Health inspection·October 29, 2025

F 0580 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, observation, interview, and review of facility policy, the facility did not ensure timely notification to the physician when Resident #67 displayed a change of condition from his baseline. This affected one resident ( Resident #67) of three residents reviewed for change of condition. The facility census was 83. Findings include: Record review for Resident #67 revealed an admission date of 09/10/25 with diagnoses including malignant neoplasm of the colon, malignant neoplasm of the liver and intrahepatic bile duct, neoplasm related pain, and encounter for palliative care. Resident #67 was admitted to hospice for malignant neoplasm of the colon per physician order dated 09/24/25. Review of the admission Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed the resident had impaired cognition. Review of Resident #67's plan of care, date revised 10/01/25, revealed Resident #67 had a diagnosis of depression. Interventions included arrange for psychiatry consult and follow up as needed, monitor/document/report as needed any risk for harm to self, suicidal plan, past attempt at suicide, risky actions ( stockpiling pills, saying goodbye to family, giving away possessions, or writing a note) intentionally harmed or tried to harm self, refusing to eat or drink, refusing medication or therapies, sense of hopelessness or helplessness, impaired judgement or safety awareness.Review of the progress notes revealed a behavior note dated 10/26/25 at 3:18 A.M. written by Registered Nurse (RN) #301. The note indicated a certified nursing assistant (CNA) found Resident #67 in his room with the call light cord around his neck so the RN removed the cord and notified the doctor, hospice and the resident's daughter. RN #301 made another entry at 6:43 A.M. indicating that hospice called back and would be in to see Resident #67. At 8:53 A.M. RN #301 charted in a nursing note that the CNA at 1230 alerted the nurse Resident #67 had the call light cord around his neck and at that time the RN observed him to have no signs of pain, no injury and vital signs were obtained. Review of the Resident Transfer Form, dated 10/26/25 at 12:41 P.M. revealed Resident #67 was transferred to the hospital at 10:30 A.M. due to concerns regarding demonstrated self-harm behavior. Review of the facility document Resident Acute Change in Condition , dated 10/26/25 at 3:51 P.M. revealed Resident #67 was found with call light cord wrapped around his neck by night shift staff. The problem started 10/26/25. The Hospice provider visited. Report was given to the physician on 10/26/25 at 10:00 A.M.Review of the hospital records dated 10/26/25 revealed Resident #67 was being evaluated for suicidal ideation. Resident #67 said he was not trying to hurt himself, and he thought he was trying to put an oxygen cord around his nose. He was not attempting to harm himself. Resident #67 was calm and cooperative. Resident #67 was readmitted to the facility on [DATE]. An observation on 10/28/25 at 2:24 P.M. of Resident #67 lying in bed with family at the bedside and the Hospice RN in the room revealed Resident #67 was alert, and in no distress at the time of the observation. Resident #67 presented as weak and frail.An interview on 10/28/25 at 2:30 P.M. with Hospice RN #413 revealed Hospice had a one-on-one presence with Resident #67 since he returned from Page 1 of 12 366394 366394 10/29/2025 Avenue Care and Rehabilitation Center, The 4120 Interchange Corporate Center Road Warrensville Heights, OH 44128

F 0580 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few the hospital, as he was having an overall decline which they felt was he was in the process of transitioning.An interview on 10/28/25 at 7:00 A.M. with Resident #67's Power of Attorney (POA) confirmed the nurse did notify them via FaceTime video call on 10/26/25 at 12:23 A.M. to show her Resident #67 had the call light cord around his neck. The POA stated the nurse was concerned Resident #67 might be trying to hurt himself. The POA stated Resident #67 was not strong enough to strangulate himself and the POA watched as Resident #67 allowed the nurse to remove the cord. Interviews on 10/28/25 from 4:45 P.M. to 4:50 P.M. with Unit Manager RN #333 and LPN #350 revealed any resident with suspected suicidal ideation or self-harm would not be left alone and a phone call to the physician would be placed immediately. LPN #350 stated all dangerous items would be removed. An interview on 10/28/25 at 8:45 A.M. with RN #301 revealed she worked the night shift and Resident #67 wrapped the call light cord around his neck. RN #301 stated at 12:30 A.M. CNA #387 alerted her Resident #67 had a call light cord around his neck. RN #301 FaceTime video called Resident #67's POA. All cords were removed from the room, and the CNAs took turns providing one-on-one observation the whole night until Hospice nurses came in the next morning because RN #301 was concerned Resident #67 may try to hurt himself. RN #301 stated she texted the physician after the incident happened, did not received a response, and did not call the physician until 9:04 A.M. RN #301 confirmed this was over eight hours after Resident #67 had been found with the call light cord around his neck. RN #301 stated the note on 10/26/25 at 3:18 A.M was a late note summarizing the events that occurred around 12:30 A.M. An interview on 10/29/25 at 9:35 A.M. with CNA #387 revealed CNA #379 first found Resident #67 with a cord around his neck. CNA #379 never left him. CNA #387 could not remember the time she alerted the nurse . CNA #387 observed Resident #67 to be confused and in distress when she observed Resident #67 in his bed with the cord around his neck. CNA #387 verified the POA was video called to observe the situation and speak to Resident #67.Interview on 10/29/25 at 9:46 A.M. with CNA #379 revealed she observed Resident #67's call light on, and it was unusual for Resident #67 to ring his call light. CNA #379 stated she observed Resident #67 with the call light cord around his neck and that was a change in behavior for Resident #67. CNA #379 verified the POA was video called to observe the situation and speak to Resident #67.Interview on 10/29/25 at 11:00 A.M. with Unit Supervisor RN #333 revealed if a resident had a change in condition the nurse needed to report the findings to the physician immediately for interventions, and this needed to be done by a phone call regarding a change in condition, not a text message.Review of the facility policy titled Resident Change In Condition, dated 07/28/22, revealed an Acute Change in Condition was a sudden, clinically important deviation from a resident's baseline. Without interventions the condition may result in complications or death . In the event the physician could not be reached within thirty (30) minutes and the resident maintained stable condition, 911 would be called for transport, then the doctor would be updated on transfer.This deficiency resulted from incidental findings during investigation of Complaint Number 2653275 and represents continued non-compliance from the survey dated 08/13/25. 366394 Page 2 of 12 366394 10/29/2025 Avenue Care and Rehabilitation Center, The 4120 Interchange Corporate Center Road Warrensville Heights, OH 44128

F 0677 Provide care and assistance to perform activities of daily living for any resident who is unable. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, record review, and review of the facility policy, the facility failed to ensure timely incontinence care was provided for four residents (Resident #34, #40, #43 and #84) of four residents reviewed for incontinence care. The facility census was 83.Findings include: 1. Record review for Resident #43 revealed an admission date of 09/21/21. Diagnoses included hemiplegia and hemiparesis following cerebral infarction and dementia. Review of the Annual Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed Resident #43 was rarely or never understood. Resident #43 was always incontinent of bowel and bladder, had impairment to one side of the upper and lower extremities, used a wheelchair for mobility, was dependent for toileting hygiene, chair/bed to chair transfers, and wheelchair mobility. Review of the care plan initiated 07/16/22 and revised 08/25/25 for Resident #43 revealed Resident #43 was incontinent of bowel and bladder. Interventions included to check for incontinence every two hours and as needed. Observation on 10/27/25 at 9:30 A.M. revealed Resident #43 was sitting in a chair in the lounge area across from the nurse's station. Resident #43 looked at the surveyor when spoken to but did not verbally respond. Further observations on 10/27/25 at 9:58 A.M., 11:30 P.M., and 1:20 P.M. revealed Resident #43 was still in the same area, in the same position sitting in her chair in the lounge across from the nurses' station. Observation on 10/27/25 at 2:45 P.M. revealed Certified Nursing Assistant (CNA) #359 removed Resident #43 from the lounge and placed her in her room. CNA #354 gathered towels and washcloths and joined Resident #43 and CNA #359 in the resident room. CNA #354 confirmed she was Resident #43's primary CNA. CNA #354 revealed that her 12-hour shift began at 7:00 A.M. and revealed the night shift (third shift) got Resident #43 up at around 5:00 A.M. every day and placed her in her chair in the lounge across from the nurses' station. CNA #354 confirmed Resident #43 was not moved from the lounge across from the nurses' station since she was placed there around 5:00 A.M. and stated, This is the first time today she will be checked and changed, there is just not enough staff. Observation revealed CNA #359 and #354 assisted Resident #43 to bed. Resident #43's clothes were soiled with food and dried spills of liquid. CNA #354 confirmed Resident #43 had an odor of urine, and the brief was heavily saturated in urine. CNA #354 again confirmed Resident #43 had not had incontinence care provided for a duration of 5:00 A.M. to 2:45 P.M. 2. Record review for Resident #34 revealed an admission date of 10/12/23. Diagnoses included visual loss of both eyes, acquired absence of the left leg below the knee and acquired absence of the right leg above the knee. Review of the Annual MDS 3.0 assessment dated [DATE] revealed Resident #34 was cognitively intact. Resident #34 was always incontinent of bowel and bladder, required substantial/maximal assistance with bed mobility, was dependent for chair/bed to chair transfers, and for toileting hygiene. Review of the care plan for Resident #34 revealed Resident #34 had an activity of daily living (ADL) self-care performance deficit related to impaired balance and need for assistance for personal care. Interventions included the resident required assistance by staff for toileting. Interview on 10/28/25 at 10:10 A.M. with Resident #34 revealed sometimes she just got soaked with urine. When she called for assistance with incontinence care, staff would say they would be right back but then they don't come back for long periods of time if at all. Resident #34 revealed she was last changed at 6:20 A.M., and she stated she recalled the time because she looked at the clock, and it was before the 7:00 A.M. shift started. Resident #34 revealed that she had not been checked or changed since then and she needed changed. Interview on 10/28/25 at 11:00 A.M. with CNA #354 revealed she was running behind and confirmed she had just finished checking and changing Resident #34 for the first time on her shift. CNA #354 confirmed her shift started at 7:00 A.M. and revealed there was just not Residents Affected - Some 366394 Page 3 of 12 366394 10/29/2025 Avenue Care and Rehabilitation Center, The 4120 Interchange Corporate Center Road Warrensville Heights, OH 44128

F 0677 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some enough help. CNA #354 revealed Resident #34's brief was saturated and the pad under her was also wet with urine. Observation revealed CNA #354 applied new linen on Resident #34's bed and revealed she worked 12-hour shifts and at times residents were only checked and changed two times a shift. 3. Record review for Resident #40 revealed an admission date of 04/12/24. Diagnoses included unspecified hemiplegia affecting left non-dominant side and spinal stenosis of the cervical region. Review of the Modification of the Annual MDS 3.0 assessment dated [DATE] revealed Resident #40 was moderately cognitively impaired. Resident #40 was always incontinent of bowel and bladder, required substantial/maximal assistants for bed mobility, was dependent for toileting hygiene and chair/bed to chair transfer. Review of the care plan initiated 04/14/24 and revised 08/18/25 revealed Resident #40 had a self-care deficit related to legally blind, limited mobility, and impaired cognition. Interventions included Resident #40 was dependent for toilet use. Interview on 10/27/25 at 10:16 A.M. with CNA #309 revealed there were not enough staff to check and change residents' or get them out of bed timely. CNA #309 revealed Resident #40 had not been checked or changed yet since the previous shift. Observation of Resident #40 with CNA #309 revealed Resident #40 was lying in bed. Resident #40 had a gauze wrap/dressing to the right leg. The bottom sheet near the dressing had multiple areas of dried blood. The dressing was dated 10/26/25 but had no blood on it. Resident #40 revealed when the staff help him, It's rush, rush, rush. Resident #40 revealed staff did not change him enough. Observation on 10/27/25 at10:30 A.M. of CNA #309 and #359 providing incontinence care for Resident #40 revealed Resident #40's brief was saturated with urine and stool. The stool was partially dried on Resident #40's skin. Resident #40 had a foul odor. Resident #40's abdominal fold, buttocks, upper thighs, peri area, and both arm pits were deep red. Resident #40 revealed the red areas of his skin were sensitive from sitting in urine and stool. Observation revealed the bed sheets and the mattress Resident #40 was lying on had multiple food crumbs. CNA #309 and #359 verified the observations. Interview on 10/27/25 at 3:00 P.M. with Registered Nurse (RN) Regional Director of Clinical Operations #410 revealed residents' should be checked and changed every two to three hours. 4. Closed record review for Resident #84 revealed an admission date of 10/08/25 and a discharge date of 10/13/25. Diagnoses included sepsis due to enterococcus, altered mental status, dependance on renal dialysis, and adjustment disorder. Review of the Medicare five-day MDS 3.0 assessment dated [DATE] revealed Resident #84 was barely /never understood. Resident #84 had shortand long-term memory problems, was always continent of bowel and bladder, used a wheelchair and walker, had no impairment to the upper or lower extremities, required partial/moderate assistants with bed mobility, chair/bed to chair transfer, substantial/maximal assistants for toilet transfer and dependent for toileting hygiene. Review of the care plan for Resident #84 dated 10/08/25 revealed bowel and bladder incontinence care/catheter care. Interventions included toileting per request and as needed. Interview on 10/27/25 at 9:07 A.M. with Resident #84's Guarantor/Emergency Contact #1 revealed on Sunday, 10/12/25 from 2:00 P.M. until 8:00 P.M. Resident #84's family was at the facility with Resident #84. At 2:00 P.M. when they arrived, they asked for assistance from staff because Resident #84 was soiled. The nurse on the floor said she would be in soon. At 4:00 P.M. staff still had not come in to assist Resident #84. The nurse was again asked for assistance with care. No one came. Resident #84's Guarantor/Emergency Contact #1 revealed at 6:00 P.M she went and asked the nurse again and expressed again Resident #84 had urine and stool on her and required assistance. The nurse became upset and said, I am only one person, I cannot babysit your sister. Resident #84's Guarantor/Emergency Contact #1 revealed at that point her older aunt went and asked for supplies revealing they would change her themselves, and staff did not offer assistance. After receiving the supplies, they changed Resident #84 themselves. Resident #84's 366394 Page 4 of 12 366394 10/29/2025 Avenue Care and Rehabilitation Center, The 4120 Interchange Corporate Center Road Warrensville Heights, OH 44128

F 0677 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Guarantor/Emergency Contact #1 stated, The bed was so saturated it was a puddle of pee. The nurse said to put a cover over it. Resident #84's Guarantor/Emergency Contact #1 revealed she took pictures of the saturated bed. Resident #84's Guarantor/Emergency Contact #1 stated, The next morning she was again saturated in bed, I called the Assistant Director of Nursing (ADON #355) and Monday morning I had a meeting with her and I showed her the pictures. Resident #84's Guarantor/Emergency Contact #1 confirmed it was ADON #355 she had spoken to about the lack of incontinence care for Resident #84. Interview on 10/27/25 at 4:49 P.M. with previous ADON #355 confirmed she was now the Interim DON. Interim DON confirmed she remembered Resident #84 and speaking with the daughter. Interim DON reviewed the five pictures provided by Resident #84's Guarantor/Emergency Contact #1. The first picture was a mattress with a blanket folded and lying in the middle of the mattress, the next was a saturated brief, and three remaining pictures were saturated bedding. Interim DON revealed she did see the same pictures with Resident #84's Guarantor/Emergency Contact #1 when they met on that day. Interim DON revealed it was not the level of care they strive for. The LPN that worked that day was LPN #384. Interim DON revealed all the staff were given education after that, but nothing was written down. LPN #384 said she was going to get the supplies but by the time she did, the family had already changed her. Interim DON revealed the family did get supplies to change her, they just had to wait. Interim DON stated, I have had other families and residents express concerns about not getting checked or changed timely, I am sure the resident (Resident #84) was not changed timely, I saw the pictures, I spoke to the family, I spoke to the staff, it was clear she was not changed timely. Interim DON revealed residents ‘should be checked and changed every two hours and as needed. Interview on 10/28/25 at 5:06 P.M. with CNA #309 revealed she cared for Resident #84. CNA #309 stated, She was continent, if we were busy we would ask her to wait, she could hold it for about five minutes but not much longer or she would be incontinent, that's why we put a brief on her. Sometimes I came in in the mornings, she was soaked, saturated to the mattress. Interview on 10/28/25 at 5:08 P.M. with LPN #393 revealed he admitted Resident #84. On admission Resident #84 required the assistance of one staff to use the bathroom and was incontinent at times. Review of the facility policy titled, Activities of Daily Living (ADL's) dated March 2023 revealed to specify the responsibility to create and sustain an environment that humanizes and individualizes each residents quality of life by ensuring all staff , across all shifts and departments, understand the principals of quality of life, and honor and support these principals for each resident; and that the care and services provided are person-centered, and honor and support each resident's preferences, choices, values and beliefs. The facility will ensure a resident is given the appropriate treatment and services to maintain or improve his or her ability to carry out the activities of daily living. The facility will provide care and services for the following activities of daily living: Hygiene, mobility, elimination (toileting), repositioning, dining and communication. A resident who is unable to carry out activities of daily living will receive the necessary services to maintain good nutrition, grooming, and personal and oral hygiene. This deficiency represents noncompliance investigated under complaint number 2648929 and represents continued non-compliance from the survey dated 08/13/25. 366394 Page 5 of 12 366394 10/29/2025 Avenue Care and Rehabilitation Center, The 4120 Interchange Corporate Center Road Warrensville Heights, OH 44128

F 0725 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review, interviews, and review of the facility assessment, the facility did not ensure staffing levels were sufficient to provide nursing and related services to maintain the highest practicable well-being of the residents. This affected four current Residents (#26, #34, #40, and #43) and one former resident (#84) of five residents reviewed for sufficient staffing and had potential to affect an additional 79 residents residing in the facility. The facility census was 83.Findings include: 1. Review of the medical record for Resident #26 revealed an admission date of 11/28/18 with medical diagnoses including cerebral infarction, hemiplegia affecting left side, aphasia (difficulty speaking), type two diabetes mellitus, vascular dementia and adjustment disorder.Review of the Minimum Data Set (MDS) 3.0 quarterly assessment dated [DATE] revealed Resident #26's cognition was moderately intact. Resident #26 was dependent on staff for toilet hygiene and did not attempt to transfer to the toilet. Resident #26 was always incontinent with bowel and bladder.Review of Resident #26's care plan, date initiated 10/19/19, revealed Resident #26 was incontinent of bowel and bladder with incontinence related to limited mobility. Interventions included check and change every two hours and as required for incontinence. Wash, rinse and dry perineum, and change clothing as needed after incontinent episodes.An observation on 10/29/25 at 2:44 P.M. revealed the call light was lit up/activated on the outside of Resident #26's door and could be seen lit up outside the door in the hallway. No staff were observed in the room with Resident #26 while the call light was activated until at 3:00 P.M. a female caretaker was observed to enter Resident #26's room, turned off the call light and stated to Resident #26 someone would be in soon. Observation at 3:00 P.M. of Resident #26 in her room revealed a smell of urine was in the room and Resident #26 stated she had been waiting a while to have her diaper changed. She stated she was sitting in a wet diaper and wanted to be changed. Observation at 3:12 P.M. revealed Certified Nursing Assistant (CNA) #340 entered Resident #26's room with linens to assist Resident #26 and verified this was the first chance they had to change Resident #26 since the call light was activated at 2:44 P.M.An interview on 10/29/25 at 3:12 P.M. with CNA #340 revealed the staffing levels made it difficult to get all the resident care done timely because so many residents needed to be fed and changed and were dependent on staff for care.2. Record review for Resident #34 revealed an admission date of 10/12/23. Diagnoses included visual loss of both eyes, acquired absence of the left leg below the knee and acquired absence of the right leg above the knee. Review of the Annual MDS 3.0 assessment dated [DATE] revealed Resident #34 was cognitively intact. Resident #34 was always incontinent of bowel and bladder, required substantial/maximal assistance with bed mobility, was dependent for chair/bed to chair transfers, and for toileting hygiene. Review of the care plan for Resident #34 revealed Resident #34 had an activity of daily living (ADL) self-care performance deficit related to impaired balance and need for assistance for personal care. Interventions included the resident required assistance by staff for toileting. An interview on 10/28/25 at 10:10 A.M. with Resident #34 revealed sometimes she just got oaked with urine. When she called for assistance with incontinence care, staff would say they would be right back but then they don't come back for long periods of time if at all. Resident #34 revealed she was last changed at 6:20 A.M., and she stated she recalled the time because she looked at the clock, and it was before the 7:00 A.M. shift started. Resident #34 revealed that she had not been checked or changed since then and she needed changed. An interview on 10/28/25 at 11:00 A.M. with CNA #354 revealed she was running behind and confirmed she had just finished checking and changing Resident #34 for the first time on her shift. CNA #354 confirmed her shift started at 7:00 A.M. and revealed there was 366394 Page 6 of 12 366394 10/29/2025 Avenue Care and Rehabilitation Center, The 4120 Interchange Corporate Center Road Warrensville Heights, OH 44128

F 0725 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some just not enough help. CNA #354 revealed Resident #34's brief was saturated and the pad under her was also wet with urine. Observation revealed CNA #354 applied new linen on Resident #34's bed and revealed she worked 12-hour shifts and at times residents were only checked and changed two times a shift. 3. Record review for Resident #40 revealed an admission date of 04/12/24. Diagnoses included unspecified hemiplegia affecting left non-dominant side and spinal stenosis of the cervical region. Review of the Modification of the Annual MDS 3.0 assessment dated [DATE] revealed Resident #40 was moderately cognitively impaired. Resident #40 was always incontinent of bowel and bladder, required substantial/maximal assistants for bed mobility, was dependent for toileting hygiene and chair/bed to chair transfer. Review of the care plan initiated 04/14/24 and revised 08/18/25 revealed Resident #40 had a self-care deficit related to legally blind, limited mobility, and impaired cognition. Interventions included Resident #40 was dependent for toilet use. An interview on 10/27/25 at 10:16 A.M. with CNA #309 revealed there were not enough staff to check and change residents' or get them out of bed timely. CNA #309 revealed Resident #40 had not been checked or changed yet since the previous shift. Observation of Resident #40 with CNA #309 revealed Resident #40 was lying in bed. Resident #40 had a gauze wrap/dressing to the right leg. The bottom sheet near the dressing had multiple areas of dried blood. The dressing was dated 10/26/25 but had no blood on it. Resident #40 revealed when the staff help him, It's rush, rush, rush. Resident #40 revealed staff did not change him enough. An interview on 10/27/25 at 10:23 A.M. with Resident #40's wife revealed there was not enough staff to assist her husband timely, and at times while on the phone with him, she would have to call the facility to get assistance for him due to him asking her for help because the staff were not coming to change him.An observation on 10/27/25 at 10:30 A.M. of CNA #309 and #359 providing incontinence care for Resident #40 revealed Resident #40's brief was saturated with urine and stool. The stool was partially dried on Resident #40's skin. Resident #40 had a foul odor. Resident #40's abdominal fold, buttocks, upper thighs, peri area, and both arm pits were deep red. Resident #40 revealed the red areas of his skin were sensitive from sitting in urine and stool. Observation revealed the bed sheets, and the mattress Resident #40 was lying on had multiple food crumbs. CNA #309 and #359 verified the observations. An interview on 10/27/25 at 3:00 P.M. with Registered Nurse (RN) Regional Director of Clinical Operations #410 revealed residents' should be checked and changed every two to three hours. 4. Closed record review for Resident #84 revealed an admission date of 10/08/25 and a discharge date of 10/13/25. Diagnoses included sepsis due to enterococcus, altered mental status, dependance on renal dialysis, and adjustment disorder. Review of the Medicare five-day MDS 3.0 assessment dated [DATE] revealed Resident #84 was barely /never understood. Resident #84 had short- and long-term memory problems, was always continent of bowel and bladder, used a wheelchair and walker, had no impairment to the upper or lower extremities, required partial/moderate assistants with bed mobility, chair/bed to chair transfer, substantial/maximal assistants for toilet transfer and dependent for toileting hygiene. Review of the care plan for Resident #84 dated 10/08/25 revealed bowel and bladder incontinence care/catheter care. Interventions included toileting per request and as needed. An interview on 10/27/25 at 9:07 A.M. with Resident #84's Guarantor/Emergency Contact #1 revealed on Sunday, 10/12/25 from 2:00 P.M. until 8:00 P.M. Resident #84's family was at the facility with Resident #84. At 2:00 P.M. when they arrived, they asked for assistance from staff because Resident #84 was soiled. The nurse on the floor said she would be in soon. At 4:00 P.M. staff still had not come in to assist Resident #84. The nurse was again asked for assistance with care. No one came. Resident #84's Guarantor/Emergency Contact #1 revealed at 6:00 P.M she went and asked the nurse again and expressed again Resident #84 had urine and stool on her and required assistance. The nurse became upset and said, I 366394 Page 7 of 12 366394 10/29/2025 Avenue Care and Rehabilitation Center, The 4120 Interchange Corporate Center Road Warrensville Heights, OH 44128

F 0725 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some am only one person, I cannot babysit your sister. Resident #84's Guarantor/Emergency Contact #1 revealed at that point her older aunt went and asked for supplies revealing they would change her themselves, and staff did not offer assistance. After receiving the supplies, they changed Resident #84 themselves. Resident #84's Guarantor/Emergency Contact #1 stated, The bed was so saturated it was a puddle of pee. The nurse said to put a cover over it. Resident #84's Guarantor/Emergency Contact #1 revealed she took pictures of the saturated bed. Resident #84's Guarantor/Emergency Contact #1 stated, The next morning she was again saturated in bed, I called the Assistant Director of Nursing (ADON #355) and Monday morning I had a meeting with her, and I showed her the pictures. Resident #84's Guarantor/Emergency Contact #1 confirmed it was ADON #355 she had spoken to about the lack of incontinence care for Resident #84. An interview on 10/27/25 at 4:49 P.M. with previous ADON #355 confirmed she was now the Interim Director of Nursing (DON). Interim DON confirmed she remembered Resident #84 and spoke with the daughter. Interim DON reviewed the five pictures provided by Resident #84's Guarantor/Emergency Contact #1. The first picture was a mattress with a blanket folded and lying in the middle of the mattress, the next was a saturated brief, and three remaining pictures were saturated bedding. Interim DON revealed she did see the same pictures with Resident #84's Guarantor/Emergency Contact #1 when they met on that day. Interim DON revealed it was not the level of care they strive for. The Licensed Practical Nurse (LPN) that worked that day was LPN #384. Interim DON revealed all the staff were given education after that, but nothing was written down. LPN #384 said she was going to get the supplies but by the time she did, the family had already changed her. Interim DON revealed the family did get supplies to change her; they just had to wait. Interim DON stated, I have had other families and residents express concerns about not getting checked or changed timely, I am sure the resident (Resident #84) was not changed timely, I saw the pictures, I spoke to the family, I spoke to the staff, it was clear she was not changed timely. Interim DON revealed residents ‘should be checked and changed every two hours and as needed. An interview on 10/28/25 at 5:06 P.M. with CNA #309 revealed she cared for Resident #84. CNA #309 stated, She was continent, if we were busy, we would ask her to wait, she could hold it for about five minutes but not much longer or she would be incontinent, that's why we put a brief on her. Sometimes I came in in the mornings, she was soaked, saturated to the mattress. An interview on 10/28/25 at 5:08 P.M. with LPN #393 revealed he admitted Resident #84. On admission Resident #84 required the assistance of one member of staff to use the bathroom and was incontinent at times. 5. Record review for Resident #43 revealed an admission date of 09/21/21. Diagnoses included hemiplegia and hemiparesis following cerebral infarction and dementia. Review of the Annual MDS 3.0 assessment dated [DATE] revealed Resident #43 was rarely or never understood. Resident #43 was always incontinent of bowel and bladder, had impairment to one side of the upper and lower extremities, used a wheelchair for mobility, was dependent for toileting hygiene, chair/bed to chair transfers, and wheelchair mobility. Review of the care plan initiated 07/16/22 and revised 08/25/25 for Resident #43 revealed Resident #43 was incontinent of bowel and bladder. Interventions included to check for incontinence every two hours and as needed. An observation on 10/27/25 at 9:30 A.M. revealed Resident #43 was sitting in a chair in the lounge area across from the nurse's station. Resident #43 looked at the surveyor when spoken to but did not verbally respond. Further observations on 10/27/25 at 9:58 A.M., 11:30 P.M., and 1:20 P.M. revealed Resident #43 was still in the same area, in the same position sitting in her chair in the lounge across from the nurses' station. An observation on 10/27/25 at 2:45 P.M. revealed Certified Nursing Assistant (CNA) #359 removed Resident #43 from the lounge and placed her in her room. CNA #354 gathered towels and washcloths and joined Resident #43 and CNA #359 in the resident room. CNA #354 confirmed she was Resident #43's 366394 Page 8 of 12 366394 10/29/2025 Avenue Care and Rehabilitation Center, The 4120 Interchange Corporate Center Road Warrensville Heights, OH 44128

F 0725 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some primary CNA. CNA #354 revealed that her 12-hour shift began at 7:00 A.M. and revealed the night shift (third shift) got Resident #43 up at around 5:00 A.M. every day and placed her in her chair in the lounge across from the nurses' station. CNA #354 confirmed Resident #43 was not moved from the lounge across from the nurses' station since she was placed there around 5:00 A.M. and stated, This is the first time today she will be checked and changed, there is just not enough staff. Observation revealed CNA #359 and #354 assisted Resident #43 to bed. Resident #43's clothes were soiled with food and dried spills of liquid. CNA #354 confirmed Resident #43 had an odor of urine, and the brief was heavily saturated in urine. CNA #354 again confirmed Resident #43 had not had incontinence care provided for a duration of 5:00 A.M. to 2:45 P.M. Review of the Facility Assessment provided by the Administrator, dated 09/30/25, revealed the facility bed capacity was 97 and the average daily census at the facility was 91.75 percent of the capacity. Under Part Four: Acuity Levels: Self-Care, only nine residents were independent for eating and six residents were independent for oral hygiene. The remaining residents in the facility needed a range of staff assistance from set-up or clean up assistance, supervision or touching assistance, partial/moderate assistance, substantial/maximal assistance, or were dependent (helper does all the effort or needs the assistance of two or more helpers to complete activity) residents for eating, oral hygiene, toileting program, shower/bath, upper body dressing, lower body dressing, putting on/taking off footwear, personal hygiene, bed mobility, sit to stand, transferring and walking, picking up objects and using assistive devices. Part 12: Facility Wide Daily Staffing Needs (page 23) of the Facility Assessment under Nursing Services indicated first shift required one DON, one staff Registered Nurse (RN), three Licensed Practical Nurses (LPN) and six Certified Nursing Assistants (CNA) to meet resident acuity needs. Second shift was left blank and third shift required two LPNs and six CNAs. It was noted that Nursing Service Direct care staff worked 12-hour shifts (7:00 A.M. to 7:00 P.M. and 7:00 P.M. to 7:00 A.M.) Further review of the Facility Assessment revealed the staffing plan in Part 13: Daily Staffing Needs by Unit for the Upper Level (page 28) was based on the staffing data outlined in Part 12. First shift on the upper level was to be staffed with two licensed nurses and three CNAs, and the lower level (page 29) was to be staffed with two licensed nurses and three CNAs for a total of four licensed nurses and six CNAs on first shift. Third shift on the upper level (page 28) was to be staffed with two licensed nurses and three CNAs and the lower level (page 29) was to be staffed with two licensed nurses and three CNAs for a total of four licensed nurses and six CNAs on third shift. The Facility Assessment noted that staffing needs will fluctuate based on population requirements. An interview was conducted on 10/28/25 at 10:00 A.M. with the Administrator who verified the contents of the Facility assessment dated [DATE] as the staffing plan for the facility and confirmed there were no additional policies and procedures related to nursing staffing for the facility. An interview on 10/29/25 at 2:20 P.M. with LPN/Minimum Data Set (MDS) Nurse # 310 revealed on 10/29/25 based on the current census of 83 residents, the facility had 14 residents who were totally dependent on staff to feed them, 28 residents who were totally dependent on two or more staff for a bath/shower, 25 residents who were totally dependent on two or more staff to dress upper body, 25 residents who were totally dependent on two or more staff to dress lower body, and 28 residents were totally dependent on two or more staff to provide personal hygiene. The facility also had a total of 25 residents who were totally dependent on two or more staff for transfers from bed to chair, toilet transfers and tub/shower transfers. LPN/MDS #310 confirmed other residents in the facility also needed varying levels of staff assistance with activities of daily living ranging from set-up/clean-up assistance to maximum assistance by staff. Additional concerns related to staffing were identified during the survey through the following interviews with 366394 Page 9 of 12 366394 10/29/2025 Avenue Care and Rehabilitation Center, The 4120 Interchange Corporate Center Road Warrensville Heights, OH 44128

F 0725 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some direct care staff: An interview on 10/27/25 at 9:58 A.M. with LPN #393 revealed the CNAs were burnt out from working with less than sufficient staffing to care for residents. LPN #393 revealed that some days the facility was working short of staff and on those days the residents who required assistance to get out of bed were left in bed.An interview on 10/27/25 at 10:01 A.M. with CNA #359 revealed CNA #359 stated we try our best, at times showers are not completed so we will just wash them up in bed instead. Residents can't always get up or lay down timely, then they want water or Boost, but we can't always get to that. CNA #359 revealed sometimes they report to work in the mornings, and the residents were soaked and wet because the third shift stated they did not have enough staff. First shift also did not have enough staff either.An interview on 10/27/25 at 10:55 A.M. with CNA #362 revealed there was not enough staff to complete daily tasks. CNA #362 revealed residents on their assignments who were incontinent were usually changed one time per shift (a shift of 12 hours) and residents often received bed baths instead of showers because there were not enough staff to provide showers.An interview on 10/27/25 at 11:00 A.M. with CNA #354 revealed there were not enough CNAs, so residents were not changed timely. CNA #354 stated residents were changed two times during a 12 hour shift due to not having enough time to meet all the resident care needs. This deficiency represents noncompliance investigated under complaint number 2648929. 366394 Page 10 of 12 366394 10/29/2025 Avenue Care and Rehabilitation Center, The 4120 Interchange Corporate Center Road Warrensville Heights, OH 44128

F 0880 Provide and implement an infection prevention and control program. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, record review, and review of the facility policy, the facility failed to maintain infection control practices while providing care to Resident #40 who required Enhanced Barrier Precautions (EBP). This affected one resident (Resident #40) of one resident observed for EBP and had the potential to affect an additional 41 residents (Resident #1, #2, #3, #6, #7, #8, #11, #15, #18, #19, #20, #21, #22, #23, #24, #26, #27, #28, #29, #31, #34, #35, #36, #39, #41, #43, #44, #46, #51, #55, #56, #59, #60, #61, #66, #75, #76, #77, #78, #81, and #83) who resided on the upper floor. The facility identified 19 residents (Resident #10, #11, #14, #17, #18, #20, #38, #39, #40, #45, #50, #53, #54, #56, #60, #66, #73, #74, and #75) as requiring EBP. The facility census was 83. Findings include:Record review for Resident #40 revealed an admission date of 04/12/24. Diagnoses included unspecified hemiplegia affecting left non-dominant side and spinal stenosis of the cervical region. Review of the Modification of the Annual Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed Resident #40 was moderately cognitively impaired. Resident #40 had one unstageable pressure injury presenting as a deep tissue injury. Resident #40 was always incontinent of bowel and bladder, required substantial/maximal assistance for bed mobility, was dependent for toileting hygiene and chair/bed to chair transfer. Review of the care plan initiated 04/19/24 and revised 08/18/25 revealed Resident #40 required Enhanced Barrier Precautions (EBP) to reduce transmission of multidrug-resistant organisms (MRDO's) related to wounds. Interventions included to use disposable gowns and gloves during high contact care activities, remove gowns and gloves promptly after care activities and dispose of in proper receptacle. Review of the physician order for Resident #40 revealed Resident #40 had an order dated 10/21/25 to cleanse the right shin with normal saline, pat dry and apply collagen, cover with non-border super absorbent dressing and wrap with kerlix securing with paper tape every night shift. EBP: Gloves and gown to be worn when providing: Dressing, bathing, transferring, providing hygiene care, changing linen, changing brief or assisting with toileting, devise care and wound care dated 08/04/25. Observation on 10/27/25 at 10:16 A.M. with Certified Nursing Assistant (CNA) #309 revealed Resident #40 was lying in bed. Resident #40 had a gauze wrap/dressing to the right leg. The bottom sheet near the dressing had multiple areas of dried blood. The dressing was dated 10/26/25 but had no blood on it. Observation revealed Resident #40 had a sign at the entrance of the doorway for EBP. Observation revealed the sign had fallen to the floor. Observation revealed no Personal Protective Equipment (PPE) including gloves or gowns were available inside Resident #40's room or near the entrance to the room. Observation on 10/27/25 at 10:30 A.M. revealed CNA #309 went to several resident rooms to find gloves to provide care for Resident #40. Observation with CNA #309 and #359 providing incontinence care for Resident #40 revealed during the entire incontinence care provided (incontinent of stool and urine) to Resident #40 and the changing of Resident #40's linen, neither CNA #309 nor #359 wore an isolation gown. CNA #309 and #359 confirmed they never wore an isolation gown and confirmed none were available in Resident #40's room or outside the doorway near the entrance of the room. CNA #359 revealed he did not even know Resident #40 was on EBP. Both CNA's confirmed they assisted/have worked in all areas of the facility and gowns were often not readily available. CNA #309 and #359 confirmed they could potentially provide care to any of the 41 residents residing on the upper floor during their shift. Review of the facility policy titled, Enhanced Barrier Precautions dated August 2022 revealed EBP are utilized to prevent the spread of multi-drug-resistant organisms (MRDO's) to residents. EBP's employ targeted gown and glove use during high contact resident care activities when contact precautions do not otherwise apply. Examples of high-contact resident care activities requiring the use of gown and gloves for Residents Affected - Some 366394 Page 11 of 12 366394 10/29/2025 Avenue Care and Rehabilitation Center, The 4120 Interchange Corporate Center Road Warrensville Heights, OH 44128

F 0880 Level of Harm - Minimal harm or potential for actual harm EBP's include dressing, bathing, transferring, providing hygiene, changing linens, changing briefs or assisting with toileting, device care use and wound care. This deficiency represents noncompliance investigated under complaint number 2648929 and represents continued non-compliance from the survey dated 08/13/25. Residents Affected - Some 366394 Page 12 of 12