Health inspection·September 17, 2025

F 0689 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Few Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, closed record review, review of emergency services report, review of hospital records, facility policy review and interview, the facility failed to maintain a safe environment to prevent Resident #51 from accessing a locked soiled utility room and falling from the third-floor secured unit to the facility basement via a laundry chute. This resulted in Immediate Jeopardy and Actual Harm on 08/07/25 at approximately 1:30 P.M. when Resident #51 was observed in the laundry chute room, inside a laundry bin, behind a locked door in the facility's basement. Maintenance Director (MD) #400 reported he had been in the facility basement outside of the laundry chute room when he heard a loud thud sound from inside the room. Upon opening the locked door of the laundry chute room, MD #400 observed Resident #51 inside a laundry bin, and confirmed the only points of entry into the room were the laundry chute and the locked door he had opened. MD #400 recalled Resident #51 had bleeding around his mouth and eye and a large bump on the back of his right hand. MD #400 reported Former Administrator #500 was present in the facility's basement with another unknown resident at the time of the incident and was informed Resident #51 was in the laundry bin. Former Administrator #500 proceeded to escort Resident #51 out of the laundry chute room and back to his room on the third floor prior to the resident being comprehensively assessed for injury. Resident #51 was transported to the hospital by Emergency Medical Services (EMS) at approximately 2:55 P.M. Upon arrival to the hospital, Resident #51 was found to have a C6 compression fracture (a collapse of one of the cervical vertebra in the neck) of unknown chronicity, an acute T4 anterior fracture (a break of the fourth thoracic vertebra in the mid-back), and multiple left-sided rib fractures of the second through seventh ribs. Resident #51 was hospitalized from [DATE] until 09/03/25 at which time he was transferred to a local long term acute care hospital (LTACH) for ongoing care and treatment. Resident #51 did not return to the facility. This affected one resident (#51) of three residents reviewed for accidents. The facility census was 88. On 09/08/25 at 3:04 P.M., the Administrator, Director of Nursing (DON), and Regional Clinical Support Registered Nurse (RCSRN) #401 were notified Immediate Jeopardy began on 08/07/25 at approximately 1:30 P.M. when Resident #51 was able to gain access to the secured soiled utility room (in which the laundry chute access was contained in) on the third floor and was subsequently observed inside a laundry bin in the laundry chute room of the facility's basement. Resident #51 was transported to a local hospital where he was admitted for multiple traumatic injuries. In addition, the facility failed to ensure an accurate and timely investigation and documentation regarding the circumstances of the incident were completed at the time of the incident. Immediate Jeopardy was removed on 08/08/25 when the facility implemented the following corrective actions: On 08/07/25 at approximately 1:30 P.M., Former Administrator #500 was informed by Maintenance Director (MD) #400 that Resident #51 was in the basement laundry chute room. On 08/07/25 at approximately 1:45 P.M. Former Administrator #500 instructed Licensed Practical Nurses (LPN) #283, #291, #303, and #342 to conduct Page 1 of 7 365879 365879 09/17/2025 Cityview Healthcare and Rehabilitation 6606 Carnegie Ave Cleveland, OH 44103

F 0689 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Few head counts of their units to ensure all residents were accounted for and had not wandered off their units. On 08/07/25 at approximately 2:00 P.M., Former Administrator #500 checked the soiled utility room containing the laundry chute on the 200 unit to determine if the door was locking properly. On 08/07/25 at 2:11 P.M., the DON called EMS to transport Resident #51 to a local hospital. On 08/07/25 at approximately 2:15 P.M., Former Administrator #500 checked the soiled utility room containing the laundry chute on the 400 unit to determine if the door was locking properly. On 08/07/25 at approximately 2:30 P.M., Former Administrator #500 checked the soiled utility room containing the laundry chute on the 300 unit to determine if the door was locking properly. On 08/07/25 at approximately 3:00 P.M., Former Administrator #500 coordinated an ad hoc Quality Assurance (QA) meeting to discuss the incident with Resident #51. In attendance at the meeting included Former Administrator #500, the DON, Assistant Director of Nursing (ADON) #279, and RCSRN #401. Regional Director of Operations (RDO) #510 and Medical Director #650 attended via phone. A root cause analysis was performed, and the team discussed a plan to prevent the incident of a resident wandering into secured places and/or off the unit. The QA team decided to re-educate staff on the importance of ensuring the utility room doors were latched and always locked, after each entry and exit, as well as installing an extra lock on each (laundry) chute access on each unit. Additional staff training would include ensuring residents on secured units were always supervised and present on their units, ensuring maintenance work orders and all work orders would be placed into TELS (an electronic method for placing, tracking, and communicating work orders that are needed) and emergency orders would be additionally communicated to the Administrator. The meeting was completed at approximately 3:45 P.M. On 08/07/25, RCSRN #401 and Unit Manager (UM) LPN #287 conducted wandering assessments on 87 current residents. All assessments were completed at approximately 3:57 P.M. The facility identified 15 residents (#36, #41, #43, #49, #51, #65, #66, #67, #68, #69, #78, #79, #84, #87 and #88) who triggered as high risk for wandering; the remaining 72 in-house residents were identified as low risk for wandering. On 08/07/25 at approximately 4:00 P.M., the facility installed padlocks on the laundry chute access doors on all three resident care units. On 08/07/25, the DON, ADON #279, UM LPN #253, UM LPN #287, and RCSRN #401 educated all staff on the importance of ensuring utility room doors where the laundry chutes were contained were latched and always locked after each entry and exit. Staff were educated that an extra lock had been applied to the chute access doors on each unit and ensuring the padlocks were in a position after each use. Staff were additionally educated on ensuring residents on secured units were supervised and ensuring maintenance work orders were placed into TELS and emergency orders communicated to the Administrator. All staff education was completed at 5:30 P.M. The facility implemented a plan beginning with staff hired after 08/08/25, that all new hires would be educated during orientation by the Administrator or designee on ensuring utility room doors were secured when not in use, the process for submitting maintenance work orders, and ensuring emergency orders were communicated to the Administrator. Additional new hire training would ensure laundry chute doors would be always locked when not in use. On 08/08/25, the DON or designee began ongoing audits for all three soiled utility rooms in which the laundry chute access was contained, five days per week, for a duration of four weeks to ensure all doors and chutes were locked and secured appropriately. The results of the audits would be reviewed in the facility's QA meetings. On 08/08/25, the DON or designee implemented ongoing, every shift head counts at the end of each nursing shift to ensure all residents were accounted for. The DON or designee would complete these head counts every shift, seven days per week, for a duration of four weeks. The results of the audits would be reviewed in the facility's QA meetings. Although the Immediate Jeopardy was removed on 08/08/25, the facility remained out of compliance at 365879 Page 2 of 7 365879 09/17/2025 Cityview Healthcare and Rehabilitation 6606 Carnegie Ave Cleveland, OH 44103

F 0689 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Few Severity Level 2 (no actual harm with potential for more than minimal harm that is not Immediate Jeopardy) as the facility was still in the process of implementing their corrective actions and monitoring to ensure on-going compliance. Findings include:Review of Resident #51's closed medical records revealed an admission date of 07/19/23 with medical diagnoses including schizophrenia, dementia, muscle weakness and difficulty walking. Resident #51 resided on the third floor secured Connections unit of the facility. Resident #51 was transferred to the hospital on [DATE] and did not return to the facility. Review of the Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #51 had a brief interview for mental status (BIMS) score of 8 indicating the resident had moderately impaired cognition. The assessment revealed Resident #51 required supervision with mobility, and bathing. Review of the care plan dated 07/29/25 revealed Resident #51 required the need for placement on the secured locked unit related to aggressive behaviors. Resident #51 had the potential for physical aggression related to schizophrenia and dementia. Interventions included administering medications as ordered and providing redirection when agitated. Resident #51 had displayed verbally and physically aggressive behaviors and had been destructive to property that included removing soap dispenser from the wall and thermostat covers (updated 08/06/25). Interventions included administering medications as ordered, and providing redirection when agitated. Resident #51 was additionally noted to be at risk for wandering and elopement. Interventions included providing a safe environment and noted the need for Resident #51 to reside on the secured unit. Review of Resident #51's physician's orders for August 2025 revealed an order for the resident to reside on the secured unit. Review of an EMS report dated 08/07/25 revealed a call for service was placed at 2:11 P.M. and EMS arrived at the facility at 2:35 P.M. The EMS report stated facility staff reported Resident #51 was found at the bottom of the stairs, it was unclear if he had fallen down the stairs and how many. The EMS report further revealed (upon EMS arrival) Resident #51 was found lying in his bed (on the third floor) and was observed with multiple contusions and hematomas (swelling and discoloration) to his head, arms, and hands. Resident #51 was noted in the report to have bleeding from his mouth, and it was unknown if Resident #51 had broken teeth or if he had bitten his jaw. Resident #51 was transported by EMS to a local hospital on [DATE] at 2:55 P.M. Review of a transfer assessment dated [DATE] authored by Licensed Practical Nurse (LPN) #287 revealed the DON had called report to the hospital at 2:00 P.M. Resident #51 had some scrapes and minor bruising. The assessment did not provide additional details regarding the circumstances of the incident or related to any of Resident #51's injuries (as noted by EMS). Review of a progress note dated 08/07/25 and timed 4:46 P.M., authored by the DON, revealed she had been made aware Resident #51 was observed wandering in the laundry area. The note revealed Resident #51 was returned to his unit; an assessment and vital signs were obtained which noted new skin alterations. Resident #51 was noted to be alert and oriented and denied pain. Nurse Practitioner (NP) #343 had been made aware and ordered Resident #51 to be sent to the hospital for evaluation. An attempt was made to notify Resident #51's guardian and a message was left, and Resident #51's emergency contact was notified. The progress note failed to contain information related to the resident actually sustaining a fall and/or the circumstances of the fall. Review of hospital records dated 08/07/25 and timed 3:37 P.M. revealed Resident #51 had presented to the emergency department (ED) as a trauma activation after a fall down approximately 20 stairs. A physical assessment noted Resident #51 had a hematoma to his left upper cheek, blood at his bilateral nares, and blood in his mouth with broken dentition. Additional injuries listed a right hip hematoma, left upper extremity hematoma, abrasion to his bilateral knees and mid left shin, and cervical spine tenderness. The assessment further stated laboratory and imaging tests were ordered and chest x-ray demonstrated several posterior rib 365879 Page 3 of 7 365879 09/17/2025 Cityview Healthcare and Rehabilitation 6606 Carnegie Ave Cleveland, OH 44103

F 0689 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Few fractures. Imaging revealed a C6 fracture and T4 anterior body and transverse process fracture (a complex injury pattern, likely referring to a T4 vertebra fracture involving both the front (anterior) part of the bone and the small side processes (transverse processes). This type of injury typically results from high-energy trauma and is often unstable, potentially leading to spinal cord or nerve damage. Resident #51 was also noted to have multiple left-sided rib fractures of the second through seventh ribs. Assessment further revealed due to Resident #51's multiple rib fractures and altered mental status he had been admitted to the trauma intensive care unit (TICU). Review of the facility investigation dated 08/07/25 revealed the following: Review of Maintenance Director (MD) #400's written statement dated 08/07/25 revealed he was going to the soiled utility room to let a vendor into check equipment and found Resident #51 in the laundry bin. The report referenced that he immediately notified Former Administrator #500. Review of Former Administrator #500's written statement dated 08/07/25 revealed he observed Resident #51 in the laundry chute area standing up behind the door. When asked what he was doing, Resident #51 mumbled and asked for a soda. Former Administrator #500 proceeded to the vending machine and purchased him a soda, and ambulated Resident #51 to the dining room until the DON and an unspecified Unit Manager arrived. Review of the DON's written statement dated 08/07/25 revealed Resident #51 was observed in the basement in the laundry bin by MD #400. Former Administrator #500 was notified, who was nearby with another (unnamed) resident at the vending machines. Former Administrator #500 left Resident #51 in the care of an unspecified activity staff member while he retrieved clinical staff to assess the resident. Clinical staff (unnamed) assessed Resident #51 and passive range of motion and active range of motion were performed without difficulty. Resident #51 was noted to have several abrasions noted to his skin. Resident #51 was returned to his unit on the third floor, vitals obtained, and EMS was called to transport the resident to the ED for evaluation. The DON's statement further references that staff were interviewed and reported safety checks had been performed and that all doors with locks were secured. Staff denied seeing the resident go into the laundry chute as it was lunch time and they were passing trays. Review of LPN #323's written statement dated 08/07/25 revealed the nurse had last seen Resident #51 at lunch time between approximately 12:45 and 1:00 P.M. Resident #51 was provided with his lunch, and he stood at the nurse's station and ate his lunch. Review of a written statement dated 08/07/25 authored by Certified Nursing Assistant (CNA) #244 revealed she last saw Resident #51 in the dining room at lunch time. CNA #244 handed him his tray, and he walked back into his room. Review of a written statement dated 08/07/25 authored by CNA #203 revealed she did not witness the incident. CNA #203 was passing lunch trays, and referenced the last time she saw Resident #51, she had brought his tray to his room. Review of a facility incident and accident investigation form, dated 08/07/25 revealed Resident #51 was the listed resident, and the type of incident was listed as wandering. Resident #51 was listed to have abrasions and had been wandering and restless. There was no narrative or explanation for what had happened. The section to list immediate actions taken was blank. A corresponding bath and skin report listed the resident had abrasions to his bilateral lower knees and extremities, his right forearm and upper arm, and left hand. There were no measurements or descriptions of any areas. The bottom of the form stated the treatment order was send to ED. The incident and accident investigation form was incomplete to reflect the resident fell down the laundry chute from the third floor to the basement or to clarify why/how EMS and hospital staff were provided information that the resident fell down stairs. The investigation and accident form failed to provide evidence the resident was comprehensively assessed and/or that EMS services were summoned prior to the resident being moved from the ground. Review of a root cause analysis, dated 08/07/25, completed by the QA team members during the ad hoc 365879 Page 4 of 7 365879 09/17/2025 Cityview Healthcare and Rehabilitation 6606 Carnegie Ave Cleveland, OH 44103

F 0689 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Few QA meeting following the incident, , revealed Resident #51 had last been observed during lunch at the nurse's station at approximately 12:45 P.M. Resident #51 had refused his tray due to his hotdog being mechanically altered per his ordered diet. At approximately 1:30 P.M., Resident #51 was witnessed by MD #400 in the laundry bin in the basement and was transported to the hospital. The root cause was listed as Resident #51 having a history of destroying property, removing soap dispensers, and picking locks. Based on review of the facility information as part of the State agency investigation, it could not be determined how the facility reached this root cause for this incident. Interview on 09/03/25 at 3:14 P.M. with Housekeeper #292 revealed he was present on 08/07/25 and had heard Resident #51 had fallen down the laundry chute. Housekeeper #292 stated the laundry chute doors did not have locks on them prior to the incident and stated Former Administrator #500 had asked him to place locks on the chute doors (following the incident). Observation of laundry chute door with Housekeeper #292 at the time of the interview revealed the door to the laundry chute was locked and Housekeeper #292 had to put in a code to open the door. Observation further revealed a pad lock was in place on the outside of the metal door to the laundry chute at the time of the observation. Interview and observation on 09/03/25 at 3:24 P.M. with Maintenance Director #400 revealed on 08/07/25 between approximately 1:00 P.M. and 1:30 P.M., he and an outside vendor were present in the basement outside of the laundry chute area. MD #400 stated he had heard a loud thud from inside the laundry area. MD #400 stated he had attempted to open the locked door to the chute room, but it had been difficult to open, and he had to push the door a few times as it appeared something was blocking the door. MD #400 stated he eventually opened the door to the laundry chute room, and upon entry he observed a laundry bin on its side, and he saw a hand sticking out of it. MD #400 revealed he was able to identify Resident #51 as the person in the area. MD #400 stated Former Administrator #500 was present in the basement with another resident at the vending machine that was near the laundry chute room. MD #400 advised Former Administrator #500 of the situation. MD #400 stated Former Administrator #500 helped Resident #51 up out of the laundry bin and MD #400 observed Resident #51 with bleeding around his mouth and eye and with a large bump on his right hand. MD #400 stated Former Administrator #500 then walked Resident #51 to the kitchenette area located in the basement near the laundry chute area. MD #400 stated the DON then came and checked Resident #51 out in the basement and then Resident #51 was taken back to his room. MD #400 stated that same day Former Administrator #500 had asked him to place locks on the laundry chute doors and new locks on the door that lead to the chute areas. MD #400 further explained the only entry points into the basement's laundry chute room were from the chute itself or through the locked door he had entered after he heard the thud and found Resident #51 in the bin. Observation of laundry chute room with MD #400 at time of interview revealed the laundry room chute door was locked and required a code to access the room. The laundry chute room had two large, plastic bins on wheels inside the room below the metal laundry chute, with no other doors or points of entry. MD #400 stated approximately two days after the 08/07/25 incident with Resident #51, the staff had received a text message from Former Administrator #500 that the Administrator would not be returning to the facility. Interview on 09/03/25 at 3:52 P.M. with the DON revealed on 08/07/25 Former Administrator #500 had informed her Resident #51 was in the basement, however she had not been made aware how the resident had gotten down there. Former Administrator #500 reported to her he had observed Resident #51 wandering in the basement. The DON stated when she had arrived in the basement, Resident #51 was seated in the kitchenette area drinking a soda. The DON stated she had observed Resident #51 had some scrapes and some redness but was not able to state how the injuries occurred. The DON stated she had heard a rumor Resident #51 had gone down the laundry chute but during the 365879 Page 5 of 7 365879 09/17/2025 Cityview Healthcare and Rehabilitation 6606 Carnegie Ave Cleveland, OH 44103

F 0689 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Few investigation no staff had observed Resident #51 to have left the secured unit via the elevator or the stairs. The DON stated based on her nursing judgement and to err on the side of caution she had called EMS to have Resident #51 transferred to the hospital. The DON was asked where Resident #51 was currently and/or information about the resident's status and the DON stated she did not know. Interview on 09/04/25 at 8:06 A.M. with CNA #209 revealed the lock on the door to the third-floor soiled utility room which contained the laundry chute had been broken for approximately a week before the 08/07/25 incident with Resident #51. CNA #209 revealed Former Administrator #500 had been made aware of this. During the interview, CNA #209 stated on 08/07/25 she observed Resident #51 in the dining room during lunch and Resident #51 had refused his lunch tray and had left the dining room. CNA #209 stated approximately 20 minutes later, an unknown staff member had asked her to do a head count of the residents on the unit as Resident #51 had fallen down the laundry chute. Interview on 09/04/25 at 9:09 A.M. with RDO #510, who was the acting Interim Administrator, revealed she had been made aware of the incident involving Resident #51 via phone on 08/07/25. RDO #510 stated the facility had done an investigation and had not been able to determine how Resident #51 had ended up in the basement's laundry chute room and stated the door to the room may have been left open and stated Resident #51 had a history of wandering. RDO #510 denied staff had reported any locks that had been broken. A telephone interview with Resident #51's guardian on 09/04/25 at 10:07 A.M. revealed he had received a call from the facility that Resident #51 had fallen down the stairs and was found in the basement. The guardian stated the caller had not provided any specific information and he was confused on how the resident had gotten off the secured locked unit and into the basement to have fallen. The guardian stated he had spoken with the hospital and had been informed Resident #51 had numerous fractures on his back and he had remained at the hospital from [DATE] unit 09/03/25 at which time Resident #51 was transferred to a local LTACH for continued medical care needs. Interview on 09/04/25 at 12:34 P.M. with CNA #275 revealed he had seen the door to the third-floor soiled utility room containing the laundry chute not functioning properly from time to time prior to the incident involving Resident #51 on 08/07/25. A telephone interview on 09/04/25 at 12:41 P.M. with Nurse Practitioner (NP) #343 revealed she had been on call on 08/07/25 and had received a call from a staff member regarding Resident #51. NP #343 recalled she had received vague information that Resident #51 was found in the basement and had some scratches on him. NP #343 stated she had recalled asking the caller how Resident #51 had gotten into the basement as he resided on a secured unit; however, the caller had not been able to provide an explanation. NP #343 stated she had been told Resident #51 had some scratches on his face and was not made aware of any other injuries. NP #343 stated she had advised the caller if they felt Resident #51 needed to be sent to the hospital to go ahead and send him out. NP #343 stated she had not received any additional follow-up calls regarding Resident #51. A telephone interview on 09/08/25 at 12:57 P.M. with Former Administrator #500 revealed he was in his office on 08/07/25 and received a call from MD #400; however, he did not see the message immediately. Former Administrator #500 was unable to recall at what approximate time he received the message but stated once he received MD #400's message he had gone to the basement and had observed Resident #51 inside the laundry chute room standing up behind the door. Former Administrator #500 stated Resident #51 had told him he was looking for a soda. Former Administrator #500 stated he was unsure how Resident #51 had been inside the laundry chute area as the door was locked and required a code to get inside. Former Administrator #500 stated he had observed some cuts on Resident #51's arms and stated he had gone upstairs to get the DON. Former Administrator #500 stated he had not returned to the basement and had then proceeded to go to the units where he advised the staff to perform a head count of all the 365879 Page 6 of 7 365879 09/17/2025 Cityview Healthcare and Rehabilitation 6606 Carnegie Ave Cleveland, OH 44103

F 0689 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Few residents. Former Administrator #500 stated he had then done an audit of all the doors on each unit with MD #400 and had observed the door on the 3rd floor had not been closing effectively. Former Administrator #500 stated he had advised MD #400 to repair the lock on the third-floor door to the soiled utility room at that time. Former Administrator #500 stated he had done an investigation beginning on 08/07/25 and stated he had turned in his resignation effective immediately on 08/08/25. The Former Administrator did not provide any additional information related to his resignation. Review of the undated facility policy Connections Unit revealed the Connections unit was a secured unit which provided a living environment that was supportive for those with mental health diagnoses that supported a need for increased safety and supervision. It emphasized structured activities and programs to meet physical, mental, and psychosocial needs in a comforting and safe manner. The goal of Connections unit was to respect the privacy and dignity of residents, administer care and treatment, provide a smaller environment with increased supervision that focuses on daily routines, and/or offer an environment that allows individuals to be comfortable with themselves while decreasing the potential for self-harm or escalation of negative behaviors. The Connections unit was a locked unit with coded keypads to unlock the doors. Benefits of the unit include reduction of external stressors and expectations to promote self-worth and a safe living environment. Staff who were trained to provide support and care for residents with aggression and behaviors related to their diagnosis or other need for increased supervision and activities that are specifically chosen for the interest and needs of the residents on the unit. Review of the policy Compliance/Ethics: Records and Documentation dated 08/2025 revealed accurate and complete recordkeeping and documentation is critical to virtually every aspect of the facility's operations. It is the policy of the facility that all documentation should be timely, accurate, and consistent with applicable professional, legal, and facility guidelines and standards. This includes all aspects of the facility's documentation, including resident assessments and care plans, clinical records and all billing and payment documentation. This deficiency represents non-compliance investigated under Complaint Number 2594724. 365879 Page 7 of 7