Main Street Care Center
Inspection history, citations, penalties and survey trends for this long-term care facility in Avon Lake, Ohio.
- Location
- 500 Community Drive, Avon Lake, Ohio 44012
- CMS Provider Number
- 365865
- Inspections on file
- 33
- Latest survey
- January 9, 2025
- Citations (last 12 mo.)
- 0
Citation history
Health deficiencies cited at Main Street Care Center during CMS and state inspections, most recent first.
A resident with cognitive impairments was found outside the facility after an unwitnessed fall, having pushed through a window screen. Despite being assessed with no injuries, the incident was not reported to the State Agency as required. The facility's policy on elopement and reporting was not followed, as the incident was not reported as an elopement, and an investigation was not completed.
A resident with multiple diagnoses, including dementia, was found outside the facility after an unwitnessed fall. Despite being high risk for falls, the incident was not documented as an elopement, and no report was filed with the State Agency. The resident was last seen in the dining room and later found on the grass outside, but the incident was not immediately reported to management. Documentation errors and miscommunications contributed to the deficiency.
A resident with moderate cognitive impairment and a history of dementia eloped from the facility by pushing through a window screen. The resident was found outside by staff after another resident reported hearing calls for help. The incident was not immediately reported to management, and the facility failed to follow its elopement policy, resulting in a deficiency in supervision and response.
A resident with Parkinson's disease experienced a significant medication error due to a transcription mistake by an RN, receiving only one-third of the prescribed Carbidopa/Levodopa dose. This led to a decline in the resident's condition, including altered mental status and decreased mobility, resulting in hospitalization for evaluation. The facility's policies on medication administration and physician orders were not properly followed.
A resident at high risk for pressure ulcers developed a deep tissue injury after being left on a bedpan for an unknown duration. Despite care plans and interventions, the resident was not consistently turned and repositioned, leading to a serious pressure injury. The facility's staff could not determine who was responsible, and the situation was described as mortifying by a nurse involved.
The facility failed to provide appropriate incontinence care for three residents, leading to potential harm and discomfort. A resident with moderate cognitive impairment expressed frustration over delayed care, resulting in a small abrasion. Another resident was found with wet incontinence products and irritated skin due to delayed care. A third resident with severe cognitive impairment had soiled liners and dried feces on her skin, causing redness and irritation. The use of multiple liners, against manufacturer's instructions, was observed in all cases.
A resident with a history of alcohol dependence was found inebriated after receiving vodka from a visitor, despite having a care plan and physician's order restricting leave of absence. The facility failed to implement care planned interventions, and staff were unaware of multiple incidents of alcohol use. The facility did not provide a substance abuse treatment policy for review.
A resident with Parkinson's and dementia was inappropriately placed in a secured unit without proper clinical indication or authorization, leading to distress and an elopement incident. Despite being cognitively intact, the resident was confined based on verbal communication and assumptions, rather than documented evidence. The facility failed to secure the environment, allowing the resident to exit through a window, highlighting lapses in safety and communication.
A resident experienced significant delays in receiving assistance after activating her call light due to incontinence. Despite multiple staff members entering her room for other tasks, her request for help was not addressed for nearly an hour, leading to distress and refusal of a meal. Staff interviews confirmed the delay in response.
Failure to Report Elopement Incident
Penalty
Summary
The facility failed to report an incident of possible neglect involving a resident to the State Agency as required. The resident, who had a history of cerebrovascular disease, vascular dementia, and other conditions, was found outside the facility after an unwitnessed fall. The incident occurred when the resident, who used a walker and wheelchair, was found lying on the grass outside a window after reportedly getting tangled in a window screen and pushing through it. Despite being assessed with no noted injuries, the incident was not immediately reported to the appropriate authorities. The incident was discovered when another resident heard someone yelling for help outside her window and informed a CNA. The CNA, along with an LPN and another CNA, went outside to assist the resident. The LPN confirmed that he should have notified management immediately but did not contact the ADON until several hours later. The DON was informed of the incident the following morning but was initially unaware that the resident had been found outside the facility. The facility's policy on elopement and reporting of key events was not followed, as the incident was not reported as an elopement to the State Agency. The DON confirmed that an elopement incident investigation was not completed, and no self-reported incident report was made. The facility's policy requires immediate notification of the charge nurse, Administrator, DON, and Quality Assurance in the event of an elopement, but this protocol was not adhered to in this case.
Failure to Accurately Document Elopement Incident
Penalty
Summary
The facility failed to maintain an accurate medical record for Resident #195, who was admitted with multiple diagnoses including cerebrovascular disease, vascular dementia, and type II diabetes mellitus with chronic kidney disease. On 12/24/24, Resident #195 experienced an unwitnessed fall and was found outside the facility, lying on the grass after reportedly exiting through a window. Despite being assessed as high risk for falls, the incident was not accurately documented as an elopement, and the necessary incident report was not filed with the State Agency. The incident occurred when Resident #195 was last seen in the dining room around 8:35 P.M. by CNA #59. Shortly after, CNA #56 was informed by another resident that someone was yelling for help outside her window. Upon investigation, CNA #56 found Resident #195 outside on the grass. The resident was brought back inside without noted injuries, but the incident was not immediately reported to management. LPN #58, who assisted in bringing the resident back inside, delayed notifying the ADON until after 2:00 A.M. the following day. The Director of Nursing (DON) was not informed of the resident being found outside until 4:00 A.M. on 12/25/24, and no elopement incident investigation was conducted. The DON mistakenly believed the event was a change in status rather than an elopement. Additionally, the ADON admitted to entering incorrect times for the fall risk and safety assessments, which were actually completed on 12/25/24. This series of documentation errors and miscommunications led to the deficiency being cited under Complaint Number OH00161157.
Resident Elopement Due to Inadequate Supervision
Penalty
Summary
The facility failed to provide adequate supervision to prevent the elopement of a resident, identified as Resident #195, who was not initially assessed as being at risk for elopement. Resident #195 had a history of cerebrovascular disease, vascular dementia, and other conditions, and was noted to have moderate cognitive impairment. Despite these conditions, the resident's care plan did not indicate a risk for elopement or wandering. On the night of the incident, the resident was last seen in the dining room before being found outside the facility after falling through a window. The incident occurred when Resident #195 was found lying on the grass outside a window by a CNA after another resident reported hearing someone yelling for help. The resident had apparently pushed through a window screen and exited the building. Staff members, including CNAs and an LPN, assisted in bringing the resident back inside. The resident was assessed and found to have no injuries, but the incident was not immediately reported to management, and the LPN involved did not document the incident in a nursing progress note or complete a witness statement. The Director of Nursing (DON) was not informed of the resident being outside until hours after the incident. The facility's policy on elopement was not followed, as the incident was not treated as an elopement, and no investigation or self-reported incident report was completed. The DON confirmed that the incident should have been considered an elopement, but it was mistakenly viewed as a change in the resident's status. This oversight represents a deficiency in the facility's supervision and response to potential elopement risks.
Medication Error Due to Transcription Mistake
Penalty
Summary
The facility failed to ensure that a resident was free from significant medication errors, affecting one resident during a short respite stay. The resident, who had medical diagnoses including Parkinson's disease, dementia, and adjustment disorder, was prescribed Carbidopa/Levodopa to be taken in a specific dosage. However, due to a transcription error by RN #64, the resident received only one-third of the prescribed dose from 12/20/24 to 12/23/24. This error was identified when the Director of Nursing (DON) reviewed the admission paperwork and discovered the discrepancy in the medication order transcription. As a result of the medication error, the resident experienced a decline in their condition, including altered mental status, drowsiness, and decreased mobility, leading to hospitalization for evaluation. The facility's Medication Administration Policy and Physician Order Policy were not followed, as the error was not initially reported, and the correct dosage was not administered. The incident was documented in the Medication Error Log, and the resident's condition was monitored, but no actual harm was reported.
Failure to Prevent Pressure Ulcer in High-Risk Resident
Penalty
Summary
The facility failed to provide adequate care to prevent pressure ulcers for a resident, resulting in a deep tissue pressure injury. The resident, who was at high risk for pressure ulcers due to her medical conditions, was left on a bedpan for an unknown duration, leading to a serious pressure injury on her bilateral buttocks. The resident's medical history included atherosclerotic heart disease, type two diabetes, a wedge compression fracture, and moderate protein-calorie malnutrition, all contributing to her vulnerability. Observations and interviews revealed that the resident was not consistently turned and repositioned as required, despite being at very high risk according to the Braden Scale. The resident was found on a bedpan by the wound nurse practitioner and a nurse, indicating that she had been left in that position from the night shift. The facility's staff, including agency staff, could not determine who was responsible for leaving the resident on the bedpan, and the situation was described as mortifying by the nurse involved. The facility's documentation and observations showed inconsistencies in the care provided to the resident. Despite care plans and interventions being in place, there was no evidence that the resident was turned and repositioned regularly, as required. The facility's policy on wound prevention and management was not effectively implemented, leading to the development of a deep tissue injury that progressed to an unstageable pressure ulcer. The deficiency was investigated under a complaint, highlighting the facility's non-compliance with care standards.
Inadequate Incontinence Care for Residents
Penalty
Summary
The facility failed to provide appropriate incontinence care for three residents, leading to potential harm and discomfort. Resident #48, who had moderate cognitive impairment and was frequently incontinent, expressed frustration over delayed incontinence care, which caused her to miss activities she enjoyed. During an observation, it was noted that she had a small open abrasion on her buttocks, and she reported having to wait a long time for her incontinence products to be changed. She was found wearing two liners in her pull-up, contrary to the manufacturer's instructions, which stated that wearing multiple liners could cause skin damage and discomfort. Resident #56, who was dependent on others for toileting hygiene, was observed to have not received incontinence care for an extended period. When care was finally provided, it was discovered that she was wearing a wet incontinence brief with two liners, resulting in red and irritated skin. The STNA responsible for her care admitted that this was the first time she had checked on the resident since starting her shift. The Director of Nursing confirmed the inappropriate use of two liners, which was against the manufacturer's guidelines. Resident #43, with severe cognitive impairment and frequent incontinence, was also found to have received inadequate care. Observations revealed that her incontinence brief had not been changed since the beginning of the STNA's shift, and she was found with a soiled liner and dried feces on her skin, causing redness and irritation. The facility's policy and the manufacturer's instructions were not followed, as multiple liners were used, which is considered bad practice and can lead to skin damage.
Failure to Implement Substance Abuse Interventions
Penalty
Summary
The facility failed to implement care planned interventions for a resident with substance abuse issues, leading to a deficiency. The resident, who was cognitively intact, had a history of alcohol dependence with alcohol-induced mood disorder and bipolar disorder. Despite having a physician's order restricting leave of absence (LOA) except for medical appointments, the resident was found inebriated after a visit from his girlfriend, who provided him with vodka in a water bottle. This incident was reported to the nightshift nurse and the physician, but no further interventions were documented. The resident's care plan included interventions such as one-to-one visits, involving family, and making referrals as needed. However, after the incident of alcohol use, there was no evidence that these interventions were implemented. The care plan was revised to note the resident's non-compliance with alcohol use, but the goals and interventions remained unchanged. The facility's records did not show any further orders or actions taken to address the resident's substance abuse following the incident. Interviews with facility staff revealed a lack of communication and awareness regarding the resident's alcohol use. The Director of Nursing was unaware of the second episode of inebriation, and the Social Services Designee did not offer additional psychological services due to being informed of only one incident. The physician involved stated that the resident's LOA should have been revoked for safety reasons, but there was confusion about who authorized the resident's LOA for a fishing trip. The facility did not provide a substance abuse treatment policy for review, only an illegal substance policy.
Inappropriate Secured Unit Placement and Lack of Proper Documentation
Penalty
Summary
The facility failed to ensure appropriate placement and interventions for a resident, leading to a deficiency in behavioral health services. The resident, who had Parkinson's Disease and dementia with agitation, was admitted to the facility for therapy and strengthening. Despite being cognitively intact and having a BIMS score of 14, the resident was placed in a secured unit without a clear clinical indication or proper authorization. This decision was based on verbal communication and assumptions rather than documented evidence or a formal order from the attending physician. The resident expressed frustration and confusion about being in the secured unit, which was not aligned with his cognitive status and personal capabilities. He was able to manage his finances and expressed a desire to leave the facility, indicating that he did not belong in the secured unit. The resident's family and physician were not adequately consulted about the placement, and there was a lack of proper documentation to justify the decision. The facility's staff, including the DON and LPN, acknowledged that the resident was independent and did not require the restrictions of a secured unit. The deficiency was further compounded by the facility's failure to secure the resident's environment properly. The resident was able to exit the facility through a window due to loose metal brackets, highlighting a lapse in safety measures. Interviews with staff revealed confusion and miscommunication regarding the resident's placement and the necessity of the secured unit. The facility's policy required a signed consent for secured unit placement, which was not appropriately obtained or documented, leading to the resident's inappropriate confinement and subsequent distress.
Delayed Response to Resident Call Lights
Penalty
Summary
The facility failed to ensure that resident call lights were answered in a timely manner, affecting at least one resident. Resident #59 reported that when she activated her call light due to incontinence, staff often did not respond promptly. On one occasion, a staff member entered her room, turned off the call light, and left without providing assistance, leaving the resident to wait for nearly an hour. During this time, Resident #59 repeatedly called for help and expressed frustration over the delay. Observations confirmed that Resident #59's call light remained activated for an extended period without appropriate response. Multiple staff members entered the room for other reasons, such as delivering meal trays, but did not address the resident's need for assistance. The resident eventually received help from a nurse after a significant delay, during which she became upset and refused her lunch. Interviews with staff verified the prolonged activation of the call light and the lack of timely response.
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.
Trusted data from CMS and state health departments
Every citation, penalty and Plan of Correction is sourced from public CMS records (latest release May 27, 2026) and official state health department websites — never guesswork.
Trusted by long-term care providers and associations.
