Avenue Care And Rehabilitation Center, The
Inspection history, citations, penalties and survey trends for this long-term care facility in Warrensville Heights, Ohio.
- Location
- 4120 Interchange Corporate Center Road, Warrensville Heights, Ohio 44128
- CMS Provider Number
- 366394
- Inspections on file
- 32
- Latest survey
- December 18, 2025
- Citations (last 12 mo.)
- 51
Citation history
Health deficiencies cited at Avenue Care And Rehabilitation Center, The during CMS and state inspections, most recent first.
A facility allowed an Interim DON to serve and practice as a Registered Nurse with a lapsed and inactive license, despite reminders and assistance from HR to renew. The license remained inactive due to incomplete renewal, and both the Administrator and HR were unaware of the lapse until it was confirmed during a complaint investigation.
A resident with an ileostomy did not receive timely colostomy care as required by physician orders and care plan. The resident was left covered in stool for hours after her colostomy bag burst, despite activating her call light for assistance. Family intervention and photographic evidence confirmed repeated failures by staff to empty, burp, or change the ostomy bag as needed, resulting in the resident remaining soiled for extended periods.
Surveyors found that multiple dependent residents did not receive timely incontinence care, with some left in soiled briefs and bedding for extended periods. Staff and family interviews confirmed that residents were not checked or changed as required, resulting in saturated briefs, wet bedding, and skin irritation. Facility policy required checks every two to three hours, but this was not followed due to staffing shortages.
The facility failed to provide adequate nursing staff, resulting in multiple residents with complex medical needs not receiving timely incontinence care, hygiene, and assistance with daily living. Residents were left in soiled briefs and bedding for extended periods, and staff interviews confirmed that insufficient staffing led to delays in care, with some residents only checked or changed once or twice per 12-hour shift. Family members also reported having to provide care themselves due to lack of staff response.
Staff failed to follow Enhanced Barrier Precautions for a resident with a pressure injury requiring high-contact care, as CNAs did not wear required gowns and PPE was not available in or near the room. The EBP signage was not properly displayed, and staff were unaware of the resident's EBP status, with reports that gowns were often unavailable throughout the facility. This noncompliance had the potential to affect other residents on the same floor.
A resident with advanced cancer and cognitive impairment was found with a call light cord around their neck, indicating a significant change in condition. Although staff removed the cord, notified hospice, and contacted the family, the nurse delayed direct phone notification to the physician for over eight hours, contrary to facility policy requiring immediate action for acute changes. This deficiency was identified through review and staff interviews.
A resident with severe cognitive impairment and communication deficits was not protected from sexual abuse by another resident, despite a prior incident and staff awareness of her inability to consent. After an initial episode of inappropriate contact, staff failed to update the care plan or ensure adequate supervision, resulting in a second incident where the male resident was found in her room with his pants down.
The facility did not have an RN on duty for at least eight consecutive hours on two days, as confirmed by staff schedules and HR interview. This failure had the potential to impact all 87 residents in the facility.
Surveyors observed multiple instances of unclean and unsafe conditions, including stained carpets and bedding, damaged walls and fixtures, dirty medical equipment, and unsanitary bathrooms. These deficiencies were confirmed by the maintenance supervisor and were not in line with the facility's cleaning policies, potentially affecting all residents.
Surveyors found undated nectar thickened orange juice containers and expired thickener packets stored in pantries used for residents on thickened liquids. The Regional Director of Clinical Operations confirmed these findings during the inspection, and the deficiency had the potential to affect several residents receiving thickened liquids.
The facility did not maintain accurate and complete medical records for several residents, including missing physician orders for dialysis, incomplete documentation of medication administration and treatments, lack of documentation regarding diagnostic test results, and misfiled physician notes. These deficiencies were confirmed through staff interviews and review of the electronic health record.
A deficiency was cited for not ensuring a resident's right to dignity, self-determination, communication, and the exercise of their rights. The report does not specify the exact circumstances or individuals involved.
Three residents were not provided with appropriate accommodations, including a bed that fit a tall and heavy resident and accessible call lights for two residents, one of whom was blind and required extensive assistance. Staff confirmed that call lights were out of reach and the bed provided did not meet the resident's needs.
A resident with multiple serious diagnoses was transferred to and from the hospital several times without documentation that the family or responsible party was notified, despite facility policy requiring such notification. An LPN confirmed the absence of documentation for these notifications, resulting in non-compliance with the facility's procedures.
The facility failed to properly document and justify the discharge of three residents, including one with severe cognitive impairment and another with no prior behavioral issues, resulting in their transfer or denial of return after hospitalization without adequate medical record support or discharge paperwork, contrary to facility policy.
A resident with severe cognitive impairment and total dependence on staff for ADLs was observed on multiple occasions to have long, dirty fingernails, with no documentation or evidence that fingernail care was provided or refused. CNAs were unclear about their responsibilities regarding fingernail care, and the nurse was not informed of the need for trimming, resulting in inadequate personal hygiene for the resident.
The facility did not ensure that a resident received appropriate care for existing pressure ulcers and failed to implement preventive measures to avoid the development of new ulcers, as evidenced by surveyor observations and documentation review.
The facility did not consistently complete thorough fall investigations, update care plans with current fall interventions, or ensure that fall interventions were in place as ordered for three residents with cognitive and mobility impairments. One resident experienced multiple unwitnessed falls without proper care plan updates or accurate fall risk assessments, another had a fall without timely pain or fall risk assessments or documentation of vital signs, and a third was repeatedly observed without required bilateral floor mats. Staff interviews and record reviews confirmed these deficiencies in fall prevention and documentation.
Surveyors found that appropriate care was not consistently provided to residents who were continent or incontinent of bowel/bladder, and that catheter care and UTI prevention measures were inadequate.
A resident with a UTI did not receive an ordered antibiotic as scheduled due to the medication being unavailable, resulting in missed doses over several days. The error was confirmed through medical record review and staff interviews, with the issue identified after two missed administrations.
The facility did not ensure that laboratory tests or services were provided or obtained as ordered and failed to promptly notify the ordering practitioner of the results, potentially affecting timely clinical decisions for a resident.
A resident with severe cognitive impairment eloped from a facility without staff knowledge, resulting in her death due to environmental exposure. The facility failed to recognize her absence, did not perform routine checks, and did not respond to door alarms. Staff assumed the resident was on a leave of absence without verification, and the facility's elopement policies were not adequately followed.
A resident with severe cognitive impairment and at risk for elopement was not checked routinely by staff, leading to their elopement and death outside the facility. The incident was not reported to the State Agency as required by the facility's policy.
The facility failed to honor the bathing and transfer preferences of several residents, leading to deficiencies in care. Residents who preferred showers were only given bed baths, and those requiring assistance were not given a choice. Additionally, residents faced restrictions on transfers, affecting their ability to receive timely care. These issues persisted despite being reported to facility management.
Two residents in an LTC facility did not receive timely incontinence care, leading to saturated clothing and strong odors. One resident, who was always incontinent, was not checked or changed for several hours, while another, who required a Hoyer lift, was reluctant to receive care due to being told she would have to stay in bed afterward. Staff interviews confirmed the lack of adherence to the facility's policy of checking and changing residents every two hours.
A resident with bilateral above the knee amputations and balance deficits was injured during a mechanical lift transfer when staff failed to position him correctly in the chair, causing him to slide and reopen his incision. The resident required emergency care and did not return to the facility.
A resident with multiple diagnoses was found with a medicine cup containing numerous pills, indicating that the LPN did not observe the resident ingest the medications as required by facility policy. The LPN confirmed she left the medications in the room and did not watch the resident take them.
Interim DON Practiced with Lapsed RN License
Penalty
Summary
The facility failed to ensure that nursing staff were licensed in accordance with state laws, specifically allowing an individual to serve as Interim Director of Nursing (DON) while her Registered Nurse (RN) license was inactive and had lapsed. The Interim DON assumed the role in October 2025 after the previous DON resigned. Verification on the Ohio e-licensure website confirmed that the Interim DON's license had expired as of 10/31/25 and was not renewed. Despite reminders posted at the time clock and direct assistance from Human Resources (HR) to complete the renewal application, the license remained inactive due to incomplete renewal. Interviews with the Administrator and HR revealed that both were unaware the Interim DON's license was still inactive, even after attempts to prompt renewal. HR had assisted the Interim DON with the application process, but did not follow up to ensure completion. The deficiency was identified during a complaint investigation and had the potential to affect all 83 residents in the facility, as the Interim DON continued to practice without an active nursing license.
Failure to Provide Timely Colostomy Care
Penalty
Summary
A deficiency occurred when staff failed to provide timely colostomy care to a resident with a history of rectal cancer and an ileostomy. The resident had physician orders for staff to empty the ostomy every shift and as needed, and to change the appliance weekly and as needed. Despite these orders, the resident reported that her colostomy bag burst open and, after activating her call light, a nurse entered the room, turned off the call light, and left without providing care. The resident remained covered in stool for at least two hours, ultimately calling a family member for assistance. The family member arrived to find the resident still soiled, took photographs, and cleaned her up before reporting the incident to the unit manager. The family member stated that similar issues had continued to occur. Observations confirmed the resident's colostomy bag was often not emptied or changed in a timely manner, with the bag being half full of liquid stool during one interview and the resident found covered in stool during another observation. Photographic evidence provided by the family member showed dried, liquid stool on the resident's gown and bedding, and the colostomy bag not attached to the abdomen. The Interim DON acknowledged awareness of frequent leaks but was unaware of the lack of timely emptying. These findings demonstrate a failure by staff to provide appropriate and timely ostomy care as required by the resident's care plan and physician orders.
Failure to Provide Timely Incontinence Care for Dependent Residents
Penalty
Summary
Surveyors identified that the facility failed to provide timely incontinence care for four residents who were dependent on staff for activities of daily living, specifically toileting and hygiene. Observations and interviews revealed that residents were left in soiled briefs and clothing for extended periods, sometimes for over nine hours, without being checked or changed. Staff members, including CNAs, confirmed that due to insufficient staffing, residents were not checked or changed as frequently as required, with some residents only receiving incontinence care twice during a 12-hour shift. Residents were observed with saturated briefs, wet bedding, and in some cases, dried stool and urine on their skin, resulting in foul odors and visible skin irritation. One resident with hemiplegia and dementia was placed in a chair at 5:00 A.M. and was not checked or changed until 2:45 P.M., at which time staff confirmed the resident's brief was heavily saturated and the resident had an odor of urine. Another resident, who was cognitively intact but had bilateral leg amputations and was always incontinent, reported to surveyors that she was left soaked in urine and that staff did not respond promptly to her requests for assistance. Staff confirmed that this resident had not been checked or changed for several hours, and her brief and bed pad were saturated with urine. A third resident, with hemiplegia and moderate cognitive impairment, was found with a saturated brief containing urine and stool, with dried stool on the skin and deep red, sensitive areas on the body from prolonged exposure. Family members of a fourth resident reported that staff failed to provide incontinence care despite repeated requests, resulting in the family having to change the resident themselves after waiting several hours. The facility's own policy required residents to be checked and changed every two to three hours, but this standard was not met for the residents reviewed.
Failure to Provide Sufficient Nursing Staff for Resident Care
Penalty
Summary
Surveyors identified that the facility failed to provide sufficient nursing staff to meet the needs of all residents, resulting in multiple instances where residents did not receive timely incontinence care and assistance with activities of daily living. Several residents with significant medical conditions, such as hemiplegia, aphasia, visual loss, and dementia, were observed or reported to have waited extended periods—sometimes several hours—before being checked or changed. In one case, a resident's call light was activated for over 28 minutes before staff responded, and the resident was found sitting in a wet brief with a strong odor of urine. Another resident reported not being changed since early morning, resulting in a saturated brief and wet bedding, with staff confirming that due to staffing shortages, residents were sometimes only checked and changed twice in a 12-hour shift. Additional observations and interviews revealed that residents were left in soiled conditions for prolonged periods, with one resident found with dried stool and urine, deep red and sensitive skin, and soiled bedding. Family members of a former resident reported having to change their loved one themselves after staff failed to respond to repeated requests for assistance over several hours, and provided photographic evidence of saturated bedding and briefs. Staff interviews consistently indicated that there were not enough CNAs and nurses to provide timely care, with some residents only receiving incontinence care once or twice per shift, and showers often being replaced with bed baths due to lack of staff. The facility's own assessment documented the need for a specific number of licensed nurses and CNAs per shift to meet resident acuity needs, but interviews and observations confirmed that these staffing levels were not consistently met. Staff reported being unable to complete daily care tasks, and residents who were dependent on staff for mobility, hygiene, and toileting were not assisted in a timely manner. The deficiency affected multiple current and former residents and had the potential to impact the majority of the facility's population.
Failure to Implement Enhanced Barrier Precautions During Resident Care
Penalty
Summary
The facility failed to maintain proper infection control practices for a resident requiring Enhanced Barrier Precautions (EBP) to prevent the transmission of multidrug-resistant organisms (MDROs). The resident, who was moderately cognitively impaired and had an unstageable pressure injury, required substantial assistance with mobility, toileting, and hygiene. The care plan and physician orders specified the use of disposable gowns and gloves during high-contact care activities, such as dressing changes, bathing, toileting, and wound care. However, during observation, it was noted that the EBP sign had fallen to the floor, and there was no personal protective equipment (PPE), including gloves or gowns, available inside or near the resident's room. Certified Nursing Assistants (CNAs) providing incontinence care and changing linens for the resident did not wear isolation gowns, as required by the EBP protocol. Both CNAs confirmed they did not use gowns, and one was unaware that the resident was on EBP. They also reported that gowns were often not readily available throughout the facility. The lack of adherence to EBP protocols and unavailability of PPE had the potential to affect additional residents on the same floor, as staff could provide care to multiple residents during their shifts. The facility's policy required gown and glove use for high-contact care activities, but this was not followed during the observed care.
Failure to Timely Notify Physician of Resident's Change in Condition
Penalty
Summary
The facility failed to ensure timely notification to the physician when a resident exhibited a significant change in condition. The resident, who had diagnoses including malignant neoplasm of the colon and liver, was admitted to hospice care and had impaired cognition and depression. According to the care plan, staff were to monitor and report any risk for self-harm or suicidal ideation. On the night in question, a certified nursing assistant found the resident with a call light cord around his neck, which was a notable change from his baseline behavior. The registered nurse on duty was alerted and removed the cord, then notified the resident's physician, hospice, and family member. However, the nurse initially texted the physician after the incident but did not receive a response and did not make a phone call to the physician until over eight hours later. During this time, the resident was monitored by staff and hospice was contacted, but the delay in direct physician notification was contrary to facility policy, which required immediate phone notification in the event of an acute change in condition. Interviews with staff confirmed that any suspected self-harm or suicidal ideation should prompt immediate physician notification by phone, and the facility's policy specified that if the physician could not be reached within thirty minutes, emergency services should be contacted. The deficiency was identified through record review, observation, and interviews, and was found to be a continuation of non-compliance from a previous survey.
Failure to Protect Cognitively Impaired Resident from Sexual Abuse
Penalty
Summary
The facility failed to protect a resident with severe cognitive impairment, communication difficulties, and a history of paranoid schizophrenia from sexual abuse by another resident. The resident was dependent on staff for hygiene, dressing, and transfers, and her care plan had not been updated for an extended period. Despite her inability to provide informed consent, she was observed in two separate incidents involving inappropriate sexual contact with another resident. In the first incident, a nurse observed the two residents kissing in a common area and intervened to separate them. The event was reported to management, and staff were instructed to keep the residents apart. However, the care plan for the cognitively impaired resident was not updated following this event, and there was no documented reassessment of her vulnerability or supervision needs. A second, more serious incident occurred when a staff member found the same male resident in the female resident's room, on her bed with his pants down. The male resident was removed and placed on one-on-one observation only after this event. The female resident was sent to the emergency room for a rape kit, which was later reported as negative. The facility's policy required protection of residents who may lack capacity to consent to sexual activity, but the failure to maintain separation and update care planning led to a repeat incident.
Failure to Maintain Required RN Coverage
Penalty
Summary
The facility failed to maintain the services of a registered nurse (RN) for at least eight consecutive hours a day, seven days a week, as required by regulations. Review of nursing staff schedules and information revealed that no RNs were present and working in the facility on two specific days. This was confirmed during an interview with the Human Resources Director, who verified the absence of an RN on those dates. The deficiency was identified during the investigation of three separate complaints and had the potential to affect all 87 residents in the facility at the time.
Failure to Maintain Clean and Safe Environment
Penalty
Summary
The facility failed to maintain a clean, sanitary, and safe environment for its 87 residents, as evidenced by multiple observations during an environmental tour. Surveyors noted stained and debris-laden carpets throughout resident rooms and common areas, holes in walls, dislodged air conditioning covers, partially secured wall trim, and broken telephone outlets. Additionally, supplemental tube feeding poles had dried tube feed residue, and several private bathrooms and bedding items were found with brown stains. Wet clothing was left on a bathroom floor, producing a strong musty odor, and multiple rooms had water stains on the ceiling, severely scratched and chipped walls, and crumbling areas above air conditioning units. Dirty, torn, and tattered fall mats were also observed in use. These findings were confirmed by the Maintenance Supervisor at the time of observation. The facility's own Environmental Services Cleaning Guidebook, which outlines cleaning methods for infection control and presentation, was in place but not followed as intended. The deficiency was identified during the investigation of two specific complaints and had the potential to affect all residents in the facility.
Outdated and Undated Thickened Liquids and Additives Found in Storage
Penalty
Summary
During a facility tour, surveyors observed two 46-ounce containers of nectar thickened orange juice stored in unit pantries without any date indicating when they had been opened, despite a use by date of June 2025. Additionally, eight individual packets of thick and easy instant food and beverage thickener with a use by date of 10/29/23 were found in the same pantries. These items were accessible in areas serving residents who required thickened liquids. The Regional Director of Clinical Operations confirmed the presence of both the undated juice containers and the expired thickener packets during the inspection. This deficiency was identified as part of a complaint investigation and had the potential to affect four residents who were receiving thickened liquids at the time of the survey.
Incomplete and Inaccurate Medical Record Documentation
Penalty
Summary
The facility failed to ensure that medical records for several residents were accurate and complete, as required by professional standards. For one resident with end stage renal disease and multiple comorbidities, there was no physician order for dialysis in the electronic record, despite the resident receiving dialysis at the facility. Additionally, documentation was missing for medication administration and treatments during specific shifts, and staff interviews confirmed lapses in documentation and the absence of required orders. Another resident, admitted with multiple chronic conditions and using a noninvasive ventilator, had incomplete documentation regarding a scheduled CT scan. While respiratory therapy and pharmacy reviews were documented, there was no record of the CT scan results or when it was completed, which was confirmed by the DON. For a third resident, the nursing admission assessment was left blank in the electronic health record, with the DON attributing this to a possible system glitch, but no assessment information was present in the record. Additionally, the review of another resident's electronic medical record revealed that physician notes for a different resident were incorrectly filed in their record. The facility's policy requires that medical records be complete, accurately documented, and systematically organized, but these findings demonstrate that the facility did not meet these standards for multiple residents.
Failure to Honor Resident Rights
Penalty
Summary
A deficiency was identified regarding the failure to honor a resident's right to a dignified existence, self-determination, communication, and the exercise of their rights. The report notes that the facility did not ensure these resident rights were upheld, but does not provide specific details about the actions or inactions that led to this deficiency, nor does it mention any particular events or residents involved.
Failure to Accommodate Resident Needs for Bed Size and Call Light Accessibility
Penalty
Summary
The facility failed to reasonably accommodate the needs and preferences of three residents regarding appropriate bed size and accessibility of call lights. One resident, who was 6 feet 9 inches tall and weighed 387.2 pounds, was observed lying in a standard-sized bed (36 inches by 80 inches) that was too small for his height and weight. The resident reported difficulty rolling side-to-side due to the bed's width and stated that his pillow frequently fell off the bed. Observations confirmed that a makeshift foam piece placed to fill the gap between the mattress and footboard did not fit properly or provide adequate support. The resident expressed ongoing requests for a larger bed, which had not been fulfilled at the time of the observations. Additionally, two other residents were observed with their call lights on the floor and out of reach while they were in their wheelchairs. One of these residents was moderately cognitively impaired and completely blind, requiring extensive assistance with activities of daily living. Staff interviews confirmed the call lights were not accessible to the residents at the time of observation. These failures were identified through observation, resident and staff interviews, medical record review, and review of facility policy.
Failure to Notify Family of Resident's Change in Condition and Hospital Transfers
Penalty
Summary
The facility failed to ensure that a resident's family or responsible party was notified of multiple changes in the resident's condition, as required by facility policy. Medical record review for a resident with diagnoses including end stage renal disease, gastrointestinal hemorrhage, diabetes mellitus II, and paroxysmal atrial fibrillation showed several instances where the resident was sent to the hospital or returned to the facility without documentation that the family was informed. Specific nurse notes indicated the resident was transferred to the hospital or returned to the facility on multiple occasions, but there was no evidence in the electronic medical record that the family was notified at any of these times. An interview with the unit manager LPN confirmed that there was no documentation of family notification for any of the hospital transfers or returns. The facility's policy on resident change in condition requires prompt notification of the resident, attending physician, and responsible party when there is a change in the resident's condition or status. The lack of documentation and failure to notify the family of these significant events constituted non-compliance with the facility's own policy.
Failure to Document and Justify Resident Discharges
Penalty
Summary
The facility failed to ensure that residents were permitted to return following hospitalization and did not provide adequate documentation to support the need for discharge. In three cases, residents were either discharged or not allowed to return without proper documentation in their medical records to justify the discharge. One resident with severe cognitive impairment and multiple diagnoses was discharged for allegedly violating the rights of others, but the discharge notice was not supported by appropriate documentation. Another resident, cognitively intact and with no prior incidents of abuse or misappropriation, was discharged after being found in possession of another resident’s cell phone, with the discharge notice citing violation of others’ rights, again without supporting documentation. A third resident, moderately cognitively impaired and with a history of encephalopathy and dementia, exhibited agitated behavior and was sent to the emergency room for evaluation. After hospitalization, this resident was not allowed to return and was transferred to another facility, but there was no documentation in the medical record regarding the discharge or the resident’s subsequent placement. Staff interviews confirmed that discharge notices and documentation were lacking or incomplete, and the facility’s own policy required comprehensive discharge planning and documentation, which was not followed in these cases.
Failure to Provide Adequate Fingernail Care for Dependent Resident
Penalty
Summary
The facility failed to provide adequate fingernail care for a resident who was dependent on staff for activities of daily living (ADLs) due to severe cognitive impairment and multiple medical diagnoses, including senile degeneration of the brain and anxiety disorder. Despite care plan interventions that included negotiating care times and re-approaching the resident if care was initially refused, there was no documentation in the medical record or shower sheets indicating that the resident refused fingernail care or that her fingernails were long and dirty. Observations on multiple occasions revealed the resident had long fingernails, measuring about half to three-quarters of an inch, with dark brown material underneath. Certified Nurse Aides (CNAs) confirmed the condition of the resident's fingernails and expressed uncertainty about whether fingernail care should be performed during bathing. Interviews with staff, including the Director of Nursing (DON), revealed that CNAs were expected to check and document fingernail care needs on bath days and report issues to the nurse, who was responsible for trimming fingernails. However, there was no evidence that this process was followed, as the nurse was not informed of the need for fingernail care, and the issue was not documented. The facility's policy required staff to provide necessary services for personal hygiene, but this was not adhered to in the case of this resident, resulting in inadequate fingernail care.
Failure to Provide and Prevent Pressure Ulcer Care
Penalty
Summary
The facility failed to provide appropriate care for pressure ulcers and did not implement effective measures to prevent the development of new ulcers. This deficiency was identified through surveyor observations and documentation review, which indicated that residents were not consistently receiving necessary interventions to manage existing pressure ulcers or to prevent new ones from forming. The lack of proper assessment, monitoring, and timely intervention contributed to the occurrence and progression of pressure ulcers among residents.
Failure to Complete Fall Investigations and Implement Care Plan Interventions
Penalty
Summary
The facility failed to ensure thorough fall investigations were completed, resident care plans were revised to reflect current fall interventions, and fall interventions were in place as ordered for three residents reviewed for falls. For one resident with severe cognitive impairment, hemiplegia, and a history of falls, there were multiple unwitnessed falls. Documentation revealed that required interventions such as low bed position and bilateral floor mats were not consistently included in the care plan or physician orders, and fall risk assessments were inaccurately completed, failing to reflect recent falls. Additionally, the care plan was erroneously marked as resolved, resulting in the omission of necessary fall prevention interventions. Another resident with moderate cognitive impairment and mobility limitations experienced a fall that was not properly documented in the progress notes, and required post-fall assessments, including pain and fall risk assessments, were not completed in a timely manner. Vital signs were not documented at the time of the fall, and there was no evidence that witness statements were obtained or recorded. The incident report did not clarify whether the call light was within reach or activated at the time of the fall, and follow-up documentation was delayed. A third resident, with a history of falls and cognitive deficits, was observed multiple times with only one fall mat in place despite care plan interventions specifying bilateral floor mats. Staff interviews confirmed the absence of the required fall mat on one side of the bed. Facility policy required immediate assessment, investigation, and implementation of interventions after a fall, as well as documentation of the incident and notifications, but these procedures were not consistently followed for the residents involved.
Deficient Bowel/Bladder and Catheter Care Practices
Penalty
Summary
The report identifies a deficiency related to the provision of care for residents who are continent or incontinent of bowel and bladder, as well as the management of catheter care and the prevention of urinary tract infections (UTIs). Surveyors found that appropriate care was not consistently provided to residents in these areas. Specific failures included inadequate attention to the needs of residents with incontinence, improper catheter care practices, and insufficient measures to prevent UTIs. These lapses were observed during the survey and contributed to the deficiency cited.
Antibiotic Administration Omission for UTI
Penalty
Summary
A deficiency occurred when a resident with diagnoses including cellulitis, leg pain, anxiety disorder, and glaucoma did not receive an ordered antibiotic medication as prescribed for a urinary tract infection (UTI). The resident, who had intact cognition and required assistance with mobility and dressing, was ordered to receive Fosfomycin tromethamine 3 gm oral packets every Tuesday, Friday, and Sunday for three doses. The medication was to begin following a positive urine culture and specific antibiotic recommendations. However, the medication was not available on the scheduled administration dates, and the resident did not receive the antibiotic as ordered. Medical record review and staff interviews confirmed that the antibiotic was not administered on the intended dates, with documentation in the medication administration record indicating the medication was unavailable. The issue was identified after two missed doses, and the antibiotic was not given until several days after the initial order. Both the Assistant Director of Nursing and the Director of Nursing verified that the medication was not administered as scheduled, resulting in a significant medication error for the resident.
Failure to Promptly Communicate Lab Results to Practitioner
Penalty
Summary
The facility failed to provide or obtain laboratory tests or services when ordered and did not promptly inform the ordering practitioner of the results. This deficiency was identified based on a review of facility practices and documentation, which showed that laboratory results were not communicated to the practitioner in a timely manner as required. The lack of prompt notification could have impacted the clinical decision-making process for the affected resident(s).
Resident Elopement and Death Due to Inadequate Supervision
Penalty
Summary
The facility failed to provide adequate supervision to prevent a resident with severe cognitive impairment from leaving the facility without staff knowledge. The resident, who had diagnoses of metabolic encephalopathy, malnutrition, and adult failure to thrive, was last seen inside the facility at approximately 8:40 P.M. Staff identified the resident was not in the facility at various times but failed to take sufficient action to determine her whereabouts. The resident was found outside the facility the following morning, cold, wet, and unresponsive, and was later pronounced deceased due to environmental exposure. The deficiency was exacerbated by the staff's failure to recognize the resident's absence and respond appropriately to the situation. Despite the resident's cognitive impairment and recent admission status, the facility's elopement assessment did not identify her as at risk for elopement. Staff members did not perform routine checks, and there was a lack of urgency in responding to the situation. The door alarm system was not effectively monitored, and staff did not conduct a thorough search or headcount in a timely manner. The facility's policies and procedures for elopement and emergency response were not adequately followed. Staff members were unaware of the resident's whereabouts and assumed she was on a leave of absence without verifying this information. The failure to respond to door alarms and conduct immediate searches contributed to the resident's prolonged absence and subsequent death. The incident highlighted significant lapses in communication, supervision, and adherence to safety protocols within the facility.
Removal Plan
- LPN #500 phoned RN #484 and informed her Resident #95 was missing and attempts to reach the resident's brother were unsuccessful. RN #484 provided instructions to activate a code purple.
- RN #484 notified Certified Nurse Practitioner (CNP) #502.
- RN #484 arrived at the facility.
- The local police department was notified Resident #95 was missing.
- Officer #506 responded and collected information and staff statements.
- The facility remained in a code purple and continued to search for Resident #95.
- Housekeeping Staff #485 informed RN #484 of a wheelchair he observed in a lower-level stairwell. Housekeeping Staff #485 escorted RN #484 to the wheelchair.
- RN #484 identified the chair as Resident #95's, proceeded up the stairs, and opened the exit door (to the outside) at the top of the stairs. RN #484 identified Resident #95 was lying outside of the facility door and yelled for help.
- The facility's elopement policy was reviewed by Corporate Regional Nurse #505. No updates or revisions were made.
- Corporate Regional Nurse #505 re-educated the Administrator and Director of Nursing (DON) on the facility's elopement policy and procedures including assessment, identification, monitoring, and managing the elopement policy.
- The Administrator began education with all staff on the elopement policy and procedure, including door alarms and prompt response. Education was additionally provided on abuse, neglect and misappropriation. Nursing staff members received further education on nurse-to-nurse responsibilities regarding census. The education was completed.
- Corporate Regional Nurse #505, Corporate Director of Operations #507, Corporate Director of Clinical Services #508, and the Former Administrator #504 walked the building and checked all doors to ensure the doors alarmed and worked properly.
- A head count of all residents was completed by LPN #438. All residents were accounted for except for Resident #95.
- A contracted door alarm company was contacted to check doors, change door keypad codes, and discuss options to enhance the sounding of the door alarms. The door alarm company installed six additional remote sounders in different locations of the facility, including inside the door at the top of the stairs Resident #95 used to exit the facility. These sounders were installed.
- All residents residing in the facility were assessed by RN #379 and RN #407. No residents were identified to have any injuries or adverse effects. The resident assessments were completed.
- All residents were re-assessed for elopement risk by LPN Unit Manager (UM) #434. The assessments were completed. The facility identified zero in-house residents at risk for elopement. Ongoing audits would be completed by the DON or designee upon admission, re-admission, quarterly, with significant changes, and as needed.
- LPN #438 verified all elopement risk assessments were completed with no residents at risks. No care plan revisions related to elopement were required for in-house residents. This was completed.
- An ad hoc Quality Assurance Performance Improvement (QAPI) meeting was held. In attendance were Former Administrator #504, the DON, ADON #411, Maintenance Supervisor #381, Social Service Designee (SSD) #447, LPN #438, Human Resources (HR) Staff #601, Business Office Manager (BOM) #404, Corporate Regional Nurse #505, Corporate Director of Clinical Services #508, Corporate Director of Operations #507. Medical Director (MD) #503 attended via phone. During the meeting, the corrective action plan for Resident #95's elopement was presented by the Administrator and approved by the interdisciplinary team (IDT).
- The facility implemented random and unannounced elopement drills to be performed three times weekly for four weeks, monthly on all shifts for four months, then monthly on rotating shifts. The elopement drills were coordinated by the Administrator or designee. The results of the drills would be reviewed by the IDT in monthly QAPI meetings.
- Ongoing audits were implemented to ensure staff hears and responds to alarms timely and appropriately three times weekly for four weeks. The results of the audits would be reviewed by the IDT in monthly QAPI meetings.
- Ongoing audits were implemented to ensure that with each change of nurse shift, a head count was performed and verified with census records. The results of the audits would be reviewed by the DON or designee daily for 30 days. The results of the audits would be reviewed by the IDT in monthly QAPI meetings.
- All exterior doors added a door alarm that required alarm de-activation to be turned off with a manual key entry. All doors with alarms were noted to be functioning properly.
Failure to Report Neglect Incident
Penalty
Summary
The facility failed to report an incident of neglect involving a resident to the State Agency as required. The resident, who had diagnoses including adult failure to thrive, malnutrition, and metabolic encephalopathy, was admitted for short-term rehabilitation services. The resident was identified as having severely impaired cognition and was at risk for falls and elopement. Despite these risks, the facility did not perform routine checks on the resident, who subsequently eloped and was found unresponsive outside the facility. The facility's policy required immediate reporting and investigation of all allegations of abuse and neglect. However, the incident involving the resident's elopement and subsequent death was not reported to the State Agency as an incident of neglect. This oversight was confirmed during an interview with the facility's administrative staff. The deficiency was investigated under two complaint numbers, indicating a failure to adhere to the facility's abuse prohibition policy.
Failure to Honor Resident Preferences for Bathing and Transfers
Penalty
Summary
The facility failed to honor the bathing preferences of several residents, as evidenced by the medical record reviews, resident interviews, and staff interviews. Resident #21, who was cognitively intact and required assistance with daily living activities, had not received a shower since admission, despite preferring daily showers. The resident was only offered bed baths twice a week, contrary to his preference, and was told by staff that he could not be transferred more than once per shift. This restriction was frustrating for the resident, who preferred to get out of bed for breakfast and rest later in the day. Similarly, Resident #29, who was also cognitively intact and dependent on staff for showers, expressed concerns about not receiving showers during a Resident Council meeting. Despite being scheduled for showers twice a week, the resident reported only receiving bed baths and was woken up during the night for these, which he did not like. The facility's response to his concerns was inadequate, as the issue persisted despite being reported to the Unit Manager and the Director of Nursing. Residents #34 and #58 also experienced similar issues, with both residents preferring showers but only receiving bed baths. Staff interviews confirmed that residents who required assistance were not given a choice between a bed bath or a shower, and showers were scheduled based on room numbers rather than resident preferences. Additionally, Resident #65 faced issues with transfer preferences, as staff informed her that once she was in bed, she had to stay there, which affected her ability to receive timely incontinence care. The facility's policies on resident rights and personal care were not adhered to, leading to these deficiencies.
Failure to Provide Timely Incontinence Care
Penalty
Summary
The facility failed to provide timely incontinence care for two residents, leading to deficiencies in their care. Resident #16, who was cognitively impaired and always incontinent of bowel and bladder, was observed in a wheelchair with a strong odor of urine. Despite being transferred out of bed early in the morning, the resident was not checked or changed until late afternoon. Staff interviews confirmed that the resident was not offered incontinence care regularly, and when care was finally provided, the resident's clothing and wheelchair cushion were found to be saturated with urine. Resident #65, who was occasionally incontinent of bladder and always incontinent of bowel, was also affected by the facility's failure to provide timely care. The resident, who required a Hoyer lift for transfers, was left in a chair with a strong odor of stool in the room. The resident expressed reluctance to receive care due to being told she would have to stay in bed afterward. When incontinence care was eventually provided, the resident's pants were found to be saturated with urine and stool, indicating a lack of timely attention to her needs. The facility's policy on incontinence care, which mandates checking and changing residents every two hours and as needed, was not adhered to in these cases. Interviews with staff, including the Director of Nursing, confirmed the expectation for regular checks and care, but these were not consistently performed, resulting in the observed deficiencies. The report highlights the facility's noncompliance with its own policies, as evidenced by the conditions of the two residents involved.
Failure to Ensure Safe Transfer Results in Resident Injury
Penalty
Summary
The facility failed to ensure Resident #94 was provided a safe transfer via mechanical lift, resulting in a fall with injury. Resident #94, a bilateral above the knee amputee with balance deficits and moderate cognitive impairment, was dependent on staff for transfers. During a transfer from bed to chair using a mechanical lift, the resident began sliding to the floor after the bottom half of the lift sling was removed. Despite attempts by two State Tested Nursing Assistants (STNAs) to lower the resident to the ground, the resident's left amputation site hit the floor, causing the incision to reopen and bleed profusely. The resident was subsequently transferred to the emergency room and required 26 stitches. The resident did not return to the facility. The medical record review revealed that Resident #94 had multiple diagnoses, including pleural effusions, peripheral vascular disease, and type two diabetes mellitus. The resident was on Heparin, an anticoagulant, which increased the risk of bleeding. The resident's care plan indicated a need for assistance with transfers, and therapy evaluations noted significant balance deficits and a high risk for falls. Despite these assessments, the resident was not identified as a fall risk in the initial fall risk assessment. The incident occurred while the resident was being prepared for dialysis, and the nursing progress note documented the resident's pain and bleeding following the fall. Interviews with the DON and the two STNAs involved in the transfer confirmed the sequence of events leading to the fall. The STNAs reported that the resident was not positioned correctly in the chair, and when they attempted to adjust him, he began sliding forward. The STNAs tried to lower the resident to the ground, but the resident's pant leg knots caused additional trauma to the amputation sites. The facility's policies on fall management and mechanical lift usage were reviewed, highlighting the need for proper positioning and safety during transfers. The facility retrained the STNAs on mechanical lift transfers following the incident.
Failure to Ensure Resident Ingested Medications
Penalty
Summary
The facility failed to ensure that Resident #52 ingested all prescribed medications. The resident, who had diagnoses including cerebral infarction, asthma, hemiplegia, hemiparesis, and chronic obstructive pulmonary disease, was found with a medicine cup containing numerous pills on his breakfast tray. The resident reported that the nurse had given him the medications but did not watch him take them. The Licensed Practical Nurse (LPN) confirmed that she left the medications in the resident's room and did not observe him ingest them, as the resident did not like being watched while taking his medications. The LPN also confirmed that there were nine pills in the cup but was unsure if they were the same pills she had initially administered. The facility's policy on medication administration, dated December 2017, requires that residents be observed after administration to ensure the dose is completely ingested. If only a partial dose is ingested, it must be noted on the medication administration record, and appropriate action should be taken. This policy was not followed in the case of Resident #52, leading to a significant medication error. This deficiency was identified during a complaint investigation and affected one of the five residents reviewed for accidents, with the facility census being 87.
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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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