Health inspection·September 8, 2025

F 0842 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, interviews, and facility policy review, the facility failed to ensure documentation for medication administration was completed timely. This affected one resident (#10) out of three resident records reviewed for medication administration. The facility census was 38.Findings include:Review of the medical record for Resident #10 revealed an admission date of 03/13/25. Diagnoses included but were not limited to osteomyelitis of vertebra sacral and sacrococcygeal region, chronic osteomyelitis, injury at T7 - T12 thoracic spinal cord, sepsis, and paraplegia.Review of the quarterly MDS dated [DATE] revealed Resident #10 had intact cognition. Review of Resident #10's Medication Administration Record (MAR) in the electronic medical record for July 2025 revealed Cymbalta DR Particles 30 milligram (mg) give 1 capsule daily had blank spot not signed for (indicating the medication had not been received) for 7/16/25. Melatonin 3 mg give 1 tablet daily had a blank spot for 7/10/25 and 7/16/25. Bactrim Double Strength, (DS) 800-180 mg 1 tablet every 12 hours was not signed as being administered on 7/16/25. Ferrous Sulfate 325 mg 1 tablet two times a day (BID) was not signed as administered on 7/16/25. Glycolax powder give 17 gram BID was not signed as administered on 7/16/25. Omeprazole 20 mg give BID was not signed as administered on 7/16/25. Proheal liquid protein 30 milliliter (ml) BID was not signed as administered on 7/16/25. Baclofen 10 mg three times a day (TID) did not have the evening dose signed as administered, and Buprenorphine HCI-Naloxone HCI sublingual give 8-2 mg sublingually TID did not have the evening dose signed as administered. Review of Resident #10's printed MAR dated July 2025, provided by the facility, revealed the corresponding blank spaces identified in Resident #10's electronic medical record had manual initials written into the dates on which there were blank spaces. Review of Resident #10's MAR in the electronic medical record for August 2025 revealed Ceftazidime one gram (gm) intravenous every 8 hours had a blank space indicating the medication had not been administered on 08/04/25 or 08/06/25. Buprenorphine HCI-Naloxone HCI sublingual give 8-2 mg sublingually TID was not signed as administered on 08/04/25, 08/06/25, 08/13/25, 08/15/25, 08/23/25, and 08/27/25. Baclofen 10 mg TID was not signed as administered on 08/04/25, 08/06/25, 08/13/25, 08/15/25, 08/23/25, 08/24/25, or 08/27/25. Senna 8.6 mg give 1 tablet daily was not recorded as administered on 08/06/25, 08/23/25, or 08/24/25. Ascorbic Acid 500 mg 1 tablet daily was not recorded as administered on 08/06/25, 08/23/25, and 08/24/25. Glycolax powder give 17 gram BID was not recorded as administered on 08/06/25, 08/13/25, 08/23/25, and 08/24/25. Lactobacillus give 1 tablet daily was not recorded as administered on 08/06/25, 08/23/25, or 08/24/25. Ferrous Sulfate 325 mg give 1 tablet BID was not recorded as administered on 08/06/25, 08/13/25, 08/23/25, or 08/24/25. Folic Acid 1 mg give 1 mg was not recorded as administered on 08/06/25, 08/23/25, or 08/24/25. Multivitamin 1 tablet daily was not recorded as administered on 08/06/25, 08/23/25, or 08/24/25. Docusate Sodium 100 mg give one capsule daily was not recorded as administered on 08/13/25. Cymbalta DR 30 mg one capsule daily was not recorded as administered on (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 2 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 09/08/2025 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)