Avon Place Healthcare Center

F 0580 Level of Harm - Minimal harm or potential for actual harm

facility would notify the physician and resident representative of changes in the resident's medical condition or status including injuries of an unknown source, a significant change in the resident's physical condition, a need to alter the residents medical treatment, and specific instruction to notify the physician of changes in

the resident's condition.

Residents Affected - Few

FORM CMS-2567 (02/99) Previous Versions Obsolete

Event ID:

Facility ID:

If continuation sheet

Printed: 04/13/2026 Form Approved OMB No. 0938-0391

Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION

(X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER:

(X2) MULTIPLE CONSTRUCTION

B. Wing

A. Building

(X3) DATE SURVEY COMPLETED

11/18/2025

NAME OF PROVIDER OR SUPPLIER

STREET ADDRESS, CITY, STATE, ZIP CODE

Avon Place Healthcare Center

32900 Detroit Rd Avon, OH 44011

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG

SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0684 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few

FORM CMS-2567 (02/99) Previous Versions Obsolete

her leg. CNA #306 revealed the nurse should have been notified before getting the resident out of bed.

Interview on 11/18/25 at 11:50 A.M., Registered Nurse (RN) #302 revealed after she was notified of Resident #77's bruising to the hand she looked at the resident's hand and visible skin. RN #302 revealed

she had not removed the resident's gown to assess the resident's skin had not check the resident's range of motion for additional injuries. RN #302 revealed the nursing assistants had not reported the resident had indicated a concern with her leg. Interview on 11/18/25 at 1:04 P.M., LPN #402 revealed when a resident had an injury the resident should be asked how the injury occurred and also question staff who last worked with the resident. LPN #402 revealed the resident should have a complete head to toe assessment to check for additional injuries. LPN #402 revealed the resident's range of motion should be assessed if safe to do so and the physician should be notified. Interview on 11/18/25 at 4:25 P.M., the Director of Nursing (DON) revealed if a resident had an injury then staff should assess the injury and report findings. If the resident had complaints of other pain then a head to toe assessment should be completed. The DON revealed she believed the nurse assessed the resident and notified the physician and implemented the new orders. The DON revealed staff could assess the resident while they are moving in bed and do not necessarily need to include range of motion. The DON revealed based off Resident #77's initial assessment she had not believed it was necessary to complete range of motion. Review of the undated facility policy Protocol: Focused Nursing Assessment, revealed a focused assessment zeroes in on a patient's current problem or complaint to identify immediate needs, monitor changes, and evaluate the effectiveness of interventions.

Further review of the protocol revealed a focused assessment should be completed during acute changes.

Continued review of the policy revealed no specific guidelines for assessing range of motion or assessing for additional injuries when a cognitively impaired resident was found with bruising of unknown origin.

Event ID:

Facility ID:

If continuation sheet

Printed: 04/13/2026 Form Approved OMB No. 0938-0391

Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION

(X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER:

(X2) MULTIPLE CONSTRUCTION

B. Wing

A. Building

(X3) DATE SURVEY COMPLETED

11/18/2025

NAME OF PROVIDER OR SUPPLIER

STREET ADDRESS, CITY, STATE, ZIP CODE

Avon Place Healthcare Center

32900 Detroit Rd Avon, OH 44011

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG

SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0695 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few

FORM CMS-2567 (02/99) Previous Versions Obsolete

Interview on 11/18/25 at 12:12 P.M., the Director of Nursing (DON) verified there was no documentation of oxygen monitoring, respiratory assessments, and no documentation of the MAR of oxygen administration.

Interview on 11/18/25 at 12:45 P.M., RN #500 revealed she was in charge of respiratory services. RN #500 revealed she recalled a day Resident #77 looked sick and believed staff had asked to bring the resident an oxygen concentrator. RN #500 revealed she was not monitoring the resident as the resident was not receiving respiratory services. Review of the facility policy Oxygen Administration, revised 10/2010, revealed the resident would be assessed during oxygen administration including lung sounds and oxygen saturation levels. Staff would document the rate of oxygen flow, route, and rationale, the frequency and duration of the treatment, the reason for as needed administration, all assessment data obtained before, during, and after the procedure, how the resident tolerated the procedure, and would report other information in accordance with facility policy and professional standards of practice.

Event ID:

Facility ID:

If continuation sheet