North Royalton Post Acute

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

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

supervision or touch assistance for mobility. Observation on 11/20/25 at 12:15 P.M. revealed Resident #83 was in a wheelchair being pulled backwards through the entrance of the facility doors and down the hall.

Resident #83's feet were dragging on the floor. Observation revealed his elderly brother was pulling the wheelchair backwards, he ran into the wall nearly falling. Resident #83 screamed in fear. Admissions #243 approached. Interview with Resident #83 revealed he was returning from a doctor appointment. Resident #83 revealed his brother went with him and was returning him to the facility. Resident #83 revealed it was too hard to hold his legs in the air to go forward, it was too painful, and he did not have the strength, so his brother had to pull him backwards. Resident #83 expressed he was frustrated, he had asked several times for several days for foot pedals for the wheelchair, but no one had got them for him. Observation revealed Resident #83's brother then continued pulling Resident #83 down the hall backwards toward his room, staff never offered assistants. Interview on 11/20/25 at 2:21 P.M. with Physical Therapy Assistant (PTA) #322 revealed she worked with Resident #83 on ambulation for a while the previous day but Resident #83 was in too much pain in his legs, knees and back. PTA #322 revealed Resident #83 was self-limited due to pain and revealed he should not be pushed in the wheelchair with no foot pedals. Interview on 11/20/25 at 2:28 P.M. with Licensed Practical Nurse (LPN) Unit Manager (UM) #401 revealed Resident #83 did not get out of bed too often and stated, He can do more than he is willing to do, he is not doing it, he would rather everyone do it for him, back pain is normal for him; he recently had a pump put in his back. LPN UM #401 revealed when a resident was admitted to the facility, the staff normally put the foot pedals on the wheelchair for transport and revealed she did not know why no one put them on Resident #83's chair other than he did not get out of bed very often. Interview on 11/20/25 at 2:39 P.M. with Housekeeping/Maintenance Director #308 revealed foot pedals are located in different places, there was no designated place so she has to go look for them, but she found some in one of the shower rooms and Resident #83 could use those. Interview on 11/20/25 at 2:53 P.M. with Certified Nursing Assistant (CNA) #805 revealed Resident #83 was normally pushed in the wheelchair by the CNA's and because he did not have footrests, he had to be pushed backwards. Interview on 11/20/25 at 256 P.M. with Director of Nursing (DON) revealed the wheelchairs do have foot pedals, if the residents are able to move around they don't need to be pushed in the wheelchair, so they don't need foot pedals. DON confirmed residents should not be pulled backwards in a wheelchair. This deficiency represents non-compliance investigated under Complaint Number 1348042.

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

North Royalton Post Acute

9055 West Sprague Road Parma, 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 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few

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

10/17/25 or was monitored for adverse effects of missing the medications.Interview on 11/25/25 at 12:18 P.M. with Director of Nursing (DON) verified the medication errors that occurred for Resident #44 on 02/14/25 and 10/17/25. DON revealed that when there was a medication error, the resident should be monitored daily for 72 hours following the error. DON reviewed the medical record and confirmed on 02/14/25 and 10/17/25 Resident #44 was not monitored daily for 72 hours for effects related to the missed doses of medications and the physician was not notified timely of the medication errors that occurred 10/17/25.Review of the facility policy titled, Adverse Consequences and Medication Errors dated February 2023 revealed a medication error is defined as the preparation or administration of drugs or biological which is not in accordance with physician orders, manufacturer specifications, or accepted professional standard and principals of the professional providing services. Example of medication errors include omission (a drug is ordered but not administered). Medication errors are managed according to facility policy. Procedures include to monitor the resident for medication -related adverse consequences when there is a medication error. Promptly notify the provider of any significant error or adverse consequences.

Implement the providers orders and monitor the resident for 24 to 72 hours or as directed. Document the information in an incident report and in the resident's clinical record.The deficiency represents non-compliance investigated under Complaint Number 1348045.

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

North Royalton Post Acute

9055 West Sprague Road Parma, 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

Resident #14 was still sitting in the Recreational Therapy room by herself. Resident #14 confirmed she was still waiting to use the bathroom. Observation on 11/19/25 at 12:50 P.M. revealed Resident #14 was sitting

in the doorway of her room. Resident #14 verified her CNA just finished assisting her to the bathroom.

Resident #14 revealed, If my bladder is full, it does hurt and I have to go a little in my pants when I can't hold no more. Resident #14 revealed it happens some days when they are too busy to take her. Interview

on 11/19/25 at 12:51 P.M. with Licensed Practical Nurse (LPN) #267 confirmed she was Resident #14's primary nurse and revealed, (Resident #14) is continent of urine if we take her. Interview on 11/19/25 at 12:54 P.M. with CNA #394 revealed she took Resident #14 to the bathroom about 10 minutes ago. CNA #394 revealed Resident #14's brief was wet with urine, but she also urinated in the toilet too. CNA #394 revealed Resident #14 was usually continent of urine but sometimes also incontinent and revealed Resident #14 was last assisted to the bathroom right before breakfast (approximately 8:00 A.M.). Interview

on 11/20/25 at 4:00 P.M. with Director of Nursing (DON) revealed (Activities Aides #247 and #250) should have immediately notified Resident #14's nurse or CNA of her request to go to the bathroom and Resident #14 should have been assisted to the bathroom as soon as staff found out she needed to go. Review of the facility policy titled, Activities of Daily Living dated 06/08/22 revealed the purpose is to preserve activities of daily living function, promote independence and increase self-esteem and dignity.The deficiency represents non-compliance investigated under Complaint Number 1348042 and 2661500.

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

North Royalton Post Acute

9055 West Sprague Road Parma, 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 0693 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few

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

Ensure that feeding tubes are not used unless there is a medical reason and the resident agrees; and provide appropriate care for a resident with a feeding tube. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on

observation, interview, and record review, the facility failed to ensure #78 received the ordered amount of tube feeding daily. This affected one resident (Resident #78) of three residents reviewed for tube feeding management. The facility census was 119.Findings include:Record review for Resident #78 revealed an admission date of 08/01/25. Diagnosis included dysphagia following cerebral infarction, hemiplegia and hemiparesis, and aphasia. Review of the admission MDS dated [DATE REDACTED] revealed Resident #78 was severely cognitively impaired. Resident #78 was dependent for activities of daily living including bed mobility and transfers. Resident #78 had no or unknown weight loss and weight was 188. Review of the physician orders dated 08/01/25 revealed Resident #78 was NPO. Additional orders dated 08/28/25 for Resident #78 revealed an order for enteral feed order every shift for nutrition Peptamen 1.5 continuous: Give formula at 75 cc an hour flush 300 cc every six hours ok to use Jevity 1.5 if Peptamen unavailable.Review of the care plan for Resident #78 dated 08/05/25 revealed Resident #78 had a peg tube and was at risk for enteral nutrition complications related to aspiration pneumonia, clogged tubing, excessive residual, infection, nausea or vomiting, and tubing and displacement. Interventions included to monitor weight per protocol.Review of the weight log for Resident #78 revealed on 09/04/25 Resident #78 weighed 192.3 pounds. On 10/07/25 Resident #78 weighed 192.4 pounds. On 11/07/25 Resident #78 weighed 188.6 pounds. Observation on 11/19/25 at 2:23 P.M. revealed Resident #78 was in bed with his eyes closed. Observation revealed Resident #78's tube feeding pump was beeping and revealed, clog in line downstream. The containing of tube feeding was Jevity 1.5 dated as initiated on 11/19/25 at 12:50 A.M. at 75 cc an hour. The container was a 1000 ml container. Observation revealed there was 370 ml remaining

in the container and the tube feeding was not flowing.Observation on 11/19/25 at 3:09 P.M. and 4:30 P.M. revealed Resident #78' tube feeding pump was beeping, not infusing and read, clog in line downstream.Observation on 11/19/25 at 4:31 P.M. with LPN #268 confirmed Resident #78's tube feeding was not infusing. LPN #268 confirmed the tube feeding pump was beeping and revealed, clog in line downstream. The containing of tube feeding was Jevity 1.5 dated as initiated on 11/19/25 at 12:50 A.M. at 75 cc an hour. The container was a 1000 ml container. Observation confirmed there was 370 ml remaining

in the container. LPN #268 revealed she started her shift at 3:00 P.M., had not visited with Resident #78 yet and was not told his tube feeding had not been infusing. The tube feeding should have been completed at approximately 1:00 P.M. LPN #268 confirmed Resident #78 did not receive the ordered amount of nutrition.This deficiency represents non-compliance investigated under Complaint Number 2661500.

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

North Royalton Post Acute

9055 West Sprague Road Parma, 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 0759 Level of Harm - Minimal harm or potential for actual harm

included to the administer the insulin per the physician orders. Review of the facility policy titled, Administering Medications revised April 2019 revealed medications are administered in a safe and timely manner, and as prescribed. The deficiency represents non-compliance investigated under Complaint Number 1348044 and 1348045.

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

North Royalton Post Acute

9055 West Sprague Road Parma, 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 0880 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few

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

dressing. LPN #261 confirmed she did not wash her hands or use hand sanitizer after cleaning the soiled peg tube site area and confirmed she wore the same soiled gloves used to clean the site to apply the sterile dressing. Interview on 11/23/25 at 10:47 A.M. with Director of Nursing (DON) confirmed LPN #261 should have washed her hands with soap and water or used hand sanitizer after cleansing Resident #91's peg tube site and before applying the sterile dressing. DON confirmed the physician order was for a dry sterile dressing twice a day and according to the order, sterile technique should have been used to apply a sterile dressing. DON confirmed sterile techniques were never used (including sterile gloves) to provide the treatments to the peg tube site. DON revealed the order should not have been sterile due to wound care for peg tube sites were usually not a sterile technique but clean technique should have still been used. DON also confirmed that an isolation gown should be worn at all times when providing hands on care for Resident #91. Review of the facility policy titled, Enhanced Barrier Precautions dated December 2024 revealed Enhanced Barrier Precautions (EBP) are utilized to prevent the spread of multi-drug-resistant organisms (MDROs) to residents. EBP refer to infection prevention and control interventions designed to reduce the transmission of MDROs during high contact resident care activities. EBPs employ targeted gown and glove use in addition to standard precautions during high contact resident care activities when contact precautions do not otherwise apply. Gloves and gowns are applied prior to performing the high contact resident care activity. Examples of high contact care activities requiring the use of gown and gloves for EBPs include dressing, bathing, providing hygiene or grooming, changing briefs or assisting with toileting, providing bed mobility, and wound care. Review of the facility policy titled, Dressing Change (Clean) undated revealed the purpose was to protect the wound, prevent irritation, prevent infection and spread of infection and to promote healing. The procedure included to remove the soiled dressing and discard in a plastic bag, dispose of gloves, wash hands, put on a second pair of disposable gloves, cleanse wound with prescribed solution, dispose of gloves, wash hands, put on third pair of disposable gloves, apply prescribed medication if ordered, apply dressing and secure, remove gloves and discard, wash hands.The deficiency represents non-compliance investigated under Complaint Number 1348043 and 2661500.

Event ID:

Facility ID:

If continuation sheet