Avenue at North Ridgeville

In the surveyor’s words

From the most serious findings on record at Avenue at North Ridgeville, in the surveyor’s own words.

• Immediate jeopardy, isolatedF689Feb 15, 2024

  THIS IS AN INCIDENCE OF PAST NON-COMPLIANCE THAT WAS SUBSEQUENTLY CORRECTED PRIOR TO THIS SURVEY. 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. […]

• Actual harm, isolatedF684Jun 29, 2026

  Based on medical record review, staff interviews, review of hospital paperwork, review of Emergency Medical Service (EMS) run report, and review of facility policy, the facility failed to ensure timely care and services following Resident #105's change in condition and failed to implement Resident #4's skin treatments as ordered. Actual harm occurred on 05/30/26 when Resident #105, who had a history of stroke and mild cognitive impairment, was observed to have a change in his cognitive and physical status without prompt assessment and response to Resident #105's change in condition. Facility staff noted possible slurred speech earlier on 05/30/26, but the resident was not assessed or treated until a left facial droop was identified at 11:00 A.M. […]

• Actual harm, isolatedF684Apr 9, 2024

  Based on family and staff interviews, record review, review of hospital records, review of facility policy, and review of facility fall investigations, the facility failed to ensure Resident #100 received adequate and timely care and treatment following an unwitnessed fall with major injury. Actual Harm occurred on 03/03/24 following an unwitnessed fall at 7:00 P.M. when the facility failed to adequately identify the resident's injury, treat the resident's pain, and timely obtain an x-ray for Resident #100, who, over the next few days, exhibited signs of pain (including verbal complaints of pain, facial grimacing and winching in pain during care and with movement). The Nurse Practitioner (NP) was notified of Resident #100's pain on 03/05/24 at 5:40 P.M. […]

• No harm, potential for more than minimal, widespreadF725Jun 29, 2026

  Based on medical record review, resident and staff interview, review of facility call light tracking records, review of complaint intakes, and review of Resident Council meeting minutes, the facility failed to have adequate staffing to meet the care needs of all residents. This directly affected seven (#41, #14, #51, #93, #77, #101, #31) of seven residents reviewed for staffing and had the potential to affect all residents residing in the facility. The facility census was 89. Findings include:1. […]

• No harm, potential for more than minimal, widespreadF835Jun 29, 2026

  Based on observation, resident interviews, staff interviews, review of Resident Council meeting minutes, and review of the facility handbook, the facility failed to ensure staff did not utilize their personal phones in resident care areas of the facility. This had the potential to affect all residents residing in the facility. The facility census was 89.Findings include:Interview on 06/22/26 at 10:01 A.M. with Resident #51 revealed staff were often utilizing their personal cell phones while working in the facility. Resident #51 reported that on one occasion, a staff member told the resident they were being rude by interrupting the staff member who was on the phone with their boyfriend at the time.Interview on 06/22/26 at 12:42 P.M. […]