Inspection·January 31, 2024

F 0584 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few 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. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review the facility failed to provide a clean and sanitary environment for Resident #7 and #28, and failed to ensure Resident #57 had clean bed linens. This affected three (#7, #28 and #57) of ten residents observed for environment. The facility census was 83. Findings include: 1. Observations on 01/28/24 at 10:45 A.M. revealed Resident #7 was up in a wheelchair with his bedside table in front of him. Resident #7's wheelchair had dirty debris on the foot rests and on the cushioned leg brace to the left side. Resident #7's bedside table had various areas of dried spilled debris on the top of the table and in an open drawer of the table. Further observation revealed Resident #7's roommate (Resident #28) was receiving tube feeding. The tube feeding pole had various areas of dried tube feeding formula on it. Scattered debris was observed on the floor behind Resident #28's bed. Interview with Resident #28 at time of observation revealed They come in sometimes, but they don't look back there. Observations were confirmed by Licensed Practical Nurse (LPN) #587 on 01/28/24 at 11:00 A.M. 2. Observation on 01/30/24 at 7:07 A.M. revealed Resident #57 was out of bed. Observation of Resident #57's bed linens revealed multiple areas of dried blood and a large dried yellow stain on the middle of the bed sheet. Observation of and interview with Resident #57 revealed he could not say where the blood or yellow stains had come from or how long they had been there. Resident #57 said he was continent of urine and used the bathroom. Resident #57 did not have any obvious scratches, abrasions or skin tears. Interview on 01/30/24 at 10:30 A.M. with State Tested Nursing Assistant (STNA) #585 revealed Resident #57 was continent of urine and walked to the bathroom. STNA #585 had changed Residents #57's bed linens after being asked by the Administrator to change the sheets because they were soiled. STNA #585 confirmed the sheets had dried blood and a large dried yellow stain but he was unaware where the stains came from or how long they had been there. STNA #585 said Resident #57 did not have any scratches, abrasions, or skin tears that he was aware of and Resident #57 usually made his own bed in the mornings and kept his blankets pulled up over the sheets. Review of the Minimum Data Set assessment dated [DATE] revealed Resident #57 was independent with toileting, showering and ambulation. Resident #57 was incontinent of bowel and bladder. 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 01/31/2024 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)