The October 26 incident at Avenue Care and Rehabilitation Center involved Resident #67, who was under hospice care and experiencing an overall decline. CNA #379 discovered him during her rounds when she noticed his call light was on, which was unusual behavior for him.
"I observed Resident #67 with the call light cord around his neck and that was a change in behavior for Resident #67," CNA #379 told inspectors.
She never left his side. CNA #387 was called to assist and observed the resident "to be confused and in distress when she observed Resident #67 in his bed with the cord around his neck."
RN #301, working the night shift, was alerted by CNA #387 about the situation. Instead of immediately calling the physician, she made a FaceTime video call to the resident's Power of Attorney at 12:23 AM.
The POA watched through the video call as staff removed the cord from around Resident #67's neck. "The POA stated the nurse was concerned Resident #67 might be trying to hurt himself," according to the inspection report. The POA told inspectors that Resident #67 "was not strong enough to strangulate himself" and allowed the nurse to remove the cord without resistance.
RN #301 removed all cords from the room and arranged for CNAs to provide one-on-one observation throughout the night until hospice nurses arrived the next morning. But her communication with the physician fell short of facility requirements.
She sent a text message to the doctor after the incident but received no response. She didn't make an actual phone call until 9:04 AM the following morning.
"RN #301 confirmed this was over eight hours after Resident #67 had been found with the call light cord around his neck," inspectors wrote.
The delay violated the facility's own emergency protocols. Unit Supervisor RN #333 told inspectors that "if a resident had a change in condition the nurse needed to report the findings to the physician immediately for interventions, and this needed to be done by a phone call regarding a change in condition, not a text message."
Unit Manager RN #333 and LPN #350 confirmed that any resident with suspected suicidal ideation or self-harm should never be left alone. A phone call to the physician should be placed immediately, and all dangerous items should be removed.
The facility's written policy on resident condition changes, dated July 28, 2022, defines an "Acute Change in Condition" as "a sudden, clinically important deviation from a resident's baseline." The policy warns that without interventions, such conditions "may result in complications or death."
The policy requires that if a physician cannot be reached within 30 minutes and the resident remains in stable condition, staff should call 911 for transport and then update the doctor about the transfer.
RN #301 documented the incident in a late entry at 3:18 AM on October 26, summarizing events that had occurred around 12:30 AM.
CNA #387 couldn't remember the exact time she alerted the nurse about the situation. She confirmed that the POA was video called to observe what was happening and speak directly with Resident #67.
The incident represents a pattern of non-compliance at Avenue Care. Inspectors noted this deficiency "represents continued non-compliance from the survey dated 08/13/25."
Federal inspectors discovered the delayed physician notification during their investigation of a separate complaint filed against the facility. The original complaint investigation led to the discovery of this additional violation involving emergency response protocols.
The facility's policy clearly outlines escalation procedures for medical emergencies, but staff failed to follow them during a critical situation involving potential self-harm. The eight-hour delay between the initial incident and physician contact could have compromised the resident's safety and violated federal regulations requiring immediate medical consultation for significant condition changes.
While the resident was already under hospice care and experiencing decline, the unusual behavior of placing a cord around his neck represented a significant deviation from his baseline condition that required immediate medical evaluation.
The Power of Attorney's assessment that Resident #67 lacked the physical strength to harm himself doesn't diminish the facility's obligation to treat the incident as a potential emergency requiring immediate physician notification.
Staff did take some appropriate immediate actions, including removing all cords from the room and providing continuous one-on-one observation until hospice nurses arrived. However, the failure to promptly contact the physician represented a critical gap in emergency response protocols.
The incident occurred during the overnight shift when fewer staff members are typically on duty, but facility policies make no distinction between day and night requirements for physician notification during emergencies.
Avenue Care's violation of its own emergency notification procedures raises questions about staff training and adherence to critical safety protocols, particularly during situations involving potential self-harm or suicide risk among vulnerable residents.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Avenue Care and Rehabilitation Center, The from 2025-10-29 including all violations, facility responses, and corrective action plans.
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