Health inspection·January 16, 2025

F 0689 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some 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 medical record review and staff interview the facility failed to ensure an environment free of accidents hazards when smoking materials were not secured to prevent Resident #1 from smoking in his room. This affected one (#1) of three residents reviewed with a diagnosis of dementia on the locked nursing unit and the 24 (#2, #3, #4, #5, #6, #7, #8, #9, #10, #11, #12, #13, #14, #15, #16, #17, #18, #19, #20, #21, #22, #23, #24 and #25)additional residents residing on the locked memory care nursing unit. Facility census was 72. Findings include: Clinical record review revealed Resident #1 was admitted on [DATE] with diagnoses including dementia with behaviors, high blood pressure, chronic obstructive pulmonary disease, anxiety, disorder of kidney and ureter, chronic viral hepatitis, malnutrition and traumatic brain injury. A review of Resident #1's Minimum Data Set assessment dated [DATE] indicated Resident #1's cognition was intact. A review of Resident #1's hospital record dated 12/16/24 indicated he had a past medical history including the above listed diagnoses and currently smoked one pack of cigarettes per day. The hospital documentation indicated Adult Protective Services (APS) was involved and had deemed Resident #1 unfit to live alone APS assumed guardianship of Resident #1 until a formal guardian was approved by the court system. APS recommended long term care and orders for transfer to an extended care facility were obtained. A review of Resident #1's admission documentation dated 12/19/24 indicated he refused to allow the staff to inspect the belongings he brought to the facility with him. There was no documentation in Resident #1's record of an inventory of his personal effects. Review of Resident #1's nursing progress note dated 01/12/25 indicated at approximately 4:30 P.M. an alarm sounded in Resident #1's room. The staff investigated the alarm and found Resident #1's room filled with smoke. Upon entering Resident #1's room there was smoke coming from Resident #1's wardrobe (furniture used to store clothing). When Resident #1's wardrobe was opened a jacket was found smoldering on the floor of the wardrobe. Certified Nursing Assistant (CNA) #75 picked up the jacket and placed the jacket in the sink in Resident #1's bathroom and doused the jacket with water which extinguished the fire. Smoke had entered the hallway on the nursing unit and the smoke alarm sounded in the nursing unit common area. All residents were checked for safety and evacuated to the common area in the nursing unit. Resident #1 refused to allow the nursing staff to assess him for injury and (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 4 Event ID: 366114 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 366114 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/16/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Embassy of Lyndhurst 1575 Brainard Rd Lyndhurst, OH 44124 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)