Diplomat Healthcare

F 0553 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few

Allow resident to participate in the development and implementation of his or her person-centered plan of care.

Based on resident interview, medical record review, staff interview, and facility policy review, the facility failed to ensure routine care plan conferences were conducted. This affected two residents (#150 and #73) of five residents reviewed for care plan conferences. The census was 108.Findings include:1.Record review of Resident #150 revealed an admission date of 09/04/19 with diagnosis that include Parkinson's disease, schizophrenia, bipolar disorder, hypothyroidism, dementia, and muscle weakness. Review of Resident #150's Brief Interview for Mental Status (BIMS) score completed on 08/12/25 revealed a score of 0 due to resident being unable to complete assessment questions, indicating severely impaired cognition. Review of Resident #150 care plan history from 07/01/23 through 11/12/25 revealed the resident's care plan was updated on 5/23/25, 08/19/25, 09/19/25, and 10/14/25.Interview on 11/13/24 at 11:54 A.M. with Resident #150 Power of Attorney (POA) revealed she attended a care conference in March 2025 with a previous Director of Social Services but had not had one since March 2025. Resident #150's POA reported she had left messages with the new Director of Social Services but had not heard back.2. Record review of Resident #73 revealed an admission date of 07/10/25 with diagnosis that include: dementia, muscle weakness, essential hypertension, impulse disorder and insufficient sleep syndrome. Review of Resident #73's BIMS score completed on 10/15/25 revealed a score of 00 due to resident being unable to complete assessment questions, indicating severely impaired cognition. Resident #73's spouse was listed as his emergency contact and responsible party.Review of Resident #73's record revealed an admission care conference was held on 07/22/25 with Resident #73's spouse and other facility staff. Resident #73's care plan was updated on 10/22/25 but the record did not include any additional care conferences had been held.Interview on 11/13/25 at 10:07 A.M. with Director of Social Services (DSS) #421 revealed care plan meetings are held upon admission, quarterly, and whenever there is a significant change in condition. Care conferences are held with the resident, their family members, guardians, nurses, and certified nursing assistants. DSS #421 confirmed a care conference had not been held for Resident #150 and his daughter was not in attendance. Director of Social Services #421 reported she was behind on scheduling and conducting resident care conferences. DDS #421 was not aware of any missed calls from Resident #150 daughter. DDS #421 revealed Resident #73's spouse was not involved in his care conferences and that she was just the emergency contact. Review of the facility's Comprehensive Care Planning Policy dated 03/20/25 revealed the comprehensive care plan will be prepared by an interdisciplinary team that includes but is not limited to: To the extent practicable, the participation of the resident and the resident's representative(s). An explanation must be included in a resident's medical record if the participation of the resident and their resident representatives is determined not to be practicable for the development of the resident's care plan.This deficiency represents non-compliance investigated under Complaint Number

1. 2656169. 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

11/25/2025

NAME OF PROVIDER OR SUPPLIER

STREET ADDRESS, CITY, STATE, ZIP CODE

Diplomat Healthcare

9001 W 130th St North Royalton, OH 44133

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 0580 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few

was a new treatment for a skin rash. The note did not include that the resident's representative had been notified of the new orders. There was no progress notes referencing the 10/30/25 order for Permethin.

Interview on 11/18/25 at 1:45 P.M. with the DON confirmed there was no evidence Resident #103's representative had been notified of the new orders. The DON reported medication changes should be discussed with the resident's representative.

1. 3. Review of Resident #106's medical records revealed an admission date of 10/04/24. Diagnoses included

dementia, Huntington's disease and restlessness.

Review of the MDS assessment dated [DATE REDACTED] revealed Resident #106 had no cognition score due to being rarely/never understood.

Review of progress note dated 10/13/25 authored by LPN #360 revealed a new order for prednisone (steroid) for seven days for inflammation. Progress note did not include resident representative notification.

Interview on 11/18/25 at 1:45 P.M. with the DON confirmed there was no evidence Resident #106's representative had been notified of the new orders. The DON reported medication changes should be discussed with the resident's representative.

Review of facility policy titled Resident Change in Condition Policy reviewed 06/02/25 revealed physician/family/responsible party will be notified when there has been a need to alter a resident's medical treatment.

This deficiency represents non-compliance investigated under Complaint Number 2656169.

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

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

11/25/2025

NAME OF PROVIDER OR SUPPLIER

STREET ADDRESS, CITY, STATE, ZIP CODE

Diplomat Healthcare

9001 W 130th St North Royalton, OH 44133

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 0684

Provide appropriate treatment and care according to orders, resident’s preferences and goals.

Level of Harm - Minimal harm or potential for actual harm

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on

observation, interview and record review The facility failed to ensure medication consumption was monitored to ensure medications were safely swallowed. This affected one resident (#28) of four residents observed and reviewed for medication administration. The facility census was 108. Findings include: Review of Resident #28's medical records revealed an admission date of 06/05/15. Diagnoses included stroke with left sided weakness, muscle weakness dysphagia (difficulty swallowing) and dementia.Review of Resident #28's physician's orders revealed an order dated 05/12/23 that medications may be crushed unless contraindicated. Resident #28 additionally had an order dated 06/16/25 for acetaminophen (an over-the-counter mild pain reliever) 650 milligrams (mg) every six hours as needed for pain. Review of the Minimum Data Set (MDS) assessment dated [DATE REDACTED] revealed Resident #28 had no recorded cognition score due to the resident was rarely/never understood. Observation of wound care on 11/10/25 at 11:47 A.M. with Licensed Practical Nurse (LPN) #402, LPN/Assistant Director of Nursing (LPN/ADON) #341 and Regional Registered Nurse (RRN) #452 for Resident #28 revealed Resident #28 was expressing non-verbal complaints of pain that including withdrawing his leg and foot when his right leg was touched. At

the time of observation, RRN #452 had informed LPN #402 to administer pain medication as ordered. LPN #402 had exited Resident #28's room and had returned with a cup of crushed medications mixed with applesauce that LPN #402 had indicated was the resident's as-needed acetaminophen. LPN #402 administered the crushed medication to Resident #28 and exited his room. RRN #452 had remained in the room and asked if Resident #28 had swallowed his crushed medication and RRN #452 confirmed Resident #28 had not swallowed them. RRN #452 proceeded to manually massage Resident #28's throat in order to stimulate his swallowing. RRN #452 stated LPN #402 should have stayed present to ensure medications had been swallowed prior to exiting the room. This deficiency represents non-compliance investigated under Complaint Number 2657376.

Residents Affected - Few

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

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

11/25/2025

NAME OF PROVIDER OR SUPPLIER

STREET ADDRESS, CITY, STATE, ZIP CODE

Diplomat Healthcare

9001 W 130th St North Royalton, OH 44133

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 0686 Level of Harm - Actual harm Residents Affected - Few

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

Are we charting the unstageable wound on Resident #150's bottom. And moving forward I'm charting everything I see to protect by license as well as my residents. LPN #376 received a response from LPN/ADON #341 which stated Its documented as MASD. WNP is trying everything to not change it to pressure. LPN #376's response to LPN/ADON #341 was You and I know what his wound really is. A follow-up interview on 11/13/25 at 9:56 A.M. with LPN #376 revealed she had been told by LPN/ADON #341 to not document Resident #150's wound as a pressure ulcer and to continue to document the wound as MASD. LPN #376 confirmed she had documented Resident #150's head-to-toe assessment on 10/21/25 and had documented Resident #150's wound as MASD. She stated she should not have documented the wound that way as she knew the area to Resident #150's coccyx was an open pressure ulcer. Interview on 11/17/25 at 8:25 A.M. with Certified Nursing Assistant (CNA) #366 revealed she had cared for Resident #150 on 10/20/25 and 10/21/25. CNA #366 stated she had observed Resident #150's wound on 10/20/25 and the wound to his buttock was a large, open wound that was necrotic and had a foul odor. CNA #366 reported on the morning of 10/21/25, she had cared for Resident #150 and he seemed off. CNA #366 stated she had informed LPN #376 and had then assisted with Resident #150's incontinence care and had also observed Resident #150's wound. Interview on 11/17/25 at 9:16 A.M. with the Director of Nursing (DON) and Regional Registered Nurse #451 revealed they had interviewed LPN #376 on 11/13/25 and had obtained a statement. Review of LPN #376's statement dated 11/13/25 revealed on 10/21/25, Resident #150 had a wound and was not acting as himself. The statement included on 10/17/25, the wound was stable and on 10/20/25, LPN #376 had noted a decline in the area, and she had last seen Resident #150's wound approximately a week prior. The statement further included when LPN #376 was asked why she had documented Resident #150's wound as MASD on his head-to-toe assessment, LPN #376 responded I probably shouldn't have, but that was what everyone else was calling it. RRN #451 stated she had attempted to obtain more specific information regarding a description of Resident #150's wound from LPN #376, however LPN #376 had been difficult during the interview and had not provided any additional information. Interview on 11/18/25 at 1:45 P.M. with DON and RRN #451 revealed they had obtained a questionnaire from LPN #376 regarding Resident #150's condition prior to hospitalization. Review of LPN #376's questionnaire with the DON and RRN #451 revealed Resident #150's sacral wound had significantly declined and LPN/ADON #341 had been informed. Review of the policy Skin and Wound Care Best Practices last reviewed 09/17/25, revealed the purpose of the policy was to provide evidence based preventative skin care and wound treatment to prevent unavoidable skin complications. The policy referenced the licensed nurse will complete a Weekly Skin Check. The interdisciplinary team will review residents with pressure injuries/wounds during the resident review meeting. Review of the policy Change in condition last reviewed on 06/02/25 revealed the physician and responsible party will be notified when there has been a significant change in the resident's physical condition. This deficiency represents non-compliance investigated under Complaint Numbers 2657376 and 2656169.

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

11/25/2025

NAME OF PROVIDER OR SUPPLIER

STREET ADDRESS, CITY, STATE, ZIP CODE

Diplomat Healthcare

9001 W 130th St North Royalton, OH 44133

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 - Minimal harm or potential for actual harm Residents Affected - Few

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

unable to provide an explanation of the discrepancies in time frames for when Resident #150 fell and when EMS was summoned to the facility in response to Resident #150's fall. Review of the facility policy Fall Prevention and Management Policy dated 07/07/25 revealed falls will be reviewed by an interdisciplinary team. Such reviews should include results of fall risk assessment, discussion with resident and/or any witnessing parties as to potential causal factors, review of the environment where the fall occurred, and discussion as to any new interventions which may help to prevent future falls. This deficiency represents non-compliance investigated under Complaint Number 2656169.

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

11/25/2025

NAME OF PROVIDER OR SUPPLIER

STREET ADDRESS, CITY, STATE, ZIP CODE

Diplomat Healthcare

9001 W 130th St North Royalton, OH 44133

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 0690 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few

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

Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on

observation, interview, record review, and facility policy review, the facility failed to ensure adequate incontinence care was provided to Resident #28. This affected one resident (#28) of three residents reviewed for incontinence care. The facility census was 108. Findings include:Review of Resident #28's medical record revealed an admission date of 06/05/15. Diagnoses included stroke with left sided weakness, muscle weakness, and dementia. Review of Resident #28's Minimum Data Set (MDS) assessment dated [DATE REDACTED] revealed Resident #28 had no recorded cognition score due to resident was rarely/never understood. Resident #28 was incontinent of bowel and bladder and was dependent on staff for toileting. Review of the care plan updated 11/04/25 revealed Resident #28 was incontinent of bowel and bladder. Interventions included to assist with incontinence care as needed. Resident #28 was noted to be at risk for skin breakdown and had listed interventions to apply a skin barrier ointment after incontinence episodes. Review of Resident #28's current physician orders for November 2025 revealed an order to cleanse buttocks with soap and water and apply thick zinc barrier (barrier ointment used to form a protective barrier on the skin to shield the skin from irritants and moisture) every shift and as needed.

Observation of incontinence care on 11/10/25 at 11:39 A.M. for Resident #28 with Certified Nursing Assistant (CNA) #385 revealed a large amount of dried stool to the crease of Resident #28's buttocks.

Resident #28 was observed to have two bath blankets and a fitted sheet underneath him, which had large amounts of dried urine and other identifiable debris. There was an odor of urine coming from Resident #28's bed and bed linens. Interview with CNA #385 at time of observation revealed she had provided Resident #28 with incontinence care approximately one hour prior. CNA #385 reported Resident #28 had a reddened area to his buttocks and coccyx (tailbone) area at times and stated he required barrier cream to be applied after incontinence care. Observation of incontinence care at the time of interview revealed no evidence of barrier cream residue on Resident #28. CNA #385 confirmed the presence of the dried stool and confirmed she had not applied barrier cream to Resident #28 after she last provided incontinence care.

CNA #385 confirmed she had not seen the soiled linens when she had previously provided incontinence care one hour prior. Review of facility policy titled Perineal Care Incontinence Care Procedure reviewed 10/30/25 revealed to turn patient on his/her side and wash the rectal area, working outward to include the buttocks. The policy additionally stated to apply a moisture barrier if care planned. This deficiency represents non-compliance investigated under Complaint Numbers 2656169, 2614362 and 2597119.

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

11/25/2025

NAME OF PROVIDER OR SUPPLIER

STREET ADDRESS, CITY, STATE, ZIP CODE

Diplomat Healthcare

9001 W 130th St North Royalton, OH 44133

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 0692 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few

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

consumed and not just how much water a resident is provided. Observation on 11/18/25 at 5:00 P.M. of the secured unit with the DON and ADON #356 revealed the dinner beverage cart was present on the unit stocked with juice, lemonade, coffee, and milk. Observation of approximately 20 residents in dining room A revealed only 2 residents had water provided to them. Continued observation in dining room C revealed approximately 8 residents observed, all who did not have water provided to them. Review of the Resident Council meeting dated 09/09/25 and 10/07/25 revealed both meetings had complaints about water not being passed out. Review of in-servicing completed on 09/10/25 and 10/02/25 with staff revealed all staff had been re-educated that all staff were responsible for providing water to residents.Review of facility's Hydration Policy dated 06/22/20 revealed residents will be offered/administered sufficient fluid intake to maintain hydration. A variety of fluids will be offered to residents, depending on preference and nutritional/diagnosis considerations.This deficiency represents non-compliance investigated under Complaint Numbers 2657376, 2656169, and 2597119.

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

11/25/2025

NAME OF PROVIDER OR SUPPLIER

STREET ADDRESS, CITY, STATE, ZIP CODE

Diplomat Healthcare

9001 W 130th St North Royalton, OH 44133

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 0773 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few

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

Provide or obtain laboratory tests/services when ordered and promptly tell the ordering practitioner of the results. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on

record review, interview, and facility policy review, the facility failed to ensure laboratory results were timely obtained and results timely reported to the provider to allow for timely treatment of a urinary tract infection (UTI). This affected one resident (#12) of three residents reviewed for UTIs. The facility census was 108.

Findings include: Medical record review revealed Resident #12 was admitted to the facility on [DATE REDACTED] with diagnoses including chronic obstructive pulmonary disease, atrial fibrillation, major depressive disorder, hyperlipidemia, anxiety, hypertension and malignant neoplasm of large intestine.Continued record review revealed on 09/02/25, Resident #12 was seen by the nurse practitioner for UTI symptoms and ordered Urinalysis with Culture and Sensitivity (UA C&S). UA C&S orders were not placed until 09/04/25. On 09/04/25 a urine sample was collected and the sample was sent to the lab for testing. The urinalysis showed the resident's urine was turbid in color and tested positive for nitrite, leukocytes, epithelial, white blood cells, and bacteria. The facility received the urine culture results on 09/07/25 that indicated the resident had Escherichia coli extended-spectrum beta-lactamase (ESBL, an enzyme produced by certain bacteria that makes them resistant to many common antibiotics) in the urine. Further record review revealed on 09/10/25, Assistant Director of Nursing (ADON) #356 reported final UA C&S result to the nurse practitioner and received an order for Nitrofurantoin monohyd (an antibiotic) capsule 100 milligram (mg) twice daily for 7 days. Review of Resident #12's Medical Administration Record (MAR) for September 2025 revealed the ordered Nitrofurantoin monohyd was started on 09/10/25. Resident #12 completed the medication on 09/17/25. Interview on 11/17/25 at 3:23 P.M. with the Director of Nursing (DON) revealed she would check to see what the delay in reporting the urine culture was. The DON further stated the nurses are expected to report any abnormal laboratory results as soon as possible to the physician or ordering provider.Interview on 11/17/25 at 3:26 P.M. with ADON #356 revealed she reported the results of the urine culture to the nurse practitioner on 09/10/25 when she noticed the lab result had not been reported to the nurse practitioner. She was unsure what the reason for the delay in reporting the result was. Review of the facility policy Resident Change in Condition dated 06/27/24 revealed the Physician/Provider and Resident/Family/Responsible Party will be notified when there has been a need to alter the resident's medical treatment, including a change in provider orders.This deficiency represents non-compliance investigated under Complaint Number 2657376 and 2614362.

Event ID:

Facility ID:

If continuation sheet