Avenue Care And Rehabilitation Center, The

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

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

the hospital, as he was having an overall decline which they felt was he was in the process of transitioning.An interview on 10/28/25 at 7:00 A.M. with Resident #67's Power of Attorney (POA) confirmed

the nurse did notify them via FaceTime video call on 10/26/25 at 12:23 A.M. to show her Resident #67 had

the call light cord around his neck. The POA stated the nurse was concerned Resident #67 might be trying to hurt himself. The POA stated Resident #67 was not strong enough to strangulate himself and the POA watched as Resident #67 allowed the nurse to remove the cord. Interviews on 10/28/25 from 4:45 P.M. to 4:50 P.M. with Unit Manager RN #333 and LPN #350 revealed any resident with suspected suicidal ideation or self-harm would not be left alone and a phone call to the physician would be placed immediately. LPN #350 stated all dangerous items would be removed. An interview on 10/28/25 at 8:45 A.M. with RN #301 revealed she worked the night shift and Resident #67 wrapped the call light cord around his neck. RN #301 stated at 12:30 A.M. CNA #387 alerted her Resident #67 had a call light cord around his neck. RN #301 FaceTime video called Resident #67's POA. All cords were removed from the room, and the CNAs took turns providing one-on-one observation the whole night until Hospice nurses came in the next morning because RN #301 was concerned Resident #67 may try to hurt himself. RN #301 stated she texted the physician after the incident happened, did not received a response, and did not call the physician until 9:04 A.M. RN #301 confirmed this was over eight hours after Resident #67 had been found with the call light cord around his neck. RN #301 stated the note on 10/26/25 at 3:18 A.M was a late note summarizing the events that occurred around 12:30 A.M. An interview on 10/29/25 at 9:35 A.M. with CNA #387 revealed CNA #379 first found Resident #67 with a cord around his neck. CNA #379 never left him. CNA #387 could not remember the time she alerted the nurse . CNA #387 observed Resident #67 to be confused and in distress when she observed Resident #67 in his bed with the cord around his neck. CNA #387 verified the POA was video called to observe the situation and speak to Resident #67.Interview on 10/29/25 at 9:46 A.M. with CNA #379 revealed she observed Resident #67's call light on, and it was unusual for Resident #67 to ring his call light. CNA #379 stated she observed Resident #67 with the call light cord around his neck and that was a change in behavior for Resident #67. CNA #379 verified the POA was video called to observe the situation and speak to Resident #67.Interview on 10/29/25 at 11:00 A.M. with Unit Supervisor RN #333 revealed 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.Review of the facility policy titled Resident Change In Condition, dated 07/28/22, revealed an Acute Change in Condition was a sudden, clinically important deviation from a resident's baseline. Without interventions the condition may result in complications or death . In the event

the physician could not be reached within thirty (30) minutes and the resident maintained stable condition, 911 would be called for transport, then the doctor would be updated on transfer.This deficiency resulted from incidental findings during investigation of Complaint Number 2653275 and represents continued non-compliance from the survey dated 08/13/25.

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

10/29/2025

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 - Some

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

Guarantor/Emergency Contact #1 stated, The bed was so saturated it was a puddle of pee. The nurse said to put a cover over it. Resident #84's Guarantor/Emergency Contact #1 revealed she took pictures of the saturated bed. Resident #84's Guarantor/Emergency Contact #1 stated, The next morning she was again saturated in bed, I called the Assistant Director of Nursing (ADON #355) and Monday morning I had a meeting with her and I showed her the pictures. Resident #84's Guarantor/Emergency Contact #1 confirmed it was ADON #355 she had spoken to about the lack of incontinence care for Resident #84.

Interview on 10/27/25 at 4:49 P.M. with previous ADON #355 confirmed she was now the Interim DON.

Interim DON confirmed she remembered Resident #84 and speaking with the daughter. Interim DON reviewed the five pictures provided by Resident #84's Guarantor/Emergency Contact #1. The first picture was a mattress with a blanket folded and lying in the middle of the mattress, the next was a saturated brief, and three remaining pictures were saturated bedding. Interim DON revealed she did see the same pictures with Resident #84's Guarantor/Emergency Contact #1 when they met on that day. Interim DON revealed it was not the level of care they strive for. The LPN that worked that day was LPN #384. Interim DON revealed all the staff were given education after that, but nothing was written down. LPN #384 said she was going to get the supplies but by the time she did, the family had already changed her. Interim DON revealed the family did get supplies to change her, they just had to wait. Interim DON stated, I have had other families and residents express concerns about not getting checked or changed timely, I am sure the resident (Resident #84) was not changed timely, I saw the pictures, I spoke to the family, I spoke to the staff, it was clear she was not changed timely. Interim DON revealed residents ‘should be checked and changed every two hours and as needed. Interview on 10/28/25 at 5:06 P.M. with CNA #309 revealed she cared for Resident #84. CNA #309 stated, She was continent, if we were busy we would ask her to wait, she could hold it for about five minutes but not much longer or she would be incontinent, that's why we put a brief on her. Sometimes I came in in the mornings, she was soaked, saturated to the mattress. Interview on 10/28/25 at 5:08 P.M. with LPN #393 revealed he admitted Resident #84. On admission Resident #84 required the assistance of one staff to use the bathroom and was incontinent at times. Review of the facility policy titled, Activities of Daily Living (ADL's) dated March 2023 revealed to specify the responsibility to create and sustain an environment that humanizes and individualizes each residents quality of life by ensuring all staff , across all shifts and departments, understand the principals of quality of life, and honor and support these principals for each resident; and that the care and services provided are person-centered, and honor and support each resident's preferences, choices, values and beliefs. The facility will ensure a resident is given the appropriate treatment and services to maintain or improve his or her ability to carry out the activities of daily living. The facility will provide care and services for the following activities of daily living: Hygiene, mobility, elimination (toileting), repositioning, dining and communication. A resident who is unable to carry out activities of daily living will receive the necessary services to maintain good nutrition, grooming, and personal and oral hygiene. This deficiency represents noncompliance investigated under complaint number 2648929 and represents continued non-compliance from the survey dated 08/13/25.

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

10/29/2025

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 0725 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some

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

direct care staff: An interview on 10/27/25 at 9:58 A.M. with LPN #393 revealed the CNAs were burnt out from working with less than sufficient staffing to care for residents. LPN #393 revealed that some days the facility was working short of staff and on those days the residents who required assistance to get out of bed were left in bed.An interview on 10/27/25 at 10:01 A.M. with CNA #359 revealed CNA #359 stated we try our best, at times showers are not completed so we will just wash them up in bed instead. Residents can't always get up or lay down timely, then they want water or Boost, but we can't always get to that. CNA #359 revealed sometimes they report to work in the mornings, and the residents were soaked and wet because

the third shift stated they did not have enough staff. First shift also did not have enough staff either.An

interview on 10/27/25 at 10:55 A.M. with CNA #362 revealed there was not enough staff to complete daily tasks. CNA #362 revealed residents on their assignments who were incontinent were usually changed one time per shift (a shift of 12 hours) and residents often received bed baths instead of showers because there were not enough staff to provide showers.An interview on 10/27/25 at 11:00 A.M. with CNA #354 revealed there were not enough CNAs, so residents were not changed timely. CNA #354 stated residents were changed two times during a 12 hour shift due to not having enough time to meet all the resident care needs. This deficiency represents noncompliance investigated under complaint number 2648929.

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

10/29/2025

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)

Federal health inspectors cited AVENUE CARE AND REHABILITATION CENTER, THE in WARRENSVILLE HEIGHTS, OH for a deficiency under regulatory tag F-F0880 during a complaint investigation conducted on 2025-10-29.

Category: Infection Control Deficiencies

The facility was found deficient in the following area: Provide and implement an infection prevention and control program.

Scope/Severity Level E: pattern, no actual harm with potential for more than minimal harm.

While no actual harm was documented, there was potential for more than minimal harm to residents.

This was one of 4 deficiencies cited during this inspection of AVENUE CARE AND REHABILITATION CENTER, THE.

Correction Status: Deficient, Provider has date of correction.

The facility reported correction as of 2025-12-18.