Health inspection·December 4, 2025

F 0689 Level of Harm - Actual harm Residents Affected - Few orders for physical therapy, occupational therapy, and bilateral grab bars for mobility and positioning.Review of the Physical Therapy Evaluation dated [DATE] revealed Resident #98 presented with a decline in functional mobility and strength after a recent hospital stay secondary to a fall (prior to admission). Upon assessment, the resident demonstrated bilateral lower extremity weakness, impaired bed mobility, impaired transfers, impaired gait, impaired balance, impaired functional activity tolerance, and guarded safety awareness preventing a safe return at home alone. The resident's needs exceeded the resources available to him as he currently required minimum assistance for bed mobility and contact guard assistance (light steady touch) for transfers and gate. Clinically the resident presented as evolving with changing characteristics recovering from the above deficits complicated by a history of congestive heart failure and recent coronavirus (COVID-19). For these reasons, the evaluation revealed the resident was a moderate complexity. It noted that physical therapy services were medically necessary at this time and if physical therapy services were not provided, the resident was at risk for further functional decline, increased dependency on others, falls, skin breakdown, social isolation, pneumonia, depression, and transitioning to an alternative living situation. The plan of treatment was for the resident to demonstrate good rehabilitation potential as evident by his ability to follow multi-step directions, he was able to make needs known, he was attentive to tasks, he had a high prior level of function, was motivated to participate, and had a strong family support system.Review of a late entry nursing note dated [DATE] at 6:58 P.M. revealed at the start of the shift Resident #98 was out in the common area sitting in a chair. At approximately 4:00 P.M. the nurse witnessed Certified Nursing Assistant (CNA) #334 assist Resident #98 into his room. The note revealed the nurse was called to the resident's room at 4:14 P.M. by the CNA #334 and observed Resident #98 lying on his left side, on the floor with his head not touching the floor. Two staff assisted the resident to a standing position to help him into his wheelchair. The note documented Resident #98 had on gripper socks, the call light was not on, and his walker was in an upright position next to the chair in his room. When asked, Resident #98 stated he needed to go find the furniture that was moved out of his room. A head-to-toe assessment was completed, and neurological checks were initiated and within normal limits. The resident had full range of motion and an abrasion to his mid upper back that measured 5.5 centimeters (cm) in length by four cm in width. A new order was received to cleanse the open area with normal saline, apply antibiotic ointment, cover with a foam dressing, change every day and as needed. Resident #98 was re-educated on the importance of using the call light for assistance. Resident #98's responsible party, the Director of Nursing (DON), and physician were made aware. Following the incident the facility documented the resident required a low bed.Review of the signed witness statement completed by Licensed Practical Nurse (LPN) #238 dated [DATE] revealed she was walking past the room of Resident #98 as he was standing up and took a few steps then fell backwards into his dresser and slid down the dresser onto the floor. LPN #238 was unable to get to him in time to prevent the fall.Review of the undated, signed witness statement completed by LPN #302 revealed on [DATE], Resident #98 was confused and restless. Resident #98 was in the common area throughout the day for safety reasons. Resident #98 was toileted every two hours as per policy. He started to fall asleep in his wheelchair at approximately 3:45 P.M. so he was toileted and put to bed at 4:00 P.M. Around 4:15 P.M., LPN #302 was called to the room of Resident #98 because he was observed on the floor.Record review revealed no written statement was obtained from CNA #334 who assisted the resident to his room prior to the fall.Review of a Root Cause Analysis for the fall dated [DATE] at 2:15 P.M. revealed the root cause of the fall was confusion, restlessness, and possibly hospital delirium, new admission, unfamiliar environment, attempting to move the furniture, and the resident (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366431 If continuation sheet Page 2 of 7 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 366431 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/04/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Avenue at Aurora 425 South Chillicothe Road Aurora, OH 44202 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)

F 0689 Level of Harm - Actual harm Residents Affected - Few thought he was at home. The current intervention that was in place to address these factors was the use of gripper socks. The comment section of the form documented the resident's bed would be in a low position and Resident #98 be brought out in the common area. However, the analysis did not address Resident #98'ss supervisory needs when out in the common area and/or interventions to address root cause of the fall (i.e. confusion, restlessness). During the investigation, administrative staff indicated the analysis being timed two hours prior to the fall was documented in error. Review of the Fall Risk assessment dated [DATE] (completed after the [DATE] fall) revealed Resident #98 was at risk for falls with a score of 21. Fall safety interventions at this time were noted to be the use of gripper socks and a low bed.Record review revealed a Fall Incident Report dated [DATE] at 3:00 P.M was completed by the DON. The report stated at 1:20 P.M., Resident #98 was found on the floor. The report documented Resident #98 was seen approximately 10 minutes prior for a neurological assessment (from the fall that occurred on [DATE]). Resident #98 was unable to state what he had been doing and the fall was unwitnessed. Resident #98 was assessed and had an abrasion to his head. He was transferred to the emergency room for an evaluation and treatment. A new intervention included on the report was to adjust the resident's wheelchair seat for proper positioning. Record review revealed no written facility investigation was completed for this fall. There were no staff witness statements from staff assigned to care for the resident on this date, no information related to the circumstances of the fall and/or no evidence what safety interventions were in place at the time of the fall. There was no documentation in the nursing notes referencing this fall.Review of a Fall Root Cause Analysis also completed by the DON for the fall on [DATE] at 1:20 P.M. revealed the root cause included the resident was in an unfamiliar environment, he was observed the floor, at times he needed reminded to sit back in chair and he was newly admitted . Current interventions listed were gripper socks and the bed in the low position. In the comments section it noted the resident was in the common area and they would now implement a tilt chair (a type of wheelchair that pivots the entire seat and backrest backwards for pressure relief and postural support) for improved positioning and seating. Again, there was no indication the root cause addressed the resident's supervisory needs when out in the common area and/or interventions to address root cause of the fall (i.e. the need for reminders to sit back in the chair). Review of a nursing note dated [DATE] at 9:48 P.M. revealed Resident #98 returned to the facility via emergency medical service (EMS) from the emergency room (ER) at 9:14 P.M. with his daughter at his side. Resident #98 was diagnosed with a hematoma to his head and was to apply ice packs 15 minutes out of every hour to help with swelling and pain. A lidocaine patch was ordered for both shoulders with instructions to apply for 12 hours on and 12 hours off.Record review revealed no updates to Resident #98's plan of care following this second fall on [DATE] to ensure a comprehensive, individualized and effective fall management program was in place to decrease the resident's risk of falls/falls with injury and to address the resident's total safety and supervisory needs. There was no evidence physical therapy staff provided input or coordinated care to address the resident's increased falls and safety/supervisory needs at this time. A physician order dated [DATE] revealed Resident #98 had an order for a Dycem to always remain on the wheelchair cushion as an enabler to promote safety and for a dump seat (a fixed, angled/downward slope of the wheelchair seat that increases stability and propulsion efficiency) to the wheelchair to promote positioning, comfort, and safety. The orders did not mention a tilt chair per the Root Cause Analysis. During the onsite investigation, it could not be determined how this intervention (a dump seat would benefit the resident, who made the recommendation and/or how it was determined to be appropriate to meet the resident's safety needs. The resident's plan of care was not updated to address the resident's supervisory (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366431 If continuation sheet Page 3 of 7 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 366431 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/04/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Avenue at Aurora 425 South Chillicothe Road Aurora, OH 44202 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)

F 0689 Level of Harm - Actual harm Residents Affected - Few needs pertaining to his fall risk. Review of a handwritten facility work order dated [DATE] at 2:00 P.M. revealed the resident's wheelchair seat was lowered in the back and higher in the front for Resident #98.Review of the Medicare Five-Day Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #98 had moderately impaired cognition, had no behaviors, utilized a walker, and had no upper or lower extremity limitations. The assessment revealed Resident #98 required moderate assistance for bed mobility and sitting on the side of the bed, he required touching assistance with standing and walking within 10 feet. Resident #98 had a fall within the last month of admission and he had fallen since admission on e time with an injury.Review of a Nursing Home Initial Psychiatric Evaluation dated [DATE] revealed Resident #98 had problems with falls, agitation, questionable confusion, and visual hallucinations while sleeping. The resident's son stated Resident #98 regularly had hallucinations while sleeping, and also stated his father was happy and had not been having as many hallucinations lately. The plan was to start Buspar (a medication utilized to treat anxiety) five milligrams twice a day, though this order was not implemented due to the resident's hospitalization on [DATE].Review of a nursing note dated [DATE] at 10:35 A.M. authored by LPN #221 revealed at approximately 9:45 A.M. the nurse observed Resident #98 relaxing in the common area. The note included the nurse stepped away for a few minutes and then heard Resident #98 shouting and came running to assess. Upon return, the nurse observed Resident #98 lying on his right side with his right arm under his head. Resident #98 was actively bleeding from a laceration to the right front of his head/hairline. The nurse called for help, applied pressure to the wound, and completed an assessment on resident. The nurse directed a nursing assistant to contact 911. Resident #98 remained conscious, continued to talk and converse with the nurses and nursing assistants. When he was asked what he was trying to do, he stated he did not know. Education was provided to the resident. Neurological checks were started and were within normal limits. The resident had had full range of motion and the note revealed there were no other injuries observed. The resident's responsible party and manager on call were notified, the physician was notified, and the resident was transferred to the emergency room for an evaluation. Resident #98 left the facility at 9:48 A.M. via 911. Report was called to the emergency room nurse. The note documented Resident #98 had on gripper socks but did not include any other fall safety interventions that were in place at the time of the fall. The resident's vital signs included blood pressure at 94/60 millimeters of Mercury (mmHg) (normal ranges around 120/80 mmHg), pulse at 62 beats per minute (normal ranges from 60 to 100 bpm), and respirations at 17 breaths per minute (normal ranges from 12 to 20 breaths per minute).Review of a signed witness statement completed by LPN #221 dated [DATE] revealed she had seen Resident #98 sitting in the main parlor area calmly sitting in his wheelchair. She sated she ran to the bathroom, that was behind the nurse's station, for a few minutes. While she was in the bathroom washing her hands, she heard shouting and ran out to see what was wrong and that was when she saw Resident #98 lying on his right side with his arm under his head and blood coming from a laceration.Review of a Fall Root Cause Analysis from the fall on [DATE] at 9:40 A.M. revealed the facility determined the root cause of the resident's fall to be restlessness, confusion, and cognitive impairment. It noted the resident appeared comfortable, his gripper socks were on, he had just eaten, was being supervised, and was toileted prior to getting up. Current interventions were Buspar as added, placed Dycem to the chair, dump chair, and the bed in the low position. There was no evidence the root cause addressed the resident's supervisory needs as it pertained to his fall risk or that it addressed the resident's fall risk associated with his identified restlessness, confusion and cognitive impairment.Review of the emergency room Report dated [DATE] revealed Resident #98 presented to the emergency room by EMS for an evaluation of a fall. Resident #98 recently (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366431 If continuation sheet Page 4 of 7 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 366431 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/04/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Avenue at Aurora 425 South Chillicothe Road Aurora, OH 44202 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)

F 0689 Level of Harm - Actual harm Residents Affected - Few transferred to the skilled nursing facility for rehabilitation after multiple falls in the last few weeks. Today, he stated he was sitting up in his wheelchair after breakfast. He stated they removed his breakfast tray but had left him sitting there longer than he had anticipated. He stated he was leaning in his chair to the right and began to fall forward. He stated he fell out of his chair and struck the right side of his head. He stated she was helped up immediately by the staff though the fall was not directly witnessed. The resident was sitting upright in bed, was alert and answering questions appropriately and the resident's daughter was at bedside. Review of a Hospital Trauma Service Note dated [DATE] at 12:14 P.M. revealed Resident #98 had a left inferior fifth cervical vertebra articular facet fracture with mild subluxation of cervical 5 to cervical 6 left facet joint, a subdural hematoma, a right scalp abrasion and a right elbow skin tear.Review of a nursing note dated [DATE] at 4:49 P.M. revealed Resident #98 was admitted to the hospital for a neck fracture and an intracranial hemorrhage.Review of the death certificate dated [DATE] revealed the cause of death for Resident #98 was blunt impact to the head and neck with subdural hemorrhage and cervical spine fracture.During an interview on [DATE] at 2:40 P.M. the DON stated she had not witnessed Resident #98 fall on [DATE] however she had completed the incident report because the nurse working, LPN #333, was a new nurse. The DON stated LPN #333 did not know she was supposed to complete a note in the resident's progress notes or complete an incident report for a fall. The DON revealed there was a Unit Manger on duty who could have assisted LPN #333 with handling the paperwork for the fall, however that never happened so she filled out the incident report even though she never witnessed the fall and was not aware if fall interventions that were in place at the time of the fall.During an interview on [DATE] at 3:25 P.M. Registered Nurse (RN) #224 stated the low bed at night was a click intervention already in the system and she just clicked on it to put it on the care plan. During an interview on [DATE] at 9:55 A.M. CNA #234 stated she would look at the Kardex in Point of Care for fall interventions. She stated everyone was to get gripper socks when they were admitted , and it was not individualized for Resident #98 specifically.During an interview on [DATE] at 10:07 A.M. CNA #232 stated she would look at the Kardex or ask the nurse about fall interventions.During an interview on [DATE] at 10:20 A.M, the DON stated staff had been placing Resident #98 in the main parlor room because he needed more supervision. She stated on [DATE], the resident had been in the parlor room and the nurse went to the bathroom right behind the nurse's station and Resident #98 fell, confirming the resident had no staff supervision at the time of the fall on [DATE].During an interview on [DATE] at 2:36 P.M., the Assistant Director of Nursing (ADON) stated on [DATE] she had been in a care conference when she received a text there was an emergency and staff needed her assistance. She stated she went over to the North unit and Resident #98 was on the floor in the common area and LPN #333 was calling 911. Staff kept the resident comfortable until the squad arrived. She stated she asked LPN #333 if she needed help and LPN #333 did not indicate she required any assistance with documenting, however, she never went back to see if LPN #333 completed the required documentation (a progress note and incident report) even though she was a new nurse. She indicated Resident #98 had gripper socks on when she witnessed him on the floor, but verified there was no documentation of that in the progress notes or incident report.During an interview on [DATE] at 1:55 P.M. the DON verified the Fall Risk Assessment completed on [DATE] indicated Resident #98 was at risk for falls. She stated if someone admitted at risk for falls, the facility protocol would be to initiate interventions sch as a Dycem to the wheelchair, gripper socks, and side rails to the bed. She stated after Resident #98's fall on [DATE] a new intervention was for a low bed; however she verified the intervention documented on the resident's care plan was for a low bed at night, which was not what they decided as an intervention for the (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366431 If continuation sheet Page 5 of 7 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 366431 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/04/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Avenue at Aurora 425 South Chillicothe Road Aurora, OH 44202 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)

F 0689 Level of Harm - Actual harm Residents Affected - Few fall. She stated the low bed at night was just a click intervention or generated intervention on the care plan. She stated they would normally write an order for a low bed, but she verified Resident #98 did not have an order for a low bed. The DON further stated staff were keeping the resident out in the main parlor room for more supervision but also verified this was not written as an intervention on his care plan. The DON revealed everyone would watch the residents (in the area) as they walked past the main parlor room.During an interview on [DATE] at 1:00 P.M., LPN #221 stated on the morning of [DATE] staff had assisted Resident #98 up and brought him out to the main parlor room because he wanted to watch the television out there. She stated the resident had also eaten breakfast in the main parlor at around 7:30 A.M. (from what she recalled although she stated breakfast times did vary). LPN #221 stated she left the area with no other staff present to go to the bathroom and then heard Resident #98 call out. She then went back to the parlor room and the resident was on the floor bleeding from his head. 911 was called and the resident was transported to the hospital. Resident #98 at times did try to stand up from his wheelchair and he did become agitated.During an interview on [DATE] at 1:29 P.M., the Administrator stated the facility Fall Management policy was the facility fall protocol listed on the Kardex and Care Plan. During an interview on [DATE] at 3:09 P.M., the Administrator revealed the tilt chair and the dump seat, mentioned for Resident #98's fall interventions and Root Cause Analysis for the [DATE] fall, were the same things. No additional information was provided to determine how this intervention would be appropriate or necessary to decrease the resident's risk for falls. Review of the facility policy titled, Fall Management, dated [DATE], revealed the facility would identify each resident who was at risk for falls and would develop a plan of care and implement interventions to manage falls. The facility would provide an environment that was free from potential hazards. The licensed nurse would perform a fall risk assessment immediately if the resident was deemed to be at risk. The fall risk assessment would assist the licensed nurse in identifying the appropriate prevention and management interventions and the registered nurse would ensure that the documentation of these interventions were in the residents' care plan. The interdisciplinary team would review the falls routinely to determine the most appropriate type of intervention to be implemented to attempt and preventing future incidents from occurring.2. Review of Resident #53's medical record revealed the resident was admitted to the facility on [DATE] with diagnoses including catatonic disorder, falls, generalized anxiety disorder, diabetes, disorders of bone density, hypertension, spinal stenosis, peripheral vascular disease, chronic kidney disease, major depressive disorder, dyspnea, vertigo, heart failure, and muscle weakness.Review of Resident #53's care plan dated [DATE] revealed the resident was at risk for falls related to weakness, limited mobility, atrial fibrillation, overactive bladder, malaise, and anxiety. Interventions included anti-roll backs to manual wheelchair as a safety enabler dated [DATE] and resident to be in communal areas while awake dated [DATE].Review of Resident #53's Minimum Data Set (MDS) assessment dated [DATE] revealed the resident was moderately cognitively impaired, she utilized a wheelchair for mobility, and she had two or more falls without injury since admission.Review of a restorative note dated [DATE] at 3:30 P.M. authored by Restorative Nurse #203 revealed Resident #53 was to be in a tilt in space wheelchair when out of bed as an enabler to promote positioning, comfort, and safety. It noted that this would be re-assessed quarterly and with any changes.Review of the [DATE] physician's orders revealed Resident #53 had an order (dated [DATE]) to be in a tilt in space wheelchair when out of bed as an enabler to promote positioning, comfort and safety.Review of Resident #53's care plan dated [DATE] revealed the resident required a tilt in space wheelchair. Interventions included for the resident to be in a tilt in space wheelchair when out of bed as an enabler to promote positioning, comfort and (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366431 If continuation sheet Page 6 of 7 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 366431 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/04/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Avenue at Aurora 425 South Chillicothe Road Aurora, OH 44202 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)

F 0689 Level of Harm - Actual harm Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete safety.Review of the [DATE] fall risk assessment revealed Resident #53 was at risk for falls.An observation on [DATE] at 11:45 A.M. revealed Resident #53 was sitting in the main parlor room, at the table, in a standard style wheelchair with her head down sleeping. She had shoes on, and anti-roll backs to the back wheels of the wheelchair.During an interview on [DATE] at 12:10 P.M., Unit Manager #238 verified Resident #53 was not to be in the standard wheelchair and had an order to be in the tilt in space wheelchair when she was out of bed.Review of the facility policy titled, Fall Management, dated [DATE] revealed the facility would identify each resident who was at risk for falls and would develop a plan of care and implement interventions to manage falls. The facility would provide an environment that was free from potential hazards. The licensed nurse would perform a fall risk assessment immediately if the resident was deemed to be at risk. The fall risk assessment would assist the licensed nurse in identifying the appropriate prevention and management interventions and the registered nurse would ensure that the documentation of these interventions were in the residents' care plan. The interdisciplinary team would review the falls routinely to determine the most appropriate type of intervention to be implemented to attempt and prevent future incidents from occurring.This deficiency represents non-compliance investigated under Complaint Number 2671661. Event ID: Facility ID: 366431 If continuation sheet Page 7 of 7