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Complaint Investigation

Grande Pointe Healthcare Commu

Inspection Date: October 27, 2025
Total Violations 2
Facility ID 366008
Location RICHMOND HEIGHTS, OH
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Inspection Findings

F-Tag F0686

Quality of Life and Care Deficiencies
Harm Level: Potential for More Than Minimal Harm

F 0686

Provide appropriate pressure ulcer care and prevent new ulcers from developing.

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 a physician order for a pressure ulcer treatment was transcribed into the electronic medical records. This affected one resident (#136) of three residents reviewed for physician orders. The facility census was 151.Findings include:Review of Resident #136 ' s medical record revealed an admission date of 02/04/25. Diagnoses included a stage four pressure ulcer (a full thickness wound involving muscle, tendon, and/or bone involvement) to the sacrum (tailbone area), stroke with right sided weakness, and malnutrition.Review of

the Minimum Data Set (MDS) assessment dated [DATE REDACTED] revealed Resident #136 had intact cognition.

Resident #136 was dependent on staff for toileting, bathing, and personal hygiene. Review of the care plan dated 09/18/25 revealed Resident #136 had an actual skin impairment. Interventions included a negative pressure wound vac set at 125 millimeters of mercury (mmHg) of pressure and change the wound vac dressing three times a week on every Tuesday, Thursday, and Saturday, and as needed. Review of Resident #136 ' s physician orders for October 2025 revealed to change wound vac dressing three times a week on Tuesdays, Thursdays and Saturdays and as needed. Physician orders had not included specific information regarding the type of dressing or treatments.Review of a progress note dated 10/17/25 authored by Wound Nurse Practitioner (WNP) #355 revealed orders that included cleanse the sacral area with Dakins (antiseptic) solution, apply skin prep and stoma paste, apply a transparent drape to the area, cut black foam to fit the wound area and apply a transparent dressing over the black foam and set the wound vac to negative 125 mmHg continuously every Tuesday, Thursday, and Saturday.Interview on 10/21/25 at 3:00 P.M. with Registered Nurse (RN) #230, who was the facility's wound nurse, confirmed WNP #355 ' s orders had not been transcribed into his medical records and stated specific wound care orders should have been included in Resident #136 ' s physician orders. Review of the facility policy titled Physician Orders undated revealed physician orders will be transcribed into the electronic medical records.This deficiency represents non-compliance investigated under Complaint Number 2645034.

Residents Affected - Few

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

10/27/2025

NAME OF PROVIDER OR SUPPLIER

STREET ADDRESS, CITY, STATE, ZIP CODE

Grande Pointe Healthcare Commu

Three Merit Dr Richmond Heights, OH 44143

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)

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F-Tag F0880

Infection Control Deficiencies
Harm Level: Potential for More Than Minimal Harm

F 0880

Provide and implement an infection prevention and control program.

Level of Harm - Minimal harm or potential for actual harm

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

observation and interview, the facility failed to ensure appropriate infection control techniques were used

during incontinence care. This affected one resident (#136) of two residents observed for incontinence care.

The facility census was 151.Findings include:Review of Resident #136's medical records revealed an admission date of 02/04/25. Diagnoses included stroke with right sided weakness, muscle weakness, and malnutrition.Review of the Minimum Data Set (MDS) assessment dated [DATE REDACTED] revealed Resident #136 had intact cognition. Resident #136 was dependent on staff for toileting and was incontinent of bowel and bladder.Review of the care plan dated 09/18/25 revealed Resident #136 was dependent on staff for toileting. Interventions included to check the resident for incontinence.Observation of incontinence care on 10/20/25 at 10:57 A.M. with Certified Nursing Assistant (CNA) #255 revealed Resident #136 was incontinent of liquid stool. CNA #255 had proceeded to provide Resident #136 with incontinence care while wearing gloves. Upon completion of incontinence care CNA #136 had not removed her soiled gloves and had then proceeded to apply Vaseline to Resident #136's arms and legs using the same soiled gloves she had used to provide incontinence care. Interview with CNA #255 at time of observation revealed she should have removed the soiled gloves after completion of incontinence care. This deficiency represents an incidental finding identified during the complaint investigation.

Residents Affected - Few

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

Event ID:

Facility ID:

If continuation sheet

📋 Inspection Summary

GRANDE POINTE HEALTHCARE COMMU in RICHMOND HEIGHTS, OH inspection on recent inspection.

Found 0 violation(s). Severity: Standard violations. Status: 0 corrected, 0 pending.

What this means: Health inspections identify deficiencies that facilities must correct. Violations range from minor documentation issues to serious safety concerns. All deficiencies must be corrected within required timeframes and are subject to follow-up verification.

Frequently Asked Questions

What is an F-tag violation?
F-tags are federal deficiency codes used by CMS to categorize nursing home violations. Each F-tag corresponds to a specific federal regulation (42 CFR Part 483). For example, F607 relates to abuse prevention policies, F880 relates to infection control.
Were these violations corrected?
Facilities must submit plans of correction and implement changes within required timeframes. CMS conducts follow-up inspections to verify corrections. Check the inspection report for specific correction dates and follow-up verification status.
How often do nursing home inspections happen?
CMS conducts unannounced inspections of all Medicare/Medicaid-certified nursing homes at least once per year. Additional inspections may occur based on complaints, facility-reported incidents, or follow-up to verify previous violations were corrected.
What should families do about these violations?
Families should: (1) Review the full inspection report for details, (2) Ask facility administration about specific corrective actions taken, (3) Check if this represents a pattern by reviewing prior inspections, (4) Compare with other facilities in RICHMOND HEIGHTS, OH, (5) Report new concerns to state authorities.
Where can I see the full inspection report?
Complete inspection reports are available on Medicare.gov's Care Compare website (www.medicare.gov/care-compare). You can also request copies directly from GRANDE POINTE HEALTHCARE COMMU or from the state Department of Health. Reports include deficiency codes, facility responses, and correction timelines.
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