Inspection·December 17, 2024

F 0657 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals. Based on medical record review, observation, and staff interview, the facility failed to ensure care plans were updated to include new interventions for falls. This affected two (Residents #1 and #29) of three residents reviewed for falls. The facility census was 41 residents. Findings include: 1. Review of the medical record for Resident #1 revealed an admission date of 10/24/24 with diagnoses including kidney failure, congestive heart failure (CHF), insomnia, muscle weakness and history of stroke. Review of the care plan for Resident #1 dated 10/26/24 revealed the resident was at risk for falls due to an unstable health condition. Interventions included assistance with all transfers and mobility, bed in a low position, call light within reach, and commonly used articles within reach. Review of the Minimum Data Set (MDS) assessment for Resident #1 dated 11/01/24 revealed the resident was moderately cognitively impaired and required setup help for eating, and substantial or maximum assistance for oral hygiene, toileting and personal hygiene. Review of the nurses' note for Resident #1 dated 11/07/24 timed at 2:15 A.M. revealed the resident had an unwitnessed fall from bed at 1:30 A.M. The aide notified the nurse Resident #1 was on the floor with both legs bent on the right side. Resident #1 denied hitting his head and had no complaints of pain. Review of the fall review for Resident #1 dated 11/07/24 revealed new interventions to prevent further falls included placing a mattress to the floor in the resident's room and 30-minute safety checks. Review of the fall care plan for Resident #1 revealed the new fall prevention interventions were not added to the resident's care plan. Observation on 12/16/24 at 8:45 A.M. revealed there was no mattress to the floor in Resident #1's room. Interview on 12/16/24 at 9:49 A.M. with the Director of Nursing (DON) confirmed there was no mattress to the floor of Resident #1's room and the facility had not updated the resident's care to include the mattress to the floor and 30-minute safety checks as recommended by the facility fall review. (continued on next page) 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 Page 1 of 5 Event ID: 365006 Printed: 05/15/2026 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 365006 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/17/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Hillside Plaza 18220 Euclid Ave Cleveland, OH 44112 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)