Health inspection·September 16, 2021

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** Based on observation, record review, and interview, the facility failed to ensure peripherally-inserted central catheter (PICC) protective dressings were changed weekly according to facility policy and standards of practice. This affected one (Resident #71) of one resident reviewed for proper intravenous access (IV) care. The facility census was 81 residents. Residents Affected - Few Findings include: Observation of Resident #71 on 09/14/21 at 11:42 A.M. revealed he had a PICC in his right arm with a dressing dated 09/04/21. Interview with the resident at this time revealed he was unsure when it was changed but believed it was over a week ago. Interview with Registered Nurse #112 on 09/14/21 at 11:57 A.M. confirmed the above observation. She then gathered supplies and changed the PICC dressing. Record review of Resident #71 he was admitted [DATE] with diagnoses including polyneuropathy, osteomyelitis, congestive heart failure, and local infection of the skin. He had an order dated 09/05/21 for the central catheter dressing to be changed weekly. Review of his MAR revealed it was documented as done as-ordered on 09/10/21. Interview with the Director of Nursing (DON) on 09/15/21 at 9:17 A.M. revealed the facility investigated the above findings following surveyor notification. The DON interviewed the nurse who documented the dressing change on 09/10/21 and learned the nurse signed it off as done and gathered supplies to do the change, then was distracted when the resident requested pain medications and forgot to go back and change the dressing. The facility then did one-to-one re-education for the nurse on 09/14/21. Review of the facility's PICC dressing change policy dated 01/2009 revealed central catheter dressings were to be changed every seven days. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366343 If continuation sheet Page 2 of 4 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 366343 B. Wing A. Building (X3) DATE SURVEY COMPLETED 09/16/2021 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE North Royalton Post Acute 9055 West Sprague Road Parma, OH 44133 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 0880 Provide and implement an infection prevention and control program. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation interview, record review, and policy review the facility failed to ensure proper infection control measures were followed during incontinence care and wound care. This affected two (Residents #12 and #71) of three residents reviewed for infection control. The facility census was 81 residents. Residents Affected - Few Findings include: 1. Medical record review for Resident #12 revealed an admission date of 04/05/13 with diagnoses that included multiple sclerosis, dysphasia, and abscess of the spine. Review of Resident #12's 08/18/21 physician order revealed an order to cleanse abscess base of spine, apply calcium alginate and a dressing every other day and as needed. Observation on 09/14/21 at 11:45 A.M. revealed Registered Nurse (RN) #99 disinfect Resident #12's bedside table, lay a barrier down, and place wound supplies. She then washed her hands and applied gloves. At 11:46 A.M. RN #99 turned Resident #12 on her side, removed her dressing, cleansed the resident's spine with saline, and measured the wound. At this time she removed her gloves and without disinfecting her hands she placed new gloves on her hands. RN #99 then placed calcium alginate into the wound and a patch over the wound. After removing her gloves and washing her hands RN #99 disposed of the barrier and its contents on the residents bedside table, and without disinfecting the table she placed the residents water cup on the table and pulled the table over to the resident. Interview on 09/16/21 at 11:58 A.M. with RN #99 confirmed that she did not follow proper infection controls practices during Resident #12's dressing change. Review of the Non-Sterile Dressing Change policy, revised 04/16, indicated to verify the physician order, knock on the door, perform hand hygiene, introduce self, setup area, place waste receptacle with a leak proof bag under the table, provide privacy, perform hand hygiene, apply latex free non-sterile gloves, remove soiled dressing and discard in trash, removed soiled gloves and perform hand hygiene, apply new gloves, cleanse wound per physician orders, removed soiled gloves and discard, perform hand hygiene, and apply latex free non-sterile gloves, apply dressing per order and apply tape with initials and date of dressing change. 2. Medical record review for Resident #12 revealed an admission date of 04/05/13 with diagnoses that included multiple sclerosis, dysphasia, and abscess of the spine. Observation on 09/14/21 at 11:50 A.M. RN #99 and Licensed Practical Nurse (LPN) #800 washed their hands and applied gloves. RN #99 and LPN #800 begin incontinence care by unhooking Resident #12's incontinence brief, turning the resident on her side, and placing a clean brief underneath her. RN #800 cleaned the resident with incontinence wipes and LPN #800 removed the soiled brief. LPN #800 then walked to the residents bathroom and opened the door with her soiled glove. RN #99 with her soiled gloves then repositioned the resident, moved the residents catheter bag, and covered the resident with her sheets. Interview on 09/14/21 at 11:58 A.M. with RN #99 and LPN #800 confirmed proper infection control practice was not followed during incontinence care. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366343 If continuation sheet Page 3 of 4 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 366343 B. Wing A. Building (X3) DATE SURVEY COMPLETED 09/16/2021 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE North Royalton Post Acute 9055 West Sprague Road Parma, OH 44133 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 0880 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Review of the facility policy, Hand Hygiene, dated 03/2020, revealed facility staff should wash their hands after having direct contact with body fluids or excretions. 3. Review of Resident #71's medical record revealed the resident was readmitted to the facility on [DATE] with diagnoses including hyperlipidemia, diabetes and peripheral vascular disease. Review of Resident #71's Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed the resident exhibited intact cognition. Review of Resident #71's physician orders revealed an order dated 08/17/21 to apply Vashe wound cleanser to a 4 x 4 then apply to the right gluteal fold and let soak on wound for three minutes, pack with silver alginate and cover with a foam dressing daily and as needed; and an order dated 08/18/21 to apply a foam dressing topically to the left ischium for preventative care. On 09/15/21 at 12:57 P.M., observation with Licensed Practical Nurse (LPN) #801 revealed she washed her hands, applied disposable gloves, removed the undated foam dressing to the left ischium, removed the soiled dressing to the right gluteal fold, removed her gloves and put both soiled dressings in the trash can with her gloves. She applied clean disposable gloves, placed Vashe wound cleanser on a 4 x 4 dressing and placed the 4 x 4 dressing on the right gluteal fold. She removed her gloves and stated she was to leave the Vashe wound cleanser on the right gluteal fold for three minutes. She replaced her gloves, removed the 4 x 4 with the Vashe wound cleanser and placed the dressing in the trash, packed the right gluteal fold with silver alginate using a sterile cotton applicator (Q-tip), removed her gloves, donned new disposable gloves, placed a clean 4 x 4 gauze dressing over the right gluteal fold and then a foam dressing. She then removed her gloves, applied new gloves and cleansed the left ischium with Vashe wound cleanser and then placed a foam dressing on the left ischium. She removed her gloves, cleaned up her area and washed her hands. Interview on 09/15/21 at 1:16 P.M. with LPN #801 confirmed she did not sanitize or wash her hands after removing the soiled dressings to the left ischium and right gluteal fold prior to completing wound care for both pressure areas. Review of the Non-Sterile Dressing Change policy, revised 04/16, indicated to verify the physician order, knock on the door, perform hand hygiene, introduce self, setup area, place waste receptacle with a leak proof bag under the table, provide privacy, perform hand hygiene, apply latex free non-sterile gloves, remove soiled dressing and discard in trash, removed soiled gloves and perform hand hygiene, apply new gloves, cleanse wound per physician orders, removed soiled gloves and discard, perform hand hygiene and apply latex free non-sterile gloves, apply dressing per order and apply tape with initials and date of dressing change. This deficiency substantiates Complaint Number OH00112912. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366343 If continuation sheet Page 4 of 4