed, and served according to professional food safety standards. Review of logs showed repeated missing entries for breakfast, lunch, and dinner services in both the Harrison and McClellan dining areas, and the Senior Director of Culinary Services confirmed that temperatures had not been recorded for those meals, potentially affecting all residents receiving meals from those kitchenettes.
The facility failed to conduct and document required periodic care conferences for two residents, despite multiple comprehensive, quarterly, and significant change MDS assessments and a policy requiring periodic care conferences with resident and/or family participation. One resident with Parkinson’s disease, post-stroke hemiplegia, TIA, DMII, and depression had only two documented care conferences over a year, while another resident with aphasia, cerebrovascular disease, DMII, gait difficulty, coagulation defect, depression, and muscle weakness had no documented care conferences in the past year, aside from a declined invitation to the representative. The UCC confirmed that care conferences were expected to occur quarterly and that no additional documentation existed for either resident.
A resident with Alzheimer's disease and type II DM, who required extensive assistance with ADLs and was receiving scheduled Lantus and sliding-scale Humalog, experienced a severely elevated blood glucose level. The on-call provider was notified and ordered an additional dose of lispro insulin with a directive to recheck the blood glucose after administration. Nursing staff administered the extra insulin but did not document any follow-up blood glucose check, and the DON confirmed that this reevaluation was required by the facility's abnormal blood glucose policy and was not completed or documented.
A resident with Parkinson’s disease, dementia, and hypothyroidism was prescribed levothyroxine once daily along with other medications. A consultant pharmacist’s monthly drug regimen review recommended that levothyroxine be given in the morning on an empty stomach, 30–60 minutes before food, per manufacturer instructions. The medical record contained no documented physician response to this recommendation, and the MAR showed the drug scheduled for morning administration while the resident was observed eating breakfast and receiving the medication at the same time. An LPN confirmed administering levothyroxine during the meal, and the DON verified there was no documentation explaining whether or why the pharmacist’s recommendation was or was not followed, resulting in a failure to act on and document the identified irregularity.
A resident with severe cognitive impairment, multiple comorbidities, documented gait and balance abnormalities, and a high fall risk was care planned and assessed by therapy to require contact guard assistance and use of a gait belt for transfers and ambulation. While being assisted by a CNA from a recliner to the bathroom with a walker, the CNA did not apply a gait belt, even though the resident had a known tendency to lean backward when standing. As the CNA reached to open the bathroom door, the resident lost balance and fell backward, striking the back of the head, and was later found by an LPN without a gait belt in place, contrary to the facility’s gait belt policy and the resident’s assessed needs.
A resident with CKD stage five requiring peritoneal dialysis (PD) was admitted with pre-admission physician orders for three daily PD exchanges and monitoring for peritonitis (fever, abdominal pain, cloudy effluent), but these monitoring orders were not entered into the facility’s physician orders. The care plan referenced PD and general monitoring but did not specifically address peritonitis monitoring. Paper PD flowsheets showed incomplete and inconsistent documentation of exchanges and resident condition, including missing condition/comments for individual treatments and no record of one ordered PD exchange. The PD cycler flowsheet lacked effluent descriptions on multiple days. The PD nurse reported facility staff were expected to monitor effluent and symptoms, and the DON confirmed the absence of specific peritonitis monitoring orders, lack of an order for the PD cycler, and documentation gaps, despite a facility policy requiring ongoing assessment and monitoring for complications before, during, and after dialysis treatments.
A nurse was observed preparing multiple oral medications for a resident with depression, traumatic brain injury, anxiety, and impaired cognition by pushing tablets and capsules from unit-dose cards directly into her ungloved hand and then using her fingers to place them into a medication cup. In a follow-up interview, the RN confirmed this practice and acknowledged that the correct procedure is to dispense medications directly from the card into the cup, contrary to the facility’s medication administration policy requiring adherence to good nursing principles and practices.
A resident with Alzheimer’s disease, diabetes, anxiety, significant ADL dependence, and behavioral symptoms was observed seated in a chair positioned against the nursing station with a locked wheelchair placed directly in front, also against the nursing station, effectively restricting movement. An LPN confirmed both wheelchair wheels were locked and that it should not have been placed there, while a CNA stated she had positioned the wheelchair to prepare for lunch, was unable to complete the transfer, and left it in place, acknowledging this was wrong. This arrangement conflicted with the facility’s restraint policy, which prohibits physical restraints except when alternatives are ineffective for treating a medical symptom and defines restraints as devices adjacent to the body that cannot be easily removed and that restrict freedom of movement or access to the body.
Failure to Issue Required SNF ABN When Discontinuing Medicare Part A Services
Penalty
Summary
The deficiency involves the facility’s failure to issue a Skilled Nursing Facility Advance Beneficiary Notice (SNF ABN) when Medicare Part A services were discontinued for a resident who still had available benefit days. The resident was admitted with a diagnosis of metabolic encephalopathy and had intact cognition per the Minimum Data Set assessment. The facility’s own SNF Beneficiary Notification Review documented that Medicare Part A skilled services began on 02/11/26 and the last covered day was 03/11/26, and that the facility initiated discharge from Medicare Part A services before the resident’s benefit days were exhausted. Despite this, no SNF ABN was provided to the resident or the resident’s representative. During interviews, the Social Services Director stated that the SNF ABN was issued hours prior to the last covered day but, upon reviewing her files, confirmed that no SNF ABN had actually been issued for this resident. She further explained that she believed an SNF ABN was only required if one skilled service remained and that if all skilled services were being discontinued, only the Notice of Medicare Non-Coverage (NOMNC) needed to be issued. The Administrator, however, stated that a resident should always receive both a SNF ABN and a NOMNC when Medicare Part A services are discontinued and benefit days remain. Review of the facility’s written policy dated 03/28/23 showed that the facility was required to issue SNF ABNs for initiation, reduction, or termination of extended care items or services when Medicare payment was not expected, which did not occur in this case.
Plan Of Correction
This Plan of Correction is submitted as required under State and Federal law. This Plan of Correction does not constitute an admission on the part of the Facility that the findings cited are accurate, that the findings constitute a deficiency or that the scope and severity regarding the deficiency cited are correctly applied. Any changes to the Facility's policies and procedures should be inadmissible in any proceeding on that basis. Without admitting or denying the validity or the existence of the alleged noncompliance, the Facility submits this Plan of Correction with the intention that it be inadmissible by any third party in any civil or other action against the facility or any employee, agent, officer, director or shareholder of the Facility. The Facility is utilizing this Plan of Correction as its allegation of substantial compliance as of 05/29/2026 F-0582 Corrective action for resident/s: On 5/14/26 Resident #34 was informed of rights and responsibilities related to Advanced Beneficiary Notice and voiced understanding of information for future reference by administrator. Identification of other residents who may be affected: Any resident receiving skilled services from nursing or therapy services. The Administrator audited all residents who were discharged from skilled services in the past 30 days to ensure they were issued a Notice of Non-Coverage and Advanced Beneficiary Notice on 5/29/26. No non-compliance was noted. Measures for systemic change: On 5/14/2026 Business Office Manager, Director of Rehab, Minimum Data Set nurse, Director of Nursing and Social Services Director were educated on proper procedure of issuing of Notice Of Medicare Non Coverage and Advanced Beneficiary Notice by administrator. All upcoming discharges from skilled services will be reviewed weekly at Utilization Review meeting to ensure notices will be delivered timely. How Corrective Action will be monitored: Administrator or designee to complete audits of all residents being discharged from skilled services to ensure they were issued a Notice of Non-Coverage and Advanced Beneficiary. This audit will be completed weekly x 4 weeks, then monthly x 2 months. Corrective action will be initiated for any noted non-compliance. Audit findings will be reviewed as part of the monthly quality assurance process to determine the need for further monitoring. Date of Compliance 5/29/26
Insulin Administration Errors and Failure to Prime Insulin Pens
Penalty
Summary
The deficiency involves the facility’s failure to maintain a medication error rate below 5%, with surveyors identifying 3 errors out of 28 medication administration opportunities, resulting in a 10.71% error rate. For one resident with type 2 diabetes mellitus and moderate cognitive impairment, the physician’s order directed Novolog insulin 10 units via subcutaneous pen-injector to be given before meals. During an observed medication pass, the LPN administered 10 units of Novolog insulin without priming the pen and did so after the resident had already consumed approximately 50% of the breakfast meal. The LPN later confirmed she did not prime the pen and acknowledged that the insulin was ordered to be administered prior to meals. Manufacturer instructions for the Novolog FlexPen specified that an air shot (priming) must be performed before each injection to ensure proper dosing. Another resident, also diagnosed with type 2 diabetes mellitus and with intact cognition, had orders for insulin glargine 35 units subcutaneously twice daily and insulin lispro 20 units subcutaneously before meals, plus 12 units subcutaneously if blood glucose was between 251 mg/dL and 300 mg/dL. During an observed medication administration, an LPN administered 35 units of insulin glargine and 32 units of insulin lispro without priming the insulin pens and after the resident had consumed approximately 90% of the breakfast meal, despite orders for insulin lispro to be given before meals. The LPN later stated she could not remember if she had primed the pen and acknowledged that the insulin was ordered to be administered prior to meals. Manufacturer information for insulin lispro stated that the pen must be primed before each injection to confirm insulin delivery and remove air, and that failure to prime could result in too much or too little insulin. The DON confirmed the expectation that insulin be administered as ordered, including priming each pen with two units before dialing the prescribed dose, and facility policy required medications, including insulin, to be administered safely, timely, and in accordance with prescriber orders and required time frames.
Plan Of Correction
This Plan of Correction is submitted as required under State and Federal law. This Plan of Correction does not constitute an admission on the part of the Facility that the findings cited are accurate, that the findings constitute a deficiency or that the scope and severity regarding the deficiency cited are correctly applied. Any changes to the Facility's policies and procedures should be inadmissible in any proceeding on that basis. Without admitting or denying the validity or the existence of the alleged noncompliance, the Facility submits this Plan of Correction with the intention that it be inadmissible by any third party in any civil or other action against the facility or any employee, agent, officer, director or shareholder of the Facility. The Facility is utilizing this Plan of Correction as an allegation of substantial compliance as of 5/29/2026. F-0759 Corrective action for resident/s: Residents #21 and #22 were assessed and evaluated by nurse and Director of Nursing 5/14/26. Resident #21 and #22 both denied any adverse effects and none were noted upon assessment by the Director of Nursing on 5/14/2026. Notification made to physician on 5/14/2026. LPN # 2 competency Eval on insulin administration with the Director of Nursing completed 5/14/2026. Identification of other residents who may be affected: Diabetic residents on assignment of LPN #2/station 2 have the potential to be affected and were assessed by the DON/Designee on 5/14/26 and found to be within normal limits. Measures for systemic change: All Nurses were educated by the Director of Nursing on the steps for Insulin administration per competency, diabetes clinical protocol policy, Medication and treatment orders policy, administering medications policy, and Obtaining fingerstick Glucose Level policy On 5/14/2026. How Corrective Action will be monitored: Director of Nursing and Assistant Director of Nursing will complete insulin administration audits on 5 nurses. This audit will be completed weekly x 4 weeks, then monthly x 2 months. Corrective action will be initiated for any noted non-compliance. Audit findings will be reviewed as part of the monthly quality assurance process to determine the need for further monitoring. Date of Compliance: 5/29/2026
Failure to Document Tray Line Food Temperatures in Dining Room Kitchenettes
Penalty
Summary
The deficiency involves the facility’s failure to document tray line food temperatures for meals served from the Harrison and McClellan Dining Room kitchenettes, as required by professional standards for food service safety and the facility’s own policy. Review of the “Trayline Taste & Temperature Log” (revised September 2018) showed missing temperature documentation for multiple meals from the Harrison Dining Room kitchenette, including dinner on 03/30/26 and 03/31/26, lunch and dinner on 04/01/26 and 04/02/26, dinner on 04/07/26, and lunch and dinner on 04/08/26 and 04/10/26. The Senior Director of Culinary Services confirmed during interview that tray line food temperatures were not documented on the log for these meals. Similarly, review of the same log for the McClellan Dining Room kitchenette revealed that tray line food temperatures were not documented for dinner on 04/01/26, breakfast and lunch on 04/02/26, and lunch and dinner on 04/07/26. The Senior Director of Culinary Services also verified these omissions during interview. The facility census at the time was 27 residents, and the governing “Food and Nutrition” policy, approved on 09/07/21, stated that the facility must store, prepare, distribute, and serve food in accordance with professional standards for food service safety.
Plan Of Correction
F812 The facility will continue to ensure food temperatures are completed before meals are served for all residents. To ensure compliance with this standard the following measures have been taken: 1. Immediately 4/15/26 culinary supervisor #224 was re-educated by Dietary Manager to this standard and policy "Food and Nutrition" which includes documentation of food temperatures. 2. All dietary staff have been re-educated to the standard and policy "Food and Nutrition" during the month of April 2026. 3. Audits of food temperature documentation to be completed by Dietary Manager 4 x per week for 4 weeks then weekly for 4 weeks. 4. Administrator to validate audits/compliance and provide additional training as needed. Administrator will present to QAPI committee for ongoing monitoring and further direction.
Failure to Conduct and Document Required Care Conferences
Penalty
Summary
The deficiency involves the facility’s failure to complete and document comprehensive care conferences at required intervals in accordance with care plan regulations and facility policy. For one resident with Parkinson’s disease with dyskinesia, cognitive communication deficit, hemiplegia and hemiparesis following cerebral infarction, transient cerebral ischemic attack, type II diabetes mellitus, and major depressive disorder, the record showed multiple MDS assessments over a one-year period, including annual, quarterly, and significant change assessments. However, only two care conferences were documented during the last 12 months, despite the expectation that care conferences be conducted quarterly with the resident and family when possible. The Unit Care Coordinator confirmed that no additional care conference documentation existed for this resident beyond the notes dated 04/21/25 and 01/02/26. A second resident, with diagnoses including aphasia following cerebrovascular disease, cerebral infarction, type II diabetes mellitus, unsteadiness on feet, difficulty in walking, coagulation defect, depression, and muscle weakness, also had multiple MDS assessments completed over the review period, including quarterly and annual assessments. The record contained a note that a care conference was offered to the resident’s representative, who declined to attend, but there was no documentation of any care conferences for the most recent 12 months. The Unit Care Coordinator confirmed that no other care conference documentation was available for this resident. Facility policy stated that periodic care conferences involving the resident, family, and the interdisciplinary team are part of the care planning process, but the required periodic care conferences and corresponding documentation were not completed for these two residents.
Plan Of Correction
THIS PLAN OF CORRECTION SERVES AS BERKELEY SQUARE'S CREDIBLE ALLEGATION OF SUBSTANTIAL COMPLIANCE AS OF June 1, 2026. Without admitting or denying the validity or existence of the alleged deficiencies, Berkeley Square provides the following Plan of Correction: F657 The facility will continue to document completion of care conferences at the required intervals for all residents, including residents #04 & #15. To ensure compliance with this standard the following measures have be taken: 1. The social service designee and the inter- disciplinary team were re-educated by the administrator to the facility policy "Care Conference" on 4/29/26 and verbalized understanding. 2. Care conferences for resident #04 and resident #15 were conducted on or before 4/29/2026 by the interdisciplinary team. 3. Review of all other residents was conducted by the social service designee to validate and ensure that care conference schedule is up to date with timely care conferences scheduled for them on 4/15/2026. Audits of care conferences to be completed weekly for four weeks and then monthly after that by the social service designee. Documentation of the care conference including any identified concerns in the medical record. Administrator to validate audits/compliance and provide additional training as needed. Administrator will present results of these audits to QAPI committee for ongoing monitoring and further direction.
Failure to Reevaluate Blood Glucose After Treatment for Hyperglycemia
Penalty
Summary
The facility failed to ensure that a resident with diabetes received treatment in accordance with professional standards of practice when nursing staff did not reevaluate the resident's blood glucose after treatment for severe hyperglycemia. The resident, admitted with diagnoses including Alzheimer's disease, type II diabetes mellitus, and depression, had physician orders for Humalog insulin on a sliding scale before meals, Lantus insulin 25 units daily, and lisinopril 5 mg daily. The resident required extensive assistance with activities of daily living, including transfers, toileting hygiene, eating, and bathing. On the evening in question, the resident's blood glucose was documented as 532 mg/dL, and the on-call provider was notified. The provider gave a new order to administer an additional 8 units of lispro (Humalog) and to recheck the blood glucose in 30 minutes. The electronic medication administration record showed that the blood glucose of 532 mg/dL was obtained at 9:00 p.m. and that the additional 8 units of lispro were administered at 9:21 p.m. However, there was no documentation in the resident's chart that the blood glucose was rechecked after the additional insulin was given. In an interview, the DON confirmed there was no evidence of reevaluation and verified that, according to the facility's "Abnormal Blood Glucose Procedure" policy, the resident should have been reevaluated and that the evaluation step should have been included in the progress note documentation.
Plan Of Correction
F684 The facility will continue to ensure all residents, including #03, receive treatment in accordance with professional standards of practice and reevaluated for hyperglycemia. To ensure compliance with this standard the following measures have been taken: 1. The director of nursing assessed resident #03, reviewed documentation and orders and found no ill effects immediately 4/16/26. 2. All licensed nurses were re-educated to facility policy "Blood Glucose Monitoring" by the Director of Nursing/designee in April 2026. 3. Audits of like-residents that require blood sugar checks to be completed by the director of nursing/designee two times a week for 4 weeks and then monthly after that to validate correct follow through when there is abnormally high blood glucose result. The Administrator will bring results of these audits to the QAPI committee for ongoing monitoring and further direction.
Failure to Act on Pharmacist Drug Regimen Recommendation for Thyroid Medication
Penalty
Summary
The deficiency involves the facility’s failure to ensure that pharmacy recommendations from the monthly drug regimen review were acted upon and documented for a resident. The resident was admitted with diagnoses including Parkinson’s disease, dementia, and hypothyroidism, and had current physician orders for levothyroxine 150 mcg once daily, buspirone 50 mg twice daily, and losartan 100 mg once daily. A medication regimen review dated 11/25/2025 included a consultant pharmacist recommendation that levothyroxine be administered consistently in the morning on an empty stomach, at least 30–60 minutes before food, per manufacturer instructions. There was no specific physician response in the medical record to this recommendation, and the facility’s policy stated that consulting pharmacist reviews are sent to nursing and addressed with the primary care provider or consulting specialist for review and follow-up. Review of the resident’s medication administration record for April 2026 showed levothyroxine scheduled for 9:00 a.m. On observation, the resident was seen eating breakfast in the dining area at 8:03 a.m., and an LPN reported administering the levothyroxine 150 mcg to the resident while the resident was in the dining area eating breakfast. The DON confirmed there was no evidence in the resident’s medical record explaining why the consultant pharmacist’s recommendation from 11/25/2025 was or was not acted upon. This lack of documented physician review and action on the pharmacist’s identified irregularity constituted noncompliance with the drug regimen review requirements.
Plan Of Correction
F756 The facility will continue to ensure the pharmacy recommendations from the monthly drug regimen review by a licensed pharmacist are acted upon for all residents, including #08. To ensure compliance with this standard the following measures have been taken: 1. Resident #08 was assessed by the registered nurse and med review completed by 4/28/26. After review of resident's drug regime's, it was discovered that resident #8 had 2 separate medication recommendations on the same form, to be reviewed by two separate practitioners, pharmacy has been instructed and agreed to separate meds on individual forms. 2. Licensed nurses re-educated to facility policy "Drug Regimen Review" by Director of nursing/designee in April 2026 and no later than 5/8/26. Licensed nurses are responsible for ensuring the reviews and recommendations are given to the physician for timely review. 3. Review of all other current residents Drug Regimen orders completed by Director of nursing/designee on 4/16/26 to ensure recommendations were followed up on/reviewed by the physician and address concerns if needed. 4. Audit of drug regime recommendations, pharmacy recommendations, and physician follow up to be completed weekly for four weeks by the Director of nursing/designee. Administrator will present results of these audits to the QAPI committee for ongoing monitoring and further direction.
Failure to Use Required Gait Belt During Ambulation Resulting in Resident Fall
Penalty
Summary
The deficiency involves the facility’s failure to ensure that a required gait belt was used while assisting a high fall‑risk resident with ambulation, resulting in a fall with head injury. The resident had multiple diagnoses including metabolic encephalopathy, hypertension, osteoarthritis, muscle weakness, gait and mobility abnormalities, major depressive disorder, anxiety, and visual hallucinations. Admission and subsequent MDS and fall risk assessments documented that the resident was severely cognitively impaired, required moderate to maximal assistance with transfers and ambulation, could not independently come to a standing position, exhibited loss of balance while standing, used an assistive device, and had decreased muscle coordination. The resident had a history of falls prior to admission and was assessed as being at high, later moderate, risk for falls. The resident’s fall care plan identified her as at risk for falls and included interventions such as providing maximum to moderate assistance with transfers and walking short distances, use of a walker and wheelchair, and following the facility’s fall protocol. Therapy notes and care conference documentation indicated that the resident leaned backwards when standing, required contact guard to minimal assistance for bed mobility and transfers, and needed constant verbal cueing for safe sequencing during toilet transfers. The physical therapist confirmed that the resident was to use a gait belt with staff when ambulating, and the DON verified that therapy had assessed the resident as requiring contact guard assistance and a gait belt for ambulation and transfers. On the day of the incident, a CNA was assisting the resident from her recliner to the bathroom using a walker. The CNA walked beside the resident, providing guidance and support, and reported having a hand on the resident while assisting her. As they approached the bathroom door, the CNA reached for the doorknob to open it, and at that moment the resident began to lose her balance and fell backwards to the floor, striking the back of her head. The nurse who responded found the resident on her back at the foot of the bed with her feet near the bathroom, noted a red raised area on the back of the head, and documented that the resident was not wearing a gait belt and that the gait belt was on the dresser. In the facility’s investigative summary and in interviews, the CNA acknowledged that she did not have a gait belt on the resident while ambulating her, despite the resident’s assessed need for hands‑on assistance and gait belt use per facility policy and the resident’s care and therapy plans.
Failure to Implement PD Orders and Monitor Resident Receiving Peritoneal Dialysis
Penalty
Summary
The deficiency involves the facility’s failure to implement pre-admission physician orders for peritoneal dialysis (PD) and to provide ongoing monitoring for a resident with chronic kidney disease (CKD) stage five who required PD. Pre-admission orders dated 11/14/25 specified three daily PD exchanges at 6:00 A.M., 2:00 P.M., and 10:00 P.M., and directed staff to monitor for signs and symptoms of peritonitis, including fever, abdominal pain, and cloudy effluent. These monitoring orders were not entered into the facility’s physician orders. The resident’s care plan noted the need for PD and included general monitoring interventions (labs, signs of bleeding, bacteremia, septic shock, and significant vital sign changes), but did not specifically address the ordered monitoring for peritonitis. Review of PD documentation showed incomplete and inconsistent charting of treatments and resident condition. The paper peritoneal flowsheet had columns for time of PD and condition/comments, including instructions to call the nurse immediately for cloudy fluid, abdominal pain, or fever. However, the first entry on 11/15/26 at 2:00 P.M. only noted that the PD nurse completed the exchange, and the 10:00 P.M. entry that day had no condition/comment documentation. Subsequent days (11/16/25, 11/17/25, and 11/18/25) contained only one condition/comment entry per day rather than for each exchange, and there was no documentation that the 6:00 A.M. PD on 11/18/25 was completed. The PD cycler flowsheet starting 11/19/25 lacked any description of the effluent on multiple days. The PD nurse from the dialysis company stated facility staff were expected to monitor effluent for cloudiness and assess for abdominal pain and fever, and the DON confirmed there was no electronic physician order for peritonitis monitoring or for use of the PD cycler, that the paper charting did not allow for effluent description or symptom documentation for each treatment, and that PD was not documented at one ordered time. The facility’s dialysis policy required ongoing assessment and monitoring for complications before, during, and after treatments, which was not reflected in the documentation for this resident.
Improper Infection Control During Medication Administration
Penalty
Summary
Surveyors identified a deficiency in infection prevention and control related to medication administration for Resident #29. The resident was admitted on 02/28/14 with diagnoses including depression, traumatic brain injury, and anxiety, and had impaired cognition per a quarterly MDS assessment. During an observation on 03/25/26 at 6:58 A.M., RN #281 prepared the resident’s medications by removing an Amoxicillin-Pot Clavulanate tablet from the medication card and pushing it directly into her ungloved hand, then using her fingers to place the pill into a medication cup. The same process was observed for multiple other medications, including Escitalopram Oxalate, Furosemide, Sennosides, Lyrica, and Vitamin D, each being pushed from the card into the RN’s ungloved hand and then transferred by her fingers into the medication cup before administration to Resident #29. In a subsequent interview at 7:27 A.M. the same day, RN #281 confirmed she had placed each medication into her ungloved hands prior to administration and acknowledged that the proper procedure was to push the pills directly from the card into the medication cup. Review of the facility’s “Medication Administration – General guidelines” policy, revised 10/08/25, stated that medications are to be administered in accordance with good nursing principles and practices. This practice failure was cited as a deficiency under Complaint Number 2681777.
Improper Use of Wheelchair as a Physical Restraint
Penalty
Summary
Surveyors identified a deficiency related to the facility’s failure to ensure a resident was free from physical restraints. Resident #7, admitted with diagnoses including Alzheimer’s disease, diabetes mellitus, and anxiety disorder, was documented on a recent MDS as rarely understood and dependent for ADLs except eating. The resident ambulated independently on the unit without an assistive device and had documented verbal and other behaviors occurring one to three days during the look-back period. The care plan noted the resident had potential to be physically aggressive, chase staff, throw objects, and be combative with care, with interventions such as offering choices, administering medications as ordered, and intervening early when agitation occurred. During an observation and interview, Resident #7 was found sitting in a chair with the right arm of the chair positioned against the nursing station and a wheelchair placed directly in front of him. The left arm of the wheelchair was also against the nursing station, and both wheelchair wheels were locked, creating a barrier that appeared to restrain the resident, who was sleeping with his knees touching the locked wheelchair. An LPN confirmed both wheelchair wheels were locked and that the wheelchair should not have been placed in front of the resident. A CNA reported she had placed the wheelchair there in preparation to get the resident up for lunch, was unable to transfer him, and left the wheelchair in that position, acknowledging it was wrong to keep it there. The facility’s physical restraint policy stated that physical restraints are not used except when alternatives are not appropriate or effective for treating a medical symptom and defined physical restraints as any device attached or adjacent to the body that the individual cannot easily remove and that restricts freedom of movement or access to the body.
Trusted data from CMS and state health departments
Every citation, penalty and Plan of Correction is sourced from public CMS records (latest release May 27, 2026) and official state health department websites — never guesswork.
Trusted by long-term care providers and associations.
