Northwestern Healthcare Center

F 0568 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few

Properly hold, secure, and manage each resident's personal money which is deposited with the nursing home.

Based on record review, resident and staff interviews, and facility policy review, the facility failed to ensure

the residents received quarterly statements for their resident funds account. This affected one (#54) of six residents reviewed for resident trust funds account. The facility identified 38 residents had resident funds account. The facility census was 81.Findings included: Review of the medical record for Resident #54 revealed an admission date of 09/10/24 and was listed as the primary responsible party for billing. Review of the Resident Fund Management Service Authorization Agreement to Handle Resident Funds, revealed Resident #54 signed the document to set up a resident fund account. The document indicated with a signature, the person was authorizing the facility to establish an insured interest-bearing account and the person signing the document would receive a statement at least quarterly.Review of the facility document Resident Fund Statement dated 08/18/25, revealed Resident #54 had a resident fund account with a balance of $300.55. Resident #54's quarterly statements for the period of 04/01/25 through 06/30/25 revealed the resident had a balance of $300.55. Interview with Resident #54 on 08/11/25 at 10:27 A.M. revealed he had not received any quarterly statements and did not know what was in his personal fund account. Resident #54 stated he had asked multiple times to see his balance but was never given a statement as promised. Interview with Business Office Manager (BOM) # 612 stated she was new to the facility and has not provided any of the quarterly statements to the residents or guardians. BOM #612 verified Resident #54 has not received any quarterly statements. Review of the facility's policy titled Resident Trust Fund dated 10/19/17 revealed the purpose was to hold, safeguard, manage, control and reconcile the personal needs funds deposited with the facility by the residents, as authorized, in a manner and in compliance with all laws and regulations to provide the residents with accurate and timely information regarding their personal funds. Employee #1 will mail quarterly Resident Trust Fund Statements once approved by Employee #3.

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

Event ID:

Printed: 04/13/2026 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

B. Wing

A. Building

(X3) DATE SURVEY COMPLETED

08/27/2025

NAME OF PROVIDER OR SUPPLIER

STREET ADDRESS, CITY, STATE, ZIP CODE

Northwestern Center

570 North Rocky River Drive Berea, OH 44017

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 0600 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Few Note: The nursing home is disputing this citation.

FORM CMS-2567 (02/99) Previous Versions Obsolete

time of Resident #87 requesting and receiving pain medications. Resident #54 also believed EMS had been called on two different occasions but believed they had been turned away as they never came into the room. This was concerning to Resident #54, but the concerns reported did not rise to the level of abuse/neglect without further investigation. RN #422 was suspended pending investigation. - No date listed.

An investigation was initiated, other residents were assessed with no concerns, staff statements were obtained, and the facility requested the EMS run report.- On [DATE REDACTED], Admissions #705 called Family Member (FM) #425 to offer condolences. No questions, concerns or requests were made at this time.From [DATE REDACTED] to [DATE REDACTED] (inaccurate dates) it was determined from statements collected that RN #422 stated EMS arrived at the facility because Resident #87 had called them, stating he had fallen. RN #422 had gone to Resident #87's room and talked with Resident #87 who had not fallen and went back to the desk to report this information to EMS. EMS left the facility. Later that night (no time listed) EMS called the facility and stated they received a call from Resident #87; RN #422 talked to EMS and told them Resident #87 was okay. Later than night (no time listed) RN #422 was completing a treatment on Resident #87 when he went unresponsive and was lowered to the floor. RN #422 alerted staff (not specified, no time listed) for additional assistance. At that time (not listed) Resident #87 had a pulse. At some point while trying to place Resident #87 in the bed, he lost his pulse and respirations, and EMS was called, and CPR was initiated.

EMS arrived, continued CPR and took Resident #87 to the hospital. A discrepancy was identified regarding RN #[TRUNCA

Event ID:

Facility ID:

If continuation sheet

Printed: 04/13/2026 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

B. Wing

A. Building

(X3) DATE SURVEY COMPLETED

08/27/2025

NAME OF PROVIDER OR SUPPLIER

STREET ADDRESS, CITY, STATE, ZIP CODE

Northwestern Center

570 North Rocky River Drive Berea, OH 44017

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 - Actual harm Residents Affected - Few

FORM CMS-2567 (02/99) Previous Versions Obsolete

#90's air mattress between 01/08/25 and 02/05/25 to ensure proper inflation was maintained or evidence

the functionality of the air mattress was included as part of the investigation of the resident's fall. An attempt to interview CNA #432 during the survey was unsuccessful. Review of the facility's undated policy titled Specialty Mattresses revealed the nurse would validate the bed was functional, plugged into the proper outlet and the cords and bed were in good working condition. Review of the facility's undated policy titled Routine Resident Care revealed the facility would provide routine daily care by a CNA with specialized training in rehabilitation/restorative care under the supervision of a licensed nurse including but not limited to maintaining proper body position and alignment for all residents. This deficiency represents non-compliance investigated under Complaint Number 2574706, Complaint Number OH00165814 (1317322), Complaint Number OH00162622 (1317319), and OH00162278 (1317317).

Event ID:

Facility ID:

If continuation sheet