Health inspection·June 10, 2025

F 0607 Develop and implement policies and procedures to prevent abuse, neglect, and theft. Level of Harm - Potential for minimal harm Based on record review, facility policy review and interview, the facility failed to maintain written evidence a background check was completed as required for the Interim Director of Nursing (IDON) at the time of hire. This had the potential to affect all 31 residents residing in the facility. Residents Affected - Many Findings Include: Review of IDON #320's employee file revealed a hire date of 03/25/25. Review of the employee's personnel file revealed no written evidence a background check was completed at the time of hire. Interview on 06/09/25 at 11:39 A.M. with Administrator revealed IDON #320 started as the interim director of nursing on 03/25/25 and it was unknown when her background check was completed (it was to be completed on hire). The Administrator revealed there had been a transition of human resource (HR) director and they realized there was no copy of the IDON's background check. The Administrator stated she asked the IDON if she completed the background check and she stated she did and that she would get a copy of it. However, no copy was provided. The facility followed-up with the agency who completed their background checks and determined a new background check would be obtained on 06/06/25. The Administrator revealed the Nurse Aide Registry was verified for the IDON at the time of hire as well as verification the employee had an active/valid nursing license. Interview on 06/10/25 at 9:05 A.M. with Human Resource (HR) #310 revealed she had been in the HR position since March 2025 and was in training when IDON #320 was hired. She stated at the end of May 2025 she realized the facility had not received IDON #320's background check and asked IDON #320 if she had gone to get it completed. IDON #320 reported she needed to go pick it up. HR #310 stated she told IDON #320 the background checks were sent directly to facility and felt that something was wrong after the IDON reported she needed to go pick it up. HR #310 revealed she reported this concern to the Administrator. Review of the facility Abuse, Neglect and Exploitation Policy dated 2025 revealed potential employees would be screened for a history of abuse, neglect, exploitation, or misappropriation of resident property. Background, reference, and credentials' checks shall be conducted on potential employees, contracted temporary staff, students affiliated with academic institutions, volunteers, and consultants. The facility would maintain documentation of proof that the screening occurred. Review of the facility Background Investigation dated 2024 revealed job reference checks, drug screenings, licensure verifications and criminal conviction record checks were conducted on all personnel making application for employment with the company. Page 1 of 2 365452 365452 06/10/2025 Pearlview Rehab & Wellness Ctr 4426 Homestead Dr Brunswick, OH 44212

F 0851 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Many Electronically submit to CMS complete and accurate direct care staffing information, based on payroll and other verifiable and auditable data. Based on review of the Centers for Medicare and Medicaid (CMS) Payroll Based Journal (PBJ) report, review of staff schedules and interview, the facility failed to ensure accurate staffing data was reported to CMS. This had the potential to affect all 31 residents residing in the facility. Findings Included: Review of the CMS PBJ report from 01/01/25 through 03/31/25 revealed the facility triggered for excessively low weekend staffing. Interview on 06/10/25 at 9:28 A.M. with the Administrator revealed Certified Nurse Assistant (CNA)/Activities #315 worked on the floor providing direct (resident) care on 01/18/25 but believed her hours were not coded correctly on the staffing data submitted to CMS, therefore the facility staffing was not reported accurately. The Administrator revealed the facility tried to staff two nurses and two CNAs on every shift unless someone called off and this could possibly explain why the PBJ showed low weekend staffing during the above time period. The Administrator revealed on the weekend of 01/18/25 and 01/19/25 there was only one CNA on night shift with two nurses. The Administrator revealed on 01/18/25 and 01/19/25 there was only one CNA working on night shift, but the average direct care was over 2.5 and there were no concerns identified from the provider. Review of the facility staffing from 01/17/25 through 01/19/25 revealed on 01/18/25 there were two nurses and one CNA working on night shift. The daily direct care was calculated to be 2.86 hours and was lower than the weekdays average daily direct care of 3.4 hours Review of the staffing schedule from 01/17/25 through 01/19/25 revealed CNA #315 worked eight hours on these dates. 365452 Page 2 of 2