Avenue At Lyndhurst

F 0573 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few

Let each resident or the resident's legal representative access or purchase copies of all the resident's records.

Based on medical record request review, email review, staff interview and facility policy review, the facility failed to fulfill a request for medical records in a timely manner. This affected one (Resident #100) of three residents reviewed for medical records requests. The facility census was 86. Findings include:Review of the medical record for former Resident #100 revealed an admission date of 10/07/24 and discharge date of 10/29/24. Resident #100 passed away while at the facility. Review of the medical records request dated 03/31/25 revealed a law firm representing Resident #100's personal representative requested a complete copy of all resident records in the possession of the facility for Resident #100. The request included a medical authorization form signed by Resident #100's administrator of estate and a court order for the release of the medical records and medical billing records. Review of the medical records request dated 05/12/25 revealed a second request was made for the medical records of Resident #100 by a law firm representing Resident #100's personal representative. Review of the email chain dated 08/20/25 between Medical Records #374 and the facility's corporate office revealed Medical Records #374 requested an update on sending the medical records as requested for Resident #100's administrator of estate. The corporate office responding indicating a secure link was sent to the law firm for access to the medical records on 08/20/25. Review of the uploads to the secure link revealed Resident #100's medical record from 08/01/24 to 07/31/25 was uploaded on 08/13/25. Interview on 08/25/25 at 8:48 A.M. with Medical Records #374 confirmed the requests on 03/31/25 and 05/12/25 were not fulfilled in a timely manner.

Medical Records #374 confirmed the law firm was unable to access the medical records until 08/20/25 via

a secure link. Interview on 08/25/25 at 8:58 A.M. with the Licensed Nursing Home Administrator (LNHA) revealed the former medical records employee had not fulfilled the medical record requests for Resident #100. LNHA indicated the former medical records employee had been terminated.Review of the facility policy Medical Records Request, dated January 2023, revealed record requests must be approved by the Corporate Clinical Director. A written consent from the resident or representative was required. Fees would be applied per page for medical records.This deficiency represents noncompliance investigated under Complaint Numbers 2581623, 1401397 (OH00163878) and 1401396 (OH00163306).

Any deficiency statement ending with an asterisk (*) denotes a deficiency which the institution may be excused from correcting providing it is determined that other safeguards provide sufficient protection to the patients. (See instructions.) Except for nursing homes, the findings stated above are disclosable 90 days following the date of survey whether or not a plan of correction is provided. For nursing homes, the above findings and plans of correction are disclosable 14 days following the date

these documents are made available to the facility. If deficiencies are cited, an approved plan of correction is requisite to continued program participation.

LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER REPRESENTATIVE'S SIGNATURE

TITLE

(X6) DATE

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

Facility ID:

If continuation sheet

Event ID:

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

08/28/2025

NAME OF PROVIDER OR SUPPLIER

STREET ADDRESS, CITY, STATE, ZIP CODE

Avenue at Lyndhurst

5442 Rae Road Lyndhurst, OH 44124

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 0628 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few

Provide the required documentation or notification related to the resident's needs, appeal rights, or bed-hold policies. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on

record review and interview, the facility failed to ensure the Ombudsman was notified of transfers for Residents #10 and #93, and the facility failed to ensure a transfer notice was issued for Resident #98. This affected three (Residents #10, #93, and #98) of three residents reviewed for hospitalization. The facility census was 86. Findings include:1. Review of the medical record revealed Resident #10 was admitted to

the facility on [DATE REDACTED] with diagnoses including acute kidney failure and multiple sclerosis.

Review of the medical record revealed Resident #10 was sent to the hospital on [DATE REDACTED] and was subsequently admitted to the hospital. Reviews of both the electronic and hard charts revealed no documented evidence that the Ombudsman was notified of the residents transfer to the hospital.

Interview on 08/20/15 at 2:00 P.M. with Social Service Designee (SSD) #388 revealed that the Ombudsman was not notified that Resident #10 went to the hospital on [DATE REDACTED].

1. 2. Review of the medical record revealed Resident #93 was admitted to the facility on [DATE REDACTED] with a

discharge date of 07/25/25. Diagnoses included diabetes mellitus, general anxiety disorder, and acute respiratory failure.

Review of the medical record revealed Resident #93 was sent to the hospital on [DATE REDACTED], 05/28/25, and 07/01/25 and was subsequently admitted to the hospital. Reviews of both the electronic and hard charts revealed no documented evidence that the Ombudsman was notified of the residents’ transfers to

the hospital.

Interview on 08/20/15 at 2:00 P.M. with SSD #388 revealed the Ombudsman was not notified of Resident #93’s transfers to the hospital on [DATE REDACTED], 05/28/25, and 07/01/25.

2. 3. Review of the medical record for Resident #98 revealed an admission date of 02/06/24. Diagnoses

included cerebral infarction, pneumonia, hemiplegia and hemiparesis, sepsis, gastrostomy status, and dementia. The resident was discharged from the hospital on [DATE REDACTED].

Review of the Discharge Return Anticipated Minimum Date Set (MDS) 3.0 dated 08/21/24 revealed Resident #98 had severely impaired cognition and required maximum assistance eating, oral hygiene, dressing, personal hygiene, and bathing/showers.

Record review revealed there were no transfer notices for a hospitalization on 06/17/24 or a hospitalization

on 08/08/24.

The lack of the required transfer notices was verified Corporate Director of Operations #409 on 08/25/25 at 1:42 P.M.

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

08/28/2025

NAME OF PROVIDER OR SUPPLIER

STREET ADDRESS, CITY, STATE, ZIP CODE

Avenue at Lyndhurst

5442 Rae Road Lyndhurst, OH 44124

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 0677

said she would be right back.

Level of Harm - Minimal harm or potential for actual harm

Interview on 08/20/25 at 3:24 P.M., Resident #15 stated she needed to be in bed, and the nurse said she would be right back.

Residents Affected - Some

Interview on 08/20/25 at 3:25 P.M., Resident #9 stated she needed to be changed, and the nurse said she would be right back. Resident #9 stated staff always come in, turn the light off and then leave and never return.

Interview on 08/20/25 at 3:37 P.M., LPNs #303 and #346 were observed sitting at the nurse’s desk from 3:10 P.M. to 3:37 P.M. Both staff stated CNA #359 was working on the unit. Both staff were asked why

they were sitting at the desk with three call light activated. Both staff stated they were doing training.

1. 3. Review of the medical record for Resident #69 revealed an admission date of 09/19/23. Diagnoses

included type II diabetes, Alzheimer’s disease, encephalopathy, morbid obesity, overactive bladder and depression.

Review of the quarterly MDS 3.0 assessment dated [DATE REDACTED] revealed Resident #69 had impaired cognition.

The resident was dependent on staff for eating, toileting, showering and dressing. Resident #69 was incontinent of bowel and bladder.

Review of the progress note dated 06/27/25 at 5:02 A.M. written by LPN #398 stated Resident #69’s power of attorney (POA) contacted the facility to inform nursing that Resident #69 had not been checked and changed for a while. The resident was laid down for bed at 9:30 P.M. The CNA reported back to the nurse and stated the last time she checked on the resident was at 1:00 A.M. LPN #389 educated the CNA

on the facility policy to check and change resident every two hours. Resident #69’s POA called back ten minutes later to inquire again about care. LPN #398 checked on the CNA, and she was proving care to another resident. The CNA then went into Resident’s #69 room and provided care, and the brief was mildly saturated. The resident was now in bed, resting comfortably and the POA was satisfied.

Interview on 08/21/25 at 9:30 A.M. with LPN #389 stated Resident #69’s POA was very strict about times when the resident was changed. LPN #389 verified Resident #69 was not changed every two hours per facility policy. LPN #389 educated the CNA on the facilities policy.

Interview on 08/25/25 at 5:00 P.M. with the Director of Nursing (DON) stated she directed LPN #389 to document the incident.

Review of the facility policy titled Incontinence Care, revised March 2022, revealed the policy is to ensure a resident who is incontinent of bowel and/or bladder receives appropriate treatment and services to prevent urinary tract infections and to restore continence to the extent possible.

This deficiency represents noncompliance investigated under Master Complaint Number 2589262 and Complaint Numbers 2579574 1401332 (OH00167486), 1401404 (OH00167479), 1401399 (OH00165474), 1401397 (OH00163878), and 1401393 (OH00162964).

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

08/28/2025

NAME OF PROVIDER OR SUPPLIER

STREET ADDRESS, CITY, STATE, ZIP CODE

Avenue at Lyndhurst

5442 Rae Road Lyndhurst, OH 44124

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 0689 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some

assigned to Resident #39 on 08/10/25. CNA #331 stated it was early in the morning, and she was doing check and change rounds. CNA #331 stated she was changing Resident #39 and turned her on her right side. CNA #331 stated there was no bed rail on the right side for Resident #39 to hold onto. CNA #331 stated while Resident #39 was turned onto her side she went to the bathroom to get wash cloths from the sink in the bathroom. CNA #331 stated upon her return Resident #39 was already falling out of bed. CNA #331 stated she checked on Resident #39 and got her into a comfortable position then went to get help from the nurse. CNA #331 stated Resident #39 was dependent on staff for care related to quadriplegia.

CNA #331 stated it would have been more appropriate to have two people in room while changing Resident #39.

Interview on 08/26/25 at 8:42 A.M. with RN #306 revealed she had worked night shift and was assigned to Resident #39. RN #306 stated CNA #331 came to her and indicated Resident #39 fell out of bed. RN #306 stated CNA #331 had changed her story of what happened several times and the way Resident #39 fell was not making sense. RN #306 indicated when she questioned Resident #39, she reported CNA #331 left her turned on her side when she fell. RN #306 stated Resident #39 did not have a side rail on the right side of her bed. RN #306 stated Resident #39 should not have been turned onto her right side and left without support.

1. 5. Review of the closed medical record for Resident #99 revealed an admission date of 02/13/25.

Diagnoses included pneumonia, malignant neoplasm of esophagus, encephalopathy, attention deficit hyperactivity disorder, anxiety disorder, and bipolar disorder. The resident was discharged to another facility

on 03/11/25.

Review of the fall risk assessment dated [DATE REDACTED] revealed Resident #99 was not at risk for falls.

Review of the Modification of admission MDS 3.0 assessment dated [DATE REDACTED] revealed Resident #99 had intact cognition. Resident #99 required supervision or touching assistance for sit-to-stand, chair-to-bed transfers, and walking. Medications received: antipsychotic, antianxiety, antidepressant, antiplatelet, hypoglycemic, anticonvulsant. Antipsychotics received on an as needed (PRN) basis only.

Review of the nurse’s note dated 03/04/25 at 5:15 P.M. Resident #99 was returning to the facility from a radiation therapy appointment, when resident fell on the walkway outside of the building. The fall was witnessed by the receptionist and the person transporting the resident. Resident #99 had a right index finger skin tear, a minor right knee scrape, and minor left pinky finger scrape. The nurse cleaned the area and notified all parties. The resident did not have any injuries to the head. Vital signs were taken. Pain was three on scale of zero to ten.

Review of the fall investigation dated 03/04/25 revealed the fall was unwitnessed (although nursing note stated it was witnessed by the receptionist and the transporter). Nursing assessed the resident. Vital signs were taken. The resident had a right index finger skin tear, a minor right knee scrape, and minor left pinky finger scrape. The pain assessment form and the fall assessment form were not completed.

Interview on 08/22/25 at 1:48 P.M. RDCS #502 verified the pain assessment form and the fall assessment form were not completed.

This deficiency represents noncompliance investigated under Master Complaint Number 2589262, and Complaint Numbers 2579574, 1401332 (OH00167486), 1401397 (OH00163878), 1401396 (OH00163306), and 1401401 (OH00162944).

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

08/28/2025

NAME OF PROVIDER OR SUPPLIER

STREET ADDRESS, CITY, STATE, ZIP CODE

Avenue at Lyndhurst

5442 Rae Road Lyndhurst, OH 44124

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 0756 Level of Harm - Minimal harm or potential for actual harm

one tablet by mouth at bedtime for anxiety was not given on 02/14/25, 02/15/25, and 02/17/25. It was noted to see nurse’s note on 02/14/25, 02/15/25, and 02/17/25.

Review of the nursing progress notes for Resident #99 for 02/14/25 revealed no notes regarding the missed dose of Alprazolam oral tablet 0.5 mg.

Residents Affected - Few

Review of the nursing progress note dated 02/15/25 at 2:17 A.M. revealed the Alprazolam oral tablet 0.5 mg was pending delivery. There was no indication that any action had been taken regarding obtaining the medication.

Review of the nursing progress note dated 02/15/2025 at 8:51 PM revealed Alprazolam oral tablet 0.5 mg: Provider notified about script for this medication by this nurse. Provider asked this nurse to call the pharmacy and gave them his cell phone number for pharmacy to call him. The nurse called the pharmacy as instructed and gave them provider's number. The medication was pending.

Review of the nursing progress notes for Resident #99 for 02/17/25 revealed no notes regarding the dose missing for Alprazolam oral tablet 0.5 mg, give one tablet by mouth at bedtime for anxiety.

Interviews on 08/22/25 at 1:48 P.M. RDCS #502 verified there was no nursing note regarding Alprazolam

on 02/14/15 or 02/17/25. It appeared no action was taken until late 02/15/25. There was a delay in Resident #99 receiving Alprazolam.

This deficiency represents noncompliance investigated under Complaint Numbers 1401397 (OH00163878) and 1401401 (OH00162944).

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

08/28/2025

NAME OF PROVIDER OR SUPPLIER

STREET ADDRESS, CITY, STATE, ZIP CODE

Avenue at Lyndhurst

5442 Rae Road Lyndhurst, OH 44124

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 0803 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some

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

Ensure menus must meet the nutritional needs of residents, be prepared in advance, be followed, be updated, be reviewed by dietician, and meet the needs of the resident.

Based on observation, review of the meal spreadsheet, interview, and review of the facility policy, the facility failed to ensure accurate portions were served according to the menu diet spread sheet. This affected 22 (Residents #10, #14, #18, #29, #30, #37, #41, #42, #45, #46, #47, #51, #54, #56, #59, #66, #69, #73, #74, #78, #79, and #103) in the main dining room who were not on a pureed diet. The facility identified four (Residents #1, #48, #65, and #90) in the main dining room who received a pureed diet. This had the potential to affect all residents who received meals from the facility. The facility identified four (Residents #4, #19, #49, and #60) who received nothing by mouth (NPO). The facility census was 86. Findings include:Observation on 08/18/25 from 12:00 P.M. through 12:25 P.M. revealed residents were served by table. During the meal service, observation of the chicken and wild rice casserole revealed the portion appeared less than the spread sheet indicated. Interview on 08/18/25 at 12:23 P.M. with Resident #30 revealed that he was still hungry. Business Office Manager (BOM) #311 asked the kitchen for more food for Resident #30. Observation and interview of the lunch tray line on 08/18/25 at 12:24 P.M. revealed the utensil that was being used to serve the chicken and wild rice casserole was a #8 scoop. [NAME] #363 verified that she was giving one #8 scoop portion, which equaled four ounces. Review of the facility's spreadsheet for 08/18/25 lunch meal service revealed that the serving size for chicken and wild rice casserole was one cup, and the serving instructions stated to use either an eight-ounce spoodle or two four-ounce scoops. This was verified by Mobile Dietary Manager (MDM) #500 at time of observation. This deficiency represents noncompliance investigated under Complaint Numbers 1401399 (OH00165474) and 1401394 (OH00163002).

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

08/28/2025

NAME OF PROVIDER OR SUPPLIER

STREET ADDRESS, CITY, STATE, ZIP CODE

Avenue at Lyndhurst

5442 Rae Road Lyndhurst, OH 44124

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 0809 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some

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

Ensure meals and snacks are served at times in accordance with resident’s needs, preferences, and requests. Suitable and nourishing alternative meals and snacks must be provided for residents who want to eat at non-traditional times or outside of scheduled meal times.

Based on observation, interview, and record review, the facility failed to ensure meals were served in a timely manner. This affected three (Residents #37, #666, and #103) and had the potential to affect all resident receiving food from the kitchen. The facility identified four (Residents #4, #19, #49, and #60) as receiving nothing by mouth (NPO). The facility census was 86. Findings include:Review of the undated facility mealtimes revealed breakfast was served from 7:00 A.M. to 8:45 A.M., lunch was served from 11:30 A.M. to 1:00 P.M., and dinner was served from 4:30 P.M. to 5:30 P.M. The identified order of serving was first dining room, assisted living, premium suites, front hall, middle hall and back hall. Observation of tray line on 08/18/25 at 12:25 P.M. revealed food was above 165 degrees Fahrenheit (F) on the tray line, preferences were honored, condiments were available, and every tray had appropriate silverware including adaptive equipment. Observation on 08/18/25 revealed the food cart left the kitchen at 1:24 P.M. and was delivered to the back hall. Interview on 08/18/25 at 1:24 P.M. with the Mobile Dietary Manager (MDM) #500 verified that the meal trays were delivered 24 minutes late according to the posted mealtimes. Observation

during interview with Resident #63, who resided in the Middle Hall, on 08/18/25 at 1:55 P.M. revealed Corporate Registered Nurse (CRN) #410 delivered the lunch tray. Interview on 08/18/25 at 1:56 P.M. with CRN #410 confirmed he had delivered Resident #63's lunch meal tray. CRN #410 indicated he was unsure why the meal trays were late. CRN #410 reported he had been asked to help pass meal trays. During interviews with residents during the Resident Council meeting on 08/20/25 at 11:15 A.M., Residents #37, #666, and #103 voiced concerns that meals were often served late. Review of the posted mealtimes for lunch meal service revealed that the Middle Hall should have had their meal trays delivered at 12:45 P.M. and the Back Hall meal trays should have been delivered by 1:00 P.M. This deficiency represents noncompliance investigated under Complaint Numbers 1401399 (OH00165474) and 1401394 (OH00163002).

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

08/28/2025

NAME OF PROVIDER OR SUPPLIER

STREET ADDRESS, CITY, STATE, ZIP CODE

Avenue at Lyndhurst

5442 Rae Road Lyndhurst, OH 44124

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 0812 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Many

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

Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.

Based on observations, interviews and facility policy review, the facility failed to ensure clean food service areas including opened food that was not labeled or dated. This had the potential to affect all residents who received meals from the kitchen. The facility identified four (Residents #4, #19, #49, and #60) as receiving nothing by mouth (NPO). The facility census was 86. Findings include:Initial tour of the kitchen on 08/18/25 from 8:24 A.M. through 8:40 A.M. revealed potato chips and white cake mix were not dated in the dry storage area. In the prep area, the slicer had dried food on the blade, and the mixer had dried batter on the back splash. In the reach-in refrigerator located under the prep table in the cook's area there was bacon, chicken noodle soup, and lima beans that were not labeled and dated. In the reach-in freezer, there was breaded chicken patties, chicken fingers, unbreaded chicken breasts, onion rings and French fries that were not labeled or dated. The findings were verified by the Administrator at the time of the observation.

Review of the undated facility policy titled, Food and Sanitation revealed that open packages and leftovers will be labeled and dated. Review of the undated facility policy titled, General Sanitation of the Kitchen revealed that the food and nutrition will maintain the sanitation of the kitchen through compliance with a written cleaning schedule.

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

08/28/2025

NAME OF PROVIDER OR SUPPLIER

STREET ADDRESS, CITY, STATE, ZIP CODE

Avenue at Lyndhurst

5442 Rae Road Lyndhurst, OH 44124

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 0880

Provide and implement an infection prevention and control program.

Level of Harm - Minimal harm or potential for actual harm

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on

record review, observation, interview and facility policy review, the facility failed to ensure proper infection control with Resident #69 during incontinence care. This affected one (Resident #69) of one resident reviewed for incontinence care and had the potential to affect six additional (Residents #1, #22, #42, #55, #59, and #77) whom required incontinence care on the Certified Nursing Assistant's (CNA) #365's assignment. The facility census was 86. Findings include:Review of the medical record for Resident #69 revealed an admission date of 09/19/23. Diagnoses included type II diabetes, Alzheimer's disease, encephalopathy, morbid obesity, overactive bladder and depression. Review of the quarterly Minimum Data Set (MDS) 3.0 assessment dated [DATE REDACTED] revealed Resident #69 had impaired cognition. The resident was dependent on staff for eating, toileting, showering and dressing. Resident #69 was incontinent of bowel and bladder. Observation on 08/20/25 at 9:20 A.M. of incontinence care with Resident #69, with CNA #365, revealed she gathered the incontinence supplies, washed her hands and donned gloves. CNA #365 removed Resident #69's brief and began providing care. CNA# 365 finished cleaning Resident #69 applied

a clean brief and continued to reposition and adjust the bed by touching the remote with the same soiled gloves. CNA #365 removed her gloves and washed her hands and left the room. Interview on 08/20/25 at 9:29 A.M. with CNA #369 stated since the gloves were not visibly dirty, she did not have to change them while repositioning Resident #69 or adjusting her bed. Review of the facility policy titled Incontinence Care, revised March 2022, revealed the procedure stated to clean and dry the resident, replace and drape the resident as requested, dispose of gloves, perform hand hygiene, and ensure call light is in place. This deficiency represents noncompliance identified under Complaint Number 1401393 (OH00162964) and 1401394 (OH00163002).

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

08/28/2025

NAME OF PROVIDER OR SUPPLIER

STREET ADDRESS, CITY, STATE, ZIP CODE

Avenue at Lyndhurst

5442 Rae Road Lyndhurst, OH 44124

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 0949 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some

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

Provide behavior health training consistent with the requirements and as determined by a facility assessment. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on

review of the Facility Assessment, personnel record review, and interview, the facility failed to provide behavioral health training upon hire and/or annually to all staff who were employed at the facility. This had

the potential to affect all 86 residents in the facility. Findings include:Review of the nursing in-service regarding behaviors on 05/06/25 revealed it included nursing staff but did not include housekeeping, dietary, or maintenance. Review of the facility's Facility assessment dated [DATE REDACTED] included under staff training, education and competency training would be provided to all staff (beginning July 2023) about caring for residents with mental and psychosocial disorders, as well as residents with a history of trauma and/or post-traumatic stress disorder. Training included review of competencies and skills to provide patient care services that reflect the resident's goals. Review of the personnel record for Housekeeper #418 revealed he was contract staff with a hire date of 05/27/25 with no documented evidence of behavioral training. Review of the personnel record for Floor Tech #415 revealed he was contract staff with a hire date of 11/03/24 with no documented evidence of behavioral training. Review of the personnel record for Certified Nursing Assistant (CNA) #329 revealed she had a hire date of 07/23/25 with no documented evidence of behavioral training. Review of the personnel record for CNA #313 revealed she had a hire date of 07/25/25 with no documented evidence of behavioral training. Review of the personnel record for CNA #323 revealed she had a hire date of 06/11/25 with no documented evidence of behavioral training.

Interview on 08/20/25 at 10:10 A.M. with Corporate Human Resource Manager (CHR) #501 verified that new hires do not get behavioral training during orientation and it was not included on the company mandated 12 hours of annual in-services. Interview on 08/20/25 at 10:36 A.M. with Director of Nursing (DON) revealed that she did in-service staff on behaviors on 05/06/25 because she felt there was a need for staff to be trained on behaviors at the time. Interview on 08/20/25 at 2:56 P.M. with the contracted Regional Housekeeping Director (RHD) #423 verified that there was no documented behavioral training for housekeeping employees. This deficiency represents noncompliance investigated under Complaint Numbers 1401332 (OH00167486), 1401404 (OH00167479), and 14011397 (OH00163878).

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