Inspection visit
Inspection
13 citations recorded
Inspector’s narrative
What the inspector wrote
This survey cited 13 deficiencies. The full statement and the facility’s plan of correction follow, verbatim from the federal record.
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.
Based on medical record review, staff interviews, and facility policy review, the facility failed to notify
Resident #50's physician and resident representative of significant weight changes. This affected one
(Resident #50) of three residents who were reviewed for nutrition. The facility census was 55.
Findings include:
Review of medical record for Resident #50 revealed an admission date of 12/08/18 with diagnoses
including myelodysplastic syndrome (disorder caused by blood cells that are poorly formed or do not work
properly), unspecified psychosis, major depressive disorder, anxiety disorder, and schizophreniform
disorder (a mental disorder diagnosed when symptoms of schizophrenia are present for a significant
portion of time). Minimum Data Set (MDS) 3.0 annual assessment, dated 10/03/22, revealed moderately
impaired cognition; independent with no staff assistance for set-up for bed mobility, transfers, walk in room
and corridor, locomotion, dressing, toilet use, and personal hygiene; and supervision with staff assistance
for set-up for eating.
Review of Resident #50's physician orders revealed a 10/24/22 diet order of regular diet, regular texture,
regular thin consistency liquids with small portions; Boost pudding (supplement) two times a day; Boost
Breeze (supplement) three times a day; frozen nutrition treat (supplement) daily in the evening; and
Mirtazapine one tablet 7.5 milligrams (mg) by mouth at bedtime for appetite stimulant.
Review of Resident #50 weights revealed weights of 108.6 pounds on 04/01/22, 104.6 pounds on 05/06/22,
105.9 pounds on 06/06/22, 94.6 pounds on 07/14/22, 93.6 pounds on 07/20/22, 93.0 pounds 08/05/22,
84.6 pounds on 09/05/22, 84.0 pounds on 09/22/22, 86.2 pounds on 09/29/22, 87.8 pounds on 10/06/22,
84.0 pounds on 10/11/22, and 86.8 pounds on 10/13/22. Resident #50 experienced a significant weight
loss of 11.3 pounds, 10.6 percent (%), from 06/06/22 to 07/14/22 and a significant weight loss of 8.4
pounds, 9%, from 08/05/22 to 09/5/22.
Review of the 08/28/22 dietary progress notes for Resident #50 revealed the resident had shown a
significant weight loss with the resident consuming 25-50% of most meals documented and Frozen nutrition
treat, Boost Pudding, and Boost Breeze supplementation were in place to promote weight
maintenance/gain. Fair-good intake of supplement per Medication Administration Record (MAR). Resident
ordered Mirtazapine, which could help stimulate appetite. There was no documented evidence the
physician or the resident representative was notified of the significant weight loss.
Interview with Dietitian #53 on 10/27/22 at 12:38 P.M. confirmed Resident #50 had a significant weight loss
from 06/06/22 to 07/14/22 of 10.6% and another significant weight loss of 9% from 08/05/22
(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 19
Event ID:
365713
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
365713
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
11/03/2022
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Embassy of Painesville
70 Normandy Dr
Painesville, OH 44077
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 0580
Level of Harm - Minimal harm
or potential for actual harm
Residents Affected - Few
to 09/05/22. He stated, if the resident representative or physician were notified, it should be documented in
the medical record. He confirmed there was no documented evidence in Resident #50's medical record the
resident representative or physician were notified of the significant weight losses from 06/06/22 to 07/14/22
and 08/05/22 to 09/05/22. He stated he had only been working at this facility since September 2022.
Review of care plan dated 03/09/21 revealed Resident #50 was at risk for alteration in nutrition related to
being underweight, having had significant weight loss, and having inadequate oral intakes. Goal was to
maintain or gain weight until the 106 pounds to 116 pounds range was reached. Interventions included
obtain resident's weight per protocol and report to the dietitian, physician, and family of unplanned and
undesirable weight changes.
Review of progress notes for Resident #50 from 06/01/22 to 10/27/22 revealed there was no documented
evidence the resident representative or the physician were notified of the significant weight losses of 10.6%
from 06/06/22 to 07/14/22 and of 9% from 08/05/22 to 09/05/22.
Interview on 10/31/22 at 12:40 P.M. with Licensed Practical Nurse (LPN) #16 stated the facility should notify
the doctor and resident representative of any resident significant change, and an example of a significant
change would be a significant weight loss.
Review of the facility document titled Interdisciplinary Team Care Conference Summary, dated 09/14/22,
revealed Resident #50 currently weighed 85 pounds and 95 pounds in July 2022. Resident #50's guardian
did not attend, and the facility had left a voice mail message with no indication of what was left on the
voicemail. There was no documented evidence Resident #50's resident representative or doctor were
notified of the weight loss.
Interview with the Administrator on 10/31/22 at 12:15 P.M. confirmed there was no way of knowing if the
guardian was notified of the weight loss from the care conference summary, and there was no documented
evidence the doctor was notified from looking at the care conference summary sheet.
Review of the undated facility policy title Notification of Changes revealed the facility must inform the
resident, consult with the resident's physician and/or notify the resident's family member or legal
representative when there is a change requiring such notification. Circumstances required notification
included significant change in the resident's physical condition.
Review of the facility policy titled Charting and Documentation, with a revised date of July 2017, revealed
changes in a resident's condition shall be documented in the resident medical record which was to include
the notification of family and physician if indicated.
This is a recite to the complaint survey dated 10/06/22.
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
365713
If continuation sheet
Page 2 of 19
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
365713
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
11/03/2022
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Embassy of Painesville
70 Normandy Dr
Painesville, OH 44077
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 0641
Ensure each resident receives an accurate assessment.
Level of Harm - Minimal harm
or potential for actual harm
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on
medical record reviews, interviews, and the Center of Medicaid and Medicare Services Resident
Assessment Instrument version 3.0 manual, the facility failed to accurately code the Minimum Data Set
(MDS) for Resident's #50 and #33. This affected two (Resident's #50 and #33) of twenty-three residents
reviewed for MDS accuracy. The facility census was 55 residents.
Residents Affected - Few
Findings include:
1. Review of medical record for Resident #50 revealed an admission date of 12/08/18 with diagnoses
including myelodysplastic syndrome (disorder caused by blood cells that are poorly formed or do not work
properly), unspecified psychosis, major depressive disorder, anxiety disorder, and schizophreniform
disorder (a mental disorder diagnosed when symptoms of schizophrenia are present for a significant
portion of time). The MDS 3.0 annual assessment dated [DATE] revealed moderately impaired cognition;
independent with no staff assistance for set-up for bed mobility, transfers, walk in room and corridor,
locomotion, dressing, toilet use, and personal hygiene; supervision with staff assistance for set-up for
eating; no significant weight changes; and no therapeutic diet.
Review of Resident #50's physician orders revealed a 10/24/22 diet order of regular diet, regular texture,
regular thin consistency liquids with small portions and supplement orders for Boost pudding two times a
day; Boost Breeze three times a day; and frozen nutrition treat daily in the evening.
Review of Resident #50's medication administration record (MAR) from July 2022 to October 2022 revealed
supplements were substantially given as ordered.
Review of Resident #50 weights revealed weights of 108.6 pounds on 04/01/22, 104.6 pounds on 05/06/22,
105.9 pounds on 06/06/22, 94.6 pounds on 07/14/22, 93.6 pounds on 07/20/22, 93.0 pounds 08/05/22,
84.6 pounds on 09/05/22, 84.0 pounds on 09/22/22, 86.2 pounds on 09/29/22, 87.8 pounds on 10/06/22,
84.0 pounds on 10/11/22, and 86.8 pounds on 10/13/22. Resident #50 experienced a significant weight
loss of 11.3 pounds, 10.6 percent (%), from 06/06/22 to 07/14/22 and a significant weight loss of 8.4
pounds, 9%, from 08/05/22 to 09/5/22.
Review of the 08/28/22 dietary progress note for revealed Resident #50 had shown a significant weight loss
with resident consuming 25-50% of most meals documented and Frozen nutrition treat, Boost Pudding, and
Boost Breeze supplementation were in place to promote weight maintenance/gain. Fair-good intake of
supplement per Medication Administration Record (MAR). Resident #50 was ordered Mirtazapine, which
could help stimulate appetite.
Interview with Dietitian #53 on 10/27/22 at 12:38 P.M. confirmed Resident #50 had a significant weight loss
from 06/06/22 to 07/14/22 of 10.6% and another significant weight loss of 9% from 08/05/22 to 09/05/22
and for the MDS dated [DATE], confirmed both unplanned significant weight loss and therapeutic diet
should have been coded on the 10/03/22 annual MDS 3.0 assessment.
Review of care plan dated 03/09/21 revealed Resident #50 was at risk for alteration in nutrition related to
being underweight, having had significant weight loss, and having inadequate oral intakes. The goal was to
maintain or gain weight until the 106 pounds to 116 pounds range was reached. Interventions included
provide meals based on resident food preferences and provide nutritional supplements as ordered.
(continued on next page)
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
365713
If continuation sheet
Page 3 of 19
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
365713
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
11/03/2022
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Embassy of Painesville
70 Normandy Dr
Painesville, OH 44077
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 0641
Level of Harm - Minimal harm
or potential for actual harm
Residents Affected - Few
Review of the Center for Medicare and Medicaid Services Resident Assessment Instrument version 3.0
manual, dated October 2019, revealed supplements are coded as a therapeutic diet when they are being
administered to manage problematic health conditions, such as malnutrition. If the resident's weight in the
observation period compared to a point closest to thirty days preceding the current weight showed a five
percent or greater weight loss and the weight loss was not planned, it should be coded as an unplanned
significant weight loss.
2. Review of medical record for Resident #33 revealed an admission date of 10/05/20 with diagnoses
including Parkinson's disease, unspecified protein calorie malnutrition, schizoaffective disorder, major
depressive disorder, and chronic obstructive pulmonary disease (lung disease). The MDS 3.0 quarterly
assessment, dated 09/08/22, indicated Resident #33 was not cognitively intact; required total dependence
of two staff for bed mobility, transfers, and toilet use; required total dependence of one staff for locomotion,
dressing, personal hygiene, and bathing; required extensive assistance of one staff member for eating; was
always incontinent of bowel and bladder; was on a mechanically altered diet; and was not on a therapeutic
diet.
Review of Resident #33's physician orders revealed a diet order of puree with nectar thick liquids and
supplement orders for house commercial shake four ounce with meals, house supplement 2.0 in the
afternoon, Boost pudding at bedtime, and frozen nutrition treat with meals.
Interview on 10/26/22 at 3:38 P.M. with Licensed Practical Nurse (LPN) #16 revealed Resident #33
consumed 25-50 percent (%) of her meals and supplements.
Review of the care plan dated 01/06/21 revealed Resident #33 was at risk for altered nutritional status
related to protein calorie malnutrition, mechanically altered diet, significant changes, and need for a
supplement with a goal of not having any significant weight loss. Interventions included provide meals and
nutritional supplements as ordered.
Interview on 10/27/21 at 12:38 P.M. with Dietitian #53 confirmed a therapeutic diet should have been
marked on the MDS 3.0 quarterly assessment dated [DATE] for Resident #33.
Review of the Center for Medicare and Medicaid Services Resident Assessment Instrument version 3.0
manual, dated October 2019, revealed supplements are coded as a therapeutic diet when they are being
administered to manage problematic health conditions, such as malnutrition.
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
365713
If continuation sheet
Page 4 of 19
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
365713
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
11/03/2022
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Embassy of Painesville
70 Normandy Dr
Painesville, OH 44077
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** 2. Review of
the medical record revealed Resident #47 was admitted to the facility on [DATE] with diagnoses including
end stage renal disease dependent on dialysis, high blood pressure, diabetes, depression, and anxiety.
Residents Affected - Few
Review of the physician's orders for Resident #47 revealed no order for dialysis.
Review of the care plans for Resident #47 revealed he attended dialysis on Mondays, Wednesdays, and
Fridays at 5:30 A.M.
Interview with Resident #47 on 10/26/22 at 3:24 P.M. revealed he went to dialysis on Mondays,
Wednesdays, and Fridays.
Interview with the DON on 10/27/22 at 12:07 P.M. revealed Resident #47 attended dialysis every Monday,
Wednesday, and Friday. The DON said she did not know why there was no physician's order for dialysis and
confirmed there was no order after reviewing the resident's chart.
Review of the facility's Dialysis Care policy, last revised January 2016, revealed the medical record will
reflect the physician's specific orders for each individual resident needs for dialysis.
Based on record review, interview, and facility policy review the facility failed to ensure Resident #2 had
physician's orders for a morphine pump, Resident #47 had physician's order for dialysis treatments, and
Resident #52 had physician's order for oxygen treatments. This affected three (Resident's #2, #47, and
#52) of 15 residents reviewed for physician's orders. The facility census was 55.
Findings include:
1. Review of the medical record for Resident #2 revealed admission date of 06/21/22. Diagnoses included
dementia with agitation, anxiety disorder, muscle weakness, and diabetes mellitus.
Review of physician order dated 06/28/22 revealed to monitor pain level at each shift and physicians order
dated 10/25/22 revealed Resident #2 had appointment on 11/01/22 for morphine pump refill. Review of
current physician's orders for 10/31/22 revealed no order for use of morphine pump.
Review of progress notes from June 2022 to October 2022 revealed no documented evidence of a
physician's order for use of morphine pump.
Review of current care plan for October 2022 revealed Resident #2 was at risk for alteration in comfort. The
care plan had no indication of use of morphine pump.
Interview on 10/31/22 at 11:27 A.M. with the Director of Nursing (DON) verified there was no order or care
plan for Resident #2's morphine pump.
Review of the facility policy Charting and Documentation, dated July 2017, revealed all services provided to
the resident shall be documented in the resident's medical record. Documentation should include
medications administered and treatments performed.
3. Review of Resident #52 medical record revealed an admission date of 09/27/22 with diagnoses
(continued on next page)
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
365713
If continuation sheet
Page 5 of 19
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
365713
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
11/03/2022
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Embassy of Painesville
70 Normandy Dr
Painesville, OH 44077
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
including unspecified heart failure, respiratory failure with hypoxia, chronic obstructive pulmonary disease
(COPD), and anxiety disorder. admission Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed
Resident #52 was independent with staff set-up for bed mobility, transfers, walk in room and corridor,
locomotion, dressing, toileting, personal hygiene, and bathing; supervision with staff set up for eating;
always continent of bowel and bladder; and received oxygen while a resident.
Residents Affected - Few
Observation of Resident #52's room on 10/26/22 at 8:01 A.M. revealed a portable oxygen unit with tubing
attached in the room.
Interview on 10/26/22 at 3:38 P.M. with Licensed Practical Nurse (LPN) #16 stated Resident #52 was on
oxygen as needed. She stated the other day, Resident #52 was short of breath during the day and required
oxygen for a half an hour.
Review of the hospital discharge paperwork dated 09/27/22 for Resident #52 revealed no orders for
oxygen.
Review of the current physician orders revealed there was no order for oxygen.
Review of the care plan dated 10/15/22 revealed Resident #52 had a potential for complications related to
COPD and respiratory failure with a goal of will be free of signs and symptoms of respiratory distress.
Interventions included give oxygen as ordered by the physician.
Review of the respiratory progress note dated 10/05/22 revealed a pulmonary assessment was done due to
COPD and respiratory failure, and Resident #52 was on three liters of oxygen at night and two liters of
oxygen during the day.
Review of the respiratory progress note dated 10/24/22 revealed Resident #52 was on four liters of oxygen.
Resident #52 stated when she left her room without oxygen, she had to hurry back when she got winded.
Resident #52 was advised to wear her oxygen.
Interview with the DON on 10/27/22 at 3:25 P.M. confirmed Resident #52 did not have oxygen ordered upon
discharge from hospital and had no order for oxygen until a new order was written on 10/27/22 for oxygen
two to four liters as needed to maintain oxygen saturation levels greater than 90 percent (%).
This is a recite to the complaint survey dated 10/06/22.
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
365713
If continuation sheet
Page 6 of 19
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
365713
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
11/03/2022
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Embassy of Painesville
70 Normandy Dr
Painesville, OH 44077
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 0689
Level of Harm - Minimal harm
or potential for actual harm
Residents Affected - Few
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to
prevent accidents.
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on
record review, observations, staff interviews, and facility policy review, the facility failed to ensure fall
interventions were in place as care planned for Resident #33. This affected one (Resident #33) of five
residents reviewed for falls. The facility census was 55.
Findings include:
Review of the medical record for Resident #33 revealed an admission date of 10/05/20 with diagnoses
including Parkinson's disease, unspecified protein calorie malnutrition, schizoaffective disorder, major
depressive disorder, and chronic obstructive pulmonary disease (COPD). The Minimum Data Set (MDS)
3.0 quarterly assessment dated [DATE] indicated Resident #33 was not cognitively intact; required total
dependence of two staff for bed mobility, transfers, and toilet use; required total dependence of one staff for
locomotion, dressing, personal hygiene, and bathing; required extensive assistance of one staff member for
eating; and was always incontinent of bowel and bladder.
Review of Resident #33's fall assessment dated [DATE] in the medical record revealed Resident #33 was at
high risk for a fall and had no falls in the last three months.
Review of Resident #33's care plan in the medical record dated 01/06/21 revealed Resident #33 was at risk
for fall due to bowel and bladder incontinence, impaired cognition with decreased safety awareness,
needed assistance with activity of daily living (ADL) with a goal to minimize risks for fall and to minimize
injuries related to falls. Interventions included mat next to bed when occupied.
Observation on 10/24/22 at 12:25 P.M., 10/25/22 at 7:54 A.M., 10/25/22 at 3:40 P.M., and at 10/27/22 at
8:42 A.M. revealed Resident #33 was in bed and the mat was at the end of the bed laying on the floor
between the foot board and the wall.
Interview on 10/25/22 at 8:45 A.M. with State Tested Nursing Assistant (STNA) #47 confirmed the mat was
not next to the bed as it should be while Resident #33 was in the bed and moved the mat next to the bed.
Interview on 10/26/22 at 3:38 P.M. with Licensed Practical Nurse (LPN) #16 confirmed Resident #33 was at
risk for falls and should have a mat next to her bed when Resident #33 was in the bed.
Interview on 10/27/22 at 8:48 A.M. with STNA #2 verified Resident #33's mat was at the end of the bed
between the foot board and the wall.
Review of the facility policy titled Fall Prevention Program, dated 08/01/22, revealed each resident will be
assessed for fall risk and will receive care and services in accordance with their individualized level of risk
to minimize the likelihood of falls, which included providing interventions as directed by the resident's
assessment.
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
365713
If continuation sheet
Page 7 of 19
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
365713
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
11/03/2022
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Embassy of Painesville
70 Normandy Dr
Painesville, OH 44077
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 0698
Provide safe, appropriate dialysis care/services for a resident who requires such services.
Level of Harm - Minimal harm
or potential for actual harm
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on
interview, record review, and policy review, the facility failed to ensure communication was received from
the dialysis provider after each dialysis treatment. This affected one resident (Resident #47) of one resident
reviewed for dialysis. The facility census was 55.
Residents Affected - Few
Findings include:
Review of the medical record revealed Resident #47 was admitted to the facility on [DATE] with diagnoses
including end stage renal disease dependent on dialysis, high blood pressure, diabetes, depression, and
anxiety.
Review of the physician's orders for Resident #47 revealed no order for dialysis.
Review of the care plans for Resident #47 revealed he attended dialysis on Mondays, Wednesdays, and
Fridays at 5:30 A.M.
Review of the dialysis communications received from the dialysis provider for Resident #47 revealed the
facility received communications from the dialysis provider for 12/17/21, 12/30/21, an undated note,
04/25/22, 05/30/22, 06/06/22, 06/10/22, 07/08/22, and 08/05/22.
Dialysis notes for Resident #47 were requested from the Administrator on 10/27/22 at 1:40 P.M.
Interview with the Administrator on 10/27/22 at 3:12 P.M. revealed he looked for the dialysis notes for
Resident #47 but was unable to find any except for what is in the electronic medical record. The
Administrator said he went to the resident's room and asked him if the dialysis provider gave him
paperwork to bring back to the facility and Resident #47 told him they had never given him anything. The
Administrator said he then called the dialysis provider and was told Resident #47 does bring
communication paperwork, but they do not bother filling it out as they are not required to. If a problem
occurs during dialysis, they just call the facility.
Review of the facility's Dialysis Care policy, last revised January 2016, revealed there was to be a source of
communication between the facility and the dialysis provider after each visit.
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
365713
If continuation sheet
Page 8 of 19
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
365713
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
11/03/2022
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Embassy of Painesville
70 Normandy Dr
Painesville, OH 44077
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 0758
Level of Harm - Minimal harm
or potential for actual harm
Residents Affected - Few
Implement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated,
prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic
medications are only used when the medication is necessary and PRN use is limited.
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on
interview and record review the facility failed to ensure an end date was provided for as needed
psychotropic medications. This affected one resident (Resident #109) of five residents reviewed for
psychotropic medications. The facility census was 55.
Findings include:
Review of the medical record revealed Resident #109 was admitted to the facility on [DATE] with diagnoses
including Parkinson's disease, diabetes, atrial fibrillation, dementia without behavioral disturbance,
depression, and insomnia.
Review of the physician's orders for Resident #109 revealed an order for Trazadone (an antidepressant)
100 milligrams orally every 24 hours as needed for anxiety. No end date was ordered.
Review of the medical record revealed no pharmacist recommendations had been completed for Resident
#109 due to being a new admission.
Interview with the Director of Nursing (DON) on 10/31/22 at 2:00 P.M. revealed she was unaware Resident
#109 had an as needed order for Trazadone with no stop date. The DON confirmed anxiety was not a
diagnosis for the use of Trazadone.
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
365713
If continuation sheet
Page 9 of 19
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
365713
B. Wing
(X3) DATE SURVEY
COMPLETED
A. Building
11/03/2022
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Embassy of Painesville
70 Normandy Dr
Painesville, OH 44077
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 0809
Level of Harm - Minimal harm
or potential for actual harm
Residents Affected - Many
Ensure meals and snacks are served at times in accordance with resident’s needs, preferences, and
requests. Suitable and nourishing alternative meals and snacks must be provided for residents who want to
eat at non-traditional times or outside of scheduled meal times.
Based on observation, interview, and record review the facility failed to serve meals in a timely manner. This
had the potential to affect all residents residing in the facility who receive meals. The facility identified two
residents (Resident's #36 and #260) with physician's orders for nothing by mouth (NPO). The facility census
was 55.
Findings include:
Upon entry on 10/24/22 at 8:30 A.M. a list of mealtimes was requested and received. Review of the list
indicated mealtimes were 7:30 A.M. for breakfast, 11:30 A.M. for lunch, and 5:30 P.M. for dinner.
Observation on 10/24/22 at 8:58 A.M. revealed staff passing breakfast trays on the 100-unit.
Observation 10/24/22 at 11:30 A.M. revealed six residents sitting in dining room waiting for lunch meal.
Observed residents filtering into dining room for lunch meal from 11:31 A.M. to 12:00 P.M. At 12:00 P.M.
observed administrator enter kitchen.
Interview on 10/24/22 at 12:10 P.M. with Administrator revealed dinner mealtime was changed to 5:30 P.M.
during week of 10/14/22. The Administrator indicated the updated dinner mealtime was posted for resident
notification. The Administrator reported the lunch mealtime was also supposed to be changed to 12:30 P.M.
however it had not been posted to notify residents. The Administrator indicated as of 10/24/22 lunch meal
should be at 12:30 P.M. The Administrator provided updated list of mealtimes with lunch as 12:30 P.M.
Observations on 10/24/22 from 12:10 P.M. to 12:50 P.M. revealed residents continued to wait in dining room
for lunch. At 12:43 P.M. observed residents asking staff when meals would be ready. Lunch trays for dining
room began to be served at 12:50 P.M. and was completed by 1:10 P.M.
Observation on 10/24/22 at 1:07 P.M. revealed family member approached the administrator asking where
the hall trays were. The Administrator told the family member the mealtime was changed. The family
member was unaware of any changes to mealtimes.
Observation on 10/24/22 at 12:45 P.M. revealed 100-unit lunch trays arrived.
Observation on 10/24/22 at 1:01 P.M. revealed 300-unit lunch trays arrived.
Observation on 10/24/22 at 1:18 P.M. revealed 200-unit lunch trays arrived.
Observation on 10/24/22 at 1:23 P.M. revealed 400-unit lunch trays arrived.
Observations on 10/25/22 revealed 100-unit breakfast trays were delivered at 8:13 A.M. and 200-unit
breakfast trays were delivered at 8:28 A.M. Observation of a resident standing on 200-unit at 8:32 A.M.
complaining to staff while standing by meal cart. The resident was upset trays were late. Staff asked the
resident to wait patiently, and the resident indicated he had been waiting and now the food would be cold by
the time they passed it. Breakfast meal trays were delivered to 300-unit at 8:19
(continued on next page)
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
365713
If continuation sheet
Page 10 of 19
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
365713
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
11/03/2022
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Embassy of Painesville
70 Normandy Dr
Painesville, OH 44077
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 0809
A.M. and 400-unit at 8:33 A.M.
Level of Harm - Minimal harm
or potential for actual harm
Interviews on 10/24/22 from 10:15 A.M. to 12:41 P.M. and on 10/25/22 at 9:41 A.M. with Residents #14,
#24, #33 #37, #48, and #52 revealed meals were often late. Residents indicated lunch was usually around
1:00 P.M. - 1:30 P.M. and dinner around 6:30 P.M. - 7:00 P.M. Residents were unaware of mealtime
changes, had not given input for mealtime changes, and had not been notified of the change.
Residents Affected - Many
Interview on 10/25/22 at 11:25 A.M. with Corporate Dietitian #51 and Dietary Manager #8 revealed
mealtimes were now 7:30 A.M. for breakfast, 12:30 P.M. for lunch, and 5:30 P.M. for dinner. Corporate
Dietitian #51 indicated the Administrator was informed the week of 10/14/22 to push back dinner to 5:30
P.M. Dietary Manager #8 indicated mealtimes were adjusted last week but the change to lunch meal was
not posted to inform the residents, so they were confused. Dietary Manger #8 indicated the order in which
trays were served was first 100-unit, then 300-unit, then dining room, then 200-unit, and last 400-unit.
Interview on 10/25/22 at 3:56 P.M. with the Administrator and Dietary Manager #8 revealed the expectation
for meal service was 30 minutes to serve all trays.
Observation on 10/27/22 at 8:30 A.M. revealed breakfast trays had arrived at 200-unit.
Interview on 10/27/22 at 12:39 P.M. with Registered Dietitian (RD) #45 revealed mealtimes need to be
reviewed as they have been different than what was posted. RD #45 indicated he hoped to work with the
new dietary manager on having consistent mealtimes. RD #45 indicated he was unaware there had been
mealtime changes to 12:30 P.M. for lunch and 5:30 P.M. for dinner.
Review of the Activities Daily Happenings handouts from 10/17/22 to 10/24/22 revealed as of 10/21/22
mealtimes were 7:30 A.M. for breakfast, 11:30 A.M. for lunch, and 5:30 P.M. for dinner.
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
365713
If continuation sheet
Page 11 of 19
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
365713
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
11/03/2022
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Embassy of Painesville
70 Normandy Dr
Painesville, OH 44077
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 0812
Level of Harm - Minimal harm
or potential for actual harm
Residents Affected - Many
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve
food in accordance with professional standards.
Based on observation, interview, and policy review the facility failed to maintain a clean and sanitary
kitchen area. This had the potential to affect all residents residing in the facility who received meals. The
facility identified two (Resident's #36 and #260) with nothing by mouth (NPO) diet orders. The facility
census was 55.
Findings include:
Observations on 10/24/22 from 9:00 A.M. to 9:15 A.M. of facility kitchen revealed the double door reach in
cooler had a tray with seven bowls of uncovered and undated beets and a second tray was a bowl of
mandarin oranges and seven bowls of apples which were uncovered and undated. Additionally, in the
double door reach-in cooler was an unidentified covered bowl without date and a pot of vegetable soup
covered with plastic wrap with no label or date. In the single door reach-in cooler there was a spill down
back of cooler. Observation of the microwave revealed food splatter on the inside top and sides.
Observation of food splatter on the inside of the door of kitchen. Observation of the walk-in cooler revealed
a bag of lettuce hanging out of box which was ripped open in the middle. The bag was uncovered and had
no date. Observation of the walk-in freezer revealed a frozen bag of alfredo sauce on the floor under the
racks and a bag of ice on the floor next to the rack.
Interview on 10/24/22 at 9:15 A.M. with Corporate Dietitian #51 confirmed the above findings at the time of
the observation.
Review of the undated facility policy titled Sanitary Conditions revealed all foods would be appropriately
stored. Foods would be stored off floors, covered, labeled, and dated. The policy revealed all equipment
would be maintained in clean and sanitary fashion.
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
365713
If continuation sheet
Page 12 of 19
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
365713
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
11/03/2022
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Embassy of Painesville
70 Normandy Dr
Painesville, OH 44077
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 0814
Dispose of garbage and refuse properly.
Level of Harm - Potential for
minimal harm
Based on observation and interview the facility failed to maintain a clean dumpster area. This had the
potential to affect all residents residing in the facility. The facility census was 55.
Residents Affected - Many
Findings include:
Observation on 10/24/22 at 9:17 A.M. with Corporate Dietitian #51 revealed three dumpsters. Observation
behind the dumpsters revealed six milk crates scattered on ground. Observation of the grassy area behind
the dumpsters revealed trash had blown across yard including used gloves and disposable paper products.
Observation revealed a broken orange couch on its side on a pallet next to the dumpsters.
Interview on 10/24/22 at 9:20 A.M. with Corporate Dietitian #51 confirmed the findings and was unaware of
where the couch came from.
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
365713
If continuation sheet
Page 13 of 19
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
365713
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
11/03/2022
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Embassy of Painesville
70 Normandy Dr
Painesville, OH 44077
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 0842
Level of Harm - Minimal harm
or potential for actual harm
Residents Affected - Some
Safeguard resident-identifiable information and/or maintain medical records on each resident that are in
accordance with accepted professional standards.
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on
interview, record review, and policy review, the facility failed to ensure documentation was completed on five
residents (Residents #26, #30, #37, #48, and #262) of 25 residents reviewed for documentation. The facility
census was 55.
Findings include:
1. Review of the medical record revealed Resident #26 was admitted to the facility on [DATE] with
diagnoses including cardiomyopathy, bipolar disorder, diabetes, and high blood pressure.
Review of the progress notes for Resident #26 revealed on 08/27/22 at 11:44 P.M. paged Physician (MD)
#56 regarding the resident for an unknown reason. At 11:52 P.M. MD #56 returned the page and ordered
Zofran (an anti-nausea medication) 8 milligrams three times a day as needed for nausea as well as an
abdominal x-ray. Further review revealed the last documentation regarding Resident #26 was on 08/30/22
by Social Services Designee (SSD) #37.
2. Review of the medical record for Resident #30 revealed the resident was admitted on [DATE] with
diagnoses including heart disease, transient ischemic attacks (mini strokes), high blood pressure, and
repeated falls. Review of the comprehensive admission Minimum Data Set (MDS) 3.0 assessment dated
[DATE] revealed the resident was severely cognitively impaired and had fallen prior to admission.
Review of the progress notes for Resident #30, dated 09/14/22 at 6:03 P.M., revealed the resident was
admitted to the facility with no information regarding where the resident had been admitted from or why he
was admitted to the facility. The last documentation for Resident #30 was dated 09/16/22 at 12:10 P.M. by
SSD #37 when the resident's care conference was held. No further documentation was found.
3. Review of the medical record revealed Resident #262 was admitted to the facility on [DATE] with a
diagnosis of a left femur fracture with surgical repair.
Review of the nursing documentation revealed a note dated 10/04/22 was not entered into the electronic
medical record until 10/20/22.
Interview with the Director of Nursing (DON) on 10/27/22 at 12:07 P.M. confirmed the nurses'
documentation was poor. She in-serviced the staff on documentation but had not noticed improvement.
A second interview with the DON on 10/31/22 at 11:28 A.M. revealed she expects the nurses to document
all changes, when they speak with the family/responsible party, or new physician orders were given. The
staff state they are charting by exception, but she wants to see what is going on from start to finish.
Review of the facility's Charting and Documentation policy, last reviewed July 2017, revealed all services
provided to the resident, progress toward the care plan goals, or any changes in the resident's medical,
physical, functional, or psychosocial condition, shall be documented in the resident's medical record. The
medical record should facilitate communication between the interdisciplinary team regarding the resident's
condition and response to care.
(continued on next page)
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
365713
If continuation sheet
Page 14 of 19
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
365713
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
11/03/2022
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Embassy of Painesville
70 Normandy Dr
Painesville, OH 44077
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 0842
Level of Harm - Minimal harm
or potential for actual harm
4. Review of the medical record for Resident #37 revealed admission date of 06/29/21 with diagnoses
including peripheral vascular disease, diabetes mellitus, cellulitis, difficulty walking, hypertension, and
chronic kidney disease.
Review of the MDS 3.0 quarterly assessment dated [DATE] revealed Resident #37 had intact cognition.
Residents Affected - Some
Review of Progress Notes from February 2022 to April 2022 revealed no indication of how Resident #37's
wound occurred and no indication of blister opening to wound.
Review of Progress Notes from March 2022 revealed no progress note indicating Resident #37 had
acquired blister on 03/28/22. Noted on 03/20/22 Resident #37 was noted to have right lower extremity
phlebitis and area was reddened with large blister in center.
Review of facility Skilled Nurse's Note assessment dated [DATE] revealed Resident #37's skin was within
normal limits.
Review of facility Skin Grid Non-Pressure assessment dated [DATE] revealed Resident #37 had blister to
right lower leg. The blister measured 3.5 centimeters (cm) x 4.0 cm. The assessment indicated skin
condition was acquired on 03/28/22.
Review of facility assessments from March 2022 revealed no documentation of situation causing blister or
hematoma to right lower extremity.
Review of facility progress note dated 04/04/22 revealed Resident #37 was sent to hospital for antibiotics
and assessment of right leg wound.
Review of Care Plan dated 04/01/22 revealed Resident #37 had actual area of skin impairment of open
hematoma to right lower extremity. Interventions included evaluate for pain, observe and document wound
weekly, elevate legs, and wound treatments as ordered.
Review of facility Skin Grid Non-Pressure assessment dated [DATE] revealed Resident #37 had wound to
right lateral tibia that was acquired 03/28/22 related to trauma. The wound measured 9.5 cm x 8.0 cm x 0.6
cm.
Interview on 10/24/22 at 10:42 A.M. with Resident #37 revealed she could not remember exact dates but
indicated around April 2022 she was making her bed and leaned on controls of motorized wheelchair.
Resident #37 indicated when she leaned on controls the wheelchair moved forward and knocked her onto
bed. Resident #37 indicated she hit her right lower leg on metal bar holding mattress in place on bed frame.
Resident #37 indicated hitting her leg caused a large hematoma.
Interview on 10/27/22 at 11:42 A.M. with Resident #37 revealed at first the wound was just a bruise then
became a blister. Resident #37 indicated the physician sent her to the hospital when she returned, she
wanted a shower and the dressing was removed causing the blister to burst. Resident #37 indicated the
area became a large wound that the facility had been treating with various methods until present.
Interview on 10/31/22 at 11:30 A.M. with the DON verified lack of documentation in Resident #37's medical
record related to the incident causing the wound.
(continued on next page)
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
365713
If continuation sheet
Page 15 of 19
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
365713
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
11/03/2022
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Embassy of Painesville
70 Normandy Dr
Painesville, OH 44077
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 0842
Level of Harm - Minimal harm
or potential for actual harm
Residents Affected - Some
Review of the facility Charting and Documentation policy, dated July 2017, revealed all services provided to
the resident or any changes in the resident's medical, physical, functional, or psychosocial condition shall
be documented in the resident's medical record. Documentation shall be objective, complete, and accurate.
5. Review of the medical record for Resident #48 revealed admission date of 12/04/19 with diagnoses
including age-related physical debility, muscle wasting, weakness, difficulty walking, and right femur
fracture.
Review of the MDS 3.0 annual assessment dated [DATE] revealed Resident #48 had intact cognition.
Review of the progress note dated 07/19/22 revealed Resident #48 complained of right knee pain. The
physician was notified of the pain, and new orders were received for as needed Tylenol and a lidocaine
patch daily.
Review of the progress note dated 07/20/22 revealed Resident #48 continued to complain of right knee
pain. The physician was notified, and new orders were received to obtain an x-ray of knee. An X-ray was
obtained and resulted in acute distal femur fracture. The physician was again notified, and an order was
obtained to send the resident to the emergency room for further evaluation.
Review of the Radiology Interpretation report dated 07/20/22 revealed acute fracture not displaced with
noted osteopenia and degenerative changes.
Review of the progress notes from July 2022 revealed no indication of the situation which led to Resident
#48 complaining of right knee pain.
Review of the assessments from July 2022 revealed no indication of the situation which led to Resident #48
complaining of right knee pain.
Review of the progress note dated 10/11/22 revealed Resident #48 was ordered a two view x-ray of the left
knee for pain.
Review of progress notes from October 2022 revealed no indication of situation which led to Resident #48
complaining of left knee pain.
Review of assessments from October 2022 revealed no indication of situation which led to Resident #48
complaining of left knee pain.
Review of Radiology Interpretation report dated 10/11/22 revealed impression of osteopenia and
osteoarthritis of left knee with small avulsion fracture of level of medical tibial plateau.
Review of care plan dated 07/21/22 revealed Resident #48 was at risk for pain related to history of fracture
of right distal femur. Interventions included encourage use of affected limb, evaluate pain, provide
medications as ordered, handle gently, maintain body alignments, and therapy evaluation as ordered.
Interview on 10/24/22 at 10:49 A.M. with Resident #48 revealed back in July 2022 she was working on
transfers with therapy. Resident #48 indicated during therapy she felt weak and tried to sit. When trying to
sit Resident #48 indicated she missed the wheelchair. Resident #48 indicated this caused
(continued on next page)
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
365713
If continuation sheet
Page 16 of 19
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
365713
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
11/03/2022
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Embassy of Painesville
70 Normandy Dr
Painesville, OH 44077
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 0842
Level of Harm - Minimal harm
or potential for actual harm
Residents Affected - Some
her leg to break. Resident #48 then reported she began working with therapy again once she could bear
weight in October 2022. Resident #48 indicated the same occurrence happened and she fractured her
knee.
Interview on 10/31/22 at 11:32 A.M. with the DON indicated the facility had quality assurance file for
fractures; however, the DON verified the lack of documentation in Resident #48's medical record related to
incidents causing fractures on 07/19/22 and 10/11/22.
Review of the facility Charting and Documentation policy, dated July 2017, revealed all services provided to
the resident or any changes in the resident's medical, physical, functional, or psychosocial condition shall
be documented in the resident's medical record. Documentation shall be objective, complete, and accurate.
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
365713
If continuation sheet
Page 17 of 19
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
365713
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
11/03/2022
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Embassy of Painesville
70 Normandy Dr
Painesville, OH 44077
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 0921
Level of Harm - Minimal harm
or potential for actual harm
Residents Affected - Some
Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and
the public.
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on
observation, staff interview, and facility policy review the facility failed to have a well-maintained
environment. This affected nine resident occupied rooms (rooms #102, #105, #107, #108, #110, #202,
#205, #207, #303). The facility census was 55.
Findings include:
An environmental tour was conducted on 10/27/22 between 12:00 P.M. and 12:15 P.M. with the
Maintenance Supervisor #32. The following was verified and observed at the time of the tour:
•
room [ROOM NUMBER] had one extra-large sheet of vinyl adhesive applied to the wall behind the bed,
which was partially coming off the wall. Behind the sheet of vinyl were four large holes in the wall.
•
room [ROOM NUMBER] had one medium size hole in the brown wooden hollow bathroom door with white
patching material partially covering the hole.
•
room [ROOM NUMBER] had one large white patched area on the wall between the two televisions and four
large white patched areas on the wall next to the bed closest to the hallway.
•
room [ROOM NUMBER] had four extra-large white patched areas on the wall across from the bathroom
door.
•
room [ROOM NUMBER] had 13 medium white patched areas around the television on the wall.
•
room [ROOM NUMBER] had 20 small white patched areas and one large white patched area around the
television on the wall.
•
room [ROOM NUMBER] had two long and narrow strips of missing wallpaper behind the headboard of the
bed closest to the window.
•
(continued on next page)
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
365713
If continuation sheet
Page 18 of 19
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
365713
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
11/03/2022
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Embassy of Painesville
70 Normandy Dr
Painesville, OH 44077
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 0921
Level of Harm - Minimal harm
or potential for actual harm
Residents Affected - Some
room [ROOM NUMBER] had five small white patched areas under the television and fifteen gouged areas
with drywall exposed between the closet and the bathroom.
•
room [ROOM NUMBER] had an approximate two-inch area of different colored paint on all four walls near
the ceiling.
Review of undated facility policy titled Resident Rights revealed residents had a right to a safe, clean, and
comfortable and homelike environment and the facility was to provide maintenance services necessary to
maintain a comfortable interior.
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
365713
If continuation sheet
Page 19 of 19
Reading this as a family member? Your long-term care ombudsman is a free advocate for residents and families.
Back to topCitations
13 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.
F580 - Notification of Changes
Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.
F689 - Accidents
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
F698 - Dialysis
Provide safe, appropriate dialysis care/services for a resident who requires such services.
F758 - Medication Errors
Implement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic medications are only used when the medication is necessary and PRN use is limited.
F809 - Frequency of Meals
Ensure meals and snacks are served at times in accordance with resident’s needs, preferences, and requests. Suitable and nourishing alternative meals and snacks must be provided for residents who want to eat at non-traditional times or outside of scheduled meal times.
F812 - Food safety requirements
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
F814 - Food Safety Requirements
Dispose of garbage and refuse properly.
F842 - Resident-identifiable information
Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.
F921 - Other Environmental Conditions
Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public.
- 0511GeneralS&S Epotential for harm
Have properly installed electrical wiring and gas equipment.
F741 - The facility must have sufficient staff who provide direct services to
Have posted "No-smoking" signs in areas where smoking is not permitted or ashtrays provided where smoking was allowed.
F684 - Quality of care
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
F641 - Accuracy of Assessments
Ensure each resident receives an accurate assessment.
FAQ · About this visit
Common questions about this visit
What happened during the November 3, 2022 survey of Heritage Healthcare of Painesville?
This was a inspection survey of Heritage Healthcare of Painesville on November 3, 2022. The surveyor cited 13 deficiencies, recorded on the federal Form 2567 statement of deficiencies.
Were any deficiencies cited at Heritage Healthcare of Painesville on November 3, 2022?
Yes, 13 deficiencies were cited, each with a CMS Scope and Severity grade. The first was: "Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) tha..."
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.