Health inspection·January 4, 2024

F 0600 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview, the facility failed to ensure Resident #53 was free from verbal abuse. This finding affected one (Resident #53) of three residents reviewed for abuse. Findings include: Review of Resident #53's medical record revealed the resident was initially admitted on [DATE] and readmitted on [DATE] with diagnoses including Alzheimer's disease, vascular dementia and anxiety disorder. Review of Resident #53's Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed the resident exhibited severe cognitive impairment. Review of an Emotional/Verbal Abuse Self-Reported Incident (SRI) Form Tracking #241367 dated 11/20/23 revealed on 11/17/23 at approximately 1:45 P.M., the Hospice State Tested Nursing Assistant (STNA) #810 asked Licensed Practical Nurse (LPN) #811 (facility staff) to assist her with care for the resident. While performing the care, Resident #53 started getting verbally and physically aggressive with the nurse. The nurse continued to assist the STNA with care but got overwhelmed with the aggressiveness from the resident and spoke to the resident unprofessionally. The Hospice STNA spoke to her hospice case manager regarding the incident that day. The Administrator was notified by the family on 11/20/23 and the investigation was opened. The SRI was unsubstantiated (evidence indicates abuse, neglect or misappropriation did not occur). Review of a Witness Statement dated 11/22/23 authored by Hospice STNA #810 indicated on Friday, 11/17/23, the STNA needed help with caring for Resident #53 and asked LPN #811 for assistance. The witness statement indicated STNA #810 felt the nurse was being verbally and physically aggressive with the resident and she reported the concern to the case manager and the Hospice Director of Nursing (DON). Review of a Witness Statement dated 11/22/23 authored by Hospice Registered Nurse (RN) #814 indicated the nurse notified the direct manager immediately after she was informed of the incident. RN #814 encouraged STNA #810 to notify the facility DON and notify the resident's daughter. Interview on 01/02/24 at 9:11 A.M. with the Administrator indicated a nurse got overwhelmed and did not typically work the unit that Resident #53 resides on. The Administrator confirmed she viewed the surveillance video provided by Resident #53's family and thought the nurse lost her cool. The Administrator confirmed the facility was not aware of the abuse allegation until 11/20/23 and at that (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 8 Event ID: 366454 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 366454 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/04/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Avenue at Macedonia 9730 Valley View Road Macedonia, OH 44056 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)