Inspection visit
Health inspection
2 citations recorded
Inspector’s narrative
What the inspector wrote
This survey cited 2 deficiencies, 1 of them serious (actual harm or immediate jeopardy). The full statement and the facility’s plan of correction follow, verbatim from the federal record.
F 0689
Level of Harm - Immediate
jeopardy to resident health or
safety
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to
prevent accidents.
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** THIS IS AN
INCIDENCE OF PAST NON-COMPLIANCE THAT WAS SUBSEQUENTLY CORRECTED PRIOR TO THIS
SURVEY.
Residents Affected - Few
Based on observation, interviews with staff and local police officers, review of medical records, review of
the facility's investigation, review of data from the Weather Underground website, and review of the facility
policy for elopement, the facility failed to ensure one resident (Resident #38) with diagnoses of dementia,
mild cognitive impairment, age related cognitive decline, multiple sclerosis (MS) and lack of coordination
did not walk away from the facility unsupervised and without staff knowledge. This resulted in Immediate
Jeopardy and the potential for serious life-threatening harm, injury and/or death when on 07/30/23 at 5:38
P.M., Resident #38 exited through the front door, without staff knowledge, after following another resident's
family member out the door which required a code to be entered to exit. Resident #38 was subsequently
located in a shopping plaza parking lot after the police received a concerned citizen call at 7:39 P.M.
indicating there was an individual who appeared disoriented and was having difficulty ambulating. The
police brought Resident #38 back to the facility at 7:50 P.M. at which time she was identified as a facility
resident. This affected one (#38) of three residents reviewed for elopement risk of eight sampled residents
selected for review during the complaint investigations. The facility identified a total of 24 residents (#2, #9,
#14, #24, #34, #51, #55, #59, #65, #70, #73, #84, #87, #88, #89, #92, #95, #96, 97, #98, #99, #100, #101
and #102) as being an elopement risk. The facility census was 102.
On 02/06/24 at 3:36 P.M., the Administrator and Regional Registered Nurse (RRN) #301 were notified
Immediate Jeopardy began on 07/30/23 at 5:38 P.M. when Resident #38, who had diagnoses of dementia,
mild cognitive impairment, age related cognitive decline and lack of coordination walked away from the
facility unsupervised and without staff knowledge. Resident #38 was located in a shopping plaza parking lot
and returned to the facility by police after a concerned citizen call was received by the local police
department on 07/30/23 at 7:39 P.M. indicating there was an individual who appeared disoriented and was
having difficulty ambulating in a parking lot. The resident was returned to the facility by the police at 7:50
P.M., approximately two hours after she had eloped from the facility unsupervised and unknown to staff that
she was missing. The progress note dated 07/30/23 timed at 7:50 P.M. authored by Licensed Practical
Nurse (LPN) #205 revealed LPN #205 received a phone call from another nurse stating Resident #38 was
found by the police. LPN #205 made his way outside; however, the police had already dropped Resident
#38 off at the facility and left. Resident #38 was without signs of injury and appeared to be overjoyed,
dancing and celebrating that she was able to get out. While laughing, Resident #38 stated one of the family
members here let me out, he probably thought I was also a family member. Resident #38 was unable to
state when she had left the facility; she said she had breakfast at the facility but not lunch. When asked why
she left the facility, Resident #38 stated she was tired of looking at the four walls, it felt like a prison, and
she did not regret
(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 9
Event ID:
366477
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
366477
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
02/15/2024
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Avenue at North Ridgeville
6200 Lear Nagle Road
North Ridgeville, OH 44039
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 - Immediate
jeopardy to resident health or
safety
Residents Affected - Few
getting out for some fresh air. Resident #38 returned with shopping bags from a local dollar store that
included cookies and picture frames. Review of the progress note dated 07/31/23 timed at 7:40 A.M.
authored by Nurse Practitioner (NP) #297 revealed she was notified Resident #38 had left the building,
went shopping and returned hours later with energy drinks. The note indicated Resident #38 did not recall
going shopping. On 07/31/23, the resident was transferred to the secured memory care unit.
The Immediate Jeopardy was removed on 08/02/23 when all residents were re-assessed for their
elopement risk and care plans updated as warranted for all residents identified as being at risk for
elopement. The deficiency remained at Severity Level 2 (no actual harm with the potential for more than
minimal harm that is not immediate jeopardy) until it was corrected on 09/21/23 when the facility
implemented the following corrective actions:
•
On 07/30/23 at 7:50 P.M., Resident #38 was returned to the facility by the local police and was assessed by
nursing staff with no signs of injury.
•
Beginning 07/30/23 at 8:00 P.M., the Administrator began educating all staff on the elopement policy,
emergency door codes, not sharing door codes with families, reporting malfunctioning doors to
maintenance, staff members to use the rear entrance, use of radios for elopement event, updating door
map locations, and calling the Administrator and DON to report an event. Agency staff received education
prior to the start of their shifts. Review of an employee roster dated 07/30/23 - 08/01/23 revealed the
Administrator placed check marks by each employee name indicating he had provided the staff person the
education either via phone or in person and the date the education had been provided. The document
indicated all staff had received the training by 08/01/23 at 5:00 P.M. Interviews with staff members across
all shifts on 02/14/24 through 02/15/24 confirmed they had received education on elopement policies and
procedures by the Administrator. Each staff member was knowledgeable regarding the current policies and
procedures.
•
On 07/31/23, the Corporate Director of Clinical Services #415 re-educated the Administrator and the
Director of Nursing (DON) on elopement policies and procedures including assessment, identification,
monitoring and managing residents at risk for elopement. Review of education acknowledgement
documentation dated 07/31/23 confirmed the signatures of the Administrator and DON indicating receipt of
the training.
•
Review of a document titled Door Audits for Alarms Checks for Pressure and Release Checks revealed
documentation random door audits were completed by the Administrator for a four-week period from
07/31/23 through 09/14/23 with no concerns noted.
•
From 07/31/23 through 12/31/23, monthly elopement drills were completed by Maintenance Director
(continued on next page)
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
366477
If continuation sheet
Page 2 of 9
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
366477
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
02/15/2024
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Avenue at North Ridgeville
6200 Lear Nagle Road
North Ridgeville, OH 44039
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 - Immediate
jeopardy to resident health or
safety
Residents Affected - Few
#224. Review of the elopement drill documentation revealed on 07/31/23 an elopement drill was completed
at 10:30 A.M., 08/30/23 an elopement drill was completed at 8:00 P.M., and on 09/21/23 an elopement drill
was completed at 2:00 A.M. indicating each shift had completed an elopement drill with no concerns noted.
•
From 08/01/23 through 08/02/23, all residents were re-assessed for their elopement risk by the Assistant
Director of Nursing (ADON), Minimum Data Set (MDS) Nurse #221 and Unit Manager #222. Medical record
review on 02/12/24 confirmed elopement risk assessments were completed, and care plans updated as
warranted for all residents identified as being at risk for elopement.
•
On 08/02/23, a Quality Assessment and Assurance (QAA) meeting was held that included the
Administrator, DON, ADON, Housekeeping Supervisor #416, Maintenance Director #224, Social Services
Designee #425, Central Supply Department Head #428, Admissions Director #426, Marketing Director
#427, Therapy Director #417, Minimum Data Set (MDS) Nurse #292, Human Resources #41, Pharmacy
Consultant #430, Business Officer Manager #429 and Medical Director #420. At this meeting the corrective
action plan for Resident #38's elopement was presented by the Administrator and approved. Review of the
sign in sheet for the meeting confirmed attendance.
•
On 08/09/23, the Administrator provided education to families regarding the changing of the door codes
and the need to be vigilant that residents were not following visitors out of the building. The administrator
posted a sign on the front entrance door for families that were not present at the meeting. Review of an
education sign in sheet confirmed families and residents were in attendance.
Findings include:
Review of the medical records for Resident #38 revealed an admission date of 07/02/21. Diagnoses
included dementia, mild cognitive impairment, age related cognitive decline, lack of coordination, multiple
sclerosis (MS), anxiety, bipolar, depression, falls, weakness and unsteadiness on feet.
Review of Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #38 had impaired
cognition, required supervision with ambulation and assistance of one staff for toileting and personal
hygiene. The assessment indicated Resident #38 had no behaviors.
Review of the elopement assessment dated [DATE] timed at 9:40 P.M. revealed Resident #38 was at risk for
elopement.
Review of the progress note dated 07/30/23 timed at 7:50 P.M. authored by Licensed Practical Nurse (LPN)
#205 revealed LPN #205 received a phone call from another nurse stating Resident #38 was found by the
police. LPN #205 made his way outside; however, the police had already dropped Resident #38 off at the
facility and left. Resident #38 was without signs of injury and appeared to be overjoyed, dancing and
celebrating that she was able to get out. While laughing, Resident #38 stated one of the family members
here let me out, he probably thought I was also a family member. Resident #38 was unable to state when
she had left the facility; she said she had breakfast at the facility but not
(continued on next page)
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
366477
If continuation sheet
Page 3 of 9
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
366477
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
02/15/2024
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Avenue at North Ridgeville
6200 Lear Nagle Road
North Ridgeville, OH 44039
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 - Immediate
jeopardy to resident health or
safety
Residents Affected - Few
lunch. When asked why she left the facility, Resident #38 stated she was tired of looking at the four walls, it
felt like a prison, and she did not regret getting out for some fresh air. Resident #38 returned with shopping
bags from a local dollar store that included cookies and picture frames. Resident #38's guardian, alternate
contact, unit manager and DON were notified.
Review of the progress note dated 07/31/23 timed at 7:40 A.M. authored by Nurse Practitioner (NP) #297
revealed she was notified Resident #38 had left the building, went shopping and returned hours later with
energy drinks. The note indicated Resident #38 did not recall going shopping.
Review of the progress note dated 07/31/23 timed at 3:17 P.M. revealed Resident #38 was transferred to
the secured memory care unit.
Review of the elopement assessment dated [DATE], which was completed to determine if it was
appropriate to transfer Resident #38 back to the unit she previously resided on because she was not
adjusting well to the secured memory care environment, revealed Resident #38 was not at risk for
elopement.
Review of the care plan dated 10/04/23 revealed Resident #38 had impaired self-care abilities related to
MS and dementia diagnoses. Interventions included provide cues to use walker during ambulation,
supervise transfers and toileting, and assistance of one staff for dressing. Resident #38 had periods of
bowel and bladder incontinence. Interventions included check for incontinence every two hours and as
needed. Resident #38 had communication deficits related to dementia. Interventions included do not rush
and allow time to process information, speak directly to the resident in a clear voice and ask simple yes/no
questions and allow adequate time to respond. Resident #38 was at risk for falls related to MS diagnosis
and poor safety awareness. Interventions included remind to utilize walker for ambulation. Resident #38 had
dementia. Interventions included reorienting resident to unit as needed. Resident #38 was at risk for
elopement related to dementia and impaired thought process with history of exit seeking behaviors (this
was not in line with the elopement assessment dated [DATE] which indicated Resident #38 was not at risk
for elopement). Interventions included escorting resident outside for a walk as needed, provide 1:1 as
needed, and document attempts to leave the facility unattended.
Review of the progress note dated 10/05/23 timed at 4:02 P.M. revealed Resident #38 was moved from the
secured memory care unit to the 200 Hall.
Review of the progress note dated 10/31/23 timed at 9:19 P.M. revealed Resident #38 activated a door
alarm on the 200 Hall. Resident #38 was observed repeatedly pushing and slamming her shoulder into the
door. The progress note did not indicate staff response or if Resident #38 was easily redirected.
Interview on 02/05/24 at 11:10 A.M. with Resident #38 revealed Resident #38 was confused and unable to
recall leaving the facility. Resident #38 did not know the current month or the day of the week.
Interview on 02/05/24 at 11:15 A.M. with LPN #202 revealed she was the assigned nurse for Resident #38
on 07/30/23 from 6:00 A.M. to 6:00 P.M. LPN #202 stated Resident #38 was not alert and oriented and was
confused at times with fixated behaviors. Resident #38 ambulated with a walker. LPN #202 recalled
administering medications to Resident #38 sometime between 2:00 P.M. and 4:00 P.M. and when she left
the facility at approximately 6:00 P.M. she was not aware Resident #38 was not present. LPN #202 said
upon her return to work a few days later she was informed Resident #38 had left the facility. LPN #202 was
not aware of the details as to what occurred.
(continued on next page)
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
366477
If continuation sheet
Page 4 of 9
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
366477
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
02/15/2024
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Avenue at North Ridgeville
6200 Lear Nagle Road
North Ridgeville, OH 44039
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 - Immediate
jeopardy to resident health or
safety
Residents Affected - Few
Interview on 02/05/24 at 12:00 P.M. with STNA #240 revealed she was present on 07/30/23 but she was
working on another unit. STNA #240 was aware Resident #38 had left the facility and thought she had been
gone for possibly two hours. STNA #240 spoke with Resident #38 after the incident and Resident #38 told
her she followed a family member out of the building and went to a restaurant and the dollar store. STNA
#240 stated the restaurant and dollar store were approximately a five-minute walk for the average person;
however, due to Resident #38's MS it could have taken her longer to get to the location. STNA #240 stated
Resident #38 did not adjust well to the surroundings of the secured memory care unit and after a few
months she was moved back to the 200 Hall.
Telephone interview on 02/05/24 at 1:50 P.M. with a staff member who wished to remain anonymous due to
fear of retaliation revealed the staff member was present on the evening of 07/30/23. The staff member
received a phone call from the local police department asking if the facility was missing a resident. The
description that was provided sounded like Resident #38. The police arrived at the facility and the
anonymous staff member, and another staff member identified Resident #38. Resident #38 did not appear
to have any injuries and was confused when she arrived.
Interview on 02/05/24 at 3:55 P.M. with the Administrator and DON revealed an investigation related to the
elopement of Resident #38 was not completed; however, the Administrator had asked staff members some
questions. The Administrator stated he was informed Resident #38 had a bout of confusion at the dollar
store while reaching for her wallet to pay for her items; however, the Administrator was unable to state who
had reported Resident #38 appearing to be confused at the dollar store. The Administrator stated he was
unable to determine what time Resident #38 had left the facility. He did state it may have been late
afternoon, possibly around dinner time. The Administrator stated local police informed the facility Resident
#38 had been located outside of the facility and had she not been found by the police the nurse would have
realized she was missing when medications were administered. The DON stated she was not employed at
the facility during the event and was not aware of the details related to Resident #38's elopement.
Telephone interview on 02/06/24 at 7:33 A.M. with LPN #205 revealed he was the assigned nurse for
Resident #38 on 07/30/23 from 6:00 P.M. until 6:00 A.M. When LPN #205 arrived on duty he was not aware
Resident #38 was not present in the building and during his evening medication pass (could not recall
time), he went to Resident #38's room and she was not present. LPN #205 looked for Resident #38 in the
library because she often sat in there, but she was not in the library. Sometime later (unable to recall time)
he was notified by STNA #230 the police dropped Resident #38 off at the facility. LPN #205 spoke with
Resident #38 upon her return and Resident #38 told him she had seen another resident's family exiting the
facility and she had taken the chance and left. LPN #205 stated Resident #38 appeared happy and was
dancing when she returned saying she was happy she got out. LPN #205 stated Resident #38 was
confused at times and ambulated with a walker.
Telephone interview on 02/06/24 at 7:43 A.M. with STNA #237 revealed she was present on 07/30/23 from
6:00 P.M. to 6:00 A.M., but she was not assigned to Resident #38. Approximately an hour or two into her
shift STNA #230 received a phone call from the police regarding a missing resident. Based on the
description the police had given, STNA #230 identified it was Resident #38. STNA #237 and STNA #230
met the police at the door and assisted Resident #38 back into the building. Resident #38 told STNA #237
she went to a restaurant to get a few drinks. Resident #38 also told STNA #237 she left sometime after
lunch. STNA #237 described Resident #38 as being pleasantly confused and ambulatory with a walker.
Telephone interview on 02/06/24 at 10:46 A.M. with Police Officer (PO) #400 revealed he and another
(continued on next page)
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
366477
If continuation sheet
Page 5 of 9
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
366477
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
02/15/2024
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Avenue at North Ridgeville
6200 Lear Nagle Road
North Ridgeville, OH 44039
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 - Immediate
jeopardy to resident health or
safety
Residents Affected - Few
officer received a call about an individual who was disoriented and stumbling in a parking lot. PO #400 did
not respond to the call; the other officer was the responding officer. PO #400 had been advised the
individual was unable to state her name but was able to state the name of the facility she resided at but did
not know how to get back to the facility. PO #400 stated the other officer took Resident #38 to the facility
and staff identified her as being a resident at the facility.
Interview on 02/06/24 at 12:17 P.M. with the ADON revealed Resident #38 was placed on the secured
memory care unit following the elopement but had not adjusted well. The ADON spoke with Resident #38
and her guardian. Resident #38 promised she would not leave the facility again. Resident #38 and the
guardian were in agreement that Resident #38 could be moved back to her previous unit on the 200 Hall.
A follow up interview on 02/06/24 at 1:19 P.M. with the Administrator and DON revealed the Administrator
was unable to locate the incident number that had been given by the police officer. The Administrator again
stated he had not completed an official investigation; however, he had spoken with staff about the incident.
A telephone interview on 02/06/24 at 1:47 P.M. with STNA #300 revealed he was not present on 07/30/23
because he had called off work due to illness. STNA #300 stated the next morning he was told by the
evening shift STNA that Resident #38 had left the facility.
Observation and interview of Resident #38 on 02/07/24 at 8:50 A.M. revealed she had not had breakfast
and she would like to go to the dining room. Resident #38 put her shoes on, obtained her rollator walker
and exited her room. Resident #38 was unable to state where the dining room was located. As Resident
#38 attempted to locate the dining room she walked with a shuffling gait.
Review of the facility investigation which was provided on 02/07/24 at 1:18 P.M. revealed the following:
•
A statement dated 07/30/23 authored by the Administrator indicating he was notified by the nursing staff
Resident #38 was returned to the facility at approximately 7:30 P.M. by the local police department.
Resident #38 was placed on 1:1 supervision at time of return.
•
A statement dated 07/30/23 given by Resident #38 revealed she wanted to go outside and take a walk
because it was nice and sunny out. Resident #38 had money and wanted to go to the dollar store to
purchase some snacks and other things. Resident #38 stated she went from Point A to Point B and no
sooner had she arrived than the police came to bring her back. When asked what time she went to the
store she said after dinner, before 6:00 P.M.
•
A statement dated 07/31/23 by Dietary Aide (DA) #298 revealed he delivered a dinner meal to Resident
#38 on 07/30/23 between approximately 5:00 P.M. and 5:15 P.M.
•
(continued on next page)
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
366477
If continuation sheet
Page 6 of 9
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
366477
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
02/15/2024
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Avenue at North Ridgeville
6200 Lear Nagle Road
North Ridgeville, OH 44039
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 - Immediate
jeopardy to resident health or
safety
Residents Affected - Few
A statement dated 07/31/23 authored by Maintenance #224 and the Administrator revealed camera footage
was reviewed and Resident #38 was observed exiting the facility at approximately 5:38 P.M. Resident #38
followed visiting family members out of the building.
•
A statement dated 08/01/23 authored by Receptionist #299 revealed the receptionist did not observe
Resident #38 exiting the facility during her shift on 07/30/23 which ended at 4:15 P.M.
•
A timeline of events that indicated at 4:15 P.M. Receptionist #299 verified Resident #38 was present in the
building, and at 5:15 P.M. DA #298 served Resident #38 dinner. Resident #38 left the facility at 5:38 P.M.
using her rollator [walker]. At approximately 5:50 P.M. State Tested Nursing Assistant (STNA) #248
observed Resident #38 walking around in the facility parking lot. The timeline indicated Resident #38 was
out of the facility for a maximum of one hour and 48 minutes.
A telephone interview on 02/07/24 at 5:31 P.M. with another staff member who wished to remain
anonymous due to fear of retaliation, revealed administrative staff had not asked the staff about the incident
prior to 02/07/24. The anonymous staff member received a call on 02/07/24 from a corporate office staff
asking if she had observed Resident #38 outside of the building on 07/30/23. The anonymous staff told the
corporate office staff when she arrived at the facility at approximately 5:50 P.M. on the evening of 07/30/23,
she observed an individual outside on the sidewalk in front of the facility with a walker; however, the
anonymous staff member could not identify that individual. The anonymous staff member did not provide a
written statement.
A follow up telephone interview on 02/08/24 at 10:33 A.M. with STNA #300 (the STNA who previously
indicated he called off the day of the incident) revealed he had been present on 07/30/23 but he was unable
to recall specific information regarding Resident #38.
Interview on 02/08/24 at 10:46 A.M. with Maintenance Director (MD) #224 revealed on the morning of
07/31/23 he and the Administrator reviewed camera footage and observed Resident #38 exiting the facility.
MD #224 was unable to recall the time Resident #38 exited the facility but did recall the footage showed
she had exited behind another resident's family.
Interview on 02/08/24 at 11:02 A.M. with DA #298 revealed he observed Resident #38 in the dining room
on the evening of 07/30/23 and served Resident #38 dinner between 5:00 P.M. and 5:15 P.M. DA #298
stated he was told Resident #38 left the facility shortly after DA #298 served her meal and that she exited
behind a family member.
Telephone interview on 02/08/24 at 11:25 A.M. with PO #401 revealed he responded to a call for concerns
regarding a disoriented individual in a parking lot of a shopping plaza on 07/30/23 at 7:39 P.M. PO #401
stated upon arrival the individual appeared to be confused. The individual was able to state where she lived
but did not know how to get there. PO #401 took the individual to the facility where staff identified her as a
resident, and he departed the facility at 7:50 P.M.
Review of the Weather Underground website (httpps://www.wunderground.com) data revealed on 07/30/23
the temperature was between 78-82 degrees Fahrenheit (F), with fair conditions.
(continued on next page)
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
366477
If continuation sheet
Page 7 of 9
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
366477
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
02/15/2024
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Avenue at North Ridgeville
6200 Lear Nagle Road
North Ridgeville, OH 44039
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 - Immediate
jeopardy to resident health or
safety
Review of facility policy titled Elopement revised August 2022 revealed a detailed investigation would be
completed by the Administrator and DON. An incident report would be completed, staff interviews would be
gathered and interventions to prevent further incidents were to be implemented.
This deficiency represents non-compliance investigated under Complaint Number OH00149915.
Residents Affected - Few
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
366477
If continuation sheet
Page 8 of 9
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
366477
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
02/15/2024
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Avenue at North Ridgeville
6200 Lear Nagle Road
North Ridgeville, OH 44039
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 0729
Level of Harm - Minimal harm
or potential for actual harm
Residents Affected - Many
Verify that a nurse aide has been trained; and if they haven't worked as a nurse aide for 2 years, receive
retraining.
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on
interview and personnel file review, the facility failed to ensure all State Tested Nursing Assistants met the
competency verification requirements. This had the potential to affect all residents residing in the facility.
The facility census was 102.
Findings include
Interview on [DATE] at 12:00 P.M. with State Tested Nursing Assistant (STNA) #240 revealed she had
worked with Dietary Aide (DA) #200 numerous times and DA #200 performed tasks of an STNA. DA #200
had been at the facility for approximately a year and a half and had not taken the STNA certification test.
Telephone interview on [DATE] at 1:50 P.M. with STNA #230 revealed DA #200 had been employed at the
facility for a long time and was allowed to work as and STNA without having taken the STNA certification
test. STNA #230 stated the Administrator was aware DA #200 was not state tested and allowed DA #200 to
continue to work as an STNA.
Telephone interview on [DATE] at 2:29 P.M. with DA #200 revealed she had been employed at the facility for
approximately a year and a half. DA #200 did not have an active STNA certification during that time. DA
#200 had been told by the previous Human Resources (HR) staff the facility would arrange for her to take
classes and pay for the state test but the facility had not made the arrangements. DA #200 stated about a
month ago the Administrator informed her they would need to change her classification from an STNA to a
dietary aide until she completed the classes and test. DA #200 asked them not to change her classification
because it would decrease her pay. The Administrator changed her classification anyway and took her off
the schedule until she completed the classes and test.
Interview on [DATE] at 3:20 P.M. with HR #277 revealed she had been working at the facility for about a
month and a half. When HR #277 performed a license/certification check on all employees it was
discovered DA #200 did not have an active certification. HR #277 immediately informed the Administrator
and DA #200 was taken off the schedule. DA #200 provided HR #277 with a copy of her STNA license
dated [DATE]. Review of DA #200's personnel file with HR #277 revealed an STNA certification with an
expiration date of [DATE]. The application date for employment was [DATE] and the desired position of
STNA was noted on the application. HR #277 confirmed the expired license and stated DA #200's hire date
was [DATE].
Interview on [DATE] at 3:55 P.M. with Administrator and Director of Nursing revealed DA #200 had been
hired under the four month staffing waiver and DA #200 had not completed the requirements to renew her
certification. After HR #277 performed an audit of all employee licenses/certifications the Administrator was
made aware DA #200's certification was not current. DA #200 was immediately taken off the schedule until
she completed her classes and test.
This deficiency represents non-compliance investigated under Complaint Number OH00149915.
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
366477
If continuation sheet
Page 9 of 9
Reading this as a family member? Your long-term care ombudsman is a free advocate for residents and families.
Back to topCitations
2 citations recorded*CMS
What do CMS severity letters mean?
Serious (G-L). Actual harm to a resident, or immediate jeopardy. Codes G through I indicate actual harm; J through L indicate immediate jeopardy to resident health or safety.
General (A-F). No actual harm found, or harm that is minimal. The facility must still submit a Plan of Correction. Most CMS citations land here.
Each letter combines severity with scope: how many residents the deficiency affected.
F689 - Accidents
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
F729 - Registry verification
Verify that a nurse aide has been trained; and if they haven't worked as a nurse aide for 2 years, receive retraining.
FAQ · About this visit
Common questions about this visit
What happened during the February 15, 2024 survey of AVENUE AT NORTH RIDGEVILLE?
This was a inspection survey of AVENUE AT NORTH RIDGEVILLE on February 15, 2024. The surveyor cited 2 deficiencies, recorded on the federal Form 2567 statement of deficiencies.
Were any deficiencies cited at AVENUE AT NORTH RIDGEVILLE on February 15, 2024?
Yes, 2 deficiencies were cited, each with a CMS Scope and Severity grade. The first was: "Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents."
What type of survey was this?
This was a inspection survey conducted by state surveyors under federal Centers for Medicare & Medicaid Services (CMS) oversight. Findings are published on CMS Care Compare.
SourceView on CMS Care Compare
Next steps
Concerned about a resident’s care?Find your local ombudsman through the Eldercare Locatoror file a complaint with your state survey agency.
Researching this visit professionally?Book a 15-minute calland we will walk through what we have on file.
Data from CMS Care Compare public records. Dataset last refreshed . If you believe any information is inaccurate, report it here.