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. Page 1 of 6 366488 366488 03/04/2024 Avenue at Lyndhurst 5442 Rae Road Lyndhurst, OH 44124

F 0624 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Review of the hospital referral dated 01/19/24 at 10:24 A.M. revealed the post-acute discharge plan: [Resident #78] was brought to the Emergency Department (ED) by APS social worker. Per ED note, the resident was financially exploited by her daughters, one of who she lives with. There is a PSO in the physical chart; stating that the resident is incapacitated; however, requesting a psychiatric exam to determine capacity. The resident is pending state guardianship. Courts would like for the resident to be placed in a skilled nursing facility (SNF). APS is the temporary decision maker moving forward in this case until a guardian is appointed. Resident #78 will need SNF placement pending evaluations as she cannot return to recent livening environment. Review of the Statement of Expert Evaluation dated 01/19/24 to 01/22/24 Resident #78 was physically impaired, unable to ambulate independently, reports of exploitation from APS, possible exploitation from caregivers, and is cognitively impaired and cannot adequately assess or make decisions about housing or care. The resident is not capable of managing finances and property due to impaired cognition and memory. Guardianship should be established/continued. Review of the physician's order dated 01/30/24 included Resident #78 may leave the facility for field trips. A review of Resident #78's face sheet listed an APS worker as first contact. Review of the admission Minimum Data Set (MDS) assessment dated [DATE] revealed a Brief Interview of Mental Status (BIMS) score of 12 out of 15, indicating Resident #78 was moderately cognitively impaired. Review of the Nurse Practitioner progress note dated 02/06/24 revealed Resident #78 recently admitted to the facility from the hospital after being admitted for psychiatric/geriatric evaluation due to an APS consult. Resident #78 was being financially exploited by family and a pastor. She is currently pending guardianship. The impression and plan stated guardianship pending. A progress note dated 02/13/24 revealed that the charge nurse advised the Director of Nursing (DON) that Resident #78 had signed out of the facility at 6:00 P.M. on 02/12/24 with her daughter. Resident #78 stated she was going to dinner. Attempts were made to contact daughter in order to locate Resident #78, but the calls were unanswered and there was no voicemail box available. The progress note also revealed that Resident #78 had an APS case worker. The DON and Social Service Director (SSD) #214 contacted the APS supervisor on file. The DON spoke with local police officer as well and provided legal documents regarding court order. Police officer stated resident is alert and oriented and has a BIMS of 12. Police officer states resident was able to leave with daughter and is not considered missing therefore, their involvement is not needed at this time. Police will update facility if any new information becomes available. A police report, incident number 202400826, dated 02/13/24 revealed the police were called at 12:31 P.M. The DON stated to them Resident #78 had a court order to be at facility. Stated daughter checked her out last night. Police were advised by the APS supervisor that he was the only one able to check resident out of facility. Family was called and not aware the resident was not allowed to leave facility. The resident was picked up from home and transported back to the facility. The police were informed by the DON that they could not accept Resident #78 due to there being no payment information for her since she was discharged on 02/12/24. APS was contacted. Resident #78 was to be transported to the hospital. Resident #78 was transported back to the police station where she was checked by Emergency Medical Services (EMS). She was then transported by EMS to the local hospital. 366488 Page 2 of 6 366488 03/04/2024 Avenue at Lyndhurst 5442 Rae Road Lyndhurst, OH 44124

F 0624 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few On 03/04/24 at 9:25 A.M., an interview with the DON revealed Resident #78 left the faciity on [DATE] with family to go out to dinner and did not return. The DON tried multiple times to contact family but there were no return calls nor was a voicemail box available. The DON then contacted APS and they advised her to call the police. The DON stated there was nothing in protective order that stated Resident #78 could not leave the facility. The DON stated she was not aware until after four days of Resident #78 being admitted that a PSO was in place. The DON also stated Resident #78 was not permitted back in building when returned by the police because resident had been gone over 24 hours and there was no medical need. At 2:00 P.M. the DON stated Resident #78 was not able to return to building due to no listed payer source. On 03/04/24 at 12:33 P.M. an interview with the Admissions and Marketing Assistant #222 revealed that she took the referral from the hospital for Resident #78 via a computerized system and verified that APS involvement was on the referral. On 03/04/24 at 12:55 an interview with Regional Nurse Consultant revealed Resident #78 did not have APS listed as guardian, and Resident #78 was only going out to dinner. Stated Resident #78 was not re-admitted as she was gone over 24 hours. On 03/04/24 at 1:45 P.M. an interview with APS revealed a PSO grants APS temporary decision making. APS follows and does not close case until a guardian is appointed. The APS worker stated she was notified that skilled days were up, and the facility was going to work with them until Medicaid could be obtained. At that point the PSO was provided to facility. Resident #78 is currently in another SNF, and a guardianship court date is set for 03/12/24. A review of the facility policy titled, Admission, Transfer and Discharge, dated November 2022, revealed a resident can be transferred or discharged : • If the transfer or discharge is necessary for the resident's welfare and his/her needs cannot be met in the healthcare facility. • If the resident's health has sufficiently improved so that the resident no longer needs the services of the health care facility. • If the safety and health of other residents within the health care facility is endangered. • If the resident has failed, after reasonable and appropriate notice, to pay for a stay in the health care facility. • The facility will assure that sufficient preparation and orientation is provided to the resident 366488 Page 3 of 6 366488 03/04/2024 Avenue at Lyndhurst 5442 Rae Road Lyndhurst, OH 44124

F 0624 for a safe and orderly transfer or discharge. Level of Harm - Minimal harm or potential for actual harm This deficiency represents non-compliance investigated under Master Complaint Number OH00151203. Residents Affected - Few 366488 Page 4 of 6 366488 03/04/2024 Avenue at Lyndhurst 5442 Rae Road Lyndhurst, OH 44124

F 0626 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Permit a resident to return to the nursing home after hospitalization or therapeutic leave that exceeds bed-hold policy. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, interview, review of hospital records, review of a police report, and facility policy review, the facility failed to permit Resident #78, who had a Protection Service Order (PSO) in place from a case brought by Adult Protective Services (APS), to return to the facility after an unauthorized leave of absence (LOA) with family. This affected one resident (#78) of three residents reviewed for discharge. The facility census was 76. Findings Include: A review of 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 hospital record reviews revealed an emergency room record dated 01/19/24 revealed Resident #78 was there for evaluation and guardianship. There were social and financial concerns. A psychiatry evaluation dated 01/22/24 while Resident #78 was in the hospital revealed Resident #78 lacked capacity to make own medical decisions, had moderate cognitive and memory impairment, poor understanding of domestic and financial situation. An Expert Evaluation dated 01/22/24 while Resident #78 was hospitalized revealed the resident was physically impaired, there were allegations of exploitation made by APS, exploitation by caregivers, cognitive impaired, and cannot adequately assess or make decisions about care and that guardianship should be established. APS was temporary decision maker until a guardian can be appointed. Review of the physician's order dated 01/30/24 included Resident #78 may leave the facility for field trips. A review of Resident #78's face sheet listed an APS worker as first contact. Review of the admission Minimum Data Set (MDS) assessment dated [DATE] revealed a Brief Interview of Mental Status (BIMS) score of 12 out of 15, indicating Resident #78 was moderately cognitively impaired. Review of the Nurse Practitioner progress note dated 02/06/24 revealed Resident #78 recently admitted to the facility from the hospital after being admitted for psychiatric/geriatric evaluation due to an APS consult. Resident #78 was being financially exploited by family and a pastor. She is currently pending guardianship. The impression and plan stated guardianship pending. A progress note dated 02/13/24 revealed that the charge nurse advised the Director of Nursing (DON) that Resident #78 had signed out of the facility at 6:00 P.M. on 02/12/24 with her daughter. Resident #78 stated she was going to dinner. Attempts were made to contact daughter in order to locate Resident #78, but the calls were unanswered and there was no voicemail box available. The progress note also revealed that Resident #78 had an APS case worker. The DON and Social Service Director (SSD) #214 contacted the APS supervisor on file. The DON spoke with Lyndhurst police officer as well and provided legal documents regarding court order. Police officer stated resident is alert and oriented and has a BIMS of 12. Police officer states resident was able to leave with daughter and is not considered missing therefore, their involvement is not needed at this time. Police will update facility if any new information becomes available. 366488 Page 5 of 6 366488 03/04/2024 Avenue at Lyndhurst 5442 Rae Road Lyndhurst, OH 44124

F 0626 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few A police report, incident number 202400826, dated 02/13/24 revealed the police were called at 12:31 P.M. The DON stated Resident #78 had a court order to be at the facility, and the resident's daughter checked her out last night. Police were advised by the APS supervisor that he was the only one able to check resident out of facility. Family was called and stated they were not aware that the resident was not allowed to leave the facility. The resident was picked up from home and transported back to the facility. Upon arrival, the police were informed by the DON that they could not accept Resident #78 due to there being no payment information for her since she was discharged . APS was contacted. Resident #78 was to be transported to the hospital. Resident #78 was transported back to the police station where she was checked by Emergency Medical Services (EMS) and then transported by EMS to the local hospital. On 03/04/24 at 9:25 A.M., an interview with the DON revealed Resident #78 left the faciity on [DATE] with family to go out to dinner and did not return. The DON tried multiple times to contact family but there were no return calls nor was a voicemail box available. The DON then contacted APS and they advised her to call the police. The DON stated there was nothing in protective order that stated Resident #78 could not leave the facility. The DON stated she was not aware until after four days of Resident #78 being admitted that a PSO was in place. The DON also stated Resident #78 was not permitted back in building when returned by the police because resident had been gone over 24 hours and there was no medical need. At 2:00 P.M. the DON stated Resident #78 was not able to return to building due to no listed payor source. On 03/04/24 at 12:33 P.M. an interview with the Admissions and Marketing Assistant #222 revealed that she took the referral from the hospital for Resident #78 via a computerized system and verified that APS involvement was on the referral. On 03/04/24 at 12:55 an interview with Regional Nurse Consultant revealed Resident #78 did not have APS listed as guardian, and Resident #78 was only going out to dinner. Stated Resident #78 was not re-admitted as she was gone over 24 hours. On 03/04/24 at 1:45 P.M. an interview with APS revealed a PSO grants APS temporary decision making. APS follows and does not close case until a guardian is appointed. The APS worker stated she was notified that skilled days were up, and the facility was going to work with them until Medicaid could be obtained. At that point the PSO was provided to facility. Resident #78 is currently in another SNF, and a guardianship court date is set for 03/12/24. A review of the facility policy titled, Leave of Absence, dated October 2022, revealed a Physician order will be obtained for a resident requesting LOA from the facility regardless of length. If the physician objects to the resident leaving the facility, then resident will be leaving against medical advice. Nothing in the policy stated if a resident is out after midnight they are discharged . This deficiency represents non-compliance investigated under Master Complaint Number OH00151203. 366488 Page 6 of 6