Inspection·July 31, 2023

F 0842 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. Based on record review, interviews, and facility policy review the facility failed to ensure accurate documentation in the medical record for respiratory care and enteral tube feeding care for Resident #93. This affected one resident (#93) of three residents reviewed for respiratory care and enteral tube feeding care. The facility census was 92. Findings include: Review of the medical record for Resident #93 revealed an admission date of 04/07/23 with diagnoses including traumatic subdural hemorrhage, acute and chronic respiratory failure, gastrostomy, tracheostomy, and personal history of traumatic brain injury. Review of Resident #93's physician's orders revealed he had orders for staff to check the residuals of his tube feeding every shift dated 05/28/23 and discontinued 06/05/23; to administer well water only, no tap water every shift dated 05/28/23 and discontinued 06/05/23; perform tracheostomy care twice daily and as needed every day and evening shift dated 05/28/23 and discontinued 06/05/23; change the tracheostomy inner cannula daily and as needed dated 05/28/23 and discontinued 06/05/23; and to monitor his oxygen level every four hours and if any signs of distress or oxygen is less than 90 percent (%), staff were to uncap him and apply humification dated 07/05/23. Review of the Medication Administration Record (MAR) and Treatment Administration Record (TAR) reviewed for June 2023 and July 2023 revealed nursing staff did not document these items as being completed: Tube feeding residuals on dayshifts on 06/01/23, 06/03/23 and 06/04/23 and on evening shift on 06/02/23. Well water only, no tap water on dayshifts on 06/01/23, 06/03/23 and 06/04/23 and on evening shift on 06/02/23. Tracheostomy care on dayshifts on 06/01/23 and 06/04/23 and on evening shift on 06/02/23. Change tracheostomy inner cannula on 06/01/23 and 06/04/23. Oxygen saturation on 07/07/23 at 8:00 A.M., 12:00 P.M. and 4:00 P.M.; on 07/09/23 at 8:00 A.M. and 12:00 P.M.; on 07/11/23 at 8:00 A.M. and 12:00 P.M., and on 07/12/23 at 8:00 A.M. and 12:00 P.M. Interview on 07/27/23 at 3:49 P.M. with the Director of Nursing (DON) revealed there were times the (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 2 Event ID: 366343 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 07/31/2023 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)