Inspection visit
Health inspection
3 citations recorded
Inspector’s narrative
What the inspector wrote
This survey cited 3 deficiencies. The full statement and the facility’s plan of correction follow, verbatim from the federal record.
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.
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on
interview, record review and facility policy review the facility failed to update Resident #118's
comprehensive fall prevention care plan to ensure fall prevention interventions were implemented. This
affected one resident (Resident #118) of three residents reviewed for falls. The facility census was 117
residents.
Findings include:
Review of Resident #118's closed medical record revealed an admission date of [DATE] with diagnoses
including dementia with other behavioral disturbance, diabetes, hyperlipidemia, epilepsy, hypertension,
encephalopathy and hypothyroidism. Resident #118 expired in the facility on [DATE].
Review of Resident #118's admission minimum data set (MDS) 3.0 assessment dated [DATE] revealed
Resident #118 was cognitively impaired, totally dependent on two staff for bed mobility and transfer and
totally dependent on one staff for personal hygiene. Resident #118 had one fall without injury and two falls
with minor injury since admission.
Review of an admission fall risk assessment dated [DATE] identified Resident #118 was a high fall risk due
to factors including having altered awareness of his immediate physical environment, requiring assistance
or supervision for mobility, transfer and ambulation, incontinence, being on a high fall risk medication and
having one or more falls in the last six months.
Review of a fall investigation dated [DATE] revealed Resident #118 had a witnessed fall during transport to
the shower room resulting in a small scratch to the skin surrounding his left eye. As a result of the fall,
Resident #118 received a new chair from therapy.
Review of a fall investigation dated [DATE] revealed Resident #118 had a witnessed fall without injury. While
activity staff was passing out popsicles in the dining room, Resident #118 attempted to stand up out of his
wheelchair and slid out of the chair onto the floor, landing on his buttocks. As a result of the fall, Resident
#118 had dycem (grippy surface to prevent slipping) placed in his wheelchair.
Review of a fall investigation dated [DATE] revealed Resident #118 had an unwitnessed fall from a table in
the dining room, resulting in a bump/raised area to the left temporal area. As a result of the fall, Resident
#118 was placed in his wheelchair closer to the nurses' station.
Review of Resident #118's plan of care dated [DATE] and revised [DATE] revealed Resident #118 was at
risk for falling related to past and current falls. A goal was listed that Resident #118 would
(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 6
Event ID:
365432
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
365432
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
11/13/2023
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Diplomat Healthcare
9001 W 130th St
North Royalton, 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 0657
Level of Harm - Minimal harm
or potential for actual harm
Residents Affected - Few
remain free from injury. The following approaches were included on the plan of care: keep call light in reach
at all times, keep personal items and frequently used items within reach, and provide proper,
well-maintained footwear. The interventions implemented as a result of the resident's falls on [DATE],
[DATE], and [DATE] were not identified on the care plan.
Interview on [DATE] starting at 10:09 A.M. with Licensed Practical Nurse (LPN)/Assistant Director of
Nursing (ADON) #206 and LPN/ADON #207 revealed the MDS nurse would usually put new interventions
on the plan of care. LPN/ADON #206 and LPN/ADON #207 were asked regarding the interventions from
Resident #118's fall investigations including a new chair from therapy, dycem to Resident #118's wheelchair
and placing Resident #118 closer to the nurse's station and their absence from the care plan. LPN/ADON
#207 verified the dycem, better fitting wheelchair and keeping the resident closer to the nurses' station
should have been included on Resident #118's plan of care. LPN/ADON #206 stated Resident #118 was
placed in a low bed on admission and verified this was not a care planned approach to prevent falls for
Resident #118. LPN/ADON #206 and LPN/ADON #207 also shared there was no [NAME] or care card for
staff to refer to that would contain Resident #118's updated fall interventions.
Review of the facility policy, Fall Prevention and Management, revised [DATE] revealed residents would be
addressed for fall risk on admission, quarterly, after any fall and as needed. If risks are identified
preventative measures would be put into place and care planned. All falls will be reviewed and investigated.
Falls would be reviewed by an interdisciplinary team and any new interventions identified will be
implemented and the care plan updated as necessary. Such review should include discussion as to any
new interventions which may help prevent further falls.
This deficiency represents non-compliance investigated under Complaint Number OH00146883.
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
365432
If continuation sheet
Page 2 of 6
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
365432
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
11/13/2023
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Diplomat Healthcare
9001 W 130th St
North Royalton, 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
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
interview and record review, the facility failed to ensure physician's orders were faxed timely to receiving
providers for prompt scheduling of services. This affected one resident (Resident #118) of three residents
reviewed for accidents. The facility census was 117 residents.
Residents Affected - Few
Findings include:
Review of Resident #118's closed medical record revealed an admission date of [DATE] with diagnoses
including dementia with other behavioral disturbance, diabetes, hyperlipidemia, epilepsy, hypertension,
encephalopathy and hypothyroidism. Resident #118 expired in the facility on [DATE].
Review of Resident #118's admission minimum data set (MDS) 3.0 assessment dated [DATE] revealed
Resident #118 was cognitively impaired, was totally dependent on two staff for bed mobility and transfer
and was totally dependent on one staff for personal hygiene. Resident #118 had one fall without injury and
two falls with minor injury since admission.
Review of a nurses' note dated [DATE] at 5:12 P.M. authored by Licensed Practical Nurse (LPN) #205
revealed Resident #118's daughter, family member (FM) #200 was concerned about the resident's fall on
[DATE] and requested a CT scan soon. This nurse notified CNP #203 who gave order to call hospital in the
morning and schedule CT of head without contrast. FM #200 was aware and agreeable to order and for call
to be made in the morning to schedule CT scan.
Review of a nurses' note dated [DATE] at 6:37 P.M. and authored by LPN #205 revealed FM #200 did not
want Resident #118 transported to hospital tonight for CT scan. CNP #203 was notified. Continue to
monitor for CT scan orders in the morning.
Review of Resident #118's paper medical record revealed a telephone order dated [DATE] for scheduling a
computed tomography (CT) scan of the head without contrast as soon as possible at [hospital name]. Fax
results to [phone number]. The order was signed by Certified Nurse Practitioner (CNP) #203 on [DATE].
Review of a nurses' note dated [DATE] at 11:57 A.M. and authored by LPN #201 revealed a call was placed
to [hospital name] radiology to schedule CT scan. Order and face sheet needed in order to schedule
appointment. Documents faxed to [fax number].
Review of a nurses' note dated [DATE] at 2:59 P.M. and authored by LPN #201 revealed face sheet and
order for CT scan without contrast faxed to [hospital name] central scheduling was received by [staff name].
The CT scan could not be scheduled due to the order not being signed by the CNP or a physician.
Review of a nurses' note dated [DATE] at 6:03 P.M. and authored by LPN #204 revealed FM #200 was in
that day to follow up on request for Resident #118's CT scan and was told staff would follow up with her in
the morning about appointment.
Review of a facsimile transmission revealed the order dated [DATE] for Resident #118's CT scan was faxed
to [hospital name] on [DATE] at 6:00 P.M.
(continued on next page)
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
365432
If continuation sheet
Page 3 of 6
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
365432
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
11/13/2023
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Diplomat Healthcare
9001 W 130th St
North Royalton, 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
Review of a progress note dated [DATE] at 10:59 A.M. and authored by Licensed Social Worker (LSW)
#210 revealed Resident #118 was admitted to [company name] hospice as of [DATE].
Review of a nurses' note dated [DATE] at 11:02 A.M. also recorded as a late entry written on [DATE] at
11:02 A.M. and authored by LPN #204 revealed FM #200 called regarding Resident #118's CT scan for
[DATE] which was rescheduled for [DATE] and stated that because Resident #118 was on hospice she no
longer wanted him to go out for CT scan.
Interview on [DATE] at 12:21 P.M. with FM #200 revealed an order was written for the CT scan on [DATE]
but the hospital did not get the order that day.
Interview on [DATE] starting at 10:09 A.M. with LPN/Assistant Director of Nursing (ADON) #206 and
LPN/ADON #207 revealed the order dated [DATE] was the only order for Resident #118's CT scan.
LPN/ADON #206 was asked who faxed the order to the hospital on [DATE] and LPN/ADON #206 stated
she did not know as they did not write a progress note and should have. LPN/ADON #206 stated CNP #203
had text-messaged her that the order with signature had been faxed but she could not find the text
message during the interview.
Interview on [DATE] at 11:22 A.M. with CNP #203 revealed her last day rounding at the facility was [DATE].
On [DATE] during the evening CNP #203 stated she was made aware of FM #200's request for Resident
#118 to have a CT scan so she told them she would have to fax the order as she was not in the facility.
CNP #203 stated she e-mailed LPN/ADON #206 on [DATE] at 7:14 A.M. with the completed signed
telephone order for Resident #118's CT scan. CNP #203 could not speak to anything that may have
transpired after this point as she did not work for that company anymore and no longer provided services to
the facility.
Review of an e-mail dated [DATE] at 7:14 A.M. from CNP #203 to LPN/ADON #206 titled Resident #118 CT
order included an attachment also dated [DATE].
Follow up interview on [DATE] at 1:48 P.M. with LPN/ADON #206 verified the e-mail from [DATE] that was
provided was hers and the attachment included the signed order for Resident #118's CT scan which was
the same document included in the resident's paper chart also dated and signed [DATE]. LPN/ADON #206
stated she took the order upstairs for them (staff not specified) to fax to the hospital. During the interview
LPN/ADON #206 was informed the signed order was delayed being faxed and there was no documented
evidence of any other attempts to schedule Resident #118's CT scan in a timely manner. LPN/ADON #206
indicated she did not send Resident #118's CT order herself at the time of receipt as she was drowning in
other work.
This deficiency represents non-compliance investigated under Complaint Number OH00146883.
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
365432
If continuation sheet
Page 4 of 6
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
365432
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
11/13/2023
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Diplomat Healthcare
9001 W 130th St
North Royalton, 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 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, interviews, and policy review, the facility failed to ensure proper wound treatment and
pressure relieving interventions were implemented timely for Resident #18's unstageable pressure ulcer.
This affected one (Resident #118) out of three residents reviewed for pressure ulcers. The facility census
was 117.
Residents Affected - Few
Findings include:
Review of the medical record revealed Resident #118 was admitted on [DATE] with diagnoses including
dementia, diabetes mellitus and hypertension.
Review of the admission Observation dated 09/05/23 at 3:26 P.M. revealed Resident #118 had no
alterations in skin. He was at mild risk for skin impairment. There were no interventions implemented to
assist in preventing skin breakdown.
Review of the physician's orders for Resident #118 revealed an order dated 09/05/23 to cleanse his left
heel wound with normal saline, pat dry, pad and protect with an abdominal (ABD) pad and Kerlix three
times a week. This order was discontinued on 09/07/23.
Review of Resident #118's baseline care plan dated 09/05/23 revealed that the resident would be provided
skin care to prevent skin breakdown. He also had a care plan related to having a pressure injury dated
09/05/23 that was related to diabetes mellitus and dementia. The goal was not to have Resident #118's
pressure ulcer increase in size or have it exhibit signs of infection. Interventions listed were to keep him
clean and dry as possible to minimize skin exposure to moisture, provide incontinence care after each
incontinent episode and to use moisture barrier products to perineal area. The care plan did not state
where the pressure ulcer was located on Resident #118's body or have specific interventions to prevent
further breakdown to the left heel.
Review of Resident #118's State Tested Nurse Aide (STNA) Point of Care documentation revealed turning
and repositioning was performed on 09/05/23 and 09/22/23. The moisture barrier lotion was only applied on
09/05/23, 09/06/23 and 09/22/23.
Review of the Wound Management Detail Report created date of 09/07/23 at 11:40 A.M. revealed Licensed
Practical Nurse (LPN) #206 identified a pressure ulcer to the left heel of Resident #118 on 09/05/23 at 3:40
P.M. The description of the left heel stated the wound was 4.1 centimeters (cm) in length by 4.3 cm in width
and a depth that could not be measured. There was moderate serous (clear, amber, thin and watery)
drainage. LPN #206 staged the wound at an unstageable wound with 40% granulation tissue (new vascular
tissue) and 15% eschar (dead tissue). In the comments section LPN #206 stated Resident #118 was
admitted with the wound to his left medial heel, no orders were obtained from admission paperwork, a pad
and protect dressing was placed and the resident would be evaluated by the wound care nurse practitioner
that week.
Review of Resident #118's Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed his cognition
was severely impaired. He needed extensive assistance of two staff members for bed mobility, transfers and
toileting. He had an unstageable pressure ulcer that was present on admission and interventions listed
were application of dressings to the feet and a pressure reducing device for the bed.
(continued on next page)
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
365432
If continuation sheet
Page 5 of 6
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
365432
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
11/13/2023
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Diplomat Healthcare
9001 W 130th St
North Royalton, 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 0686
Level of Harm - Minimal harm
or potential for actual harm
Residents Affected - Few
Interview on 11/13/23 at 10:09 A.M. with LPN #206 verified the documentation under the Wound
Management Detail report dated for 09/05/23 at 3:40 P.M. revealed Resident #118 had an unstageable
pressure ulcer to his left heel. She verified the order she had placed in for Resident #118 was a pad and
protect to the area and not a treatment to the unstageable pressure ulcer. She stated there was an error in
the charting as she had copied the assessment from 09/07/23 to 09/05/23. She stated the wound was an
open blister that was not draining so she had placed a pad and protect order to Resident #118's left heel
until the physician could assess it on 09/07/23. She verified this assessment was not in the medical record
and that it was recorded as an unstageable pressure ulcer with serous drainage and eschar.
Interview on 11/13/23 at 12:15 P.M. with the Director of Nursing (DON) revealed when new interventions
are implemented, staff sign an in-service sheet. She provided an in-service sheet dated 09/05/23 for
Resident #118 that stated to offload bilateral heels on pillows while in bed as tolerated and to reposition
every two hours as tolerated. She verified this was signed by the facility staff and was not signed by any
agency staff that had worked. She also verified these interventions were not recorded in Resident #118's
medical record for staff to see or document as being performed. DON stated that the in-service sheets are
hung on the bulletin board at the nurse's station for staff to see during their shifts. She could not verify if
Resident #118's in-service sheet had hung at the nurse's station during his stay.
Interview on 11/13/23 at 1:37 P.M. with Registered Nurse (RN) #211 revealed she had worked at the facility
for three years. She verified pressure relieving interventions were placed in the computer system and she
would then see the orders and sign off that they were in place.
Interview on 11/13/23 at 1:40 P.M. with RN #202 revealed she had worked at the facility for three years. She
verified pressure relieving interventions would be in the physician's orders and she would sign off that they
were completed and in place. She stated facility management staff do in-services with papers and have
them sign, however, she has never seen those in-services hung on the bulletin boards.
Interview on 11/13/23 at 1:43 P.M. with STNA #213 revealed she had worked at the facility for over a year.
She stated facility management would come to her with in-service sheets educating her on new
interventions to assist in relieving pressure for residents. She verified she had never seen interventions
hung on the bulletin board at the nurse's station. She also stated in her documentation system, Point of
Care, interventions would be listed for her to know what needed to be done including turning and
repositioning a resident.
Review of the facility policy titled, Pressure Injury Prevention and Treatment Policy, dated 07/17/23 and last
revised on 09/18/23, revealed residents admitted with existing pressure injuries would receive necessary
treatment and services consistent with professional standards of practice, to promote healing and prevent
infection. Pressure injuries identified would be documented and orders obtained from providers for
treatment.
This deficiency represents non-compliance investigated under Complaint Number OH00146883.
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
365432
If continuation sheet
Page 6 of 6
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Back to topCitations
3 citations recorded*CMS
What do CMS severity letters mean?
Serious (G-L). Actual harm to a resident, or immediate jeopardy. Codes G through I indicate actual harm; J through L indicate immediate jeopardy to resident health or safety.
General (A-F). No actual harm found, or harm that is minimal. The facility must still submit a Plan of Correction. Most CMS citations land here.
Each letter combines severity with scope: how many residents the deficiency affected.
F657 - Comprehensive Care Plans
Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.
F684 - Quality of care
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
F686 - Skin Integrity
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
FAQ · About this visit
Common questions about this visit
What happened during the November 13, 2023 survey of DIPLOMAT HEALTHCARE?
This was a inspection survey of DIPLOMAT HEALTHCARE on November 13, 2023. The surveyor cited 3 deficiencies, recorded on the federal Form 2567 statement of deficiencies.
Were any deficiencies cited at DIPLOMAT HEALTHCARE on November 13, 2023?
Yes, 3 deficiencies were cited, each with a CMS Scope and Severity grade. The first was: "Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a t..."
What type of survey was this?
This was a inspection survey conducted by state surveyors under federal Centers for Medicare & Medicaid Services (CMS) oversight. Findings are published on CMS Care Compare.
SourceView on CMS Care Compare
Next steps
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