Health inspection·March 4, 2024

F 0624 Prepare residents for a safe transfer or discharge from the nursing home. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, interview, review of court documents, review of the Statement of Expert Evaluation, review of a police report, and facility policy review, the facility failed to prevent an unauthorized leave of absence (LOA) and subsequent discharge of Resident #78 who had a Protection Service Order (PSO) in place from a case brought by Adult Protective Services (APS). This affected one resident (#78) of three residents who were reviewed for discharge. The facility census was 76. Residents Affected - Few Findings Include: Review of the medical records for Resident #78 revealed an admission date of 01/29/24 and a discharge date of 02/12/24 with diagnoses including hypertension and Alzheimer's dementia. Review of a sworn affidavit in Resident #78 medical records dated 01/09/24 completed by an APS social worker revealed Resident #78 suffers from dementia and is frail and unsteady on her feet. It also revealed Resident #78 was unable to state what to do in an emergency. Impairments of short- and long-term memory were noted. The home was cluttered with severe bug infestation. There was no food in the refrigerator or freezer. Resident #78 stated that daughters are emotionally and verbally abusive. Money has been used by others without permission and bills have not been paid. There was an electric bill notice of shut off. Review of the court document titled Cuyahoga County Division of Senior and Adult Services (CCDSAS) case number 2024 ADV dated 01/17/24 stated upon petition of the CCDSAS, for an order authorizing the provision of Protective Services pursuant to Ohio Revised Code (O.R.C.) 5101.68 for [Resident #78]. The court finds by clear and convincing evidence that Resident #78 is in need of protective services, is incapacitated and that there is no person authorized by law or court order to give consent or is willing to consent to said protective services. Therefore, it is ordered that the Director of CCDSAS or his/her designee, shall be authorized to give consent for said adult for protective services. It is further ordered that the Director of CCDSAS, Adult Senior Protective Services or his/her designee shall have authority to consent to an evaluation and/or medical treatment as may be ordered by the adult's physician, and nursing home admission and authority is given for purposed of completing/assisting with any and all forms of associated with obtaining Medicare and/or Medicaid. It is further ordered that all persons be restrained from interfering with this order and the provision of protective services of the adult. It is further ordered that the adult be transported and admitted to the nearest hospital from her residence for a complete medical and geriatric-psychiatric examination to determine is she has capacity and to determine her care needs and for care and treatment as prescribed by his/her attending physician and for placement to other appropriate placement as determined by CCDSAS, APS. The adult is to be discharged to an appropriate care facility. This judgement will be effective from 01/17/24 and for six-month period unless otherwise ordered by this court. (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 6 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 03/04/2024 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)