Woodside Village Care Center
Inspection history, citations, penalties and survey trends for this long-term care facility in Mount Gilead, Ohio.
- Location
- 841 W Marion Rd, Mount Gilead, Ohio 43338
- CMS Provider Number
- 366028
- Inspections on file
- 22
- Latest survey
- June 2, 2025
- Citations (last 12 mo.)
- 0
Citation history
Health deficiencies cited at Woodside Village Care Center during CMS and state inspections, most recent first.
A CNA physically struck a resident with dementia and behavioral disturbances during breakfast after the resident became combative and attempted to bite the CNA. Witnesses and the CNA confirmed the incident, which violated the facility's abuse prevention policy prohibiting staff from striking residents under any circumstances.
A resident with cognitive impairment and multiple comorbidities became agitated and struck a CNA, who then struck the resident in the face during care. The incident was witnessed by staff and another resident, but was not reported by those present. The DON was informed and confirmed the event through an internal investigation, but neither the DON nor the Administrator reported the results to the State Survey Agency, contrary to facility policy.
A staff member was not removed from resident care duties during an abuse investigation involving a resident with dementia and other complex medical conditions. The staff member continued to work after an incident in which the resident was struck in the face, contrary to facility policy requiring immediate removal pending investigation.
The facility failed to maintain proper infection control practices for water pathogen risk reduction, affecting all residents. There was no water management team, and no logs or documentation of water system assessments or controls like chlorine testing. Interviews confirmed the absence of a water management team and lack of monitoring, with reliance on city-supplied chlorinated water without records.
The facility failed to maintain a clean and sanitary kitchen environment, with a large hole-like area on the wall behind the steamer and a hole in the floor underneath the oven. These issues were confirmed by dietary staff and noted in multiple health inspection reports and facility audits.
The facility failed to provide complete beneficiary notices to three residents, omitting essential information such as the last day of covered services, appeal rights, and notification dates. This affected residents with varying cognitive abilities who were transitioning from skilled services. Interviews confirmed the absence of required details on the forms used by the facility.
The facility failed to update comprehensive care plans for two residents, affecting their fall interventions. One resident's care plan included interventions like hanging a coat on a hook and monitoring orthostatic blood pressures, but these were not implemented in the new room setup. Another resident's care plan included visual reminders for walker use and non-skid footwear, but these were absent, and the rollator walker was cluttered. The DON confirmed the care plans were not updated to reflect changes in interventions.
A facility failed to have physician orders for a treatment being performed on a resident with pressure ulcers and did not clarify treatment orders for existing pressure injuries. The resident had multiple diagnoses and a mild cognitive impairment. An LPN performed wound care, which involved removing barrier cream that had no physician order. The DON confirmed the absence of an order for the barrier cream and noted that Dakin's solution is not typically used on MASD.
A resident with cognitive impairment and a history of Parkinson's disease was dissatisfied with her pureed diet, as she was unaware she could request mechanical soft pleasure foods. Despite having her own teeth and no issues with chewing, the resident was not informed about her dietary options, leading to dissatisfaction. Staff interactions and documentation lacked clarity on the resident's ability to request alternative food options.
A facility failed to provide proper parameters for as-needed pain medication orders and did not document pain levels for a resident with multiple diagnoses, including COPD and low back pain. Nursing staff confirmed the absence of parameters and documentation, contrary to the facility's pain management policy.
A resident with multiple medical conditions experienced a delay in the processing of a diet order change recommended by hospice due to dental pain. The resident's diet was not adjusted to a pureed form until four days after the recommendation, despite the resident having difficulty chewing and swallowing. The DON confirmed the delay in implementing the hospice's dietary recommendation.
The facility failed to adequately inform residents and their representatives about arbitration agreements, affecting four residents. Interviews revealed that residents with varying cognitive abilities did not understand or recall signing the agreements. The facility's policy requires clear explanations, which were not provided, as residents were given electronic forms to sign without sufficient explanation.
Two residents were prescribed Amoxicillin for prophylactic use without adequate justification or proper assessments, leading to a deficiency in the facility's antibiotic stewardship program. Despite the lack of infections and assessments, the antibiotics were administered as ordered, highlighting a failure to optimize infection treatment and reduce adverse events.
The facility failed to conduct reference checks for five newly hired staff members, including RNs, CNAs, and the Administrator, as required by its abuse prevention policy. This oversight, confirmed by administrative management, had the potential to affect all 62 residents, as the personnel files lacked documentation of previous work history or confirmation of reference checks.
A resident with dementia and identified as an elopement risk managed to exit a facility through a window, bypassing the wanderguard system. The incident occurred when a nurse noticed an open window and initiated the elopement protocol. The resident was found nearby without injuries. Staff interviews revealed that the wanderguard system did not function on windows, indicating a lapse in the facility's supervision and security measures.
CNA Strikes Resident During Care in Response to Aggressive Behavior
Penalty
Summary
A deficiency occurred when a Certified Nursing Assistant (CNA) physically struck a resident during care. The resident, who had diagnoses including dementia, encephalopathy, hypertension, diabetes mellitus, and end stage renal disease, exhibited impaired cognition and required assistance with mobility, transfers, bathing, and feeding. The resident had a documented history of increased agitation and aggressive behaviors, such as hitting and kicking staff during care. On the date of the incident, the CNA was assisting the resident during breakfast when the resident became combative, swinging her arms and attempting to kick and bite the CNA. In response, the CNA held down the resident's arms and, when the resident attempted to bite, struck the resident in the face with an open hand to push her head back. Multiple interviews corroborated the incident, including statements from another resident and a CNA who witnessed the event. The CNA involved admitted to striking the resident, describing it as a knee-jerk reaction to the attempted bite. Review of the facility's Abuse Prevention Program Policy & Procedure confirmed that striking a resident is not acceptable under any circumstances, regardless of intent or whether the action was reflexive. The policy explicitly states that retaliation by staff is considered abuse and is not permitted.
Failure to Report Abuse Investigation Results to State Agency
Penalty
Summary
The facility failed to report the results of an abuse allegation involving a resident with dementia, encephalopathy, hypertension, diabetes mellitus, and end stage renal disease. The resident, who had impaired cognition and required supervision for mobility and transfers, exhibited increased agitation and aggressive behaviors, including hitting and kicking staff. During a breakfast incident, a CNA restrained the resident's arms and, when the resident attempted to bite her, struck the resident in the face with an open hand. Multiple staff and another resident witnessed the event, but the CNA and a witness did not report the incident to management. The Director of Nursing was notified of the incident by an LPN and initiated an internal investigation, confirming that the CNA had struck the resident. However, both the DON and the Administrator concluded that the CNA did not intend harm and, as a result, did not report the incident or the investigation results to the State Survey Agency as required by facility policy and state law. The facility's policy mandates reporting the results of all investigations to the appropriate authorities within five working days, but this was not done in this case.
Failure to Remove Staff from Resident Care During Abuse Investigation
Penalty
Summary
The facility failed to remove a staff member from resident care duties while an allegation of abuse was being investigated. Specifically, a certified nursing assistant (CNA) was involved in an incident with a resident who had dementia, encephalopathy, hypertension, diabetes mellitus, and end stage renal disease. During breakfast, the resident became physically aggressive, swinging arms and attempting to kick the CNA. In response, the CNA restrained the resident's arms and, when the resident attempted to bite, struck the resident in the face with an open hand to prevent being bitten. Despite the incident being reported and an investigation initiated, the CNA was not removed from resident care and continued to work during the investigation. The facility's policy required immediate removal of the alleged perpetrator from resident care pending the outcome of the investigation, but this was not followed. The administrator confirmed awareness of the incident and the decision to allow the CNA to continue working, based on the belief that there was no intent to harm.
Inadequate Water Pathogen Risk Reduction
Penalty
Summary
The facility failed to maintain proper infection control practices related to water pathogen risk reduction, which had the potential to affect all residents. During a record review and facility tour, it was found that the facility did not have a water management team in place, nor were there logs or documentation of water system assessments, monitoring, or controls such as chlorine testing. The facility's policy required a water management team to conduct environmental screenings and assessments of the water system, but this was not being followed. Interviews with the Maintenance Director and the Administrator confirmed the absence of a water management team and the lack of water monitoring or documentation. The Maintenance Director acknowledged that a new Legionella Assessment policy had been received, but no actions had been taken to implement it. The Administrator also confirmed the lack of evidence for water management activities and stated that the facility relied on the city for chlorinated water without maintaining records of city water testing or controls.
Kitchen Sanitation Deficiencies
Penalty
Summary
The facility failed to maintain a clean and sanitary kitchen environment, as evidenced by multiple observations and interviews. A large hole-like area was observed on the wall behind the steamer on two separate occasions, and this was confirmed by both the Dietary Supervisor and another dietary staff member. The Local Health Department Inspector noted that this issue had been cited in the last three health inspection reports. Additionally, facility audits from October to December 2024 consistently reported damage to the wall behind the steamer. Furthermore, a hole in the floor underneath the oven was observed and confirmed by the Dietary Supervisor and another dietary staff member. The County Health Department Food Inspection Report also noted damage to the floor near the ovens. Facility audits from October to December 2024 reported damaged areas on the floor. The facility's Kitchen Safety policy emphasized the importance of keeping floors in good repair and free from hazards, which was not adhered to in this case.
Failure to Provide Complete Beneficiary Notices
Penalty
Summary
The facility failed to provide and document all required information when issuing beneficiary notices to residents, affecting three residents. Resident #11, who was cognitively intact, was receiving physical and occupational therapy and had reached a plateau in progress. The intent to discharge form lacked the last day of covered services and a signature section for the resident or representative. The Medicare Coverage Ending notice did not specify which skilled services were ending or include appeal rights, and there was no date indicating when the resident was informed. Similarly, the Advanced Beneficiary Notice of Non-Coverage (ABN) form lacked details about the services ending and appeal rights. Resident #21, with significant cognitive impairment, was receiving speech therapy and had exhausted skilled nursing days. The intent to discharge form did not state the last day of covered services or provide a signature section. The Medicare coverage ending notice failed to include information about appeal rights or the specific services ending, and there was no record of when the resident's representative was informed. The ABN form also lacked details about the services ending and appeal rights. Resident #320, who was cognitively intact, had exhausted skilled nursing days and transitioned to Medicare Part B. The intent to discharge form did not have a signature section. The notice of Medicare coverage ending did not include appeal rights or a notification date. Interviews with Social Services and the Administrator confirmed the absence of required appeal information and notification dates on the forms, and there was no evidence of appeal information being provided to the residents or their representatives.
Failure to Update Comprehensive Care Plans for Fall Interventions
Penalty
Summary
The facility failed to ensure comprehensive care plans were updated for two residents, affecting their fall interventions. Resident #11, who was cognitively intact and independent for transfers, had a care plan that included interventions such as hanging a coat on a hook at the end of the bed and obtaining orthostatic blood pressures every shift. However, upon observation, there was no hook in the resident's new room, and no orthostatic blood pressure monitoring was recorded. The Director of Nursing (DON) confirmed that the care plan was not updated to reflect the resident's new room setup and the discontinuation of certain interventions. Similarly, Resident #29, who was also cognitively intact and required setup or clean-up assistance for activities of daily living, had a care plan with interventions like visual reminders to use a walker and apply non-skid footwear. During observation, no visual reminders were present, and the resident's rollator walker was cluttered with blankets and a pillow. The DON verified that the care plan was not updated to discontinue interventions that were no longer necessary. The facility's policy required comprehensive care plans to reflect changes in residents' preferences and goals, which was not adhered to in these cases.
Lack of Physician Orders for Pressure Ulcer Treatment
Penalty
Summary
The facility failed to have physician orders for a treatment being performed and did not clarify treatment orders for existing pressure injuries for Resident #7. The resident, who was admitted with multiple diagnoses including sepsis, type II diabetes, and chronic obstructive pulmonary disease, had a mild cognitive impairment. The medical record review revealed an order for cleaning the resident's left posterior thigh with Dakin's solution and applying calcium alginate, but there was no order for the application of barrier cream, which was observed to be used. During an observation, an LPN performed wound care on Resident #7, which involved cleansing three wounds with Dakin's solution and applying calcium alginate. The LPN had to remove barrier cream from the resident's buttocks and thigh areas before performing the wound care, despite there being no physician order for the barrier cream. Interviews with the DON confirmed the absence of a current order for the barrier cream and acknowledged that Dakin's solution is not typically used on moisture-associated skin damage (MASD) as it might break down the skin. The DON contacted the physician to clarify the order.
Resident Unaware of Dietary Options Leading to Dissatisfaction
Penalty
Summary
The facility failed to ensure that a resident understood the option of requesting pleasure foods, which led to dissatisfaction with the prescribed diet. The resident, who had a history of Parkinson's disease, cognitive impairment, and other medical conditions, was on a pureed diet with nectar thick liquids. Despite having her own teeth and no reported issues with chewing, the resident was unaware that she could request mechanical soft pleasure foods if she did not like the pureed meals provided. This lack of communication and understanding about dietary options contributed to the resident's dissatisfaction with her meals. The deficiency was further highlighted during interviews and observations, where the resident expressed her dislike for the pureed diet and her ability to chew regular food. Staff interactions revealed a lack of clarity regarding the resident's dietary needs and preferences, as well as the absence of documentation about the resident's ability to request alternative food options. The Director of Nursing confirmed that the diet was downgraded due to previous swallowing difficulties, but there was no consistent documentation or communication to ensure the resident was informed about her dietary choices, leading to the deficiency noted in the report.
Inadequate Pain Management Documentation and Parameters
Penalty
Summary
The facility failed to provide proper parameters for as-needed pain medication orders and did not document pain levels for all uses of as-needed pain medication for a resident. The resident, who had a mild cognitive impairment, was admitted with multiple diagnoses including pneumonia, COPD, and low back pain. The physician orders for the resident included acetaminophen and tramadol for pain management, but lacked specific parameters to guide the administration of these medications based on the resident's pain level. Interviews with nursing staff revealed that there were typically parameters in place to determine which pain medication to administer, but in this case, they were absent. The staff confirmed that pain levels should be documented prior to administering any as-needed pain medication, which was not done in this instance. The facility's pain management policy required pain assessments and documentation, but these were not consistently followed, leading to the deficiency in pain management for the resident.
Delayed Diet Order Processing for Resident
Penalty
Summary
The facility failed to ensure a diet order was processed in a timely manner for a resident with multiple medical conditions, including Parkinson's disease and cognitive impairment. The resident was on a pureed diet with nectar thick liquids and had specific requirements for eating utensils. On a hospice visit, it was noted that the resident had a bad tooth, and the hospice nurse recommended a change to a pureed diet with no ice in drinks. However, the diet change was not implemented until four days later when the resident was observed having difficulty chewing and holding food in her mouth. Interviews revealed that the resident did not like the pureed diet and claimed to have no trouble chewing food, despite being told she had choked once. The Director of Nursing confirmed that the diet was not changed per the hospice recommendation on the date of the visit, but rather on a later date when the resident exhibited issues with food pocketing and swallowing. This delay in processing the diet order highlights a lapse in timely communication and implementation of dietary changes based on the resident's needs.
Failure to Inform Residents About Arbitration Agreements
Penalty
Summary
The facility failed to ensure that residents and/or their representatives were adequately informed about arbitration agreements in a manner that was understandable to them. This deficiency affected four residents who were reviewed for arbitration agreements. The facility had a total of 48 residents with signed arbitration agreements out of a census of 62. The review of medical records and interviews with residents and family members revealed that residents with varying levels of cognitive impairment were not clearly informed about the arbitration agreements. For instance, one resident with moderate cognitive impairment could not recall if the arbitration agreement was explained, and her husband, who signed the paperwork, also had memory issues. Another resident with moderate cognitive impairment did not remember signing an arbitration agreement and could not explain what it was. Interviews with residents who were cognitively intact also indicated a lack of understanding regarding arbitration agreements. One resident stated she did not know what an arbitration agreement was and did not recall signing one. Another resident, who was also cognitively intact, was unaware of signing an arbitration agreement and did not understand its purpose. The facility's social worker explained that residents and their representatives are given a tablet to sign electronic forms, including the arbitration agreement, but the explanation provided was insufficient for the residents to understand the agreement. The facility's policy requires that the arbitration agreement be explained in a form and manner that is understandable to the resident and their representative, including in a language they understand, which was not adhered to in these cases.
Inadequate Justification for Antibiotic Use in Two Residents
Penalty
Summary
The facility failed to provide adequate justification for the use of antibiotic medication for two residents, leading to a deficiency in their antibiotic stewardship program. Resident #7, who had a mild cognitive impairment and multiple diagnoses including sepsis and urinary tract infection (UTI), was prescribed Amoxicillin 500 mg daily for prophylactic use against UTIs. However, the McGeer Assessment completed on 10/30/24 indicated that the antibiotic did not meet the criteria for administration. Despite this, the Amoxicillin was administered as ordered without any further evaluation to determine if it could be discontinued, and there was no infection present in the subsequent months. Similarly, Resident #21, who had significant cognitive impairment and diagnoses including pneumonia and sepsis, was also prescribed Amoxicillin 500 mg daily for prophylactic use against upper respiratory infections (URI). The facility did not complete a McGeer Assessment for either order of Amoxicillin for this resident, and the antibiotic was administered without justification or evaluation for discontinuation. The Director of Nursing confirmed the lack of assessments and justification for both residents, highlighting a failure in the facility's antibiotic stewardship program, which aims to optimize infection treatment and reduce adverse events associated with antibiotic use.
Failure to Conduct Reference Checks for New Hires
Penalty
Summary
The facility failed to adhere to its abuse prevention policy by not completing reference checks for five newly hired personnel, which included two Registered Nurses (RNs), two Certified Nursing Assistants (CNAs), and the Administrator. The personnel files for these staff members lacked documentation of previous work history or confirmation that reference checks had been completed, despite the facility's policy requiring such checks for all new hires. This oversight had the potential to affect all 62 residents in the facility. During an interview, administrative management and the Administrator confirmed that reference checks had not been conducted for the newly hired staff members, acknowledging the deviation from the facility's policy. The facility's abuse prevention policy explicitly states that all applicants for employment must be checked with previous and/or current employers, and reasonable efforts should be made to uncover information about any past criminal prosecutions. The absence of these checks represents a significant lapse in the facility's hiring process, potentially compromising resident safety.
Resident Elopement Due to Inadequate Supervision and Security Measures
Penalty
Summary
The facility failed to ensure adequate supervision of a resident, leading to an elopement incident. The resident, who had a history of dementia and was identified as an elopement risk, was supposed to have a wanderguard in place to prevent such incidents. However, the resident managed to exit the facility through a window in the Director of Nursing's office, which did not trigger the wanderguard alarm. This lapse in supervision and security measures allowed the resident to leave the premises unnoticed. The incident occurred when a registered nurse noticed a window open in the Director of Nursing's office and initiated the facility's elopement protocol, known as the 'happy feet protocol.' The resident was found shortly after by a certified nursing assistant on a nearby street, sitting in a driveway. The resident was assessed by emergency medical services and facility staff, who found no injuries or immediate distress. The resident was returned to the facility without further incident. Interviews with staff revealed that the wanderguard system did not function on windows, and this was a known issue. The facility's policy on elopement prevention and management was not effectively implemented, as the resident was able to exit through a window without triggering any alarms. The deficiency was identified during a complaint investigation, highlighting a failure in the facility's supervision and security protocols for residents at risk of elopement.
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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