Wood Glen Alzheimer's Community
Inspection history, citations, penalties and survey trends for this long-term care facility in Dayton, Ohio.
- Location
- 3800 Summit Glen Drive, Dayton, Ohio 45449
- CMS Provider Number
- 365722
- Inspections on file
- 37
- Latest survey
- March 6, 2025
- Citations (last 12 mo.)
- 0
Citation history
Health deficiencies cited at Wood Glen Alzheimer's Community during CMS and state inspections, most recent first.
The facility failed to report injuries of unknown origin in a timely manner for two residents. One resident, with cognitive impairment and multiple diagnoses, experienced a fall and later discovered a femoral fracture, which was not investigated or reported. Another resident, also cognitively impaired, had a finger fracture with an incomplete investigation and no self-reported incident. The facility did not follow its policy on timely reporting of such incidents.
The facility failed to investigate injuries of unknown origin for two residents. One resident, with cognitive impairment and multiple diagnoses, experienced a fall and later a femoral fracture, but no investigation was conducted. Another resident, also cognitively impaired, had a finger fracture with an incomplete investigation and no self-reported incident. The facility did not adhere to its policy on timely reporting of such incidents.
The facility failed to maintain complete and accurate medical records for two residents. One resident's fall was not properly documented, with LPNs denying knowledge of the incident or related assessments. Another resident's behavioral incidents and resulting injury were not recorded, with only x-ray results noted. These deficiencies highlight significant gaps in documentation practices.
A resident with dementia and severe cognitive impairment eloped from an LTC facility due to inadequate supervision, despite being assessed as at risk and ordered for 1:1 supervision. The resident was found outside the facility without injuries. Observations later revealed continued lapses in supervision, and staff interviews confirmed the deficiency.
A resident with severe cognitive impairment and multiple medical conditions did not receive enteral feeding as ordered. Despite a physician's order for continuous feeding, the feeding was temporarily stopped due to a residual volume check, which was below the threshold for holding feeding. The resident showed no signs of distress, but the feeding was not resumed as required, leading to a deficiency finding.
A facility failed to follow infection control policies for a resident receiving enteral feedings. The resident, with severe cognitive impairment and multiple medical conditions, required Enhanced Barrier Precautions (EBP) during tube feeding. An RN administered the feeding without donning a gown, despite EBP signage, and confirmed the absence of PPE in the room. The DON acknowledged the need for PPE availability and adherence to EBP during such procedures.
The facility failed to ensure medications were properly labeled with a date after being opened, discarded after their expiration date, and not left unattended at residents' bedside. These deficiencies affected multiple residents and were confirmed by staff during observations.
The facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food service safety. Observations included unlabeled and undated food items, dirty kitchen floors, unknown substances on walls and ceilings, rusted equipment, and dead bugs in light fixtures. These deficiencies had the potential to affect 133 residents.
The facility failed to ensure care conferences were completed for three residents, as required by their policy. One resident missed conferences due to scheduling conflicts with dialysis, another had not received any care conferences since July, and a third had no documented care conferences since admission. This was confirmed by both the residents and the Licensed Social Worker.
A facility failed to provide necessary ancillary services for a resident with hearing impairments. Despite being admitted with hearing aids, the resident was observed without them, and no referral services were completed. Interviews revealed a lack of awareness and communication among staff regarding the resident's needs.
The facility failed to ensure adequate indications for antipsychotic medications for three residents, despite severe cognitive impairments and known risks. The care plans did not address contraindications or explore non-pharmacological interventions.
A resident's iPad was confiscated due to the discovery of child pornography, but the facility failed to document the incident in the medical record. The Licensed Social Worker and Administrator confirmed the iPad was taken and the police were called, but no documentation was made, violating facility policy.
A facility failed to ensure a resident's mattress fit properly on the bed frame, resulting in a 12-inch gap between the headboard and the mattress. The resident, who had multiple diagnoses and was dependent on staff for all ADLs, was at risk due to this safety issue. The facility's policy on mattress inspection and bed safety was not followed.
The facility failed to ensure falls were reviewed and discussed by the IDT and a root cause analysis was determined for two residents. Both residents experienced falls, and there was no documented evidence of IDT meetings to review and discuss the incidents, as confirmed by an LPN.
A resident's cell phone was reported missing during a hospital transfer, and despite a VA representative's promise to replace it, the facility failed to follow up. The resident, who was moderately cognitively impaired, did not receive the replacement, and the Licensed Social Worker admitted to not contacting the VA representative.
Failure to Timely Report Injuries of Unknown Origin
Penalty
Summary
The facility failed to report injuries of unknown origin in a timely manner, affecting two residents. Resident #17, who was cognitively impaired and had multiple diagnoses including dementia and violent behavior, experienced a fall on 01/13/25. Initially, no injuries were noted, and the resident refused vital signs. However, on 01/16/25, the resident complained of pain in the right lower extremity, leading to an x-ray that revealed a proximal femoral fracture. Despite the fracture being discovered, no investigation was completed to determine the cause, and the injury was not reported as an injury of unknown origin. Resident #30, also cognitively impaired with diagnoses including Alzheimer's disease and vascular dementia, was found to have a fracture of the distal phalanx of the left fourth digit on 02/27/25. The resident reported an incident involving another resident, but there was no documentation of behavioral outbursts or injuries prior to the x-ray. The investigation into the fracture was incomplete, and the injury was not reported as a self-reported incident. Interviews with facility staff revealed a lack of clarity and communication regarding the investigation and reporting process. The facility's policy on abuse, neglect, and misappropriation requires timely reporting of incidents, bruises, and injuries of unknown origin. However, the facility did not adhere to this policy, as evidenced by the lack of timely reporting and investigation of the injuries sustained by Residents #17 and #30. This deficiency was investigated under Complaint Number OH00162164.
Failure to Investigate Injuries of Unknown Origin
Penalty
Summary
The facility failed to thoroughly investigate injuries of unknown origin in a timely manner, affecting two residents. Resident #17, who was cognitively impaired and had multiple diagnoses including dementia and violent behavior, experienced a fall on 01/13/25. Initially, no injuries were noted, and the resident refused vital sign checks. However, on 01/16/25, the resident complained of pain in the right lower extremity, leading to an x-ray that revealed a proximal femoral fracture. Despite this, no investigation was conducted to determine the cause of the fracture, and the Director of Nursing (DON) acknowledged that an investigation should have been completed. Resident #30, also cognitively impaired with diagnoses including vascular dementia and Alzheimer's disease, was found to have a fracture of the distal phalanx of the left fourth digit on 02/27/25. The resident reported an incident involving another resident, but there was no documentation of behavioral outbursts or injuries prior to the x-ray. The investigation into the fracture was incomplete, with the DON and Regional Director of Operations (RDO) unsure of the details and involvement of other residents. The facility failed to report the injury as a self-reported incident, as confirmed by the Regional Risk Manager. The facility's policy on abuse, neglect, and misappropriation requires timely and accurate reporting of incidents, including injuries of unknown origin. However, the facility did not adhere to this policy, as evidenced by the lack of timely investigations and reporting for both residents' injuries. This deficiency was investigated under Complaint Number OH00162164.
Incomplete and Inaccurate Medical Records
Penalty
Summary
The facility failed to ensure the completeness and accuracy of medical records for two residents, leading to deficiencies in documentation. For one resident, the medical record indicated a fall occurred, but there was no documentation of neurological checks being completed following the incident. A paper document titled 'Neurological Assessment' was found, but the LPNs whose signatures appeared on it denied completing or even being aware of the document or the fall incident. This discrepancy highlights a significant gap in the facility's documentation practices, as the medical record did not accurately reflect the resident's condition or the care provided. For another resident, the medical record lacked documentation of behavioral incidents and subsequent injuries. Although the resident was found to have a fracture, there was no record of behavioral outbursts or any staff intervention following the incident. The only documentation in the medical record was the x-ray results, with no details about the injury or any change in the resident's condition. This lack of documentation contravenes the facility's policy on maintaining accurate and timely medical records, as it failed to provide a complete representation of the resident's experience and care.
Failure to Prevent Resident Elopement Due to Inadequate Supervision
Penalty
Summary
The facility failed to provide adequate supervision and interventions for a resident assessed as being at risk for elopement. The resident, who had a history of dementia and other medical conditions, was admitted to the facility and identified as having a severe cognitive impairment. Despite being assessed as at risk for elopement, the resident was not provided with the required 1:1 supervision, which was ordered to prevent elopement. On the morning of the incident, the resident was last seen by staff at 7:20 A.M. and was discovered missing at 8:00 A.M. An elopement code was called, and the resident was found near a local park at 8:19 A.M. The resident was returned to the facility without injuries. Observations made on a subsequent date revealed that the resident was again left unsupervised in their room, contrary to the 1:1 supervision order. Interviews with staff, including the Administrator, Director of Nursing, and other personnel, confirmed the lapse in supervision and the resident's elopement. The facility conducted an investigation but was unable to determine how the resident managed to leave the premises. The facility's policy on elopement prevention and management was reviewed, highlighting the need for proper supervision and intervention to prevent such incidents.
Failure to Administer Enteral Feeding as Ordered
Penalty
Summary
The facility failed to administer enteral feeding as ordered for Resident #137, who was admitted with medical diagnoses including dementia, chronic kidney disease stage III, hypertensive heart disease, and dysphagia. The resident had severe cognitive impairment and required substantial staff assistance for daily activities. The medical record indicated that the resident received more than 51% of total calories through tube feeding. A physician's order specified the administration of Jevity 1.5 at 55 ml per hour for 22 hours via pump, with specific instructions to check for residuals and hold feeding if residuals were 100 cc or more. On the day of the incident, the tube feeding was placed on temporary hold at 10:15 A.M. due to a residual volume of approximately 50 ml, which was below the threshold to hold feeding. Despite the resident showing no signs of distress, the feeding was not resumed as per the physician's order. Observations later in the day confirmed that the tube feeding pump was turned off, and the resident was not receiving any feeding. The facility's policy on enteral feeding emphasized continuous delivery using a programmable pump, with interruptions only as ordered by a physician. This deficiency was identified during a complaint investigation.
Infection Control Deficiency in Enteral Feeding
Penalty
Summary
The facility failed to adhere to its infection control policies, specifically regarding Enhanced Barrier Precautions (EBP) for a resident receiving enteral feedings. Resident #30, who was severely cognitively impaired and dependent on staff for various activities, had medical diagnoses including right-sided hemiplegia, Alzheimer's disease, and dysphagia. The resident was on a nothing by mouth (NPO) status and received nutrition through a gastrointestinal tube (g-tube) with specific orders for Nepro 1.8 and water flushes. The facility's policy required the use of personal protective equipment (PPE) such as gowns and gloves during high-contact activities, including tube feeding administration, to prevent the transmission of multi-drug resistant organisms. During an observation, Registered Nurse (RN) #275 administered a bolus tube feeding to Resident #30 without donning a gown, despite the presence of an EBP sign on the resident's door. The RN confirmed the absence of PPE in the resident's room and acknowledged not wearing a gown during the procedure. The Director of Nursing (DON) also confirmed that staff should follow EBP during tube feeding administration and that PPE should be available in rooms of residents with EBP orders. This deficiency was identified during a complaint investigation, highlighting a lapse in the facility's infection control practices.
Medication Labeling, Expiration, and Administration Deficiencies
Penalty
Summary
The facility failed to ensure medications were properly labeled with a date after being opened, affecting one resident observed for medication administration. Specifically, Resident #58's Humalog KwikPen and Insulin Glargine pen were found opened but not labeled with an open date. This was confirmed by RN #54 during an observation of the Heatherwood medication cart. Additionally, the facility failed to discard medications after their expiration date, affecting six residents who received medication from the Magnolia medication cart. A bottle of Geri-knot 8.6 mg with an expiration date of March 2024 was found, and RN #45 confirmed it was expired. The affected residents had orders to receive this medication, which was not properly managed according to the facility's policy on medication storage and expiration checks. Furthermore, the facility failed to ensure medications were not left unattended at residents' bedside, affecting one resident observed. Resident #01, who was cognitively intact, was found with two white pills inside a clear plastic container on their bedside table. LPN #23 confirmed she left the medication cup with two potassium pills at the resident's bedside and acknowledged that she was supposed to watch the resident take the medication. This incident highlights a lapse in following the facility's policy on the safe and secure storage of medications, which mandates that medications should be administered directly and not left unattended.
Failure to Maintain Food Safety Standards
Penalty
Summary
The facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food service safety. During an initial kitchen tour, it was observed that the reach-in refrigerator contained multiple food items, including bowls of salads, cups of pears, and pureed fruit, all without labels or dates. Additionally, a large fast-food container was found with no label or date. The kitchen floor under the dishwasher was dirty with dried food particles, and there was an unknown black substance on the walls and under the appliances. The ceiling had an unknown brown substance splattered on it, and a long metal table in front of the dishwasher had a rusted bottom shelf with chunks of metal missing. The trash receptacles had dried food debris and a dried, splattered substance running down the sides, and the light fixtures above the dishwasher contained dead bugs. The Registered Dietician confirmed these findings during the tour. The facility's policies, dated 09/2017, stated that all food preparation, service, and dining areas should be maintained in a clean and sanitary condition, and that all foods should be stored wrapped or in covered containers, labeled and dated to prevent cross-contamination. The facility's failure to adhere to these policies had the potential to affect 133 residents who received meals from the facility kitchen, with one resident identified as not receiving food from the kitchen.
Failure to Conduct Required Care Conferences
Penalty
Summary
The facility failed to ensure care conferences were completed for three residents, as required by their policy. Resident #01, who was cognitively intact and had multiple diagnoses including heart failure and dementia, did not have care conferences every three months. The facility scheduled care conferences on days when Resident #01 was out for dialysis, resulting in missed conferences. This was confirmed by both the resident and the Licensed Social Worker (LSW) #123. Resident #15, who was moderately cognitively impaired and had diagnoses including coronary artery disease and Alzheimer's disease, had not received any care conferences since their last one dated 07/17/23. This was confirmed by both the resident and LSW #123. Additionally, Resident #91, who had impaired cognition and multiple diagnoses including dementia and PTSD, had no documented care conferences since admission. LSW #123 confirmed that a care conference should have been scheduled in December 2023 but was not. The facility's policy required care conferences to be scheduled and documented, which was not adhered to in these cases.
Failure to Provide Ancillary Services for Hearing Impairment
Penalty
Summary
The facility failed to ensure ancillary services were provided to residents with hearing and visual impairments, specifically affecting Resident #116. The resident, who had diagnoses including parkinsonism, dementia, generalized anxiety disorder, and hypertension, was admitted with hearing aids and batteries. Despite this, observations during the annual survey revealed that the resident was not wearing hearing aids and did not have them present in his room. The care plan for the resident included interventions for sensorineural bilateral hearing loss, but these were not followed through as no ancillary referral services had been completed for the resident. Interviews with the Administrator and Social Services Director (SSD) revealed a lack of awareness regarding the resident's hearing aids. The Administrator was initially unaware that the resident had hearing aids, and the SSD confirmed that no ancillary referral services had been completed. This indicates a communication breakdown and failure to implement the care plan effectively, leading to the resident not receiving the necessary hearing services.
Inadequate Indications for Antipsychotic Medications
Penalty
Summary
The facility failed to ensure residents' antipsychotic medications were given with adequate indications for use, affecting three residents. Resident #104 was prescribed Seroquel for agitation and Alzheimer's Disease despite severe cognitive impairment and the medication's black box warning against use in elderly patients with dementia-related psychosis. The Director of Nursing (DON) confirmed the prescription and the associated risks, but the care plan only indicated the provision of the medication per physician's orders without addressing the contraindications or exploring non-pharmacological interventions. Similarly, Resident #61, who had severe cognitive impairment and multiple diagnoses including dementia and depression, was prescribed Trazodone for mood and mental health. The care plan for this resident also failed to address the necessity of the medication or consider alternative interventions. Resident #71, with diagnoses including Alzheimer's disease and dementia, was prescribed Seroquel for dementia behaviors, despite the known risks. The DON confirmed awareness of the black box warning but did not ensure the medication was used appropriately. The facility's failure to implement gradual dose reductions and non-pharmacological interventions before continuing psychotropic medications was evident in these cases.
Failure to Document Confiscation of Resident's iPad
Penalty
Summary
The facility failed to ensure proper documentation in the medical record for a resident who had their personal iPad confiscated. The resident, who was admitted with multiple medical diagnoses including Alzheimer's disease and dementia, reported that his iPad was taken away three days after admission without any explanation. The Licensed Social Worker (LSW) confirmed that the iPad was removed because it contained passwords for different accounts and, upon attempting to shut it off, discovered a gallery of child pornography. The LSW reported this to the Administrator, who then called the police. However, there was no documentation in the resident's medical record regarding the confiscation of the iPad or the subsequent police involvement. The Administrator confirmed that no documentation was entered into the resident's electronic record because the matter was handed over to the police. This lack of documentation is a violation of the facility's policy, which requires social service workers to document progress notes and pertinent information affecting the resident's health and well-being. The failure to document the incident in the medical record was identified during a review of the resident's progress notes and interviews with the staff and the resident.
Improper Mattress Fit on Bed Frame
Penalty
Summary
The facility failed to ensure a resident's mattress fit properly on the bed frame, affecting one resident out of the 134 residents in the facility. The resident, who had multiple diagnoses including dementia, epilepsy, and congestive heart failure, was dependent on staff for all activities of daily living and had impaired cognition. A bed safety evaluation revealed the resident had poor bed mobility and difficulty sitting on the side of the bed, and was unable to transfer independently or use a call light for help. An observation of the resident's bed showed a gap of approximately 12 inches between the headboard and the mattress, which was confirmed by a staff member as a safety risk. The facility's policy on the use of support surfaces indicated that mattresses should be inspected regularly to identify areas of possible entrapment and ensure they fit the bed frame properly. However, the policy was not followed in this case, as evidenced by the large gap observed. The Regional Clinical Nurse confirmed that such a gap could pose a safety risk and potentially harm the resident. The facility's failure to adhere to its own policy on mattress inspection and bed safety led to this deficiency.
Failure to Conduct IDT Meetings for Fall Incidents
Penalty
Summary
The facility failed to ensure falls were reviewed and discussed by the Interdisciplinary Team (IDT) and a root cause analysis was determined for two residents. Resident #20, who had diagnoses including non-traumatic brain disorder, renal insufficiency, diabetes, dementia, and psychotic disorder, experienced falls on two separate occasions. On 12/12/23, Resident #20 was found on the floor next to his bed with minor injuries, and on 02/19/24, the resident fell again and was sent to the hospital. In both instances, there was no documented evidence of an IDT meeting to review and discuss the falls or to determine a root cause analysis. This was confirmed by an interview with an LPN on 04/11/23. Similarly, Resident #01, who had medical diagnoses including cardiorespiratory conditions, heart failure, peripheral vascular disease, renal insufficiency, and non-Alzheimer's dementia, fell while ambulating in the hall using her walker on 01/20/24. The resident hit her head on the floor, and although neuro checks were initiated and were negative, there was no documented evidence of an IDT meeting to review and discuss the fall or to determine a root cause analysis. This was also confirmed by the same LPN during the interview. The facility's policy on Fall Prevention and Management mandates that the IDT should review all falls at the next daily clinical meeting, discuss potential causes, and document the discussion, which was not followed in these cases.
Failure to Follow Up on Missing Cell Phone
Penalty
Summary
The facility failed to follow up on a missing cell phone reported by Resident #15, who was moderately cognitively impaired and had multiple diagnoses including coronary artery disease, heart failure, peripheral vascular disease, renal insufficiency, diabetes, Alzheimer's disease, and dementia. The resident's cell phone was lost during a transition to the hospital from another facility, and a VA representative had indicated that the phone would be replaced. However, there was no documentation in the progress notes from 07/17/23 through 04/11/24 regarding the lost cell phone or any follow-up communication with the VA representative. An interview with the resident on 04/09/24 revealed that the cell phone had not been replaced as promised. The Licensed Social Worker (LSW) acknowledged knowing about the missing cell phone but admitted to not following up with the VA representative. The facility's policy on Social Services emphasizes the importance of meeting the social and psychological needs of residents, including communication with outside agencies. This deficiency was investigated under Complaint Number OH00152479.
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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