Health inspection·September 5, 2023

F 0557 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Honor the resident's right to be treated with respect and dignity and to retain and use personal possessions. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, observations, and interview the facility failed to allow residents to have personal items in their rooms. This affected one (Resident #65) of three residents reviewed for access to personal items. The census was 65. Findings included: Review of the medical record for Resident #65 revealed an admission date of 03/30/22. Diagnoses included multiple sclerosis (MS), Alzheimer's disease, and dementia. Review of the comprehensive Minimum Data Set (MDS) assessment, dated 07/19/23, revealed Resident #65 had intact cognition. Review of plans of care care dated 01/17/23 revealed Resident #65 had behaviors of including calling emergency services and daughter several times a day. No behaviors were documented related to threatening staff, recording staff or other residents. Review of the nurse progress notes for the past three months revealed no entries regarding Resident #65 having unsafe behaviors. Interview on 08/31/23 at 7:49 A.M. with Resident #65 revealed she had MS and it was difficult to use her hands. Resident #65 stated her daughter gave her an Echo Show (a physical device that is used to interact with [NAME] [artificial intelligence service] to listen to music, watch movies and speak to family through facetime. Resident #65 stated the device did not have the capability to video record staff or other residents. Interview on 08/31/23 at 1:39 P.M. with the daughter of Resident #65 revealed the Echo Show device did not have the capability to video record and the device was used to listen to music, watch movies and call family. Resident #65 had a behavior of calling emergency services; however, the device was disabled to prevent Resident #65 from calling emergency medical services. The intent of the Echo Show device was not for recording purposes. The daughter stated the facility removed the Echo Show device from Resident #65's room in July 2023. Interview on 08/31/23 at 1:48 P.M. with the Administrator revealed Resident #65's Echo Show device was taken away to prevent video recording of staff and residents in the facility. The Administrator stated the facility policy stated any recording device must be secured/mounted to a wall to protect staff and residents. The Administrator confirmed they had no knowledge Resident #65 was using the device to record staff or residents. The Administrator indicated the family did not bring in the device so they could monitor Resident #65. The Administrator stated she had limited knowledge of the (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 4 Event ID: 366488 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 366488 B. Wing A. Building (X3) DATE SURVEY COMPLETED 09/05/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Avenue at Lyndhurst 5442 Rae Road Lyndhurst, OH 44124 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)