Health inspection·July 22, 2021

F 0646 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Notify the appropriate authorities when residents with MD or ID services has a significant change in condition. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical records review, facility policy review and staff interview, revealed the facility failed to ensure the Preadmission Screening and Resident Review (PASARR) was current and up to date. This affected two (#28 and #54) of two residents reviewed for PASARR. The facility census was 75. Findings include: 1. Review of medical record for Resident #28 revealed an admission date of 01/29/21. Diagnoses included paranoid schizophrenia, insomnia, major depressive disorder, schizoaffective disorder, generalized anxiety disorder, and schizophrenia unspecified. Review of Resident #28's quarterly Minimum Data Set (MDS) assessment dated [DATE], revealed Resident #28 was cognitively intact. Resident #28 was independent with bed mobility, transfers, eating and toileting. She required extensive assistance with one person assist with dressing, supervision with set up assistance for personal hygiene and was total dependent for bating. Review of the PASARR dated 01/29/21 revealed a check mark denoted the resident had a serious mental disorder of schizophrenia and delusional disorder. Review of monthly physician orders dated July 2021 revealed the resident had been diagnosed with insomnia, major depressive disorder, and generalized anxiety disorder on 03/02/21. 2. Review of medical record for Resident #54 revealed an admission date of 06/24/19. Diagnoses included unspecified dementia with behavioral disturbances, dementia in other diseases classified with behavioral disturbances, unspecified mental disorder due to known physiological condition, delusional disorder, hallucinations, altered mental status, major depressive disorder, and Parkinson's disease. Review of Resident #54's quarterly MDS assessment dated [DATE] revealed Resident #54 was cognitively impaired. Resident #54 required extensive assistance with two-person assist with bed mobility, dressing, toileting, and personal hygiene. She was total dependent with one person assist with transfers, eating and bathing. Review of the PASARR dated 06/23/19 revealed a check mark denoted the resident had a diagnosis of dementia. Review of the physician orders for 07/2021 revealed the resident had been diagnosed with delusional (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 5 Event ID: 365645 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 365645 B. Wing A. Building (X3) DATE SURVEY COMPLETED 07/22/2021 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Northridge Health Center, The 35990 Westminster Ave North Ridgeville, OH 44039 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)