Health inspection·August 7, 2024

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 medical record review, observation, resident interview, staff interview, and review of facility policy, the facility failed to ensure medications were administered and were not left at the resident bedside. This affected one resident (Resident #20) of one resident observed. The facility census was 79. Findings include: Review of Resident #20's medical record revealed an admission date of 07/26/24. Diagnoses included periprosthetic fracture around internal prosthetic right hip joint, generalized muscle weakness, difficulty in walking, history of trans ischemic attack (TIA), osteoporosis, hypertension (HTN), alcohol abuse (in remission), nicotine dependence, major depressive disorder, acute cystitis without hematuria. Review of Resident #20's most recent Medicare 5 Day Minimum Data Set (MDS) evaluation dated 08/02/24, revealed a Brief Interview for Mental Status (BIMS) score of 15, indicating the resident was cognitively intact. Observation on 08/06/24 at 9:40 A.M. revealed Resident #20 had a medication cup containing five unidentified pills located on a table in the resident room. During an interview on 08/06/24 at 9:40 A.M., Resident #20 reported the medication in the cup was their morning medications. Resident #20 reported approximately 20 minutes prior to this encounter, the nurse, identified as Licensed Practical Nurse (LPN) #147, brought their medications into the room when they were in the restroom and left the medications on the table for them to consume. Interview on 08/06/24 at 9:45 A.M. with LPN #147 revealed they had taken Resident #20 their morning medications, placed them in a medication cup and placed them on the table in Resident #20's room and left. Review on 08/06/24 at approximately 10:30 A.M. of the electronic medical record (EMR) for Resident #20 revealed no order for self-administration of medication. Interview on 09/08/24 at 11:27 A.M. with the Director of Nursing (DON) and the Assistant Director of Nursing (ADON) revealed Resident #20 does not have an order for self-administration of medication. Review of the facility policy titled, Medication Administration, dated 06/21/17 revealed medications will be administered by legally-authorized and trained persons in accordance to applicable State, (continued on next page) 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 Page 1 of 2 Event ID: 365155 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 08/07/2024 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)