Inspection visit
Health inspection
9 citations recorded
Inspector’s narrative
What the inspector wrote
This survey cited 9 deficiencies. The full statement and the facility’s plan of correction follow, verbatim from the federal record.
F 0552
Ensure that residents are fully informed and understand their health status, care and treatments.
Level of Harm - Minimal harm
or potential for actual harm
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on
medical record review, resident interviews and staff interviews, the facility failed to ensure 22 residents
(Residents #2, #3, #5, #6, #7, #8, #11, #12, #13, #15, #17, #19, #23, #29, #30, #31, #34, #37, #38, #39,
#43 and #45) were informed, in advance, of proposed treatment and provided the option to choose or
decline. The facility census was 48.
Residents Affected - Some
Findings include:
Interview with Resident #17 occurred on 12/27/19 at 2:14 P.M. Resident #17 identified on 12/12/19 a
unknown male came into her room told her he was getting her free diabetic shoes and custom molded
inserts. Resident #17 revealed, the man then measured her feet and took pictures of them. Resident #17
confirmed she was never asked, prior to this person's arrival if she wished to obtain this service. The
interview identified her roommate, Resident #8, whom can not provide any consent, was also measured for
these shoes.
Interview with the facility Administrator on 12/27/19 at 2:46 P.M. was completed. The interview confirmed
the facility could provide no evidence each of the 22 residents (Residents #2, #3, #5, #6, #7, #8, #11, #12,
#13, #15, #17, #19, #23, #29, #30, #31, #34, #37, #38, #39, #43 and #45) whom were measured for
diabetic shoes and or inserts on 12/12/19, were provided information regarding the proposed treatment to
make an informed decision.
Interview with Social Services Director (SSD) #73 was conducted on 12/27/19 at 3:04 P.M. SSD #73
provided a listing of 22 residents (Residents #2, #3, #5, #6, #7, #8, #11, #12, #13, #15, #17, #19, #23, #29,
#30, #31, #34, #37, #38, #39, #43 and #45) whom were listed as having a medical diagnosis of diabetes.
The form identified the above patients are not Medicare Part A (skilled) or Hospice, unless otherwise noted,
was used by the company to measure residents feet for the shoes. The interview confirmed a person from
an outside company came to the facility on [DATE] and measured each of the 22 residents feet and took
photographs. The interview confirmed there was no evidence any of the residents and/ or their families
were asked prior to this occurring.
Review of the listing of the 22 residents included Resident #12, whom was bed-bound and receiving
hospice services. Resident #37 was additionally identified as receiving hospice services, for end of life care.
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 10
Event ID:
365452
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
365452
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
12/28/2019
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Pearlview Rehab & Wellness Ctr
4426 Homestead Dr
Brunswick, OH 44212
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
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, family and staff interviews, the facility failed to ensure one (Resident #25)
of 16 sampled residents/families were invited to participate, on at least a quarterly basis, to plan their care
meeting. The facility census was 48.
Findings include:
Review of Resident #25's medical record identified admission occurred 01/19/19 with medical diagnosis
including dementia, repeated falls and colon cancer. The record identified an initial care planning
conference occurred on 01/25/19, which included Resident #25's family. The record lacked any evidence of
additional care planning meetings in which the family/resident was invited to participate. The record
identified a significant change in condition assessment was completed on 11/13/19 (due to initiation of
hospice), a quarterly assessment was completed on 10/28/19 and 07/20/19. The facility was noted to
conducted the meetings without family participation.
Interview with Resident #25's daughter occurred on 12/27/19 at 1:45 P.M. The interview identified the family
had not been invited to participate in any care plan meetings since Resident #25's admission to the facility.
The interview confirmed they would like to be able to attend the meetings regarding their father's care. The
interview revealed the family had concerns regarding lack of showers and lack of daily shaving, which
would be Resident #25's normal wishes prior to coming to the facility.
Interview with Licensed Practical Nurse (LPN)/ Minimum Data Set (MDS) Coordinator #61 occurred on
12/27/19 at 9:05 A.M. He stated he is the person whom sets the schedules for the care plan meetings and
provides the list to Receptionist #122. LPN #61 identified he thinks Receptionist #122 is the person who is
inviting families/residents. He stated the meetings are set up at the times of the MDS assessments, at least
quarterly and with significant changes in condition. The interview identified Receptionist #122 was currently
on vacation and could not locate any evidence of invitations to care planning meetings investigations.
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
365452
If continuation sheet
Page 2 of 10
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
365452
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
12/28/2019
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Pearlview Rehab & Wellness Ctr
4426 Homestead Dr
Brunswick, OH 44212
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 0677
Provide care and assistance to perform activities of daily living for any resident who is unable.
Level of Harm - Minimal harm
or potential for actual harm
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on
observations, medical record review, family and staff interviews, the facility failed to provide one (Resident
#25) of two residents, whom was dependent, with daily shaving. The facility census was 48.
Residents Affected - Few
Findings include:
Review of Resident #25's medical record identified admission occurred 01/19/19 with medical diagnoses
including dementia, repeated falls, colon cancer and anemia. Review of the most recent Minimum Data Set
(MDS) 3.0 assessment dated [DATE] revealed Resident #25 required extensive assistance of one staff with
all activities of daily living (ADL). Review of Resident #25's written plan of care identified he was unable to
perform his ADL. The written plan did not evidence the residents preferences to be shaved daily. The plan
did not address what the staff should do if the resident refused showers and or shaving.
Interview with Resident #25's daughter occurred on 12/27/19 at 1:45 P.M. The interview identified the family
had come in several times to visit, and the resident had not been showered or shaved. The interview
confirmed Resident #25 always shaved daily throughout his life and that would be his preference.
Observation of Resident #25 occurred on 12/26/19 at 11:48 A.M. Resident #25 was noted to have
approximately one inch to one and a half inches of facial hair. Resident #25 was unable to identify if he
wished to be shaved daily and/ or the last time he received a shave.
Observation of Resident #25 occurred on 12/27/19 at 7:24 A.M. and 9:18 A.M. Resident #25 remained
unshaved.
Interview with State Tested Nursing Assistant (STNA) #101 was completed on 12/27/19 at 11:28 A.M. The
interview confirmed Resident #25 most recent shower was completed on 12/18/19. The interview confirmed
he was listed as refusing showers on 12/21/19 and 12/25/19, and she was unsure of the last time he had
been shaved.
Interview with STNA #33 was conducted on 12/27/19 at 2:13 P.M. The interview confirmed she did provide
Resident #25 with a shave because she noticed he really needed one, when he came down to the first
floor. STNA #33 confirmed she was not the person whom was taking care of the resident and was in the
building for administrative duties today.
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
365452
If continuation sheet
Page 3 of 10
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
365452
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
12/28/2019
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Pearlview Rehab & Wellness Ctr
4426 Homestead Dr
Brunswick, OH 44212
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 0679
Provide activities to meet all resident's needs.
Level of Harm - Minimal harm
or potential for actual harm
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on
observation, interview and record review, the facility failed to ensure Resident #46 received activities to
meet his current and past interests. This affected one resident (Resident #46) of one resident reviewed for
activities.
Residents Affected - Few
Findings include:
Resident #46 was admitted on [DATE] and readmitted on [DATE] with diagnoses including major depressive
disorder, dementia and Alzheimer's Disease. Resident #46's quarterly Minimum Data Set (MDS) 3.0
assessment dated [DATE] revealed his cognition was severely impaired, was totally dependent on staff for
transfers and required extensive assistance with locomotion.
Resident #46's Activity assessment dated [DATE] revealed the resident was a former railroad engineer and
was active in his Catholic religion.
Resident #46's active comprehensive care plan revealed a focus for alteration in supervised/organized
recreation characterized by little or no involvement, and lack of attendance related to preference for
independent self-directed activities. Intervention to address this focus included but were not limited to
activities will provide the resident with low functioning activities to ensure achievement of maximum
therapeutic benefits from activities.
Review of Resident #46's Monthly Activity Participation Record for November 2019 and December 2019,
revealed no evidence the resident participated in religious services or activity related to railroads. Review of
his one on one (1:1) program documentation revealed he had one 1:1 activity in November 2019 and one in
December 2019. Resident did receive one Catholic service on 11/14/19, but this was through hospice
services.
Observations on 12/26/19 at 10:15 A.M., 12/27/19 at 9:35 A.M. and 1:16 P.M. revealed the resident was
sitting in the common area watching television.
Interview on 12/27/19 at 1:20 P.M. with Activities Director (AD) #58 revealed she meets with Resident #46
daily for about ten minutes, but does not record this activity on his participation log. AD #58 revealed she
was unaware the resident was a railroad engineer, therefore there was no evidence the resident
participated in railroad related activities. AD #58 confirmed there was no evidence the resident participated
in religious services. AD #58 revealed Resident #46 observed group activities often, and the resident was
required two 1:1 activities a month. AD #58 confirmed there was evidence he only received one 1:1 activity
in November and December 2019.
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
365452
If continuation sheet
Page 4 of 10
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
365452
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
12/28/2019
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Pearlview Rehab & Wellness Ctr
4426 Homestead Dr
Brunswick, OH 44212
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 0725
Level of Harm - Minimal harm
or potential for actual harm
Residents Affected - Some
Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in
charge on each shift.
Based on observations, medical record reviews, resident and staff interviews, the facility failed to ensure
adequate staffing was available to ensure eight residents (Residents #3, #14, #17, #21, #22, #28, #36 and
#46) of 48 residents received medications timely on 12/26/19. The facility census was 48.
Findings include:
Review of Resident #17's medical record identified admission to the facility occurred on 06/05/17, with
medical diagnoses including paraplegia, chronic kidney disease, borderline personality, post-traumatic
stress disorder (PTSD), Lupus, neurogenic bladder, anemia, anxiety, diabetes mellitus and morbid obesity.
The record revealed Resident #17 was cognitively intact and able to make her needs know.
Interview with Resident #17 occurred on 12/26/19 at 9:42 A.M. and revealed she believed there was not
enough staff working in the facility. The resident stated at times she had a difficult time being put to bed
when she wanted to be. The resident additionally identified her medications, scheduled for 8:00 A.M. this
morning, had not been administered, including her insulin.
Observation of Registered Nurse (RN) #118 was completed on 12/26/19 at 10:03 A.M. RN #118 confirmed
she was still in the process of passing morning medications, including Resident #17's. The interview
identified a nurse called off this morning and she was called in to replace that person. RN #118 identified
she had eight residents (Resident #3, #14, #17, #21, #22, #28, #36 and #46) medications still to administer
all whom resided on the second floor east side of the building. RN #118 confirmed she typically worked on
the evening shift and was called into to work following the nurse calling off.
Review of a nursing call off form dated 12/25/19 at 8:00 P.M. identified the nurse for 2 East unit called off for
her 6:30 A.M. to 6:30 P.M. shift for 12/26/19.
Review of the time card for RN #118, whom replaced the nurse whom called off, revealed she arrived at the
facility at 9:30 A.M.
Interview on 12/28/19 at 11:55 A.M. with the Director of Nursing (DON) revealed she was unaware the
nurse called off on 12/25/19 until 12/26/19 at 8:10 A.M. The DON revealed it was a communication issue as
the nurse downstairs started medication pass downstairs, rather than going upstairs to give insulin to the
residents upstairs. The interview confirmed there were eight residents at 10:03 A.M. who had not received
medications, including three residents (Resident #17, #21 and #28) who had insulin orders to be given with
meals. The DON verified medications should be given within one hour of the ordered time.
This deficiency substantiates Complaint Number OH00109011.
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
365452
If continuation sheet
Page 5 of 10
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
365452
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
12/28/2019
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Pearlview Rehab & Wellness Ctr
4426 Homestead Dr
Brunswick, OH 44212
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 0755
Level of Harm - Minimal harm
or potential for actual harm
Residents Affected - Few
Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a
licensed pharmacist.
Based on medication administration observation, medical record review, review of manufacture's
recommendations and staff interviews, the facility failed to ensure insulin pens were properly utilized to
ensure adequate dosing. This affected Resident #38 and had the potential to affect 11 additional residents
(Resident #4, #13, #16, #17, #21, #22, #23, #24, #26, #28 and #45) identified as utilizing insulin pens. The
facility census was 48.
Findings include:
Medication administration observation occurred with Registered Nurse (RN) #110 on 12/27/19 at 7:30 A.M.
RN #110 prepared medications for Resident #38, which included a Lispro insulin pen and Flovent inhaler
(corticosteriod). RN #110 was unable to locate the Lispro insulin pen for Resident #38 and obtained a new
one. She set the dial to four units of Lispro insulin and administered the medication to Resident #38. RN
#110 did not prime the insulin pen prior to setting and/or giving the dose of insulin to the resident.
Review of Resident #38's medical record revealed admission to the facility occurred on 11/26/14 with
medical diagnoses including diabetes and chronic respiratory failure. The record revealed on 12/26/19 the
physician's orders included Lispro insulin four units subcutaneously (sq) with the Kwikpen (pre-filled
syringe).
Interview with RN #110 on 12/27/19 at 7:53 A.M., following the administration, verified at no time did she
prime the insulin pen, and she was unaware of the need to do this with all insulin pens.
Review of the manufactures instructions recommended priming the insulin pen before each injection.
Priming means removing the air from the needle and cartridge that may collect during normal use. It is
important to prime your pen before each injection so that it will work correctly. If you do not prime before
each injection, you may get too much or too little insulin.
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
365452
If continuation sheet
Page 6 of 10
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
365452
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
12/28/2019
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Pearlview Rehab & Wellness Ctr
4426 Homestead Dr
Brunswick, OH 44212
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
Ensure medication error rates are not 5 percent or greater.
Level of Harm - Minimal harm
or potential for actual harm
Based on observation, medical record review, review of manufacturer's recommendations and staff
interviews, the facility failed to ensure one (Resident #38) of three sampled residents received medications
as ordered by the physician. Medication administration observation identified two of 27 medications were
not administered in accordance with physician's orders, resulting in a medication error rate of 7.4%. This
had the potential to affect all 48 residents residing in the facility.
Residents Affected - Few
Findings include:
Medication administration was observed with Registered Nurse (RN) #110 on 12/27/19 at 7:30 A.M. RN
#110 prepared medications for Resident #38 which included a Lispro insulin pen and Flovent inhaler
(corticosteriod). RN #110 administered two puffs of the Flovent inhaler for Resident #38. RN #110 also
administered four units of Lispro insulin subcutaneously (sq).
Review of Resident #38's medical record revealed admission to the facility occurred on 11/26/14 with
medical diagnoses including diabetes and chronic respiratory failure. The record revealed on 12/26/19 the
physician's orders included the Flovent 220 micrograms (mcg) one puff two times a day and Lispro insulin
four units sq three times daily .
Interview with RN #110 on 12/27/19 at 7:53 A.M., following the observation, confirmed at no time did she
prime the insulin pen, and she was unaware of the need to do so with all insulin pens. She also verified she
gave Resident #38 two puffs of the Flovent inhaler, and the current physician's order was to administer one
puff.
Review of the manufactures instructions recommended priming the insulin pen before each injection.
Priming means removing the air from the needle and cartridge that may collect during normal use. It is
important to prime your pen before each injection so that it will work correctly. If you do not prime before
each injection, you may get too much or too little insulin.
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
365452
If continuation sheet
Page 7 of 10
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
365452
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
12/28/2019
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Pearlview Rehab & Wellness Ctr
4426 Homestead Dr
Brunswick, OH 44212
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 0760
Ensure that residents are free from significant medication errors.
Level of Harm - Minimal harm
or potential for actual harm
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 3. Resident
#21 was admitted on [DATE] with diagnoses including type one diabetes mellitus, history of diabetic foot
ulcer, morbid obesity, hyperlipidemia, lymphedema, hypothyroidism, abnormal glucose, venous
insufficiency, hypertension, cellulitis of right lower limb, and chronic embolism and thrombosis of deep veins
of unspecified lower extremity. Resident #21 was followed by endocrinology for blood glucose control.
Residents Affected - Some
Resident #21's physician's order dated 09/25/19 revealed she was ordered insulin regular human (conc)
solution, 500 unit per milliliter, inject 145 units subcutaneously one time a day at 8:00 A.M. and inject 65
units subcutaneously one time a day at 11:30 A.M. for type one diabetes mellitus with hyperglycemia.
Review of Resident #21's physician's order dated 12/26/19 revealed per certified nurse practitioner, may
administer morning medications late, one time order on this date.
Interview on 12/28/19 at 12:00 P.M. with Director of Nursing (DON) revealed although Resident #21's
insulin was administered late, Resident #21 did not have any ill effect as a result of late medication.
This deficiency substantiates Complaint Number OH00109011.
Based on observation, medical record review, resident and staff interviews, the facility failed to ensure
insulin was administered according to physician's orders. The affected three residents (Residents #17, #21
and #28) of three residents observed for medication administration. The facility census was 48.
Findings include:
1. Review of Resident #28's medical record identified admission to the facility occurred on 10/30/15 with
medical diagnoses including mild cognitive impairment, panic disorder, bipolar disorder, Hepatitis C and
diabetes. The record revealed physician's orders for December 2019 included Levemir insulin 10 units in
the morning and Novolog insulin 13 units with meals.
2. Review of Resident #17's medical record identified admission to the facility occurred on 06/05/17 with
medical diagnoses including paraplegia, chronic kidney disease, borderline personality, post-traumatic
stress disorder (PTSD), Lupus, neurogenic bladder, anemia, anxiety, diabetes mellitus and morbid obesity.
The record revealed Resident #17 was cognitively intact and able to make her needs know.
Interview with Resident #17 occurred on 12/26/19 at 9:42 A.M. and identified she believed there was not
enough staff working in the facility. The resident stated at times she had a difficult time being put to bed
when she wanted to be. The resident additionally stated her medications, scheduled for 8:00 A.M. this
morning, had not been administered, including her insulin.
Observation of Registered Nurse (RN) #118 was completed on 12/26/19 at 10:03 A.M. RN#118 verified she
was still in the process of passing morning medications, including medications for Residents #17, #21 and
#28. She stated a nurse called off this morning and she was called in to replace that person. RN #118
stated she had eight resident's medications left to administer all whom resided on the
(continued on next page)
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
365452
If continuation sheet
Page 8 of 10
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
365452
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
12/28/2019
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Pearlview Rehab & Wellness Ctr
4426 Homestead Dr
Brunswick, OH 44212
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 0760
second floor, east side of the building. RN #118 confirmed Residents #17, #21 and #28 had insulin ordered
which not been administered at the time ordered by the physician.
Level of Harm - Minimal harm
or potential for actual harm
Residents Affected - Some
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
365452
If continuation sheet
Page 9 of 10
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
365452
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
12/28/2019
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Pearlview Rehab & Wellness Ctr
4426 Homestead Dr
Brunswick, OH 44212
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 0803
Level of Harm - Minimal harm
or potential for actual harm
Residents Affected - Few
Ensure menus must meet the nutritional needs of residents, be prepared in advance, be followed, be
updated, be reviewed by dietician, and meet the needs of the resident.
Based on observation, interview and record review, the facility failed to ensure Resident #24 was served
the correct portion size of pureed chili. This affected one resident (Resident #24) of one resident observed
to be served a pureed diet, with the potential to affect two residents (Resident #24 and Resident #37) who
were ordered a pureed diet in the facility.
Findings include:
Review of the Menu Extension spreadsheet for lunch on 12/27/19, revealed residents on a pureed diet
should be served pureed chili with a number six scoop.
Review of the Disher Scoop Sizes and Conversions- Chefs Resources form, undated, revealed a number
six scoop was 5.33 ounces and a number eight scoop was 4 ounces.
Observation on 12/27/19 at 12:10 P.M. revealed [NAME] #104 used a number eight scoop to serve pureed
chili to Resident #24. Interview with Dietary Technician #77 at this time confirmed a number eight scoop
was used, and the spreadsheet identified a number six scoop.
Review of the list of resident diets, provided by the facility, revealed Resident #24 and Resident #37 were
ordered a pureed diet.
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
365452
If continuation sheet
Page 10 of 10
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Back to topCitations
9 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.
F552 - Planning and Implementing Care
Ensure that residents are fully informed and understand their health status, care and treatments.
F759 - Medication Errors
Ensure medication error rates are not 5 percent or greater.
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.
F677 - A resident who is unable to carry out activities of daily living receives
Provide care and assistance to perform activities of daily living for any resident who is unable.
F679 - Activities
Provide activities to meet all resident's needs.
F725 - Nursing Services
Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift.
F755 - Pharmacy Services
Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
F760 - Residents are free of any significant medication errors
Ensure that residents are free from significant medication errors.
F803 - Menus and nutritional adequacy
Ensure menus must meet the nutritional needs of residents, be prepared in advance, be followed, be updated, be reviewed by dietician, and meet the needs of the resident.
FAQ · About this visit
Common questions about this visit
What happened during the December 28, 2019 survey of PEARLVIEW REHAB & WELLNESS CTR?
This was a inspection survey of PEARLVIEW REHAB & WELLNESS CTR on December 28, 2019. The surveyor cited 9 deficiencies, recorded on the federal Form 2567 statement of deficiencies.
Were any deficiencies cited at PEARLVIEW REHAB & WELLNESS CTR on December 28, 2019?
Yes, 9 deficiencies were cited, each with a CMS Scope and Severity grade. The first was: "Ensure that residents are fully informed and understand their health status, care and treatments."
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
Concerned about a resident’s care?Find your local ombudsman through the Eldercare Locatoror file a complaint with your state survey agency.
Researching this visit professionally?Book a 15-minute calland we will walk through what we have on file.
Data from CMS Care Compare public records. Dataset last refreshed . If you believe any information is inaccurate, report it here.