Avon Place Healthcare Center
Inspection history, citations, penalties and survey trends for this long-term care facility in Avon, Ohio.
- Location
- 32900 Detroit Rd, Avon, Ohio 44011
- CMS Provider Number
- 365155
- Inspections on file
- 27
- Latest survey
- March 18, 2026
- Citations (last 12 mo.)
- 11
Citation history
Health deficiencies cited at Avon Place Healthcare Center during CMS and state inspections, most recent first.
A former resident who had been hospitalized after a hip fracture and later died had her medical records requested by her family’s attorney, who supplied all required authorizations and identifying documents. The facility initially sent only partial records and, despite repeated written, faxed, and telephone follow-up requests for specific missing items such as MDS, assessments, nursing notes, MD progress notes, therapy notes, MARs, TARs, and ADL logs, did not provide evidence that a complete record was released within the timeframe outlined in its own policy. The medical records staff stated that all requests are routed through the Administrator to corporate and are not released without corporate approval, and the Administrator acknowledged receiving multiple requests and forwarding them to corporate but could not provide a corporate contact, resulting in delayed and incomplete access to the former resident’s records.
A resident with paraplegia, ventilator dependence, and a stage 4 pressure ulcer had ordered oral medications, including a blood thinner, iron, and fludrocortisone for blood pressure, left unattended in a medication cup on the bedside table while the resident was asleep and the nurse was at the nurse’s station. The unit manager confirmed the medications and that they were left in the room while the resident slept. Facility policy required medications to be administered as prescribed and to remain in the sight of the nurse until administration, but this was not followed.
A resident with multiple chronic conditions was hospitalized after a fall, yet an LPN documented over several days that the resident remained in the facility, had no change in condition, was receiving skilled PT/OT/speech therapy, and had comprehensive assessments completed. The notes also stated the resident reported generalized pain and was given PRN Percocet. Review of the MAR and narcotic count sheets showed no Percocet was administered during that time, and interviews confirmed the resident was in the hospital when these entries were made. Facility policy required objective, complete, and accurate documentation, which was not met.
A resident with dementia, COPD, and atrial fibrillation experienced multiple changes in condition, including bruising, diarrhea, emesis, and decreased oxygen saturation requiring supplemental oxygen. Staff failed to promptly report or document these changes to the physician or family, and there was no evidence of timely communication or follow-up as required by facility policy.
A resident with severe cognitive impairment and multiple health conditions was found with unexplained bruising on the right hand. Staff did not perform a comprehensive assessment for additional injuries or range of motion, and failed to respond to the resident's verbalized leg pain. Only the bruised hand was documented, and further injuries were identified later at the hospital. Facility policy lacked specific guidance for such assessments in cognitively impaired residents.
A resident with COPD and severe cognitive impairment was not properly assessed or monitored during oxygen therapy after a change in condition. Despite care plan and physician orders requiring respiratory monitoring and documentation, staff failed to document ongoing assessments, oxygen administration, or notify the physician when oxygen was started. The facility's policy for oxygen administration was not followed, and the DON confirmed the lack of required documentation.
The facility did not provide wound care as ordered by physicians and failed to ensure wound dressings were initialed and dated according to policy. Several residents with pressure ulcers or wounds were observed without proper dressings or documentation, and staff interviews confirmed lapses in wound care and awareness of dressing status.
Two residents with suprapubic catheters did not have securement devices in place as required by their care plans and physician orders. Despite documentation and policy requiring securement to prevent dislodgement, observations and staff interviews confirmed the absence of securement devices, and the residents were either unaware of or had never received the devices.
A resident with multiple chronic conditions was care planned and ordered to have a urinary catheter securement device, with staff required to monitor it each shift. Despite this, the device was not in place, and staff, including an LPN, admitted to documenting its presence and monitoring in the medical record when it was not actually present, resulting in falsified documentation.
The facility did not post required Enhanced Barrier Precautions (EBP) signage outside the rooms of two residents with pressure ulcers and failed to ensure staff wore appropriate PPE, such as gowns and gloves, during wound and personal care. Staff were observed using only gloves and not following proper infection control procedures, despite facility policy and physician orders requiring EBP.
A resident with significant physical limitations and high risk for pressure ulcers was found with their call light out of reach, resulting in an inability to request assistance for turning, repositioning, or toileting. The resident reported no staff entered the room overnight, leading to an episode of incontinence without the ability to call for help. Facility policy required call lights to be within reach, but this was not followed.
A resident was found with a medication cup containing unidentified pills left on a table in their room, which were their morning medications. The LPN had left the medications while the resident was in the restroom, without an order for self-administration. The facility's policy requires medications to be administered by authorized personnel and that they remain with the resident until the medication is swallowed, which was not followed.
Failure to Timely Provide Complete Medical Records to Former Resident’s Representative
Penalty
Summary
The deficiency involves the facility’s failure to timely release a complete medical record for a former resident to the resident’s family and their legal representative, despite multiple written and faxed requests. The former resident was admitted on 01/11/24 and later discharged to the hospital after a fall with hip fracture, and subsequently died. On 10/30/25, the family’s attorney submitted an initial request for a certified copy of the resident’s medical record for a specified date range, providing the resident’s identifying information, a notarized affidavit of next of kin, a signed authorization for release of medical records, the death certificate, and contact information. The facility’s policy stated that residents or their representatives may obtain photocopies of records by providing at least 48 hours’ notice (excluding weekends and holidays). The facility’s medical records staff member reported that record requests are forwarded to the Administrator, who then sends them to corporate, and that records are not released until corporate approves what can be released. The attorney reported receiving only partial records on 12/11/25, including a consent to treat form for psychiatric therapy, the facility discharge form, a hospital history and physical, diagnosis and allergy audit reports, immunization audit report, order summary report, weight and vital summary, and the care plan report. On 12/15/25, the attorney notified the facility via fax and mail that the record was incomplete and specifically requested additional documents such as the MDS, all assessments, nursing notes, physician progress notes, therapy notes, MARs, TARs, caregiver notes, consultations, and ADL logs. Additional requests were sent on multiple later dates, with fax confirmations and documented phone calls and voicemails to the Administrator, but there was no response indicating that the missing portions were provided. The Administrator confirmed receiving all of the dated requests and stated that they were forwarded to corporate and that, to her knowledge, the complete record had been sent, but she did not provide a corporate contact number when asked. This sequence of events shows that the facility did not provide timely and complete access to the former resident’s medical record as required by its own policy and regulatory expectations.
Unattended Oral Medications Left at Bedside Contrary to Facility Policy
Penalty
Summary
Facility staff failed to ensure medications were administered as ordered and properly stored until administration for one resident. The resident had paraplegia, was ventilator dependent, and had a stage four pressure ulcer, with an admission date of 05/14/25. A quarterly MDS indicated the resident had intact cognitive function and required set up for eating, and the care plan documented a need for assistance with activities of daily living due to weakness, with an intervention to administer medications as ordered. Physician orders included Xarelto 10 mg by mouth in the morning, Ferrous Sulfate 325 mg by mouth once daily, and Fludrocortisone Acetate 0.1 mg, two tablets by mouth daily for blood pressure. On 03/17/26 at 8:13 A.M., surveyors observed a small medication cup containing four medications left on the resident’s bedside table while the resident was in bed sleeping with a sheet over his head, and the nurse was down the hall at the nurse’s station. The unit manager confirmed that the medications in the cup were Xarelto, Ferrous Sulfate, and Fludrocortisone Acetate and verified that the medications had been left unattended in the room while the resident was sleeping. Review of the facility’s “Administering Medications” policy, revised April 2019, showed that medications were to be administered in a safe and timely manner as prescribed, with medication administration times determined by resident need and benefit, and that during administration medications were to be kept in the sight of the nurse until given to the resident. The observed practice of leaving medications unattended in the resident’s room was inconsistent with this policy.
Inaccurate Documentation on Hospitalized Resident’s Condition and PRN Narcotic Use
Penalty
Summary
Facility staff failed to maintain accurate and complete medical record documentation for one resident during a hospitalization period. The resident, admitted with diagnoses including Parkinson's disease, Lewy Body dementia, diabetes mellitus, and congestive heart failure, had an MDS indicating intact cognition. Nursing progress notes showed the resident was transferred to a local hospital following an overnight fall and returned to the facility via stretcher several days later. Despite this, Skilled Progress Notes completed by an LPN on three consecutive days during the hospitalization documented that the resident had no change in condition, no cognitive impairment, and was receiving skilled PT, OT, and speech therapy services. These notes also described assessments of neurological/musculoskeletal, skin, cardiac/respiratory, gastrointestinal/genitourinary status, and monitoring for medication side effects, all indicating no new or negative findings. The same Skilled Progress Notes further documented that the resident complained of generalized pain and that PRN Percocet was administered as ordered. However, review of the narcotic count sheets and the MAR for the month showed no Percocet was administered during the period in question. Interviews with the LPN who authored the notes and another LPN confirmed that the resident was hospitalized and not in the facility on the dates when these assessments and medication administrations were charted, and they could not explain why documentation was completed on an absent resident. The Administrator verified there were no discrepancies in the narcotic count sheets. Facility policy on charting and documentation required that medical record entries be objective, complete, and accurate, and made only by licensed personnel in accordance with state law and facility policy, which was not followed in this instance.
Failure to Report and Document Changes in Resident Condition
Penalty
Summary
The facility failed to ensure that changes in a resident's condition were promptly reported to the physician, resident, and family as required by policy. A resident with multiple diagnoses, including dementia, COPD, and atrial fibrillation, was observed to have several changes in condition, such as visible bruising on the right hand, episodes of diarrhea, emesis, and a decline in oxygen saturation requiring supplemental oxygen. Despite these changes, there was no documentation in the medical record of timely notification to the physician or family regarding the bruising, diarrhea, or the need for oxygen administration. Surveillance video and staff interviews revealed that CNAs observed and provided care for the resident during episodes of incontinence and noted the resident voicing pain in her leg, but these concerns were not reported to nursing staff or documented. Nursing staff, including LPNs and RNs, either were not made aware of these changes or did not recall the events, and there was no evidence that the physician was notified about the resident's decline in oxygen saturation or the administration of oxygen. The physician later confirmed that he was not aware of the resident's emesis or oxygen use, and stated that protocol would have required further evaluation if he had been notified. Review of facility policies and job descriptions confirmed that staff were required to report changes in resident condition, including injuries, significant changes in physical status, and the need to alter medical treatment. However, the facility did not follow these protocols, as evidenced by the lack of timely communication and documentation regarding the resident's condition changes. This deficiency was identified through review of medical records, surveillance footage, and staff interviews.
Failure to Accurately Assess Resident for Additional Injuries After Unexplained Bruising
Penalty
Summary
A deficiency occurred when staff failed to accurately assess a resident for additional injuries after the discovery of unexplained bruising. The resident, who had severe cognitive impairment due to dementia and multiple comorbidities including osteoporosis and atrial fibrillation, was observed on surveillance video with visible bruising on the right hand during incontinence care. Later, while being assisted out of bed, the resident verbalized leg pain, but this concern was not acknowledged or reported by the CNAs present. Documentation showed that only the bruised hand was noted, and no comprehensive assessment for other injuries or range of motion was performed at that time. Subsequent hospital records revealed that the resident had sustained fractures to the right hand and possibly the left hip, with imaging recommended to further assess the hip. Interviews with staff confirmed that a full head-to-toe assessment and range of motion evaluation were not completed after the initial discovery of the injury. The nurse and CNA involved did not remove the resident's gown to check for additional injuries, nor did they respond to the resident's complaint of leg pain. The facility's policy on focused nursing assessment did not provide specific guidance for assessing range of motion or additional injuries in cognitively impaired residents with unexplained bruising. Staff interviews indicated a lack of consistent practice in assessing residents with injuries of unknown origin, particularly in residents with cognitive impairment who may not be able to clearly communicate their symptoms. The deficiency was further evidenced by the absence of documentation regarding a thorough assessment and the failure to identify additional injuries until after hospital evaluation.
Failure to Assess and Monitor Resident During Oxygen Therapy After Change in Condition
Penalty
Summary
The facility failed to ensure that a resident was properly assessed and monitored while receiving oxygen therapy following a change in condition. The resident, who had diagnoses including dementia, chronic obstructive pulmonary disease (COPD), and severe cognitive impairment, experienced vomiting and a decline in oxygen saturation. Although the care plan and physician orders required monitoring of respiratory status and oxygen administration as needed, there was no documentation of ongoing respiratory assessments, monitoring of oxygen saturation, or notification to the physician when oxygen was initiated. The medical record lacked evidence of continued monitoring or documentation of oxygen administration on the medication administration record (MAR) after the resident's condition changed. Staff interviews confirmed that the physician was not notified of the resident's need for oxygen, and nursing staff could not recall details of the resident's respiratory assessments or monitoring. The DON verified the absence of documentation regarding oxygen monitoring and administration. The facility's policy required assessment and documentation during oxygen administration, including lung sounds, oxygen saturation, and the resident's response, but these procedures were not followed. This deficiency affected one resident out of three reviewed for change in condition, with a total of nine residents in the facility receiving oxygen therapy.
Failure to Provide Wound Care per Physician Orders and Document Dressing Changes
Penalty
Summary
The facility failed to provide wound care according to physician's orders and did not ensure wound dressings were initialed and dated as required by facility policy. Multiple residents were affected, with one resident not having any of the prescribed wound dressings in place for three pressure ulcers, and several other residents observed with wound dressings that were not initialed or dated. Staff interviews confirmed that wound care was not consistently performed as ordered, and that there was a lack of awareness among nursing staff regarding the status of wound dressings. Resident records revealed that one resident with multiple sclerosis, severe protein calorie malnutrition, and a history of pressure ulcers was at very high risk for skin breakdown. This resident was dependent on staff for hygiene and positioning and had multiple stage three and four pressure ulcers. Despite clear physician orders for specific wound care regimens and dressing changes, observations showed that dressings were missing or not applied as ordered, and staff were unaware of the lapses in care. Additional observations of other residents found wound dressings that were not initialed or dated, with some dressings falling off or not changed as needed. Resident interviews indicated uncertainty about when dressings were last changed, and staff interviews confirmed that required documentation and dressing changes were not consistently performed. Review of facility policy confirmed the expectation to follow physician orders and to mark dressings with initials and dates, which was not adhered to in these cases.
Failure to Secure Suprapubic Catheters as Ordered
Penalty
Summary
The facility failed to ensure that suprapubic catheters were properly secured for two residents who required securement devices as part of their care. For one resident with multiple sclerosis, muscle weakness, and other significant diagnoses, the care plan and physician orders specified the use of a catheter securement device to prevent accidental dislodgement, with orders to replace the device every seven days and as needed. Despite documentation indicating a securement device was in place, direct observation and staff interviews confirmed that the resident did not have a securement device at the time of inspection, and the resident was unaware of how long it had been missing. A second resident with paraplegia, diabetes, morbid obesity, and other chronic conditions also had a care plan and physician orders requiring a catheter securement device, with instructions for daily and shift monitoring. Observation revealed that this resident's suprapubic catheter was not secured, and both the resident and her husband reported never having seen a securement device in use during her stay. Staff interviews further confirmed the absence of the securement device. Facility policy required the use of a securement device or leg band for catheter care, but this was not followed for either resident.
Falsification of Medical Record Regarding Catheter Securement Device
Penalty
Summary
The facility failed to ensure the accuracy and integrity of a resident's medical record, resulting in falsified documentation. A review of the medical record for a resident with multiple diagnoses, including paraplegia and chronic kidney disease, showed that the care plan required a urinary catheter securement device to be in place, and physician orders directed staff to monitor the device daily and every shift. The Treatment Administration Record (TAR) for the month indicated that nurses documented the securement device as being in place every shift. However, direct observation revealed that the resident did not have a catheter securement device, and both the resident and her husband reported that she had never had one while at the facility. Staff interviews confirmed the absence of the device, and an LPN admitted to documenting in the electronic medical record that the securement device was present and monitored, despite knowing it was not. This action was in direct violation of the facility's policy requiring objective, complete, and accurate documentation in the medical record.
Failure to Implement Enhanced Barrier Precautions and PPE Use
Penalty
Summary
The facility failed to implement proper Enhanced Barrier Precautions (EBP) for residents requiring such measures, as evidenced by observations and record reviews. For one resident with multiple diagnoses including cerebral infarction, malnutrition, diabetes, hypertension, and two stage four pressure wounds, staff did not follow correct infection control procedures during a dressing change. The LPN performing the dressing change wore only gloves, did not change gloves between tasks, and used a bottle of normal saline with both dirty and clean gloves, contrary to infection control protocols. The LPN confirmed that only gloves were worn during the procedure, despite the care plan and physician orders specifying EBP. Additionally, another resident with multiple sclerosis, severe malnutrition, and several stage three and four pressure ulcers did not have the required EBP signage posted outside the room. Observations showed that staff providing incontinence, wound, and catheter care to this resident wore only gloves and did not use gowns as required by facility policy. Staff interviews confirmed that the appropriate PPE was not used and that the necessary signage was missing. The facility's policy mandates both gown and gloves for EBP and requires signage to be posted outside the resident's room.
Call Light Inaccessible for Dependent Resident
Penalty
Summary
A deficiency was identified when a resident with multiple sclerosis, muscle weakness, severe protein calorie malnutrition, hyperlipidemia, and hypertension was found to have their call light out of reach while lying in bed. The resident's care plan indicated a need for assistance with activities of daily living and positioning due to high risk for pressure ulcers, with documented stage three and stage four pressure ulcers present. Observation revealed the call light was hanging on the tube feeding pole, not accessible to the resident. During the observation, the resident was found crying and reported that no staff had entered the room throughout the night, resulting in no assistance with turning, repositioning, or toileting. The resident stated they experienced an episode of bowel incontinence and could not call for help. A CNA confirmed the call light was out of reach and that the resident was incontinent and unable to call for assistance. Facility policy required that call lights be within reach for residents in bed or confined to a chair, but this was not followed in this instance.
Medication Administration Deficiency
Penalty
Summary
The facility failed to ensure medications were administered properly and were not left at the resident's bedside, affecting one resident. Resident #20, who was cognitively intact with a BIMS score of 15, was observed with a medication cup containing five unidentified pills on a table in their room. The resident reported that the medications were their morning doses, which had been left by an LPN while the resident was in the restroom. The LPN confirmed that they had placed the medication cup on the table and left the room. A review of the electronic medical record revealed no order for self-administration of medication for Resident #20. Interviews with the DON and ADON confirmed the absence of such an order. The facility's policy on medication administration requires that medications be administered by authorized personnel and that they remain with the resident until the medication is swallowed, which was not adhered to in this instance.
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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