Inspection·June 15, 2023

F 0744 Provide the appropriate treatment and services to a resident who displays or is diagnosed with dementia. Level of Harm - Minimal harm or potential for actual harm Based on medical record review, staff interview, and review of facility policy, the facility failed to maintain a safe environment for residents residing on the secured memory care unit, when Resident #21 was able to retrieve a steak knife from behind the nursing station. This affected one resident (#21) of three residents reviewed for environment, and had the potential to affect all 23 residents (#1, #2, #3, #4, #5, #6, #7, #8, #9, #10, #11, #12, #13, #14, #15, #16, #17, #18, #19, #20, #21, #22, and #23) residing on the secured memory care unit. The facility census was 100. Residents Affected - Some Findings include: Review of Resident #21's medical record revealed an initial admission date of 02/08/23. Diagnoses included dementia, tremor, age-related debility, hypertension, and altered mental status. Review of Resident #21's most recent completed Minimum Data Set assessment, dated 04/30/23, identified the resident was cognitively impaired with a Brief Interview for Mental Status (BIMS) score of five. The resident exhibited verbal behaviors directed toward others and other behavioral symptoms not directed toward others between one and three days within the lookback period. The resident required supervision for a majority of the activities of daily living. Review of Resident #21's current plan of care, revised 03/17/23, revealed the resident was at risk for harm to self. Goals included remaining safe in a secure setting. Interventions included assisting with decision-making as needed, allowing time to perform tasks, and minimizing environmental stimulation. Review of Resident #21's current plan of care, revised 03/17/23, revealed there was a need to monitor behaviors, resident had potential for altered behavioral patterns, disruptive interactions, disruptive verbally, resistive to care, violence/anger, agitation and/or anxiety, agitation, altered thought process, dementia, wandered into other resident rooms, refused care, rummaged in other resident belongings, carried his belongings around, hid or slept in other resident beds, got combative, and agitated with staff providing care. Interventions included administering prescribed medications, praising positive behavior, and removing from public area when behavior was unacceptable. Review of Resident #21's nursing progress notes dated 05/10/23 and timed 6:10 P.M. revealed the resident's niece attempted to cut off the resident's wander management device. The niece was educated on the importance of the resident having the device on. The niece then handed the resident a long pointed end piece of metal so he could try to take it off himself. The object was removed from the resident's possession and was in a safe keeping place. (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: 365865 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 365865 B. Wing A. Building (X3) DATE SURVEY COMPLETED 06/15/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Main Street Care Center 500 Community Drive Avon Lake, OH 44012 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)