Health inspection·October 21, 2025

F 0690 Level of Harm - Actual harm Residents Affected - Few #59's progress notes dated 12/28/24 at 5:28 P.M. revealed an aide reported to the nurse concerns Resident #59's urine was dark in color. The nurse observed Resident #59's urine was dark in color and Resident #59 stated this happened when she needed water. Resident #59 requested ice, cranberry juice and water. No blood was observed in Resident #59's urine at this time.Review of Resident #59's progress notes dated 12/30/24 at 8:49 A.M. revealed new orders to encourage fluids in place at this time.Review of Resident #59's progress notes dated 12/28/24 through 01/27/25 did not reveal evidence further observations of Resident #59's urine were made including consistency, color and urine output amount.Review of Resident #59's progress notes dated 01/27/25 at 4:56 A.M. revealed Resident #59 called the nurse into her room. Resident #59 was screaming out in pain saying her catheter was not working right. An unsuccessful attempt was made to flush the catheter, the catheter was removed and an unsuccessful attempt was made to insert a new catheter due to resistance. No urine output returned during the attempt to place a new catheter. Resident #59's abdomen was noticeably distended and Resident #59 was in excruciating pain. Resident #59's on call Nurse Practitioner was contacted and Resident #59 was transported via 911 to the ED at 4:45 A.M. Resident #59's daughter was notified via voicemail.Review of Resident #59's hospital ED Provider notes dated 01/27/25 at 5:11 A.M. revealed Resident #59 was transported to the ED for evaluation of her indwelling catheter becoming obstructed and nursing staff at the facility were unable to replace the catheter. Apparently there was blood in it and it did not appear to be draining. Onset of symptoms was several hours ago and Resident #59 was having little urine output and more discomfort. Resident #59 has had catheter in place for several months. Resident #59 reported she had pain in her suprapubic area and felt like her bladder was distended. Resident #59 had an indwelling catheter reinserted with over 500 cc of urine output, and her suprapubic tenderness resolved. Resident #59's urinalysis showed moderate leuks (leukocytes, white blood cells), cloudy appearance and moderate blood. Would treat for catheter associated UTI by starting Bactrim (antibiotic). The Impression and Disposition were foley (indwelling) catheter problem, hematuria, acute chronic urinary retention and urinary tract infection associated with indwelling urethral catheter.Review of Resident #59's progress notes dated 01/27/25 at 6:37 A.M. revealed Resident #59 returned from the ED with new orders for Bactrim (antibiotic) 800-160 milligrams (mg) twice a day for seven days for a UTI. Resident #59's foley (indwelling catheter) was replaced. Resident #59's daughter was updated.Review of Resident #59's physician orders dated 01/27/25 revealed Sulfamethoxazole Trimethoprim oral tablet 800-160 mg, give one tablet by mouth two times a day for UTI for seven days.Review of Resident #59's Quarterly Minimum Data Set assessment dated [DATE] revealed Resident #59 was cognitively intact. Resident #59 required partial to moderate assistance with toileting hygiene, bathing, and upper body dressing. Resident #59 required supervision or touching assistance with personal hygiene. Resident #59 required substantial to maximal assistance to roll left and right and return to lying on her back on the bed. Resident #59 had an indwelling catheter and was frequently incontinent of bowel. Resident #59 did not reject care during the seven-day assessment look-back period. Resident #59 used oxygen therapy.Review of Resident #59's progress notes dated 05/22/25 through 06/13/25 did not reveal evidence observations of Resident #59's urine were made including color, consistency, amount.Review of Resident #59's Medication Administration Record (MAR), TAR, progress notes and weights and vital signs dated 05/01/25 through 06/13/25 did not reveal evidence Resident #59's vital signs including blood pressure, temperature, pulse, respirations were checked.Review of Resident #59's MAR dated 05/04/25 and 06/04/25 revealed monthly vital signs, every day shift every one month on the fourth day of the month were to be checked. The vital signs were marked they were completed but Resident #59's medical record including MAR, TAR, progress notes, weights and vital signs did (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366471 If continuation sheet Page 2 of 11 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 366471 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/21/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Avenue at Broadview Heights 1201 Akins Road Broadview Heights, OH 44147 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 0690 Level of Harm - Actual harm Residents Affected - Few not reveal evidence the vital signs were recorded.Review of Resident #59's Treatment Administration Record (TAR) dated 06/01/25 through 06/13/25 did not reveal evidence Resident #59's indwelling catheter was irrigated with 50 cc normal saline every shift as needed for obstruction, increased sediment.Review of Resident #59's progress notes dated 06/13/25 at 9:07 A.M. revealed Resident #59 vomited, was complaining of being cold, and the heat was turned up in her room. Resident #59 was provided an extra cover. Resident #59's blood pressure was 135/70, heart rate was 143, respirations 20, temperature 97.9 Fahrenheit, and oxygen saturation was 97 percent. Resident #59's Nurse Practitioner was notified and new orders for CBC with diff, BMP, and UA CS stat (urinalysis and culture and sensitivity). A chest X-ray was ordered at 9:47 A.M.Review of Resident #59's progress notes dated 06/13/25 at 1:12 P.M. revealed Resident #59 was having trouble breathing, a second breathing treatment was administered, and Resident #59's oxygen saturations were from 87 to 88 percent. Resident #59 was administered oxygen via nasal cannula. Resident #59 requested to go to the hospital and was transported to the local hospital.Review of Resident #59's Resident Acute Change in Condition assessment dated [DATE] at 1:27 P.M. revealed Resident #59 had vomiting, chills, large diarrhea and shortness of breath.Review of Resident #59's hospital progress notes and discharge summary for a hospital stay dated 06/13/25 through 06/22/25 included Resident #59 had a chronic indwelling catheter, OSA (obstructive sleep apnea) and COPD (chronic obstructive pulmonary disease) complicated by chronic respiratory failure who presented to the ED from the facility with shortness of breath and was found to have septic shock secondary to CAUTI (catheter associated urinary tract infection), status post dual pressors (vasopressors) and broad-spectrum antibiotics with foley exchange. Resident #59 had acute kidney injury. Resident #59 was ill-appearing and diaphoretic. Cultures positive for enterococcus (urine) and citrobacter (urine and blood), antibiotic stewardship guided therapy with Cefepime (antibiotic) only. Episode of atrial fibrillation with rvr (rapid ventricular response), was initially on amiodarone but terminated as believed it to be sepsis induced. Resident #59's urine culture reported greater than 100,000 CFU (colony forming units) per ml citrobacter freundii and 50,000 to 100,000 CFU per ml enterococcus faecalis. Infection Disease was consulted for antibiotics and her catheter was replaced due to retention. Resident #59 needed a Urology referral scheduled on discharge. Resident #59's white blood cell count on 06/13/25 at 2:06 P.M. was 41.6 (normal was typically between 4.5 and 11, 41.6 was extremely high, leukocytosis). Resident #59's lactate was 3.1 (greater than 2.0 is a key diagnostic criterion in septic shock) on 06/13/25 at 3:16 P.M.Review of Resident #59's medical record including physician orders, progress notes, MAR and TAR dated 06/22/25 through 07/11/25 did not reveal evidence Resident #59 had a urology referral scheduled prior to the resident's discharge.Interview on 10/15/25 at 11:31 A.M. of Family Member (FM) #302 revealed the nurses were not flushing Resident #59's catheter every week. FM #302 indicated Resident #59 was transported to the hospital in January 2025 for a catheter issue, but she did not know the details of the visit. FM #302 stated she was called by the facility in June 2025 because her mom was rushed to the hospital due to shortness of breath and when she got to the hospital Resident #59's catheter was full of pus leading to sepsis, she was on life support meds, and her blood pressure was either too high or too low.Interview on 10/16/25 at 2:04 P.M. of Resident #59 revealed she told the nurses and aides two weeks before she went to the hospital on [DATE] that there was something wrong with her catheter. Resident #59 stated there was something off, it felt weird but the nurses and aides did nothing. Resident #59 could not remember the names of the nurses and aides she told about the catheter not feeling right. Resident #59 stated she was now really paranoid about her catheter, and makes sure it gets flushed like it is supposed to. Resident #59 indicated when she went to the hospital her blood pressure was almost nonexistent and (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366471 If continuation sheet Page 3 of 11 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 366471 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/21/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Avenue at Broadview Heights 1201 Akins Road Broadview Heights, OH 44147 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 0690 Level of Harm - Actual harm Residents Affected - Few she was septic.Interview on 10/16/25 at 2:35 P.M. of the Director of Nursing (DON) and the Administrator revealed the DON stated she did not remember anything about Resident #59's catheter or her urine. The Administrator stated orders were given on 06/13/25 for STAT labs, and Resident #59 was transported to the hospital on [DATE] at around 1:00 P.M.Interview on 10/20/25 at 2:31 P.M. of the Administrator and the DON revealed the DON confirmed Resident #59 did not have urine outputs documented from 11/14/24 through 06/2925. The DON stated urine outputs were not obtained if there was no order and Resident #59 did not have an order to monitor urine outputs until 06/29/25.Interview on 10/20/25 at 3:09 P.M. of Nurse Practitioner (NP) #301 revealed Resident #59 would have definitely have had symptoms with sepsis including hypotensive tachycardia, elevated white count and if she was that sick he would think she would have symptoms like a fever, altered mental status.Interview on 10/20/25 at 3:45 P.M. of Medical Director #306 revealed if Resident #59 had an indwelling catheter and she was not managing the catheter herself the nurses and aides should be monitoring Resident #59's urine and should write down how much urine was in the catheter bag when they emptied it. Medical Director #306 stated the documentation should be completed at least one time per shift, and the urine output should be recorded when a resident had an indwelling catheter. Medical Director #306 stated he did not remember Resident #59, but if she was admitted to the hospital with sepsis she would have symptoms such as fevers, altered mental status.Review of the facility policy titled Foley Catheter Care revised 08/2022 included the facility would promote urinary health and management to the resident with an indwelling catheter and ensure the appropriate care and services were provided to prevent urinary tract infections to the extent possible. The staff would observe and report to the licensed nurse any signs or symptoms of infection to include blood, odor, cloudiness, pain, elevated temperature, or absence or decrease in urine output. 2. Review of Resident #43's medical record revealed an admission date of 05/12/25 and diagnoses included traumatic subdural hemorrhage with loss of consciousness of unspecified duration, neuromuscular dysfunction of the bladder, Crohn's Disease and type two diabetes mellitus.Review of Resident #43's care plan dated 08/04/25 revealed Resident #43 had an indwelling catheter related to neurogenic bladder. Resident #43 would be, remain free from catheter related trauma through the review date of 12/14/25. Resident #43 would show no signs and symptoms of a urinary tract infection through the review date. Interventions included observe and document intake and output as per facility policy; observe and report to the physician signs and symptoms of a urinary tract infection including blood tinged urine, cloudiness, deepening of urine color, increased pulse, fever, chills.Review of Resident #43's Quarterly Minimum Data Set assessment dated [DATE] revealed A Brief Interview for Mental Status was not completed due to resident was rarely or never understood. Resident #43 was dependent for toileting hygiene, bathing, dressing and personal hygiene. Resident #43 was dependent for rolling to the left and right and return to lying on her back on the bed. Resident #43 had an indwelling catheter and was always incontinent of bowel.Review of Resident #43's progress notes dated 09/26/25 at 7:00 P.M. revealed an attempt was made to irrigate Resident #43's indwelling catheter because her incontinence brief was wet. The irrigation was unsuccessful due to the indwelling catheter being completely obstructed. The catheter was removed, a new indwelling catheter was inserted, and urine was returned right away. Resident #43's urine was slightly hazy yellow with a small amount of sediment. There was no evidence Resident #43's physician was notified of the slightly hazy yellow urine with a small amount of sediment.Review of Resident #43's medical record including progress notes dated 09/26/25 at 7:00 P.M. through 10/02/25 at 11:36 P.M. did not reveal evidence Resident #43's urine was monitored for color or consistency.Review of Resident #43's progress notes dated 10/02/25 at 11:36 P.M. revealed Resident #43's indwelling catheter was changed, and a new (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366471 If continuation sheet Page 4 of 11 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 366471 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/21/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Avenue at Broadview Heights 1201 Akins Road Broadview Heights, OH 44147 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 0690 Level of Harm - Actual harm Residents Affected - Few catheter was inserted. Resident #43's catheter was draining thick, milky looking urine. The Nurse Practitioner was contacted, and urine was collected, placed in the refrigerator, and was awaiting pick up from the lab.Review of Resident #43's progress notes from 10/02/25 at 11:36 P.M. through 10/06/25 at 10:00 P.M. did not reveal evidence Resident #43's urine was monitored for color, consistency.Review of Resident #43's lab results revealed Resident #43's urine for urinalysis and culture if indicated was collected on 10/03/25 at 12:00 A.M. and reported on 10/06/25 at 1:49 P.M. The report contained abnormal results, and the urine was extra turbid, had three plus blood, one plus protein, four plus leukocytes, RBC were greater than 50, WBC were greater than 50. The urine had probable contamination, and a urine culture was not completed. Review of Resident #43's progress notes dated 10/06/25 at 10:00 P.M. revealed Resident #43's catheter was changed and a new indwelling catheter was inserted. The catheter was draining thick, yellow looking urine. The nurse collected a urine sample and irrigated the catheter with no difficulties.Review of Resident #43's lab results for a urine culture included the urine was collected on 10/06/25 at 10:00 A.M. and reported on 10/09/25 at 1:45 P.M. Resident #43's urine had greater than 100,000 CFU per ml of Klebsiella Pneumoniae. Review of Resident #43's progress notes dated 10/10/25 at 11:40 P.M. revealed Resident #43's urine culture result was reported to the on-call physician, klebsiella pneumoniae was found and a new order for Bactrim DS (antibiotic) 800-160 mg two times a day for five dates due to a urinary tract infection was given. Resident #43's urine culture results were reported to the on-call physician approximately 34 hours after the results were reported. Resident #43's daughter was updated with the urine culture results and the new order for Bactrim DS.Review of Resident #43's physician order dated 10/11/25 at 12:16 A.M. revealed orders for Bactrim DS oral tablet 800-160 mg (Sulfamethoxazole-Trimethoprim), give one table via PEG tube two times a day for UTI for five days. Observation on 10/15/25 at 3:31 P.M. of Resident #43 with Certified Nursing Assistant (CNA) #307 and Unit Manager (UM) #308 revealed Resident #43 was lying in bed and smiled pleasantly when asked questions. Resident #43 did not speak but could nod head in a yes manner and shake her head to the right or left when the answer was no. CNA #307 provided appropriate incontinence care and catheter care with UM #308's assistance. UM #308 noticed Resident #43's catheter bag was full and emptied the catheter bag for 600 cc of cloudy, yellow orange urine.Interview on 10/16/25 at 12:04 P.M. of the Director of Nursing (DON) revealed resident's lab values do not pop up on the electronic record screen to let the nurses know the results were reported. The DON stated lab results were typically faxed and if the results were critical the lab called the facility. The DON revealed the facility had to keep checking for lab results and passed the information during shift change report if the nurses were waiting on lab results.Interview on 10/16/25 at 2:35 P.M. of the DON and the Administrator revealed Resident #43's first urine was contaminated and another urine needed to be sent. The DON confirmed Resident #43's second urine was reported to the facility on [DATE] at 1:45 P.M., but she did not know what time it was faxed to the facility. The DON stated faxes were not kept so she could not check to see when the report was faxed. The DON confirmed the results were not reported to Resident #43's physician for about 34 hours and could not explain why it took so long. The DON confirmed the nurse did not start Resident #43's antibiotics until the next morning, and confirmed the antibiotic Bactrim was stocked in the automated dispensing system at the facility. The DON did not know why the nurse did not start the Bactrim as soon as she got the order and stated maybe the Bactrim was empty in the automated dispensing system.Interview on 10/20/25 at 4:15 P.M. of Pharmacist #309 revealed Resident #43's Bactrim (Sulfamethoxazole-Trimethoprim) was filled on 10/11/25 at 12:19 A.M. and delivered timely to the facility. Pharmacist #309 stated Bactrim was available in the automated dispensing system on 10/10/25 and 10/11/25 and it was not taken (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366471 If continuation sheet Page 5 of 11 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 366471 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/21/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Avenue at Broadview Heights 1201 Akins Road Broadview Heights, OH 44147 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 0690 Level of Harm - Actual harm Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete out of the system by the nurses for Resident #43.Interview on 10/20/25 at 10:54 A.M. of Licensed Practical Nurse (LPN) #311 revealed Resident #43's indwelling catheter became occluded frequently, and it was common for her to have sediment in her urine and that was probably why she changed Resident #43's catheter on 09/26/25. LPN #311 stated she did not remember changing the catheter on 09/26/25 or if Resident #43's urine was hazy and amber colored. LPN #311 revealed if she reported Resident #43's urine to the Physician or Nurse Practitioner she would have documented it. LPN #311 stated she remembered reporting Resident #43's urine culture results as soon as she received the lab report to the Physician on 10/10/25. LPN #311 stated she did not recall details of the lab report and why it took so long for her to receive it. LPN #311 revealed someone else might have printed it off for her.Interview on 10/20/25 at 3:50 P.M. of Nurse Practitioner (NP) #301 revealed if Resident #43's urine was slightly hazy yellow and had some sediment in it he should have been notified. NP #301 revealed any time there was a change in urine clarity and consistency it could warrant further looking into. NP #301 revealed it seemed like it took a long time for the on-call Physician to be notified of the urine results which were reported on 10/09/25 at 1:45 P.M. NP #301 stated if Resident #43's urine was positive for a urinary tract infection the Bactrim could have been administered sooner.Review of the facility policy titled Foley Catheter Care revised 08/2022 included the facility would promote urinary health and management to the resident with an indwelling catheter and ensure the appropriate care and services were provided to prevent urinary tract infections to the extent possible. The staff would observe and report to the licensed nurse any signs or symptoms of infection to include blood, odor, cloudiness, pain, elevated temperature, or absence or decrease in urine output.This deficiency represents non-compliance investigated under Complaint Number 1401320. Event ID: Facility ID: 366471 If continuation sheet Page 6 of 11 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 366471 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/21/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Avenue at Broadview Heights 1201 Akins Road Broadview Heights, OH 44147 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 0695 Provide safe and appropriate respiratory care for a resident when needed. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview, record review, review of facility policy and review of hospital records the facility failed to ensure Resident #59's care planned interventions were implemented and physician orders were followed for oxygen therapy. This affected one resident (Resident #59) out of three residents reviewed for oxygen therapy. The facility census was 58. Findings include:Review of Resident #59's closed medical record revealed an admission date of 11/14/24 and diagnoses included chronic obstructive pulmonary disease with acute exacerbation, chronic respiratory failure with hypercapnia, obstructive and reflux uropathy, and retention of urine. Resident #59 had a left pneumonectomy in December, 1989. Resident #59 was discharged from the facility on 07/11/25.Review of Resident #59's care plan dated 12/19/24 and revised on 07/24/25 (Resident #59 was discharged from the facility on 07/11/25) revealed Resident #59 had an altered respiratory status and difficulty breathing related to COPD (chronic obstructive pulmonary disease) and chronic respiratory failure. Resident #59 would maintain a normal breathing pattern as evidenced by normal respirations, normal skin color and a regular respiratory rate, pattern through the review date of 09/14/25. Interventions included to administer oxygen as ordered; auto BIPAP (Bilevel Positive Airway Pressure, a non-invasive ventilation technique that provided respiratory support by delivering two different levels of air pressure during inhalation and exhalation) 20/10 cmH2O (centimeters of water and is a unit of pressure) with 3L O2 (three liters of oxygen) at bedtime and as needed; observe for changes in orientation, increased restlessness, anxiety and air hunger; observe for signs and symptoms of respiratory distress (including increased respirations, decreased pulse oximetry, increased heart rate, restlessness, diaphoresis, headaches, lethargy, confusion, skin color changes to blue-gray) and report to the physician as needed Review of Resident #59's medical record including progress notes, MAR and TAR dated 03/04/25 revealed Resident #59 refused her BIPAP, but no reason for refusing the BIPAP was documented in her medical record.Review of Resident #59's medical record including progress notes, Medication Administration Records (MAR) and Treatment Administration Records (TAR) dated 03/05/25 through 06/23/25 did not reveal evidence Resident #59 refused her BiPAP therapy.Review of Resident #59's Quarterly Minimum Data Set assessment dated [DATE] revealed Resident #59 was cognitively intact. Resident #59 required partial to moderate assistance with toileting hygiene, bathing, and upper body dressing. Resident #59 required supervision or touching assistance with personal hygiene. Resident #59 required substantial to maximal assistance to roll left and right and return to lying on her back on the bed. Resident #59 had an indwelling catheter and was frequently incontinent of bowel. Resident #59 did not reject care during the seven-day assessment look-back period. Resident #59 used oxygen therapy.Review of Resident #59's hospital Discharge Instructions for a hospital stay dated 06/13/25 through 06/22/25 included Resident #59's hospital problems as of 06/22/25 included the principal problem was septic shock secondary to CAUTI (catheter associated urinary tract infection) and citrobacter bacteremia (resolved) and other problems included chronic obstructive pulmonary disease, chronic respiratory failure with hypoxia and hypercapnia, chronic indwelling catheter and obstructive and reflux uropathy. Resident #59's condition at discharge was improved and symptoms to look out for after discharge was new or severe pain, fever, shortness of breath and unable to keep down fluids. Resident #59's oxygen requirements were three liters oxygen per minute via nasal cannula during the day and BIPAP overnight. Resident #59's BIPAP settings were 12/6. Encourage nightly BIPAP. Review of Resident #59's progress notes dated 06/22/25 at 8:00 P.M. revealed Resident #59 came back from the hospital via stretcher with EMS and was accompanied by her daughter. Resident #59's blood pressure was 117/65, pulse 91, respirations 17, temperature was 97.6 Fahrenheit, and her oxygen Residents Affected - Few (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366471 If continuation sheet Page 7 of 11 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 366471 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/21/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Avenue at Broadview Heights 1201 Akins Road Broadview Heights, OH 44147 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 0695 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few saturation was 98 percent on three liters of oxygen per minute via nasal cannula.Review of Resident #59's MAR and TAR dated 06/22/25 at 8:00 P.M. through 06/23/25 at 9:20 A.M. did not reveal evidence Resident #59 had BIPAP administered at 12/6 cmH20 with three liters oxygen at bedtime and as needed per physician orders. Review of Resident #59's medical record including progress notes, assessments, MAR and TAR dated 06/22/25 at 8:00 P.M. through 06/23/25 at 9:20 A.M. did not reveal evidence Resident #59 was monitored or assessed for fever, shortness of breath, lethargy, vital signs including respirations and oxygen saturation levels.Review of Resident #59's progress notes dated 06/23/25 at 9:20 A.M. revealed Registered Nurse/Unit Manager (RN/UM) #300 entered Resident #59's room to assist with getting Resident #59 up and ready for the day. Upon entering the room Resident #59 was observed sitting in her wheelchair with her eyes closed and her head down. RN/UM #300 asked Resident #59 if she felt okay and Resident #59 attempted to respond verbally, but opened her mouth and could not speak. Resident #59's skin was pale and warm with moderate edema of the left upper and lower extremities. Resident #59 opened her eyes halfway and her eyes looked glazed over. Resident #59's temperature was 98.1 Fahrenheit, blood pressure was 141/64, heart rate was 99, respirations 20 per minute. Resident #59 was wearing oxygen at 3 liters per minute via nasal cannula and her oxygen saturation was 66 percent.Review of Resident #59's progress notes dated 06/23/25 at 9:22 A.M. revealed Resident #59's daughter was contacted to confirm Resident #59's code status as the resident was unable to answer questions. Resident #59's daughter stated she did not know Resident #59's code status and immediately hung up on the nurse.Review of Resident #59's progress notes dated 06/23/25 at 9:23 A.M. revealed Certified Nurse Practitioner (CNP) #301 was notified of Resident #59's current status and a new order was given to send Resident #59 to the ED for evaluation.Review of Resident #59's progress notes dated 06/23/25 at 9:42 A.M. revealed Resident #59 was accompanied by EMS personnel and was transported to the hospital ED.Review of Resident #59's progress notes dated 06/23/25 at 9:44 A.M. revealed Resident #59's daughter was notified Resident #59 was transported to the hospital ED.Review of Resident #59's progress notes dated 06/23/25 at 9:55 A.M. revealed when RN/UM #300 contacted Resident #59's daughter the floor nurse administered a breathing treatment, increased her oxygen and Resident #59's oxygen saturation increased to 90 percent.Review of Resident #59's progress notes dated 06/23/25 at 10:30 A.M. revealed Resident #59's daughter was in Resident #59's room, returned to the lobby and stated you guys are going down, I set you up and hid the BIPAP. Resident #59's daughter refused to speak to the Administrator and left the facility.Review of Resident #59's progress notes dated 06/23/25 at 11:20 A.M. revealed on 06/22/25 at 10:00 P.M. the nurse was unable to encourage Resident #59 to wear her BIPAP machine. The machine was not located in the resident's room.Review of Resident #59's hospital records for a hospital stay dated 06/23/25 through 06/29/25 revealed Resident #59's admission diagnosis was hypercapnia (too much carbon dioxide in the bloodstream). Resident #59 had a past medical history of COPD and other diagnoses and was on home 3LNC (three liters oxygen per minute via nasal cannula) and BIPAP at night. Resident #59 was discharged from the hospital on [DATE] after a prolonged hospitalization due to septic shock from a CAUTI and Resident #59 had positive blood cultures. Resident #59 was discharged on antibiotics after consultation with Infectious Disease. Resident #59 was discovered on 06/23/25 in the morning, was poorly responsive and had left-sided weakness. On arrival Resident #59 was lethargic, able to answer questions, follow commands and complained of left arm weakness. Blood pressure was 171/98, pulse 133, respirations 12 and oxygen saturation was 97 percent on oxygen via nasal cannula. Resident #59's CO2 was 43 mmol/L (indicates an electrolyte and acid-base imbalance in the body, the normal range is typically 23 to 29 mmol/L) on 06/23/25 at 10:33 A.M. Resident #59 was admitted to the ICU for treatment and workup of stroke-like symptoms and (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366471 If continuation sheet Page 8 of 11 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 366471 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/21/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Avenue at Broadview Heights 1201 Akins Road Broadview Heights, OH 44147 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 0695 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few acute hypoxic hypercapnic respiratory failure (life-threatening condition characterized by a deficiency in oxygen and an excess of carbon dioxide). Resident #59's hospital course included Resident #59 was intubated in the ED and admitted to the ICU due to encephalopathy from hypercapnia and bacteremia. Resident #59 had acute hypercapnic and hypoxic respiratory failure requiring intubation. Resident #59 had a CXR and the radiologist found a questionable small, right pneumothorax versus a prominent skin fold. Review of Resident #59's progress notes dated 06/23/25 at 4:21 P.M. revealed Resident #59 was admitted to the local hospital.Interview on 10/16/25 at 10:50 A.M. with Family Member (FM) #302 revealed she accompanied Resident #59 to the facility from the hospital on [DATE] at around 6:00 P.M. to 8:00 P.M. when she was readmitted , and FM #302's daughter was also present. FM #302 stated she saw the EMS staff give Resident #59's nurse a manila envelope with her hospital discharge instructions in it. FM #302 stated Resident #59's BIPAP machine was on the windowsill when Resident #59 returned to the facility on [DATE], and none of the nurses asked Resident #59 if she wanted her BIPAP or attempted to put the BIPAP on her. FM #302 stated she never touched Resident #59's BIPAP machine and did not hide it from the staff. FM #302 stated the next morning on 06/23/25 before Resident #59 was transported to the ED she was called by a facility nurse and asked if Resident #59 was a full code, and an unidentified male physician called her and asked if Resident #59 had a BIPAP order. FM #302 stated she rushed to the facility after she was called and when she arrived the Director of Nursing (DON) told her Resident #59 did not have a BIPAP order. FM #302 stated she was so upset, the conversation escalated because the facility staff lied to my face and almost killed my mom. FM #302 revealed she snapped because she was furious and I do not remember what I said because I was so mad they lied to me and I know for a fact she was not getting her BIPAP. FM #302 stated the BIPAP machine was bone dry and dirty. Interview on 10/16/25 at 2:04 P.M. with Resident #59 revealed when she returned to the facility on [DATE] her BIPAP was in the room, and they did not put it on me. Resident #59 stated she did not refuse to wear her BIPAP, but a couple times she was wearing it, it was not working right, she felt it shoot hot air onto her face, and she could not breathe properly. Resident #59 indicated when that happened she panicked and asked her to take it off. The nurse tried again, it did not work, and she panicked again. After that Resident #59 told the nurse to come back later, and she would try again, but the nurse did not return. Resident #59 revealed she told the nurses if she was sleeping to wake her up and put the BIPAP on, and I absolutely did not tell the nurses I did not want to wear the BIPAP. Resident #59 indicated the doctor told her he wanted the instructions followed to a t. Interview on 10/16/25 at 2:35 P.M. with the Director of Nursing (DON) and the Administrator revealed on 06/23/25 Resident #59 was not feeling well and was sent to the hospital ED. The DON stated she talked to FM #302 on the phone and FM #302 indicated Resident #59 did not have her BIPAP on and said don't lie to me. FM #302 came to the facility, went to Resident #59's room, then came back to where the DON was and blew up. FM #302 stated I know the nurse did not put her on the BIPAP because I hid it, then she left the facility. The Administrator stated neither the Ombudsman nor Physician were notified FM #302 made this statement because it sounded like FM #302 was trying to trap us. The DON stated the nurse documented he tried to put Resident #59's BIPAP on. The DON stated Resident #59 had a diagnosis of pneumothorax.Interview on 10/29/25 at 9:39 A.M. with the DON revealed Resident #59's BIPAP was found at the bedside and she was not sure where it was. The DON indicated she would expect vital signs and oxygen saturations to be monitored if Resident #59 was unable to be placed on the BIPAP because it could not be found. The DON stated Resident #59 was only back in the facility about 12 hours before she went back to the hospital. The DON confirmed Resident #59's vital signs and oxygen saturations were not checked between 06/22/25 at 8:00 P.M. and 06/23/25 at 9:20 (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366471 If continuation sheet Page 9 of 11 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 366471 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/21/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Avenue at Broadview Heights 1201 Akins Road Broadview Heights, OH 44147 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 0695 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few A.M.Interview on 10/20/25 at 10:01 A.M. with Registered Nurse/Unit Manager (RN/UM) #300 revealed she was not the Unit Manager now, had recently left the position, but still worked at the facility. RN/UM #300 stated she did not remember much about the day Resident #59 was sent to the hospital. RN/Um #300 indicated she remembered FM #302 was upset and super emotional and said she hid Resident #59's BIPAP machine and we were going down.Interview on 10/20/25 at 10:20 A.M. with MDS Nurse #303 revealed care plans were updated when there were changes and Quarterly as well. MDS Nurse #303 stated she tried to update care plans the next day, but were typically updated within a week. MDS Nurse #303 confirmed Resident #59's care plan was updated on 07/24/25 after she was discharged from the facility. MDS #303 stated Resident #59's care plan was closed on 07/24/25. MDS Nurse #303 indicated she would typically try to update a residents BIPAP orders and she might not have got to Resident #59's BIPAP right away.Interview on 10/20/25 at 10:36 A.M. with Registered Nurse (RN) #304 revealed he was working on 06/22/25 when Resident #59 was readmitted to the facility. RN #304 stated Resident #59's daughter and granddaughter were with her. RN #304 indicated EMS gave him her papers from the hospital. RN #304 stated the papers included BIPAP orders, and when he looked for Resident #59's BIPAP machine on the bedside table where her oxygen tubing and nebulizer was he did not see it. RN #304 stated Resident #59's room was very cluttered with boxes and other things and he did not look other places for the BIPAP because it should be on the bedside table with the oxygen tubing and nebulizer. RN #304 indicated he was a new nurse and he highlighted the BIPAP orders because he was taught to do that if he didn't know how to facilitate items, and then he would put a report in for his supervisor and the supervisor would take care of it. RN #304 did not remember if a supervisor was working that night, and did not know who took care of the highlighted BIPAP order. RN #304 stated he was not able to find the BIPAP machine and that was why he highlighted the BIPAP orders. RN #304 indicated Resident #59 was tired from her transfer and he did not ask Resident #59 if she knew where her BiPAP machine was. RN #304 stated Resident #59 did not tell him she did not want to wear her BIPAP. RN #304 indicated he gave her pain medications and a nebulizer treatment during the night and she did not seem to be having a hard time and if she did he would ask for help. RN #304 confirmed he checked Resident #59's vital signs and oxygen saturation when she was admitted but did not check Resident #59's oxygen saturation or vital signs after that. RN #304 clarified the nursing progress note he wrote on 06/23/25 and stated he meant Resident #59 did not always wear her BIPAP the recommended amount of time. Interview on 10/20/25 at 3:50 P.M. with Nurse Practitioner (NP) #301 revealed if Resident #59's BiPAP was not available he should have been notified. NP #301 stated he should be notified with any resident change of condition. NP #301 indicated Resident #59's BIPAP helped blow off CO2 and symptoms of high CO2 included increased lethargy, confusion and change of mental status. NP #301 stated a build up of CO2 could manifest like stroke symptoms. NP #301 stated Resident #59 absolutely should have been monitored and should have had more frequent assessments during the night.Review of the facility policy titled Resident Change in Condition dated 07/28/22 included the purpose was to ensure staff provided timely and appropriate care and services when residents experience a change in condition that had or was likely to cause serious life-threatening harm or injuries and, or adverse negative health outcomes. The facility would promptly notify the resident, his or her attending physician and responsible party of changes in the resident's condition and, or status. The licensed nurse would take immediate action to ensure timely and appropriate care and services were met when a resident change in condition was identified.Review of the facility policy titled Oxygen Therapy revised 12/2022 included oxygen would be provided as needed and prescribed in a safe manner ensuring each resident received necessary respiratory care and services that was in accordance with professional standards of (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366471 If continuation sheet Page 10 of 11 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 366471 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/21/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Avenue at Broadview Heights 1201 Akins Road Broadview Heights, OH 44147 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 0695 Level of Harm - Minimal harm or potential for actual harm practice, the resident's care plan and resident's choice. Oxygen would be administered and titrated per physician order. The residents medical record should reflect ongoing assessment of the resident's respiratory status, response to oxygen therapy and the attending practitioner's orders and indication for use.This deficiency represents non-compliance investigated under Complaint Number 1401320. Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366471 If continuation sheet Page 11 of 11