Grande Oaks

F 0558 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few

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

#19 was noted to receive a minced and moist diet with thin liquids. Review of the quarterly MDS 3.0 assessment dated [DATE REDACTED] for Resident #19 revealed a BIMS score of 15 of 15, which indicated intact cognition. Review of the ADL revealed Resident #19 required staff to set up meals. Resident #19 was noted to receive a mechanically altered diet. Review of the photo submitted by Resident #19's daughter on 10/21/25 of the lunch for 10/20/25 revealed a divided plate with penne pasta with meat sauce, cooked broccoli and carrots and a dinner roll. Review of the meal ticket dated 10/21/25 for Resident #19 revealed a diet order of regular minced and moist with thin liquids. Applesauce with meals, no bread, give biscuit mashed up with gravy. Interview on 10/22/25 at 8:37 A.M. with Food Service Director (FSD) #297 confirmed

the photo submitted by Resident #19's daughter from 10/20/25 had a roll on the plate and per her request should not have had bread on it. FSD #297 confirmed broccoli, and carrots were substituted for tossed salad per her diet order. Review of the undated facility policy called; Resident Rights revealed the resident has the right to be informed of, and participate in his or her treatment including; the right to participate in establishing the expected goals and outcomes of care, the type, amount frequently and duration of care and any other factored s related to the effectiveness of the plan of care. This deficiency represents non-compliance investigated under Complaint Number 2643354.

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

10/28/2025

NAME OF PROVIDER OR SUPPLIER

STREET ADDRESS, CITY, STATE, ZIP CODE

Grande Oaks

24579 Broadway Ave Oakwood Village, OH 44146

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 0604 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few

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

restraints to maintain patient safety and continued treatment plan. She was unsure of requirements at the facility for the care and management of restraints and thought the order needed to be renewed daily; however, this was not included in the facility policy. NP #303 also revealed whenever she was visiting Resident #50, the restraints were always on the resident, and she was still able to try to remove the equipment from her. NP #303 consulted with the resident's psych team regarding psychotropic medications to assist resident with anxiety needs and harmful behaviors. Interview with Licensed Practical Nurse (LPN) #248 on [DATE REDACTED] at 2:03 P.M. revealed she routinely cared for Resident #50 and stated she needed the mitt restraints because the resident would frequently exhibit behaviors of attempting to pull the ventilator circuit off, removing her tracheostomy, thrashing out at care providers, pulling on Foley (indwelling) catheter, and actively attempting to get out of bed. LPN #248 stated there was no specific daily checklist for restraint guidance and usage, but staff are instructed to document in the skilled nursing progress notes and include skin assessments. LPN #248 stated she does check for a valid order for the resident and did provide time for the resident with removal of restraints. Review of facility policy titled, Restraint Free Environment revised

on [DATE REDACTED] revealed restraint use is limited to circumstances in which the resident has medical symptoms that warrant the use of restraints. Medical symptoms warranting the use of restraints should be documented

in the resident's medical record and needs to include documentation of less restrictive alternatives, ongoing re-evaluation of the need for the restraint and the effectiveness of the restraint in treating the medical symptom. The care plan should be updated accordingly to include the development and implementation of interventions to address any risks related to use of the restraint. This deficient represents noncompliance investigated under Complaint Number 2643354.

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

10/28/2025

NAME OF PROVIDER OR SUPPLIER

STREET ADDRESS, CITY, STATE, ZIP CODE

Grande Oaks

24579 Broadway Ave Oakwood Village, OH 44146

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

record review, interview and facility policy review, the facility failed to ensure all ordered treatments/medications were provided to residents as ordered. This affected one (Resident #19) out of four residents who were interviewed for ordered treatments/medications. The facility census was 48. Findings include:Review of the medical record for Resident #19 revealed an admission date of 06/07/24. Diagnoses included but were not limited to interstitial pulmonary disease, dependence on respirator, chronic respiratory failure, supraventricular tachycardia, neuropathy, chronic obstructive pulmonary disease, disorders of diaphragm, obstructive sleep apnea, and chronic respiratory failure with hypoxia, obesity and anxiety disorder. Review of Resident #19's care plan revealed the resident required assistance with activities of daily living (ADL) related to spinal stenosis, peripheral neuropathy, and chronic obstructive pulmonary disease (COPD). An intervention dated 07/09/25 was listed as a soft touch pad call light is to be clipped to resident's gown at all times. Review of the quarterly Minimum Data Set (MDS) 3.0 assessment dated [DATE REDACTED] for Resident #19 revealed a Brief Interview of Mental Status (BIMS) score of 15 of 15, which indicated intact cognition. Review of the ADL revealed Resident #19 required set up for eating, and was dependent on staff for toileting, bathing, dressing and transfers. Review of the October 2025 physician's orders revealed an order for Biofreeze (pain relieving gel) topically to both knees dated 07/02/24. Interview with Resident #19 and daughter on 10/23/25 at 2:00 P.M. revealed concerns regarding the resident not receiving her ordered application of Biofreeze 4% gel (pain relieving gel) to her knees. Resident #19's daughter stated that on 10/25/25, Licensed Practical Nurse (LPN) #270 did not apply the Biofreeze as ordered after Resident #19 requested it. Interview with LPN #270 on 10/27/25 at 12:50 P.M. revealed that

the Biofreeze was kept on Resident #19's bedside table and believed the resident was able to apply the gel herself when needed. LPN #270 did confirm that she did not actually apply the Biofreeze gel but did sign it off in the medication administration record (MAR) as being given. LPN #270 stated she would only sign off

the medication if she thought the resident could apply it to herself. Interview with the Director of Nursing (DON) on 10/27/25 at 8:19 A.M. regarding signing off treatment in MAR revealed that LPN #270 should not have signed the medication as being administered if not performing the task herself or observing the resident performing the administration. The DON also stated that Resident #19 does not have the dexterity to self-apply the Biofreeze gel, and it should have been applied by LPN #270. The DON stated she will re-educate LPN #270 regarding documentation in MAR. Review of the facility policy titled, Medication Administration, revised on 08/22/22, revealed that staff is to review the MAR to identify medication which is to be administered and only sign the MAR after performing the administration. This deficiency represents non-compliance investigated under Complaint Number 2643354.

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

10/28/2025

NAME OF PROVIDER OR SUPPLIER

STREET ADDRESS, CITY, STATE, ZIP CODE

Grande Oaks

24579 Broadway Ave Oakwood Village, OH 44146

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

Provide enough food/fluids to maintain a resident's health.

Level of Harm - Minimal harm or potential for actual harm

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

record review, observation, interview and facility policy review, the facility failed to ensure physician orders were followed related to obtaining weights for two (Residents #11 and #19) of three residents reviewed for weight monitoring. The facility census was 48. Findings include:1. Review of the medical record for Resident #11 revealed an admission date of 04/14/22. Diagnoses included but were not limited to chronic respiratory failure, tracheostomy, dependence upon respirator, type II diabetes with hyperglycemia, and morbid obesity.

The last weight recorded was on 07/02/25. Review of the quarterly Minimum Data Set (MDS) 3.0 assessment dated [DATE REDACTED] for Resident #11 revealed a Brief Interview of Mental Status (BIMS) score of 15 of 15, which indicated intact cognition. Review of activities of daily living (ADL) revealed Resident #11 was dependent upon staff for ADL. Review of Resident #11's care plan last reviewed on 09/04/25 revealed increased risk for malnutrition as evidenced by morbid obesity, diuretic use, and heart failure. Interventions listed were to monitor weight monthly and as needed. Review of nursing progress notes from 07/01/25 to 10/21/25 revealed a weight was obtained on 07/02/25, and no weight or refusal note was found for the month of August 2025, and refusal was noted for 09/12/25. Interview on 10/22/25 at 11:36 A.M. with the Director of Nursing (DON) confirmed she was unable to provide evidence of a monthly weight for Resident #11 for August 2025, or evidence of a noted refusal as required. 2. Review of the medical record for Resident #19 revealed an admission date of 06/07/24. Diagnoses included but were not limited to interstitial pulmonary disease, dependence on respirator, chronic respiratory failure, supraventricular tachycardia, neuropathy, chronic obstructive pulmonary disease (COPD), disorders of diaphragm, obstructive sleep apnea, and chronic respiratory failure with hypoxia, obesity and anxiety disorder. Review of Resident #19's nutrition care plan last reviewed on 04/14/25 revealed Resident #19 is at risk for alteration in nutrition and hydration related to obesity, tendency to become short of breath during meals. Interventions added on 06/12/24 included monitor weight monthly and as needed. Review of the 07/03/25 physician order for Resident #19 revealed an order to obtain weight daily at 5:00 A.M. Review of the quarterly MDS 3.0 assessment dated [DATE REDACTED] for Resident #19 revealed a BIMS score of 15 of 15, which indicated intact cognition. Review of ADL revealed Resident #19 was dependent upon staff for ADL. Review of the daily weights from 09/01/25 to 10/20/25 revealed no weights were recorded for 09/03/25, 09/06/25, 09/11/25, 09/13/25, 09/29/25, 10/02/25, 10/05/25, 10/12/25, 10/18/25 and 10/20/25. Interview on 10/22/25 at 9:32 A.M. with the DON confirmed the above daily weights were not obtained as ordered by the physician.

Review of the 12/01/22 revised facility policy called; Weight Policy revealed weights should be recorded at

the time obtained. Newly admitted residents- monitor weight weekly for four weeks. Residents with significant weight loss- monitor weight weekly. All others monitor weight monthly. Other conditions may require weights to be obtained and monitoring more frequently; physicians orders will determine the frequency. This deficiency represents non-compliance investigated under Complaint Number 2643354.

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

10/28/2025

NAME OF PROVIDER OR SUPPLIER

STREET ADDRESS, CITY, STATE, ZIP CODE

Grande Oaks

24579 Broadway Ave Oakwood Village, OH 44146

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 0695

breathing on exertion.

Level of Harm - Minimal harm or potential for actual harm

Review of the camera video footage taken on 10/25/25 at 12:44 P.M. provided by Resident #19's daughter revealed Resident #19 was eating lunch without her nasal cannula on. RT #296 had removed her AVAP mask for lunch but did not transition resident to her nasal cannula with oxygen at three liters/minute per order. Resident #19 requires oxygen at all times due to her diminished lung capacity and aspiration risk and also transitions to a cannula during medication administration.

Residents Affected - Few

Interview with RT #296 on 10/21/25 at 10:35 A.M. revealed Resident #19 remains on AVAP per preference

during the day and does change to a nasal cannula for all meals and medication administration. RT #296 stated he has not observed any shortness of breath or respiratory concerns from resident who has been maintaining her oxygen saturation both on AVAP and nasal cannula.

Interview with RT #268 on 10/23/25 at 9:30 A.M. also revealed Resident #19 transitions to nasal cannula with all meals. RT #268 stated the resident will call him when she wants to eat and change out the oxygen source and will call again when finished to be placed back on AVAP.

Review of the facility policy titled, Oxygen Administration, revised 01/04/23, revealed oxygen is administered to resident who need it, consistent with professional standards of practice, the comprehensive person-centered care plans, and the resident's goals and preferences.

This deficiency represents non-compliance investigated under Complaint Number 2643354.

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

10/28/2025

NAME OF PROVIDER OR SUPPLIER

STREET ADDRESS, CITY, STATE, ZIP CODE

Grande Oaks

24579 Broadway Ave Oakwood Village, OH 44146

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 0880

Provide and implement an infection prevention and control program.

Level of Harm - Minimal harm or potential for actual harm

Based on observation, interviews and review of the facility policy, the facility failed to ensure hand hygiene practices were being performed consistently with accepted standards of practices to prevent the transmission of communicable diseases and infections. This had the potential to affect12 (Residents #15, #23, #24, #25, #27, #28, #29, #37, #39, #41, #44, and #46) on the south hallway who did not have functioning soap dispensers in their rooms of 48 residents reviewed for infection control. The facility census was 48. Findings include:Observation during facility tour on 10/20/25 at 10:50 A.M. with the Administrator and Director of Nursing (DON) revealed multiple resident rooms which did not have functioning soap dispensers to use for hand hygiene. These included rooms of Residents #23, #25, #27, #28, #29, #37, #39, #41, #44, and #46. In the room of Resident #15, the soap dispenser was observed to be missing off the wall. Interview with the Director of Nursing (DON) and Administrator on 10/20/25 at 10:50 A.M. confirmed

the non-functional soap dispensers in resident's bathrooms. The DON and Administrator both stated that none of the staff informed them that they were not working and could not verify that all staff were performing hand hygiene as required. Multiple observations of staff from 10/20/25 through 10/28/25 revealed staff had donned gloves when removing dirty linen from resident's rooms; however, no

observations were noted using the hallway alcohol sanitizer prior to entering and exiting resident rooms. It is unknown how hand hygiene was performed in the bathrooms of residents that had no functional soap dispensers. Interview with DON on 10/21/25 at 1:15 P.M. revealed she could not verify how the staff were performing hand hygiene on the south wing that had no functional soap dispensers. She re-iterated that staff did not notify her of any non-functioning soap dispensers or she would have had them fixed. The DON also stated that she does perform hand hygiene audits and education and has had no issues with compliance. Review of the facility policy titled, Enhanced Barrier Precautions, revised 07/13/22, revealed facility ensures access to alcohol-based hand rub in every resident room (ideally both inside and outside of

the room). This deficiency represents non-compliance investigated under Complaint Number 2643354.

Residents Affected - Some

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

10/28/2025

NAME OF PROVIDER OR SUPPLIER

STREET ADDRESS, CITY, STATE, ZIP CODE

Grande Oaks

24579 Broadway Ave Oakwood Village, OH 44146

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 0921 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some

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

Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and

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

observation, interview and review of the facility policy, the facility failed to ensure room and hall soap and sanitizer dispensers were functioning properly as required and failed to ensure the wall in Resident #14's room was in good repair. This affected 14 (Residents #2, #9, #11, #14, #15, #23, #25, #27, #28, #30, #37, #39, #41, and #46) of 48 residents reviewed for a safe and sanitary environment. The facility census was

1. 48. Findings include:Observation during facility tour on 10/20/25 at 10:50 A.M. with the Administrator and

Director of Nursing (DON) revealed multiple resident rooms which did not have functioning soap dispensers to use for hand hygiene. These included rooms of Residents #23, #25, #27, #28, #30, #37, #39, #41, #44, and #46. In the room of Resident #15, the soap dispenser was observed to be missing off the wall.

Observation of the north hallway alcohol sanitization dispensers outside of Resident #2's room, the dispenser outside of Residents #9 and #11's rooms and the dispenser outside of the biohazard room revealed they were not functional for staff. Observation of Resident #14's room revealed the wall behind the head of the bed had a six-inch by eight-inch hole about 12 inches up from the floor. Plaster and drywall pieces were evident on the floor next to the fall mat on the floor. Interview on 10/20/25 at 10:55 A.M. with Resident #46 confirmed her soap had not been working for a couple days, but she uses her own sanitizer.

Interview with DON and Administration on 10/20/25 at 11:56 A.M. following the environmental tour confirmed the non-functioning soap dispensers in resident's rooms as well as the wall hand alcohol-based sanitizers on the walls in the North hallway. The DON and Administrator both stated that none of the staff informed them that they were not working and could not verify that all staff were performing hand hygiene as required. The DON and Administrator also confirmed the hole in the wall for room [ROOM NUMBER] should have been cleaned up and repaired. Review of the facility policy titled, Enhanced Barrier Precautions, revised 07/13/22, revealed facility ensures access to alcohol-based hand rub in every resident room (ideally both inside and outside of the room). Policy did not speak to hand hygiene or soap dispensers. This deficiency represents non-compliance investigated under Complaint Number 2643354.

Event ID:

Facility ID:

If continuation sheet