Health inspection·December 18, 2025

F 0691 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Provide appropriate colostomy, urostomy, or ileostomy care/services for a resident who requires such services. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview, observation and review of photographs, the facility failed to ensure timely colostomy care was provided to residents. This affected one resident (#73) of one resident reviewed for colostomy care. The facility identified only one resident (#83) in-house with an ostomy. The facility census was 83.Findings include: Review of Resident #73's medical record revealed an admission date 11/03/25. Diagnoses included rectal cancer and enterostomy (surgical opening from the intestine through the abdominal wall to allow drainage of intestinal contents).Review of the care plan dated 11/10/25 revealed Resident #73 had an ileostomy related to colon cancer. Interventions included for staff to assist Resident #73 with toileting needs as needed, check and change on care rounds and as needed, and to complete ostomy care per orders.Review of Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #73 had intact cognition and had an ostomy for stool elimination. Review of Resident #73's current physician orders for December 2025 revealed an order for staff to empty the resident's ostomy every shift and as needed and change the ostomy appliance every week and as needed.Interview on 12/09/25 at 9:41 A.M. with Resident #73 revealed a few weeks ago she had put her call light on for assistance with her colostomy bag that had burst open. Resident #73 stated a nurse (unknown name) had come in and had turned her call light off and had not provided her with care. Resident #73 stated she had continued to be covered in stool from her colostomy and she had begun to yell out for help and no one had come in and she had called a family member at that time. Resident #73 stated her family member had come to the facility shortly after and had observed her covered in stool and had taken photos at that time. Resident #73 stated she had been covered in stool for at least two hours without receiving any assistance from staff. Resident #73 stated her colostomy bag burst open often because staff did not empty, burp (expel air from the colostomy drainage bag), or change it timely. Observation of Resident #73's colostomy bag at the time of interview revealed the bag was approximately half full of liquid stool. Telephone interview on 12/09/25 at 10:41 A.M. with Resident #73's family member revealed on 11/20/25 at approximately 5:00 P.M., she received a call from Resident #73 who had been upset and crying because she had been lying in her stool for several hours. Resident #73's family member stated she immediately arrived at the facility and observed Resident #73 covered in stool. The family member stated she had taken photos at that time before she cleaned Resident #73 up and then had proceeded to speak with the unit manager about what had occurred. Resident #73's family member reported the unit manager had stated she would address the concerns, however the issue had still been occurring. At time of the telephone interview Resident #73's family member had provided photos. Review of photograph dated 11/20/25 timed 5:06 P.M. revealed a large amount of dried, liquid stool on Resident #73's gown and bedding and the resident's colostomy bag was not attached to Resident #73's abdomen. The family member provided permission to share the photograph with facility leadership. Observation on 12/09/25 at 12:50 P.M. revealed Resident #73 had a large amount of liquid stool covering (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 3 Event ID: 366394 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 366394 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/18/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Avenue Care and Rehabilitation Center, The 4120 Interchange Corporate Center Road Warrensville Heights, OH 44128 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)