Inspection·October 5, 2023

F 0580 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview the facility failed to ensure the physician was notified of an elevated lab value for Resident #5. This affected one resident (#5) of three residents reviewed for infections. The facility census was 69. Findings include: Review of the medical record for Resident #5 revealed an admission date of 6/22/2023. Diagnoses included displaced fracture of cervical vertebra, displaced fracture of clavicle, and osteoarthritis. The resident was discharged to the hospital on [DATE]. Review of the Medicare-5 Day Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #5 had severely impaired cognition. The resident required the extensive assistance of two staff for bed mobility, transfers, walking, dressing, and toilet use. Review of physician orders for August 2023 identified orders for a complete blood count (CBC) and basic metabolic panel (BMP) every Friday starting 07/07/23. A Urinalysis (UA) and Culture and Sensitivity (C&S) were ordered on 08/17/23. Review of lab results from 08/04/23 revealed Resident #5's white blood cell count was 11.0 (normal range is 4.0 to 11.0), on 08/11/23 the resident's white blood cell count was 11.3, and on 08/18/23 the resident's white blood cell count had more than tripled to 34.4, indicating the resident had an infection. Review of the nurses' notes dated 08/18/23 at 10:04 A.M. through 08/21/23 at 10:12 A.M. revealed no documented evidence the physician was notified of Resident #5's elevated white blood cell count from 08/18/23. Interview on 10/05/23 at 3:43 P.M. with the Director of Nursing (DON) verified the lack of documented evidence regarding physician notification of the elevated white blood cell count from 08/18/23. This deficiency represents non-compliance investigated under Complaint Number OH00146849. 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: 365487 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 365487 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/05/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Mount Saint Joseph Rehab Center 21800 Chardon Road Euclid, OH 44117 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)