Health inspection·December 28, 2019

F 0656 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, observation and staff interview, the facility failed to ensure care planned interventions for falls were implemented for Resident #28. This affected one (#28) of two residents reviewed for falls. The facility census was 80. Findings include: Review of the medical record for Resident #28 revealed the resident was admitted to the facility on [DATE] with diagnoses including dementia, delusional disorder and constipation. Review of the most recent Minimum Data Set (MDS) 3.0 assessment, dated 10/22/19, revealed the resident was severely cognitively impaired. Review of the care plan, dated 10/29/19, revealed Resident #28 was at risk for falls related to impaired mobility, impaired balance, risk of medication side effects, incontinence and multiple medical co-morbidities. Review of interventions for the falls care plan revealed an intervention, dated 03/12/19, for non skid strips in front of the toilet in bathroom. Observation of Resident #28's room on 12/27/19 at 9:33 A.M. with Minimum Data Set Nurse #995 revealed no non skid strips in front of Resident #28's toilet in her bathroom. Minimum Data Set Nurse #995 verified the lack of non skid strips at the time of discovery. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365155 If continuation sheet Page 2 of 4 Printed: 05/15/2026 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 365155 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/28/2019 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 0755 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. Based on record review, review of facility policy, resident interview and staff interview, the facility failed to provide physician ordered medications to one (#67) of five residents reviewed for unnecessary medications. The facility identified 18 residents whom received physician ordered eye drops. The facility census was 80. Findings include: Review of Resident #67's medical record revealed an admission date of 07/18/19. Diagnosis included glaucoma and diabetes mellitus Review of the quarterly Minimum Data Set (MDS) assessment, dated 12/08/19, revealed the resident had a high cognitive function and had adequate vision. Review of the physician's order, dated 07/29/19, revealed an order for Dorzolamide HCl-Timolol Mal Solution 22.3-6.8 milligrams/milliliters (mg./ml.). The medication is a beta blocker used to treat glaucoma. The eye drops were to be instilled one drop in both eyes daily. Review of the Medication Administration Record (MAR), dated 12/2019, revealed on 12/24/19, 12/25/19 and 12/26/19 the resident failed to receive the eye drops. Interview with Resident #67 on 12/27/19 at 9:11 A.M. revealed the resident failed to receive the physician prescribed eye drops on 12/24/19, 12/25/19 and 12/26/19 due to the medication being unavailable. Interview with the Director of Nursing on 12/27/19 at 3:01 P.M. verified Resident #67 failed to receive the Dorzolamide HCI-Timolol Mal Solution eye drops on 12/24/19, 12/25/19 and 12/26/19 due to the eye drops were not available. The DON stated the nursing staff failed to inform the DON the medication was unavailable. Once the DON learned the issue the pharmacy was notified, and the issue of non-payment was reconciled. Review of the facility's policy titled Medication Ordering and Receipt, dated 06/21/17, revealed routine medication orders will be cycle filled every 24 hours and delivered to the facility on a daily basis in resident specific, date and time specific medications pass bags. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365155 If continuation sheet Page 3 of 4 Printed: 05/15/2026 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 365155 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/28/2019 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 0814 Dispose of garbage and refuse properly. Level of Harm - Potential for minimal harm Based on observation and staff interview, the facility failed to maintain its dumpster area in a clean and sanitary manner. This had the potential to affect all 80 residents residing in the facility. Residents Affected - Many Findings include: Observation of the facilities dumpster area on 12/26/19 at 8:35 A.M. revealed the following concerns: a. Two dumpster lids were not closed. b. One dumpster's side door was open with a bag of refuse hanging off the side. c. A significant amount of corn was noted on the ground in front of the dumpsters. d. Seven red skin potatoes were noted scattered on the ground through out the dumpster. e. A significant amount of debris (plastic wear, food scraps,) were noted on the ground through out the dumpster area. Interview with [NAME] #900 on 12/26/19 at 8:45 A.M. verified the condition of the dumpster area. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365155 If continuation sheet Page 4 of 4