Inspection visit
Inspection
24 citations recorded
Inspector’s narrative
What the inspector wrote
This survey cited 24 deficiencies. The full statement and the facility’s plan of correction follow, verbatim from the federal record.
F 0558
Reasonably accommodate the needs and preferences of each resident.
Level of Harm - Minimal harm
or potential for actual harm
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on
observation, record review, staff interview, and policy review the facility failed to ensure functioning call
lights were placed within reach of residents. This affected three (Resident's #10, #31 and #38) of three
residents reviewed for call light function. The facility census was 42.
Residents Affected - Few
Findings include:
1. Review of the medical record revealed Resident #38 was admitted to the facility on [DATE] with
diagnoses including hemiplegia and hemiparesis following cerebral infarction affecting the right dominant
side, repeated falls, muscle weakness, peripheral vascular disease, and essential hypertension. Review of
the most recent Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed Resident #38 was alert
and oriented to person, place, time, and was a one-staff physical extensive assist for activities of daily living
(ADL).
Observation on 02/14/22 at 10:19 A.M. revealed Resident #38's call light was not within reach and was
located hanging near the floor on the ride side of the bed.
Interview on 02/14/22 at 10:19 A.M. with Resident #38 revealed his right side was paralyzed, and he could
not reach his call light. Resident #38 revealed his call light did not work.
Demonstration on 02/14/22 at 10:20 A.M. of call light function revealed Resident #38's call light was not in
working order.
Interview on 02/14/22 at 10:21 A.M. with Licensed Practical Nurse (LPN) #313 confirmed Resident #38's
call light was not within reach and was not in working order.
Interview and demonstration on 02/14/22 at 10:25 A.M. with Maintenance Director (MD) #342 confirmed
Resident #38's call light was not in working order.
2. Review of the medical record revealed Resident #31 was admitted on [DATE]. Diagnoses included end
stage renal disease, enterocolitis due to clostridium difficile, hyperlipidemia, pneumonia, dependence on
renal dialysis, gastro-esophageal reflux disease, morbid obesity, depression, acute respiratory failure with
hypoxia, anemia, hypertension, diabetes mellitus, gastrointestinal hemorrhage.
Review of the MDS 3.0 assessment dated [DATE] revealed Resident #31 had intact cognition. Resident #31
required extensive assistance of one staff for toileting, bed mobility, dressing, and personal hygiene.
(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 11
Event ID:
366275
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
366275
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
02/17/2022
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Northfield Village Retirement Community
10267 Northfield Road
Northfield, OH 44067
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 0558
Level of Harm - Minimal harm
or potential for actual harm
Residents Affected - Few
Review of the care plan initiated 12/25/21 revealed Resident #31 was at risk for falls. Interventions included
to use call light and wait for assistance, request assistance for all transfers, always keep call light in easy
reach and answer promptly.
Observation on 02/14/22 at 11:00 A.M. revealed Resident #31 sitting in reclining chair angled to watch
television with the call light tied to the grab bar on the bed out of reach.
Interview on 02/14/22 at 11:00 A.M. with Resident #31 reported she was unable to reach the call light and
would have to yell if she needed assistance.
Interview on 02/14/22 at 11:15 A.M. with Medical Records (MR)/State Tested Nursing Assistant (STNA)
#306 confirmed the call light was out of reach of Resident #31. MR/STNA #306 had to untangle the call
light from the bed's grab bar to hand to Resident #31.
3. Record review for Resident #10 revealed an admission date of 12/09/19 and a readmission date of
08/26/21. Diagnosis included fracture of other parts of pelvis, anxiety disorder, history of falls, and dementia
without behavioral disturbance.
Record review of the quarterly MDS 3.0 dated 02/01/22 revealed Resident #10 had severely impaired
cognition. Resident #10 required extensive assistance of one staff for transfers and limited assistance of
one staff for locomotion on the unit.
Review of the care plan for dated 08/27/21 revealed Resident #10 was at risk for falls. Interventions
included to always keep call light in easy reach and answer promptly and keep the bed in the lowest
position while occupied.
Observation and interview on 02/14/22 at 10:25 A.M. revealed Resident #10 lying in bed. Resident #10's
bed was not at lowest position, and the call light was not within reach. The bed was located against wall
with a fall mat on the side of the bed. Resident #10 stated she utilized the call light at times.
Observation and interview on 02/14/22 at 10:26 with Administrator #316 verified the observations and
stated the call light was wrapped around the grab bar located against the wall. Administrator #316 could not
get to the call light to put it within reach of Resident #10.
Review of the facility policy titled Answering the Call Light, revised September 2003, revealed the facility
had a policy in place to respond to the resident's requests and needs. Review of the policy revealed when a
resident was confined to a chair or in bed, the call light was to be within easy reach of the resident. Review
of the policy also revealed all defective call lights should be reported to the Nurse Supervisor promptly.
Review of the facility document revealed the facility did not implement the policy.
This deficiency substantiates Master Complaint Number OH00114368.
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
366275
If continuation sheet
Page 2 of 11
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
366275
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
02/17/2022
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Northfield Village Retirement Community
10267 Northfield Road
Northfield, OH 44067
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 0584
Level of Harm - Minimal harm
or potential for actual harm
Residents Affected - Some
Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited
to receiving treatment and supports for daily living safely.
Based on observation and interview, the facility failed to ensure a well-maintained and homelike
environment. This affected four residents (Resident's #8, #9, #33 and #37) of 42 residents observed during
the annual survey. The facility census was 42 residents.
Findings include:
Observation on 02/14/22 at 9:45 A.M. with Resident #8 revealed large gouges in the wall behind her bed
exposing the wall material beneath the paint. An area of water damage was noted above the heater in
Resident #8's room. Interview with Resident #8 at the time of observation revealed she did not know how
long these areas had been present.
Observation on 02/14/22 at 10:07 A.M. with Resident #9 revealed large gouges in the wall behind her bed.
Interview with Resident #9 at the time of observation revealed she had asked staff to do something about it
and someone would come in the room to spray for ants, but no one would repair her wall.
Observation on 02/14/22 at 11:10 A.M. with Resident #33 revealed a large area behind the bed had been
spackled but not repainted and an area above the heater was chipped away and had the inner wall material
exposed. Interview with Resident #33 at the time of observation revealed the wall had looked like that since
his admission in August 2021.
Observation of the facility on 02/14/22 from 4:49 P.M. to 5:26 P.M. with Regional Registered Nurse (RRN)
#361 revealed the following concerns:
•
Resident #8's room had a large gouge to the wall over approximately one foot by one foot behind the bed
exposing the inner wall material. Also, above the heater there were areas of wall chipped away exposing
the inner wall material.
•
Resident #9's room had a large gouge approximately one foot by two inches behind the bed.
•
Resident #33's room had a large area behind the bed approximately two feet by two feet spackled and not
painted and an area above the heater was chipped away exposing the inner wall and measured
approximately six inches long.
•
Resident #37's room had an area by her bathroom where the drywall was exposed down to the base of the
wall and the floor trim was coming away from the wall.
Interview with RRN #361 on 02/14/22 at 4:57 P.M. verified the above areas of concern and revealed
(continued on next page)
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
366275
If continuation sheet
Page 3 of 11
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
366275
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
02/17/2022
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Northfield Village Retirement Community
10267 Northfield Road
Northfield, OH 44067
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 0584
Level of Harm - Minimal harm
or potential for actual harm
Residents Affected - Some
maintenance issues went into an electronic system where Maintenance Staff (MS) #342 would receive an
email of the reported concern. There were no other maintenance support staff at the facility. RRN #361 was
requested to bring the surveyor three months of maintenance request documentation.
Interview with MS #342 on 02/16/22 at 1:55 P.M. revealed he got hundreds of emails regarding
maintenance requests each day. MS #342 confirmed he was the only maintenance staff at the facility and
would have to prioritize what tasks would get done each day. MS #342 stated since November 2020 there
had been conversations about obtaining plastic sheeting to go behind residents' beds to prevent wall
damage from occurring, but he kept getting pulled to other maintenance tasks and it had never come to
fruition. MS #342 was requested to bring the surveyor three months of maintenance request
documentation.
No maintenance request documentation was provided by the end of the annual survey.
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
366275
If continuation sheet
Page 4 of 11
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
366275
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
02/17/2022
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Northfield Village Retirement Community
10267 Northfield Road
Northfield, OH 44067
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
record review and staff interview, the facility failed to accurately code the Minimum Data Set (MDS) 3.0
assessments for two (Resident's #30 and #31) of twenty-one residents reviewed for assessments. The
facility census was 42.
Residents Affected - Few
Findings include:
1. Review of the medical record revealed Resident #31 was admitted on [DATE] with diagnoses including
end stage renal disease, enterocolitis due to clostridium difficile, hyperlipidemia, pneumonia, dependence
on renal dialysis, gastro-esophageal reflux disease, morbid obesity, depression, acute respiratory failure
with hypoxia, anemia, hypertension, diabetes mellitus, gastrointestinal hemorrhage
Review of MDS 3.0 assessment dated [DATE] revealed Resident #31 required extensive one staff
assistance for toileting. The assessment indicated Resident #31 was always continent of bowel and
bladder.
Review of bladder and bowel continence documentation for last 30 days revealed Resident #31 was
incontinent of bowel and bladder.
Review of the care plan initiated 12/25/21 revealed Resident #31 had bowel incontinence. Interventions
included to give peritoneal care after each episode of incontinence, apply barrier cream as needed, toilet
resident promptly, and toilet resident in advance of need.
Interview on 02/16/22 at 10:34 A.M. with State Testing Nursing Assistant (STNA) #352 confirmed
incontinence of bowel and bladder for Resident #31. STNA #352 reported Resident #31 needed assistance
during toileting.
Interview on 02/16/22 at 12:03 P.M. with Registered Nurse (RN) #339 revealed RN #339 was also the MDS
coordinator. RN #339 reported they had not completed the assessment for Resident #31. RN #339 reported
they had corporate assistance for completing assessments.
Interview on 02/16/22 at 12:20 P.M. with Regional Assessment Coordinator (RAC) #362 revealed they had
assisted RN #339 with the MDS assessment for Resident #31. RAC #362 indicated review of the look back
period for bowel and bladder indicated Resident #31 was incontinent. RAC #362 reported being confused
as Resident #31 was continent at the last assessment. RAC #362 reported the STNAs were documenting
incorrectly.
Interview on 02/16/22 at 2:14 P.M. with Restorative RN #315 revealed Resident #31 had more frequent
episodes of incontinence of bowel and bladder since return from hospital on [DATE]. Restorative RN #315
indicated Resident #31 was being reviewed in facility risk meeting for a bowel and bladder restorative
program.
2. Record review for Resident #30 revealed an admission date of 10/06/21 with diagnoses including
malignant neoplasm of prostate and retention of urine.
Record review of the quarterly MDS 3.0 assessment dated [DATE] revealed Resident #30 had mild
cognitive impairment. Review of the bladder and bowel revealed Resident #30 had no indwelling catheter.
(continued on next page)
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
366275
If continuation sheet
Page 5 of 11
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
366275
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
02/17/2022
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Northfield Village Retirement Community
10267 Northfield Road
Northfield, OH 44067
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
Review of the care plan dated 10/07/21 revealed Resident #30 required an alternate means of urinary
elimination, and a Foley catheter in place.
Review of the physician order dated 10/07/21 at 3:00 P.M. revealed 16 French five milliliter foley catheter to
continuous drainage. Resident #30 was to have catheter care every shift.
Residents Affected - Few
Review of the Treatment Administration Record (TAR) for January 2022 and February 2022 revealed the
catheter care was completed as ordered.
Observation on 02/16/22 at 7:52 A.M. revealed Resident #30 was lying in bed. Resident #30's Foley
catheter was draining clear yellow urine.
Interview on 02/16/22 at 3:50 P.M. with MDS RN #339 confirmed Resident #30 had an indwelling Foley
catheter since admission on [DATE]. MDS RN #339 confirmed an inaccurate code on the MDS submission
dated 01/10/22 regarding indwelling Foley catheter.
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
366275
If continuation sheet
Page 6 of 11
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
366275
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
02/17/2022
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Northfield Village Retirement Community
10267 Northfield Road
Northfield, OH 44067
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
observation, interview, and record review the facility failed implement interventions to prevent falls for one
resident (Resident #10) of one resident reviewed for falls. The facility census was 42.
Findings include:
Record review for Resident #10 revealed an admission date of 12/09/19 and a readmission date of
08/26/21 with diagnoses including fracture of other parts of pelvis, anxiety disorder, history of falls, and
dementia without behavioral disturbance.
Record review of the quarterly Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed Resident
#10 had severely impaired cognition. Resident #10 required extensive assistance of one staff for transfer
and limited assistance of one staff for locomotion on the unit.
Record review of the care plan dated 08/27/21 revealed Resident #10 was at risk for falls. Interventions
included always keep the call light within easy reach and answer promptly and keep the bed in the lowest
position while occupied.
Observation and interview on 02/14/22 at 10:25 A.M. revealed Resident #10 lying in bed. Resident #10's
bed was not in the lowest position, and the call light was not within reach. The bed was located against the
wall, and a fall mat was on the side of the bed. Resident #10 stated she utilized the call light at times.
Observation and Interview on 02/14/22 at 10:26 A.M. with Administrator #316 verified the observations and
stated the call light was wrapped around the grab bar located against the wall, and the bed was not in the
lowest position. Administrator #316 could not get to the call light to put it within reach of Resident #10.
This deficiency substantiates Master Compliant Number OH00114368 and Complaint Number
OH00111616.
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
366275
If continuation sheet
Page 7 of 11
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
366275
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
02/17/2022
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Northfield Village Retirement Community
10267 Northfield Road
Northfield, OH 44067
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 0805
Level of Harm - Minimal harm
or potential for actual harm
Residents Affected - Some
Ensure each resident receives and the facility provides food prepared in a form designed to meet individual
needs.
Based on observation, interview, taste test, and Diet and Nutrition Manual review the facility failed to serve
pureed foods at a smooth consistency for safe swallowing. This affected five residents (Resident's #5, #10,
#23, #24 and #40) who were prescribed a pureed diet of 42 residents who consumed meals from the
facility's kitchen. The facility census was 42.
Findings include:
1. Observation on 02/15/22 at 12:15 P.M. of the lunch meal revealed that the pureed stuffed peppers and
pureed peas and carrots had lumps, skins, and did not appear smooth. The pureed stuffed peppers and
peas and carrots were tasted. The mixture was not smooth and not of proper consistency. Interview with
Dietary Manager (DM) #363 verified the consistency of the pureed stuffed peppers and pureed peas and
carrots.
2. Observation on 02/15/22 at 3:00 P.M. of the puree preparation revealed [NAME] #338 was preparing
pureed chicken tenders for dinner meal. Taste test of puree chicken tenders revealed chunks of breading.
The mixture was not smooth and not of proper consistency. Interview with DM #363 verified the consistency
of the pureed chicken tenders.
Interview with DM #363 on 02/15/22 at 3:10 P.M. indicated upon taste test regarding the food processor I
think we need a new blade.
Review of the resident diet list revealed Resident's #5, #10, #23, #24 and #40 were prescribed a pureed
diet.
Review of the Diet and Nutrition Care Manual, dated 2019, revealed pureed foods are generally cohesive,
moist mashed potato or pudding-like consistency for people who cannot tolerate regular or mechanical soft
foods. Food is pureed in a food processor to achieve a consistent smooth and easy-to-swallow product.
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
366275
If continuation sheet
Page 8 of 11
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
366275
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
02/17/2022
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Northfield Village Retirement Community
10267 Northfield Road
Northfield, OH 44067
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
record review and staff interview, the facility failed to ensure the resident record contained current and
accurate information. This affected three (Resident's #13, #37 and #348) of three residents reviewed for
accurate medical records. The facility census was 42.
Findings include:
1. Review of the medical record revealed Resident #13 was admitted to the facility on [DATE] with
diagnoses including end stage renal disease, dependence on renal dialysis, chronic obstructive pulmonary
disease, and gastroesophageal reflux disease without esophagitis. Review of the most recent Minimum
Data Set (MDS) 3.0 assessment dated [DATE] revealed Resident #13 was alert with cognitive impairment
and required assistance of one staff for activities of daily living (ADL).
Review of the physician orders dated 12/27/21 revealed an order stating if bleeding occurs from the dialysis
site, apply pressure, call 911, and document.
Review of the physician orders dated 12/29/21 revealed an order to assess the dialysis site before and after
dialysis for unusual findings, document unusual findings, and report to physician.
Review of the physician orders dated 01/06/22 revealed an order to give one Renvela 0.8 packet three
times a day related to end stage renal disease mixed with four ounces of water with meals three times a
day.
Review of the physician orders dated 01/10/22 revealed an order for a renal diet consisting of mechanical
soft-textured chopped meats with thin consistency liquids.
Review of all other documented physician orders located in the electronic and manual medical record
revealed no other orders related to dialysis.
Review of the care plan dated 12/27/21 revealed Resident #13 required dialysis with interventions that
included dialysis as ordered and monitor daily for signs and symptoms of infection.
Interview on 02/16/22 at 12:01 P.M. with Licensed Practical Nurse (LPN) #313 confirmed Resident #13 did
not have a dialysis order in place.
2. Review of Resident #37's medical record revealed an admission date of 10/07/21 with diagnoses
including end stage renal disease, chronic kidney disease, anemia, pneumonia and type two diabetes.
Review of Resident #37's quarterly MDS 3.0 assessment dated [DATE] revealed Resident #37 had
moderately cognitive impairment, had no behaviors, required supervision for eating and required extensive
assistance of one staff for dressing. The assessment indicated Resident #37 received dialysis.
Review of Resident #37's current physician orders included an order dated 10/08/21 stating assess the
dialysis site before and after dialysis for unusual findings, document yes or no for presence/absence of
unusual findings. No physician order for dialysis services was available in the paper chart or the electronic
medical record.
(continued on next page)
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
366275
If continuation sheet
Page 9 of 11
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
366275
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
02/17/2022
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Northfield Village Retirement Community
10267 Northfield Road
Northfield, OH 44067
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
Interview on 02/16/22 at 11:18 A.M. with LPN #313 revealed Resident #37 was currently out of the facility at
dialysis. LPN #313 reviewed Resident #37's electronic medical record and paper chart and verified no
physician order for dialysis was in place. LPN #313 explained the nurse who was on the hall receiving a
new resident was responsible for their admission orders and would have obtained an order for Resident
#37's dialysis treatments. LPN #313 denied any concerns regarding Resident #37 and dialysis.
Residents Affected - Some
The Administrator was made aware of the above findings during an interview on 02/16/22 at 4:18 P.M.
3. Review of the medical record revealed Resident #348 was admitted on [DATE] with diagnoses including
left ankle/foot osteomyelitis, personal history of COVID-19, hypertension, dependence on renal dialysis,
end stage renal disease, chronic anemia, atrial flutter, hyperlipidemia, type II diabetes mellitus, diabetic
retinopathy, peripheral vascular disease, and orthopedic aftercare following surgical amputation.
Review of the MDS 3.0 assessment revealed an admission assessment was in progress.
Review of the baseline care plan dated 02/10/22 revealed Resident #348 required dialysis. Interventions
included to provide dialysis as ordered, monitor daily for signs and symptoms of infection, and no blood
pressure or blood draws in dialysis access arm.
Review of the current physician's orders for 02/16/22 for Resident #348 revealed no order to specify details
of dialysis treatments. There was no order to indicate treatment days, time, or location of dialysis.
Interview on 02/16/22 at 2:32 P.M. with Registered Nurse (RN) #339 verified the lack of dialysis order.
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
366275
If continuation sheet
Page 10 of 11
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
366275
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
02/17/2022
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Northfield Village Retirement Community
10267 Northfield Road
Northfield, OH 44067
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 0919
Make sure that a working call system is available in each resident's bathroom and bathing area.
Level of Harm - Minimal harm
or potential for actual harm
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on
observation, record review, staff interview, and policy review the facility failed to ensure it had functional call
lights in place. This affected one (Resident #38) of one resident reviewed for call light functioning. The
facility census was 42.
Residents Affected - Few
Findings include:
Review of the medical record revealed Resident #38 was admitted to the facility on [DATE] with diagnoses
including hemiplegia and hemiparesis following cerebral infarction affecting the right dominant side,
repeated falls, muscle weakness, peripheral vascular disease, and essential hypertension. Review of the
most recent Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed Resident #38 was alert and
oriented to person, place, time, and required one-staff physical extensive assist for activities of daily living
(ADL).
Observation on 02/14/22 at 10:19 A.M. revealed Resident #38's call light was not within reach and was
located hanging near the floor on the ride side of the bed.
Interview on 02/14/22 at 10:19 A.M. with Resident #38 revealed his right side was paralyzed and he could
not reach his call light. Resident #38 revealed his call light did not work.
Demonstration on 02/14/22 at 10:20 A.M. of call light function revealed Resident #38's call light was not in
working order.
Interview on 02/14/22 at 10:21 A.M. with Licensed Practical Nurse (LPN) #313 confirmed Resident #38's
call light was not within reach and was not in working order.
Interview and demonstration on 02/14/22 at 10:25 A.M. with Maintenance Director (MD) #342 confirmed
Resident #38's call light was not in working order.
Review of the facility document titled Answering the Call Light, revised September 2003, revealed the
facility had a policy in place to respond to the resident's requests and needs. Review of the policy revealed
when a resident was confined to a chair or in bed, the call light was to be within easy reach of the resident.
Review of the policy also revealed all defective call lights should be reported to the Nurse Supervisor
promptly. Review of the facility document revealed the facility did not implement the policy.
This deficiency substantiates Master Complaint Number OH00114368.
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
366275
If continuation sheet
Page 11 of 11
Reading this as a family member? Your long-term care ombudsman is a free advocate for residents and families.
Back to topCitations
24 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.
F558 - The right to reside and receive services in the facility with reasonable
Reasonably accommodate the needs and preferences of each resident.
F584 - Safe Environment
Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely.
F641 - Accuracy of Assessments
Ensure each resident receives an accurate assessment.
F689 - Accidents
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
F805 - Food and drink
Ensure each resident receives and the facility provides food prepared in a form designed to meet individual needs.
F842 - Resident-identifiable information
Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.
F919 - Resident Call System
Make sure that a working call system is available in each resident's bathroom and bathing area.
- 0353GeneralS&S Fpotential for harm
Inspect, test, and maintain automatic sprinkler systems.
- 0161GeneralS&S Fpotential for harm
Use approved construction type or materials.
- 0211GeneralS&S Fpotential for harm
Keep aisles, corridors, and exits free of obstruction in case of emergency.
- 0222GeneralS&S Epotential for harm
Add doors in an exit area that do not require the use of a key from the exit side unless in case of special locking arrangements.
- 0300GeneralS&S Fpotential for harm
Meet other general requirements that are deficient.
- 0324GeneralS&S Fpotential for harm
Provide properly protected cooking facilities.
- 0345GeneralS&S Fpotential for harm
Have approved installation, maintenance and testing program for fire alarm systems.
- 0355GeneralS&S Epotential for harm
Properly select, install, inspect, or maintain portable fire extinguishes.
- 0363GeneralS&S Fpotential for harm
Install corridor and hallway doors that block smoke.
- 0511GeneralS&S Fpotential for harm
Have properly installed electrical wiring and gas equipment.
F712 - Frequency of physician visits
Have simulated fire drills held at unexpected times.
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.
F761 - Labeling of Drugs and Biologicals
To conduct inspection, testing and maintenance of fire doors by qualified individuals.
F911 - Accommodate no more than four residents
Meet requirements for the installation and maintenance of electrical systems.
F914 - Be designed or equipped to assure full visual privacy for each
Ensure receptacles at patient bed locations and where general anesthesia is administered, are tested after initial installation, replacement or servicing.
F918 - Bathroom Facilities
Have generator or other power source capable of supplying service within 10 seconds.
F926 - Establish policies, in accordance with applicable Federal, State, and
Ensure that personnel concerned with handling of medical gases and cylinders are trained on the risk.
FAQ · About this visit
Common questions about this visit
What happened during the February 17, 2022 survey of NORTHFIELD VILLAGE RETIREMENT COMMUNITY?
This was a inspection survey of NORTHFIELD VILLAGE RETIREMENT COMMUNITY on February 17, 2022. The surveyor cited 24 deficiencies, recorded on the federal Form 2567 statement of deficiencies.
Were any deficiencies cited at NORTHFIELD VILLAGE RETIREMENT COMMUNITY on February 17, 2022?
Yes, 24 deficiencies were cited, each with a CMS Scope and Severity grade. The first was: "Reasonably accommodate the needs and preferences of each resident."
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.