Inspection·July 11, 2024

F 0550 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. Based on observation, interview, review of the facility admission agreement, and review of the facility policy, the facility failed to ensure privacy and dignity were maintained during incontinence care for Resident #12. This affected one resident (#12) of four residents who were reviewed for incontinence care. The facility census was 46. Findings include: Review of the medical record for Resident #12 revealed an admission date of 04/15/24 with diagnoses including acute and chronic respiratory failure, anoxic brain damage, morbid obesity, dysphagia, sleep apnea, major depressive disorder, and cognitive communication deficit. Review of the annual Minimum Data Set (MDS) 3.0 assessment revealed Resident #12 had severely impaired cognition and was always incontinent of bowel and bladder. Further review of the MDS revealed Resident #12 was dependent on staff for all activities of daily living, including bathing and toileting hygiene. Review of the care plan dated 04/15/24 revealed Resident #12 was totally dependent on staff for all aspects of activities of daily living, including bed mobility, toileting, and personal hygiene. Further review of the care plan revealed Resident #12 experienced bowel and bladder incontinence with interventions including providing incontinence care or perineal care every two hours and as needed for incontinent episodes. Observation of incontinence care on 07/10/24 from 2:15 P.M. to 2:25 P.M. rendered by State Tested Nurse Aide (STNA) #401 and STNA #428 revealed Resident #12 received incontinence care in front of a large window alongside a parking lot with cars parked in the lot at eye-level and a person noted sitting inside a vehicle (facing the opposite direction) that was backed-in just outside of Resident #12's window. Interview on 07/10/24 at 2:25 P.M. with STNA #401 confirmed the blinds to the window were open and there were cars in the parking lot outside Resident #12's window while she was receiving incontinence care. Interview with STNA #428 confirmed she always made sure to shut resident doors and use privacy curtains when rendering any personal care but had not thought about the window blinds needing shut for privacy. Review of the admission packet titled Embassy Healthcare admission Agreement revealed each resident (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 6 Event ID: 365825 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 365825 B. Wing A. Building (X3) DATE SURVEY COMPLETED 07/11/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Grande Oaks 24579 Broadway Ave Oakwood Village, OH 44146 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)