Health inspection·July 10, 2025

F 0684 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete right heel arterial ulcers. The sacrum/buttocks treatment was to cleanse with NSS, apply silver alginate, cover with a sacral foam dressing, then apply Calmoseptine (a moisture barrier) to the peri-wound (skin surrounding the wound) daily on night shift. The left elbow treatment was to cleanse with NSS, apply silver alginate, then cover with border gauze dressing daily on day shift. The left hallux and left heel treatments were to cleanse with NSS, apply betadine and leave open to air three times weekly on night shift. The right hallux and right heel treatments were to cleanse with NSS, apply betadine, cover with an ABD dressing, and wrap with gauze three times weekly on night shift. On 06/12/25, the right hallux treatment was changed to cleanse with NSS, apply betadine then leave open to air three times weekly on night shift. Review of the TAR for June 2025 revealed Resident #114's sacrum/buttock wound was not documented as completed on 06/12/25, 06/14/25, 06/15/25, 06/21/25 and 06/24/25. Resident #114's left elbow treatment was not documented as completed on 06/06/25. The left hallux treatment was not documented as completed on 06/05/25, 06/12/25, 06/14/25, 06/21/25 and 06/24/25. The left heel treatment was not documented as completed on 06/05/25, 06/14/25, 06/21/25 and 06/24/25. The right heel treatment was not documented as completed on 06/05/25, 06/14/25, 06/21/25 and 06/24/25. The right hallux treatment was not documented as completed on 06/05/25, 06/14/25, 06/21/25 and 06/24/25.Review of nursing progress notes from April 2025 to June 2025 revealed no evidence Resident #114's wound treatments were completed as identified in the above findings. Interview on 07/07/25 at 9:25 A.M. with Director of Nursing verified Resident #114's wound treatments were not completed as ordered by the physician as identified in the above findings.Review of facility policy, Skin Care & Wound Management Overview, undated, revealed completed treatments were to be documented in the electronic treatment administration record.This deficiency represents non-compliance investigated under Complaint Number OH00165152 (1321594) and OH00163754 (1321590). Event ID: Facility ID: 366008 If continuation sheet Page 2 of 5 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 366008 B. Wing A. Building (X3) DATE SURVEY COMPLETED 07/10/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Grande Pointe Healthcare Commu Three Merit Dr Richmond Heights, OH 44143 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 0690 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview, record review, and facility policy review, the facility failed to timely implement physician orders to insert an indwelling urinary catheter. This affected one resident (#145) of three residents reviewed for urinary tract infection (UTI) prevention. The facility census was 140.Findings include: Review of the medical record for Resident #145 revealed an admission date of 03/20/25 and discharge date of 04/01/25. Diagnoses included orthopedic aftercare, closed fracture of the lower end of left femur, closed fracture of the lateral condyle of left femur, closed fracture of the medial condyle of left femur, fracture of the ninth and tenth thoracic vertebra, and atrial fibrillation. A diagnosis of retention of urine was added upon the date of discharge on [DATE].Review of Resident #145's undated profile sheet revealed the resident was listed as his own responsible party with two children both listed as emergency contacts.Review of the nursing progress notes from 03/20/25 to 03/24/25 revealed Resident #145 was admitted to the facility for skilled therapy services due to a fall which resulted in a left femur fracture. The resident was oriented, able to make needs known, and had no complaints or concerns.Review of Resident #145's physician orders dated 03/25/25 indicated for routine laboratory testing to include a CMP (comprehensive metabolic panel) and for a post-operative orthopedic appointment on 04/01/25.Review of the Nurse Practitioner (NP) progress note dated 03/25/25 revealed Resident #145 had no acute pain and routine laboratory testing was pending. Review of a laboratory test collected on 03/26/25 revealed a high BUN (blood urea nitrogen) level and low GFR (glomerular filtration rate) which both values were used to assess kidney function.Review of the NP progress note dated 03/27/25 revealed Resident #145 denied any changes with bladder function. The laboratory test collected 03/26/25 which resulted in a low GFR indicated stage four chronic kidney disease, so nephrology was to be consulted for evaluation.Review of a laboratory test collected on 03/27/25 again revealed Resident #145 had a high BUN level and low GFR. Review of a nursing progress note dated 03/27/25 revealed the nephrologist was contacted regarding Resident #145's kidney function, and ordered an ultrasound of the kidneys, a bladder scan with PVR (post-void residual) [a measure of the amount of urine remaining in the bladder immediately after urination] and a urinalysis with culture and sensitivity (UA/ CS) [to test for a urinary tract infection] due to the elevated BUN level.Review of Resident #145's physician order dated 03/27/25 revealed to collect a urine specimen for UA/CS, a bladder scan with PVR, and an ultrasound of the kidneys due to the elevated BUN level. The corresponding Treatment Administration Record (TAR) for March 2025 indicated the ultrasound was completed on 03/28/25.Review of the admission Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #145 had moderately impaired cognition and was frequently incontinent of urine. Resident #145 did not have an indwelling urinary catheter.Review of a nursing progress note dated 03/28/25 revealed Resident #145's ultrasound of the bladder and kidneys was completed, including the PVR which resulted in 703 milliliters (mL) of urine left in the bladder after voiding. The nephrologist ordered a Foley catheter (an indwelling urinary catheter) to be inserted.Review of Resident #145's physician order dated 03/28/25 indicated to insert a Foley catheter due to PVR of 703 mL and to change the foley catheter and drainage bag as needed every shift. The corresponding TAR for March 2025 indicated the Foley catheter was inserted on 03/28/25 night shift but no urine specimen had yet been obtained as ordered. Review of the electronic medication administration note dated 03/29/25 at 3:06 P.M. indicated Resident #145 did not have a foley catheter in place as was indicated on the TAR as placed on 03/28/25. There was no indication the physician was contacted.Review of a nursing progress note dated 03/29/25 at 11:02 P.M. revealed Resident (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366008 If continuation sheet Page 3 of 5 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 366008 B. Wing A. Building (X3) DATE SURVEY COMPLETED 07/10/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Grande Pointe Healthcare Commu Three Merit Dr Richmond Heights, OH 44143 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 0690 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few #145 was straight catheterized (a urinary catheter used to drain the bladder and not designed to remain in the bladder for extended periods) which drained 1250 mL of urine, and a urine specimen was collected and placed into a refrigerator. There was no documented evidence of urinary discomfort or communication with the physician. The corresponding TAR for March 2025 indicated the urine specimen was collected on 03/29/25 night shift.Review of the electronic medication administration note dated 03/30/25 at 9:27 P.M. indicated Resident #145 continued to have no Foley catheter in place. There was no indication the physician was contacted.Review of a primary care physician progress note dated 03/31/25 revealed Resident #145 denied blood in the urine, difficulty urinating, and had no frequent urination. There was no evidence in the documentation of the physician being aware of the nephrologist's orders for an indwelling urinary catheter to be placed, or that there was a delay in executing those orders. Review of a nursing progress note dated 03/31/25 at 3:09 P.M. revealed Resident #145 had a Foley catheter placed by order of a NP due to retention. The note referenced Resident #145 tolerated the Foley catheter insertion well, having 1500 mL of urine released with some hematuria (blood in the urine) observed. The NP was made aware, and a urine culture was pending.Review of Resident #145's physician orders dated 03/31/25 indicated to insert a Foley catheter to continuous drain for a diagnosis of urinary retention, perform Foley catheter care every shift and as needed, and to change the Foley catheter as needed. The corresponding TAR for March 2025 indicated the Foley catheter was placed on 03/31/25 night shift. Review of the nursing assistant voiding documentation for Resident #145 from 03/27/25 to 03/31/25 revealed the resident was either incontinent using a brief or was continent while using a urinal or the bathroom.Interview on 07/02/25 at 9:32 A.M. with Registered Nurse (RN) #444 who was a Unit Manager confirmed Resident #145's urinalysis ordered on 03/27/25 was not sent to the laboratory until 03/31/25. RN #444 confirmed the urine was not collected until 03/29/25 which was a Saturday, and the laboratory did not pick up specimens on weekends. RN #444 verified Resident #145 had an order for a Foley catheter to be placed on 03/28/25, and although it was signed off as inserted, it was not placed until 03/31/25.Interview on 07/07/25 at 8:39 A.M. with Director of Nursing (DON) verified on 03/28/25, the nurse who received the initial order to place a Foley catheter in Resident #145 had passed the information on to the next shift which was night shift. The night shift nurse indicated the resident voided throughout the night, either by incontinence or use of a urinal, so the physician was contacted to inquire whether the Foley catheter was needed to no avail. The DON confirmed there were no additional attempts to contact the physician recorded in Resident #145's record. From 03/28/25 until the Foley catheter was placed on 03/31/25, staff reported Resident #145 as having no complaints regarding voiding. When RN #444 returned to work, she contacted the NP and inserted Resident #145's Foley catheter. Review of an undated nurse shift report sheet revealed for Resident #145 an order was placed for a foley catheter; however, the resident was using a urinal, and the doctor was called with no answer.Interview on 07/07/25 at 9:20 A.M. with NP #418 revealed Resident #145 was referred to nephrology because of abnormal laboratory values, but denied being aware of the need for a Foley catheter due to urinary retention until 03/31/25.Review of a written witness statement of Licensed Practical Nurse (LPN) #396 undated for 03/28/25 indicated placement of the foley catheter was signed off in error, and Resident #145 was voiding using a urinal, so the physician was contacted to clarify if a foley catheter was needed due to the resident voiding, but there was no answer. It was written onto the nurse report sheet.Review of a written witness statement of RN #433 dated 07/02/25 for 03/27/25 indicated speaking to the nephrologist regarding Resident #145's abnormal laboratory values and new orders received for an ultrasound of the kidneys with a bladder scan for PVR and to obtain a UA/CS. The statement indicated the oncoming shift nurse was notified. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366008 If continuation sheet Page 4 of 5 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 366008 B. Wing A. Building (X3) DATE SURVEY COMPLETED 07/10/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Grande Pointe Healthcare Commu Three Merit Dr Richmond Heights, OH 44143 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 0690 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete Review of a written witness statement of Certified Nursing Assistant (CNA) #337 dated 07/02/25 revealed resident #145 was incontinence and used a brief on 03/28/25.Review of the undated policy, Physician Orders, revealed the provider may write orders in the medical record or may enter an electronic order. A provider may give a medical order over the telephone. A provider may send a signed and dated fax medical order. Verbal orders are accepted but will be input into the electronic medical record by the nurse as soon as practicable. The nurse that takes the physician order will be responsible for executing the order or provide for the safe hand-off to the next nurse. The policy further explained that outside vendors, including laboratory services, should be contacted to execute the medical order. Review of the undated policy, Notification of Change in Condition, revealed the facility must consult with the resident's medical practitioner when there was a change requiring such notification. Circumstances requiring notification included a significant change in the resident's physical, mental or psychosocial condition, circumstances that required a need to alter treatment which may include a new treatment, or discontinuation of a current treatment. The medical practitioner was to be promptly notified of significant changes in condition, and the medical record must reflect the notification, response and interventions implemented to address the resident's condition. This deficiency represents non-compliance investigated under Complaint Number OH00164261 (1321592). Event ID: Facility ID: 366008 If continuation sheet Page 5 of 5