Woods Edge Rehab And Nursing
Inspection history, citations, penalties and survey trends for this long-term care facility in Cincinnati, Ohio.
- Location
- 1171 Towne Street, Cincinnati, Ohio 45216
- CMS Provider Number
- 366209
- Inspections on file
- 27
- Latest survey
- December 1, 2025
- Citations (last 12 mo.)
- 4 (1 serious)
Citation history
Health deficiencies cited at Woods Edge Rehab And Nursing during CMS and state inspections, most recent first.
The facility failed to thoroughly investigate, document, and assess falls for two residents with cognitive impairments and multiple diagnoses. In both cases, required post-fall evaluations and immediate interventions were not completed, and care plan interventions such as accessible call lights and non-skid strips were not maintained. The DON and an LPN confirmed lapses in documentation and adherence to facility protocols.
Staff failed to follow infection control protocols during wound care for a resident with a stage IV pressure ulcer under Enhanced Barrier Precautions. An LPN exited and re-entered the room wearing the same gown and gloves, and changed gloves multiple times without performing hand hygiene, contrary to facility policy. The DON confirmed these actions did not meet required infection control standards.
A resident with severe cognitive impairment and a history of exit-seeking behaviors made explicit threats to jump out a window, which were reported to staff including an LPN. Despite these warnings, the LPN did not assess or supervise the resident, and other staff either dismissed or failed to escalate the threats. The resident subsequently broke a second-story window and jumped out, sustaining a serious injury.
Staff failed to follow infection control protocols during wound care for a resident with a stage IV pressure ulcer and multiple comorbidities. LPNs and a CNA did not perform hand hygiene between glove changes, exited and re-entered the room wearing the same PPE, and did not remove gowns and gloves before leaving the room, contrary to facility policy and EBP requirements. The DON confirmed these actions were not consistent with established infection control procedures.
A resident with severe cognitive impairment and chronic pain received morphine sulfate solution as ordered, but the administration of this narcotic was not consistently documented on the medication administration record (MAR). Controlled drug records showed doses were signed out on multiple occasions, but corresponding entries were missing from the MAR, as confirmed by the DON. Facility policy requires immediate documentation of medication administration, which was not followed in this case.
The facility failed to label and date prepared foods in the refrigerator, affecting all residents receiving food from the kitchen. During a kitchen tour, it was found that trays of sandwiches, bowls of mandarin oranges, and cups of juice were not labeled or dated. The Kitchen Supervisor confirmed this oversight, which was against the facility's Dietary/Food Handling policy.
The facility failed to serve specialized diets as planned by the RD, affecting 15 residents. Residents with orders for puree and mechanical soft food textures did not receive the appropriate vegetables as per the diet spreadsheet. Observations revealed that none of the affected residents received the correct textured vegetables, and interviews confirmed that the diet spreadsheet was not followed during meal preparation.
A resident with cognitive impairments and a history of elopement risk managed to leave a secured unit unsupervised. The resident was last seen in the smoking room by an STNA, who lost sight of him while lighting a cigarette. The resident exited through a stairwell and was found by police outside the facility. He was returned without injury after 40 minutes.
The facility did not follow posted menus and failed to notify residents of meal changes, affecting 88 residents. Meals served on two consecutive days did not match the posted menus due to a lack of preparation and running out of certain food items. The Dietary Supervisor confirmed the discrepancies and acknowledged that residents were not informed of the changes.
The facility did not follow meal recipes, serving a meal that was visually unappealing and inconsistent with the menu. Residents expressed dissatisfaction, and the Dietary Supervisor confirmed the discrepancy, affecting nearly all residents.
The facility failed to ensure proper use of hairnets by dietary staff, affecting food safety for 88 residents. A dietary aide and a cook were observed with their braids not fully covered by hairnets while preparing and serving meals, contrary to facility policy.
A facility failed to ensure residents were fed in a dignified manner, as observed when an STNA stood behind a resident in a geri-chair, reaching around to feed them without facing them. The STNA cited a cart blocking her way as the reason for standing. This incident was noted during a complaint investigation, highlighting a breach in the facility's policy on resident dignity.
A resident with a physician's order for compression stockings to treat edema was not provided with them, despite asking. The LPN confirmed the order but did not apply the stockings, citing occasional refusals by the resident, yet failed to document any refusals. The resident was observed multiple times without the stockings, resulting in leg swelling.
A resident with multiple diagnoses and moderately impaired cognition was not seen by a physician as required due to the resident's refusal to participate in medical visits. The facility's policy required physician visits every 30 days for the first 90 days after admission, but the resident was only seen by a physician once, a PA once, and an NP twice, leading to a deficiency.
Failure to Investigate and Document Resident Falls and Implement Fall Prevention Measures
Penalty
Summary
The facility failed to ensure that falls experienced by residents were thoroughly investigated, properly documented, and that appropriate post-fall assessments and interventions were implemented. In one instance, a resident with dementia, delusional disorder, and Alzheimer's disease experienced an unwitnessed fall and was found on the floor with no documented fall interventions or post-fall evaluation. On a separate occasion, the same resident had another fall, was found with injuries, and was sent to the emergency room, but there was no documentation of a thorough investigation, fall risk assessment, or post-fall evaluation. The Director of Nursing (DON) and the responsible LPN confirmed that required documentation and assessments were not completed, and immediate interventions were not put in place. Additionally, during observation, the resident's call light was not within reach and non-skid strips were missing, contrary to care plan interventions. Another resident, diagnosed with paranoid schizophrenia, dementia, and other conditions, was also found to have experienced an unwitnessed fall. The only immediate intervention documented was a reminder to use the call light, and there was no evidence of a post-fall evaluation being completed. The care plan for this resident included fall risk assessments and environmental safety measures, but these were not followed after the incident. The DON confirmed that the post-fall evaluation was not completed for this resident. Review of the facility's policy indicated that all falls or suspected falls should be considered incidents requiring thorough investigation, documentation, and follow-up. Staff were expected to document specific details in the medical record and initiate accident/incident reports promptly. However, in both cases, the facility did not adhere to its own protocols, resulting in incomplete documentation, lack of timely assessments, and failure to implement or maintain required fall prevention interventions.
Failure to Follow Infection Control Protocols During Wound Care
Penalty
Summary
During a wound care observation for a resident with multiple diagnoses including hemiparesis, Alzheimer's dementia, peripheral vascular disease, and a stage IV pressure ulcer, staff failed to adhere to proper infection control techniques as outlined in facility policy. The resident was under Enhanced Barrier Precautions (EBP) due to the presence of a wound. Staff involved in the dressing change initially performed hand hygiene and donned gowns and gloves. However, during the procedure, one LPN exited the resident's room wearing the same isolation gown to retrieve wound cleanser and re-entered without changing the gown. Additionally, gloves were changed multiple times without performing hand hygiene between glove changes, contrary to policy requirements. Further, after completing the wound care, the LPN exited and re-entered the room with the same gown and gloves to date and initial the dressing, again failing to remove PPE as required. Interviews with the LPN and the Director of Nursing confirmed that these actions did not comply with facility policies for EBP and aseptic dressing changes, which require removal of gowns and gloves before exiting a resident's room and performing hand hygiene between glove changes. The facility's policies were reviewed and confirmed to include these steps, but staff did not follow them during the observed wound care procedure.
Failure to Supervise Resident with Exit-Seeking Behaviors Resulting in Elopement and Injury
Penalty
Summary
A resident with a history of traumatic brain injury, schizoaffective disorder, severe cognitive impairment, and documented exit-seeking behaviors was admitted to the facility with recommendations for one-to-one staff support as needed. The resident's care plan included interventions for high elopement risk, such as secured unit placement, observation for changes in mental status, and one-to-one supervision when necessary. Despite these interventions, the resident continued to display delusions, disorganized thinking, mood swings, and paranoia, and had previously made statements about leaving the facility and jumping out of a window. On the day of the incident, multiple staff members observed and reported concerning behaviors by the resident, including entering another resident's room inappropriately, attempting to take excessive food, and making explicit threats to jump out of a window. These threats were communicated to various staff, including a CNA, an activity assistant, and an LPN. However, the LPN did not assess or remain with the resident after being informed of the threats, instead allowing the resident to return to his room alone. Other staff members either dismissed the seriousness of the threats or failed to communicate them to the appropriate personnel. At the time of the incident, the LPN was reported by some staff to be sleeping at the nursing station, though the LPN denied this. Shortly after the threats were made and reported, the resident broke a second-story window and exited the building by jumping out, resulting in an open fracture to the left ankle. The resident was found on the ground outside the unit and was subsequently transported to the hospital for treatment. The facility's investigation revealed that staff did not provide adequate supervision or timely intervention in response to the resident's exit-seeking and self-harm threats, which directly led to the elopement and injury.
Removal Plan
- The Director of Nursing (DON) and the Assistant Director of Nursing (ADON) interviewed staff from the unit to gather statements regarding the incident.
- The DON and ADON provided education to current staff on suicidal and threatening behavior protocols and interventions, behavior management, and how to deal with challenging behaviors and the need to immediately respond to resident threats of self-harm.
- Staff were instructed that the resident should not be left alone or out of line of sight for their safety. If the nurse does not respond, then they should notify the DON/ADON/Administrator.
- The DON and the ADON reviewed the suicidal ideation (SI) risk assessment/questionnaire.
- The DON and the ADON educated staff on the abuse and neglect policies and procedures.
- The DON notified staff who were not present on the date(s) of the incident via online communication that they must report to the DON/ADON for education before their next scheduled shift.
- Ongoing training will continue for all employees who have not yet received it due to paid time off (PTO), sick leave, etc., and will also be provided to all new hires.
- The ADON completed suicide risk assessments and elopement assessments for all current residents on the male secured unit, and no other residents were identified with suicidal ideations or increased/current immediate elopement risk.
- The Maintenance Director (MD) audited all second-floor windows to ensure they were secured and in place with no further issues noted.
- Staff secured Resident #11's room to prevent re-entry and cleared glass debris from the courtyard for safety.
- The facility Administrator opened a Self-Reported Incident (SRI) and reported the incident to the Ohio Department of Health (ODH).
- The Administrator suspended Licensed Practical Nurse (LPN) #205 who was the unit nurse at the time of the incident, pending the outcome of the investigation.
- The Administrator and the DON notified the Medical Director and a member of the governing body (GB)/Owner of the incident.
- The facility held an ad hoc Quality Assurance and Performance Improvement (QAPI) meeting by phone with the Administrator, the DON, the Medical Director and the Facility Owner.
- The Administrator and the DON completed a root cause analysis of the incident and determined the root cause was staff did not stay with Resident #11 when the resident verbalized an intent to leave the facility by jumping out a window and LPN #205 failed to assess Resident #11 when notified by staff.
- The ADON began questioning random staff three times weekly to verify knowledge of resident safety protocols. Results are turned into the Administrator for ongoing monitoring and compliance. The ADON will continue the monitoring three times weekly for three months.
- The management team will conduct ongoing education and continue to address any issues related to suicidal and threatening behaviors.
- Staff have been and will continue to be questioned by the Administrator or designee on appropriate actions to take if a resident expresses an intent to harm themselves. This will be conducted three times per week for three months, and results will be reported to the QAPI committee.
- The facility Psych Nurse Practitioner (NP) and outside counseling service representatives met with all residents on the secured male unit to provide support.
- RCO #800 provided re-education to the current Administrator and the acting Administrator at the time of the incident on the importance of a thorough investigation and the need to review the accuracy and information provided by staff.
- The Administrator notified LPN #205 that after investigation LPN #205's employment was terminated.
Failure to Maintain Infection Control During Wound Care
Penalty
Summary
During wound care for a resident with multiple diagnoses including hemiparesis, Alzheimer's dementia, peripheral vascular disease, and a stage IV pressure ulcer, staff failed to maintain proper infection control techniques as required by facility policy and Enhanced Barrier Precautions (EBP). The resident was dependent on staff for activities of daily living and required EBP due to the presence of a severe wound. Observations revealed that staff did not consistently perform hand hygiene between glove changes, exited and re-entered the resident's room wearing the same gown and gloves, and failed to remove personal protective equipment (PPE) before leaving the room. Supplies were not gathered prior to beginning care, resulting in staff leaving the room mid-procedure while still wearing PPE. Interviews with staff and the Director of Nursing confirmed that these actions were not in accordance with facility policies for aseptic dressing changes and EBP, which require hand hygiene at specific points during wound care and the removal of gowns and gloves before exiting a resident's room. The facility's own policies outlined the necessary steps for infection prevention, but these were not followed during the observed wound care procedure for the resident.
Failure to Document Narcotic Administration on MAR
Penalty
Summary
The facility failed to ensure that the administration of a narcotic pain medication, morphine sulfate solution, was consistently documented on the medication administration record (MAR) for a resident with severe cognitive impairment and multiple diagnoses, including Alzheimer's disease, osteoporosis, uterine cancer, and chronic pain. The resident, who had transitioned to hospice care, had a physician's order for morphine to be administered as needed for pain or dyspnea. Review of the MARs for September, October, and December 2024 showed that not all doses of morphine signed out on the controlled drug record were documented as administered on the MAR. For example, doses were signed out on the controlled drug record on several dates, but corresponding documentation was missing from the MAR on those same dates. Interviews with the Director of Nursing confirmed that medications must be documented on the MAR when given, and verified the discrepancies between the controlled drug records and the MARs for the resident. Facility policy also requires that medications be documented on the MAR as soon as they are administered. The failure to document the administration of morphine as required by policy and physician order resulted in incomplete records for the resident's pain management.
Failure to Label and Date Prepared Foods in Refrigerator
Penalty
Summary
The facility failed to properly label prepared foods in the refrigerator, which had the potential to affect all residents receiving food from the kitchen. During an observation and interview with the Kitchen Supervisor, it was revealed that there were two trays of sandwiches, one tray of bowls of mandarin oranges, and three trays of cups of juice that were not labeled or dated inside the refrigerator. The Kitchen Supervisor confirmed that these items were not labeled or dated and acknowledged that they should have been. A review of the facility's Dietary/Food Handling policy, dated January 2023, indicated that food is to be dated and labeled upon arrival from the vendor and/or upon preparation. This deficiency was investigated under Complaint Number OH00162926, with the facility census being 85 at the time of the observation.
Failure to Serve Specialized Diets as Planned
Penalty
Summary
The facility failed to serve specialized diets as planned by the Registered Dietitian (RD), affecting 15 residents out of 89 who were receiving food from the kitchen. The deficiency was identified through interviews, observations, and record reviews. Specifically, residents with physician orders for puree and mechanical soft food texture consistencies did not receive the appropriate textured vegetables as per the lunch menu diet spreadsheet. Residents #01 and #69 were supposed to receive puree green beans, while the other affected residents were to receive green beans in a mechanical soft texture. During the lunch meal service, it was observed that none of the affected residents received green beans or any other similar vegetable. An interview with a staff member confirmed the oversight, revealing that the diet spreadsheet, which was available for review during meal preparation, was not followed. The RD also verified that the diet spreadsheet was accessible for cooks to prepare the textured diet foods and confirmed that the residents did not receive the correct alternate food for their prescribed diet textures. The facility's policy on Spreadsheet Guidelines for Menu Planning indicated that spreadsheets are designed to meet therapeutic requirements, but this was not adhered to, leading to the deficiency.
Resident Elopement Due to Inadequate Supervision
Penalty
Summary
The facility failed to provide adequate supervision to prevent the elopement of a resident with a history of schizophrenia, dementia, and other medical conditions. The resident, who was admitted to a secured unit due to cognitive impairments and elopement risk, was last seen in the smoking room by a State Tested Nurse Aide (STNA). The STNA provided the resident with an unlit cigarette, and upon attempting to light it, discovered the resident was missing. The resident had exited the facility through a stairwell adjacent to the smoking room. The staff immediately searched for the resident both inside and outside the facility but were unable to locate him. The local police, who were investigating a potential break-in nearby, found the resident walking around outside the facility and returned him 40 minutes later. The resident was assessed upon return and found to have no injuries. The incident was verified by the Assistant Director of Nursing and the Administrator, confirming the resident's elopement through the stairwell while under the supervision of the STNA.
Failure to Follow Menus and Notify Residents of Changes
Penalty
Summary
The facility failed to ensure that menus were followed and that residents were notified of menu changes prior to meals, affecting 88 of 89 residents. During observations, it was noted that the posted menus did not match the meals served on two consecutive days. On the first day, the menu listed a baked pork chop, stuffing, green beans, and a dinner roll, but residents were served turkey and rice casserole, green peas, and a biscuit instead. On the following day, the menu indicated turkey and rice casserole, green peas, and a biscuit, but residents received shredded pork, potatoes with peas, and a roll. The Dietary Supervisor admitted that the meals served did not match the posted menus and that residents were not informed of these changes beforehand. The discrepancy occurred because the meal scheduled for the first day was not taken out to thaw, leading to the turkey and rice casserole being served instead. Additionally, the facility ran out of biscuits, further contributing to the inconsistency. The failure to notify residents of these changes was verified by the Dietary Supervisor, who acknowledged that residents should have been informed prior to the meals.
Failure to Follow Meal Recipes and Ensure Food Appeal
Penalty
Summary
The facility failed to ensure that meals were prepared according to the specified recipes and that the food served was visually appealing. On 06/03/24, the menu indicated that residents were to receive an open-faced turkey sandwich with gravy, mashed potatoes, and a California vegetable blend for lunch. However, observations revealed that residents were served a piece of white bread with chopped meat and a reddish-brown gravy, which did not match the recipe. The mashed potatoes and mixed vegetables were served on the side, contrary to the menu's description. Multiple residents expressed dissatisfaction with the meal's appearance, comparing it to dog food and stating it looked unappetizing. The Dietary Supervisor confirmed that the meal served did not match the recipe, noting that the meat was cubed instead of sliced and the gravy was not turkey gravy. The discrepancy was attributed to the correct food not being taken out to thaw, affecting 88 of the 89 residents in the facility.
Improper Use of Hairnets in Food Service
Penalty
Summary
The facility failed to ensure that employees wore hairnets properly while preparing and serving food and beverages, which had the potential to affect 88 of 89 residents. During an observation, a dietary aide was seen at the juice machine without a hairnet, and upon being instructed to wear one, did not fully cover his braids. Similarly, a dietary cook was observed with her braids sticking out of her hairnet while stirring food at the steam table and plating meals. The dietary supervisor confirmed that both employees did not have their hair fully covered, which was against the facility's policy requiring hairnets in food service areas.
Failure to Feed Resident in a Dignified Manner
Penalty
Summary
The facility failed to ensure that residents were fed in a safe and dignified manner, specifically affecting one resident. During an observation, a State tested Nursing Assistant (STNA) was seen standing in the hallway at the nurse station, feeding a resident who was seated in a reclining geri-chair. The STNA was positioned behind the resident, reaching around to put food into the resident's mouth, rather than facing the resident. The STNA stated that she was standing because a cart containing trays for the lunch meal was in her way, but did not provide a reason for not facing the resident while feeding. The facility's policy on Resident Rights and Dignity, which was undated, indicated that all residents should be treated in a dignified manner. This deficiency was identified during a complaint investigation.
Failure to Apply Compression Stockings as Ordered
Penalty
Summary
The facility failed to ensure that a resident's compression stockings were applied as ordered to treat edema. This deficiency affected one resident, who had a physician's order to apply compression wraps to bilateral lower extremities in the morning and remove them at night. Despite the order, the resident was observed multiple times without the compression hose, and the resident reported not being provided with them despite asking. The Licensed Practical Nurse (LPN) confirmed the resident had an order for compression hose but did not apply them, citing that the resident sometimes refused them. However, there was no documentation of any refusal by the resident on the days observed. The LPN acknowledged the responsibility to ensure the compression hose were applied as per the physician's order, yet failed to do so, resulting in the resident experiencing swelling in her legs.
Failure to Ensure Required Physician Visits
Penalty
Summary
The facility failed to ensure that a resident was seen by a physician as required, affecting one of the three residents reviewed for physician visits. The resident, who was admitted with multiple diagnoses including nerve root and plexus disorder, Wernicke's encephalopathy, alcohol abuse with alcohol-induced sleep disorder, insomnia, legal blindness, depression, anxiety, and iron deficiency anemia, had moderately impaired cognition according to the comprehensive Minimum Data Set (MDS) assessment. The resident was seen by the physician on one occasion, by a physician assistant on another, and by a nurse practitioner twice, but not at the required frequency of every 30 days during the first 90 days of admission. Interviews with the Director of Nursing (DON) and the Medical Director (MD) revealed that the resident was not seen by the physician as required due to the resident's refusal to participate in medical visits, preferring to remain on the phone. The physician attempted to see the resident on two occasions, but the resident did not cooperate. The facility's policy stated that the physician should see the resident once every 30 days for the first 90 days after admission, with a qualified nurse practitioner or physician assistant allowed to make every other required visit. However, the resident's refusal and the lack of further attempts by the physician to conduct the visit contributed to the deficiency.
Latest citations in Ohio
A resident with intact cognition receiving Medicare Part A skilled services for metabolic encephalopathy had services discontinued while benefit days remained, but the facility did not issue the required Skilled Nursing Facility Advance Beneficiary Notice (SNF ABN). The Social Services Director later confirmed that no SNF ABN was provided and reported she believed only a Notice of Medicare Non-Coverage (NOMNC) was needed when all skilled services were stopped. This practice conflicted with the facility’s written policy, which required SNF ABNs to be issued when extended care items or services were initiated, reduced, or terminated due to expected non-coverage by Medicare.
Surveyors identified that the facility exceeded the acceptable medication error rate when two residents with type 2 DM received insulin doses that were not administered according to orders or manufacturer instructions. In two separate observations, an LPN administered Novolog and another LPN administered insulin glargine and insulin lispro without priming the insulin pens, and the insulin lispro and Novolog were given after the residents had already consumed a significant portion of their breakfast meals, despite orders for administration before meals. Manufacturer information for both insulin products required priming before each injection to ensure accurate dosing, and facility policy required medications, including insulin, to be administered safely, timely, and in accordance with prescriber orders and specified time frames.
Surveyors found that the facility failed to document tray line food temperatures for multiple meals served from two dining room kitchenettes, despite having a “Trayline Taste & Temperature Log” and a policy requiring food to be stored, prepared, distributed, and served according to professional food safety standards. Review of logs showed repeated missing entries for breakfast, lunch, and dinner services in both the Harrison and McClellan dining areas, and the Senior Director of Culinary Services confirmed that temperatures had not been recorded for those meals, potentially affecting all residents receiving meals from those kitchenettes.
The facility failed to conduct and document required periodic care conferences for two residents, despite multiple comprehensive, quarterly, and significant change MDS assessments and a policy requiring periodic care conferences with resident and/or family participation. One resident with Parkinson’s disease, post-stroke hemiplegia, TIA, DMII, and depression had only two documented care conferences over a year, while another resident with aphasia, cerebrovascular disease, DMII, gait difficulty, coagulation defect, depression, and muscle weakness had no documented care conferences in the past year, aside from a declined invitation to the representative. The UCC confirmed that care conferences were expected to occur quarterly and that no additional documentation existed for either resident.
A resident with Alzheimer's disease and type II DM, who required extensive assistance with ADLs and was receiving scheduled Lantus and sliding-scale Humalog, experienced a severely elevated blood glucose level. The on-call provider was notified and ordered an additional dose of lispro insulin with a directive to recheck the blood glucose after administration. Nursing staff administered the extra insulin but did not document any follow-up blood glucose check, and the DON confirmed that this reevaluation was required by the facility's abnormal blood glucose policy and was not completed or documented.
A resident with Parkinson’s disease, dementia, and hypothyroidism was prescribed levothyroxine once daily along with other medications. A consultant pharmacist’s monthly drug regimen review recommended that levothyroxine be given in the morning on an empty stomach, 30–60 minutes before food, per manufacturer instructions. The medical record contained no documented physician response to this recommendation, and the MAR showed the drug scheduled for morning administration while the resident was observed eating breakfast and receiving the medication at the same time. An LPN confirmed administering levothyroxine during the meal, and the DON verified there was no documentation explaining whether or why the pharmacist’s recommendation was or was not followed, resulting in a failure to act on and document the identified irregularity.
A resident with severe cognitive impairment, multiple comorbidities, documented gait and balance abnormalities, and a high fall risk was care planned and assessed by therapy to require contact guard assistance and use of a gait belt for transfers and ambulation. While being assisted by a CNA from a recliner to the bathroom with a walker, the CNA did not apply a gait belt, even though the resident had a known tendency to lean backward when standing. As the CNA reached to open the bathroom door, the resident lost balance and fell backward, striking the back of the head, and was later found by an LPN without a gait belt in place, contrary to the facility’s gait belt policy and the resident’s assessed needs.
A resident with metabolic encephalopathy, muscle weakness, and a history of CVA experienced a fall in his room that was not documented in the medical record until the following morning as a late entry. Two RNs acknowledged that the fall was not recorded at the time it occurred and stated that fall incidents should be documented as soon as possible after the event, resulting in a deficiency for failure to maintain timely, professionally standard medical records.
A resident with Alzheimer’s disease, diabetes, anxiety, significant ADL dependence, and behavioral symptoms was observed seated in a chair positioned against the nursing station with a locked wheelchair placed directly in front, also against the nursing station, effectively restricting movement. An LPN confirmed both wheelchair wheels were locked and that it should not have been placed there, while a CNA stated she had positioned the wheelchair to prepare for lunch, was unable to complete the transfer, and left it in place, acknowledging this was wrong. This arrangement conflicted with the facility’s restraint policy, which prohibits physical restraints except when alternatives are ineffective for treating a medical symptom and defines restraints as devices adjacent to the body that cannot be easily removed and that restrict freedom of movement or access to the body.
A resident with cirrhosis, ascites, mood disorder, and alcohol-induced major neurocognitive disorder, and with moderately impaired cognition, was observed sitting on a shower chair in a gown with buttocks exposed and visible from the hallway through an open room door. A CNA left the room quickly after hearing another resident yell and forgot to close the door or pull the privacy curtain, and an RN confirmed the exposure, demonstrating a failure to maintain the resident’s dignity and privacy.
Failure to Issue Required SNF ABN When Discontinuing Medicare Part A Services
Penalty
Summary
The deficiency involves the facility’s failure to issue a Skilled Nursing Facility Advance Beneficiary Notice (SNF ABN) when Medicare Part A services were discontinued for a resident who still had available benefit days. The resident was admitted with a diagnosis of metabolic encephalopathy and had intact cognition per the Minimum Data Set assessment. The facility’s own SNF Beneficiary Notification Review documented that Medicare Part A skilled services began on 02/11/26 and the last covered day was 03/11/26, and that the facility initiated discharge from Medicare Part A services before the resident’s benefit days were exhausted. Despite this, no SNF ABN was provided to the resident or the resident’s representative. During interviews, the Social Services Director stated that the SNF ABN was issued hours prior to the last covered day but, upon reviewing her files, confirmed that no SNF ABN had actually been issued for this resident. She further explained that she believed an SNF ABN was only required if one skilled service remained and that if all skilled services were being discontinued, only the Notice of Medicare Non-Coverage (NOMNC) needed to be issued. The Administrator, however, stated that a resident should always receive both a SNF ABN and a NOMNC when Medicare Part A services are discontinued and benefit days remain. Review of the facility’s written policy dated 03/28/23 showed that the facility was required to issue SNF ABNs for initiation, reduction, or termination of extended care items or services when Medicare payment was not expected, which did not occur in this case.
Plan Of Correction
This Plan of Correction is submitted as required under State and Federal law. This Plan of Correction does not constitute an admission on the part of the Facility that the findings cited are accurate, that the findings constitute a deficiency or that the scope and severity regarding the deficiency cited are correctly applied. Any changes to the Facility's policies and procedures should be inadmissible in any proceeding on that basis. Without admitting or denying the validity or the existence of the alleged noncompliance, the Facility submits this Plan of Correction with the intention that it be inadmissible by any third party in any civil or other action against the facility or any employee, agent, officer, director or shareholder of the Facility. The Facility is utilizing this Plan of Correction as its allegation of substantial compliance as of 05/29/2026 F-0582 Corrective action for resident/s: On 5/14/26 Resident #34 was informed of rights and responsibilities related to Advanced Beneficiary Notice and voiced understanding of information for future reference by administrator. Identification of other residents who may be affected: Any resident receiving skilled services from nursing or therapy services. The Administrator audited all residents who were discharged from skilled services in the past 30 days to ensure they were issued a Notice of Non-Coverage and Advanced Beneficiary Notice on 5/29/26. No non-compliance was noted. Measures for systemic change: On 5/14/2026 Business Office Manager, Director of Rehab, Minimum Data Set nurse, Director of Nursing and Social Services Director were educated on proper procedure of issuing of Notice Of Medicare Non Coverage and Advanced Beneficiary Notice by administrator. All upcoming discharges from skilled services will be reviewed weekly at Utilization Review meeting to ensure notices will be delivered timely. How Corrective Action will be monitored: Administrator or designee to complete audits of all residents being discharged from skilled services to ensure they were issued a Notice of Non-Coverage and Advanced Beneficiary. This audit will be completed weekly x 4 weeks, then monthly x 2 months. Corrective action will be initiated for any noted non-compliance. Audit findings will be reviewed as part of the monthly quality assurance process to determine the need for further monitoring. Date of Compliance 5/29/26
Insulin Administration Errors and Failure to Prime Insulin Pens
Penalty
Summary
The deficiency involves the facility’s failure to maintain a medication error rate below 5%, with surveyors identifying 3 errors out of 28 medication administration opportunities, resulting in a 10.71% error rate. For one resident with type 2 diabetes mellitus and moderate cognitive impairment, the physician’s order directed Novolog insulin 10 units via subcutaneous pen-injector to be given before meals. During an observed medication pass, the LPN administered 10 units of Novolog insulin without priming the pen and did so after the resident had already consumed approximately 50% of the breakfast meal. The LPN later confirmed she did not prime the pen and acknowledged that the insulin was ordered to be administered prior to meals. Manufacturer instructions for the Novolog FlexPen specified that an air shot (priming) must be performed before each injection to ensure proper dosing. Another resident, also diagnosed with type 2 diabetes mellitus and with intact cognition, had orders for insulin glargine 35 units subcutaneously twice daily and insulin lispro 20 units subcutaneously before meals, plus 12 units subcutaneously if blood glucose was between 251 mg/dL and 300 mg/dL. During an observed medication administration, an LPN administered 35 units of insulin glargine and 32 units of insulin lispro without priming the insulin pens and after the resident had consumed approximately 90% of the breakfast meal, despite orders for insulin lispro to be given before meals. The LPN later stated she could not remember if she had primed the pen and acknowledged that the insulin was ordered to be administered prior to meals. Manufacturer information for insulin lispro stated that the pen must be primed before each injection to confirm insulin delivery and remove air, and that failure to prime could result in too much or too little insulin. The DON confirmed the expectation that insulin be administered as ordered, including priming each pen with two units before dialing the prescribed dose, and facility policy required medications, including insulin, to be administered safely, timely, and in accordance with prescriber orders and required time frames.
Plan Of Correction
This Plan of Correction is submitted as required under State and Federal law. This Plan of Correction does not constitute an admission on the part of the Facility that the findings cited are accurate, that the findings constitute a deficiency or that the scope and severity regarding the deficiency cited are correctly applied. Any changes to the Facility's policies and procedures should be inadmissible in any proceeding on that basis. Without admitting or denying the validity or the existence of the alleged noncompliance, the Facility submits this Plan of Correction with the intention that it be inadmissible by any third party in any civil or other action against the facility or any employee, agent, officer, director or shareholder of the Facility. The Facility is utilizing this Plan of Correction as an allegation of substantial compliance as of 5/29/2026. F-0759 Corrective action for resident/s: Residents #21 and #22 were assessed and evaluated by nurse and Director of Nursing 5/14/26. Resident #21 and #22 both denied any adverse effects and none were noted upon assessment by the Director of Nursing on 5/14/2026. Notification made to physician on 5/14/2026. LPN # 2 competency Eval on insulin administration with the Director of Nursing completed 5/14/2026. Identification of other residents who may be affected: Diabetic residents on assignment of LPN #2/station 2 have the potential to be affected and were assessed by the DON/Designee on 5/14/26 and found to be within normal limits. Measures for systemic change: All Nurses were educated by the Director of Nursing on the steps for Insulin administration per competency, diabetes clinical protocol policy, Medication and treatment orders policy, administering medications policy, and Obtaining fingerstick Glucose Level policy On 5/14/2026. How Corrective Action will be monitored: Director of Nursing and Assistant Director of Nursing will complete insulin administration audits on 5 nurses. This audit will be completed weekly x 4 weeks, then monthly x 2 months. Corrective action will be initiated for any noted non-compliance. Audit findings will be reviewed as part of the monthly quality assurance process to determine the need for further monitoring. Date of Compliance: 5/29/2026
Failure to Document Tray Line Food Temperatures in Dining Room Kitchenettes
Penalty
Summary
The deficiency involves the facility’s failure to document tray line food temperatures for meals served from the Harrison and McClellan Dining Room kitchenettes, as required by professional standards for food service safety and the facility’s own policy. Review of the “Trayline Taste & Temperature Log” (revised September 2018) showed missing temperature documentation for multiple meals from the Harrison Dining Room kitchenette, including dinner on 03/30/26 and 03/31/26, lunch and dinner on 04/01/26 and 04/02/26, dinner on 04/07/26, and lunch and dinner on 04/08/26 and 04/10/26. The Senior Director of Culinary Services confirmed during interview that tray line food temperatures were not documented on the log for these meals. Similarly, review of the same log for the McClellan Dining Room kitchenette revealed that tray line food temperatures were not documented for dinner on 04/01/26, breakfast and lunch on 04/02/26, and lunch and dinner on 04/07/26. The Senior Director of Culinary Services also verified these omissions during interview. The facility census at the time was 27 residents, and the governing “Food and Nutrition” policy, approved on 09/07/21, stated that the facility must store, prepare, distribute, and serve food in accordance with professional standards for food service safety.
Plan Of Correction
F812 The facility will continue to ensure food temperatures are completed before meals are served for all residents. To ensure compliance with this standard the following measures have been taken: 1. Immediately 4/15/26 culinary supervisor #224 was re-educated by Dietary Manager to this standard and policy "Food and Nutrition" which includes documentation of food temperatures. 2. All dietary staff have been re-educated to the standard and policy "Food and Nutrition" during the month of April 2026. 3. Audits of food temperature documentation to be completed by Dietary Manager 4 x per week for 4 weeks then weekly for 4 weeks. 4. Administrator to validate audits/compliance and provide additional training as needed. Administrator will present to QAPI committee for ongoing monitoring and further direction.
Failure to Conduct and Document Required Care Conferences
Penalty
Summary
The deficiency involves the facility’s failure to complete and document comprehensive care conferences at required intervals in accordance with care plan regulations and facility policy. For one resident with Parkinson’s disease with dyskinesia, cognitive communication deficit, hemiplegia and hemiparesis following cerebral infarction, transient cerebral ischemic attack, type II diabetes mellitus, and major depressive disorder, the record showed multiple MDS assessments over a one-year period, including annual, quarterly, and significant change assessments. However, only two care conferences were documented during the last 12 months, despite the expectation that care conferences be conducted quarterly with the resident and family when possible. The Unit Care Coordinator confirmed that no additional care conference documentation existed for this resident beyond the notes dated 04/21/25 and 01/02/26. A second resident, with diagnoses including aphasia following cerebrovascular disease, cerebral infarction, type II diabetes mellitus, unsteadiness on feet, difficulty in walking, coagulation defect, depression, and muscle weakness, also had multiple MDS assessments completed over the review period, including quarterly and annual assessments. The record contained a note that a care conference was offered to the resident’s representative, who declined to attend, but there was no documentation of any care conferences for the most recent 12 months. The Unit Care Coordinator confirmed that no other care conference documentation was available for this resident. Facility policy stated that periodic care conferences involving the resident, family, and the interdisciplinary team are part of the care planning process, but the required periodic care conferences and corresponding documentation were not completed for these two residents.
Plan Of Correction
THIS PLAN OF CORRECTION SERVES AS BERKELEY SQUARE'S CREDIBLE ALLEGATION OF SUBSTANTIAL COMPLIANCE AS OF June 1, 2026. Without admitting or denying the validity or existence of the alleged deficiencies, Berkeley Square provides the following Plan of Correction: F657 The facility will continue to document completion of care conferences at the required intervals for all residents, including residents #04 & #15. To ensure compliance with this standard the following measures have be taken: 1. The social service designee and the inter- disciplinary team were re-educated by the administrator to the facility policy "Care Conference" on 4/29/26 and verbalized understanding. 2. Care conferences for resident #04 and resident #15 were conducted on or before 4/29/2026 by the interdisciplinary team. 3. Review of all other residents was conducted by the social service designee to validate and ensure that care conference schedule is up to date with timely care conferences scheduled for them on 4/15/2026. Audits of care conferences to be completed weekly for four weeks and then monthly after that by the social service designee. Documentation of the care conference including any identified concerns in the medical record. Administrator to validate audits/compliance and provide additional training as needed. Administrator will present results of these audits to QAPI committee for ongoing monitoring and further direction.
Failure to Reevaluate Blood Glucose After Treatment for Hyperglycemia
Penalty
Summary
The facility failed to ensure that a resident with diabetes received treatment in accordance with professional standards of practice when nursing staff did not reevaluate the resident's blood glucose after treatment for severe hyperglycemia. The resident, admitted with diagnoses including Alzheimer's disease, type II diabetes mellitus, and depression, had physician orders for Humalog insulin on a sliding scale before meals, Lantus insulin 25 units daily, and lisinopril 5 mg daily. The resident required extensive assistance with activities of daily living, including transfers, toileting hygiene, eating, and bathing. On the evening in question, the resident's blood glucose was documented as 532 mg/dL, and the on-call provider was notified. The provider gave a new order to administer an additional 8 units of lispro (Humalog) and to recheck the blood glucose in 30 minutes. The electronic medication administration record showed that the blood glucose of 532 mg/dL was obtained at 9:00 p.m. and that the additional 8 units of lispro were administered at 9:21 p.m. However, there was no documentation in the resident's chart that the blood glucose was rechecked after the additional insulin was given. In an interview, the DON confirmed there was no evidence of reevaluation and verified that, according to the facility's "Abnormal Blood Glucose Procedure" policy, the resident should have been reevaluated and that the evaluation step should have been included in the progress note documentation.
Plan Of Correction
F684 The facility will continue to ensure all residents, including #03, receive treatment in accordance with professional standards of practice and reevaluated for hyperglycemia. To ensure compliance with this standard the following measures have been taken: 1. The director of nursing assessed resident #03, reviewed documentation and orders and found no ill effects immediately 4/16/26. 2. All licensed nurses were re-educated to facility policy "Blood Glucose Monitoring" by the Director of Nursing/designee in April 2026. 3. Audits of like-residents that require blood sugar checks to be completed by the director of nursing/designee two times a week for 4 weeks and then monthly after that to validate correct follow through when there is abnormally high blood glucose result. The Administrator will bring results of these audits to the QAPI committee for ongoing monitoring and further direction.
Failure to Act on Pharmacist Drug Regimen Recommendation for Thyroid Medication
Penalty
Summary
The deficiency involves the facility’s failure to ensure that pharmacy recommendations from the monthly drug regimen review were acted upon and documented for a resident. The resident was admitted with diagnoses including Parkinson’s disease, dementia, and hypothyroidism, and had current physician orders for levothyroxine 150 mcg once daily, buspirone 50 mg twice daily, and losartan 100 mg once daily. A medication regimen review dated 11/25/2025 included a consultant pharmacist recommendation that levothyroxine be administered consistently in the morning on an empty stomach, at least 30–60 minutes before food, per manufacturer instructions. There was no specific physician response in the medical record to this recommendation, and the facility’s policy stated that consulting pharmacist reviews are sent to nursing and addressed with the primary care provider or consulting specialist for review and follow-up. Review of the resident’s medication administration record for April 2026 showed levothyroxine scheduled for 9:00 a.m. On observation, the resident was seen eating breakfast in the dining area at 8:03 a.m., and an LPN reported administering the levothyroxine 150 mcg to the resident while the resident was in the dining area eating breakfast. The DON confirmed there was no evidence in the resident’s medical record explaining why the consultant pharmacist’s recommendation from 11/25/2025 was or was not acted upon. This lack of documented physician review and action on the pharmacist’s identified irregularity constituted noncompliance with the drug regimen review requirements.
Plan Of Correction
F756 The facility will continue to ensure the pharmacy recommendations from the monthly drug regimen review by a licensed pharmacist are acted upon for all residents, including #08. To ensure compliance with this standard the following measures have been taken: 1. Resident #08 was assessed by the registered nurse and med review completed by 4/28/26. After review of resident's drug regime's, it was discovered that resident #8 had 2 separate medication recommendations on the same form, to be reviewed by two separate practitioners, pharmacy has been instructed and agreed to separate meds on individual forms. 2. Licensed nurses re-educated to facility policy "Drug Regimen Review" by Director of nursing/designee in April 2026 and no later than 5/8/26. Licensed nurses are responsible for ensuring the reviews and recommendations are given to the physician for timely review. 3. Review of all other current residents Drug Regimen orders completed by Director of nursing/designee on 4/16/26 to ensure recommendations were followed up on/reviewed by the physician and address concerns if needed. 4. Audit of drug regime recommendations, pharmacy recommendations, and physician follow up to be completed weekly for four weeks by the Director of nursing/designee. Administrator will present results of these audits to the QAPI committee for ongoing monitoring and further direction.
Failure to Use Required Gait Belt During Ambulation Resulting in Resident Fall
Penalty
Summary
The deficiency involves the facility’s failure to ensure that a required gait belt was used while assisting a high fall‑risk resident with ambulation, resulting in a fall with head injury. The resident had multiple diagnoses including metabolic encephalopathy, hypertension, osteoarthritis, muscle weakness, gait and mobility abnormalities, major depressive disorder, anxiety, and visual hallucinations. Admission and subsequent MDS and fall risk assessments documented that the resident was severely cognitively impaired, required moderate to maximal assistance with transfers and ambulation, could not independently come to a standing position, exhibited loss of balance while standing, used an assistive device, and had decreased muscle coordination. The resident had a history of falls prior to admission and was assessed as being at high, later moderate, risk for falls. The resident’s fall care plan identified her as at risk for falls and included interventions such as providing maximum to moderate assistance with transfers and walking short distances, use of a walker and wheelchair, and following the facility’s fall protocol. Therapy notes and care conference documentation indicated that the resident leaned backwards when standing, required contact guard to minimal assistance for bed mobility and transfers, and needed constant verbal cueing for safe sequencing during toilet transfers. The physical therapist confirmed that the resident was to use a gait belt with staff when ambulating, and the DON verified that therapy had assessed the resident as requiring contact guard assistance and a gait belt for ambulation and transfers. On the day of the incident, a CNA was assisting the resident from her recliner to the bathroom using a walker. The CNA walked beside the resident, providing guidance and support, and reported having a hand on the resident while assisting her. As they approached the bathroom door, the CNA reached for the doorknob to open it, and at that moment the resident began to lose her balance and fell backwards to the floor, striking the back of her head. The nurse who responded found the resident on her back at the foot of the bed with her feet near the bathroom, noted a red raised area on the back of the head, and documented that the resident was not wearing a gait belt and that the gait belt was on the dresser. In the facility’s investigative summary and in interviews, the CNA acknowledged that she did not have a gait belt on the resident while ambulating her, despite the resident’s assessed need for hands‑on assistance and gait belt use per facility policy and the resident’s care and therapy plans.
Untimely Documentation of Resident Fall Incident in Medical Record
Penalty
Summary
The deficiency involves the facility’s failure to document a resident’s fall incident in the medical record in a timely manner, in accordance with accepted professional standards. The resident was admitted with diagnoses including metabolic encephalopathy, muscle weakness, and cerebrovascular accident. According to the medical record, a progress note was entered as a late entry on 02/20/26 at 8:21 A.M., stating that the resident had suffered a fall in his room on 02/19/26 at 8:00 P.M. There was no evidence of any documentation of the fall incident entered in the medical record at the time of, or shortly after, the fall on 02/19/26 at 8:00 P.M. During an interview on 03/30/26 at 12:05 P.M., two RNs confirmed that the fall incident was not documented until the following morning and stated that fall incidents should be entered in the medical record as soon as possible following the event. This lack of timely documentation of the fall incident constituted non-compliance with requirements to safeguard resident-identifiable information and maintain medical records in accordance with professional standards.
Improper Use of Wheelchair as a Physical Restraint
Penalty
Summary
Surveyors identified a deficiency related to the facility’s failure to ensure a resident was free from physical restraints. Resident #7, admitted with diagnoses including Alzheimer’s disease, diabetes mellitus, and anxiety disorder, was documented on a recent MDS as rarely understood and dependent for ADLs except eating. The resident ambulated independently on the unit without an assistive device and had documented verbal and other behaviors occurring one to three days during the look-back period. The care plan noted the resident had potential to be physically aggressive, chase staff, throw objects, and be combative with care, with interventions such as offering choices, administering medications as ordered, and intervening early when agitation occurred. During an observation and interview, Resident #7 was found sitting in a chair with the right arm of the chair positioned against the nursing station and a wheelchair placed directly in front of him. The left arm of the wheelchair was also against the nursing station, and both wheelchair wheels were locked, creating a barrier that appeared to restrain the resident, who was sleeping with his knees touching the locked wheelchair. An LPN confirmed both wheelchair wheels were locked and that the wheelchair should not have been placed in front of the resident. A CNA reported she had placed the wheelchair there in preparation to get the resident up for lunch, was unable to transfer him, and left the wheelchair in that position, acknowledging it was wrong to keep it there. The facility’s physical restraint policy stated that physical restraints are not used except when alternatives are not appropriate or effective for treating a medical symptom and defined physical restraints as any device attached or adjacent to the body that the individual cannot easily remove and that restricts freedom of movement or access to the body.
Resident Left Exposed and Visible From Hallway Due to Failure to Maintain Privacy
Penalty
Summary
The facility failed to ensure resident dignity and privacy when a cognitively impaired resident was left exposed and visible from the hallway. The resident, who had diagnoses including cirrhosis with ascites, mood disorder, and alcohol-induced major neurocognitive disorder, had a BIMS score of eight, indicating moderately impaired cognition. During an observation, the resident was seen sitting on a shower chair in a gown with buttocks exposed, and this exposure was visible from the open room door in the hallway. A Certified Resident Care Associate and a Registered Nurse confirmed that the resident’s buttocks were visible from the hallway. The Certified Resident Care Associate reported that she had left the resident’s room quickly after hearing a resident in an adjacent room yell and, in her haste, forgot to close the door or pull the privacy curtain, resulting in the resident’s exposed state being visible to others. This incident involved one resident out of three reviewed for dignity, in a facility with a census of 52 residents, and was identified through record review, observation, and staff interviews.
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