Avenue Care And Rehabilitation Center, The

F 0550 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few

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

dysphagia. Resident #25's activities of daily living (ADL) needs would be met by staff while allowing her to participate as able. Interventions included the resident needed dependent assistance of one for eating and was dependent on the assistance of one for incontinence care.Observation on 08/05/25 at 8:47 A.M. of Resident #25 revealed she was lying in bed and the head of the bed was elevated at approximately a 30-degree angle. Interview during the observation with LPN #733 stated Resident #25 required assistance with feeding and if the nurse aides had enough time they assisted her out of bed into her wheelchair and took her to the dining room to eat, but otherwise she was fed in her room. Certified Nurse Aide (CNA) #772 carried Resident #25's meal tray in the room and stated she was going to feed her. CNA #772 set Resident #25's meal tray up, stood next to her, did not raise the height of Resident #25's bed and began feeding her while the head of her bed was still at a 30-degree angle. CNA #772 dropped food on Resident #25's gown and continued to feed her while Resident #25's head of the bed was at a 30-degree angle. After a few minutes, CNA #772 raised Resident #25's head of bed to about a 90-degree angle and continued to stand next to her while she was assisting her with eating. CNA #772 confirmed she was standing while feeding Resident #25 and dropped food on her gown. CNA #772 stated she always stood when she fed Resident #25 in the room and when she was in the dining room she sat while she fed her.Review of the facility policy titled, Resident Rights and Facility Responsibilities, dated 10/03/23, revealed the facility must treat each resident with respect and dignity and care for each resident in a manner and in an environment that promoted maintenance or enhancement of his or her quality of life, recognizing each resident's individuality.

The facility must protect and promote the rights of the resident. This deficiency represents non-compliance investigated under Complaint Number OH00167217 (1254635), Complaint Number OH00164532 (1254632) , and Complaint Number OH00162468 (1254628).

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

08/13/2025

NAME OF PROVIDER OR SUPPLIER

STREET ADDRESS, CITY, STATE, ZIP CODE

Avenue Care and Rehabilitation Center, The

4120 Interchange Corporate Center Road Warrensville Heights, OH 44128

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 0558

by 84 inches.

Level of Harm - Minimal harm or potential for actual harm

Interview on 08/06/25 at 11:11 A.M. of the Administrator revealed she ordered another bed for Resident #76. The Administrator stated Resident #76's current bed dimensions were 36 inches by 80 inches (three (3) feet by 6 feet eight (8) inches). The new bed dimensions were 48 inches ( four (4) feet) by 84 inches ( seven (7) feet).

Residents Affected - Few

Review of the facility policy titled, Resident Rights and Facility Responsibilities, included the right to reside and receive services in the facility with reasonable accommodation of resident needs and preferences except when to do so would endanger the health or safety of the resident or other residents.

1. 2. Review of the medical record revealed Resident #44 was admitted to the facility on [DATE REDACTED] with

diagnoses that included depression, chronic obstructive pulmonary disease, and hemiplegia.

Review of the most recent MDS assessment dated [DATE REDACTED] revealed Resident #95 was moderately cognitively impaired and required extensive assistance of one staff person for completing his activities of daily living

Observation of Resident #44 on 08/04/25 at 11:59 A.M. revealed Resident #44 was up in her wheelchair and his call light was on the floor and out of reach. Interview with Certified Nurse Aide (CNA) #764 verified

the placement of the call light at the time of observation.

2. 3. Review of the medical record revealed Resident #95 was admitted to the facility on [DATE REDACTED] with

diagnoses that included type two diabetes, end stage renal disease, and chronic pain.

Review of the most recent MDS assessment dated [DATE REDACTED] revealed Resident #95 was moderately cognitively impaired and required extensive assistance of one staff person for completing his activities of daily living. The assessment also noted Resident #95 as completely blind with zero visual perception noted.

Observation of Resident #95 on 08/05/25 at 8:06 A.M. revealed Resident #95 was up in his wheelchair and his call light was on the floor and out of reach. Interview with Licensed Practical Nurse (LPN) #741 verified

the placement of the call light at the time of observation.

This deficiency represents non-compliance investigated under Complaint Number OH00167095 (1254634).

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

08/13/2025

NAME OF PROVIDER OR SUPPLIER

STREET ADDRESS, CITY, STATE, ZIP CODE

Avenue Care and Rehabilitation Center, The

4120 Interchange Corporate Center Road Warrensville Heights, OH 44128

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 0580 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few

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

Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, staff interview, and review of a facility policy, the facility failed to ensure a resident's family or responsible party were notified of changes in condition. This affected one (#6) of two residents reviewed for change in condition. The census was 87.Findings include:Record review for Resident #6 revealed admission to the facility on [DATE REDACTED]. Diagnoses included end stage renal disease, gastrointestinal hemorrhage, diabetes mellitus II and paroxysmal atrial fibrillation.Review of Resident #6's electronic medical record (EMR) revealed a nurse note dated 02/14/25 at 6:57 P.M. that Resident #6 was ordered to be sent to the hospital. There was no indication the family was notified. Further review revealed a note dated 02/19/25 at 4:10 P.M. that Resident #6 returned to the facility. There is no indication the family was notified.Review of Resident #6's EMR revealed a nurse note dated 02/26/25 at 2:29 P.M. that Resident #6 was ordered to be sent to the hospital. There was no indication the family was notified.Review of Resident #6's EMR revealed a nurse note dated 03/05/25 at 4:04 P.M. that Resident #6 was sent to the hospital from dialysis. There was no indication the family was notified.Review of Resident #6's EMR revealed a nurse note dated 03/13/25 at 12:37 P.M. that Resident #6 went to the hospital from the doctor's office. There was no indication the family was notified. Further review revealed she was sent out again on 03/13/25 at 1:22 A.M. and returned same day at 4:49 A.M. There was no indication the family was notified when Resident #6 left or returned to the facility.Review of Resident #6's EMR revealed a nurse note dated 03/15/25 at 3:11 P.M. that Resident #6 was ordered to go to the hospital. There was no indication the family was notified.

Further review revealed a physician note dated 03/21/25 that Resident #6 was readmitted . There was no documentation that the family was notified.Interview with the Unit Manager Licensed Practical Nurse (LPN) #745 on 08/13/25 at 11:29 A.M. verified there was no documentation informing Resident #6's family was notified of her being sent out of the facility and to the hospital on [DATE REDACTED], 02/26/25, 03/05/25, 03/13/25, or 03/15/25.Review of the facility policy titled, Resident Change in Condition, dated 07/28/22, revealed the purpose was to ensure staff provided timely and appropriate care and services when residents experience

a change in condition that had or was likely to cause adverse negative health outcomes. The facility would promptly notify the resident, his or her attending physician and responsible party of changes in the resident's condition and, or status. This deficiency represents non-compliance investigated under Complaint Number OH00163811 (1254630).

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

08/13/2025

NAME OF PROVIDER OR SUPPLIER

STREET ADDRESS, CITY, STATE, ZIP CODE

Avenue Care and Rehabilitation Center, The

4120 Interchange Corporate Center Road Warrensville Heights, OH 44128

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 0627 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few

can. Registered Nurse (RN) #799 attempted to redirect the resident to his room as the common area was not an appropriate place to urinate. The resident refused redirection and attempted to remove other residents dinner plates while they ate. Other attempts at redirection were ineffective. The resident started walking the halls heading toward the lobby stating he was going to get to his car as he needed to work on it. RN #799 and a certified nurse aide (CNA) continued to try and redirect the resident to his room. Resident #26 attempted to open the secured door to the main entrance. RN #799 held the door shut and the resident became more agitated and attempted to hit RN #799. A second nurse notified Nurse Practitioner (NP) #811 of the resident’s aggressive behavior and gave an order to transport the resident to a local emergency room (ER) for evaluation. At 7:15 P.M. Resident #26 was transferred to the ER. No further documentation was noted regarding what occurred with the resident after transport.

Interview with the Mobile Director of Nursing on 08/11/25 at 3:35 P.M. revealed Resident #26 was admitted to the hospital. When he was discharged he would be transferred to another facility with a secured unit. He will not be returning to the facility.

Interview with the Director of Nursing (DON) on 08/11/25 at 5:10 P.M. revealed anyone who was sent to the ER for evaluation was considered discharged . The DON was unable to explain why no further documentation was in the chart regarding what happened to Resident #26 after his transfer. The DON was unable to provide any discharge paperwork regarding the resident or where he went. No immediate discharge documentation was provided regarding Resident #26 not being able to return to the facility.

Review of the facility’s policy titled, “Discharge Planning & Managing Length of Stay,” dated 12/01/22, revealed discharge planning should involve identifying each resident’s discharge goals and needs, implementing appropriate interventions, and regularly evaluating those interventions throughout the resident’s stay. When a facility anticipates discharge, a discharge summary includes

a recapitulation history will be completed. A final discharge summary will be completed upon discharge that should be given to the resident or responsible party including medication reconciliation, discharge medication orders, and a post discharge plan of care including where the resident plans to reside, any appointments made for follow up care and any post discharge medical services.

This deficiency represents non-compliance investigated under Complaint Number OH00166711 (1254468) and Complaint Number OH00167217 (1254635).

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

08/13/2025

NAME OF PROVIDER OR SUPPLIER

STREET ADDRESS, CITY, STATE, ZIP CODE

Avenue Care and Rehabilitation Center, The

4120 Interchange Corporate Center Road Warrensville Heights, OH 44128

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

08/07/25 at 11:42 A.M. of Licensed Practical Nurse (LPN) #743 revealed he was not told Resident #29's fingernails needed trimmed, and he would make sure they were trimmed today.

Interview on 08/11/25 at 10:31 A.M. of CNA #788 revealed she had no issues with Resident #29 refusing care, she did not refuse care, and it was all in the way Resident #29 was approached when care was provided.

Review of the facility policy titled, Activities of Daily Living (ADLs), dated 03/2023, included the purpose was to specify the responsibility to create and sustain an environment that humanizes and individualizes each resident's quality of life by ensuring all staff, across all shifts and departments, understand the principles of quality of life, and honor and support these principles for each resident; and that the care and services provided were person-centered, and honor and support each resident's preferences, choices, values and beliefs. A resident who was unable to carry out activities of daily living would receive the necessary services to maintain good nutrition, grooming, and personal and oral hygiene.

This deficiency represents non-compliance investigated under Master Complaint 2564323, Complaint Number OH00162468 (1254628), Complaint Number OH00164532 (1254632), and Complaint Number OH00167217 (1254635).

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

08/13/2025

NAME OF PROVIDER OR SUPPLIER

STREET ADDRESS, CITY, STATE, ZIP CODE

Avenue Care and Rehabilitation Center, The

4120 Interchange Corporate Center Road Warrensville Heights, OH 44128

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 0686 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few

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

#31's wound was not staged appropriately on 03/23/25. WN #802 stated when she saw the wound on 03/24/25 it looked pink and there was no death. WN #802 stated Resident #31 was delayed cognitively, did not get out of bed and did not complain. Resident #31 was very compliant with his care and confirmed he lays in the same position all the time. Interview on 08/14/25 at 11:42 A.M. of WN #802 revealed Resident #31 was admitted to hospice services on 04/16/25. WN #802 confirmed Resident #31's treatments to the coccyx were not always documented by the nurses they were completed, but that was because sometimes

the hospice nurse completed the treatments. WN #802 was unable to provide evidence the hospice nurses completed the undocumented treatments.Review of the facility policy titled, Pressure Ulcer Prevention and Interventions, revised 01/2023, included the purpose was to implement preventative skin measures for all residents based on the levels and areas of risk to include moisture, nutrition, activity, mobility, mental status, psychosocial status and general physical condition. Guidance for suggested and recommended assessment, documentation, interventions and treatment types included for non-blanchable erythema, Stage One to assess the location, measurement and color of the area, to assess the resident's skin daily and pay particular attention to bony prominences.This deficiency represents non-compliance investigated under Complaint Number OH00161573 (1254625) and Complaint Number OH00166806 (1254522).

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

08/13/2025

NAME OF PROVIDER OR SUPPLIER

STREET ADDRESS, CITY, STATE, ZIP CODE

Avenue Care and Rehabilitation Center, The

4120 Interchange Corporate Center Road Warrensville Heights, OH 44128

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 - Few

Diagnoses include acute respiratory failure with hypoxia, syncope and collapse, and end stage renal disease.

Review of the MDS assessment dated [DATE REDACTED] revealed Resident #24 had moderately impaired cognitive deficit. He required substantial to maximal assistance from staff for toileting hygiene, shower, upper and lower body dressing, and donning and doffing footwear.

Review of Resident #24’s care plan dated 06/24/25 revealed he was at risk for falls related to gait/balance problems and history of falls. An interventions included bilateral floor mats, ensure the call light was within reach and encourage to use it for assistance as needed, and sit in the common area when out of bed.

Observation on 08/06/25 at 10:13 A.M. revealed a fall mat to one side of Resident #24’s bed that was situated in the middle of the wall leaving the other side of the bed with no fall mat.

Observation on 08/07/25 at 11:15 A.M. revealed Resident #24 had one fall mat on one side of his bed and no fall mat on the other side of the bed. His bed was not against the wall but was situated in the middle of

the wall.

Observation and interview on 08/11/25 at 2:25 P.M. revealed Resident #24 was going to take a nap and the bed was situated in the middle of the wall with one fall mat on one side of the bed and no fall mat on the other side of the bed.

Observation on 08/12/25 at 9:15 A.M. revealed one fall mat by one side of the bed and no fall mat on the other side of the bed. Resident #24 was in bed resting.

Observation on 08/12/25 at 10:18 A.M. revealed Resident #24 had only one fall mat on one side of bed with no fall mat on the other side of his bed.

Interview on 08/12/25 at 10:18 A.M. with LPN #738 and Registered Nurse (RN) #799 verified there was only one fall mat on one of Resident #24's bed and no fall mat on the other side of the bed.

Review of the facility policy titled, Fall Management, revised 12/2022, revealed if a fall occurred the licensed nurse would assess the resident for injury from the fall immediately and initiate an investigation of the reason for the fall and implement an immediate intervention to attempt in preventing future falls. The licensed nurse would update the Fall Risk and Pain Assessment at the time of the fall.

Review of the facility policy titled, Accidents and Hazards, revised 11/2022, included when an unusual occurrence or accident/hazard occurred within the facility, the licensed nurse would immediately assess the resident for injury. The licensed nurse would open a risk management report and gather interview statements from the appropriate facility staff, resident and, or family, visitor. The licensed nurse would document a brief description of the accident, incident in the medical record. The licensed nurse would notify

the physician and the resident, responsible party and document the notification in the medical record.

This deficiency represents non-compliance investigated under Master Complaint Number 2564323, Complaint Number OH00166853 (1254633), and Complaint Number OH00166806 (1254522).

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

08/13/2025

NAME OF PROVIDER OR SUPPLIER

STREET ADDRESS, CITY, STATE, ZIP CODE

Avenue Care and Rehabilitation Center, The

4120 Interchange Corporate Center Road Warrensville Heights, OH 44128

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 0690 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few

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

resident's preferences, choices, values and beliefs. A resident who was unable to carry out activities of daily living would receive the necessary services to maintain good nutrition, grooming, and personal and oral hygiene.This deficiency represents non-compliance investigated under Master Complaint 2564323, Complaint Number OH00167095 (1253634), Complaint Number OH00166806 (1254522), Complaint Number OH00166853 (1254633), Complaint Number OH00167217 (1254635), Complaint Number OH00164532 (1254632), and Complaint Number OH00162468 (1254628).

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

08/13/2025

NAME OF PROVIDER OR SUPPLIER

STREET ADDRESS, CITY, STATE, ZIP CODE

Avenue Care and Rehabilitation Center, The

4120 Interchange Corporate Center Road Warrensville Heights, OH 44128

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 0727 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Many

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

Have a registered nurse on duty 8 hours a day; and select a registered nurse to be the director of nurses on

a full time basis.

Based on review of staffing schedules and staff interview, the facility failed to maintain the services of a registered nurse (RN) for at least eight consecutive hours a day, seven days a week as required. This had

the potential to affect all 87 residents currently residing in the facility. The census was 87.Findings include:

Review of the nursing staff information and staff schedules for 06/28/25 and 07/04/26 revealed no RNs were present working in the facility during those days.On 08/13/25 at 3:15 P.M., interview with Human Resources Director (HRD) #890 verified the facility did not have an RN on duty on 06/28/25 and 07/04/26.This deficiency represents non-compliance investigated under Complaint Number OH00161573 (1254625), Complaint Number OH00164532 (1254632), and Complaint Number OH00166711 (1254468).

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

08/13/2025

NAME OF PROVIDER OR SUPPLIER

STREET ADDRESS, CITY, STATE, ZIP CODE

Avenue Care and Rehabilitation Center, The

4120 Interchange Corporate Center Road Warrensville Heights, OH 44128

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 0760

Ensure that residents are free from significant medication errors.

Level of Harm - Minimal harm or potential for actual harm

Based on medical record review and staff interview, the facility failed to ensure an antibiotic medication was administered as ordered. This affected one (#102) of two residents reviewed for urinary tract infections. The census was 87.Findings include: Review of the medical record for Resident #102 revealed an admission date of 05/01/25. Diagnoses included cellulitis of the left lower limb, pain in the left and right legs, anxiety disorder, and glaucoma. The resident discharged against medical advice (AMA) to an independent living facility on 07/22/25. Review of the Minimum Data Set (MDS) assessment, dated 05/08/25, revealed Resident #102 had intact cognition. The resident required supervision or touching assistance for dressing and mobility, used a walker and a wheelchair, and was occasionally incontinent.Review of Resident #102's physician orders for June 2025 revealed the resident was ordered a urinary analysis (UA) collection one time only for possible urinary tract infection (UTI) on 06/07/25 at 8:00 P.M.; the medication to treat UTI symptoms Pyridium oral tablet 100 milligrams (mg) with instructions to take by mouth two times a day for urinary urgency for two days on 06/13/25 at 8:00 P.M.; and the antibiotic Fosfomycin tromethamine oral packet three (3) grams (gm) with instructions to give one packet by mouth in the morning every Tuesday, Friday, and Sunday for three admissions ordered on 06/13/25 at 7:00 A.M. and discontinued on 06/16/25.

The Fosfomycin tromethamine 3 gm oral packet was reordered on 06/16/25 and started 06/17/25. Review of Resident #102's laboratory report revealed a urine sample was collected on 06/07/25 and received on 06/10/25. Further review of the a report revealed on 06/12/25 the resident's urine was positive for a UTI and antibiotic recommendations were given. Review of the nurse's notes dated 06/12/25 at 3:17 P.M. revealed Resident #102 was educated on the new order for an antibiotic and the medication would be in that night.

Review of Resident #102's nurse's notes dated 06/15/25 at 12:07 P.M. noted Fosfomycin tromethamine 3 gm oral packet was not available.Review of Resident #102's medication administration record (MAR) for June 2025 revealed Fosfomycin tromethamine 3 gm oral packet was marked as See nurse notes on Friday 06/13/25 and Sunday 06/15/25. The medication was not available and the resident did not receive the medication until 06/17/25. On 08/11/25 at 10:21 A.M. Assistant Director of Nursing (ADON) #704 revealed

on Friday, 06/13/25 Resident #102's Fosfomycin tromethamine was to be started and given Tuesday, Friday, and Sunday and stated it was not available. ADON #704 confirmed the medication was given Friday, 06/13/25 or Sunday, 6/15/25. On Monday, 6/16/25 ADON #704 caught the problem, contacted the nurse practitioner (NP),, had the medication reordered, and the first dose was given on Tuesday, 06/17/25. On 08/11/25 at 4:51 P.M. the Director of Nursing (DON) verified the antibiotic for Resident #102 had not been given until 06/17/25. This deficiency represents non-compliance investigated under Complaint Number OH00166711 (1254468), Complaint Number OH00164532 (1254632), Complaint Number OH00163811 (1254630), and Complaint Number OH00166806 (1254522).

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

08/13/2025

NAME OF PROVIDER OR SUPPLIER

STREET ADDRESS, CITY, STATE, ZIP CODE

Avenue Care and Rehabilitation Center, The

4120 Interchange Corporate Center Road Warrensville Heights, OH 44128

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 0773 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few

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

during the seven-day assessment look-back period. Resident #59 used a wheelchair. Resident #59 used a mechanical lift and was a two staff assist for transfers. Resident #59 required the assistance of one staff member for bathing and bed mobility. Interview on 08/12/25 at 10:19 A.M. of the Director of Nursing (DON) revealed Resident #59's physician should have been notified as soon as possible after his urine culture results were reported by the laboratory. The DON confirmed Resident #59's urine culture results were reported on 12/01/25, but the physician was not notified until 12/03/25. The DON did not know why there was a two day delay for Resident #59's urine culture results to be reported to the physician, and there should have been a progress note about it. The DON confirmed Resident #59 had a urine specimen for urinalysis and culture and sensitivity collected on 12/03/25 and there was no order in his record or progress note regarding the urine specimen. The DON was unable to explain why the urine specimen was collected

on 12/03/25. The DON confirmed Resident #59 had a urine for urinalysis and culture and sensitivity ordered on 11/22/24, and there was no evidence the urine was collected and sent to the laboratory.

Interview on 08/12/25 at 2:05 P.M. of NP #801 revealed if she ordered Resident #59's urine for urinalysis and culture and sensitivity she would expect it to be collected within 48 hours. NP #810 stated if she ordered Resident #59's urine specimen for urinalysis and culture and sensitivity twice it was probably because she was frustrated that she had not received the report and ordered it again. NP #810 stated she could not remember the details because it was awhile ago. NP #810 indicated she did not know there was a delay of two days for reporting Resident #59's urine culture results and hoped a member of the physician team would have been called with the results and would have responded on 12/01/25 with an antibiotic order if they felt it was appropriate. NP #810 stated she would have wanted to treat Resident #59's infection as soon as possible and did not have an explanation for the two delay from 12/01/25 through 12/03/25.Review of the facility policy titled, Resident Change in Condition, dated 07/28/22, included the purpose was to ensure staff provided timely and appropriate care and services when residents experience

a change in condition that had or was likely to cause adverse negative health outcomes. The facility would promptly notify the resident, his or her attending physician and responsible party of changes in the resident's condition and, or status. The licensed nurse would take immediate action to ensure timely and appropriate care and services were met when a resident change in condition was identified. The appropriate level of care and treatment would be delivered as required to best manage a resident's change

in condition and the effort to treat a residents physical or emotional status such as an illness or injury based

on the outcome of severity during assessment.This deficiency represents non-compliance investigated under Complaint Number OH00166711 (1254468).

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

08/13/2025

NAME OF PROVIDER OR SUPPLIER

STREET ADDRESS, CITY, STATE, ZIP CODE

Avenue Care and Rehabilitation Center, The

4120 Interchange Corporate Center Road Warrensville Heights, OH 44128

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 - Some

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

observation and staff interview, the facility failed to ensure outdated drinks and food and beverage additives were stored in a manner to prevent spoilage. This had the potential to affect four ( #3, #28, #70, and #77) of four residents identified by the facility as receiving on thickened liquids. The facility census was 87.Findings include:Observation during a tour of the facility on 08/06/25 from 8:40 A.M. to 9:35 A.M. revealed two 46 ounce containers of nectar thickened orange juice were found in the [NAME] panties on the units. There was no date written on them to show when they had been opened. The use by date was June 2025. Further

observation revealed eight individual thick and easy instant food and beverage thickener packets with a use by date of 10/29/23 found in the [NAME] pantries. On 08/06/25 at 9:41 A.M., Regional Director of Clinical Operations #808 verified the two containers of outdated nectar thickened orange juice and the eight outdated thick and easy instant food and beverage thickener packets. This deficiency represents non-compliance investigated under Complaint Number OH00166853 (1254633).

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

08/13/2025

NAME OF PROVIDER OR SUPPLIER

STREET ADDRESS, CITY, STATE, ZIP CODE

Avenue Care and Rehabilitation Center, The

4120 Interchange Corporate Center Road Warrensville Heights, OH 44128

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 0842

This deficiency represents non-compliance investigated under Master Complaint Number 2564323, Complaint Number OH00167217 (1254635), and Complaint Number OH00166806 (1254522).

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

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

08/13/2025

NAME OF PROVIDER OR SUPPLIER

STREET ADDRESS, CITY, STATE, ZIP CODE

Avenue Care and Rehabilitation Center, The

4120 Interchange Corporate Center Road Warrensville Heights, OH 44128

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 0921 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Many

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

Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and

the public.

Based on observation, staff interview, and policy review, the facility failed to maintain a clean, sanitary, and safe environment. This deficient practice had the potential to affect all 87 residents residing in the facility.

The facility census was 87.Findings included:Observation during an environmental tour conducted on 08/06/25 between 1:00 P.M. and 1:55 P.M. with Maintenance Supervisor (MS) #748 revealed carpeted areas throughout resident rooms and common areas were noted with stains and debris, the room occupied by Resident #59 had a two-inch long hole in the wall, the air conditioning cover in Resident #124's room was dislodged and on the floor, the wall trim on the bathroom door in Resident #31's room was half secured to the wall, the outlet for the telephone line in Resident #25's room was broken in half, the supplemental tube feeding poles used by Resident #19 and Resident #72 had residual dried tube feed on the pole and base, the private bathroom used by Resident #33 had multiple brown stains on the tub floor, the pillowcases and blankets on Resident #27's bed were stained brown, Resident #77's bathroom contained approximately ten to fifteen articles of wet clothing on the floor producing a strong musty odor, Resident #36, Resident #82, and Resident #83's rooms had multiple areas of water stains on the ceiling, the closed closet door in Resident #81's room had multiple brown spots, the walls in Resident #14 and Resident #83's rooms were severely scratched with chipped paint, the wall above the air conditioning unit in Resident #4 and Resident #13's rooms was starting to crumble, Resident #67's bed had a blanket with multiple brown and orange stains, and the fall mats used by Resident #14 and Resident #65 were dirty, torn, and tattered.Interview with MS #748 during the observations on 08/06/25 between 1:00 P.M. and 1:55 P.M. verified all the above findings at the time of discovery. Review of the facility policy titled, Environmental Services Cleaning Guidebook, dated 04/20/23, revealed the guidebook was provided to all housekeeping employees to maximize efficiency, outline preferred cleaning methods for infection control and presentation, and emphasize the proper use of chemicals as critical to the success of maintaining a safe and sanitary environment.This deficiency represents non-compliance investigated under Complaint Number OH00166853 (1254633) and Complaint Number OH00164532 (1254632).

Event ID:

Facility ID:

If continuation sheet